Every finding on record at Solera at West Houston

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one resident (Resident #2) out of five residents reviewed for ADLs. The facility failed to provide timely incontinent care for Resident #2, which resulted in the resident's incontinent brief being saturated with urine and the wet indicator being faded on 08/13/2026 at 3:37 p.m. This failure could have placed residents at risk of skin breakdown and reduced feelings of self-worth.Findings included: Record review of Resident #2's face sheet, dated 08/13/2026, revealed a [AGE] year-old male who was admitted on [DATE] from the hospital. Resident #2 had diagnoses which included: obesity (an excessive amount of body fat), hypertension (when the pressure in the blood vessels was too high), and diabetes mellitus (body could not properly control sugar levels in the blood). Record review of Resident #2's admission MDS assessment, dated 07/05/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #2 was dependent on staff for toilet use. It also revealed the resident was frequently incontinent of bowel and bladder. Record review of Resident #2's care plan, revised 07/10/26, revealed the resident had frequent bladder incontinence. Intervention: used disposable briefs. Clean peri- area (the area between the private parts and the back passage) with each incontinence episode. During an observation and interview on 08/13/26 at 3:57 p.m., revealed Resident #2 was lying on his bed during the interview. Resident #2 said he was last changed between 11:30 and 11:45 a.m. today. Resident #2 said he had pulled on his call light twice today, and someone came and turned the call light off, and he told the staff who came and turned off the call light that he wanted to be changed. Resident #2 said he did not want to be sitting in a wet brief because he did not want his skin to break down. Resident #2 said this happened almost every day, and he had not reported it to the Administrator, and he did not respond when he was asked why he had not reported it. During an observation on 08/13/26 at 4:03 p.m., during incontinent care it revealed Resident #2's incontinent brief was saturated, and the cotton filling in the incontinent brief was breaking apart, and the wet indicator (showed the incontinent brief was wet with urine) had faded. During an interview on 08/13/26 at 4:10 p.m., CNA B said she came to work at 2:30 p.m., and she was Resident #2's aide. CNA B said the aides were required to make rounds every two hours and as needed for incontinent care. CNA B said she had not changed Resident #2 since she came to work because she was providing incontinent care for other residents. She said Resident #2 would call when he was ready to be changed, and she did not turn off the resident's call light, and none of the staff told her the resident needed to be changed. She said the incontinent brief was soaked and very wet, and the cotton filling inside of the brief was breaking apart. She said Resident #2 could have had skin breakdown if the resident was left in a saturated incontinent brief with urine. During an interview on 08/13/26 at 4:27 p.m., LVN D said she came to work at 2:00 p.m. LVN D said the nurses and the aides were supposed to make rounds every two hours and as needed. LVN D said she saw Resident #2 when she made rounds around 2:30 p.m. but did not ask him if he needed incontinent care. LVN D said she knew that the brief was saturated when the line indicator changed color and the brief was soaked with urine. She said if Resident #2 was left in a saturated incontinent brief, the resident could have developed a bed sore and infection. During an interview on 08/13/26 at 6:16 p.m., the RDCS said he had been overseeing the facility for about three weeks since the facility did not have a DON. He said the staff should have made rounds every two hours and as needed to check and change residents' incontinent briefs. He said the aides were supposed to check on residents during shift change. He said the outgoing and the incoming aides should have communicated, done walking rounds, and the outgoing aide should have communicated to the incoming aide which resident she was not able to provide incontinent care for before the shift change, but the outgoing aide should have had time to provide incontinent care before shift change. The RDCS said he was not aware Resident #2 had not been changed timely. He said hypothetically if Resident #2 was not changed for an extended time, Resident #2 could have had skin breakdown. Record review of the facility policy on activity of daily living dated 12/01/25 revealed in part . policy explanation and compliance guidelines: #3 a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . care and services would be provided for the following activities of daily living. #3 toileting.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 out of 5 staff (CNA A and CNA) observed for infection control.The Facility failed to ensure CNA A did not wear the same gloves throughout incontinent care For Resident #1 on 08/13/26 at 11:35 a.m. The Facility failed to ensure CNA B did not wear the same gloves throughout incontinent care For Resident #2 on 08/13/26 at 4:03 P.m. This failure could have placed the residents at risk for infection. Findings included:Resident #1Record review of Resident #1's face sheet, dated 08/13/2026, revealed a [AGE] year-old female admitted on [DATE] from the hospital. Resident #1 had diagnoses which included: dementia (disorders that cause slow memory, thinking, and reasoning), hypertension (when the pressure in the blood vessels is too high), and cerebral infarction (brain tissue death). Record review of Resident #1's quarterly MDS assessment, dated 07/29/26, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed Resident #1 needed substantial assistance with one staff assistance and was dependent on staff for toilet use. It also revealed the resident was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #1's care plan, revised 05/03/26, revealed the resident had bladder incontinence. Interventions: use disposable briefs. Clean peri area with each incontinence episode. During an interview on 08/13/26 at 11:22 a.m., an attempt was made to communicate with Resident 1 while she was sitting in a wheelchair in her room. Resident #1 did not respond. During an observation on 08/13/26 at 11:35 a.m., revealed while providing incontinent care in Resident #1's room, CNA A took off Resident #1's incontinent brief that was saturated with urine no feces, and she used the same gloves she used to take off the dirty incontinent brief throughout the care. CNA A turned Resident #1 to her left side. She placed the incontinent brief and wipe packet on the nightstand. She took two wipes from the wipe packet and folded the two wipes together. She wiped Resident #1's rectum from back to front and then wiped both buttocks from back to front with the same wipe. Then CNA A placed the clean incontinent brief under Resident #1 with the same gloves. She then applied barrier cream on the resident's buttocks with the same gloves. CNA A turned Resident #1 to her back on the clean incontinent brief. She took three wipes and folded the wipes together, and she wiped below the resident's abdomen, left and right pubic area (the lower part of the belly, right and left above sexual organ) from front to back, and then she wiped again from back to front, and she still used the same wipes and cleaned the labia from back to front and did not separate the resident's labia (the folds of skin on the outside of private parts). Then she applied the incontinent brief with the same gloves. During an interview on 08/13/26 at 11:48 a.m., CNA A said she did not provide the incontinent care for Resident #1 properly because she cleaned the rectum and buttocks first, wiped from back to front, applied the barrier cream, and placed the clean incontinent brief under Resident #1 with the same dirty gloves. She also said she took wipes from the wipe container with the same gloves. She said she used the same wipe to clean the peri area, wiped Resident #1 from front to back and from back to front, and forgot to separate the resident's labia. She said it was an infection control issue because Resident #1 could get UTI (unitary tract infection). CNA A said when she wiped from back to front that could have introduced germs into the resident's private area. She said she should have cleaned Resident #1's private area first, separated the labia to make sure the area was clean, then turned the resident to the sides and cleaned from front to back away from the resident's private area. CNA A said she should have changed her gloves when going from dirty to clean to prevent cross contamination. During an interview on 08/13/26 at 2:16 p.m., LVN C said CNA A should have wiped from front to back, and when the aide wiped from back to front, she could have introduced germs into Resident #1's private area, which could have caused infection (UTI) for Resident #1. LVN C said CNA A should not have used the wipe more than once to prevent infection because the wipe was dirty after the first use. LVN C said she should have changed her gloves when she went from dirty to clean. He said the aide should have separated Resident #1's labia to make sure the area was cleaned properly to prevent rashes and infection. During an interview on 08/13/26 at 6:24 p.m., the RDCS said when CNA A provided incontinent care for Resident #1, she should have cleaned Resident #1 from front to back and not back to front because it was a high risk for infection. He said CNA A was supposed to clean once with one wipe and throw it away to prevent infection for the resident. The RDCS said CNA A was supposed to separate Resident #1's labia during incontinent care and clean the area properly to prevent rash and infection. He said CNA A was supposed to change gloves whenever she went from dirty to clean, and she should have washed or sanitized her hands before she donned(put on gloves) clean gloves. The RDCS said CNA A was not supposed to take wipes from the packet with dirty gloves because it was an infection control issue. Resident #2Record review of Resident #2's face sheet, dated 08/13/2026, revealed a [AGE] year-old male admitted on [DATE] from the hospital. Resident #2 had diagnoses which included: obesity (an excessive amount of body fat), hypertension (when the pressure in the blood vessels is too high), and diabetes mellitus (body cannot properly control sugar levels in the blood). Record review of Resident #2's admission MDS assessment, dated 07/05/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #2 was dependent on staff for toilet use. It also revealed the resident was frequently incontinent of bowel and bladder. Record review of Resident #2's care plan, revised 07/10/26, revealed the resident had frequent bladder incontinence. Intervention: use disposable briefs. Clean peri- area with each incontinence episode. During an observation on 08/13/26 at 4:03 p.m., revealed Resident #2 was lying in his bed in his room during incontinent care provided by CNA B, who used the same gloves throughout the incontinent care. CNA B took a couple of wipes from the packet with the same gloves she used to remove the dirty incontinent brief. She folded the wipes together and wiped Resident #2's pubic area and penis with the same wipes. CNA B wiped Resident #2's penis from the base of the penis towards the head of the penis. She did not retract the skin or wipe the penis head and meatus in a circular motion. CNA B applied the clean incontinent brief with the same gloves. During an interview on 08/13/26 at 4:17 p.m., CNA B said she provided incontinent care for Resident #2 with the same gloves with which she removed the dirty incontinent brief and took wipes from the wipe container. She said she was supposed to remove the dirty gloves, wash or sanitize her hands, and donned another pair of gloves before going into a clean wipe packet or applying a clean incontinent brief on Resident #2. CNA B said she wiped the resident multiple times with the same wipe but should have used one wipe once to prevent the spread of germs. CNA B said she did not pull back Resident #1's foreskin and clean the penis head and meatus in a circular motion, and if Resident #2's penial head was not properly cleaned, Resident #2 could have infection (UTI, urinary tract infection). During an interview on 08/13/26 at 4:30 p.m., LVN D said CNA B should have changed her gloves after she removed Resident #2's dirty incontinent brief. LVN D said CNA B should have changed her gloves whenever she went from dirty to clean to prevent cross contamination. She said CNA B should have used one wipe once, pulled back Resident #2's foreskin, cleaned the head of the penis and meatus in a circular motion, and then cleaned the shaft (body of the of the penis) using downward strokes toward the scrotum (loss pouch of skin that hangs behind the penis). She said CNA B should not have cleaned the shaft of the penis towards the head of the penis to prevent contamination, which could have caused infection (UTI) for Resident #2. During an interview on 08/13/26 at 6:37 p.m., the RDCS said CNA B should have cleaned Resident #2's penial head and urinary meatus in a circular motion after she had pulled the foreskin back. He also said CNA B should have wiped the shaft of the penis towards the scrotum. He said CNA B should not have used the same gloves throughout when she provided incontinent care for Resident #2 or cleaned Resident #2 with the same wipe more than once because of infection control. Record review of the facility policy on perineal care dated 11/12025, revised 12/1/2025, revealed in part .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. Definition Perineal care refers to the care of the external genitalia and the anal area. Females:Assist resident in bending her knees slightly and spreading her legs.Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain the wet cloth. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus).Repeat on opposite side using separate section of washcloth or new disposable wipe. clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke. Males:Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain the wet cloth.Gently retract the foreskin if applicable.Hold the shaft of the penis with one hand and was with the other. Begin cleansing tip of penis at urethral meatus using a circular motion and working outward.Replace foreskin, if applicable.Cleanse the shaft of the penis, using downward strokes toward the scrotum. Use separate section of washcloth or new disposable wipe with each stroke.Cleanse the scrotum, using a clean portion of the washcloth, new washcloth or new disposable wipe with each stroke.

Based on observation, interview, and record review, the facility failed to ensure that residents who were continent of bladder and bowel on admission received services and assistance to maintain continence and that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 5 residents (Residents #1 and Resident #2) reviewed for incontinent care. The facility failed to ensure CNA A separated Resident #1's labia, cleaned from back to front, cleaned Resident #1 with the same wipe multiple times and wore the same gloves throughout incontinent care on 08/13/26 at 11:35 a.m. The facility failed to ensure CNA B retracted Resident #2's foreskin (loose stretch fold of skin that cover the tip or head of the penis) and cleaned the penis head in a circular motion, wiped Resident #2 with the same wipe multiple times and wore the same gloves throughout incontinent on 08/13/26 at 4:03 p.m. This failure could place residents at risk of infection, pain, injury, hygiene issues, and hospitalization. Findings included: Resident #1Record review of Resident #1's face sheet, dated 08/13/2026, revealed a [AGE] year-old female admitted on [DATE] from the hospital. Resident #1 had diagnoses which included: dementia (disorders that cause slow memory, thinking, and reasoning), hypertension (when the pressure in the blood vessels is too high), and cerebral infarction (brain tissue death). Record review of Resident #1's quarterly MDS assessment, dated 07/29/26, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed Resident #1 needed substantial assistance with one staff assistance and was dependent on staff for toilet use. It also revealed the resident was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #1's care plan, revised 05/03/26, revealed the resident had bladder incontinence. Interventions: use disposable briefs. Clean peri area with each incontinence episode. During an interview on 08/13/26 at 11:22 a.m., an attempt was made to communicate with Resident 1 while she was sitting in a wheelchair in her room. Resident #1 did not respond. During an observation on 08/13/26 at 11:35 a.m., revealed while providing incontinent care in Resident #1's room, CNA A took off Resident #1's incontinent brief that was saturated with urine no feces, and she used the same gloves she used to take off the dirty incontinent brief throughout the care. CNA A turned Resident #1 to her left side. She placed the incontinent brief and wipe packet on the nightstand. She took two wipes from the wipe packet and folded the two wipes together. She wiped Resident #1's rectum from back to front and then wiped both buttocks from back to front with the same wipe. Then CNA A placed the clean incontinent brief under Resident #1 with the same gloves. She then applied barrier cream on the resident's buttocks with the same gloves. CNA A turned Resident #1 to her back on the clean incontinent brief. She took three wipes and folded the wipes together, and she wiped below the resident's abdomen, left and right pubic area (the lower part of the belly, right and left above sexual organ) from front to back, and then she wiped again from back to front, and she still used the same wipes and cleaned the labia from back to front and did not separate the resident's labia (the folds of skin on the outside of private parts). Then she applied the incontinent brief with the same gloves. During an interview on 08/13/26 at 11:48 a.m., CNA A said she did not provide the incontinent care for Resident #1 properly because she cleaned the rectum and buttocks first, wiped from back to front, applied the barrier cream, and placed the clean incontinent brief under Resident #1 with the same dirty gloves. She also said she took wipes from the wipe container with the same gloves. She said she used the same wipe to clean the peri area, wiped Resident #1 from front to back and from back to front, and forgot to separate the resident's labia. She said it was an infection control issue because Resident #1 could get UTI (unitary tract infection). CNA A said when she wiped from back to front that could have introduced germs into the resident's private area. She said she should have cleaned Resident #1's private area first, separated the labia to make sure the area was clean, then turned the resident to the sides and cleaned from front to back away from the resident's private area. CNA A said she should have changed her gloves when going from dirty to clean to prevent cross contamination. During an interview on 08/13/26 at 2:16 p.m., LVN C said CNA A should have wiped from front to back, and when the aide wiped from back to front, she could have introduced germs into Resident #1's private area, which could have caused infection (UTI) for Resident #1. LVN C said CNA A should not have used the wipe more than once to prevent infection because the wipe was dirty after the first use. LVN C said she should have changed her gloves when she went from dirty to clean. He said the aide should have separated Resident #1's labia to make sure the area was cleaned properly to prevent rashes and infection. During an interview on 08/13/26 at 6:24 p.m., the RDCS said when CNA A provided incontinent care for Resident #1, she should have cleaned Resident #1 from front to back and not back to front because it was a high risk for infection. He said CNA A was supposed to clean once with one wipe and throw it away to prevent infection for the resident. The RDCS said CNA A was supposed to separate Resident #1's labia during incontinent care and clean the area properly to prevent rash and infection. He said CNA A was supposed to change gloves whenever she went from dirty to clean, and she should have washed or sanitized her hands before she donned(put on gloves) clean gloves. The RDCS said CNA A was not supposed to take wipes from the packet with dirty gloves because it was an infection control issue. Resident #2Record review of Resident #2's face sheet, dated 08/13/2026, revealed a [AGE] year-old male admitted on [DATE] from the hospital. Resident #2 had diagnoses which included: obesity (an excessive amount of body fat), hypertension (when the pressure in the blood vessels is too high), and diabetes mellitus (body cannot properly control sugar levels in the blood). Record review of Resident #2's admission MDS assessment, dated 07/05/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #2 was dependent on staff for toilet use. It also revealed the resident was frequently incontinent of bowel and bladder. Record review of Resident #2's care plan, revised 07/10/26, revealed the resident had frequent bladder incontinence. Intervention: use disposable briefs. Clean peri- area with each incontinence episode. During an observation on 08/13/26 at 4:03 p.m., revealed Resident #2 was lying in his bed in his room during incontinent care provided by CNA B, who used the same gloves throughout the incontinent care. CNA B took a couple of wipes from the packet with the same gloves she used to remove the dirty incontinent brief. She folded the wipes together and wiped Resident #2's pubic area and penis with the same wipes. CNA B wiped Resident #2's penis from the base of the penis towards the head of the penis. She did not retract the skin or wipe the penis head and meatus in a circular motion. CNA B applied the clean incontinent brief with the same gloves. During an interview on 08/13/26 at 4:17 p.m., CNA B said she provided incontinent care for Resident #2 with the same gloves with which she removed the dirty incontinent brief and took wipes from the wipe container. She said she was supposed to remove the dirty gloves, wash or sanitize her hands, and donned another pair of gloves before going into a clean wipe packet or applying a clean incontinent brief on Resident #2. CNA B said she wiped the resident multiple times with the same wipe but should have used one wipe once to prevent the spread of germs. CNA B said she did not pull back Resident #1's foreskin and clean the penis head and meatus in a circular motion, and if Resident #2's penial head was not properly cleaned, Resident #2 could have infection (UTI, urinary tract infection). During an interview on 08/13/26 at 4:30 p.m., LVN D said CNA B should have changed her gloves after she removed Resident #2's dirty incontinent brief. LVN D said CNA B should have changed her gloves whenever she went from dirty to clean to prevent cross contamination. She said CNA B should have used one wipe once, pulled back Resident #2's foreskin, cleaned the head of the penis and meatus in a circular motion, and then cleaned the shaft (body of the of the penis) using downward strokes toward the scrotum (loss pouch of skin that hangs behind the penis). She said CNA B should not have cleaned the shaft of the penis towards the head of the penis to prevent contamination, which could have caused infection (UTI) for Resident #2. During an interview on 08/13/26 at 6:37 p.m., the RDCS said CNA B should have cleaned Resident #2's penial head and urinary meatus in a circular motion after she had pulled the foreskin back. He also said CNA B should have wiped the shaft of the penis towards the scrotum. He said CNA B should not have used the same gloves throughout when she provided incontinent care for Resident #2 or cleaned Resident #2 with the same wipe more than once because of infection control. Record review of the facility policy on perineal care dated 11/12025, revised 12/1/2025, revealed in part .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. Definition Perineal care refers to the care of the external genitalia and the anal area. Females:Assist resident in bending her knees slightly and spreading her legs.Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain the wet cloth. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus).Repeat on opposite side using separate section of washcloth or new disposable wipe. clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke. Males:Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain the wet cloth.Gently retract the foreskin if applicable.Hold the shaft of the penis with one hand and was with the other. Begin cleansing tip of penis at urethral meatus using a circular motion and working outward.Replace foreskin, if applicable.Cleanse the shaft of the penis, using downward strokes toward the scrotum. Use separate section of washcloth or new disposable wipe with each stroke.Cleanse the scrotum, using a clean portion of the washcloth, new washcloth or new disposable wipe with each stroke.

Based on observation, interview, and record review the facility failed to ensure that resident with pressure ulcers receives treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1(Resident #1) of 5 resident's reviewed for pressure ulcers. -LVN A failed to follow physician orders while changing Resident #1's dressing to right hip. LVN A failed to apply skin prep to peri wound edge and apply Santyl (ointment used to remove dead tissue from skin ulcer) to resident wound bed. This failure could place residents with wounds at risk for delayed healing and tissue damage. Finding Included: Record review of Resident #1's face sheet dated 02/03/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 01/19/26. Resident #1's diagnoses included scoliosis (abnormal sideways curvature of the spine, forming an S or C shape), type 1 diabetes mellitus with hyperglycemia (blood sugar is above the normal range due to lack of insulin, causing the sugar to build up in the blood), end stage renal (kidney) disease, dependent of dialysis, and legally blind. Record review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 13 indicating resident's cognition was intact. Review of section M (Skin) revealed that Resident #1 was admitted to the facility with pressure ulcer. Record review of Resident #1's Comprehensive Care Plan dated 12/29/25 and revised 01/02/26 Resident #1 care plan for skin concerns. Interventions included providing treatment as ordered. Record review of Resident #1's Physician order summary report for the month of February 2026 reflected the following wound treatment order: -Dated 01/30/26 Right hip, unstageable pressure injury: Cleanse with ns (normal saline) or house wound cleanser, pat dry with gauze, apply skin prep to peri wound edge (the skin immediately surrounding a wound), apply Santyl (, apply alginate calcium (absorbent dressing), cover with border gauze, everyday shift. Record review of Resident #1's MAR/ TAR for the month of February 2026 revealed that the facility was following the above prescribed order. Observation on 02/18/26 at 12:04 PM of wound care for Resident #1 by LVN A. Resident #1 said it was okay for surveyor to observe dressing change to her right hip. LVN A sanitize Resident #1's bedside table with disinfectant sani-wipes, washed her hands with soap and water, donned her PPE that consisted of disposable gown and gloves, and mask. LVN A then took wound supplies in resident's room including a small red biohazard bag and placed on top of parchment paper on top of bedside table. LVN A removed old dressing to resident's right hip, removed her gloves, sanitized her hands, and placed on a new set of clean gloves. LVN A cleaned Resident #1's wound bed with wound cleanser one wipe at a time. Resident #1's wound bed was dry and pink with tiny specs of black dots. LVN A changed her gloves again, sanitized her hands, and placed on a new set of clean gloves. LVN A did not apply skin prep to peri wound edge instead or applied Santyl to wound bed. LVN A applied to the wound bed calcium alginate covering with a border dressing. Resident #1 tolerated the procedure without complaints of discomfort. During an interview on 02/18/26 at 1:48PM, the DON said after reviewing Resident #1's orders, LVN A should have followed the physician wound care orders to apply skin prep to wound edges and applied the Santyl. The DON was asked for the facility policy on wound care, following physician orders, and quality of care. During an interview on 02/18/26PM at 1:57PM with wound care nurse LVN A said when she made rounds with the Wound Specialist NP earlier in the day, the NP said not to apply the Santyl to Resident #1's wound on the right hip. LVN A said she had not transcribed the order in the system because she had not gotten around to it. LVN A said she had not worked at the facility in months and when she did work at the facility, it was usually on the weekend. LVN A said until the new order is put in the system, one would have to follow the present order. Interview on 02/18/26 at 2:26PM with the DON when asked what order the nurse would follow if a new wound care order had not been updated in the system and the wound dressing became soiled and the dressing needed to be changed? The DON said that would not happen because herself or the ADON would have transcribed the new wound treatment. During an interview on 02/18/26 at 2:40PM, RN B (charge nurse) said she worked at the facility full time on the 2pm-10pm shift. RN B said if a wound dressing became soiled and had to be changed, she would look in the system to see what was ordered and go by the order transcribed in the system. RN B said whenever the Wound Care Specialist NP came to the facility to make rounds on residents with wounds, the wound care nurse made rounds with the specialist. RN B said the Wound Care NP Specialist normally put in any new orders at the time she made her wound rounds. RN B said the Wound Care NP utilized a cart with a laptop , so she could put new orders into the system before she left the facility. Record review of the facility policy on Medication Administration dated 11/01/25 and revised 12/01/25 reflected in part: .Medications are administered by the licensed nurse, 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. Record review of the facility policy on Provision of Quality of Care dated 10/01/25 reflected in part: .Based on comprehensive assessments, the facility will ensure that residents receive treatment that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered, care plans, and the residents' choices.

Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers receive necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for wound care. The facility failed to properly identify the pressure ulcer and provide immediate oversight by a wound care specialist when the wound was first identified as a Stage 2 Pressure Ulcer on 10/15/25. CR#1 was admitted to the hospital on [DATE] with a necrotic pressure ulcer to the right heel and the need for possible amputation of the lower right extremity. On 11/17/25, CR#1's family member stated that CR#1's right leg was amputated above the knee due to an infected pressure ulcer of her heel. An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 3:31 pm. While the IJ was removed on 11/15/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. These failures could place residents at risk for delayed treatment, worsening of condition, hospitalization, and death.Findings Include:Record review of CR #1's facesheet revealed a seventy-six-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses was a pulmonary embolism without acute pulmonale (blood clot in the lung), secondary malignant neoplasm of bone (cancer that has spread throughout the body), hyperlipidemia, difficulty walking, and the presence of a pacemaker. Record review of CR#1's admitting hospital records dated 09/15/25 documented that CR#1 had Type 2 Diabetes, a pressure injury to the right heel that was present upon admission, and a right arthroplasty of the and hip (hip replacement) on 8/18/25. Record review of CR #1's care plan initiated 09/18/25 documented pain management and interventions stated that if pain was present, LVN should assess and document the pain assessment including location, nature, intensity, and duration of pain. Pressure ulcer interventions included floating heels as tolerated and using a pressure redistribution mattress. Record review of CR#1's MDS dated [DATE] revealed a BIMS score of 11 (moderate cognitive impairment). Section GG titled Functional Abilities upon admission noted that CR#1 was dependent to sit to stand, transfer from chair to bed, toilet transfer, and walking 10, 50, and 150 feet. Section M titled Skin conditions documented that CR#1 was at risk at developing a pressure ulcer based off a formal and clinical assessment. In the subsection unhealed pressure ulcers/injuries, it was documented that CR#1 had no present skin conditions. Record review of CR#1's admission assessment completed on 9/18/25 by RN A, documented that no wound was present upon admission. She was marked as bed bound due to prior hip replacement surgery. Record review of CR#1's weekly head to toe assessment located on the TAR for September 2025 reflected on the following:* 09/22/25, WCN marked E that identified an existing wound alteration (location not specified). *09/29/25, WCN marked 0, which was not listed as an abbreviation on the assessment key. Review of the weekly skin assessments for October 2025 documented the following:*10/6/25, WCN marked 0*10/13/25, WCN marked 0*10/21/25, WCN marked E*10/27/25, WCN marked 0 Record review of CR#1's active orders as of 9/18/25 were as follows:*09/22/15: ordered weekly head to toe assessments every Monday where N=new, E= existing skin altercation, and C= clear. *10/16/25: Wound Treatment - Xeroform every day shift every other day for open blister. Cleanse open blister right heel with saline, pat dry, apply skin prep to skin of surrounding area, apply xeroform to bruised open wound, cover with ABD. Secure with kerlix wrap. Elevate and off load. Monitor for discomfort. This order was discharged on 10/22/25. *10/17/25: Doxycycline ordered.*10/23/25: Wound Treatment - Dry Dressing every day shift every other day for wound healing. Cleanse right heel eschar wound with saline, pat dry, apply iodosorb gel to wound bed then cover with ABD, secure with kerlix wrap as directed and PRN. *10/31/25: Wound Treatment - Dry Dressing everyday shift for Wound healing. Cleanse right heel eschar with betadine, then apply moist to dry betadine gauze followed by ABD, Secure w/ kerlix wrap qd. Record review of CR#1's progress notes documented by the NP on 10/2/25, the NP identified calluses during examination (location unspecified) and CR#1 was started on Tylenol after complaints of pain during her PT sessions. Record review of CR#1's progress notes documented on 10/7/25, the NP, documented complaints of worsening foot pain contributed to bilateral lower extremity edema with marked swelling and multiple large, thick calluses present on both feet, particularly prominent on pressure-bearing areas. The calluses appeared dry, hyperkeratotic, and well-established, causing discomfort and contributing to her pain. Skin was noted as noticeably discolored and had chronic venous changes consistent with chronic venous insufficiency. Record review of CR#1's progress notes documented on 10/9/25 by the NP indicated the chronic venous skin changes was consistent with pressure related changes, with difficulty lifting lower right extremity. Record review of CR#1's progress notes documented on 10/15/25, the NP identified the wound on the right heel as a Stage 2 pressure ulcer with drainage and partial thickness skin loss involving the epidermal. Wound management initiated. Record review of CR#1's progress notes documented by the WCN on 10/15/25, that on 10/14/25, a skin issue identified as a blister had appeared on CR#1's right heel after it burst during PT. CR#1 stated that she tried telling PT on 10/13/25 but they could not hear her and in PT again on 10/14/25, she felt pain and stated that her heel started bleeding and draining because the blister popped. WCN assessed the skin issue on 10/15/25 and the area measured 4.5x7.5. The open area measured 2.5x3.5 and was bruised with dark brown discoloration surrounded by maroon tissue with no drainage. NP notified and doppler ordered. Skin was prepped, xeroform applied to bruised area, followed by ABD, and wrapped with kerlix. Prevalon boot in place and monitored for pain and discomfort. NP was notified of doppler results. Record review of CR#1's progress notes documented by WCN on 10/17/25 stated that the right heel wound was monitored frequently throughout the day by wound care/ charge nurses and CR #1's right heel was offloaded and elevated. No weight should be barred to the right heel until the blister was resolved. She was currently stable, no odor, the wound bed remained bruised to the center surrounded by pink tissue. The wound edges were detached and white in color. The skin was monitored for any new open areas, and no areas were currently noted. RP made aware of current progress. Record review of CR#1's progress notes documented on 10/20/25 by NP recorded that the clinical indication for the venous doppler found the appropriate compression and color flow throughout the visualized deep venous system with no evidence of deep venous thrombosis. Impression revealed no DVT identified in the visualized veins. Record review of CR#1's progress notes documented on 10/22/25 by WCN identified a new skin issue on the right heel. The issue type was a blister and progress had stalled, were previously improving wound characteristics plateaued. Wound acquired in-house. Signs and symptoms of infection: Non-healing. Painful: No. Staged by: Health care provider. Length (cm): 3.5 Width (cm): 3.5 Depth (cm): 0 Undermining: No. Tunneling: No. Epithelial: 10%. Eschar: 90. Exudate amount: None. Periwound temperature: Normal. Cleansing solution: Povidone iodine. Other primary dressing was iodosorb gel, ABD, Kerlix wrap, and utilized prevalon boots. Record review of CR#1's progress notes documented on 10/29/25 by WCN identified a new skin issue on the right heel. The issue type was a blister and progress had stalled, were previously improving wound characteristics plateaued. Wound acquired in-house. Signs and symptoms of infection: Smell increased. Signs and symptoms of infection: Size has increased. Signs and symptoms of infection: Non-healing. Painful: No. Staged by: Health care provider. Length (cm): 4.5 Width (cm): 4.5 Depth (cm): 0 Area (cm2): 0 Undermining: No. Tunneling: No. Granulation: 20%. Eschar: 80%. Exudate amount: None. Periwound temperature: Normal. Cleansing solution: Povidone iodine. Other primary dressing was ABD, Kerlix wrap, and utilized prevalon boots. In a telephone interview with CR #1 and CR#1's family member on 11/8/25 at 12:57 p.m., CR#1 stated she had complained about pain to her foot for 3 weeks before it began to bleed during physical therapy. CR#1 stated that she complained of pain to the nurses, the NP, and the PT. She stated upon admission, her mattress looked like it had a sunken hole in it and was very uncomfortable and the facility told her it could not be replaced. CR#1 and her family member denied the presence of a wound upon admission and CR#1's family member stated that when CR#1 went to her orthopedic appointment on 11/4/25 at 3p.m., she requested the Orthopedic doctor to examine CR#1's foot. CR#1's family member explained that when the doctor saw her foot, he was shocked and immediately advised that she be admitted to the hospital for further evaluation. Both stated that they had not seen the wound in some time and were shocked that it had gone from the size of a quarter to the whole heel, with black and blue tissue. When asked about wound care at the facility, CR#1 stated that she was not getting wound care every day and someone only unwrapped her foot for wound care once a week. In an interview on 11/10/25 at 9:36 a.m. while visiting CR#1 in the hospital, she stated that she was not feeling too well, and her stomach was hurting. She explained that she was currently waiting on the hospital to give her an MRI. She said at the facility, a woman would come in once a week to put what she perceived was Vaseline on it. She did remember seeing a NP and she stated that she could not recall how often she would see the WCN, but she knew it was not every day for sure and stated, I know they were not coming as often as they have been coming at the hospital to do wound care. When she was at the facility, she constantly told them her foot was killing her, but nobody listened and the gave her pills to help with the pain, but they put her to sleep. She also recalled seeing the WCNP at some point as well. In an interview on 11/10/25 at 9:49 a.m., the HRN in the hospital, stated that they were currently awaiting approval for CR#1 to receive an MRI because she had a pacemaker and the cardiologist had to sign off on it. The MRI would determine if the wound was infected or not and whether her foot could be saved by antibiotics or she needed amputation. Currently, she explained the wound was unstageable because of all the slough on it. She said that it looked pretty bad, and they were providing wound care on it once a day so that a lot of air would not get into it. HRN also provided a picture of the foot that was taken on 11/4/25 when CR#1 was admitted . Observation on 11/10/25 at 9:51 a.m. of the hospital admission photograph of CR#1's right heel dated for 11/4/25 at 5:27 p.m., the heel looked completely dark brown/black in color. The heels appeared to have some tunneling and dark burgundy tissue could be seen on the parameters of the heel. In an interview on 11/10/25 at 11:36 a.m., NP stated that when she began to visit CR#1, she was alert, oriented, and could answer questions but due to her diagnoses, she was weak and deconditioned. CR#1 had complaints of pain and when she examined her right heel upon admission it was not open. Due to her recent cancer diagnosis, NP stated that she was placed on two oncology medications. After she began taking them. She eventually could not get out of bed or sit in the dining room like she used to. The WCN told her it was a blister developed on her right heel and the WCN probably thought it was a blister because it burst. She explained she did not stage wounds and left that up to the experts and wound care, but she did monitor her wound and prescribed antibiotics and labs so that she would help treat it systemically. NP stated that she did not see the wound every visit and was only able to see the wound if she caught WCN providing wound care. Otherwise, she would ask for an update from the WCN on its progress. She encouraged interviewing CR#1 because she felt she would be able to accurately state what went on. In an interview on 11/10/25 at 1:02 p.m., WCN stated that she had been working at the facility since 2015 and she was currently treating 10 residents with wounds. She explained that when a resident was admitted , she does a skin assessment and identifies any wounds or abrasions. This assessment was documented and if she had any skin issues, she would contact their doctor and inform the WCNP who came to the facility every Thursday. She stated that she first noticed CR#1's wound on 10/14/25 but prior to then, the foot only had a lot of calloused skin. She explained that on 10/14/25, she was on employee leave, but she received a phone call from the ADON letting her know that the blister had popped and she advised her how to treat it. WCN stated that when the blister popped, there was fluid inside. When she examined the blister the next day, the blister measured 4.5x7.5 and the opened part measured 2.5x3.5 with no drainage or odor. NP ordered a doppler to check for any arterial blockages. She explained that she diagnosed it as a blister initially and then it eschared over on 10/20/25. When asked if she consulted with the WCNP when the heel burst open, WCN stated that she consulted with the WCNP to see CR#1 on Thursday that week but she was not seen by the WCNP. She explained that she thought she might have had an oncology appointment that Thursday and it conflicted with his schedule. She also stated that NP would still see her often and she believed she would view the wound on every visit. Until then, skin prep was done around the outer area of the wound and xeroform was used for the wound itself. On 10/27/25, WCN noticed an odor to the wound the NP order doxycycline antibiotics to help treat a possible infection and she was seen by the WCNP that week on 10/30/25. Although she had orders to provide wound care every other day, she stated that she would check on the wound daily and make sure preventative measures like the boots were in place. On 11/3/25, WCN noticed the odor had returned and the NP stated that she wanted CR#1 to be sent out for evaluation. WCN stated the wound did not look any different from the last time she saw it, where it was still covered with eschar but it had a smell. She was aware of an appointment for CR#1 the following day (11/4/25) and was not sure why she was not sent out the day the NP requested further evaluation. Record review of CR#1's progress notes showed that on Thursday 10/16/25, no doctor's appointment was documented. Record review of CR#1's progress note documented on 11/3/25 by NP stated: Discussed wound care progress with the wound care nurse. The left foot wound has developed an odor, prompting the addition of a vascular surgery consultation for evaluation and management of the right lower extremity wound. Laboratory studies today reveal significant hyperglycemia with glucose readings ranging from 140-278 mg/dL throughout the day. Additional lab abnormalities include hemoglobin of 8.5 g/dL, elevated BUN of 29 mg/dL, creatinine of 1.49 mg/dL, and decreased eGFR of 36. In an interview on 11/10/25 at 2:01 p.m., ADON stated that she had worked at the facility since June 2024 and she had begun to cover some of the DON responsibilities since his termination on 10/12/25. She stated that when there is a new wound, the WCN should assess it and put orders in. She should then reach out to their PCP or NP and get their orders and then let the WCNP know so that when they round on Thursdays, he can make his own assessment and give treatment recommendations. In a follow up interview with the NP on 11/10/25 at 3:05 p.m., she explained that CR#1 had many things going on and because she had an odor to the right heel, she wanted her to see a specialist. She explained that it was better for her to see a specialist than go to the ER because they would provide a different type of care. Due to CR#1 being very deconditioned and having several comorbidities, care staff would have to take it easy with her. In an interview on 11/12/25 at 8:24 a.m., CR#1's family member stated that she was very upset because she had just gotten news from the hospital that CR#1 would have to her right leg amputated due to an infection of her right heel. She stated the doctors initially told her that the amputation would occur below the knee, but now the amputation would occur above the knee. In an interview on 11/13/25 at 10:20 a.m., the WCNP stated that he visited the facility every Thursday and was given a list of each patient to review. He first saw CR#1 on 10/23/25 and again on 10/30/25. During his initial visit, the treatment order for the wounds iodozone and iodine paste and it was appropriate for the wound at that time. The pressure wound was a Stage 2, superficial, with scant to moderate drainage, and the frequency of treatment was 3xs a week because it was superficial. ABD and a floater. wrap with kerlix gauze, heel was off loaded, and a PRN order was in place. On the visit of 10/30/25, she was on doxycycline from the facility. The measurements were 4x5x0.1, with no tunneling or undermining. WCNP explained that he switched treatments from xeroform to Betadine because he noticed the wound had become dark and became eschar, and once the eschar comes off, the wound would be unstageable. He could not say that the wound had gotten worse in between visits but he used the betadine because he wanted to stable the wound. He felt that with her diagnoses, she was not a good candidate for debridement. If she had a blister, the facility should have let it pop naturally, and he would only see her once the wound had been opened. If he suspected there was an infection, he would have escalated it immediately. In an interview on 11/13/25 at 1:28 p.m., the PT stated for the first 10 days of October, he only worked with CR#1. She had a lot of aches and pains but she was doing well with her walking and mobility. He recalled that she often complained of pain in her thigh but never recalled her mentioning her heel. Whenever he would come and get her for therapy, she was always dressed and wearing her shoes. After staff found out about the wound on her heel, she no was no longer able to participate in physical therapy because she could not bear weight on that heel to transfer. He stated that when he saw her heels, they appeared very soft and boggy and it was probably happening the whole time but it went undetected. In a follow-up interview on 11/13/25 at 3:00 p.m., the WCN was asked questions based off her weekly skin assessments ordered to be completed every Monday on CR#1's TAR. She explained that when there was a new resident, she would normally see them on day they were admitted or on the following day. No note was present in the progress notes and WCN stated she could not explain why she did not document a progress note. Review of the progress notes showed that her first note on CR#1 was on 9/22/25 and she stated that she could not explain why it had been 6 days post admittance that she documented assessing CR#1. In the middle of this interview, WCN stepped out to get her timecard from human resources and she confirmed that she was not absent on any of those days. During tan interview on 11/14/25 at 3:00 p.m., the WCN explained that she was off the day CR #1's blister opened but review of the TAR showed that on 10/13/25, she documented that nothing was there. Review of the progress notes showed that WCN documented a late entry on 10/15/25 to explain the wound condition for 10/14/25. When asked if she was off on 10/14/25, how could she document a note on regarding the observation and treatment of the wound? WCN stated that she tried to convey to the reader that the wound occurred on 10/14/25. When asked why there wasn't a progress note from the ADON regarding her observation and treatment of the wound since she was the one who provided care when informed that it had burst, she could not speak to it, but she stated when she returned to work on 10/15/25 CR#1 was the first person she saw. WCN expressed that she did not initially check CR#1's clinical records prior to providing care and she did not know until her heel burst on 10/14/25 that her admittance hospital records had documented the presence of a wound to the right heel on 9/15/25 (admission date 9/18/25). She felt that 3 days was not enough time for a wound to heel and suspected that upon admission, perhaps the wound had healed on the outside but not on the inside. When asked if she did an SBAR for the heel's change in condition, she stated that she did not complete SBAR assessments and documented in the progress notes instead. On 09/24/25, WCN described the wound as a blister that was greyish white with a hole in the center and on 10/15/25, she documented the blister to be bruised with dark brown discoloration surrounded by maroon tissue. She said she had nothing but scar tissue on the balls of her feet and she had no idea where the blister came from. WCN stated that upon admittance, all she saw were calluses on her foot and no wounds. She stated that she felt like it was a blister because it had fluid in it when it burst. She felt that the wound was stable while she was at the facility and not out of her scope. She could not say why she documented the presence of a skin issue incorrectly on her weekly skin assessments and said it was a mistake. In a follow up interview on 11/13/25 at 4:39 p.m., the ADON stated that while CR#1 was in therapy, her heel had burst and someone from therapy had asked her to come and look at her foot. When she saw her heel, the fluid had already burst and no blood was present. She described the right heel to have a clear top layer of skin that was pulled back and there was no drainage. She called the WCN, and she was told to clean with normal saline, pat dry, and wrap with kerlix. She did not see anything on the bottom of her feet but noticed the skin issue on the back of her right achilleas. She stated that she did not document this in the progress notes or complete an assessment for it because she completely forgot. She was supposed to do an SBAR assessment, and a progress note but it was not documented. Review of hospital records, admittance date 11/4/25, progress note dated 11/12/25 stated CR#1 was admitted due to a necrotic right heel pressure ulcer and podiatry was consulted and pending the decision from family and CR#1 regarding possible amputation. In an interview on 11/18/25 at 8:22 a.m., CR#1's family member, she stated that CR#1 received surgery to amputate her right leg above the knee on 11/17/25. The surgery had gone well, but her family and CR#1 were exhausted and resting at that time. Record review of the facility's Skin Assessment Policy implemented on 10/01/25 stated that it was policy to perform a full body skin assessment as part of the systematic approach to pressure Injury prevention and management. A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, and weekly thereafter. Procedures stated to:1. Remove any special garments or devices, if not contraindicated or ordered to remain in place.2. Remove any dressings, using clean technique, unless contraindicated or ordered to remain in place, and note findings. 3. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. Documentation of a skin assessment consisted of:4. Include the date and time of the assessment, your name, position, and title.5. Document observations (skin conditions, how the resident tolerated the procedure, etc.)6. Document type of wound.7. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain).8. Document if resident refused assessment and why. 9. Document other information as indicated appropriate. Considerations for patients with darkly pigmented skin indicators were:10. Bogginess11. Skin discolorationThe ADM, Regional VP, and Regional Nurse were notified on 11/14/25 at 3:31 p.m., that an IJ had been identified and an IJ template was provided. The following POR was approved on 11/14/25 at 5:31 p.m.: Immediate JeopardyPlan of Removal11/14/2025F686 Pressure Ulcers CR#1 was admitted to the hospital on [DATE] with a necrotic pressure ulcer to the right heel and the need for possible amputation of lower right extremity. The facility failed to properly identify the pressure ulcer and provide immediate oversight by a wound care specialist when the wound was first identified as a Stage 2 Pressure Ulcer on 10/15/25. Immediate action:Please accept this as a Plan of Removal to remove the IJ Identified F686 Pressure Ulcers initiated on 11/14/2025.The facility took the following immediate actions to ensure there are no residents in jeopardy or threat of harm: Skin sweep of all residents to assess for any worsening or unidentified pressure ulcers to identify and provide treatment to all pressure ulcers. The skin sweep was completed by RDCS, DON, DON #2, UNIT MANAGER, and Treatment Nurse on 11/14/2025 with no new findings or negative outcomes. Conducted Emergency QAPI meeting on 11/14/2025 regarding pressure ulcers including notification to the medical director. On 11/14/2025 RDCS/DON/Designee audited new admissions and readmissions for last 14 days to ensure any pressure injuries were identified appropriately, prevention measures in place, and treatment orders, as applicable. Completed in-services regarding pressure ulcers for all licensed nursing staff including head to toe skin assessments, newly identified wounds will be assessed and document with notifications to RP and medical provider, skin assessment will be completed by charge nurse treatment nurse for any new admission or readmission, and treatment orders will be obtained as applicable. This includes implementing quick interventions to prevent further breakdown of identified pressure ulcers by providing air mattresses for residents as applicable. In-services were completed on 11/14/2025 by RDCS, DON, ADON, and UM. Each Licensed Nurse will complete a post-test after their education was completed to ensure staff comprehend in-services. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. DON/Designee will utilize a staff roster to ensure 100% compliance with education. Licensed nurses will not be allowed to work until in-services completed by DON/Designee.Systematic Approach: Resident #1 was discharged on 11/4/2025. The facility plans to ensure quality of care for residents including: Head to toe skin assessments of all residents were completed on 11/14/2025 by the Director of Nursing (DON), Treatment Nurse, Assistant Director of Nursing (ADON), and Regional Compliance Nurse. No worsening or unidentified pressure ulcers were noted on any residents. All newly admitted residents will have a head-to-toe skin assessment completed by the licensed nurse or treatment nurse and verified by the DON/Designee to ensure all pressure ulcers are identified upon admission and readmission and ensure appropriate treatment. The nursing staff was in-serviced on 11/14/2025 by the RDCS, DON, ADON, UM and Treatment Nurse on these protocols. Completed in-services on 11/14/2025 regarding pressure ulcers for all licensed nursing staff including how to complete head to toe skin assessments, newly identified wounds will be assessed and document with notifications to RP and medical provider, skin assessment will be completed by charge nurse treatment nurse for any new admission or readmission, and treatment orders will be obtained as applicable. This includes implementing quick interventions to prevent further breakdown of identified pressure ulcers by providing air mattresses for residents as applicable Clinical staff will not be allowed to work their scheduled shift until they have completed all education related to the IJ. The Treatment Nurse or Nurse Manager designee will complete a head-to-toe assessment and document in the EMR to validate the findings of the initial skin assessment. Head-to-toe assessments must be completed weekly. The Treatment Nurse and Nurse Managers were in-serviced by the RDCS/DON on 11/14/2025 regarding these protocols. Any newly identified wounds will be addressed by the Treatment Nurse or Licensed Nurses to include assessment and documentation of the skin site and initiate appropriate clinical interventions. Notify the Patient's Representative and Medical Provider of any new or change in the existing wound(s) and document in EMR. The Treatment Nurse and Licensed Nurses were in-serviced on 11/14/2025 by the RDCS/DON on these protocols. A Wound Assessment will be completed by the Treatment Nurse or Licensed Charge Nurse and a narrative of each site will be documented weekly for any pressure injury. The Treatment Nurse and Licensed Nurses were in-serviced on 11/14/2025 by the DON on these protocols. RDCS/DON completed an audit of all findings to ensure implementation of skin system on 11/14/2025. The Medical Director was notified of the Immediate Jeopardy on 11/14/2025 by Executive Director. The facility conducted an emergency QAPI meeting on 11/14/2025 The Treatment Nurse received 1:1 education and counseling regarding identification of pressure ulcers including worsening of wounds and obtaining orders from the physician for appropriate treatments. This education was completed by the RDCS and DON on 11/14/2025 The treatment nurse will present a clinical wound report every day during the Clinical Stand-Up Meeting beginning 11/14/2025. The Treatment Nurse was in-serviced on 11/14/2025 by the RDCS and DON on this protocol.Monitoring: DON/Designee will monitor new admissions during daily clinical IDT Stand Up meeting to ensure skin assessments has been completed upon admission and interventions and treatment orders are in place, as applicable. RN Weekend Supervisor will monitor new admissions on the weekend to ensure skin assessments has been completed upon admission and interventions and treatment orders are in place, as applicable.Policy and Procedures: Facility policies & procedures were reviewed by the DON, RDCS, VP of Operations, VP of Clinical Services and Director of Education on 11/14/2025. The following policies and procedures were reviewed and determined to be compliant with meeting the needs of residents. The policies and procedures were included in the staff in-servicing. Patient Care Management System #1 Skin Guidelines.Monitoring Day 1:Reviewed the QAPI and reflected that a facility wide skin sweep was completed on 11/13/25. QAPI and revisit the list for all staff in attendance. Reviewed all CNAs was in serviced on skin patient care management. Utilized the skin assessment policy for the in-service learning materials. WCN was in-serviced on 11/14/25 on skin patient care management. RN's and LVN's were also in serviced. Also had post skin assessment test completed by all RN's. Record review of all residents had skin sweeps on head-to-toe skin assessments completed on 11/14/25. Reviewed the residents with pressure ulcers or skin issues list with charting. Charting showed resident name, admission date, if a skin assessment was completed upon admittance, if there was a pressure ulcer on admission, if there was a tx order in place, and listed out what the preventative measures that have implemented. Staff Interviews: 11/15/2510:20 am- Interview with ADON. She stated that all facility staff had been in-service on Pressure Ulcers. Record review of the accepted POR, no concerns. 10

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 (CR#1) of 3 residents reviewed for accuracy of assessments. The WCN failed to accurately document the presence of an existing wound on CR#1's weekly skin assessment after a new skin issue occurred on 10/15/25. CR#1's initial MDS Assessment failed to document the presence of a skin issue. These failures could place residents at risk for delayed treatment, worsening of condition, and hospitalization Findings include:Record review of CR #1's facesheet revealed a seventy-six-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses was a pulmonary embolism without acute pulmonale (blood clot in the lung), secondary malignant neoplasm of bone (cancer that has spread throughout the body), hyperlipidemia, difficulty walking, and the presence of a pacemaker. Record review of CR#1's admitting hospital records dated 09/15/25 documented that CR#1 had Type 2 Diabetes, a pressure injury to the right heel that was present upon admission, and a right arthroplasty of the and hip (hip replacement) on 8/18/25. Record review of CR #1's care plan initiated 09/18/25 documented pain management and interventions stated that if pain was present, LVN should assess and document the pain assessment including location, nature, intensity, and duration of pain. Pressure ulcer interventions included floating heels as tolerated and using a pressure redistribution mattress. Record review of CR#1's MDS dated [DATE] revealed a BIMS score of 11 (moderate cognitive impairment). Section GG titled Functional Abilities upon admission noted that CR#1 was dependent to sit to stand, transfer from chair to bed, toilet transfer, and walking 10, 50, and 150 feet. Section M titled Skin conditions documented that CR#1 was at risk at developing a pressure ulcer based off a formal and clinical assessment. In the subsection unhealed pressure ulcers/injuries, it was documented that CR#1 had no present skin conditions. Record review of CR#1's admission assessment completed by RN A documented that no wound was present upon admission. She was marked as bed bound due to prior hip replacement surgery. Record review of CR#1's weekly head to toe assessment located on the TAR for September 2025 reflected on the following:* 09/22/25, WCN marked E that identified an existing wound alteration. *09/29/25, WCN marked 0, which was not listed as an abbreviation on the assessment key. Review of the weekly skin assessments for October 2025 documented the following:*10/6/25, WCN marked 0*10/13/25, WCN marked 0*10/21/25, WCN marked E*10/27/25, WCN marked 0 Record review of CR#1's active orders as of 9/18/25 were as follows:*09/22/15: ordered weekly head to toe assessments every Monday where N=new, E= existing skin altercation, and C= clear. *10/16/25: Wound Treatment - Xeroform every day shift every other day for open blister. Cleanse open blister right heel with saline, pat dry, apply skin prep to skin of surrounding area, apply xeroform to bruised open wound, cover with ABD. Secure with kerlix wrap. Elevate and off load. Monitor for discomfort. This order was discharged on 10/22/25. *10/17/25: Doxycycline ordered.*10/23/25: Wound Treatment - Dry Dressing every day shift every other day for wound healing. Cleanse right heel eschar wound with saline, pat dry, apply iodosorb gel to wound bed then cover with ABD, secure with kerlix wrap as directed and PRN. *10/31/25: Wound Treatment - Dry Dressing everyday shift for Wound healing. Cleanse right heel eschar with betadine, then apply moist to dry betadine gauze followed by ABD, Secure w/ kerlix wrap qd. Record review of CR#1's progress notes documented by WCN on 09/24/25 stated that her skin was assessed with no open areas and the heels were clear. Record review of CR#1's progress notes documented by the NP on 10/2/25, the NP identified calluses during examination (location unspecified) and CR#1 was started on Tylenol after complaints of pain during her PT sessions. Record review of CR#1's progress notes documented on 10/7/25, the NP documented complaints of worsening foot pain contributed to bilateral lower extremity edema with marked swelling and multiple large, thick calluses present on both feet, particularly prominent on pressure-bearing areas. The calluses appeared dry, hyperkeratotic, and well-established, causing discomfort and contributing to her pain. Skin was noted as noticeably discolored and had chronic venous changes consistent with chronic venous insufficiency. Record review of CR#1's progress notes documented on 10/9/25 by the NP indicated the chronic venous skin changes was consistent with pressure related changes, with difficulty lifting lower right extremity. Record review of CR#1's progress notes documented on 10/15/25, the NP identified the wound on the right heel as a Stage 2 pressure ulcer with drainage and partial thickness skin loss involving the epidermal. Wound management initiated. Record review of CR#1's progress notes documented by the WCN on 10/15/25, that on 10/14/25, a skin issue identified as a blister had appeared on CR#1's right heel after it burst during PT. CR#1 stated that she tried telling PT on 10/13/25 but they could not hear her and in PT again on 10/14/25, she felt pain and stated that her heel started bleeding and draining because the blister popped. WCN assessed the skin issue on 10/15/25 and the area measured 4.5x7.5. The open area measured 2.5x3.5 and was bruised with dark brown discoloration surrounded by maroon tissue with no drainage. NP notified and doppler ordered. Skin was prepped, xeroform applied to bruised area, followed by ABD, and wrapped with kerlix. Prevalon boot in place and monitored for pain and discomfort. NP was notified of doppler results. Record review of CR#1's progress notes documented on 10/22/25 by WCN identified a new skin issue on the right heel. The issue type was a blister and progress had stalled, where previously improving wound characteristics plateaued. Wound acquired in-house. Signs and symptoms of infection: Non-healing. Painful: No. Staged by: Health care provider. Length (cm): 3.5 Width (cm): 3.5 Depth (cm): 0 Undermining: No. Tunneling: No. Epithelial: 10%. Eschar: 90. Exudate amount: None. Periwound temperature: Normal. Cleansing solution: Povidone iodine. Other primary dressing was iodosorb gel, ABD, Kerlix wrap, and utilized prevalon boots. Record review of CR#1's progress notes documented on 10/29/25 by WCN identified a new skin issue on the right heel. The issue type was a blister and progress had stalled, were previously improving wound characteristics plateaued. Wound acquired in-house. Signs and symptoms of infection: Smell increased. Signs and symptoms of infection: Size has increased. Signs and symptoms of infection: Non-healing. Painful: No. Staged by: Health care provider. Length (cm): 4.5 Width (cm): 4.5 Depth (cm): 0 Area (cm2): 0 Undermining: No. Tunneling: No. Granulation: 20%. Eschar: 80%. Exudate amount: None. Periwound temperature: Normal. Cleansing solution: Povidone iodine. Other primary dressing was ABD, Kerlix wrap, and utilized prevalon boots. In a telephone interview with CR #1 and CR#1's family member on 11/8/25 at 12:57 p.m., CR#1 stated she had complained about pain to her foot for 3 weeks before it began to bleed during physical therapy. CR#1 stated that she complained of pain to the nurses, the NP, and the PT. She stated upon admission, her mattress looked like it had a sunken hole in it and was very uncomfortable and the facility told her it could not be replaced. CR#1 and her family member denied the presence of a wound upon admission and CR#1's family member stated that when CR#1 went to her orthopedic appointment on 11/4/25 at 3p.m., she requested the Orthopedic doctor to examine CR#1's foot. CR#1's family member explained that when the doctor saw her foot, he was shocked and immediately advised that she be admitted to the hospital for further evaluation. Both stated that they had not seen the wound in some time and were shocked that it had gone from the size of a quarter to the whole heel, with black and blue tissue. When asked about wound care at the facility, CR#1 stated that she was not getting wound care every day and someone only unwrapped her foot for wound care once a week. In an observation and interview on 11/10/25 at 9:36 a.m. while visiting CR#1 in the hospital, she stated that she was not feeling too well, and her stomach was hurting. She explained that she was currently waiting on the hospital to give her an MRI. She said at the facility, a woman would come in once a week to put what she perceived was Vaseline on it. She did remember seeing a NP and she stated that she could not recall how often she would see the WCN, but she knew it was not every day for sure and stated, I know they were not coming as often as they have been coming at the hospital to do wound care. When she was at the facility, she constantly told them her foot was killing her, but nobody listened and the gave her pills to help with the pain, but they put her to sleep. She also recalled seeing the WCNP at some point as well. In an interview on 11/10/25 at 9:49 a.m. with HRN in the hospital, she stated that they were currently awaiting approval for CR#1 to receive an MRI because she had a pacemaker and the cardiologist had to sign off on it. The MRI would determine if the wound was infected or not and whether her foot could be saved by antibiotics or she needed amputation. Currently, she explained the wound was unstageable because of all the slough on it. She said that it looked pretty bad, and they were providing wound care on it once a day so that a lot of air would not get into it. HRN also provided a picture of the foot that was taken on 11/4/25 when CR#1 was admitted . Observation on 11/10/25 at 9:51 a.m. of the hospital admission photograph of CR#1's right heel dated for 11/4/25 at 5:27 p.m., the heel looked completely dark brown/black in color. The heels appeared to have some tunneling and dark burgundy tissue could be seen on the parameters of the heel. In an interview on 11/10/25 at 11:36 a.m., NP stated that when she began to visit CR#1, she was alert, oriented, and could answer questions but due to her diagnoses, she was weak and deconditioned. CR#1 had complaints of pain and when she examined her right heel upon admission it was not open. Due to her recent cancer diagnosis, NP stated that she was placed on two oncology medications. After she began taking them. She eventually could not get out of bed or sit in the dining room like she used to. The WCN told her it was a blister developed on her right heel and the WCN probably thought it was a blister because it burst. She explained she did not stage wounds and left that up to the experts and wound care, but she did monitor her wound and prescribed antibiotics and labs so that she would help treat it systemically. NP stated that she did not see the wound every visit and was only able to see the wound if she caught WCN providing wound care. Otherwise she would ask for an update from the WCN on it's progress. She encouraged interviewing CR#1 because she felt she would be able to accurately state what went on. In an interview on 11/10/25 at 1:02 p.m., WCN stated that she had been working at the facility since 2015 and she was currently treating 10 residents with wounds. She explained that when a resident was admitted , she does a skin assessment and identifies any wounds or abrasions. This assessment was documented and if she had any skin issues, she would contact their doctor and inform the WCNP who came to the facility every Thursday. She stated that she first noticed CR#1's wound on 10/14/25 but prior to then, the foot only had a lot of calloused skin. She explained that on 10/14/25, she was on employee leave, but she received a phone call from the ADON letting her know that the blister had popped and she advised her how to treat it. WCN stated that when the blister popped, there was fluid inside. When she examined the blister the next day, the blister measured 4.5x7.5 and the opened part measured 2.5x3.5 with no drainage or odor. NP ordered a doppler to check for any arterial blockages. She explained that she diagnosed it as a blister initially and then it eschared over on 10/20/25. When asked if she consulted with the WCNP when the heel burst open, WCN stated that she consulted with the WCNP to see CR#1 on Thursday that week but she was not seen by the WCNP. She explained that she thought she might have had an oncology appointment that Thursday and it conflicted with his schedule. She also stated that NP would still see her often and she believed she would view the wound on every visit. Until then, skin prep was done around the outer area of the wound and xeroform was used for the wound itself. On 10/27/25, WCN noticed an odor to the wound the NP order doxycycline antibiotics to help treat a possible infection and she was seen by the WCNP that week on 10/30/25. Although she had orders to provide wound care every other day, she stated that she would check on the wound daily and make sure preventative measures like the boots were in place. On 11/3/25, WCN noticed the odor had returned and the NP stated that she wanted CR#1 to be sent out for evaluation. WCN stated the wound did not look any different from the last time she saw it, where it was still covered with eschar but it had a smell. She was aware of an appointment for CR#1 the following day (11/4/25) and was not sure why she was not sent out the day the NP requested further evaluation. Record review of CR#1's progress notes showed that on Thursday 10/16/25, no doctor's appointment was documented. Record review of CR#1's progress note documented on 11/3/25 by NP stated: Discussed wound care progress with the wound care nurse. The left foot wound has developed an odor, prompting the addition of a vascular surgery consultation for evaluation and management of the right lower extremity wound. Laboratory studies today reveal significant hyperglycemia with glucose readings ranging from 140-278 mg/dL throughout the day. Additional lab abnormalities include hemoglobin of 8.5 g/dL, elevated BUN of 29 mg/dL, creatinine of 1.49 mg/dL, and decreased eGFR of 36. In a follow up interview with the NP on 11/10/25 at 3:05 p.m., she explained that CR#1 had many things going on and because she had an odor to the right heel, she wanted her to see a specialist. She explained that it was better for her to see a specialist than go to the ER because they would provide a different type of care. Due to CR#1 being very deconditioned and having several comorbidities, care staff would have to take it easy with her. In an interview on 11/13/25 at 10:20 a.m., the WCNP stated that he visited the facility every Thursday and was given a list of each patient to review. He first saw CR#1 on 10/23/25 and again on 10/30/25. During his initial visit, the treatment order for the wounds iodozone and iodine paste and it was appropriate for the wound at that time. The pressure wound was a Stage 2, superficial, with scant to moderate drainage, and the frequency of treatment was 3xs a week because it was superficial. ABD and a floater. wrap with kerlix gauze, heel was off loaded, and a PRN order was in place. On the visit of 10/30/25, she was on doxycycline from the facility. The measurements were 4x5x0.1, with no tunneling or undermining. WCNP explained that he switched treatments from xeroform to Betadine because he noticed the wound had become dark and became eschar, and once the eschar comes off, the wound would be unstageable. He could not say that the wound had gotten worse in between visits but he used the betadine because he wanted to stable the wound. He felt that with her diagnoses, she was not a good candidate for debridement. If she had a blister, the facility should have let it pop naturally, and he would only see her once the wound had been opened. If he suspected there was an infection, he would have escalated it immediately. In a follow-up interview on 11/13/25 at 3:00 p.m., the WCN was asked questions based off her weekly skin assessments ordered to be completed every Monday on CR#1's TAR. She explained that when there was a new resident, she would normally see them on day they were admitted or on the following day. No note was present in the progress notes and WCN stated she could not explain why she did not document a progress note. Review of the progress notes showed that her first note on CR#1 was on 9/22/25 and she stated that she could not explain why it had been 6 days post admittance that she documented assessing CR#1. In the middle of this interview, WCN stepped out to get her timecard from human resources and she confirmed that she was not absent on any of those days. Interview and record review on 11/13/25 at 3:33 p.m. of the skin assessment on 9/22/25, WCN marked E that identified an existing wound alteration, but on 9/29/25 she documented 0, which she identified to mean the skin was clear because it was not listed on the assessment's key. On 10/14/25, she explained that she was off the blister opened but review of the TAR showed that on 10/13/25, she documented that nothing was there. Review of the progress notes showed that WCN documented a late entry on 10/15/25 to explain the wound condition for 10/14/25. When asked if you were off on 10/14/25, how could she document a note on regarding the observation and treatment of the wound? WCN stated that she tried to convey to the reader that the wound occurred on 10/14/25. When asked why there was not a progress note from the ADON regarding her observation and treatment of the wound since she was the one who provided care when informed that it had burst, she could not speak to it, but she stated when she returned to work on 10/15/25 CR#1 was the first person she saw. WCN expressed that she did not initially check CR#1's clinical records prior to providing care and she did not know until her heel burst on 10/14/25 that her admittance hospital records had documented the presence of a wound to the right heel on 9/15/25 (admission date 9/18/25). She felt that 3 days was not enough time for a wound to heal and suspected that upon admission, perhaps the wound had healed on the outside but not on the inside. When asked if she did an SBAR for the heel's change in condition, she stated that she did not complete SBAR assessments and documented in the progress notes instead. On 09/24/25, WCN described the wound as a blister that was greyish white with a hole in the center and on 10/15/25, she documented the blister to be bruised with dark brown discoloration surrounded by maroon tissue. She said she had nothing but scar tissue on the balls of her feet and she had no idea where the blister came from. WCN stated that upon admittance, all she saw were calluses on her foot and no wounds. She stated that she felt like it was a blister because it had fluid in it when it burst. She felt that the wound was stable while she was at the facility and not out of her scope. She could not say why she documented the presence of a skin issue incorrectly on her weekly skin assessments and said it was a mistake. Review of hospital records, admittance date 11/4/25, progress note dated 11/12/25 stated CR#1 was admitted due to a necrotic right heel pressure ulcer and podiatry was consulted and pending the decision from family and CR#1 regarding possible amputation. In an interview on 11/18/25 at 8:22 a.m., CR#1's family member, she stated that CR#1 received surgery to amputate her right leg above the knee on 11/17/25. The surgery had gone well, but her family and CR#1 were exhausted and resting at that time. Record review of the facility's Skin Assessment Policy implemented on 10/01/25 stated that it was policy to perform a full body skin assessment as part of the systematic approach to pressure Injury prevention and management. A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, and weekly thereafter. Procedures stated to:1. Remove any special garments or devices, if not contraindicated or ordered to remain in place.2. Remove any dressings, using clean technique, unless contraindicated or ordered to remain in place, and note findings. 3. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. Documentation of a skin assessment consisted of:1. Include the date and time of the assessment, your name, position, and title.2. Document observations (skin conditions, how the resident tolerated the procedure, etc.)3. Document type of wound.4. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain).5. Document if resident refused assessment and why. 6. Document other information as indicated appropriate. Considerations for patients with darkly pigmented skin indicators were:1. Bogginess2. Skin discoloration

Based on observation, interview, and record review, the facility must develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and include the minimum healthcare information necessary to properly care for residents for 3 (Residents #139,#140, and #143) of 5 residents reviewed for baseline care plans -Resident #139 had a tracheostomy and an enteral feeding tube that were not baseline care planned. -Residents 139, #140, and #143's baseline care plans did not designate the code status of the residents. The failures could place the residents at risk for not receiving the care and services needed and placed them at risk for deteriorating health. Findings included: Resident #139 Record review of the admission Record for Resident #139 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, tracheostomy status, and dysphagia (inability to swallow). His code status was reflected as Full Code. Record review of the Physician's Orders for Resident #139, dated 07/25/25, revealed the resident had an indwelling urinary catheter. The Orders reflected the resident was to have blood glucose monitoring four times daily. The Orders reflected the resident had an enteral feeding tube. Review of the electronic medical record for Resident #139 revealed there was an entry MDS assessment, but no admission MDS. Record review of the Care Plan initiated 07/18/25 revealed Resident #139 was on EBP because he had a tracheostomy. However, the Care Plan did not reflect any care instructions or precautions related to the tracheostomy. The Care Plan did not mention Resident #139 had an enteral feeding tube. The Care Plan did not mention the resident required blood glucose monitoring. The Care Plan did not reflect the code status of the resident. Observation on 07/22/25 at 8:05 a.m. revealed Resident #139 was lying in his bed in his room. He was awake and alert. He had a tracheostomy, a catheter, and an enteral feeding tube. Resident #140 Record review of the admission Record for Resident #140 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute kidney failure, type 2 diabetes mellitus, and hypertension (high blood pressure). His code status was reflected as Full Code. The baseline care plan dated 07/17/25 for Resident #140 read, in part, Resident request Code Status of [Specify]: Full Code/DNR. Date initiated 07/17/25. The baseline care plan did not reflect the resident's code status. The baseline care plan dated 07/17/25 for Resident #140 read, in part, The resident expresses (SPECIFY) desire for/little or no activity involvement r/t Date initiated 07/17/25. The baseline care plan did not specify the possible reason for the decreased desire to participate in activities. The baseline care plan dated 07/17/25 for Resident #140 read, in part, The resident has an ADL self-care performance deficit r/t Date initiated 07/17/25. The baseline care plan did not specify a possible reason for the deficit. The baseline care plan dated 07/17/25 for Resident #140 read, in part, The resident has altered cardiovascular status r/t Date initiated 07/17/25. The baseline care plan did not provide what contributed to the altered cardiovascular status. Resident #143 Record review of the admission Record for Resident #143 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, severe sepsis with septic shock, and pneumonia. His code status was reflected as Full Code. The baseline care plan dated 07/17/25 for Resident #143 read, in part, Resident request Code Status of [Specify]: Full Code/DNR. Date initiated 07/17/25. The baseline care plan did not reflect the resident's code status. The baseline care plan dated 07/17/25 for Resident #143 read, in part, The resident expresses (SPECIFY) desire for/little or no activity involvement r/t Date initiated 07/17/25 The baseline care plan did not specify the possible reason for the decreased desire to participate in activities. The baseline care plan dated 07/17/25 for Resident #143 read, in part, The resident has an ADL self-care performance deficit r/t Date initiated 07/17/25. The baseline care plan did not specify a possible reason for the deficit. The baseline care plan dated 07/17/25 for Resident #143 read, in part, The resident wishes to (SPECIFY return/be discharged ) to (SPECIFY home, another facility) Date initiated: 07/17/25 The baseline care plan did not specify where the resident wished to be discharged to. The baseline care plan dated 07/17/25 for Resident #143 read, in part, The resident has impaired cognitive function/dementia or impaired thought processes r/t Date initiated 07/17/25 The baseline care plan did not reveal the possible cause of the impaired thought processes. The baseline care plan dated 07/17/25 for Resident #143 read, in part, .The resident has a communication problem r/t Date initiated: 07/17/25 The baseline care plan did not provide a possible reason or description of the communication problem. The baseline care plan dated 07/17/25 for Resident #143 read, in part, The resident has an infection of the (SPECIFY) Date initiated 07/17/25 The baseline care plan did not specify where the infection was. In an interview on 07/24/25 at 12:12 p.m., the DON said MDS Coordinator A was responsible for care plans. He said he reviewed care plans, but had not had a chance to review the new admission (baseline) care plan. He said the care plans were used to document patient care and goals. It was used to address acute issues and how the facility would address them.At that time, the DON reviewed the baseline care plan for Resident #139. He confirmed there was no care plan for the enteral feeding tube. He reviewed the baseline care plan for the tracheostomy. The DON said Looks pretty short. Only Enhanced Barrier Precautions. He should have an area for the trach care plan. He said a possible outcome would be the resident would not receive proper care. He said It could be bad for their health and treatment goals. The DON reviewed he baseline care plans of Residents #140 and #143. He said he could not tell the code status of either resident from the baseline care plan. He said the baseline care plans should be personalized, and should have specific information. The facility policy Care Plans - Baseline (revised March 2022) read, in part, .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:. Initial goals based on admission orders and discussion with the resident/representative;1. Physician orders;2. Dietary orders;.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #9 and #47) of 21 residents reviewed for comprehensive care plans. The facility failed to ensure that Resident #47 has a comprehensive care plan that included all care areas triggered on her assessment. The facility failed to ensure that Resident #9 comprehensive care plan included her hospice service and oxygen. These failures could place residents at risk of not receiving proper care and service to develop and improve their mental, physical and psychosocial well-being. Findings Included Resident#47 Record review of Resident#47 admission face sheet dated 7/25/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included urinary tract infection(infection of the urinary tract), hypertension (high blood pressure), osteoporosis(a disease of the bone) , gastro esophageal reflux disease (heart burn), chronic obstructive pulmonary disease ( a lung disease that blocks air flow making it difficult to breath), chronic kidney disease (the inability to filter from the blood), atrial fibrillation (irregular/rapid heart rate that causes poor blood flow. , protein calorie malnutrition ( insufficient intake of both protein and calories), muscle weakness(decrease strength in the muscle) and lack of coordination (impaired balance due to damage nerves, brain of muscles). Record review of Resident #47's admission MDS dated [DATE] revealed she coded as having a BIMS score of 14 indicating she was cognitively aware, was occasionally incontinent of bladder and bowel and had a fall with fracture in the last 6 months. Further record review revealed Resident #47 was triggered for incontinence, pressure sore, nutrition, activities of daily living, falls and dehydration. Record review of the care plan initiated 6/18/2025 revealed it did not address falls dehydration and incontinent care. Further record review revealed the care plan was updated on 7/25/2025 to address dehydration and falls but did not address incontinent care. Observation on 7/22/2025 at 10:00am Resident #47 was observed in her room she was alert and oriented and good make her needs known. She was clean and without any offensive odor. Call light was observed to be reached. In an interview on 7/22/2025 at 10:00am, Resident #47 said they answer her call light. She said she had to ask for help because she did not want to fall again. She said she fell at home and that was why she was in the facility for rehabilitation. She said she rehab was working with her, and she was able to move around much better. In an interview on 7/25/2025 at 10:15 am with the MDS Coordinator she said all triggered areas should be captured on the care plan. She said if the area were not captured on the care plan, they would not have a full picture on how to take care of the residents and they would not know what resident's daily needs were. She said moving forward they going to ensure that all triggered area were captured on the care plan and completed by day 21. Resident #9Record review of Resident #9's face sheet dated July 25th, 2025, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included malignant neoplasm of the lungs(cancer that begins in the lungs), chronic obstructive pulmonary disease(lung disease that blocks air flow), hypertension(high blood pressure), acute metabolic acidosis (too much acid accumulates in the body), lack of coordination(impaired balance due to brain or muscle damage), chronic respiratory failure with hypoxia (lungs cannot adequately exchange oxygen and carbon dioxide leading to insufficient carbon dioxide and oxygen in the body), muscle weakness(decreased strength in the muscles)weak, lack coordination (impaired balance or coordination due to damage brain, nerves or muscle) hyperlipidemia (high levels of fat in the blood), acute kidney failure, metastatic breast cancer with brain tumor(where the cancer cells spread from the original cancer cell to the brain, and atrial fibrillation (irregular/rapid heartbeat causing poor blood flow). Record review of Resident #9's admission MDS dated [DATE] revealed the resident was coded as having a BIMS score of 5 indicating she was severely impaired for cognition, For ADL's the resident was code as dependent of staff for eating, oral hygiene, toileting, shower, upper body dressing, putting/on taking off footwear, and personal hygiene. For Special Care she was coded as being on hospice care. For incontinence she was coded as always incontinent of bowel and bladder. Record review of Resident #9's admission nurses notes dated 6/26/2025 revealed the resident was admitted on respite care with hospice. Her primary diagnosis was metastatic breast cancer with brain tumor. Record review of physician order dated 6/26/2025 revealed order for 02 via nasal canula at 2LPM. Record review of the Resident #9's care plan initiated 7/1/2025 revealed the care plan did not address hospice care and oxygen use for Resident #9. Further review of Resident #9's care plan revealed the care plan was updated to address hospice care and oxygen use on 7/25/25 after the surveyor's intervention. In an interview on 7/25/2025 at 10:15am MDS Coordinator B said she was aware the resident was on respite care by a hospice company when she was first admitted to the facility. She said Resident #9 was a private paid resident then place on hospice. She said, the initial care plan should have address hospice care. She said not updating the care plan to address the resident's status will prevent the resident from getting the care and services needed to improve their quality of life. She said moving forward she was going to ensure that care plan captures all triggered areas and completed by day 21. In an interview on 07/25/2025 2:50 pm, the DON said the expectation of the MDS Nurses were to ensure all care areas that were triggered on the MDS should be captured on the care plan. He said the IDT team should come together along with the family and work on the plan of care. He said he will be in servicing the nursing staff on MDS and care plan accuracy, and ensuring they were done in a timely manner. Record review of the Care Plans Comprehensive Person-Centered dated March 2022 read in part.Policy StatementA comprehensive, person-centered care plan that includes measurable objectives, timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation1. The Interdisciplinary Team in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident.2. The comprehensive person-centered care plan is developed within (7) days of the completion of the MDS assessment (admission, annual or significant change in status) and no more than 21 days after assessment.

Based on observation, interview and record review, the facility failed to ensure that foods are store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen in that:1.Foods were not sealed, labeled, and dated.2.Plates with dried food particles were stored with clean plates.3. Food items on the steam table was not maintained at 135 degrees F and above.4. Equipment were clean.5. Dry storage room free of dented cans. These failures could place residents who ate food prepared by the kitchen at risk for food borne disease and illness. Findings included: Observation of the kitchen on 07/22/2025 at 9:10 AM revealed the following:1.The coffee machine had an accumulation of brown stains on the coffee machine. At the time the DM immediately started to clean the coffee machine.2.Plates and bowls with stains and food particles in them were stock with clean plates and bowls. Observation on 7/22/2025 at 9:30 am revealed the deep fat fryer had very dark oil and burnt food particles in it. Observation on 7/22/2025 at 9:35 am of the dry storage room revealed the following:1. 1- 6lbs. dented can of beans.2. 1 single serving plastic container of cheerios was open not sealed. Observation on 7/22/2025 at 9:40 am of the walk-in-freezer revealed the following:1. 1 plastic bag with chicken tenders that was open not sealed.2. 1 plastic bag with mixed vegetables open not sealed3. 1 box with French toast open not sealed. 4. Instant vanilla pudding and chocolate pudding mix not dated. Observation on 7/23/2025 at 12:15pm of the steam table revealed two menu items not at the correct holding temperature:1. Baked fish at 76 degrees 2. Cream pie was at 42 degrees.The fish was reheated to 160 and above and the cream pie was chilled to 41 degrees and below. In an interview on 7/22/2025 at 9:20 AM the Dietary Manager said the coffee machine was clean daily. The Dietary Manager said when cleaning the dishes they should pre rinse ensuring that there was no food in the plates and bowls, and then put in the machine to wash rinse and sanitized. He said after the washing procedure they should check to ensure there were no food particles in the plates and bowls and then they would pack them away. In an interview with the DM on 7/22/2025 at 10:00am he said all food particles should clean from the plates, and they should wash rinse and sanitized allow to air dry and then check to ensure they were clean with no food particles before they were packed away. The DM he said the deep fat fryer was cleaned on Fridays and the coffee machine was cleaned daily. He said he had used the fryer cooked the previous day to cook and that was why the oil was black. Interview with the DM on 7/22/2025 at 10:45 am he said he was going to in-service the staff ensuring that when foods were open, they should be sealed, labeled and dated. In an interview on 7/23/2024 at 12:45 PM Dietary Staff A said food not served at the correct food temperature could get resident sick. He said he was going to ensure that food was always at the correct temperature during meal service. Record review of the policy on Food Temperatures dated May 2008 read in part.Policy:The Dietary Services Manager shall check food temperature routinely.Procedures.1. All hot and cold food items must be served to the resident at a palatable temperature. All hot food must be held at a minimum of 145 degrees Fahrenheit.2. All cold foods must hold at 40 degrees F or below.6. Temperatures should be taken periodically to ensure hot foods stay above 145 degrees F and cold foods stay below 40 degrees F during the tray line period. Record review of the policy on Food Storage dated read in part. Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Refrigeration:a. Temperatures for refrigerators should be between 40 degrees Fahrenheit or lower. Thermometers should be checked at least twice daily. (See Freezer and Refrigerator Temperature Form).b. Every refrigerator must be equipped with an internal thermometer. e. All foods should be covered, labeled and dated.f. All foods should be stored to allow air circulation.g. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel for three of five medication carts observed in common areas accessible to staff and residents. -Three unlocked and unattended medication carts were observed in areas accessible to residents, staff, and visitors. This failure could place residents at risk of ingesting medications not prescribed to them and placed the facility at risk for drug diversion. Findings included:Observation on 07/22/25 at 10:55 a.m. revealed an unlocked/unattended medication cart in front of room [ROOM NUMBER]. The cart was facing the door, which was closed. There was no staff visible from the cart. At 10:56 a.m. revealed MA A opened the door of room [ROOM NUMBER] and exited the room. MA A said the medication cart should have been locked. She said she thought she had locked it. MA A open the top drawer of the medication cart without using keys. Observation revealed the top drawer of the cart contained multiple plastic containers of various over the counter medications. Observation and interview on 07/22/25 at 11:33 a.m. revealed an unlocked/unattended medication cart in front of room [ROOM NUMBER]. The medication cart was facing the door, which was closed. There was no staff visible in the area. At 11:38 a.m. revealed the DON was walking in the hallway approaching the cart. At that time LVN G exited room [ROOM NUMBER]. She said she did not have a key to the medication cart, and that the keypad lock was inoperable. She said a MA had the key. She said this was the second room she went to where she had to leave the cart unlocked. The DON was present, and told LVN G that she could not leave the medication cart unlocked and unattended.Observation and interview on 07/23/25 at 11:20 a.m. revealed an unlocked and unattended medication cart in front of room [ROOM NUMBER]. The medication cart was facing the door, which was closed. At 11:21 a.m. LVN H walked up to the medication cart. She stated it was unlocked. She said I stopped what I was doing because another resident needed me. In an interview on 07/24/25 at 12:12 p.m. the DON said the medication carts should have been secured. He said a resident could get into the medications and ingest medications that were not meant for them. The facility policy Security of Medication Cart (revised April 2007) read, in part, The medication cart shall be secured during medication passes.Policy Interpretation and Implementation1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.1.4.Medication carts must be securely locked at all times when out of the nurse's view.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 of 4 residents (Resident #1, Resident #2, and Resident #3) and 4 of 5 staff (CNA B, CNA C, CNA L, CNA F) observed for infection control. 1-The facility failed to ensure CNA B followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #1 on 04/22/2025. 2-The facility failed to ensure CNA C followed appropriate infection control and hand hygiene procedure while assisting resident to the bathroom for Resident #2 on 04/22/2025. 3-The facility failed to ensure CNA L followed appropriate infection control and hand hygiene procedure during and after incontinent care for Resident #3 when she was seen leaving a resident's room with gloves on 04/24/2025. 4-The facility failed to ensure CNA F followed appropriate infection control when two plastic bags with soiled items were left opened and on the floor outside a resident's room observed on 04/24/2025. These failures could place the residents at risk for infection. Findings included: 1-Record review of Resident #1's face sheet dated 04/24/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #1 diagnosis included: metabolic encephalopathy (a condition where brain function is disrupted), hypertension (force of blood against the walls of the arteries is consistently too high), and cognitive communication deficit (someone has difficulty communicating because their thinking processes, like memory, attention, and reasoning) Record review of Resident #1's admission assessment dated [DATE] revealed on BIMS of 02 indicating severely impaired cognition. Further review revealed Resident #1 dependent on staff for ADL care with one to two staff assist. Record review of Resident #1's comprehensive care plan revealed Resident #1 had ADL self - care performance deficit related to dementia and impaired balance. Interventions: The resident requires assistance with 1 or x2 staff for toileting. This may fluctuate with weakness, fatigue, or weight bearing status. During an observation on 04/22/24 at 1:30 p.m., CNA B walked into Resident #1's room and donned (put on) gloves without sanitizing or washing her hands. CNA B provided incontinent care to Resident #1 with the same gloves throughout, pulled wipes from the container with the same dirty gloves she used to clean the resident, and did not change gloves when she went from dirty to clean. She used the same gloves, applied barrier cream, and applied a clean incontinent brief on Resident #1. CNA B removed her gloves and left Resident #1's room after she provided care and did not wash or sanitize her hands. 2-Record review of Resident #2's face sheet dated 04/25/25 revealed a [AGE] year-old female was initial admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 diagnosis included: Parkinson's disease (a progressive neurodegenerative disorder leading to movement related to tremors, slow movement, and rigidity), hypertension (force of blood against the walls of the arteries is consistently too high), and diabetes mellitus (a condition where the body has trouble regulating blood sugar levels) Record review of Resident #2's quarterly assessment dated [DATE] revealed on BIMS of 13 indicating intact cognition. Further review revealed Resident #2 needed moderate assistance with transfer with one staff assist. Record review of Resident #2's care plan dated 03/13/25 revealed Resident #2 had ADL self - care performance. Interventions: transfer: the resident requires 1 x2 staff assistance for transfers. During an observation on 04/22/25 at 3:16 p.m., CNA C did not wash her hands before she put on gloves when assisting Resident #2 in the restroom. She removed her gloves when she finished attending to Resident #2 in the restroom and left the resident's room without washing her hands. 3-Record review of Resident #3's face sheet dated 04/25/25 revealed a [AGE] year-old female was initial admitted to the facility on [DATE]. Resident #3 diagnosis included: urinary tract infection (an infection in any part of the urinary system), ovarian cyst (a fluid filled sac that developed on or inside an ovary), and diabetes mellitus (a condition where the body has trouble regulating blood sugar levels) Record review of Resident #3's admission assessment MDS dated [DATE] revealed on BIMS of 15 indicating intact cognition. Further review revealed Resident #3 incontinent of bowel and bladder and dependent on staff for ADL care with one to two staff assist. Record review of Resident #3's comprehensive care plan revealed Resident #3 had ADL self - care performance deficit related to activity intolerance and impaired balance. Interventions: The resident requires assistance with 1 or x2 staff for toileting. This may fluctuate with weakness, fatigue, or weight bearing status. During an observation on 04/24/25 at 4:06 a.m., CNA L did not wash or sanitize her, took gloves from her uniform pocket, and put on the gloves. CNA L used the same gloves she was wiping the bowel movement and pulled wipes from the wipe packet. When she ran out of wipes, she removed her gloves and left Resident #3's room without washing her hands. When CNA L returned, she did not wash her hands, took gloves from her uniform pocket again, and continued to clean Resident #3's bowel movement. She still pulled wipes from the container and her gloves, which had bowel movements. CNA L removed her gloves after providing incontinent care for Resident #3 and left the room without washing her hands. 4-Observation on 4/24/2025 at 4:00am, there were briefs in original bags and about 8 white bedsheets stacked on top of a wheelchair. There were also two untied plastic bags with used briefs and gloves inside them, with gloves partly outside the bag on the floor. A later observation on 4:43am, CNA L was observed walking out of a resident's rooms with gloves on. At the same time, a food tray cart with approximately nine trays were seen eaten with cutlery outside the Kitchen entrance. During an interview on 04/22/25 at 1:48 p.m., CNA B said she was supposed to wash or sanitize her hands before she donned (put on) gloves and wash her hands before going from dirty to clean and after providing incontinent care for Resident #1. CNA B said she did not wash her hands or change gloves while she provided incontinent care for Resident #1. CNA B said she used the same gloves she wiped the resident to take wipes from the packet and it could have contaminated the wipes in the packet because you do not go from dirty to clean. CNA B said she had a skill check off on infection control and was educated not to use dirty gloves to take wipes from the clean packet and to wash her hands before and after providing care for residents. She said the nurse monitors the aides throughout the shift. During an interview on 04/22/25 at 3:42 p.m., CNA C said she did not wash her hands before and after attending to Resident #2 in the restroom. CNA C said she should have washed her hands to prevent cross-contamination. CNA B said the nurse monitored the aide throughout the shift. CNA C said she was in serviced on infection control and was educated to wash or sanitize her hands before and after providing care for the resident. During an interview on 04/23/25 at 9:23 a.m., the DON said CNA C should wash her hands before she donned gloves and after doffing (took off) when she finished assisting residents in the bathroom. The DON said hand washing would prevent the spread of germs. The DON also said CNA B should have pulled enough wipes from the wipe container and should not go back into the wipe container because there was a risk of cross-contamination. The DON said CNA B should change gloves when going from dirty to clean while providing incontinent care for Resident #1 because of cross-contamination. He said the aides were provided skills check-off and had been in-serviced (an in-service is a training for staff typically as a periodic refresher on a topic related to their duties)on infection control and ADL care, which included incontinent care. The DON said the staff were educated according to the facility policy. During an interview on 04/24/25 at 4:59 a.m., LVN M said CNA L should wash her hands before and after providing incontinent Care for Resident #3. LVN M said CNA L should not have used the gloves from her uniform pockets or the same dirty gloves and pulled wipes from the wipe container because it was cross-contamination. LVN M said she had in service on hand washing and PPE (Personal Protective Equipment). LVN M said the nurses monitored the aides throughout the shift, and the nurse managers monitored the nurses during rounding. During an interview on 04/24/25 at 5:54 a.m., CNA L said she did not wash her hands, and she donned the gloves she took from her uniform pockets, and it was infection control (cross-contamination). She said she used the same gloves to wipe bowel movements and pull out the wipes from the wipe packets. CNA L said she left the room without washing or sanitizing her hands when she took off her gloves and left the room when she went to get another packet of wipes. CNA L said that when she came back, she did not wash or sanitize her hands, donned other gloves taken from her uniform pocket, and continued to provide incontinent care for Resident #3. She said she continued pulling wipes from the new packet with the same dirty gloves she used to wipe her bowel movements. CNA L stated that was an infection control issue (cross-contamination). She said she had an in-service on hand washing and PPE. She stated the nurses monitored the aides throughout the shift. She said she was educated to wash hands before and after taking care of a resident and to change gloves when going from dirty to clean. During an interview on 04/24/25 at 11:55 a.m., the ADON said CNA C should have washed her hands before and after providing care for Resident #2. She said the aides had in-service on infection control, including hand washing and PPE. The ADON said the nurses monitored the aides during rounds, and the nurse managers monitored nurses during random rounds. In a later interview on 4/24/2025 at 11:58am, she said staff should put supplies in a bag and have everything they need to provide resident care before entering a room. Staff should place dirty briefs and used supplies in a bag. Staff should use wash their hands before donning PPE. During incontinent care, staff should not be using used gloves to pull wipes from the container because that would be infection control. Female genitalia should be cleaned from front to back, and the labia should be cleaned front to back with staff spreading and wiping each side and throwing away the wipe in between sides. When incontinence care is completed, staff should tie the bag with soiled items, wash their hands before leaving the room to avoid infection control issues. If incontinence care is not provided as instructed, residents could develop smells or a UTI, develop skin breakdown, pressure ulcers. Residents could develop open areas if they were in a soiled diaper for extended periods of time. The ADON said staff were not supposed to use gloves from their pocket as that is an infection control issue. Staff were not supposed to come out of a resident's room with opened soiled bags and should not have left them sitting on the floor but be taken immediately to the dirty linen room. Confused residents could grab it or fall over it. Staff should be using trash bags to bring in clean items to resident rooms. If items were transported on the wheelchair without bags, that would be infection control. She said staff were in-serviced on infection control. Interview with CNA F on 4/24/2025 at 4:43am, who said she was using the wheelchair observed by the surveyor was not how items were usually transported down the hall, she usually used carts. CNA F said the bedsheets were clean. Interview with CNA L on 4/24/2025 at 4:43am, who said she wore her gloves outside the room because she was carrying a dirty bag and used the gloves to carry the bag to the soiled linen room and didn't want to touch it. She said she forgot about it and shouldn't have done it because it was an infection control issue. Interview with LVN O on 4/24/2025 at 4:43am, who said that any resident could come and eat the used trays that were left outside the kitchen, which was a potential for infection control. LVN O also said aides usually used wheelchairs to transport items, and that was clean linen on the wheelchair that CNA F was using. Interview with the Administrator on 4/24/2025 at 5:19am, he said clean linens should not be stored on the wheelchair without being transported in plastic bags, because that could cause an infection control issue. Gloves should not be in a staff's pocket and pulled out for use, as that would also be an infection control concern. Regarding CNA F leaving bags with soiled items on the floor after changing residents, the Administrator said items should have been taken to the dirty room. He also said food trays should be placed in the dining room and placed in the kitchen after dinner and he had them moved the left cart after it was observed by surveyors. He would do education on that, and a risk to residents would be someone could go eat the food that was left out, which was the reason why food was to be taken out of resident's rooms after they're done eating. Interview with the DON on 4/25/25 at 12:17 p.m., the DON said staff are not supposed to carry gloves in the uniform pocket and use the gloves on the resident because of cross-contamination. The DON said all staff should wash or sanitize their hands before and after providing care for the residents. The DON said CNA L should have pulled out enough wipes before she started to give incontinent care to Resident #3 to prevent cross-contamination. He said the aides were in service on infection control, which covered hand washing and PPE. He said the nurses monitored the aides throughout the shift, and the nurse managers monitored the nurses during random rounds. In a later interview with the DON on 4/25/2025 at 12:22pm, he said clean linen should be transported in bags on supply carts. If that, that could cause cross-contamination. Before leaving a room, staff should tie up bags with dirty items inside to prevent any escape of things in the bag into the atmosphere to avoid cross-contamination. Food trays should be in the kitchen after dinner. Residents with poor or impaired cognition could grab something, causing cross-contamination. Staff could get sick, and cutlery could cause injury to residents if used. Interview with the Unit Manager on 4/24/25 at 11:04am, female genitalia should be wiped from front to back. Staff should raise residents' legs up and open and clean the labia to make sure every part of the area was clean. If residents were not cleaned properly, they could develop UTIs. During incontinent care, staff should come in with a bag and all the items they needed so they do not have to leave the room. Staff should change gloves before getting new wipes, and if they did not that would mean they were not being sanitary and causing an infection control issues especially if the staff's gloves were soiled. Staff should not place bags containing soiled items on the floor but should take bags directly to the dirty linen room for disposal. Staff should not place linens on wheelchairs around the facility without placing them in plastic bags, and that was not how linen was supposed to be stored and could cause infection control issues to be passed on. Record review of the facility policy on Infection Control dated 2001 (Revised October 2018)) read in part . 1. The facility must establish an infection prevention and control program (IPCP) that must include . A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. This applies to all Patients, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment .Policy Interpretation and Implementation . Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge . 2. Personal protective equipment provided to our personnel includes but is not necessarily limited to: 2b. gloves (sterile, non-sterile, heavy- duty and/or puncture-resistant) . Record review of the facility policy on hand washing dated 2001 (Revised August 2019) read in part . policy statement . This facility considers hand hygiene the primary means to prevent the spread of infections . Policy interpretation and implementation . #2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . #8. Hand hygiene is the final step after removing and disposing of personal protective equipment . #9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . applying and removing gloves .#1. Perform hand hygiene before applying non-sterile gloves . #5. Perform hand hygiene .

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 3 of 4 residents (Resident #1 and Resident #2) reviewed for privacy in that: -The facility failed to ensure CNA B provided privacy during incontinent care for Resident #1. -The facility failed to ensure CNA C provided privacy during toilet use for Resident #2. -The facility failed to ensure CNA L provided privacy during incontinent care for Resident #3. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy. Findings included: RESIDENT #1 Record review of Resident #1's face sheet dated 04/24/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #1 diagnoses included: metabolic encephalopathy (a condition where brain function is disrupted), hypertension (force of blood against the walls of the arteries is consistently too high), and cognitive communication deficit (someone has difficulty communicating because their thinking processes, like memory, attention, and reasoning) Record review of Resident #1's admission assessment dated [DATE] revealed on BIMS of 02 indicating severely impaired cognition. Further review revealed Resident #1 dependent on staff for ADL care with one to two staff assist. Record review of Resident #1's undated care plan revealed Resident #1 had ADL self - care performance deficit related to dementia and impaired balance. Interventions: The resident requires assistance with 1 or x2 staff for toileting. This may fluctuate with weakness, fatigue, or weight bearing status. During an observation on 04/22/25 at 1:30 p.m., CNA B entered Resident #1's room without knocking on the resident's room door when she went to provide incontinent care and did not close the window blind while she provided incontinent care for Resident #1. RESIDENT #2 Record review of Resident #2's face sheet dated 04/25/25 revealed a [AGE] year-old female was initial admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 diagnoses included: Parkinson's disease (a progressive neurodegenerative disorder leading to movement related to tremors, slow movement, and rigidity), hypertension (force of blood against the walls of the arteries is consistently too high), and diabetes mellitus (a condition where the body has trouble regulating blood sugar levels). Record review of Resident #2's quarterly assessment dated [DATE] revealed on BIMS of 13 indicating intact cognition. Further review revealed Resident #2 needed moderate assistance with trans fer with one staff assist. Record review of Resident #2's care plan dated 03/13/25 revealed Resident #2 had ADL self - care performance. Interventions: transfer: the resident requires 1 x2 staff assistance for transfers. During an observation on 04/22/25 at 3:26 p.m., CNA C entered Resident #2 without knocking on the resident's room door before she entered the resident's room. CNA C left the restroom door open when she pulled down Resident #2's pant and incontinent brief and placed her on the toilet while the two visitors could see the resident exposed body. During an observation on 04/22/25 at 3:26 p.m., CNA C entered Resident #2's room without knocking on the resident's room door before she entered the resident's room. CNA C left the restroom door open when she pulled down Resident #2's pants and incontinent brief and placed her on the toilet while the two visitors could see the resident's exposed body. Resident #3 Record review of Resident #3's face sheet dated 04/25/25 revealed a [AGE] year-old female was admitted to the facility on [DATE]. Resident #3 diagnoses included: urinary tract infection (an infection in any part of the urinary system), ovarian cyst (a fluid filled sac that developed on or inside an ovary), and diabetes mellitus (a condition where the body has trouble regulating blood sugar levels). Record review of Resident #3's admission assessment MDS dated [DATE] revealed on BIMS of 15 indicating intact cognition. Further review revealed Resident #3 incontinent of bowel and bladder and dependent on staff for ADL care with one to two staff assist. Record review of Resident #3's undated care plan revealed Resident #3 had ADL self - care performance deficit related to activity intolerance and impaired balance. Interventions: The resident requires assistance with 1 or x2 staff for toileting. This may fluctuate with weakness, fatigue, or weight bearing status. During an observation on 04/24/25 at 4:06 a.m., while CNA L was providing incontinent care for Resident #3 and she ran out of wipes, she left Resident #3 uncovered from the waist down to her feet and left the room to get another wipe packet. During an interview on 04/22/25 at 1:57 p.m., CNA B said she did not knock on the door before she entered Resident #1, and it was a dignity issue because the resident's room was her home, and the resident could feel disrespected. CNA B also forgot to close the window blind while she provided incontinent care for Resident #1. CNA B said she had in-service on privacy, and dignity which included closing the door and the blind to protect resident dignity. CNA B said the nurse monitors the aides during rounds throughout the shift. During an interview on 04/22/25 at 3:42 p.m., CNA C said when she went to assist Resident #2 in using the toilet, she should have knocked on her room door before she entered because her room was her home. She also said it was a sign of respect. CNA C said she did not close the restroom door before she pulled Resident #2's pants and incontinent brief down and exposed her body while she had two visitors in the room who were able to see the resident's exposed body. CNA C said it was a dignity issue. CNA C said she had training on privacy and dignity and was educated to knock and announce herself before entering a resident room and provide complete privacy during any care. During an interview on 04/23/25 at 9:30 p.m., the DON said CNA B should have closed the door and the window blind to provide complete privacy. The DON said that since the window blind was not closed, anybody who walked past the window during the incontinent care could see the exposed body part of Resident#1. During an interview on 04/23/35 at 9:32 a.m., the DON said CNA B should have knocked on Resident #1's door before she entered Resident #1's room for privacy and dignity. He said the resident's room was the resident home. The DON said Resident #2 could become upset because CNA B violated her personal space. He said the nurse and staffing coordinator monitored the aides, the nurse managers monitored the nurses, and all the staff were trained before working on the floor according to the facility policy. During an interview on 04/23/25 at 9:38 a.m., the DON said CNA C should have knocked on the door before she entered Resident #2's room, and her bathroom door should have been closed to prevent the visitors in her room from seeing the resident exposed body because it was dignity issue. He said the nurses monitored the aides throughout the shift, and the nurse managers monitored the nurses during random rounding. The DON said the aides were trained according to the facility policy on privacy and dignity. During an interview on 04/24/25 at 4:56a.m., CNA L said she should have covered Resident #3 to provide privacy and dignity for the resident. CNA L said she had in service on privacy and was educated to cover the resident whenever a resident was left unattended. CNA L said the nurses monitored the aides throughout the shift. During an interview on 04/24/25 at 4:59 a.m., LVN M said CNA L should have covered Resident #3 before she left the resident, which would have provided privacy for Resident #3. LVN M said Resident #3 could feel bad or uncomfortable because she was exposed. LVN M said the nurses monitored the aides throughout the shift, and the nurse managers monitored the nurses during random rounds. Interview with the Administrator on 4/24/2025 at 5:19am, he said staff were supposed to knock and ask for a resident's permission to enter the room. Residents could feel a little annoyed if staff did not knock. Privacy is to be maintained by closing the door at a minimum for private rooms, and for shared rooms curtains and blinds should be used. If these actions were not done, a resident's privacy could be compromised. Before assisting a resident with removing their clothes in the restroom, staff should ask residents before closing the bathroom door. Interview with the Unit manager on 4/24/2025 at 11:01am, staff should knock on the door before entering room because another aide might be in there, and also due to privacy and it would just be proper thing to do when entering someone's room. If a resident's room was barged into, it would make them feel bad because they should have privacy, in case they were doing something they didn't want others to know. When providing incontinent care, staff should make sure doors, windows and blinds were closed. If windows were open, someone could walk by and see the care being provided to the resident and that would not be considered respecting a resident's privacy. Staff have received competency training on privacy, and it would be on their skills check-off list and also it would be common sense. Nurses and aides received training and a skills check-off upon hire. A nurse would go into a room and train staff, and the skills check-off list should be completed before going on to the floor. Nurses and unit managers would monitor aides. Interview with the ADON on 4/24/2025 at 11:55am, she said staff needed to knock before entering a room. Staff must then let the resident know who they are and provide a name badge . If residents did not know who entered the room, they could feel uncomfortable or scared since they are in an unfamiliar place. During patient care, staff should close the doors, curtains and blinds for privacy. If this was not done, staff would not be providing total privacy for residents. Someone could see them in the middle of care which would be an issue with dignity. Staff should cover residents back up after leaving the room, and if not, they were not providing the resident with dignity and privacy. The facility in-serviced staff accordingly. During an interview on 04/25/25 at 12:20 p.m., the DON said CNA L did not provide dignity to Resident #3 when she left the resident uncovered and walked out of the room. The DON said the nurses monitored the aides throughout the shift. The DON said aides were trained according to the facility's policy . Record review of the facility policy on dignity dated 2001 MED - PASS, Inc, (Revised August 2009) read in part . Policy Interpretation and Implementation .1. Residents shall be treated with dignity and respect at all times .6. Residents' private space and property shall be respected at all times 6a. staff will knock and request permission before entering residents' rooms .10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #1 and Resident #3) reviewed for incontinent care. The facility failed to ensure CNA B properly cleaned Resident #1 during incontinent care when CNA B did not separate Resident #1's labia on 04/22/2025. The facility failed to ensure CNA L properly cleaned Resident #3 during incontinent care when CNA L did not separate Resident #3's labia during incontinent care on 04/24/2025. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: 1. Record review of Resident #1's face sheet dated 04/24/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #1 diagnosis included: metabolic encephalopathy (a condition where brain function is disrupted), hypertension (force of blood against the walls of the arteries is consistently too high), and cognitive communication deficit (someone has difficulty communicating because their thinking processes, like memory, attention, and reasoning) Record review of Resident #1's admission assessment dated [DATE] revealed on BIMS of 02 indicating severely impaired cognition. Further review revealed Resident #1 dependent on staff for ADL care with one to two staff assist. Record review of Resident #1's undated care plan revealed Resident #1 had ADL self - care performance deficit related to dementia and impaired balance. Interventions: The resident requires assistance with 1 or x2 staff for toileting. This may fluctuate with weakness, fatigue, or weight bearing status. During an observation on 04/22/25 at 1:30 p.m., CNA B did not separate Resident #1's labia when she cleaned the resident during incontinent care. CNA B was about to apply a clean incontinent brief when the surveyor intervened, and the aide separated Resident#1's labia and cleaned the area three times. There was a brown substance on the wipes. During an interview on 04/22/25 at 1:40 p.m., CNA B said she tried to separate Resident #1's labia, but she did not because her legs were straight. CNA B stated if she did not clean Resident #1's labia well, the skin could get irritated and infected. CNA B said she had training in providing incontinent care. She said she was educated to bend the resident's leg at the knee, open the labia clean side, side, and middle, and ensure the resident was clean. She said the nurse monitors the aides during rounds throughout the shift. During an interview on 04/23/25 at 9:15 a.m., the DON said staff should completely clean Resident #1's labia. He stated CNA B should open the labia and clean. The DON said if CNA B did not clean Resident #1's labia area properly, it could result in infection. He said the staff should have a skills check-off before working on the floor. The DON said he would refer to the facility protocol and policy to see what was taught to the staff and get back to the surveyor. 2. Record review of Resident #3's face sheet dated 04/06/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #1 diagnosis included: malignant neoplasm of bilateral ovaries (cancerous tumors are present in both ovaries), diabetes mellitus (a condition where the body has trouble regulating blood sugar levels), and cystitis (inflammation of the bladder) Record review of Resident #3's admission assessment dated [DATE] revealed on BIMS of 15 indicating intact cognition. Further review revealed Resident #3 dependent on staff for ADL care with one to two staff assist. Record review of Resident #3's care plan revision dated 04/24/25 revealed Resident #3 had ADL self - care performance deficit related to activity intolerance and impaired balance. Interventions: The resident requires assistance with 1 or x2 staff for toileting. This may fluctuate with weakness, fatigue, or weight bearing status. During an observation on 04/24/25 at 4:06 a.m., CNA L did not separate Resident #3's labia during incontinent care for Resident #3. The surveyor intervened when CNA L was about to apply a clean incontinent brief. CNA L separated the resident labia and cleaned three more times, and there were bowel movements on the wipes. During an interview on 04/24/25 at 4:56 a.m., CNA L did not separate Resident #3's labia when she provided incontinent care and when she was about to place clean incontinent brief, and the surveyor intervened. CNA L said she wiped the resident several times and the wipes had bowel movement. CNA L said if she did not clean Resident #3 correctly, the resident could have infection, rashes, and skin breakdown. CNL L said she had been in service for incontinent care and was educated to separate the labia and clean the labia area properly. She stated the nurses monitored the aides throughout the shift. During an interview on 04/24/25 at 4:59 a.m., LVN M said CNA L should have separated Resident #3's labia and cleaned properly to prevent the resident from getting any infection. LVN M stated the nurses monitored the aides throughout the shift, and the nurse manager monitored the nurses during random rounds. During an interview on 04/24/25 at 11:55 a.m., the ADON said CNA L should have cleaned Resident #3 genitalia from front to back, and the labia should be separated cleaned front to back, wiped side, side, and middle with a different wipe each time. The ADON said if CNA L did not appropriately clean Resident #3 labia area, Resident #3 could have a UTI, and her private area would smell bad. Interview with the Administrator on 4/24/2025 at 5:19am, he said that staff were supposed to make rounds at least every two hours. If residents were left in their soiled briefs for a prolonged period of time without being changed, they could get a UTI. Interview with the Unit Manager on 4/24/2025 at 10:56am, she said aides should be checking on residents every two hours. Aides should check on non-interviewable residents during rounds to make sure if they're wet or dry. If they're in the soiled brief for so long, their skin would break down. Female genitalia should be wiped from front to back. Staff should raise residents' legs up and open and clean the labia to make sure every part of the area was clean. If residents were not cleaned properly, they could develop UTIs. During incontinent care, staff should come in with a bag and all the items they needed so they do not have to leave the room. Staff should change gloves before getting new wipes, and if they did not that would mean they were not being sanitary and causing an infection control issues especially if the staff's gloves were soiled. Staff should not bring soiled gloves outside a resident's room because that could spread their infection to another person. Gloves should not be carried in the back pocket because that would not be a sterile practice, and having something else in the pocket with the glove could cause infection. Staff should wash their hands before leaving a room. Nurses and aides received training and a skills check-off upon admissions. A nurse would go into a room and train staff, and the skills check-off list should be completed before going on to the floor. Nurses should be monitoring aides on the floor, and managers monitor the nurses. Interview with the ADON on 4/24/2025 at 11:58am, she said staff should put supplies in a bag and have everything they need to provide resident care before entering a room. Staff should place dirty briefs and used supplies in a bag. Staff should use wash their hands before donning PPE. During incontinent care, staff should not be using used gloves to pull wipes from the container because that would be infection control. Female genitalia should be cleaned from front to back, and the labia should be cleaned front to back with staff spreading and wiping each side and throwing away the wipe in between sides. When incontinence care is completed, staff should tie the bag with soiled items, wash their hands before leaving the room to avoid infection control issues. If incontinence care is not provided as instructed, residents could develop smells or a UTI, develop skin breakdown, pressure ulcers. Residents could develop open areas if they were in a soiled diaper for extended periods of time. Incontinent care policy was requested but was not provided prior to exit.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/prepared discarded after used date of 2 - 3 days per facility policy. These failures could place residents at risk of food borne illness and disease. Findings Included: Observation of the 1 of 1 facility kitchen freezer on 04/22/2025 at 8:56 a.m., revealed the following: 1. 1-gallon ziplocked sealed bag full of frozen premade waffles unlabeled/undated. 2. 4-single waffles sealed in saran wrap unlabeled/undated. In an observation on 04/22/2025 at 08:56 a.m., during the initial tour with Dietary Manager (DM) of 1 of 1 walk-in freezers in 1 of 1 kitchen observed 1-gallon ziplocked sealed bag full of frozen premade waffles unlabeled/undated and 4-premade waffles sealed in saran wrap unlabeled/undated. In an interview on 04/22/2025 at 08:56 a.m., Dietary Manager (DM) stated the waffles were served for breakfast on 04/20/2025. He stated Swing [NAME] (SC) served the waffles and it had been her responsibility to ensure that the waffles were labeled and dated before storing. He stated it was importance for foods to be labeled to know when it had surpassed its serve by dated and when it needed to be discarded. He stated food items were to be labeled to identify its content and dated to identify when its shelf life had expired, and the items needed to be discarded. In an interview on 04/22/2025 at 03:24 p.m., SC stated that she had worked for the facility for 10-years. She stated she had not cooked or served any waffles on 04/20/2025. She stated 2-weeks ago, she cooked chicken and waffles for a dinner meal. She stated on 04/20/2025, she served toast. She stated she had not used nor left the waffles and it had been someone else who left the waffles unlabeled/undated. She stated she would normally use the waffles seal them in a bag and replace back into the box it came in within the freezer. She stated on 04/21/2025 the DM who was responsible for ordering foods, performed an inventory check to determine what food items needed to be reordered. She stated being that he had gone into the freezer he should have seen that the waffles were not labeled and ensured they were labeled. She stated that everyone in the kitchen had access to the freezer and were responsible for properly storing and labeling food items. She stated once a food item was opened for use, it was to be used within 3-days and/or thrown out. She stated that the importance of labeling and properly storing food items after opening, was to ensure that that it had not remained longer than it shelve life, avoid becoming freezer burnt, and was not served to residents after those 3-days. She stated serving resident improperly stored food could cause them to become ill. She stated that she had an in-service (training) with her staff on labeling foods a couple of months ago. In an interview on 04/23/2025 at 09:09 a.m., the Director of Nursing stated that the DM had been responsible for ensuring that the food storage policy and procedures were relied to the kitchen staff. She stated it had been her expectation that the kitchen staff followed storing and labeling procedures appropriately and according to the policies. She stated the importance of labeling food was to know what food was stored and how long it had been stored and when to discharged . She stated the negative outcomes of storing unlabeled food could be serving spoiled food that could make the residents ill. Record review of facility's in-service training report dated 04/22/2025 reflected: Topic Labeling and dating evaluation, comments, or suggestion. Presented by DM manager and signed by the dietary staff to include SC. Record review of facility's policies and procedures titled Food Storage Nutrition Services Policy & Procedures . Food Production and Food Safety POLICY: dated March 2009; Rev 3/2019. Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 9. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food was used within 2-3 days or discarded. 16. Frozen Foods: Foods should be covered, labeled, and dated.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 3 residents (Resident #1and Resident #3) reviewed for ADLs. - The facility failed to ensure Resident #1 and Resident #3 were provided incontinent care in a timely manner by facility staff. These failures could place residents at risk for not receiving incontinent care needed to maintain personal hygiene which could lead to skin breakdown, pressure injuries or infection. Findings included: RESIDENT #1 Record review of Resident #1's face sheet dated 04/24/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #1 diagnoses included: metabolic encephalopathy (a condition where brain function is disrupted), hypertension (force of blood against the walls of the arteries is consistently too high), and cognitive communication deficit (someone has difficulty communicating because their thinking processes, like memory, attention, and reasoning). Record review of Resident #1's admission MDS assessment dated [DATE] revealed BIMS score of 02 indicating severely impaired cognition. Further review revealed Resident #1 was dependent on staff for ADL care with one to two staff assist. Record review of Resident #1's undated care plan revealed Resident #1 had ADL self - care performance deficit related to dementia and impaired balance. Interventions: The resident requires assistance with 1 or x2 staff for toileting. This may fluctuate with weakness, fatigue, or weight bearing status. During an interview on 04/22/25 at 1:26 p.m., CNA B said Resident #1 was assigned to her today, and she came to work at 6:10 a.m. CNA B said she provided incontinent once for Resident # 1 at 7:00 a.m. CNA B said she would change her now. During an observation on 04/22/25 at 1:30 p.m., Resident #1's incontinent brief was saturated from front to back, and the incontinent line on the brief was mashed and faded when CNA B opened the resident's incontinent brief. During an interview on 04/22/25 at 1:40 p.m., CNA B said Resident #1's incontinent brief was very wet with urine, and the wet indicator lines faded. CNA B said when she went to check on the resident the second time in the day (time unknown) she did not check to see if Resident #1 was wet because she had a lot of residents (14). CNA B said she should make rounds every two hours and change residents. CNA B said Resident #1 could have a skin breakdown because she was left in a wet incontinent brief. CNA B said she had a skills check-off on incontinent care and rounding. CNA B said she was educated to do rounding and incontinent care every two hours and to change the resident to prevent skin breakdown and infection. She stated the nurse monitors the aides during rounds throughout the shift. During an interview on 04/23/25 at 9:09 a.m., the DON said the aides should make rounds every two hours. He stated CNA B should check the resident's brief during rounding. The DON said if Resident #1 was left in a wet incontinent brief for an extended time, it could lead to skin breakdown. He stated the nurse monitored the aides and the staffing coordinator, while the nurse managers monitored the nurses during random rounding. He said the aides were trained before they started working on the floor on rounding and providing incontinent care. The DON responded that he would provide documentation of the care areas covered during CNA training. During an interview on 04/24/25 at 10:56 a.m., the Unit Manager said aides should check on residents every two hours. The Unit Manager said aides should check non-interviewable residents' incontinent briefs during rounds to make sure the resident was dry or wet and provide care. The Unit Manager said CNA B should not have left Resident #1 in a soiled brief for so long because her skin could break down. She said the aides had skill checkoffs before working with residents on the floor. The Unit Manager said the nurse monitored the aides, and the nurse managers monitored the nurses during rounding. Resident #3 Record review of Resident #3's face sheet dated 04/06/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #3 diagnoses included: malignant neoplasm of bilateral ovaries (cancerous tumors are present in both ovaries), diabetes mellitus (a condition where the body has trouble regulating blood sugar levels), and cystitis (inflammation of the bladder). Record review of Resident #3's admission MDS assessment dated [DATE] revealed BIMS score of 15 indicating intact cognition. Further review revealed Resident #3 was dependent on staff for ADL care with one to two staff assist. Record review of Resident #3's care plan revision dated 04/24/25 revealed Resident #3 had ADL self - care performance deficit related to activity intolerance and impaired balance. Interventions: The resident requires assistance with 1 or x2 staff for toileting. This may fluctuate with weakness, fatigue, or weight bearing status. During an observation on 04/24/25 at 4:06 a.m., incontinent care for Resident #3 provided by CNA L which revealed Resident #3's incontinent brief had feces from the lower back to the pubic area and the draw sheet was stained with feces. The feces was semi-dry. During an interview on 04/24/25 at 4:52 a.m., CNA L said she had not changed Resident #3 because she was working in another hall and came over to this hall around 1:30 a.m., and she had not made her way to Resident #3. CNA L said Resident #3 had a bowel movement, which was not fresh. CNA L said Resident #3's skin could break down if she did not change Resident #3 often. She stated the nurses monitored the aides throughout the shift. She said she was educated to make rounds every two hours and changed the resident to prevent skin breakdown. During an interview on 04/24/25 at 4:59 a.m., LVN M said the aide makes rounds every two hours to check the resident and change if the resident is dirty. LVN M said CNA L should have changed Resident #3 timely to prevent the resident skin from breaking down. She said the nurses monitored the aides throughout the shift. LVN M said she made rounds and saw Resident #3 but did not check the resident incontinent brief. During an interview on 04/24/25 at 11:55 a.m., the ADON said the aides round every two hours. The ADON said CNA L should change Resident #3 often to prevent her skin from breaking down. The ADON said nurses monitored the aides while the nurse managers monitored the nurse, and the staff had in serviced on incontinent care. ADL policy was requested but it was not provided. Record review of the facility in- service on staff rounding dated 10/20/25 through 01/23/25 read in part . staff (nurses and CNA's) must round every 2 hours and as needed, and charge should alternate with the CNA's .

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Resident #10 and Resident #22) reviewed. -The facility failed to ensure that Resident #10's status of full code was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #10's status of allergies was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #10's status of impaired thought processes was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #10's status of cellulitis was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #10's status of nutritional problems and use of a feeding tube (also called a g-tube) were a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #22's status of nutritional problems and use of a feeding tube were a focus area in the resident's comprehensive care plan and no intervention was in place. These deficient practices could affect residents by not providing and meeting resident-specific care and needs and lead to a worsening of health. The findings included: Resident #10 Record review of Resident #10's facility admission record dated 4/25/25 revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included cellulitis of both right and left lower limbs (Cellulitis is usually a superficial infection of the skin (left). But if severe (right) or if left untreated, it can spread into the lymph nodes and bloodstream. Cellulitis usually affects the lower legs, but it can occur on the face, arms and other areas.), bipolar disorder (bipolar disorder is a mental health condition characterized by significant mood swings.), mild protein-calorie malnutrition (Protein calorie malnutrition is a type of undernutrition. Undernutrition happens when you don't consume enough essential nutrients, or when you use/excrete the nutrients faster than they are replaced.), and cognitive communication deficit (cognitive communication deficit refers to difficulties in communication that arise from impairments in cognitive processes such as attention, memory, perception, and executive function). Record review also revealed that her advanced directive was full code. Record review of Resident #10's admission MDS dated [DATE] revealed Resident #10 had a BIMS score of 13 out of 15 indicating she was cognitively intact. Resident #10 was dependent to requiring substantial/maximal assistance with ADL's. She was always incontinent of bladder and frequently incontinent of bowel. Record review of section I (active diagnoses) diagnoses included malnutrition, bipolar disorder, cellulitis of both right and left lower limbs. Record review of Resident #10's comprehensive care plan revealed there were no care plans to address full code, allergies, impaired thought processes, cellulitis, and nutritional problems. Interview on 4/24/25 at 1:45 pm with the Corporate Nurse, she said that the care plans were important to follow a resident's plan of care and that a negative outcome could be the resident not receiving care. Interview on 4/24/25 at 1:47 pm with the DON said that the areas of full code, allergies, impaired thought processes, cellulitis, and nutrition problems should have had a comprehensive care plan, the care plan was important because it showed what the residents needed, and a negative outcome could be the resident not receiving those things. On 4/24/25 at 2:00 pm, an interview with MDS Nurse K, she said the importance of comprehensive and base line care plans were that the care plans provided a picture of the resident and how to take care of their needs. Staff that were responsible for the care plans included Circle of Excellence, IDT team which included Social Work, Nurses, Managers, and Therapy. Interview on 4/24/25 at 2:10 pm with MDS Nurse M, she said that the facility used the RAI Manual to complete assessments, that the care plans were important to provide care to the residents. Resident #22 Record review of Resident #22's face sheet revealed a [AGE] year-old female originally admitted on [DATE] and most recently readmitted on [DATE]. Her medical diagnoses included: Type 2 Diabetes Mellitus (high blood sugar), unspecified severe protein-calorie malnutrition, Metabolic Disorder (a group of diseases which can increase negative health outcomes such as high fat, high blood sugar, and high blood pressure), dysphagia (difficulty swallowing), and cognitive communication deficit. Record review of Resident #22's care plan captured 4/22/2025, she did not have a feeding tube-specific focus area. Record review of Resident #22's Order Summary report dated 04/24/2025, she had the following: -Enteral Feed Order every night shift, open system container or gravity feeding with a start date of 03/01/2025. -Enteral Feed Order every shift, continuous feed, check every 4-6 hours prior to irrigation and PRN (Confirm with physician regarding withholding feedings) -Enteral Feed Order every shift Diabetisource AC (Advanced-Control) 70 ml/hour 18 hours per day via feeding tube with a start date of 04/13/2025. Record review of Resident #22's PPS (Prospective Payment System, an alternate form for residents) MDS dated [DATE], she had a BIMS score of 00, indicating severe cognitive impairment related to thinking and memory. She required total assistance for all her ADLs, including eating, toileting and dressing. Resident #22 was marked as receiving a feeding tube at the facility. She was marked as admitting to the facility with parenteral/IV feeding. Observation of Resident #22 on 4/22/2025 at 1:29pm, she was sleeping in an elevated bed in no visible discomfort. Her feeding was located next to her bed, with tubes kink-free and off the ground. Interview with MDS Nurse A on 4/25/2025 at 9:51am, she checked Resident #22's record on her computer and said resident should have enteral feeding on her care plan if she was on it. MDS Nurse A then said Resident #22 had care plans for being a one-person set-up and supervision, which could include feeding. She then said she could add it and confirmed that Resident #22 was admitted with g-tube to the facility. Interview with the DON on 4/25/2025 at 10:15am, he said Resident #22's g-tube should have been care-planned based off the physician's orders. A risk to not placing g-tube in the care plan would be the resident receiving the incorrect order. Record review of the facility policy and procedure entitled Care Plans, Comprehensive Person-Centered, dated revised March 2022, read in part .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .the comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission .the comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #2) reviewed for accidents and for food trays left out in the halls after meals. -The facility failed to ensure CNA C used gait belt when she transferred Resident #2 from bed to walker and walked the resident to the bathroom. -There was a food cart with nine food trays eaten with cutlery left out in the hall observed on 4/23/2025 at 4:43am. This failure could place residents who required assistance from staff to transfer out of bed and ambulatory residents at risk for accidents and injury. The findings were: RESIDENT #2 Record review of Resident #2's face sheet dated 04/25/25 revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 diagnoses included: Parkinson's disease (a progressive neurodegenerative disorder leading to movement related to tremors, slow movement, and rigidity), hypertension (force of blood against the walls of the arteries is consistently too high), and diabetes mellitus (a condition where the body has trouble regulating blood sugar levels). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Further review revealed Resident #2 needed moderate assistance with transfer with one staff assist. Record review of Resident #2's care plan dated 03/13/25 revealed Resident #2 had ADL self - care performance. Interventions: transfer: the resident requires 1 x2 staff assistance for transfers. Further review revealed the resident had Parkinson's affecting. Interventions: adaptive devices as recommended by therapy or MD. Monitor for safe use. Monitor/document to ensure appropriate use of safety/assistive devices. During an observation on 04/22/25 at 3:16 p.m., CNA C assisted Resident #2 by holding the resident's left arm with both of her hands and pulling on Resident #3 while she was still lying on the bed, but she could not get the resident out of the bed without a gait belt. CNA C then pulled the back of Resident #2's pants with one hand and one arm under Resident #3 left armpit, pulled her up from the bed, and asked her to hold onto her walker because she could walk. Resident #3 was wobbling, and she told the resident to walk, when she did not move, she moved the resident's walker forward. Resident #3 shuffled as she walked. When Resident #2 walked to the restroom door, the resident's gait became very unsteady, and she almost lost her balance while the aide was walking on the resident's right side. The surveyor alerted the aide, and CNA C walked to the resident's back and assisted the resident. During an observation on 4/24/2025 at 4:43am, a food cart was observed in a resident hall directly in front of the kitchen door entrance with nine eaten food trays which were unsealed, with used cutlery on trays. During an interview on 04/22/25 at 3:35 p.m., CNA C said she did not use a gait belt to transfer Resident #3 because the resident did not have a gait belt and asked where she was expected to get a gait belt. She did not respond when asked if she had any training on using a gait belt and what could have happened to Resident#3 during transfer without a gait belt. During an interview on 04/23/25 at 9:38 a.m., the DON said CNA C should have transferred Resident # 2 with a gait belt because she was one person assist. He said if the staff did not use a gait belt, then the resident could fall and fracture her bone. The DON said if the staff was walking the resident, the staff should walk slightly behind and to the side with a hand on the gait belt to support the resident and prevent the resident from falling. Interview with LVN O on 4/24/2025 at 4:43am, they said the trays were from residents who preferred to have a later dinner. They said that a risk of leaving the trays out and not bringing them inside the Kitchen was that any resident could come and eat off the tray. They said that it was also an infection control issue. Interview with the Administrator on 4/24/2025 at 5:19am, he said staff were supposed to transfer residents with a gait belt. There could be potential for residents to fall if a gait belt was not used. He also said food trays should be placed in the dining room and placed in the kitchen after dinner and he had them moved after it was observed by surveyors. He would do education on that, and a risk to residents would be someone could go eat the food that was left out, which is the reason why food is to be taken out of resident's' rooms after they're done eating. Interview with the Unit manager on 4/24/2025 at 10:56am, she said that food trays were usually left outside on the cart after dinner but that the trays should have been taken off the hall and pushed into the closed kitchen door. If residents passed and tried to eat it. it would have caused harm as they could have been on a different diet. Staff who assist a resident to the restroom should wait outside the bathroom door and not leave the resident's room for safety reasons, in case the resident fell. Staff should use a gait belt when doing a one-person transfer with a resident, and this would be done for the staff's and resident's safety. The Unit Manager said she did in-services on transferring with gait belt, and staff were aware they need to use a gait belt. Interview with the ADON on 4/24/2025 at 12:09pm, she said staff were to use a gait belt for one-person assist. Without a gait belt that could cause staff injury during transfer or resident and staff could fall causing injury to the resident. Staff had been trained on proper transfers. Resident #2 could have fallen, hit her head or dislocated her shoulder. Interview with the DON on 4/25/2025 at 12:22pm, he said food trays should be in the kitchen after dinner. Residents with poor or impaired cognition could grab something, causing cross-contamination. Staff could get sick, and cutlery could cause injury to residents if used. Record review of facility Continuing Care Network - Nursing Policy & Procedure Mobility Section 10 - Transfers read in part . when transferring a patient even with minimal assistance) always place a belt around his waist . note: if at all unsure of transfer process, seek help or consult with PT or OT for further instruction . A policy was requested on accidents and hazards. The facility stated they did not have a specific policy.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 8 resident halls observed for proper garbage disposal. The facility failed to dispose of garbage when a food tray cart safely and properly with nine trays that were eaten including cutlery laying on the trays were seen outside the Kitchen entrance on 4/24/2025. This failure could place residents at risk of eating food incompatible with their prescribed diet and which could attract pests. Findings included: During an observation on 4/24/2025 at 4:43am, a food cart was observed in a resident hall directly in front of the kitchen door entrance with nine eaten food trays which were unsealed, with used cutlery on trays. Interview with LVN O on 4/24/2025 at 4:43am, they said the trays were from residents who preferred to have a later dinner. LLVN O said that a risk of leaving the trays out and not bringing them inside the Kitchen was that any resident could come and eat off the tray. LVN O said that it was also an infection control issue. Interview with the Administrator on 4/24/2025 at 5:19am, who said food trays should be placed in the dining room and placed in the kitchen after dinner and he had them moved the food cart after it was observed by surveyors. He would do education on that, and a risk to residents would be someone could go eat the food that was left out, which was the reason why food was to be taken out of resident's rooms after they're done eating. Interview with the Unit manager on 4/24/2025 at 10:56am, who said that food trays were usually left outside on the cart after dinner but that the trays should have been taken off the hall and pushed into the closed kitchen door. If residents passed by and tried to eat the food, it would have caused harm as they could have been on a different diet. Interview with the DON on 4/25/2025 at 12:22pm, who said food trays should be in the kitchen after dinner. Residents with poor or impaired cognition could grab something, causing cross-contamination. Staff could get sick, and cutlery could cause injury to residents if used. Record review of the facility's policy on food-related garbage and refuse disposal last revised October 2017, it read in part that, 1. All food waste shall be kept in containers . 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. Record review of the facility's policy on food-related garbage and refuse disposal last revised October 2017, it read in part that, 1.All food waste shall be kept in containers . 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests.

Based on observation, interview, and record review, the facility failed to ensure each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 (Resident #1) residents reviewed for abuse and neglect. The facility failed to ensure that Resident #1 was free from sexual abuse when staff observed Resident #1 being touched inappropriately by CR #2 on 12/26/2024. The noncompliance was identified as Past Non-Compliance. The IJ began on 12/26/2024 and ended on 12/27/2024. The facility corrected the noncompliance before the survey began. This failure placed residents at risk of experiencing abuse and neglect. Findings include: Record review of Resident #1's face sheet dated 12/27/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with anxiety disorder, unspecified, Malignant neoplasm of uterus (A cancerous tumor), Unspecified kidney failure (A condition where the kidneys are not functioning properly), Hypothyroidism (When the thyroid gland doesn't make enough thyroid hormones to meet your body's needs, Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, heart failure. Record review of Resident #1's quarterly MDS (minimum data set) assessment dated [DATE] revealed she had difficulty communicating some words or finishing thoughts but was able if prompted or given time; she missed some part/intent of the message but comprehended most conversation; she had a BIMS score of 7 (severe cognitive impairment); she did not exhibit any behavioral symptoms or rejection of care; she was partial dependent on staff (helper did less than half the effort. Helper lifts or holds trunk or limbs and provides more than half the efforts) for toileting hygiene, showers, and personal hygiene; she required partial/moderate assistance from staff (helper did more than half the efforts Helper lifts or holds trunk or limbs but provides more than half the effort.) for chair/bed-to-chair transfers, (helper does more than half the effort. Helper lifts or holds trunk or limbs but provides more than half the effort). Record review of Resident #1's care plan revised 12/21/2024 revealed: * Communication: Resident is sometimes understood in ability to express ideas and wants. Goal included: Resident will communicate requests, needs, and feelings over the next 90 days. Interventions included: Allow adequate time to express self; complete word or sentence if Resident is unable to do so. Ask short simple questions that can be answered, yes or no. If restless, assess for pain/discomfort or other physical needs (fluid, hunger, incontinence). * Resident is Short-term memory impaired-unable to recall after 5 minutes. Goal included: Resident will participate in ADLs and facility routines/activities over the next 90 days. Interventions included: Encourage/help Resident participate on recreational activities. Maintain consistent routine; introduce change slowly to reduce confusion. Provide clocks, calendars, and a schedule of facility routines. Provide direct guidance when Resident is unable to follow through with instructions. Re-orient to time, location, events, and activities as needed. Use cues to enhance participation in self-care. Report any decline in ability to participate/perform ADL care. Record review of Resident #1's nursing progress notes for December 2024 revealed: * On 12/26/2024, at 9:30 p.m. DON wrote, Received call from RP, caregiver of Resident #1, stating person was in Resident's room near the bed. Spoke with RP again requesting permission to transport Resident to hospital or sexual assault exam. RP states from her view of the camera, the person was not able to open Resident legs wide enough to get full access to Resident's genitalia for sexual intercourse. RP states taking Resident to hospital and revealing to her touching was inappropriate and nonmedical would be more upsetting to Resident than the act of touching by the male perpetrator. * On 12/27/2024, at 12:00 a.m. LVN A wrote, Call from DON, telling staff to go at once to Resident #1's room. DON stated, he received a call from Resident #1's RP. RP stated a person was in Resident #1's room near the bed. Staff and LVN A ran to Resident #1's room, only to find male resident standing over female resident (Resident #1). Assisted male resident out of female resident's room and explained to him, he is not to be in other resident's room and especially not a female resident's room. Assessed female resident at this time to make sure she was alright and free from any injuries. Female resident was lying in bed on her back with shirt pulled up and her breast exposed, diaper open and diaper was located under female resident. DON calls again letting staff know, he spoke with Resident #1's RP. At this time DON requested permission to transport female resident to hospital for sexual assault exam. DON stated, RP said from her view of the camera, the person was not able to open Resident #1's leg wide enough to get full access to Resident #1's genitalia for sexual intercourse. RP also stated, taking Resident #1 to hospital and revealing to her the touching was inappropriate and nonmedical would be more upsetting to mom than the act being touch by the male resident. Police called and are in building talking to staff and female Resident's RP who are here at the facility at this time. DON made aware of police wanting to send resident to the hospital and family member refusing. Record review of Resident #1's EMR (electronic medical record) dated 12/27/2024 revealed, Neuro-checks were completed. Record review of CR #2 face sheet dated 12/27/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Sepsis, unspecified organism. Anxiety disorder, hemiplegia, essential (primary) hypertension, disease of stomach and duodenum, unspecified, unspecified Dementia, moderate, with agitation, major depressive disorder. Record review of CR #2's quarterly MDS assessment dated [DATE] revealed he had the ability to express ideas and wants, clear comprehension in ability to understand others, sees fine detail, such as regular print in newspaper/books.; he had a BIMS score of 12; he did not have any history of elopement, wandering or inappropriate behaviors. Record review of CR #2's nursing progress notes for December 2024 revealed: On 12/27/2024, at 1:21 a.m. RN D wrote, Report received from the outgoing nurse that CR #2 was found in the female resident's room with the diaper pulled down and the female breast exposed. The nurse redirected him to his room. The family called, no response. DON notified. On 12/27/2024, at 4:25 a.m., RN D wrote, The Sheriff's Officers and the investigator Deputy from Sheriff's Department came in for the investigation, carried out the DNA test from the resident, and transferred CR #2 to the County jail. Family Member unable to contact with several attempts. DON notified and able to speak with Deputy Investigator. On 12/27/2024, at 11:42 a.m., ED (executive director) wrote, CR #2's family returned the facility's calls from 12/26/20204 regarding incident. ED spoke to family and notified of incident and CR #2's current location. CR #2's family stated, oh my thank you for letting us know. ED asked if this type of behavior had ever happened before. Family stated, no. ED asked if the family had any questions and family stated, no. ED thanked family member for her time and instructed to reach out to him if she had any further questions or concerns. Observation of Resident #1 on 12/27/2024, at 3:56 p.m. revealed she in her room lying in bed with RP at bedside. There were no concerns observed. Resident #1 was dressed and alert but not interview-able. The bed was in low position, call light was in reach and hydration was present. There was no environmental concerns or foul odors. RP asked to step out of the room, and she refused interview with Resident. Interview with Resident #1's RP on 12/27/2024 at 3:57 p.m. she stated she viewed the electronic monitoring of Resident #1, and she observed an unknown male (CR#2) at 9:33 p.m. in Resident#1's room. RP stated during the observation, the male resident was observed touching Resident #1 inappropriately. RP stated she contacted the DON and at 9:34 p.m., staff entered the room and removed the male resident (CR#2) from Resident #1's room. She stated the facility called the police and charges were filed. She stated the facility offered to send Resident #1 to the hospital, but she declined. She stated the resident have Dementia and she think that the male resident that entered her room was a physician that came to examine her, and she would like to keep things that way. She stated the resident hallucinates at times and she thinks bringing up the incident and telling her what really happened would do more harm to the resident. She stated she did not have any concerns with the facility. She stated the facility did everything they were supposed to do and reacted immediately when she informed them of what was going on in the resident's room. In an interview with LVN E on 12/27/2024 at 4:09 p.m., she stated he worked yesterday (12/26/2024) on 100 hall from 2:00 p.m.-10:00 p.m. She stated there was in incident with a Resident on resident, between CR #2 and Resident #1. She stated the DON called at 9:30 p.m. and stated the RP of Resident #1 saw a male in the room on camera. The assigned nurse (LVN A), CNA C, and another nurse, LVN B, went to the room (Resident #1's room). She stated CR #2 was standing over Resident #1 and her breast and brief exposed and he was foundling breast. She stated the residents were separated and head to toe assessments were completed. CR #2 was placed on 1:1 supervision with CNA C. She stated Law enforcement came and CR #2 was arrested. She stated Resident #1 was moved to another room to be closer to the nurse station. LVN E stated CR #2 has dementia but is alert and oriented x3. She stated he had not had behaviors before of wandering into rooms or inappropriate sexual behaviors. She stated she last saw CR #2 at the nurse station around 8:30 p.m. drinking coffee. She stated they round every two hours. She stated she did not see CR #2 go into the room of Resident #1. She stated she had been trained on abuse neglect, she was knowledgeable on types of abuse, to include sexual abuse. She stated if abuse is suspected it should be reported to the DON and ED immediately. She stated she was also trained if resident on resident abuse; to separate immediately, assess residents, and report. In an interview with LVN A on 12/27/2024 at 4:12 p.m., she stated she rounded around 8:00 p.m. and CR #2 was seen at the nursing station drinking coffee in the bistro. She stated she stated she left the hall around 8:30 p.m. to do a new admission and CR #2 was still at the bistro. She stated she returned to the hall around 9:00 p.m. to chart and CR #2 was no longer at the bistro. She stated 9:30 p.m. the DON called and reported that the RP of Resident #1 informed that a male was on the camera in the room foundling Resident #1. LVN A, LVN B, CNA C went to Resident #1's room. LVN A stated the door was closed and the wheelchair was blocking it, but she pushed it open. She stated CR #2 was fully cloth and standing over Resident #1. Resident #1's breast was exposed, and her brief was open. CR #2 had his hand between Resident #1's legs and his other hand on Resident #1 breast. LVN A stated she asked CR #2 what he was doing and he was startled and tried to cover Resident #1 with the sheet. LVN A stated she was not aware that CR #2 could stand up on own because he is usually in a wheelchair and has to be transferred. LVN A stated LVN B and CNA C transferred CR #2 to his wheelchair and took him to his room. CNA C remained with CR#2 until Law enforcement arrived. She stated she and LVN B completed a head to toe assessment on Resident #1 and there were no injuries. LVN A reported she contacted Law enforcement while LVN B called the medical director and RP's. She stated the DON called the ED. She stated the RP of Resident #1 came to the facility and she refused to have Resident #1 transferred of to hospital for medical evaluation. LVN A stated Law enforcement arrived about 11:00 p.m. She stated that CR #2 was arrested right before 1:00 a.m. LVN A stated CR #2 did not have behaviors of wandering in rooms or inappropriate touching prior to the incident. LVN A stated the staff rounds every two hours and she did not see CR #2 go into Resident #1's room. LVN A stated she had been trained on abuse neglect, she was knowledgeable on types, to include sexual abuse; and if resident on resident abuse to separate immediately, assess residents, and report. LVN A stated abuse should be reported to the DON and ED immediately. In an interview with CNA C on 12/27/2024 at 4:25 p.m., she stated she stated she stated she worked at the facility on last night (12/26/2024). She stated she was assigned to 300 and 400 halls. She stated there was an incident on last night in which she was informed by the DON to go to Resident #1's room due to a male resident being in the room. She stated when she entered the room, she observed the male resident- CR#2 standing over Resident #1. She stated Resident #1's shirt up above her breast in which her breast was exposed and her diaper was exposed. She stated it is unknown if CR #2 lifted the resident's shirt or the resident lifted her own shirt since she did not witness it. She stated she had never observed anything like that in the facility. She stated it was her first time working with the resident. She stated CR #2 was removed from the room and placed on one to one until law enforcement arrived. She stated she checks on the residents every two hours. She stated she has been trained on abuse and neglect and was knowledgeable about the different types of abuse. She stated any concerns of abuse is reported to the ED who is the abuse coordinator. She stated if there is resident on resident abuse, she is trained to separate them immediately, assess and report it. In an interview with CNA F on 12/27/2024 at 4:41 p.m., she stated she worked on 12/26/2024 and she was assigned to hall 700. She stated she last worked hall 200, 2 months ago. She stated she was informed by staff of the incident that occurred between Resident #1 and CR #2. She stated she was familiar with CR #2 due to working with him in the past and stated he was alert and oriented. She stated he did not have behaviors of going into rooms of residents or inappropriate behavior prior to this incident. She stated she had been trained on abuse and neglect, she was knowledgeable on types to include sexual abuse, and should be reported to DON and ED immediately. She stated she was trained if resident on resident abuse to separate immediately and report. She said that they must round every 2 hours, but she does 30 minutes. In an interview with CNA G on 12/27/2024 at 4:47 p.m., she stated she did not work on yesterday (12/26/2024) or the day prior (12/25/2024). She stated she had been trained on abuse and neglect, she was knowledgeable on types, and abuse should be reported to the DON and ED immediately. She stated she was trained if resident on resident abuse occurs to separate immediately and report. She said that they have to round every 2 hours, but she does 30 minutes. She stated she returned to work today and during morning report she was told that a male resident on 300 halls abused another female resident. She stated she was informed the male resident was touching the female resident inappropriately. She stated that the male resident was arrested, and female resident room was changed. She stated the staff had abuse and neglect in-service because of it. She stated they round every two hours. Male resident is usually in w/c and can ambulate on the hall but did not observe him wandering in other rooms or have inappropriate behaviors. In an interview with CNA H on 12/27/2024 at 4:55 p.m., she stated she had worked at the facility for 4 months. She stated her hall assignments rotate. She worked last night (12/26/2024) on hall 200 from 2:00 p.m.-10:00 p.m. She stated the DON called to check Resident #1 room because the family saw a male in the room. She stated the nursing staff went to the room. She stated the male was the resident in room with Resident #1 She stated the male resident had open the diaper of the female residents. She stated she did not know what happened to the male resident or female resident; she just know that the police were called. She stated she was not at the facility when police came. She stated the male resident is usually in a wheelchair and can ambulate on the hall but she did not ever observe him wandering in other rooms or have inappropriate behaviors. She stated she had been trained on abuse and neglect, she was knowledgeable on types to include sexual abuse, she stated abuse and neglect should be reported to the DON and ED immediately. She stated she was trained if resident on resident abuse to separate immediately and report. She said that they have to round every 2 hours, but she does 30 minutes. In a phone interview with LVN B on 12/27/2024 at 5:16 p.m., she stated she worked on last night (12/26/2024) on hall 200 from 2:00 p.m.- 10:00 p.m. She stated trained on abuse and neglect. She stated she was knowledge on types of abuse to include sexual, and they report it immediately to the ED. She stated she was trained when there is resident to resident abuse to separate them immediately, assess, head to toe assessment, and report. She stated she was at the nursing station charting at about 9:30 p.m. and the DON called and informed to check on Resident #1, and she went to room with CNA C and Nurse assigned LVN A. She stated when they approached the room the door was close. She stated upon entering the room the female resident was in bed, her shirt was over her head, breast was exposed, and her brief was open. She stated the male resident was standing over the female resident fully clothes, he was touching her breast with one hand, and other the other hand was near her brief. She stated he was asked what he was doing, and he jumped and pulled the cover over her. She stated she immediately got him in his wheelchair and took him to his room. She stated the aide was asked to stay 1:1 with male resident. She stated she did not know that the resident could ambulate out wheelchair without help. She stated she and the assigned nurse went to assess the female resident, she had no visible injuries, and she was not interview-able. She stated they then assessed the male resident, and he did not have any injuries. She reported the DON said that they should call RP's, MD's and 911. She stated the family of the female resident was enroute and came to the facility. She stated she called the RP of the male resident and left a message. She stated the assigned nurse called the MD. She stated law enforcement came to the facility, did an interview with them and she left. She stated she was not sure what happened to the male resident because her shift ended. She stated that at 8:30 p.m. the male resident was at the bistro near nursing station drinking coffee in his wheelchair, but she did not see him leave but assumed he went back to the room. She stated she did not see the male resident go into the room of the female resident. She stated the male resident said that the female resident called him into the room and told him to do it. She stated the male resident is alert and oriented x4. She stated the female resident is alert and oriented x1. In an interview with DON on 12/27/2024 at 5:39 p.m., he stated he has been employed at the facility for 4 months. He stated he was off duty at home on 12/26/2024 and at about 9:30 p.m., he was contact by RP of Resident #1. He stated RP informed that there was male in the room standing over Resident #1 from what she could see from electronic monitoring in the room. He stated RP informed that the male was touching the resident. The DON stated RP described the resident as a black male, and stated he was touching Resident #1's legs. The DON stated he called the assigned nurse and had her go to the room of Resident #1, and he remained on the phone. DON stated the nurse informed that the male resident, CR #2, was in the room. DON stated the nurse reported that CR #2's hands were touching Resident #1 near her brief and her breast were exposed. The DON stated he instructed the nurse, to separate the residents, 1:1 supervision for CR #2, head to assessment for both residents, call police, call MD, and RP to CR #2. He stated he called the RP back for Resident #1, who was in route to the facility. He stated he called the ED. He stated that Resident #1's room was changed closer to the nurse's station. The DON reported CR #2 was arrested by the Sheriff's Department, because he admitted to being in the room uninvited. He reported that CR#2 was alert and oriented x 3-4, so the DA picked up charges. He stated that initially the plan was to transfer CR #2 to a behavioral hospital because he does have a Dementia diagnosis, but law enforcement refused. He stated that the electronic monitoring was live stream, and RP said she was unable to provide a copy. The DON stated they tried to send Resident #1 to the hospital, but RP refused because she could see that there was not a sexual assault that warranted hospital transfer; she stated it would upset the resident even more. The DON stated CR #2 did not have behaviors of inappropriate sexual contact or behaviors of wandering into other resident's rooms. DON stated CR #2 was admitted as a skill resident, and then moved to long term care. He stated he was not aware of CR #2 to have criminal history of sexually in appropriate behaviors prior to admission. The DON reported CR #2 would not have been admitted to the facility if he had a history of sexual assault. He stated the facility has taken the following steps since the incident has occurred: Changed the female resident room close to nurse station, Male resident placed on 1;1 until police arrested, Head to toe assessment for both resident, Safety surveys with residents on the hall, and adjoining hall and In-servicing. In an interview with SW on 12/27/2024 at 6:30 p.m., she stated she had been employed at the facility since April 2023. She stated she had been trained on abuse and neglect; she was knowledgeable about different types of abuse to include sexual. She stated abuse should be reported immediately to the ED. She stated residents should be separated immediately if resident/resident abuse occurs. She stated she is unable to touch residents so she would notify nursing staff to get involved immediately. She stated on last night (12/26/2024) there was resident/resident incidents involving, Resident #1 and CR #2. She stated she did not witness the incident but she was informed of what occurred. She stated she spoke the RP of Resident #1, and she was informed that the RP observed on camera that Resident #1's shirt was up above her head. She stated Resident #1 was assessed and her room was changed for more supervision. She stated CR#2 was arrested after being interviewed by police. She stated she completed a well-being assessment with the Resident #1 and safety check surveys with other residents throughout the building ongoing. She stated CR #2 was alert and oriented, and she was unsure if he had a diagnosis of Dementia. She stated CR #2 did not have behavior of inappropriate touching or wandering into residents. She stated he did not have any criminal history in lined with behaviors of sexual inappropriate behaviors. In an interview with Executive Director (ED) on 12/27/2024 at 6:38 p.m., he stated he had been employed at the facility since March of 2022 and he was the Abuse Coordinator. He stated he was contacted by the DON at 9:36 p.m. informing that CR #2 was seen on camera in a resident's room from RP. He stated he gave the following instructions: Nurses to assess both residents, Nurses were to call 911, Nurses were to call MD. He stated RP of Resident #1 was aware and in route to the facility, so he informed staff to contact RP of CR #2. He stated CR #2 was to be placed on 1:1 supervision until LE came and he left out the facility. He stated they made efforts to get electronic monitoring from RP but was unsuccessful due to the video being live feed only. He stated he started his investigations and Law enforcement was notified, he made a self-report last night, safe surveys with residents were initiated by the social worker and on-going, abuse and neglect in-services initiated and on-going, the social worker completed assessment for emotional issues with Resident #1, Resident #1's room was changed and she was moved closer to the nursing station, witness statements have been initiated and ongoing, efforts to send Resident #1 to the hospital was unsuccessful because RP refused. He stated Law enforcement arrested CR #2 because he admitted to going into Resident #1's room when he should not have. He stated it was initially planned to send CR #2 to the behavioral hospital due to his Dementia diagnosis, but Law enforcement did not agree. He stated the Medical Director was contacted. He stated he will continue with safe surveys, frequent rounding, and in-services. He stated CR #2 did not have behaviors of wandering into resident's rooms or inappropriate touching. He stated CR#2 did not have criminal history upon admission of any sexual behaviors, and if he had he would not have been admitted . In an interview with LVN I on 12/30/2024 at 5:27 p.m., she stated she has been employed at the facility for 6 months. She stated she is assigned to 800 hall. She stated she works 2-10 shift Monday through Friday. She stated she did not witness the resident-on-resident incident and she was not familiar with the residents. She stated she was trained on abuse and neglect daily. LVN I was knowledgeable about the different types of abuse and who to report abuse to. She stated if she suspected abuse or neglect, she would inform the ED who is also the abuse coordinator know and if he is not available, she would let another administrator know. She stated staff checks on the residents every 2 hours. In an interview with CNA J on 12/30/2024 at 5:31 p.m., she stated she had been employed at the facility for 2.5 years. She stated she was assigned to the 300 hall today. She stated she works all over but mostly hall 300. She stated she was familiar with CR #2 and she had worked with him in the past. She stated she had never observed the resident being inappropriate with other residents. She stated she has never observed the resident wandering into other residents' rooms. She stated she was trained on abuse and neglect 2 days ago as well as today. She stated they were trained on what to do if they see a resident abusing another resident (separate), then who they would report it to (ED; Abuse Coordinator). She stated she checks on the resident every 30 minutes. In an interview with CNA K on 12/30/2024 at 5:36 p.m., she stated she has been employed at the facility for one year. She stated she was assigned to hall 700 and 800 today but she typically works all over. She stated they always get training for abuse and neglect. She stated if abuse or neglect is suspected she would report it to the ED, ED assistant or the DON. She stated if she observed resident to resident abuse, she would separate the residents and report it. She stated she checks on the residents any time their light is on and they are to position the residents every 2 hours. Record review of the facility's document titled, Abuse Protocol dated April 2019 revealed, 1. The Patient has the right from Abuse, neglect, mistreatment of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treating the Patients symptoms 2. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation of Patient property and exploitation (collectively. Patient Abuse) by anyone, including staff members, other Patient, family members, legal guardians, sponsors, friends, and other individuals. Record review of the facility's policy entitled, Resident Rights revised February 2021 revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, misappropriation of property and exploitation . Record review of the facility's Emergency QAPI plan dated, 12/26/2024 revealed; On Thursday 12/26/2024 facility self-reported allegation of reside to resident inappropriate touching. Male resident was found in female resident room. Facility held an emergency QAPI meeting with the Medical Director on 12/27/2024 regarding steps to ensure the safety of all residents. Steps Taken regarding incident: *RPs, Police, Ombudsman, Physician, Medical Director immediately notified *Facility immediately assessed female resident, no negative findings. RP refused to have patient sent to ER. *Facility conducted psychosocial mental evaluation, no negative findings. *Facility immediately placed male resident 1:1 until discharged from facility. *Facility to initiate safe surveys at random to ensure facility residents feel safe. *Facility to initiate immediate discharge notice to male patient to ensure he does not return. *DON/Designee initiated abuse/neglect in-service with all staff with continue weekly x 4 weeks. *The leadership team will monitor safe surveys weekly to ensure patients feel safe and secure in the facility and are free from abuse. *The leadership team will monitor through daily rounds to ensure patients feel safe and secure. Will report any negative findings to the administrator immediately. Record review of In-Service Training Report dated 12/27/2024- on going revealed all staff all were educated by the ED and Assistant ED regarding recognizing and reporting abuse and neglect. Record review of the facilities document titled, Patient Abuse Investigation Questionnaire dated 12/28/2024 revealed, Questionnaires with residents were completed by the activity director. Interviews were conducted with staff on 12/27/2024 between 2:15 p.m. until 8:30 p.m. and on 12/30/2024, between 3:30p.m.-6:00 p.m. including LVN A, LVN B, CNA C, RN D, LVN E, CNA F, CNA G, CNA H, SW, LVN I, CNA J, and CNA K to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations. LVN A, LVN B, CNA C, RN D, LVN E, CNA F, CNA G, CNA H, SW, LVN I, CNA J, and CNA K were able to explain the importance of recognizing abuse and neglect and reporting as well as immediately reporting abuse to the abuse coordinator. The noncompliance was identified as Past Non-Compliance. The IJ began on 12/26/2024 and ended on 12/27/2024. The facility corrected the noncompliance before the survey began. On 12/27/2024 at 8:20 p.m., the facility's Administrator and Regional Director of Clinical Services were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 12/30/2024 at 8:20 p.m.

Based on record review and interview the facility staff failed to ensure residents with pressure ulcers received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of 5 residents reviewed for wound care. The facility failed to perform wound care for Resident #1 when her bandages became soiled with urine. The facility failed to request a PRN order to change the bandage on Resident #1's sacral wound if it became soiled. This failure could place residents at risk for infection, deterioration of the wound and diminished quality of care. Findings included: Record review of Resident #1 face sheet reviewed 9/18/24 revealed a forty-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were an urinary tract infection, osteomyelitis of vertebra (form of spinal infection), pressure ulcer of the sacral region stage IV, and quadriplegia (paralysis of all four limbs. Record review of Resident #1's baseline care plan completed on 9/9/24 documented that Resident #1 needed assist x2 at bed rest, she was a fall risk, her bed should be in the lowest position. Resident #1 had a stage IV pressure ulcer to her sacrum., was a 2 person assist with bathing, and dependent on staff for meals. Her care plan also reflected that Resident #1 wore a nephrostomy (a procedure that creates an artificial opening in the skin and kidney to allow urine to drain directly from the kidney) bag and a colostomy (a surgical procedure that creates an opening in the abdomen to allow stool to pass into an external pouch) bag. Record review of Resident #1's Nursing Admissions assessment dated [DATE] by LVN A, documented that Resident #1 was oriented x4 to person/place/situation, had no memory loss, had clear speech, and she had a stage IV pressure ulcer to her sacrum upon admission. Under the gastrointestinal section, she was identified to be incontinent, and she utilized a colostomy bag. The Indwelling Cather Risk Assessment highlighted that the risks included but were not limited to symptoms of blockage of the catheter associated with bypassing urine, expulsion of the catheter, pain, and discomfort. Record review of Resident #1's BIMS score reviewed 9/18/24 undated revealed a score 15 out of 15, meaning the resident was cognitively intact with decision making. Record review of Resident #1's hospital discharge record dated 9/6/24 reflected that Resident #1 was to continue wound care for Stage IV pressure ulcer of sacral region, but she was advised that she would benefit from consulting with a plastic surgeon for flap management of her multiple ulcers. Records stated that her wounds on the sacrum were chronic, but she would also benefit from moisture control and frequent repositioning. Record review of Resident #1's initial wound care progress note dated 9/11/24 by the WCD documented that Resident #1 had a stage 4 pressure wound to the sacrum that measured 23.5x 19.5x 1 cm (LxWxH), with moderate serous (clear watery fluid), and 20% slough (the yellow/white material in the wound be). Treatment was to apply hypochlorous (weak, unstable acid) acid solution vashe and ABD pad once daily for 30 days. The WCD noted the resident had this wound for well over a year and she had written a consultation for a plastic surgeon evaluation. The WCD communicated with Resident #1 that her current treatment was to control infection and drainage, but she would need more aggressive surgical intervention if she attempted to close such a large chronic wound. The objective for wound care was to control infection and manage exudate (drainage). Record review of Resident #1's wound care progress note dated 9/18/24 by the WCD documented that Resident #1 had a stage 4 pressure wound to the sacrum that measured 23x 18x 1 cm (LxWxH), with moderate serous (clear watery fluid), and 20% slough (the yellow/white material in the wound be). Record review of the Resident #1's Physician Orders dated 9/18/24 reflected that wound care orders for stage IV sacral wound were to cleanse with wound cleaner, pat dry, apply Dakin's moist gauze, ABD (pads designed to provide high absorbency of wound exudate), and cover daily. Further review reflected there was not a PRN for this order. In an interview on 9/18/24 at 12:17 pm, CNA A stated she had worked at the facility for [AGE] years and she normally worked the 2pm- 10pm shift, but she had come in the morning of 9/18/24 to assist . She stated when she worked with Resident #1, she used a bed pad and briefs because there was so much water coming out of the wound. She stated the resident she had a colostomy bag coming from her body and she did not require her diaper changed because she did secrete waste (fecal matter or urine) in her diaper . CNA A stated the residents was always wet because of the wound that covered her entire buttock. She stated Resident #1 was total care, able to communicate her needs, and was able to use the call light on her own. In an interview with 9/18/24 at 12:38 pm, LVN A stated he had worked at the facility for [AGE] years and he worked the 6am- 2pm shift. LVN A stated the nurses changed the bandages as needed for wound care residents, but it was mainly done by the wound care nurse. LVN A stated Resident #1 was admitted with wounds and described them as bad. He stated the resident wore a brief just to wear one, but she did not physically need it because she did not use the restroom naturally. He explained because the wound was a stage IV and large, he would think there would be a lot of drainage. LVN A stated when Resident #1 first entered the facility, she had 2 waste bags attached to her, but one of the bags came out and she had to be sent to a urologist to try and get it replaced. In an observation and interview on 9/18/24 at 12:48 pm with Resident #1, The room had a strong odor in the air, but it could not be identified of what it was. Resident #1 stated that she was admitted to the facility on [DATE] for wound care. She stated the wound on her bottom caused her a lot of pain and although she had a waste bag (nephrostomy), she would still leak urine to the point where her diaper would be soaked, and the wound would burn. She stated the aides would only change the wetness from under her, but they would not change her bandages because they stated they were not allowed to touch the wound. The male nurse (DON) informed her the wound care nurse had not been available and the facility only had one wound care nurse. Resident #1 stated the DON told her the other nurses could perform wound care, but they had not been doing it. In a follow up interview on 9/18/24 at 1:55pm. Resident #1 stated she did not know when she would leak urine because she was a paraplegic and partially paralyzed from the waist down. However, she was able to tell when she had soiled herself because she would begin to feel icky, it would start to seep out from under the sides of her body, and she would start smelling urine. She explained she had let the aides know she was leaking and she did not know where they thought the fluid was coming from. She said she knew that she was leaking urine and it was not drainage from the wound was because of the smell of urine and she knew the difference. She stated leaking urine had always been an issue and when admitted , she came in with a pure wick (external catheter that allows for simple, non-invasive urine output management in female patients) in between her legs. In an interview on 9/18/24 at 2:21 pm, CNA B stated she had worked at the facility for one month. She stated Resident #1 as a 2-person total assist, and she would be wet on her back and bottom because of the drainage from the wound. She stated the resident's sheets would be wet and they would place a disposable pad on top of her sheets to prevent this. CNA B stated Resident #1's bandage and pads would be wet before she received wound care, but she changed her before wound care started and so the bed pad would be dry. CNA B stated on 9/17/24, Resident #1 was soaked so she changed her brief and repositioned her before she received wound care from the DON. She stated her vaginal area would be wet but expressed Resident #1 had never told her she had an incontinence episode. CNA B believed the drainage was due to her wound. In an interview and observation on 9/18/24 at 1:27 pm, the RRN stated that before she stepped into her current role in November of 2023, she used to be the DON at the facility. She stated if a resident received wound care to their sacral region, the best practice would be to have PRN orders in place. The RRN pulled up the treatment orders for Resident #1 and stated she did not see any PRN orders. The RRN stated because she had a nephrostomy and coloscopy bag, both types of body waste should be excreted in the appropriate bags. She stated a nephrostomy bag was hooked into the left and/or right kidney. She stated if the body was not producing urine, the tubes would take the urine directly from the source. The RRN stated that she believed Resident #1 may had the sensation, but she would not be truly urinating. She called the WCD during this interview and asked her to join them inside of the conference room. In an interview on 9/18/24 at 1:41 pm, the WCD stated that she had seen Resident #1 in the morning of 9/18/24. She explained Resident #1 was leaking urine from her urethra and the nephrostomy bag would not completely remove it, but urology was not her expertise so she could not explain how or why. The WCD stated Resident #1 was not going to be completely dry and her bandages should be changed if they were soaked through. She stated all sacral wounds have a PRN order to be changed and the RRN informed her that no PRN orders were associated with this treatment. The WCD told the RRN to put in a PRN order for Resident #1's bandage to be changed every time it was soiled and stated the wound did not get worst from last week to the current week. The State Investigator informed the WCD that the aides witnessed a substantial amount of drainage coming from Resident #1's wound and the WCD stated no it's not, it's urine and explained that she knew what urine smelled like. The WCD stated that all urine would soak through the bandage and the aids should have notified the nurse if the bandage was soiled or had fallen off. The WCD explained that if a nurse needed to change a bandage and the did not have an order, they would need to reach out and get one. She would have hoped that a nurse would have gotten a PRN order before changing the bandages on a wound. In an interview on 9/18/24 at 2:54 pm with the DON, he stated that he had been working at the facility for almost 3 months. He stated the admission process for a new resident was the admission department would let the nurses know through text that a new admit was coming to the facility and the nurse working at the time of arrival was responsible for completing the initial assessment. He stated if the wound care nurse was available, she would also do the skin assessment, but if she was not then the nurse doing the admission would put in an interim order for wound care. He stated that as a nurse manager, he would review the admission assessment to make sure it was completed, but he would not preform another evaluation of the resident unless there was a complaint or a concern. He stated when Resident #1 was admitted , she had 2 nephrostomy bags that were positioned into each kidney, but one had fallen out. She did go see a urologist, but they were not able to put the bag back in due to internal damage, so it was left out. Resident #1 was also not able to tolerate a catheter due to previous damage to her urethra. He stated even with the use of a nephrostomy bag, Resident #1 could still experience leakage because the nephrostomy bag would not catch everything. He explained that if her bandages were soiled, there should be a PRN order to address it. The DON stated the facility's wound care nurse was out and the floor nurses were currently completing wound care. He stated the facility did not use a pure wick (an External Catheter for females) and did not know Resident #1 was admitted with a pure wick. He stated he did not know that she was still urinating. The DON stated the harm in a resident having a soiled bandage over a wound could be infection. If a resident had a soiled bandage, it could allow bacteria to grow, infect the skin, and infect the tissues that were trying to heal. In an interview on 9/18/24 at 3:52 pm, LVN A stated she used to be one of the wound care nurses at the facility but currently worked the floor due to a decrease in the census. She stated when she performed the initial assessment with Resident #1, she did notice she had a pure wick in between her legs but she did not think anything of it. The facility did not use pure [NAME], so LVN A took it out and discarded it. LVN A stated the day of the assessment, an aide informed her that when they changed her brief, the brief was soiled, but they said it was due to drainage from the wound and they cleaned her up and put on a new brief. LVN A stated when she did wound care for Resident #1, she did not see a lot of drainage and she was not aware that Resident #1 would leak urine. She stated the harm in a resident having urine-soaked bandages over a wound would be a decline and a decreased healing process. Record review of the facility's Wound Care policy revised October 2010 reflected that in preparation for wound care, nurses should: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the resident may have PRN orders for pain medication to be administered prior to would care.

Based on interview and record review the facility failed to ensure the resident's right to be free from abuse for 1 of 6 residents (Resident #1), in that:. CNA C was seen on camera being verbally abusive aggressive towards Resident #1 which resulted in the resident feeling unsafe at the facility. This failure could place residents receiving care at risk of experiencing continued psychological distress and declining mental health. Findings included: Record review of Resident #1's clinical notes dated 3/20/24 at 1:29am by the Social Worker, resident is alert and oriented x4 (a measure indicating an individual is aware of their surroundings, knows who they are, where they are and what time it is, a positive sign of cognitive function). Record review of Resident#1's facesheet dated 3/21/24 revealed he was admitted on [DATE] with diagnoses of transverse myelitis (spinal cord inflammation, causing pain, muscle weakness and paralysis), paraplegia (the loss of the ability to move the legs and lower body), ocular hypertension (pressure increases within the eye and can cause damage and vision loss), anxiety disorder (group of mental illnesses that cause constant fear, worry and restlessness) and hyperlipidemia (abnormally high levels of lipids or fats in the blood). Record review of Resident #1's MDS dated [DATE] revealed that his BIMS (Brief Interview for Mental Status, an assessment to determine cognitive function) score was 13. Record review of Resident #1's care plan dated 3/8/2024 revealed: -Resident has a diagnosis of Anxiety Disorders manifested by Verbal Distress -Resident has a diagnosis of Anxiety Disorder with physical manifestations of anxiety. -Resident requires extensive assistance with: turning/positioning in bed, transfers, dressing, toileting, locomotion on and off his wheelchair -Resident is totally dependent on the staff for bathing Record review of the facility's grievance log revealed there was no record of the incident on 3/19/24. Record review of the facility's Incident/Accident report log date revealed no record of the incident on 3/19/24. Record review of Resident #1's Grievance Reports revealed that on 8/17/23 Resident #1's family member reported to the facility that a staff member was rude. The former DON met with Resident #1 alone, who stated he did not have an issue with the nurse but feels like she talks loudly at times. The DON stated she will provide education and guidance to the nurse on customer service. DON also provided her number to Resident #1 and told him to call with any concerns. On 12/28/23, Resident #1's family member said the facility did not allow resident to go to bed at his preferred time. Resident #1 told the staff that he does not have a problem. On 2/28/2024, Resident #1's family member said she believed a staff member bumped Resident #1's toes while transferring him and that the staff blocked the camera. The facility educated staff on ensuring no items are obstructing the camera's view going forward. The facility also conducted an interview to determine if there were incidents where Resident #1 could have been injured; therapy also evaluated Resident #1 for wheelchair safety. Interview with Resident #1's family member on 3/21/24 at 1:10pm, she said on 3/19/24 around 9:00pm she has video evidence of CNA F and CNA C being rude to Resident #1 and accusing him and his family member of being verbally and racially abusing staff members. She denied this and stated that she does raise her voice but has never been racist towards staff. She was difficult to follow as she required frequent redirection back to answering questions. She mentioned several incidents of inadequate care which ended in her asking Administration to limit certain staff from providing care to Resident #1. Additional interview with Resident #1's family member on 3/21/24 at 3:06pm, she stated that she reported this incident on 3/20/2024 as a grievance to the front desk. She said when the DON returned to the facility the morning of 3/21/2024, she went to Resident #1's room and discussed the incident with her around 1:00pm that day and after watching the videos told the family member the facility is looking into it. Interview with Resident #1 on 3/21/2024 at 3:20pm, he stated that he felt like he was not treated with dignity and respect regarding the incident with CNA C. He said he felt unsafe being at the facility. During an interview with CNA A on 3/22/2024 at 10:50am, she stated she had abuse in-services the previous week, including reporting injuries of unknown origins and who to report to including the state. Interview with CNA G on 3/21/24 at 3:20 PM, said that the facility uses 2 staffs for Hoyer lift transfer from bed to wheelchair and from wheelchair to bed . She had abuse training and knew who to report to including the state. Interview with the DON on 3/21/2024 at 4:31pm, she said that in the video Resident #1 showed her, she witnessed an employee making inappropriate comments toward a resident. She said Resident #1's family member has grievances almost every day, and that it's not the resident but his family member who doesn't like a lot of staff. She is inconsistent about which staff she wants to provide care to Resident #1. The DON stated she has received reports of the resident's family member being verbally aggressive. She feels that it's unfair that the family member treats staff like this, but she tells staff that it's part of the job. She reviews the grievance log and investigates abuse and neglect. Interview with the Administrator on 3/21/24 at 4:46pm, he stated that he is the Abuse Coordinator at the facility. He has tried to set up a meeting with the resident and the Ombudsman but was told the request had to come from the resident or their representative. He said Resident #1's family member has refused to meet with the facility's Ombudsman. Interview with CNA H on 3/22/24 at 10:48 AM, said she had abuse training and knew who to report to including the state. Interview with CC.NA I on 3/21/24 at 3:55 PM, reflected that she worked for the facility for 3 years on Resident #1's hall. She had abuse training and knew who to report to including the state. Interview via telephone with C.CNA F on 3/22/24 at 10:15 AM, he said he had worked with facility for 6 months. He said he had weekly training on abuse and neglect. Attempted interview via telephone with the alleged perpetrator C.CNA C on 3/22/24 at 11:30AM and 12:00 PM with number provided and left message on voice mail and no response. Interview with the Administrator on 3/22/24 at 11:55am, he stated that Resident #1's wife has told 90% of the staff they don't want them to care for him, and that does not leave many people left. Resident's wife is also verbally abusive to staff, and that he records incidents in Administration notes . Record review of Resident #1's camera revealed that on 03/19/2024 between 9:13pm to 9:41pm, CNA F and CNA C were in resident's room providing care during a transfer from wheelchair to bed using a mechanical lift. During the transfer the video revealed: -At 9:17pm, CNA C addressed Resident #1, Is it your bath day today? I'm not giving you a bath today, shit. -At 9:20pm, C.NA C asked Resident #1, And nobody can come in here. What's your problem? What's going on? Ya'll call black people monkeys? Huh? When Resident #1 responded that blacks are all humans with whites, C.CNA C asked So why do you all call them monkeys? Your family does. That's not nice. -At 9:22pm, CNA C stated Resident #1 and his family member call black people monkeys and that's why nobody wants to come in to assist the resident. She then said that Resident #1 tells his family about negative stuff, and you know she don't play about [Resident #1]. -At 9:32pm, CNA C said not even a nurse can even come in here, boy this is some dumb shit. Immediately after, CNA C turns to face the camera, shook her right index finger while addressing Resident #1's family, you need some help, before turning to the resident and saying not even a nurse can come in here. Call your family, tell her to look in the camera, call her right now, act like we're mistreating you. Record review of C.CNA C's personnel files revealed that the last background check was conducted 10/2/2023 and found no concerns. Record review of C.CNA F's personnel files revealed that the last background check was conducted 11/22/23 and found no concerns. Record review of the facility's Abuse and Neglect in-service for All Staff revealed it was conducted on 3/14/2024. Record review of the facility's Abuse Prohibition Policy dated April 2019 stated that: 1. The patient has the right to be free of abuse, neglect, mistreatment of resident property and exploitation . Our Facility will not condone patient abuse, neglect . 2. The Abuse prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment. It further defines abuse as: the willful infliction of injury .intimidation or punishment with resulting physical harm or pain or mental anguish, and that willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It goes on to say that verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to the patient or their families, or within their hearing distance, to describe Patient, regardless of their age, ability to comprehend, or disability.

Based on record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 4 residents (CR#1) reviewed for pharmaceutical services. The facility failed to acquire and dispense [MEDICATION(S)] 550 mg tablets, a medication used to lower the risk of reduced brain function for individuals with liver [CONDITION(S)], as ordered on 03/30/21 through 04/04/21 . CR#1 missed 10 doses of this medication resulting in her increased [MEDICATION(S)] levels, increased confusion, altered mental status in CR #1 and subsequent hospitalization . This failure could place residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: CR#1 Record review of CR #1's face sheet revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: fracture of right femur, type 2 diabetes, [CONDITION(S)], hypertension and [CONDITION(S)] of the liver. There was no documented diagnoses of [CONDITION(S)] and an incorrect diagnosis of irritable bowel syndrome. Record review of CR #1's Admission Minimum Data Set (MDS) dated [DATE] revealed: resident had adequate vision, a worsening of behaviors or other symptoms, extensive assistance with most activities of daily Living (ADL), received insulin, received occupational/physical therapy ambulated with a wheelchair and was frequently incontinent of bladder and bowel. Record review of CR #1's document titled Brief Interview of Mental Status dated 04/02/21 revealed: intact cognition with a BIMS score of 13 out of 15. Record review of CR #1's incomplete comprehensive care plan initiated 03/31/21 revealed in part: risk for falls, ulcer prevention. There were appropriate goals and intervention for identified problems. Incorrectly identified Problem: Antibiotic and at risk for adverse reactions, Goals- infection will be resolved or resolving at the end of therapy. Interventions: follow universal/standard precaution to prevent cross contamination and spread of infection. There was no documentation of CR #1's need for therapy services, use of insulin, diagnoses of liver [CONDITION(S)], hypertension, and [CONDITION(S)]. Record review of CR #1's Hospital Lab- Chemistry dated 03/21/21 revealed resident's [MEDICATION(S)] level was high at 113. Record review of CR #1's Physician Orders dated 03/26/21 revealed: [MEDICATION(S)] ([MEDICATION(S)]) 550 mg, 1 tablet twice daily for 30 days, [MEDICATION(S)] ( a medication that help increase bowel movement and decreases the amount of [MEDICATION(S)] in the blood) 10 grams/15 milliliters 30 ml every 6 hours. Record review of Pharmacare (Pharmacy) Packing Slip dated 03/26/21 revealed in part: 6 tablets of [MEDICATION(S)] 550 mg were delivered to the facility for CR #1. Record review of CR #1's Medication Not Administered report for 03/26/21 - 04/20/21 revealed in part: - 03/30/21- 08:00 PM [MEDICATION(S)] 550 mg tablet, not administered awaiting delivery at 03/30/21 at 22:18 PM signed by LVN U. - 03/31/21- 08:00 PM [MEDICATION(S)] 550 mg tablet, not administered still awaiting delivery at 03/31/21 at 22:33 PM signed by LVN U. - 04/01/21- 08:00 PM [MEDICATION(S)] 550 mg tablet not administered signed by RN O. - 04/02/21- 08:00 AM [MEDICATION(S)] 550 mg tablet not administered signed by RN O. - 04/02/21- 08:00 PM [MEDICATION(S)] 550 mg tablet not administered signed by LVN U. Record review of Physician Progress note dated 03/30/21 revealed: patient continues to tolerate all medications including [MEDICATION(S)] ([MEDICATION(S)]) for [CONDITION(S)]. Patient is awake and pleasant and conversant; mentation is relatively clear. Record review of Clinical Notes Report dated 04/03/21 revealed: Patient spouse present at bedside and states would like patient [MEDICATION(S)] increased. Called and left message for on call team, return call received, telephone order obtained for [MEDICATION(S)] 45 ml by mouth 4 times daily. Record review of Nurse Practitioner (NP) Progress Note dated 04/05/21 revealed: Over the weekend spouse noticed increased confusion and requested for [MEDICATION(S)] dose to be increased. Upon further investigation it was noticed [MEDICATION(S)] is not currently available from pharmacy. Nurse states family is planning to bring medication to facility from home supply. [CONDITION(S)]- continue management with [MEDICATION(S)] and [MEDICATION(S)], I discussed with family about making [MEDICATION(S)] available. Record review of CR #1's April MAR dated 04/05 revealed: Notes- Medication ([MEDICATION(S)]) was not available pharmacy notified, NP aware signed by LVN N. The administration record was changed on 04/05/21 at 11:14 AM by the ADON with reset reason: patient now able to take (indicating medication is now available at the facility for administration). The original recorded status of not administered for CR #1's 04/05/21 08:00 [MEDICATION(S)] signed by RN J on 04/05/21 at 9:11 AM. Medication supplied by family and administered as order, ADON aware signed by LVN N. Record review of facility visitation log for 04/05/21 revealed: FM #2 visited CR#1 on 04/05/01 at 10:57 AM. Record review of CR #1's Clinical Notes Report dated 04/12/21 revealed: CR #1 had labored breathing and was difficult to arouse and was transferred to the hospital at 8:00 AM per the NPs order. Record review of CR #1's Hospital Records dated 04/12/21 revealed: Chief Complaint- Altered Mental Status (AMS), note- patient arrived by emergency medical services (EMS) from {facility}due to AMS .per EMS from {facility} staff patient is normally alert and oriented to person, place and time, currently patient only responds to painful stimuli. Record review of facility emergency kit (E-Kit) inventory provided on 04/14/21 revealed: no [MEDICATION(S)] 550mg is stored in the E-Kit. Record review of pharmacy email thread provided on 04/14/21 revealed: On 03/26/21 the pharmacy sent an email to the DON, ADON, ED and Unit Manager with the subject: [MEDICATION(S)] price approval request for CR #1. The email read- the indicated medication(s) is a high cost item that will reflect on your outlier. The pharmacy will send a three-day supply while waiting for approval from the DON or ED. Please contact the pharmacy with an approval as soon as possible during normal pharmacy hours. On 04/05/21 the pharmacy sent another email to the DON, ADON, ED and unit manager with subject: Re: [MEDICATION(S)] price approval for CR #1. The email read- received another request. Please respond to price authorization. In an interview conducted on 04/14/21 at 11:47 AM, FM #1 said on 04/05/21 she noticed increased confusion in CR #1 and asked if she was receiving her [MEDICATION(S)]. FM #1 said she was informed that the facility did not have [MEDICATION(S)] available for CR #1 because it needed authorization. FM #1 said a family member brought in CR #1's [MEDICATION(S)] at her request on 04/05/21. In an interview conducted on 04/14/21 at 03:50 PM, the RPH said the pharmacy received an order for [MEDICATION(S)] 550 mg on 03/26/21 and a onetime 3-day supply of 6 tablets was delivered to the facility on [DATE] at 12:00 AM. The RPH said the medication delivered would provide doses for 03/27/21, 03/28/21 and 03/29/21 if administered as ordered. The RPH said an email was sent on 03/26/21 to the DON, ED and unit manager stating [MEDICATION(S)] was a high price medication and authorization was needed but no response was received. The RPH said a reminder was sent to the facility on [DATE] but there was no response and the facility E-Kit did not contain [MEDICATION(S)] because it was a high price item. Observation and interview on 04/20/21 at 10:17 AM with the ADON revealed: an unlabeled Ziplock bag containing 9 foil wrapped tablets with a manufacturer stamp of [MEDICATION(S)] 550 mg, equivalent to a 4 ½ day supply if administered as ordered. The ADON said the medication for CR # 1 was delivered in an unlabeled bag and she does not know the date it was delivered. The ADON said she did not know why the family member brought in CR #1's medication and maybe the pharmacy said the cost was not covered. The ADON said there is no requirement to log resident medications brought from home, but receipt should be documented in the resident's chart. In an interview conducted on 04/20/21 at 10:30 AM, the DON said CR #1's [MEDICATION(S)] was delivered by the family on 04/05/21 per the MAR note. She said she did not know why there were no notes for medication administration on 04/03/21- 04/04/21 but the medication was not at the facility yet. The DON said she did not know why the medication was not administered. The DON said when resident home meds are received, they should be labeled with the resident's name, medication name, route of administration, dosage and room number. The DON said LVN U was on vacation and LVN N had resigned. In an interview conducted on 04/20/21 at 11:41 AM, FM #2 said on the 04/05/21 he brought 10 days, 20 tablets, of [MEDICATION(S)] 550 mg to the facility after he was informed that CR #1 did not have any medication and an authorization would need to be completed for the facility to receive more. In an interview conducted on 04/20/21 at 12:00 PM, the ADON said per the MAR LVN M administered CR #1's [MEDICATION(S)] on 03/30/21-03/31/21 and it was available in the facility. The ADON said she did not have any documentation to show the medication was received prior to 04/05/21 and her assertation was based on what LVN M told her. The ADON said LVN U must have made documentation errors on her 03/30/21-03/30/21 night shifts since she documented that the medication was not available. The ADON said LVN U was on vacation, out of the country, and would not be available for an interview. In an interview conducted on 04/20/21 at 12:12 PM, Case Manager G said CR #1 was admitted to the hospital on 04/20/21 with diagnoses of urinary tract infection, severe [CONDITION(S)] secondary to aspiration pneumonia and acute [CONDITION(S)] (becoming unresponsive, unconscious, and entering into a coma) with an [MEDICATION(S)] level of 170. In an interview conducted on 04/20/21 at 01:10 PM, RN O said she did not work with the resident and did not know her. RN O was showed CR#1's MAR where she documented she did not administer [MEDICATION(S)] to CR #1 on 04/01/21 - 04/02/21 . RN O then said she did not administer the medication because the medication was not available at the facility. In an interview conducted on 04/20/21 at 02:21 PM, the NP said over the weekend (04/03/21) CR #1's family was concerned about her increased confusion. The NP said when she visited on the following Monday CR #1 appeared to be confused, so she talked to an unnamed nurse about the resident's medication regimen. The NP said the nurse informed her that CR #1's [MEDICATION(S)] was unavailable because it needed authorization and the pharmacy provided the previous doses of [MEDICATION(S)]. The NP said the family said they would bring in the medication. The NP said that if CR #1 did not receive her [MEDICATION(S)] as ordered, the resident would have increased confusion and altered mental status, but the resident had a known history of confusion. The NP said she was not sure of the date she was informed CR #1's [MEDICATION(S)] needed approval but she will look through her notes and call the surveyor back. In an interview conducted on 04/20/21 at 04:54 PM, the NP said that she was informed that CR #1's [MEDICATION(S)] needed authorization on 04/05/21. The NP said CR #1's [MEDICATION(S)] level was 113 on 03/21/21 and missing doses of [MEDICATION(S)] would result in an increased [MEDICATION(S)] level, increased confusion and altered mental status. The NP said CR #1's mentation was clear on 3/29/21 but on her next visit on 04/05/21 the resident was confused; the residents mental status went back and forth during the time she saw her. The NP said on 04/12/21 she received a call from a nurse saying CR #1 was not arousable and having trouble breathing so she gave the order for the resident to be sent out to the hospital. In an interview on 04/22/21 at 12:47 AM, LVN M said she administered [MEDICATION(S)] to CR #1 during her shifts on 03/30/21 - 03/31/21 and documented it on the eMAR. She said the medication was in an unlabeled bag in the medication cart with the rest of CR #1's medication. LVN M said the medication was brought in by CR#1's family member and it was only a few tablets; she did not receive CR #1's [MEDICATION(S)] and does not know the exact quantity or date it was delivered to the facility. LVN M said the night shift nurse, LVN U, may not have seen the medication to administer on her night shifts because it was in an unlabeled bag. In an interview on 04/22/21 at 12:59 PM, the ED said LVN N had resigned and LVN U was still on vacation and unavailable for interview. Record review of facility policy titled Nursing Policy & Procedures Manual- Documentation of Medication Administration on eMAR/eTAR dated 03/2016 revealed in part: 5. When removing medication(s) from the package the RN, LVN or CMA will electronically sign the eMAR/eTAR then administer the medication or the RN, LVN or CMA will remove the medication from the package, administer the medication then initial the eMAR/eTAR. If the patient refuses or the medication is not given due to other situations . the refusal is noted in the eMAR/eTAR. Record review of facility policy titled Patient Care Management System 4- Medications dated 11/2017 revealed in part: The DON or his/her designee must audit medication carts according to re-order protocol located in the Nursing Policy & Procedure Manual. Record review of undated facility policy titled [name of pharmacy consultant] Consultant Pharmacist Services, LLC Medication Administration revealed in part: You must document on MAR and administration notes why dose was not given. Interview on 04/20/21 at 10:00 AM and 04/22/21 at 10:00 AM, facility policy for medication acquisition was requested from the ADON was not provided prior to exit. Attempts were made to contact LVN N on 04/20/21 and 04/21/21 by telephone, there was no response. Attempts were made to contact LVN U on 04/20/21 and 04/21/21 by telephone, there was no response.

Based on observation, record review and interview the facility failed to consult with the resident's physician when a significant change occurred on 10/28/2019 in the resident's physical and psychosocial status for 1 of 11 residents (Resident #1) reviewed for physician consultation in that: The facility failed to consult Resident #1's physician for 7 days when on 10/28/2019 bruising was noted on the resident's chest. Resident #1's physician was not consulted of the bruising until a family member observed the bruising that was in various stages and colors and covered the resident's entire chest area on 11/03/2019. An immediate jeopardy ( IJ) was identified on 11/08/2019. While the IJ was lowered the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy due to the facility continued to monitor the plan of removal for effectiveness. This failure affected 1 Resident (Resident #1) and placed her at risk of her physician not managing her health care needs which lead to delay in medical treatment and continuation of anticoagulant therapy. Findings Include: Record review of clinical face sheet for Resident #1 revealed she was an [AGE] year-old female admitted to the facility 06/22/2016. [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] indicated a BI[CONDITION] score of a 3 out of 15, indicating severe cognitive impairment. MDS further noted that Resident #1 required extensive assistance with 1-person physical assist for bed mobility, transfer, toilet use and personal hygiene. Resident #1 was total dependence of 1 staff for ambulation. MDS further revealed Resident #1 was always incontinent of bowel and bladder. Resident #1 was not steady moving from seated position to standing position and was not steady for surface to surface transfer. Record review of Resident #1's care plans read in part . Resident #1 is at risk for bleeding/bruising related to medication regimen ([MED]) not dated. Goals- Resident #1 will have 0 to minimal episodes bruising or uncontrollable bleeding within the next 90 days. Interventions: Assess for presence of factors placing at risk for increase bleeding, observe for signs of bleeding in stool, urine, sputum, vomitus, gums, abnormal bruising, petechia, purpura or presence of nosebleeds. Vital signs as indicated. Follow anticoagulant protocol. Use caution with manual transferring or positioning. Check for new bruising/bleeding with ADL care. Report any abnormal bleeding or new bruising to health care provider and RP. Monitor lab results and report abnormal results to health care provider. Transfers (to/from: bed chair wheelchair, standing position) not dated. Goals- Resident #1 will complete transfers with assistance of 1-2 people/lift devices as required. Interventions: Resident #1 to be out of bed in chair. Explain to resident the process when transferring. Resident #1 is dependent on 1 staff for transfers. Resident #1 has impaired bed mobility not dated. Goals- Resident will have improved bed mobility next review date. Interventions: Resident #1 requires extensive assist by 1 staff for bed mobility. Record review of Physician order [REDACTED].#1 dated October 2019 revealed the following orders: Aspirin 81 mg tablet, delayed release ([MEDICATION NAME] coated) oral every morning for [DIAGNOSES REDACTED]. Order date of 10/07/2019 X-ray of left shoulder, left humerus. Left elbow and left forearm to rule out fracture and/or dislocation. RP aware. Ordered date of 11/05/2019 (date was on document) Anticoagulant Side Effects. Notes: [MED] RP aware. Order date of 0[DATE] Record review of Physician order [REDACTED].#1 dated November 2019 revealed the following orders: Aspirin 81 mg tablet, delayed release ([MEDICATION NAME] coated) oral every morning for [DIAGNOSES REDACTED]. Order date of 10/07/2019 X-ray of left shoulder, left humerus. Left elbow and left forearm to rule out fracture and/or dislocation. RP aware. Ordered date of 11/05/2019 Anticoagulant Side Effects. Notes: [MED] RP aware. Order date of 0[DATE] Record review of Treatment Administration Record for Resident #1 dated 11/01/2019-11/05/209 revealed the following orders: Weekly head to toe assessment, one time weekly starting 06/18/2017. Documentation revealed that head to toe assessment had been completed by Treatment Nurse #9 on 11/02/2019, no bruising or discoloration to Resident #1's chest or abdomen was documented. Record review of Weekly Head to Toe Assessment Notes for 10/26/2019 documented by Treatment Nurse #9 revealed the following . Skin condition- pressure Documentation of Head to Toe Assessment Note did not reveal any documentation of bruising or discoloration to Resident #1's chest or abdomen. Record review of Weekly Head to Toe Assessment Notes for 11/02/2019 documented by Treatment Nurse #9 revealed the following . Skin condition- pressure. Documentation of Head to Toe Assessment Note did not reveal any documentation of bruising or discoloration to Resident #1's chest or abdomen. Record review of SBAR dated 11/03/2019 and completed by RN #4 read in part . Family member came visiting and she wanted to reposition Resident #1. On turning her, we noticed there was discoloration on her upper chest region. Family member took pictures of it. Vital signs taken, and the NP notified. Skin evaluation portion of SBAR had the No changes observed box marked. No description of the bruising or measurements were noted. Record review of nurse's notes written by RN #4 dated 11/03/2019 at 10:28 PM read in part . Patient is alert and responsive lying in bed when family member came visiting. Family member wanted to reposition Resident #1. On turning her, we noticed there was discoloration on her upper chest region (ecchymosis). The family member took pictures of it. NP notified, she ordered [MED] be discontinued. Patient is made comfortable, v/s taken, she remains stable while I continue to watch for any change in condition. Further review of nurse notes did not reveal any other documentation of bruising for dates 10/27/19-11/03/19. Record review of physician progress notes [REDACTED]. History/Visit Type New problem, nursing concern, coordination of care, medical records reviewed Chief Complaint: follow up needed to evaluate due to notified by nursing on Sunday PM, 11/03/2019, due to noted extensive bruising on Left upper extremity, chest and bilateral breast, no reports of falls or trauma. Resident with [MED]-induced coagulopathy due to left upper extremity [MEDICAL CONDITION]. Order given to discontinue [MED] and continued [MEDICAL CONDITION] monitoring. Record review of hand-written statement from Restorative Aide #5 (RA) not dated, read in part . I, RA #5 on November 1, 2019 at 10:00 am in the morning, I checked the weight of Resident #1. When I was assisting her, and I saw bruised on her chest. Immediately I notified to the nurse: RN #6. Interview with Restorative Aide #5 on 11/08/19 at 10:17 AM, she said she was performing monthly weights on 11/01/2019. She said when she went to weigh Resident #1, she noticed a dark purple color across her chest. RA #5 said she said to herself What the hell. She said she then went to her nurse RN #6 and told her about the bruising and the nurse told her that she was aware and that the bruising was getting better. RA #5 said that RN #6 said the resident was on blood thinners. RA said she said ok and continued with the weighing of Resident #1. RA said that nurse RN #6 did not get up to assess resident and continued to sit at the nurse's station and type on her computer. RA #5 said the bruising was across the resident's chest and she could see it because the clothes she was wearing was low cut. RA #5 said she did not pull her clothes black to look at the bruising any further because the nurse said she was already aware of the bruising. Record review of email statement written by RN #4 to Administrator dated 11/06/2019 read in part . On 11/03/19 while repositioning Resident #1, in presence of family member. We noticed a discoloration on her upper chest region. (Ecchymosis). Family member took pictures and SN (staff nurse?) assessed the patient, notified the NP and supervisor on duty. NP ordered [MED] be discontinued. Documented on the nurses skilled note and SBAR. Interview with RN #4 on 11/08/19 at 10:26 AM, she said that she was repositioning Resident #1 with the help of her family member on 11/03/19 and she noticed discoloration on her chest. RN #1 said she notified the NP and the NP asked if she was on blood thinners. NP discontinued the blood thinner. RN #4 said she took Resident #1's vitals, fixed the bed and continued to monitor for change of condition throughout her shift. RN #1 said she documented her findings on the SBAR and in her nurse note. RN said she did not check range of motion or check anywhere else on resident's skin bruising. RN #4 said she notified the weekend supervisor (RN #3) of the bruising. RN #4 said that the protocol is to notify the supervisor of changes in condition, notify the physician/NP, notify the RP and follow any orders. Interview with CNA #2 on 11/06/2019 at 11:50 AM, she said that when she transfers Resident #1, she lifts her up by her pants. She said she always had someone with her for the transfer because I'm little and not going to hurt my back. Interview with Therapy Director on 11/07/2019 at 11:30 AM, she said staff should have been transferring Resident #1 with a gait belt due to her size and condition. Therapy Director said that it would not be safe to transfer Resident #1 via a hoyer lift and staff shouldn't put her through that. She said for transfer that 1 staff member should be holding her legs and the other staff member should be transferring by holding her arms. Therapy Director was asked if a gait belt or the transfer she just described would be safe for Resident #1 and she said that she couldn't be sure if the gait belt or transfer she described was safe at the time because there is no cookie cutter approach. Director of Therapy said that the transfer methods change per CNA visit to the residents room because the residents requirements change daily. Director of Therapy said she is a Speech Therapist by trade and can't speak for any other staff. Director of Therapy said that she trains staffing on resident transfers along with the staffing coordinator. Record review of staff statement signed by CNA #2 on 11/07/19 read in part . I CNA #2 returned to facility on October 28, 2019. On the day of 10/28/2019, I was heading into Resident #1's room and was stopped by the nurse. The nurse informed me of a bruise on her chest area. Interview with CNA #2 on 11/08/19 at 10:14 am, she said she returned to work on 10/28/2019 and was heading to Resident #1's room to provide activity of daily living care (ADL) as resident is dependent on staff for care. CNA said she was stopped by nurse (RN #6) and was told not to get resident out of bed because she had bruising to her chest. CNA #2 said she saw the bruising to Resident #1's chest on 10/28/19 after she was notified by the nurse and that the bruising was purplish with green and yellow and it was on her chest. CNA #2 said the bruise looks the same today (11/08/2019) as it did on 10/28/19. CNA said she did not document the bruise in her notes because the nurse already knew about it and she thought the nurse had already taken care of it. Record review of staff statement that was emailed to the Regional Director of Operations (RDO) from staff member RN #3 (weekend supervisor) dated 11/07/19 read in part . When RN #4 stopped me about Resident #1, she told me she had found a bruise across her chest area. She said she notified the Nurse Practitioner (NP) and that she got a new order to stop blood thinner patient was taking at the time. I told her to make sure she did an assessment on patient and to notify everyone else as well as do proper charting on the patient. She said ok. Interview with RN #3 on 1[DATE]19 at 2:59 PM, she said that she was notified by RN #4 that Resident #1 had bruising across her chest on. RN #3 said that she told RN #4 to notify the physician of the bruising and do an assessment. RN #3 said the bruising was probably caused by the [MED] as she has seen bruising before on residents who are on [MED]. RN #3 said she had never seen a bruise that large before but Resident #1 is very fragile. Record review of hand-written statement dated November 7, 1920 (2019?) and signed by LVN #7 read in part . In regard to bruising on Resident #1, I was notified by CNA on 11/30/19 (10/30/19?) about bruising. I noted some redness which I explained to CNA was due to [MED]. Record review of hand-written statement dated 11/07/2019 and signed by Shower Aide #8 read in part . On the [DATE], when I was giving Resident #1 a bed bath, I noticed a black spot on her. I called my nurse to come and see it, and she told me its because of the medication. On 11/01/2019, I still saw it there getting bigger. Interview with Shower Aide #8 on 1[DATE]19 at 2:55 PM, she said that she noticed a large black area of bruising on the left side of Resident #1's chest that covered the whole left side of her chest and went across to the other side of Resident #1's chest. Shower Aide #8 said the right side of Resident #1's chest was not as bad and it was lighter in color. Shower Aide #8 said she informed LVN #7 of the bruising on [DATE]. Shower Aide #8 said LVN #7 looked at the bruising and said it was because the resident was on blood thinners. Shower Aide #8 said she did not tell anyone else of the bruising because she thought LVN #7 took care of it. Observation of Resident #1 on 11/05/19 at 4:51 PM revealed resident lying in bed on her left side. RN #1 accompanied surveyor to resident's room. RN #1 lifted resident's gown and a large deep purple, burgundy bruise with various shades of blue and black was observed on Resident #1's chest that started under her left arm and extended down to her upper abdomen and went across her chest to the right side and went under her right arm. Bruise was in different stages of healing as it had colors of deep purple, burgundy, blue, black and outside edges had green and yellow. Dark purple bruising was observed around resident's right breast that covered the lower half of her breast and surrounded the areola. Upper area of Resident #1's abdomen had large yellow/green area across the top half of her abdomen with greater than five dark blue areas of bruising that were the size of a dime inside of the yellow/green area at various stages of healing. Interview with RN #1 on 11/05/2019 at 5:10 PM, she said she was not aware that Resident #1 had bruising to her chest until she raised resident's gown and observed it earlier with surveyor. RN #1 did say that she was told that the resident had ecchymosis. RN #1 was asked if it looked like ecchymosis to her and she said no. RN #1 said that this was her first time to see it and she would have to call the NP. Interview with RN #1 on 11/05/19 at 5:15 PM, she said the NP said she had been at the facility earlier in the day and assessed Resident#1. RN #1 said that the NP believes the bruising is from [MED] and that is why she stopped it. RN #1 said that the NP said that the bruising went across her chest because that is how the resident keeps her arms (across her chest) and her body/chest rest on her arms. Interview with Resident #1's family member on 11/05/2019 at 4:00PM, family member said that she was concerned because Resident #1 has severe bruising across her chest that goes from her left arm to her right arm, its deep purple in color with green around it and it is from her upper chest area to the top of her abdomen. Family member said that she was concerned for Resident #1's health and safety, because during a visit, she witnessed a staff member manhandle Resident #1 during a transfer. Family member said one of the nursing staff grabbed Resident #1 by her shirt and waist of her pants and picked her up from the bed and put her in a chair. Family member said the facility has her on anticoagulants and feels that she should be transferred with a lift because she can't help during a transfer and her legs are contracted. Family member said Resident #1 is totally dependent on staff for all her needs and is not able to express needs or provide for herself. Family member said she has photos of the bruising to Resident #1's chest. Interview with the Administrator on 11/06/19 at 11:30 AM, he said he was not aware of the bruising to Resident #1's chest until he went into the room on 11/05/19 with surveyor, RN #1 and Treatment Nurse #10. Administrator said that when bruising like that is observed that staff should notify the unit managers immediately. Administrator said he was the Abuse Coordinator but when there is bruising that was related to clinical reasons then staff report it to unit managers. Administrator said that since the bruising was related to the [MED] per the NP and that staff should have notified the unit managers. Interview with Regional Director of Clinical Services, on 11/06/19 at 11:45 AM, she said she was not aware of the bruising to resident's chest until 11/05/19 when surveyor mentioned it. She said it had not been reported previously. Regional Director of Clinical Services said she was assisting facility as the facility currently did not have a DON. Interview with the NP in person on 11/06/19 at 12:00PM, she said she was notified by the nurse of the bruising to Resident #1's chest area on 11/03/19 and that was the first notification of bruising from nursing staff. NP said the nurse sent her a photo of the bruising and she was able to see it from the photo. NP said she discontinued the [MED] because she believed the bruising was caused by a spontaneous hemorrhage. NP said she remembered saying something like ugg when she saw the picture of the bruised area and asked the nurse if there had been a fall or any trauma and the nurse said no. NP said resident has a history of [MEDICAL CONDITION]. NP said resident was started on [MED] because of a [MEDICAL CONDITION] to her left arm. NP said she truly believed the bruising is from the [MED] and does not believe the staff is abusing or being rough with the resident or residents. Interview with Unit Manger/RN #11 on 11/08/19 at 10:43 AM, she said she first became aware of the bruising to Resident #1's chest on 11/05/19 when she received a text from the facility. Unit Manger said she looked in the resident's chart online from home and saw that an SBAR was done and that the NP had been notified by the nurse on 11/03/19. Unit Manager said that the resident's RP said the NP discontinued the blood thinner because she believed it caused spontaneous bruising to resident's chest. Unit Manager was asked what the expectations of her staff are on care of residents on anticoagulant therapy and assessments and change in condition. Unit Manger said that nurses are supposed to notify the supervisor that is working during the shift of change in condition, bruising or issues, notify the physician, notify the RP and follow any new orders. Unit Manger said she would like to be notified of changes, as well. Unit Manager said that the DON should be notified but the facility currently does not have a DON. Unit Manger said that the nurse should have called the physician on 10/28/19 when the bruising was first noted. Unit Manager said that if Residents are on blood thinners that staff are to visually inspect their skin on every shift to monitor for any changes. Unit Manger said if she observed a bruise on a resident that was like the one Resident #1 had, she would be concerned. Unit Manger said she started interviewing staff on Tuesday about the bruising. Interview with Treatment Nurse #10 on 11/06/19 at 1:10PM, she said she had been providing wound care to Resident 1's mid back pressure ulcer for the past 1-2 weeks but had not noticed the bruising to the chest area or abdominal area prior to state being in the building. Interview with RN #12 on 11/07/19 at 11:17 AM, he said he was trained recently on anticoagulants and assessments but did not know who provided the training or when it was, but he believed it was a few days ago. Interview with Unit Manager #1, on 11/07/19 at 11:20 AM, she said that they recently had in-services for assessments and anti-coagulants, but she wasn't sure when. She said the Unit Mangers perform the in-services along with the DON but the facility doesn't currently have a DON. In an interview with RN #6 on 11/08/19 at 10:08 AM via phone. She said that she became aware of the bruising to Resident #1's chest on Monday 11/04/2019. RN #6 said that there was old bruising to Resident #1's left arm and she noticed bruising to her chest. She said that she read the progress notes from the weekend shift and saw that there was a nurse note that said the NP was notified on 11/03/19. RN #6 said that she had not been informed by any CNA's or Restorative Aides that Resident #1 had bruising across her chest prior to 11/04/2019. RN #6 said she had worked on 10/28/19-11/01/2019 and cared for Resident #1 but had not seen any bruising nor had she been informed of any bruising by the CNA's or Shower Aides. Interview with RDO on 11/07/2019 at 11:45 AM, she said that she does not believe the bruising occurred due to transferring Resident #1 with a gait belt. She said that she interviewed staff and staff noticed the bruising on Resident #1's chest on 10/30/19 originally. She said that she does not believe it is an IJ level but believes staff did not report the bruising to the NP until 11/03/19 when the RP and nurse noticed it. RDO said she thought the bruising was from a drug reaction because the resident was prescribed [MEDICATION NAME], aspirin and [MED] at the same time and no one realized the resident was on that combination. She said staff should have notified the NP on 10/30/19 of the bruising when it was first noted. Record review of Physician Notification policy dated November 2016, updated March 2019, provided by facility administrator read in part . It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment. The physician; physician assistant; nurse practitioner; or clinical nurse specialist is to be promptly notified of the results of radiology, labs and other diagnostics. The nurses will: Recognize the condition change. Monitor the Patient and continue to assess the condition and changes. Notify the physician, patient and patient representative of any change in condition. Record review of Anticoagulant Therapy policy dated 1/04/2016 provided by the Administrator read in part . Policy It is the policy to monitor any patient prescribed an anticoagulant therapy for side effects and drug-drug interactions. Responsibility To test for therapeutic levels of anticoagulant therapy ([MEDICATION NAME]) as prescribed by the physician. Procedure Orders for all patients on anticoagulation medications are entered into the electronic medical record system. Lab testing for monitoring is conducted weekly or as requested by physician. Side effect monitoring is completed every[***]in the electronic medical record system. The facility Administrator and Regional Director of Clinical Services were notified on 11/08/2019 at 5:12 PM that immediate jeopardy was identified due to the above failures , a copy of the IJ template was provided at this time and a plan of removal was requested. A plan of removal was accepted after several revisions on 1[DATE]19 at 11:05 AM 1. Notification of Physicians a. The facility has begun to conduct in-services to licensed nursing staff on notification of physicians per the facility policy. The licensed Nursing staff was also inserviced on immediate notification of bruising/bleeding and critical changes noted of any Patient receiving Anticoagulant therapy with appropriate documentation in the clinical records. The facility policy includes conditions which may arise from as well as the nurses responsibility to act. If changes exist that warrant a change in treatment, the physician is to be notified, as well as the responsible person, if indicated. The inservices began on 11/08/19 and will be completed 11/09/19. CNAs were inserviced on 11/08/19 using Stop & watch tool, on notification of all noted changes in conditions, behavior, meal/fluid intake, injuries, bruises to the charge nurse b. The facility has begun to conduct in-services to facility staff on the interact process, SBAR and stop and watch tool. The interact Process is a systematic approach by which each facility staff member is assigned the responsibility of notifying nursing of any change in condition. Inservices on the Interact process began on 11/ 08/ 19 and will be completed by 11/09/19. c. The Facility immediately conducted an evaluation, to include record auditing on those Patients receiving anticoagulants. Head to toe assessment were completed on [DATE] on all Patients receiving anticoagulant medication (no issues noted) d. The facility shall use both the Interact process and the 24 hour Electronic report to verify action on change of status. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the tour of duty. The off going nurse will utilize the 24hour report to report off to the oncoming nurse any changes in conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The inservices began on 11/08/19 and will be completed 11/09/19 e. The facility will document monitoring of change of status on the change of status log and EMR tracking tool as of 11/08/19 f. As a systematic change, monitoring of assessments and clinical needs will be conducted by the nurse managers daily with status report presented in stand up meeting. This review will include verification of the care needs carried forward from shift to shift with changes in status, monitoring and notification documented in the clinical record starting 11/08/19 g. No facility staff will be allowed to return to active duty until such a time as the education described above is completed. h. Results of all monitoring shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. i. Changes identified by non-nursing staff will be communicated using the Interact Process. Non nursing staff (CNAs, therapist, Housekeeping and dietary staff were also inserviced on 11/08/19 and 11/09/19 notification to the DON and Executive if licensed nursing staff fail to address changes in condition such as bruising, bleeding specific to patients taking Anticoagulants j. Completion Date for the education of Non nursing and Licensed staff will be completed by 11/09/19 regarding notification of changes to related to anticoagulant therapy Monitoring The surveyors confirmed the Plan to lower the Immediate Jeopardy had been implemented sufficiently by: Interviews with different staff including nursing staff (10 nurses and 10 CNAs) from multiple shifts on 1[DATE]19 through 1[DATE]19 revealed they had been in-serviced on A/N/E policies and procedures, proper assessment, physician notification of change in condition, stop and watch and anticoagulant therapy. Record review of in-services conducted included: Anticoagulant Therapy and Side Effects and Notification conducted on 11/08/2019 Anticoagulant Monitoring 11/08/2019 24 Hour Reports 11/08/2019 Assessment/Stop and Watch/SBAR/Interact 11/08/2019 Change in Condition 11/08/2019 Resident Rights 11/08/2019 Abuse Protocol 11/08/2019 Notification to Executive Director/DON/Unit Manager/Physician/Provider/Charge Nurse 11/08/2019 Record review of the 24-hour report revealed it was implemented and documentation was done on the computer. During the monitoring phase, interviews were conducted by the surveyors on different shifts with the nursing staff, nurses and nurse management. All interviewed nursing staff verbalized up to date knowledge on physician notification, change in condition, physician notification of change in condition, RP notification, abuse/neglect, 24-hour report, assessment of change in condition, documentation, stop and watch and monitoring of residents on anti-coagulant therapy. The Administrator was notified that the IJ was lowered on 1[DATE]19 at 10:16 AM. However, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy due to the facility continued to monitor the plan of removal for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to accurately assess Resident #1 after nursing staff observed a large bruised area on her upper chest on 10/28/2019, [DATE] and 11/01/2019. The facility failed to consult Resident #1's physician for 7 days after severe bruising was observed by nursing staff and facility continued to administer [MED] until 11/03/2019 when it was discontinued. The facility continued to administer [MED] 20mg tablet daily to Resident #1 after bruising to chest area was noted on 10/28/2019 and it was not discontinued until NP was notified of bruising to chest area on 11/03/2019. The facility failed to adequately monitor Resident #1 who was on anticoagulant therapy following a [DIAGNOSES REDACTED]. The facility failed to implement Resident #1's care plan for risk of bleeding/bruising related to anticoagulant medication regimen. The facility did not identify, train and ensure staff used appropriate and consistent method to transfer Resident #1 who was on anticoagulant therapy, at increased risk of bleeding and dependent on staff for all ADLs . An immediate jeopardy was identified on 11/08/2019. While the IJ was lowered on 1[DATE]19, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy due to the facility continued to monitor the plan of removal for effectiveness. These failures affected one resident who continued to receive anticoagulant therapy following severe bruising to chest area, delayed treatment and delay in assessment and placed all residents in the facility at risk of delay in treatment, decline in health and continued administration of medications that increase risk of bleeding. Findings include: Record review of clinical face sheet for Resident #1 revealed she was an [AGE] year-old female admitted to the facility 06/22/2016. [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] indicated a BI[CONDITION] score of a 3 out of 15, indicating severe cognitive impairment. MDS further noted that Resident #1 required extensive assistance with 1-person physical assist for bed mobility, transfer, toilet use and personal hygiene. Resident #1 was total dependence of 1 staff for ambulation. MDS further revealed Resident #1 was always incontinent of bowel and bladder. Resident #1 was not steady moving from seated position to standing position and was not steady for surface to surface transfer. Record review of Resident #1's care plans read in part . Resident #1 is at risk for bleeding/bruising related to medication regimen ([MED]) not dated. Goals- Resident #1 will have 0 to minimal episodes bruising or uncontrollable bleeding within the next 90 days. Interventions: Assess for presence of factors placing at risk for increase bleeding, observe for signs of bleeding in stool, urine, sputum, vomitus, gums, abnormal bruising, petechia, purpura or presence of nosebleeds. Vital signs as indicated. Follow anticoagulant protocol. Use caution with manual transferring or positioning. Check for new bruising/bleeding with ADL care. Report any abnormal bleeding or new bruising to health care provider and RP. Monitor lab results and report abnormal results to health care provider. Transfers (to/from: bed chair wheelchair, standing position) not dated. Goals- Resident #1 will complete transfers with assistance of 1-2 people/lift devices as required. Interventions: Resident #1 to be out of bed in chair. Explain to resident the process when transferring. Resident #1 is dependent on 1 staff for transfers. Resident #1 has impaired bed mobility not dated. Goals- Resident will have improved bed mobility next review date. Interventions: Resident #1 requires extensive assist by 1 staff for bed mobility. Record review of Physician order [REDACTED].#1 dated October 2019 revealed the following orders: Aspirin 81 mg tablet, delayed release ([MEDICATION NAME] coated) oral every morning for [DIAGNOSES REDACTED]. Order date of 10/07/2019 X-ray of left shoulder, left humerus. Left elbow and left forearm to rule out fracture and/or dislocation. RP aware. Ordered date of 11/05/2019 (date was on document) Anticoagulant Side Effects. Notes: [MED] RP aware. Order date of 0[DATE] Record review of Physician order [REDACTED].#1 dated November 2019 revealed the following orders: Aspirin 81 mg tablet, delayed release ([MEDICATION NAME] coated) oral every morning for [DIAGNOSES REDACTED]. Order date of 10/07/2019 X-ray of left shoulder, left humerus. Left elbow and left forearm to rule out fracture and/or dislocation. RP aware. Ordered date of 11/05/2019 (date was on document) Anticoagulant Side Effects. Notes: [MED] RP aware. Order date of 0[DATE] Record review of Treatment Administration Record for Resident #1 dated 11/01/2019-11/05/209 revealed the following orders: Weekly head to toe assessment, one time weekly starting 06/18/2017. Documentation revealed that head to toe assessment had been completed by Treatment Nurse #9 on 11/02/2019, no bruising or discoloration to Resident #1's chest or abdomen was documented. Record review of Weekly Head to Toe Assessment Notes for 10/26/2019 documented by Treatment Nurse #9 revealed the following . Skin condition- pressure Documentation of Head to Toe Assessment Note did not reveal any documentation of bruising or discoloration to Resident #1's chest or abdomen. Record review of Weekly Head to Toe Assessment Notes for 11/02/2019 documented by Treatment Nurse #9 revealed the following . Skin condition- pressure Documentation of Head to Toe Assessment Note did not reveal any documentation of bruising or discoloration to Resident #1's chest or abdomen. Record review of SBAR dated 11/03/2019 and completed by RN #4 read in part . Patient family member came visiting when she wanted to reposition Resident #1. On turning her, we noticed there was discoloration on her upper chest region. The family member took pictures of it. Vital signs taken, and the NP notified. Skin evaluation portion of SBAR had the No changes observed box marked. No description of the bruising or measurements were noted. Record review of nurse's notes dated 11/03/2019 at 10:28 PM read in part . Patient is alert and responsive lying in bed when her family member came visiting. Family member wanted to reposition Resident #1. On turning her, we noticed there was discoloration on her upper chest region (ecchymosis). The family member took pictures of it. NP notified, she ordered [MED] be discontinued. Patient is made comfortable, v/s taken, she remains stable while I continue to watch for any change in condition. Further review of nurse notes did not reveal any other documentation of bruising for dates 10/27/19-11/03/19. Record review of physician progress notes [REDACTED]. History/Visit Type New problem, nursing concern, coordination of care, medical records reviewed Chief Complaint: follow up needed to evaluate due to notified by nursing on Sunday PM, 11/03/2019, due to noted extensive bruising on Left upper extremity, chest and bilateral breast, no reports of falls or trauma. Resident with [MED]-induced coagulopathy due to left upper extremity [MEDICAL CONDITION]. Order given to discontinue [MED] and continued [MEDICAL CONDITION] monitoring. Record review of hand-written statement from Restorative Aide #5 (RA) not dated, read in part . I, RA #5 on November 1, 2019 at 10:00 am in the morning, I checked the weight of Resident #1. When I was assisting her, and I saw bruised on her chest. Immediately I notified to the nurse: RN #6. Interview with Restorative Aide #5 on 11/08/19 at 10:17 AM, she said she was performing monthly weights on 11/01/2019. She said when she went to weigh Resident #1, she noticed a dark purple color across her chest. RA #5 said she said to herself What the hell. She said she then went to her nurse RN #6 and told her about the bruising and the nurse told her that she was aware and that the bruising was getting better. RA #5 said that RN #6 said the resident was on blood thinners. RA said she said ok and continued with the weighing of Resident #1. RA said that nurse RN #6 did not get up to assess resident and continued to sit at the nurse's station and type on her computer. RA #5 said the bruising was across the resident's chest and she could see it because the clothes she was wearing was low cut. RA #5 said she did not pull her clothes black to look at the bruising any further because the nurse said she was already aware of the bruising. Record review of email statement from RN #4 to Administrator dated 11/06/2019 read in part . On 11/03/19 while repositioning Resident #1, in presence of family member. We noticed a discoloration on her upper chest region. (Ecchymosis). Family member took picture and SN (staff nurse?) assessed the patient, notified the NP and supervisor on duty. NP ordered [MED] be discontinued. Documented on the nurses skilled note and SBAR. Interview with RN #4 on 11/08/19 at 10:26 AM, she said that she was repositioning Resident #1 with the help of her family member on 11/03/19 and she noticed discoloration on her chest. RN #1 said she notified the NP and the NP asked if she was on blood thinners. NP discontinued the blood thinner. RN #4 said she took Resident #1's vitals, fixed the bed and continued to monitor for change of condition throughout her shift. RN #1 said she documented her findings on the SBAR and in her nurse note. RN said she did not check range of motion or check anywhere else on resident's skin for possible bruising. RN #4 said she notified the weekend supervisor (RN #3) of the bruising. RN #4 said that the protocol is to notify the supervisor of changes in condition, notify the physician/NP, notify the RP and follow any orders. Record review of staff statement signed by CNA #2 on 11/07/19 read in part . I CNA #2 returned to facility on October 28, 2019. On the day of 10/28/2019, I was heading into Resident #1's room and was stopped by the nurse. The nurse informed me of a bruise on her chest area. Interview with CNA #2 on 11/08/19 at 10:14 am, she said she returned to work on 10/28/2019 and was heading to Resident #1's room to provide activity of daily living care (ADL) as resident is dependent on staff for care. CNA said she was stopped by nurse (RN #6) and was told not to get resident out of bed because she had bruising to her chest. CNA #2 said she saw the bruising to Resident #1's chest on 10/28/19 after she was notified by the nurse and that the bruising was purplish with green and yellow and it was on her chest. CNA #2 said the bruise looks the same today (11/08/2019) as it did on 10/28/19. CNA said she did not document the bruise in her notes because the nurse already knew about it and she thought the nurse had already taken care of it. Interview with CNA #2 on 11/06/2019 at 11:50 AM, she said that when she transfers Resident #1, she lifts her up by her pants. She said she always had someone with her for the transfer because I'm little and not going to hurt my back. Interview with Therapy Director on 11/07/2019 at 11:30 AM, she said staff should have been transferring Resident #1 with a gait belt due to her size and condition. Therapy Director said that it would not be safe to transfer Resident #1 via a hoyer lift and staff shouldn't put her through that. She said for transfer that 1 staff member should be holding her legs and the other staff member should be transferring by holding her arms. Therapy Director was asked if a gait belt or the transfer she just described would be safe for Resident #1 and she said that she couldn't be sure if the gait belt or transfer she described was safe at the time because there is no cookie cutter approach. Director of Therapy said that the transfer methods change per CNA visit to the residents room because the residents requirements change daily. Director of Therapy said she is a Speech Therapist by trade and can't speak for any other staff. Director of Therapy said that she trains staffing on resident transfers along with the staffing coordinator. Record review of staff statement that was emailed to the Regional Director of Operations (RDO) from staff member RN #3 (weekend supervisor) dated 11/07/19 read in part . When RN #4 stopped me about Resident #1, she told me she had found a bruise across her chest area. She said she notified the Nurse Practitioner (NP) and that she got a new order to stop blood thinner patient was taking at the time. I told her to make sure she did an assessment on patient and to notify everyone else as well as do proper charting on the patient. She said ok. Interview with RN #3 on 1[DATE]19 at 2:59 PM, she said that she was notified by RN #4 that Resident #1 had bruising across her chest on. RN #3 said that she told RN #4 to notify the physician of the bruising and do an assessment. RN #3 said the bruising was probably caused by the [MED] as she has seen bruising before on residents who are on [MED]. RN #3 said she had never seen a bruise that large before but Resident #1 is very fragile. Record review of hand-written statement dated November 7, 1920 (2019?) and signed by LVN #7 read in part . In regard to bruising on Resident #1, I was notified by CNA on 11/30/19 (10/30/19?) about bruising. I noted some redness which I explained to CNA was due to [MED]. Record review of hand-written statement dated 11/07/2019 and signed by Shower Aide #8 read in part . On the [DATE], when I was giving Resident #1 a bed bath, I noticed a black spot on her. I called my nurse to come and see it, and she told me its because of the medication. On 11/01/2019, I still saw it there getting bigger. Interview with Shower Aide #8 on 1[DATE]19 at 2:55 PM, she said that she noticed a large black area of bruising on the left side of Resident #1's chest that covered the whole left side of her chest and went across to the other side of Resident #1's chest. Shower Aide #8 said the right side of Resident #1's chest was not as bad and it was lighter in color. Shower Aide #8 said she informed LVN #7 of the bruising on [DATE]. Shower Aide #8 said LVN #7 looked at the bruising and said it was because the resident was on blood thinners. Shower Aide #8 said she did not tell anyone else of the bruising because she thought LVN #7 took care of it. Observation of Resident #1 on 11/05/19 at 4:51 PM revealed resident lying in bed on her left side. RN #1 accompanied surveyor to resident's room. RN #1 lifted resident's gown and a large deep purple, burgundy bruise with various shades of blue and black was observed on Resident #1's chest that started under her left arm and extended down to her upper abdomen and went across her chest to the right side and went under her right arm. Bruise was in different stages of healing as it had colors of deep purple, burgundy, blue, black and outside edges had green and yellow. Dark purple bruising was observed around resident's right breast that covered the lower half of her breast and surrounded the areola. Upper area of Resident #1's abdomen had large yellow/green area across the top half of her abdomen with greater than five dark blue of bruising that were the size of a dime inside of the yellow/green area of various stages of healing. Interview with RN #1 on 11/05/2019 at 5:10 PM, she said she was not aware that Resident #1 had bruising to her chest until she raised resident's gown and observed it earlier with surveyor. RN #1 did say that she was told that the resident had ecchymosis. RN #1 was asked if it looked like ecchymosis to her and she said no. RN #1 said that this was her first time to see it and she would have to call the NP. Interview with RN #1 on 11/05/19 at 5:15 PM, she said the NP said she had been at the facility earlier in the day and assessed Resident#1. RN #1 said that the NP believes the bruising is from [MED] and that is why she stopped it. RN #1 said that the NP said that the bruising went across her chest because that is how the resident keeps her arms (across her chest) and her body/chest rest on her arms. Interview with Resident #1's family member on 11/05/2019 at 4:00PM, she said that she was concerned because Resident #1 has severe bruising across her chest that goes from her left arm to her right arm, its deep purple in color with green around it and it is from her upper chest area to the top of her abdomen. Family member said that she was concerned for Resident #1's health and safety, because during a visit, she witnessed a staff member manhandle Resident #1 during a transfer. Family member said one of the nursing staff grabbed Resident #1 by her shirt and waist of her pants and picked her up from the bed and put her in a chair. Family member said the facility has her on anticoagulants and feels that she should be transferred with a lift because she can't help during a transfer and her legs are contracted. Family member said Resident #1 is totally dependent on staff for all her needs and is not able to express needs or provide for herself. Family member said she has photos of the bruising to Resident #1's chest. Interview with the Administrator on 11/06/19 at 11:30 AM, he said he was not aware of the bruising to Resident #1's chest until he went into the room on 11/05/19 with surveyor, RN #1 and Treatment Nurse #10. Administrator said that when bruising like that was observed that staff should notify the unit managers immediately. Administrator said he was the Abuse Coordinator but when there was bruising that is related to clinical reasons then staff report it to unit managers. Administrator said that since the bruising was related to the [MED] per the NP that staff should have notified the unit managers. Interview with Regional Director of Clinical Services, on 11/06/19 at 11:45 AM, she said she was not aware of the bruising to resident's chest until 11/05/19 when surveyor mentioned it. She said it had not been reported previously. Regional Director of Clinical Services said she was assisting facility as the facility currently did not have a DON. Interview with Treatment Nurse #10 on 11/06/19 at 1:10PM, she said she had been providing wound care to Resident 1's mid back pressure ulcer for the past 1-2 weeks but had not noticed the bruising to the chest area or abdominal area prior to state being in the building. Interview with the NP in person on 11/06/19 at 12:00PM, she said she was notified by the nurse of the bruising to Resident #1's chest area on 11/03/19 and that was the first notification of bruising from nursing staff. NP said the nurse sent her a photo of the bruising and she was able to see it from the photo. NP said she discontinued the [MED] because she believed the bruising was caused by a spontaneous hemorrhage. NP said she remembered saying something like ugg when she saw the picture of the bruised area and asked the nurse if there had been a fall or any trauma and the nurse said no. NP said resident has a history of [MEDICAL CONDITION]. NP said resident was started on [MED] because of a [MEDICAL CONDITION] to her left arm. NP said she truly believes the bruising is from the [MED] and does not believe the staff is abusing or being rough with the resident or residents. Interview with RN #12 on 11/07/19 at 11:17 AM, he said he was trained recently on anticoagulants and assessments but did not know who provided the training or when it was, but he believed it was a few days ago. Interview with Unit Manager #1, on 11/07/19 at 11:20 AM, she said that they recently had in-services for assessments and anti-coagulants, but she wasn't sure when. She said the Unit Mangers perform the in-services along with the DON but the facility doesn't currently have a DON. Interview with Unit Manger/RN #11 on 11/08/19 at 10:43 AM, she said she first became aware of the bruising to Resident #1's chest on 11/05/19 when she received a text from the facility. Unit Manger said she looked in the resident's chart online from home and saw that an SBAR was done and that the NP had been notified by the nurse on 11/03/19. Unit Manager said that the resident's RP said the NP discontinued the blood thinner because she believed it caused spontaneous bruising to resident's chest. Unit Manager was asked what the expectations of her staff are on care of residents on anticoagulant therapy and assessments and change in condition. Unit Manger said that nurses are supposed to notify the supervisor that is working during the shift of change in condition, bruising or issues, notify the physician, notify the RP and follow any new orders. Unit Manger said she would like to be notified of changes, as well. Unit Manager said that the DON should be notified but the facility currently does not have a DON. Unit Manger said that the nurse should have called the physician on 10/28/19 when the bruising was first noted. Unit Manager said that if Residents are on blood thinners that staff are to visually inspect their skin on every shift to monitor for any changes. Unit Manger said if she observed a bruise on a resident that was like the one Resident #1 had, she would be concerned. Unit Manger said she started interviewing staff on Tuesday about the bruising. In an interview with RN #6 on 11/08/19 at 10:08 AM via phone. She said that she became aware of the bruising to Resident #1's chest on Monday 11/04/2019. RN #6 said that there was old bruising to Resident #1's left arm and she noticed bruising to her chest. She said that she read the progress notes from the weekend shift and saw that there was a nurse note that said the NP was notified on 11/03/19. RN #6 said that she had not been informed by any CNA's or Restorative Aides that Resident #1 had bruising across her chest prior to 11/04/2019. RN #6 said she had worked on 10/28/19-11/01/2019 and cared for Resident #1 but had not seen any bruising nor had she been informed of any bruising by the CNA's or Shower Aides. Interview with RDO on 11/07/2019 at 11:45 AM, she said that she does not believe the bruising occurred due to transferring Resident #1 with a gait belt. She said that she interviewed staff and staff noticed the bruising on Resident #1's chest on 10/30/19 originally. She said that she does not believe it is an IJ level but believes staff did not report the bruising to the NP until 11/03/19 when the RP and nurse noticed it. RDO said she thought the bruising was from a drug reaction because the resident was prescribed [MEDICATION NAME], aspirin and [MED] at the same time and no one realized the resident was on that combination. She said staff should have notified the NP on 10/30/19 of the bruising when it was first noted. Record review of Patient Care Management System- Assessments policy dated February 2012 and provided by the facility read in part . A Situation, Background, Assessment and Request (SBAR) Communication Form and Progress Note must be completed upon a patient's change in condition and prior to contacting the attending physician. The SBAR Communication Form can replace a nurse's note and is filed in the patient's medical record under the Nurse's Notes tab. Documentation of a significant change in condition must have an update of the Plan of Care and Minimum Data Set. The nursing staff must observe the changes, make an assessment and notify the physician as indicated on the assessment. Record review of Physician Notification policy dated November 2016, updated March 2019, provided by facility administrator read in part . It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment. The physician; physician assistant; nurse practitioner; or clinical nurse specialist is to be promptly notified of the results of radiology, labs and other diagnostics. The nurses will: Recognize the condition change. Monitor the Patient and continue to assess the condition and changes. Notify the physician, patient and patient representative of any change in condition. Record review of Anticoagulant Therapy policy dated 1/04/2016 provided by the Administrator read in part . Policy It is the policy to monitor any patient prescribed an anticoagulant therapy for side effects and drug-drug interactions. Responsibility To test for therapeutic levels of anticoagulant therapy ([MEDICATION NAME]) as prescribed by the physician. Procedure Orders for all patients on anticoagulation medications are entered into the electronic medical record system. Lab testing for monitoring is conducted weekly or as requested by physician. Side effect monitoring is completed every[***]in the electronic medical record system The facility Administrator and Regional Director of Clinical Services were notified on 11/08/2019 at 5:12 PM that immediate jeopardy was identified due to the above failures , a copy of the IJ template was provided at this time and a plan of removal was requested. A plan of removal was accepted after several revisions on 1[DATE]19 at 11:05 AM The plan of removal included the following. Systematic Approach 1. Accurate Assessment of Patients a. Licensed nursing staff was inserviced 11/08/19 and 11/09/19 on the accurate assessment process to include: head to toe assessment with documentation of findings in the clinical record with notification to the Patient's Physician, Representative, Director of Nursing and the Executive Director. Licensed staff were also inserviced by the Regional Director of Clinical Services Renee Wilson on Anticoagulant therapy and the monitoring of side effects (bruising, nose bleeds, bleeding gums, hematuria, tarry stools and petiechiae) and a worsening of condition. Any issues noted will be addressed through assessment, notification to the Physician, Patient Representative with documentation in the clinical record. b. Nurse Managers completed head to toe assessments on 11/08/19 of all Patients including Patient Keleshian receiving anticoagulant therapy to ensure that no negative outcomes are present related to the administration of anticoagulant (no adverse side effects noted) c. Monitoring of accurate assessment of patients receiving Anticoagulant will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also retrieve tracking reports from the EMR to evidence that assessments were completed by the Licensed Nurses and appropriate documentation/notification were done on 11/08/19 d. As a systematic change, monitoring of assessments of Patient's receiving Anticoagulant therapy will be conducted by the facility Nurse Managers with a report of any change of condition, injuries of unknown origin to the DON and Executive Director for follow up and corrective actions. All changes (bruising, bleeding) related to administration of Anticoagulant will be reported to the Patient's Physician immediately for new orders as of 11/08/19 e. Licensed nursing staff who are PRN or unavailable for the inservice will not be allowed to work until such a time as the inservice is completed. All Patients receiving Anticoagulants care plan reviewed 11/08/19 to ensure that Anticoagulants use is reflected. The daily care guides were also reviewed to ensure that this is reflected in the guide accessible to CNAs and licensed nursing staff. CNAs were inserviced on the location of the information, side effects to look for in Patients taking Anticoagulant and who to report any noted side effects. 2. Physician Notification a. Licensed nursing staff was inserviced 11/08/19on physician notification of change of status when there is a need to alter care. b. Monitoring of physician notification will be completed through unit mangers and the Director of Nursing or designee during the Daily Morning Meeting 11/08/19 c. Licensed nursing staff who are PRN or unavailable for inservice will not be allowed to work until such a time as the inservice is completed. Monitoring The surveyors confirmed the Plan to lower the Immediate Jeopardy had been implemented sufficiently by: Interviews with different staff including nursing staff (10 nurses and 10 CNAs) from multiple shifts on 1[DATE]19 through 1[DATE]19 revealed they had been in-serviced on A/N/E policies and procedures, proper assessment, physician notification of change in condition, stop and watch and anticoagulant therapy. Record review of in-services conducted included: Anticoagulant Therapy and Side Effects and Notification conducted on 11/08/2019 Anticoagulant Monitoring 11/08/2019 24 Hour Reports 11/08/2019 Assessment/Stop and Watch/SBAR/Interact 11/08/2019 Change in Condition 11/08/2019 Resident Rights 11/08/2019 Abuse Protocol 11/08/2019 Notification to Executive Director/DON/Unit Manager/Physician/Provider/Charge Nurse 11/08/2019 Record review of the 24-hour report revealed it was implemented and documentation was done on the computer. During the monitoring phase, interviews were conducted by the surveyors on different shifts with the nursing staff, nurses and nurse management. All interviewed nursing staff verbalized up to date knowledge on physician notification, change in condition, physician notification of change in condition, RP notification, abuse/neglect, 24 hour report, assessment of change in condition, documentation, stop and watch and monitoring of residents on anti-coagulant therapy. The Administrator was notified that the IJ was lowered on 1[DATE]19 at 10:16 AM. However, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy due to the facility continued to monitor the plan of removal for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of thirteen residents (CR#1) reviewed for quality of care. The facility did not obtain order for CR#1 's right wrist surgical incision treatment upon admission and did not provide care /treatment to the incision for two weeks. The facility did not assess and monitor CR#1 's right wrist surgical incision for two weeks. As a result, CR#1 's incision became infected requiring readmission to the hospital for surgery incision and drainage . These failures affected one former resident and placed him at risk of infection, pain, and a decline in health. Finding include: Record review of CR#1 face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. He was discharged from the facility on 5/22/19, when he was readmitted to a local hospital. Record review of CR#1 's Nursing Admission assessment dated [DATE] revealed he was admitted from a local hospital after being treated for [REDACTED]. The section under, Wound Assessment & Description revealed CR #1 had a right wrist wound of unknown size. The dressing/treatment was described as, Elastic band aid wrapped around bilateral knee and right wrist. Record review of CR#1 's hospital records revealed he was admitted to a local hospital on [DATE] and was discharged to the facility on [DATE]. His [DIAGNOSES REDACTED]. Further review of the hospital records revealed CR#1 was readmitted to a local hospital on [DATE] due to post-operative right wrist purulent drainage in setting of previous wrist septic arthritis. Upon admission, the resident was assessed to have a pressure ulcer of sacral region of unspecified stage. On 5/23/19, CR#1 had the following procedure: Drainage of Right Wrist Joint, Open Approach and Excision of Right Xarpa,(SIC) Open Approach. The note under, History of Present Illness, dated 5/22/19 read in part, .recently hospitalized here 4/29-5/8 for Group G strep bacteremia and multifocal septic and gouty attack. He underwent incision and drainage of right wrist and bilateral knees on 5/2 . He was discharged to nursing facility for rehabilitation .His wrist has been stiff with pain and he reports the dressing was never changed .He was seen in ortho clinic today and noted to have purulent drainage from the distal 2/3 of wound and a stiff wrist. He was admitted for incision and drainage and MRI. Record review of CR#1 's Care Plan not dated (printed on 7/2/19) revealed the resident had a left foot plantar diabetic ulcer, bilateral knee surgical wound closed with sutures (no onset date) and staff were to assess the resident's skin weekly and record findings and check him for incontinence frequently. Record review of CR#1 's Admission MDS dated , 5/15/19 revealed the resident was wheelchair bound, was only able to stabilize with staff assistance, and required extensive two-person assistance with bed mobility, transfer, and toilet use. [MEDICAL CONDITION](s), Surgical Wound(s), and Moisture Associated Skin Damage were checked under the heading, Other Ulcers, Wounds and Skin Problems. Pressure reducing device for bed, Nutrition or hydration intervention to manage skin problems, Surgical wound care, and Application of ointments/medications other than to feet were checked under the heading, Skin and Ulcer/Injury Treatments. Record review of CR#1 's Clinical Notes revealed the following entries: On 5/9/19 at 3:32 a.m. , RN A wrote, Receive patient in the facility awake and oriented x4 on stretcher .Patient requires extensive assistance with ADL (activities of daily living), can feed self, requires 2 assist with bed mobility. Continent bowel and bladder under normal circumstances incontinent to bowel now due to impaired physical mobility .Picc line at left arm area single lumen, surgical wound to right wrist related to arthritis, gout, [MEDICAL CONDITION], that requires changes with Keflex (SIC) on top . On 5/9/19 at 8:15 p.m., LVN B wrote, Skin assessment by wound care nurse and noted to right arm dressing in place no breakthrough drainage noted. Per responsible party, order from surgeon dressing to be in place to right arm for the next two weeks. Interview with LVN C on 7/2/19 at 11:45 a.m., he stated per his responsible party, CR#1 had an order from the surgeon to keep the dressing to the right arm in place for the next two weeks. He said that meant the dressing was not to be removed. LVN C said the order was not uncommon and there was no order to remove the dressing or do care on his wrist. Unless there was drainage or an odor, the staff would not touch the wound on the resident's wrist. Interview with CNA D on 7/2/19 at 12:30 p.m., she stated CR#1 had casts on his arm and legs and was dependent on staff. She stated they turned him every two hours or whenever he asked. Every time they moved him, he would scream in excruciating pain. Observation and interview with CR#1 on 7/3/19 at 5:15 p.m., at a local hospital revealed he was alert and oriented. He stated the surgeon had written a note to check the surgical incision on his wrist daily. He said to check it, they would have had to take the bandages off, but they understood it to mean just look at his wrist daily. He went for a follow up appointment with his doctor and found out the wrist incision was infected. He was admitted to the hospital again for another procedure. Interview with LVN B on 7/9/19 at 11:08 a.m., she stated she was one of the wound care nurses and she did CR#1 's initial skin assessment. She said there was an order for [REDACTED]. Some surgeons do not want nurses to touch their incisions. They were only to monitor it and make sure there was no discoloration, infection, and he could move his fingers. LVN B said the facility had an in-house protocol they used when a resident admits with an open surgical incision. When asked to provide this protocol, LVN B said it was not a written protocol, but staff were trained to do this, and they did it. Telephone interview with RN A on 7/9/19, at 3:07 p.m., he stated CR#1 was admitted around 7 p.m. that night and he had a soft cast to his right arm. His responsible party had an order from the surgeon indicating they were not to remove the dressing for two weeks. He stated he had never seen an order written [REDACTED]. He had seen orders for maybe several days. He did not think about calling for clarification. He was not the admission nurse, but he was the charge nurse. In an interview with the Regional Director of Operations on 7/18/19, at 11:10 a.m., she stated at the least, the nurses should have gotten clarification from the surgeon concerning care of the wrist and should not have taken the word of the family member. She stated it was not unusual for a surgeon to request staff not remove the dressing, but staff would have needed to look at the incision for signs of infection, drainage, and redness. In a later interview with the Regional Director of Operations on 7/18/19, at 11:30 a.m., she stated she had reviewed the orders for the wrist and CR #1 had a soft cast. She said staff would not have removed it. The hospital had given the discharge paperwork to the family and did not send them to the facility. In an interview with the Interim DON on 7/18/19, at 12:48 p.m., she stated she could not locate any actual orders for CR #1 from the surgeon concerning care of the surgical wounds on his wrist or knees. When asked if they facility did not receive paper work from the hospital for review prior to making admission decision, Interim DON said care was only mentioned in the discharge paperwork provided to them by CR #1's family member. The only instructions for care were given to them verbally by the family member. The discharge hospital records the facility member provided to the facility had no care orders for the resident's surgical incisions. In an interview with LVN B on 7/18/19, at 1:30 p.m., she stated she had assessed CR #1 the day after he was admitted . When a resident has a surgical incision, they need to know what to do with it. She asked the family member if the doctor had given any instructions for the sift cast and he said the only thing the doctor said was do not touch it until he saw CR #1 for a follow up appointment. LVN B said the only thing they could do was put in an order to monitor the wrist. She said the cast was from his elbow to the wrist. The family member also told them what to do for the surgical incisions on CR #1's knees. She said she would have called the doctor for clarification, but the family member kept insisting not to touch the wrist. In an interview with CNA F on 7/18/19, at 2:15 p.m., she stated CR #1 came to the facility very weak and required total care. The resident's hands and knees were wrapped. He complained of pain whenever they moved him. In an interview with RN A on 7/18/19, at 2:30 p.m., he stated CR #1 had a plaster cast on his wrist. Interview attempt was made on 7/18/19 at 2: 32pm to speak with CR#1's surgeon who wouldn't speak to surveyor without a written release of information from CR#1. In a telephone interview with CR #1' on 7/18/19, at 3:30 p.m. he stated he did not have a plaster cast on his wrist. He said there was an ace bandage wrapped round some gauze on his wrist. He stated he guess he could have undone the dressing himself because all they had to do was unwrap it. The staff at the facility never unwrapped the dressing, they only looked at it. In a telephone interview with CR #1's family member on 7/18/19, at 4:15 p.m., he stated the dressing on CR #1's wrist looked like a wrap, like what you would uses if you banged your knee, and it had padding inside. There was gauze inside just like what was on his knee with the exception of a hand splint. The splint was only on his hand. He said the dressing was not a plaster cast. There was a Velcro strip closing it. The dressing would not have had to be cut off. The family member said he never told them anything about caring for the wrist. He said he never told them not to remove the dressing or verbalized any instructions for the wrist. The surgeon asked him if the facility staff had ever removed the bandage and asked how they checked it without removing the dressing. The family member had the dressing removed from CR #1's wrist at the follow up appointment and provided a photograph. Record review of the above photographs provided by CR #1's family member revealed a soft pliable hand immobilizer with an open top which enabled the fingers to be stretched out and held the wrist in place . The immobilizer had a side curve for the thumb . The immobilizer covered supported the palm , the fingers and from the wrist to the elbow. The immobilizer had three wide straps that held it in place while exposing the skin of the arm as well as the incision site of approximately 2.5cm long. The three straps from one side of the immobilizer crossed over the hand and wrist on the other side of the immobilizer . There was also what appeared to be a padded white soft sleeve placed under the immobilizer for additional support and to elevate the hand . (The family member stated this was wrapped with an ace bandage on top, but incision was covered with dressing). Record review of facility policy on receiving and following physician's orders [REDACTED]. However, it revealed Telephone Physician order [REDACTED].Obtain order from physician - re-read order to MD to verify correctness . Record review of facility document, Dressing Change-Clean, dated (MONTH) 2019 revealed, .Purpose: To protect wound; to prevent irritation; and to prevent infection and spread of infection .

Based on observation, interview, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one of thirteen residents ( CR #1) reviewed for skin integrity and pressure ulcers. The facility did not implement effective measures to prevent the development of CR #1's sacral pressure ulcer/injuries that deteriorated within two weeks of admission to the facility . CR#1's pressure ulcer/injury became a Stage VI requiring multiple debridement. This failure affected one closed record and placed him at risk of more skin breakdowns, pain, and a decline in health. Finding include: Record review of CR #1 face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. He was discharged from the facility on 5/22/19, when he was readmitted to a local hospital . Record review of CR #1's hospital records revealed he was admitted to a local hospital on [DATE] and was discharged to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's Nursing Admission assessment dated [DATE] revealed he was admitted from a local hospital after being treated for [REDACTED]. Further review of the above Nursing Admission Assessment revealed, .Patient is continent but is incontinent now due to impaired mobility and bed bound status .Skin Assessment: Redness at the sacrum, Bilateral lower extremities [MEDICAL CONDITION] .Braden Scale For Predicting Pressure Sore Risk: Moisture Degree to which skin is exposed to moisture: Occasionally Moist, Activity Degree of physical activity: Bedfast, Mobility Ability to change and control body position: Very Limited Record review of CR #1's Admission MDS dated , 5/15/19 revealed the resident was wheelchair bound, was only able to stabilize with staff assistance, and required extensive two-person assistance with bed mobility, transfer, and toilet use. MDS revealed the resident was at risk of developing pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. MDS revealed the resident had [MEDICAL CONDITION], Surgical Wound, and Moisture Associated Skin Damage. Pressure reducing device for bed, Nutrition or hydration intervention to manage skin problems, Surgical wound care, and Application of ointments/medications other than to feet were checked under the heading, Skin and Ulcer/Injury Treatments. Record review of CR #1's Care Plan not dated (printed on 7/2/19) revealed the resident had a left foot plantar diabetic ulcer, bilateral knee surgical wound closed with sutures (no onset date) and staff were to assess the resident's skin weekly and record findings and check him for incontinence frequently. The resident was also noted to have sacrum pressure ulcer (no onset date) and staff were to monitor areas for increased breakdown or infection, apply a wedge while in bed, roho cushion, frequent turns while in bed and decrease amount of time sitting up on wheelchair. Record review of CR #1's clinical record revealed no physician order for [REDACTED].>Record review of CR #1's Clinical Notes revealed the following entries: On 5/9/19 at 3:32 a.m. , RN A wrote, Receive patient in the facility awake and oriented x4 on stretcher .Patient requires extensive assistance with ADL (activities of daily living), can feed self, requires 2 assist with bed mobility. Continent bowel and bladder under normal circumstances incontinent to bowel now due to impaired physical mobility .Picc line at left [MEDICATION NAME] area single lumen, surgical wound to right wrist related to arthritis, gout, [MEDICAL CONDITION], that requires changes with Keflex on top . On 5/9/19 at 8:15 p.m., LVN B wrote, Skin assessment by wound care nurse and noted to right arm dressing in place no breakthrough drainage noted. Per responsible party, order from surgeon dressing to be in place to right arm for the next two weeks. Right posterior knee with two areas (1) 0.5x2 with 2 sutures, light sanguineous, (2) 1x1.5 with 2 sutures, posterior left knee, two areas, (1) 0.5x2 with 3 sutures, (2) 1x1.5 with 2 sutures. Left lateral knee wound, 0.2x0.2. Right 4th toe nail off. Left plantar wound, 1.5x1x0.3. Treatment per facility protocol, responsible party aware. On 5/13/19, at 6:00 p.m., LVN B wrote, during skin care, this nurse noted to bilateral buttock moisture associated skin damage due to maceration, measured left buttock 3x3.5, right buttock, 2.5x3 with 100% granulation tissue. Resident is incontinent and also encouraged to off-load when in bed. Resident is to be repositioned per facility protocol. Treatment ordered and in place .Doctor notified and ordered Calmoseptin ointment every shift after every incontinent care and as needed. Responsible party notified via phone . On 5/13/19, at 11:19 p.m., RN A wrote, New skin tear noticed on the bilateral buttocks this afternoon. Barrier cream applied to alleviate further exacerbation . Family member aware of skin tear . On 5/14/19, at 6:31 a.m., LVN B wrote an addendum to the 5/9/19 entry and added Moisture noted to sacrum due to resident incontinent. On 5/18/19, at 12:56 p.m., LVN C wrote, Right lateral knee continues to have drainage. Obtained new order to do wound culture from doctor .doctor states to have wound doctor consult due to breakdown on sacrum, notified staff to limit amount of time while in wheelchair and offload patient while in bed. On 5/22/19, at 12:11 a.m., RN A wrote, Patient needs to be repositioned every 2 hours per shift due to pressure injuries to buttocks to prevent exacerbation. Bedding and diapers need changes every 2 hours because patient is unable to maintain a good stream of urine while using the urinary, so most of the urine drips to the bed and can further impair skin integrity to pressure injuries . Record review of CR #1's TAR (treatment administration record) revealed the following orders: Order date: 5/9/19, Apply barrier cream to sacrum for preventative treatment. Discontinued 5/13/19 (No other treatment was ordered for the sacral area until 5/19/19 when referred to a wound consult) Order date: 5/13/19, Apply [MEDICATION NAME] to left buttock and right buttock as directed. Discontinued 5/13/19 Order date: 5/13/19, Apply [MEDICATION NAME] to left buttock and right buttock after every incontinent care and as needed. Discontinued 5/19/19. Order date: 5/19/19, Cleanse wound to sacrum with normal saline or skin cleanser. Pat dry. Apply Santyl to wound bed and calcium alginate pad. Cover with dry dressing. Responsible party notified. Record review of , Initial Wound Evaluation & Management Summary, dated 5/20/19 revealed CR #1 was seen by a wound care doctor. The summary read in part, .At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Focused Wound Exam (Site 1) Unstageable (Due To Necrosis) Sacrum Etiology (quality) .Pressure, Duration .more than one day, Wound size: 9.7 x 16 x (diameter) not measurable, Periwound radius: Surrounding DTI (Purple/Maroon), [DIAGNOSES REDACTED], Exudate: Moderate Serous, Thick adherent devitalized necrotic tissue: 40%, Skin: 60% .Site 1: Surgical Excisional Debridement Procedure, Indication For Procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue, Remove Thick Adherent Eschar and Devitalized Tissue . Record review of CR #1's TAR (treatment administration record) revealed the resident received wound care on 5/21/19 . Record review of CR #1's hospital records revealed CR #1 was readmitted to a local hospital on [DATE] due to post-operative right wrist purulent drainage in setting of previous wrist septic arthritis. Upon admission, the resident was assessed to have a pressure ulcer of sacral region of unspecified stage. Further review of CR#1's hospital record revealed a note under, Wound Ostomy and Continence Nurse Note, dated 5/28/19 and read in part, Patient admitted with bilateral buttocks pressure injuries .Left buttock injury is smaller than the right and the right buttock with the greatest surface area of necrotic epidermis. The two injuries form a butterfly shape with the gluteal crevice with intact skin and at risk with pale skin. This appears to have started as a deep tissue injury as seen on the right buttock especially as part of this wound the necrotic epidermis has been removed exposing a red tissue underlying . The note under Wound, Ostomy and Continence Nurse Note, dated 6/6/19 read in part, Follow up to assess progress of patient's unstageable pressure injury to the sacrum. This pressure injury covers a large surface area and occurred prior to admission due to his inability to tolerate any movement . This area is improved; however, he is still healing and is still unstageable. Greater than 50% of the eschar has softened and begun [MEDICATION NAME] . Interview with LVN C on 7/2/19 at 11:45 a.m., he stated CR#1 had a deep tissue injury to the sacrum which was originally moisture associated skin damage. He said when a resident is wet too long from urine or feces, the skin starts breaking down. He described the wound as an unstageable pressure injury with slough. It developed in-house and he and the other wound care nurse, LVN B, were treating it daily as ordered. Interview with CNA D on 7/2/19 at 12:30 p.m., she stated CR#1 had casts on his arm and legs and was dependent on staff. She stated they turned him every two hours or whenever he asked. Every time they moved him, he would scream in excruciating pain. She said he used a urinal but had a brief on for bowel movements. They always used barrier cream. CNA D said the resident did not develop any new wounds but his backside was very pink. Interview with RN [NAME] on 7/2/19 at 2:30 p.m., she stated she was the unit manager and worked with CR #1. The resident was on frequent checks and the staff were keeping his wounds dry. He had been in the ICU (Intensive Care Unit) at the hospital, so they expected him to come to the facility with a little redness. She said with the facility's repositioning policy and other care protocols, wound development was not expected. Observation and interview with CR #1 on 7/3/19 at 5:15 p.m., at a local hospital revealed he was alert and oriented. He stated the wounds on his backside started at the nursing facility. The resident said he sometimes had to wait up to four hours for a diaper change. He said this happened on every shift. The staff would tell him he needed to call them when he first had to go but they would just go in and tell him to go in his diaper and they would change him. He could not recall when he started feeling the pain from the wounds on his sacrum or who found them. He stated all he could remember was being in a lot of pain. He did not recall ever seeing any kind of wedge to reposition him. He stated the staff would sometimes use pillows, but he did not recall being repositioned very often. If they changed him they may have repositioned him. Telephone interview with LVN B on 7/9/19 at 11:08 a.m., she stated she was one of the wound care nurses and she performed CR#1's initial skin assessment. She said the resident had moisture breakdown on his sacrum. He was incontinent but used a urinal and they had to change his sheets all the time. There was redness surrounding his perineal area and sacrum. She said she documented that because redness could turn into something else. She put an order in for barrier cream. She was afraid he would break down because of the way he used the urinal. She stated she had to write the addendum on 5/14/19 because she looked at her notes and realized she forgot to document the sacral moisture area. She said she was not used to the facility computer system and she thought the note would be continuous with the note on 5/9/19. On 5/13/19, there was new skin breakdown to the resident's buttocks. Telephone interview with RN A who returned a phone call placed during the investigation on 7/9/19 at 3:07 p.m., he stated CR #1 was admitted around 7 p.m. that night and he had a soft cast to his right arm. He said he was not the admission nurse, but he was the charge nurse. The resident was using a urinal, but they noticed the pee was flowing back onto the bed sheets. The resident started having skin tears. He initially had redness but that was exacerbated by his use of the urinal. CR #1 had a high risk of breakdown. They did not initially notice the pee was flowing back. The aides were not changing him often because they thought he was using the urinal properly and he was laying in the urine for a while. RN A said staff started using the cream on the resident. In an interview with the Regional Director of Operations on 7/18/19, at 11:10 a.m., she stated the facility had a very good system to prevent wounds, so CR #1 should not have developed the wound at that rate even if he was at risk for wounds. In an interview with RN A on 7/18/19, at 2:30 p.m., he stated he worked that Friday after CR #1 was admitted but he did not work that weekend. He could not recall if anyone reported CR #1 had any skin breakdown over the weekend. The facility policy on pressure ulcer prevention and treatment was requested from the interim DON on 7/18/19 at 12:30pm but was not provided prior to exit. Record review of facility document, Perineal Care Protocol, dated (MONTH) 2013 revealed it read in part, Cleansing the perineal area between showers or baths helps prevent irritation, infection, and skin breakdown as well as keeping the patient comfortable .

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 19 residents (CR #1) reviewed for quality of care, the facility failed to; Monitor CR #1, who had [DIAGNOSES REDACTED]. Develop and communicate to staff on the baseline care plan interventions focusing on care procedures for CR #1 who was a diabetic with an end stage [MEDICAL CONDITION], was on isolation for shingles , had limited communication capability and was totally dependent on staff for all medical and ADL care. Assess CR#1's blood sugar when performing cardio [MEDICAL CONDITION] resuscitation (CPR). CR#1 received long acting insulin the night before and had no food for over 12 hours when found unresponsive at 9 am. CR #1's blood sugar was not checked to rule out diabetic coma. Provide timely blood sugar checks and medications. CR#1 had ordered blood sugar at 6:30am which was not documented as being completed and 8am medications which were not documented as administered by 9am when the resident was found unresponsive. CR #1 was pronounced dead on scene by Emergency Medical Services on [DATE] at 9:20AM with no resuscitation attempted due to obvious signs of death of Rigor Mortis. Develop a system and communicate this system to nursing staff to ensure nursing staff identified insulin dependent diabetic residents requiring prompt meal assistance to be provided to them. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one resident who died in the facility at an unknown time. Findings include: TX 675/Intake # 4 TX 663/Intake # 1 CR#1 Record review of the facility's Care Plans - Baseline policy (Revised (MONTH) (YEAR)) revealed in part, .1. To assure that the resident immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The interdisciplinary team will review the healthcare practitioners' orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders [REDACTED]. Dietary orders; d. Therapy services; e. Social Services; and f. PASARR recommendations, if applicable . Record review of the study [MEDICATION NAME] (Insulin detemir injection) revealed in part : .Renal impairment- Individuals with renal impairment showed no difference in pharmacokinetic parameters as compared to healthy volunteers. However, literature reports have shown that clearance of human insulin is decreased in renally impaired patients. Careful glucose monitoring and dose adjustments of insulin, including [MEDICATION NAME], may be necessary in patients with renal dysfunction . https://www.accessdata.fda.gov/drugsatfda. Record review of facility policy on insulin administration revised (MONTH) 2014 revealed general guidelines - the three-key characteristic of insulin are - onset of cation - how the insulin reached the blood stream and begin t lower blood glucose, peak effects - the time when the insulin is at its maximum effectiveness and duration of effects- the length of time during which the insulin is effective. The four times of insulin and their characteristic are: Rapid- acting insulin has onset of 10 -15 minutes, peaks between 0.5- 3 hours and has duration of ,[DATE] hours. Long acting insulin has onset of ,[DATE] hours, peaks up to 8 hours and has duration up to 24 hours. Record review of CR #1's face sheet revealed a [AGE] year-old female resident admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's admission nurses notes dated [DATE] at 10:28PM revealed in part, .medical history of [REDACTED].Patient admitted to the hospital due to [MEDICAL CONDITION], altered mental status, general weakness, and unresponsiveness for the last 1 day. Patient also has been diagnosed with [REDACTED]. Resident is a full code status . Upon assessment and observation, resident alert and mostly unable to communicate verbally, able to make needs known by nodding and facial expressions, understand instructions . Resident extensive assist on bed mobility and transfer with 2 persons help on support. Eats dependently with staff assistance . Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's physician's orders [REDACTED]. The order noted to check the blood sugar and follow the sliding scale: 61 - 150 = 0 units, 151 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 350 = 8 units, 351 - 400 = 10 units, 401 or greater = 12 units and recheck blood sugar in 15 minutes. The Humalog order was to be administered three times daily at 6:30AM, 11:30AM, and 4:30PM. Record review of the MAR for the Humalog dated [DATE] at 6:30AM reflected the blood sugar was not checked. Further review of the MAR revealed resident had 6:30AM blood sugars readings from [DATE] - [DATE] of 94, 93, 124, 70, 142, 90, 133, and 119. Record review of CR #1's physician's orders [REDACTED]. The [MEDICATION NAME] was to be given at 8:30PM. Record review of the MAR for the [MEDICATION NAME] revealed CR #1's blood sugar was 130 on [DATE] at 8:30PM and the [MEDICATION NAME] was administered. Further review of the MAR revealed the resident had 8:30PM blood sugar readings from [DATE] - [DATE] of 137, 15, 151, 176, 256, 109, 117, and 254. Record review of CR #1's physician's orders [REDACTED].=800mg) Tablet Oral to be taken with meals at 8:00AM, 12:00PM, and 6:00PM for End Stage [MEDICAL CONDITION]. Record review of CR#1's MAR for the [MEDICATION NAME] dated [DATE] at 8:00AM revealed the medication was not administered because the resident was discharged . RN #1 had signed the MAR and made the note about the medication not being administered on [DATE]. Record review of CR #1's physician's orders [REDACTED]. Review of the MAR for the [MEDICATION NAME] dated [DATE] at 8:00AM revealed the medication was not administered because the resident was discharged . RN #1 had signed the MAR and made the note about the medication not being administered on [DATE]. Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's Baseline Care Plan dated [DATE] revealed CR #1 required contact isolation, staff and visitors to follow isolation requirements. CR #1's base line care plan also revealed staff were to provide assistance with ADL's, transfers, repositioning, tray set up and feeding as needed. Further review of the baseline care plan revealed no mention of diabetes management or [MEDICAL TREATMENT] treatment. Record review of CR #1's History and Physical dated [DATE] revealed in part, . Initially presented to the emergency room with generalized weakness and episode of unresponsiveness. Patient thought to [MEDICAL CONDITION] secondary to Urinary tract infection and received IV antibiotics. Patient had elevated troponin seen by cardio and thought secondary to demand ischemia . Physical Exam - General: lying in bed, chronically ill appearing. Cardiac: S1S2 (first and second heart sound) , Murmur+. [MEDICAL CONDITION]: Bilateral diminished breath sounds. No wheezing . History and Physical was completed by the Physician. Record review of CR #1's nurses notes dated [DATE] at 12:06PM revealed, Rounded on patient at 7:00AM with night nurse, RN #2. Patient resting quietly in bed. At 8:45AM, therapist checked on patient and attempted to arouse her for her therapy session. Patient found to be unresponsive. Assessed patient myself and noted that patient had no breath sounds. Called 911, while charge nurse began to perform CPR. Houston Fire Department arrived and pronounced patient deceased . Physician notified, family notified, and patient [MEDICAL TREATMENT] center also notified. Note was written by RN #1. Interview on [DATE] at 5:00PM, CR#1's family member said the facility called her around 9:30AM and told her CR #1 had passed at 9:20AM. She said the facility did not tell her what happened, and she had concerns about how she passed away. The family said they were told by a nurse in the hallway that it was a therapist who found her unresponsive. The family said CR #1 was diabetic and should have had her blood sugar checked at 6:30AM, had her morning medications, and had her breakfast before the time she was found. The family wanted to know what her blood sugar reading was that morning and what condition she was in that morning before she became unresponsive. The family was very upset and said she felt the facility did not properly care for CR #1 and said she was fine the day before when she visited. The family also said the resident had [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays at 11:00AM and the [MEDICAL TREATMENT] center had called her saying the resident was late to her appointment on [DATE] and [DATE]. The family was concerned the facility was not getting the resident up and ready to make it to her [MEDICAL TREATMENT] appointments on time. Interview on [DATE] at 6:20PM, the DON said CR #1 was found unresponsive by an Occupational Therapist (OT) around 8:45AM. She said the nurse (RN #1) was immediately notified by the OT and she called a code blue. The staff started CPR and 911 was called, EMS came and pronounced the resident dead at 9:20AM. The DON said after they got through the code she called the family herself and notified them of what had happened and asked for them to come to the facility. The DON said she was not sure what caused the residents death or what had happened but said she suspected the resident had passed away in her sleep. The DON reviewed CR #1's MAR and said it looked like her blood sugar was not checked yet that morning ([DATE]) because the MAR was blank for the 6:30AM Humalog. The DON said it was important to have the blood sugar checked before CR #1 ate her breakfast and then said her breakfast tray had been brought to her room that morning but not fed to her yet. The DON relayed her interview with CNA#1 who told her she (CNA #1) had delivered CR #1's breakfast tray to her room and observed her sleeping and did not try to wake her. The DON said she would not expect the CNA to wake the resident if she was in a deep sleep because the resident needed assistance with eating and CNA #1 was not CR #1's assigned CNA. The DON was asked what staff worked with CR #1 the night of [DATE] and the morning of [DATE] to determine who last saw the resident awake. The DON was not sure. Record review of CNA#1's statement dated [DATE] written by the DON revealed per CNA#1 , she brought the patient (CR#1) her breakfast tray on the morning of [DATE], as she normally does. Said she put it on the bedside as she observed the patient to be asleep. Interview on [DATE] at 1:00PM, CNA #2 said she worked with CR #1 during the night shift on [DATE]. CNA #2 said she came in around 10:00PM and observed the resident sleeping, she said she checked the resident and she was calm and breathing. She changed her brief around 10:30pm and the resident woke up and was able to slowly role from side to side while she changed her. She said she looked in on the resident at 12:00AM and 2:00AM, observed CR #1 sleeping. The CNA said she last saw and changed CR #1 between 5:00AM - 5:30AM and she was able to participate with incontinent care by rolling from side to side. She said the resident moved slow and appeared to be weak in strength but said it was her normal behavior. Record review of CR #1's ADL Verification Worksheets revealed between [DATE] night shift (10PM - 6AM) and [DATE] morning shift (6AM - 2PM) she only had incontinent care documented at 11:21PM. Interview on [DATE] at 12:24PM, RN #2 said he worked with CR #1 the night of [DATE] and he did not observe her to have any changes in condition. He checked the resident every 2 hours and observed her to be at sleep. He said he had also observed the CNA going into CR #1's room to do incontinent care but was unsure of the exact time. RN #2 said at 7:00AM, he and RN #1 did rounds together and observed CR #1 to be sleeping and he knew she was sleeping/breathing because they observed her chest rising and falling. Interview on [DATE] at 10:44AM, CNA #3 said she worked with CR #1 the morning of [DATE]. CNA #3 said she did rounds when she first came in for her shift and observed CR #1 sleeping between 6:00AM and 6:15AM. She said she knew she was alive/sleeping because she could see her chest rising and falling. CNA #3 said she was doing her normal morning routine getting residents up and she was across the hall from CR #1 caring for another resident when CR #1 had been found unresponsive. She said she came out of the other resident's room and saw a bunch of staff and EMS in CR #1's room and was told about then that she had passed away. CNA #3 said she was not the CNA who delivered CR #1's breakfast tray and said the dining hall would usually be served first between 7:00AM - 7:20AM and the hall trays would come out between 8:00AM and 8:20AM. She said CR #1 needed assistance with eating and she would usually get her up and assist her with breakfast between 8:30AM - 9:00AM. She said independent residents were served first and had their tray set up for them, then the aides would begin to assist the residents who need assistance. CNA #3 said on [DATE] she had not gotten to CR #1 yet to get her up and assist her with breakfast because she was with another resident but said CR #1 would have been her next stop. CNA #3 added she did not know if CR #1 had gotten her blood sugar checked yet that morning and said the nurses usually took care of blood sugars and administering insulin before breakfast comes out. She said the CNA's are not told if blood sugars are already done before they give residents breakfast or if insulin has been administered, the nurses take care of that before breakfast. Interview and record review on [DATE] at 10:00AM, the Administrator said CNA #1 was not available to talk to because she had a medical emergency that morning and left work to go to the emergency room . CNA #1's number was provided, and a typed statement was provided stating CNA #1 had brought CR #1 her breakfast tray on [DATE] and had observed her to be peacefully sleeping. The statement did not state a time the tray was brought into the room. Calls were attempted to CNA #1 on [DATE] at 3:50PM and 4:00PM, on [DATE] at 1:40PM, and [DATE] at 1:00PM, there was no ring and phone gave a busy tone each time called. Interview on [DATE] at 1:00PM, the DON said CNA #1 had not been back to work since she left ill on [DATE] and she had not spoken with her . CNA #1 did not have another phone number on file. Interview on [DATE] at 10:34AM, CNA #4 was interviewed to clarify breakfast protocol and said breakfast was served in the dining room first between 7:00AM and 7:20AM and on the halls between 8:00AM and 8:20AM. CNA #4 said the aides helped independent residents with tray set up first and then would assist residents who needed assistance with eating after the independent residents were served. Interview on [DATE] at 12:07PM, the Dietary Manager was interviewed to clarify breakfast protocol and said breakfast was served first in the dining room at 7:00AM then once the dining hall was finished residents were then served in the halls between 8:00AM - 8:20AM. She said the aides would set up resident's trays who did not need assistance and then go through and assist residents who needed help with eating. Interview on [DATE] at 11:01AM, RN #1 said she worked with CR #1 the morning of [DATE] and she first observed the resident at 7:00AM when she did rounds with the night nurse (RN #2). She said they both observed CR #1 sleeping and knew she was sleeping because they could see her chest rising and falling that indicated she was breathing. During the interview she said she next saw the resident when an Occupational Therapist came out the room asking when she had last checked on CR #1 and said she thought the resident was unresponsive. RN #1 said she checked the resident's pulse and there wasn't one so called for help and started CPR. She said she did not check the vitals and said her Unit Manager checked them while she was giving CPR. RN #1 could not verbalized them either. she said she did not know if she had documented them somewhere. She said they continued CPR until the Fire Department got there and pronounced the resident dead. At this time RN #1 was asked when she was going to check CR #1's blood sugar and she said she had checked them that morning. RN #1 said she did another round around 7:15AM and checked CR #1's blood sugar and the reading was in the 130's. She said the resident did wake when she checked it and was drowsy but did not have any behavior out of her norm. She said she had written the blood sugar down on a notebook and was going to document later after she did morning vitals and passed her morning medications. She said she did not get to do CR #1's morning vitals or meds before she passed away and said she was actually next door to the resident's room and was coming to her next when she was found by the OT. RN #1 said she no longer had the pad where she wrote the blood sugar down. Interview on [DATE] at 11:19AM, the Occupational Therapist (OT) said at 9:00AM she went into CR #1's room to see if she could observe her eating breakfast. She said she knocked at the door and tried talking to the resident. She said CR #1 did not respond and described the room as dark because the lights were off and said there was a breakfast tray in the room with the lid still on. She said she put on the isolation gear at the door and because the resident was on contact isolation. She said she went into the room and washed her hands first then put on gloves. She went over to the resident to wake her and when she touched the resident she could feel the resident was ice cold through her gloves. She said once she got close and saw CR #1, she did not look like she was sleeping. The OT said the resident's mouth was open and when she tried shaking her to wake her, the resident body was already stiff. She said she ran out to the hallway and got the nurse who was next door (RN #1). The OT got emotional while describing the resident and said she had asked the nurse when she last checked on the resident and the nurse told her she had just checked on the resident. She said the nurse checked CR #1's pulse and there wasn't one. The OT added she was surprised to see the resident had not been gotten up yet or fed her breakfast when she got to the room because the resident should have been going out to [MEDICAL TREATMENT] soon. Interview on [DATE] at 12:35PM, the Unit Manager said the morning of [DATE] was her first day on the job. She said she was at the nurse's station when RN #1 came out of CR #1's room and said she needed help. She got to the room and the resident was already on the floor with CPR started. She said she checked the resident's vitals and there was none. She did not check CR #1 blood sugar because RN #1 said she had already checked the blood sugar earlier that morning. The Unit Manager said she did not document the vitals she took. Record review of CR #1's Fire Department report dated [DATE] revealed they were called at 9:12AM about a person being down for an unknown reason. The Fire Department arrived on the scene at 9:16AM and after assessing the resident they pronounced her dead-on scene because of obvious signs of death from rigor mortis at 9:20AM. The Report Summary revealed, units arrived on scene to find nursing home staff doing CPR on a [AGE] year-old female with an unknown downtime. CPR was stopped to check for a pulse and look for signs of rigor mortis. It was determined that patient was dead on scene. Patient's jaw was stiff and was in the beginning stages of rigor mortis. All life saving efforts were stopped at that time per Paramedics on scene. Interview on [DATE] at 1:04PM, the DON said she was in the front of the building and was told about the code called on CR #1. The DON said when she got the CR #1's room a nurse was doing CPR and she looked tired, so she took over CPR. She said as soon as she took over CPR the Fire Department arrived. She said they came in and moved the bed out of the way and looked at the resident and said, It looks like she's been down for a while. She said they told her to stop CPR and pronounced the resident dead. She said the resident body was cool to touch and her temperature felt below normal body temperature. When asked about the resident's appearance she said, she appeared to have been down for a while. She said the residents face was pale colored. She said she expected staff to check a resident's blood sugar during a code whether they were diabetic or not and said she was not present when the staff checked CR #1 vitals. When asked about expectations of her staff the DON said she expected them to do a physical assessment of the resident at the beginning of their shift to check for changes and get a baseline and then continue to assess the resident throughout their shifts. The DON was asked again about RN #1 checking CR #1's blood sugar given the condition she found the resident in and the Fire Department record and said she was not aware she claimed to have checked it and had no comment on whether she had actually checked it or not. She said she expected the staff to document everything they do at the time of completing the task, including giving meds, vitals, blood sugars, and ADL's. Record review of the Journal of Forensics Sciences and Criminal Investigation article titled, Time since Death from Rigor Mortis: Forensic Prospective published on (MONTH) 5, (YEAR) revealed in part, .Swenson Arne, Wend Otto and Fisher, Barry A.J. (1914) Stated that the biochemical changes in the body produce stiffening known as rigor mortis, which usually appears within ,[DATE] hrs. After death. Rigor mortis begins in the muscles of the jaws and neck and proceeds then downwards in the body and trunk and extremities and it is completed within ,[DATE]hrs. The rigidity remains for ,[DATE] days and disappear in the same order in which it appeared. The very young and very old will likely developed less rigidity than adults with well-developed musculature . The quoted article was found on Juniper Publishers website, https://juniperpublishers.com/jfsci/pdf/JFSCI.MS.IDXXX 1.pdf. Interview on [DATE] at 2:47PM, the Admission Nurse said she is responsible for doing the Base Line Care Plans for newly admitted residents and the Unit Manager was supposed to review the care plan the next morning. The Admission Nurse said there is a check off sheet to develop the base line care plan and Glucose monitoring is an option that should be checked off for someone who is an insulin dependent diabetic. The Admission nurse said she was not the nurse who created CR #1's baseline care plan because she was admitted on the weekend and was not sure who did. Interview on [DATE] at 2:00PM, the Corporate Administrator said the base line care plans were supposed to be reviewed by the DON or Unit Manager and that was not being done so the diabetes management on CR #1 base line care plan was missed. Interview on [DATE] at 12:00PM, the Administrator said she was out on leave on [DATE]. She was not aware of there being an issue with CR #1's death until the state began to investigate it. Record review of the facility's Routine Resident Checks policy (Revised (MONTH) 2013) revealed in part, .Staff shall make routine resident checks to help maintain resident safety and well-being . 1. To ensure safety and well-being of our resident, nursing staff shall make a routine resident check on each unit at least once per each 8-hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, as if the resident is sleeping, needs toileting assistance, etc. Record review of the facility's Charting and Documentation policy (Revised (MONTH) (YEAR)) revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the residents medical, physical, functional or psychosocial conditions, shall be documented in the residents medical record. Further review of the policy revealed in part, 2. The following information is to be documented in the resident's medical record: a. objective observations; b. Medication administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives . 3. Documentation in the medical record will be objective, complete, and accurate. Record review of the facility's Obtaining a Fingerstick Glucose Level policy (Revised (MONTH) 2011) revealed in part, .1. Verify there is a physician's orders [REDACTED]. Review the residents care plan and provide for any special needs of the resident . Further review of the policy revealed in part, .The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason why and the intervention taken. 6. The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results, etc. 7. The signature and title of the person recording the data . Record review of facility's Nursing Care of the Resident with Diabetes Mellitus policy revealed in part, Documentation should reflect the carefully assessed resident and include the following: 1. Vital signs as ordered; 2. Level of consciousness; 3. Assessment of the skin including the following: a. Color, moisture, and temperature; and b. Any redness, ulcers, irritation, abrasions, and/or pruritus (itching). 4. Accurate intake and output; 5. Percentage of meals consumed; 6. Emotional reactions, moods; 7. Careful assessment of pain . 8. Motor weakness; 9. Urinary symptoms; 10. Bowel dysfunction including diarrhea and constipation; 11. Blood pressure problems including orthostatic [MEDICAL CONDITION]; 12. Assessment of the feet should include the following: a. hygiene; b. temperature; c. color; d. circulation, e. any abrasions; f. any corns or calluses; and g. the condition of the toes and toenails. 13. Injection site rotation; 14. Blood sugar results and other pertinent laboratory studies. The Administrator and DON was notified of Immediate Jeopardy (IJ) on [DATE] at 5:00PM due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 3:56PM after several revisions were made. Immediate Jeopardy Plan of Removal [DATE] Systematic Approach 1. Quality of Care & Administration (Diabetes Management) Licensed nursing staff, in-serviced by Regional Director of Clinical Service on [DATE], [DATE], [DATE] and [DATE]. This in-service emphasized assessment of Diabetic patients including indications of monitoring parameters, necessary lab work, medication monitoring, blood sugar check and monitoring for signs and symptoms of hyper/hypo Glycemia and identifying changes in conditions related to glucose administration such as lethargy, sweating and mood changes with notification to Physician and documentation in the clinical records. All diabetic Residents MAR/TARs, clinical records and care plans were reviewed to ensure accuracy. The CNAs were in-serviced by Director of Nursing and Regional Director of Clinical Services on [DATE], [DATE], [DATE] and [DATE] on rounding protocols, recognizing and reporting changes in condition to charge nurses, DON and Nurse Managers, providing timely assistance with ADL of all dependent Residents and documenting in real time. Licensed nursing staff was in-serviced by Regional Director of Clinical Services and Pharm D on [DATE], [DATE], [DATE] & [DATE] on insulin administration, diabetes management and medication, CPR, identifying change in condition, types of insulin & action, meal service requirement of diabetic Residents, resuscitation protocols for insulin dependent diabetic residents and associated knowledge of insulin use as well as parameters of monitoring after insulin administered The facility conducted an audit [DATE], [DATE], [DATE] and [DATE] of patient records to ensure that appropriate parameters were in place for diabetic patients receiving insulin including blood sugar monitoring. As of [DATE], Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. As of [DATE], The facility will also retrieve tracking reports from the EMR to evidence blood sugars were completed by nursing staff and that there is no duplication of orders, with appropriate timely documentation in the clinical records and that orders were followed. This training provided by Regional Director of clinical services and the DON started on [DATE], [DATE] and [DATE]. The retrieval of the tracking reports from EMR to evidence blood sugars will be reviewed daily in morning meeting and will continue indefinitely as of [DATE]. As of [DATE] a systematic change was initiated regarding monitoring of admission assessments, diabetic patients record, and clinical needs will be conducted by a Registered Nurse no later 24 hours after admission and daily during morning stand up meeting. A training was also started [DATE] and completed on [DATE] with Charge nurses and Nurse Managers regarding completing baseline care plans within 48 hours of admission and added to the Residents daily care guide to ensure that staff are aware of Resident's care needs Licensed nursing staff who are PRN or unavailable for the inservice will not be allowed to work until such a time as the inservice is complet

Based on interview and record review the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of 13 residents (CR #1) reviewed for quality of care. The facility failed to promptly provide a [MEDICAL CONDITION] machine for CR #1 for two days and failed to ensure staff were trained to use the machine when it was provided. The facility failed to seek medical consultation for CR #1 when she experienced a change in condition on [DATE] and [DATE]. The facility failed to continue to monitor, assess, and provide medical interventions to CR #1 after she was assessed as having experienced a change in condition on [DATE]; and a change in condition on [DATE] that was not identified or addressed until a family member requested for 911 to be called. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern. These failures affected one resident who died in the hospital on [DATE] following a transfer for change in status and placed 22 other residents at risk of not receiving services necessary to prevent complications which could lead to a decline in their health, or death. The facility needed additional time to evaluate the effectiveness of their plan. Findings include: Intake # 0 CR #1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 was transferred to theER on [DATE] at 1:30 p.m. Record review of CR #1's discharge hospital record dated [DATE] revealed the following Diagnoses: [REDACTED]. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's Hospital discharge order for [MEDICAL CONDITION] dated [DATE] at 1:06p.m., revealed the following setting [MEDICAL CONDITION] for routine use, frequency -RQ4H, PAP mode (cm H20) -12, EPAP mode (cm h20)- 5, mode of operation -spontaneous, B.P.M-12, and FI02 -35. Record review of the facility invoice for [MEDICAL CONDITION] rental revealed the equipment was ordered from an outside company on [DATE] and delivered sometime during the ,[DATE] shift on [DATE]. Equipment delivery was signed by Unit Manager #1. Record review of CR #1's facility clinical notes report dated [DATE] at 6:32p.m. written by LVN #3 revealed assessment admitted [AGE] years old female to the facility she was transferred from hospital she does not speak English and cannot communicate, she appears to be very anxious and restless at this time . heart rate irregular, lungs wheezing bilaterally, both legs are swollen from knees to feet she does not show any non-verbal signs of pain at this time admitted to hospital for respiratory problems, found to have pneumonia [MEDICAL CONDITION]. Presently on intravenous antibiotics, she is confused and is total care at this time. Record review of CR #1's facility clinical records revealed no interim care plan. Record review of CR #1's facility clinical note report dated [DATE] at 4:58p.m. written by LVN #1 revealed patient continues with [MEDICATION NAME] intravenous first dose this AM. Peripheral intravenous central catheter on the right upper arm. Patient tolerated well. Patient went to dining room for lunch and sat on the wheel chair. Patient was lethargic and was not eating. Patient's face started to be pale, they rushed patient to her room. Nurse came to patient's room and assessed her. Oxygen saturation ,[DATE]% at 2 liters was elevated to 5 liters and the oxygen saturation started to be increased to ,[DATE]%. Patient requested some thicken water and it was given to her, Nurse also fed some pureed meat and vegetable to her. Patient became alert and was trying to smile and talk to the nurse. patient ate all the chocolate pudding, head of bed elevated and pillows were placed under both legs, will continue to monitor. Record review of the facility's 24 hour report for the ,[DATE] shift on [DATE] revealed no documentation of the incident or of CR #1. There was no further documentation about CR #1 on the facility's 24 hour report until her transfer toER on [DATE]. None were provided as requested. Record review of CR #1's facility clinical notes report dated [DATE] at 11:00p.m., written by RN #1 revealed 7a.m.- resident in bed with oxygen ,[DATE] liters nasal cannula 90%. PICC line to the right arm double lumen, both ports patent dressing clean and intact. Assisted to feed for breakfast, tolerated only ¼ of share. Head of bed elevated 45 degrees. At 9a.m., intravenous [MEDICATION NAME] infused. At 11:00a.m., try to fit [MEDICAL CONDITION], oxygen saturation at 88% to 90%. Change nasal cannula to non-rebreather mask, resident's family concerned about condition, DON and administrator aware, called 911, NP notified, transfer to ER at 1:30p.m. Record review of CR #1's MAR indicated [REDACTED]. Order was signed by the DON as implemented on [DATE] and [DATE]. Interview on [DATE] at 3:30p.m., CR #1's family members said CR #1 admitted to the facility on [DATE] and was not properly cared for. She was not provided a [MEDICAL CONDITION] which she needed for breathing due to her [MEDICAL CONDITION]. This family member said CR #1 used a [MEDICAL CONDITION] while in the hospital and was discharged with an order to continue using it. The family member said the facility did not have the [MEDICAL CONDITION] for two days and when it came, staff did not know how to use it. The family member said the facility did not notify them about any change the resident may have had prior to their visit on [DATE] about midday when they found CR #1 half naked in bed, with half of her body hanging off the bed. The family member said CR #1 was very weak, could not be understood, did not know family and was not herself since they last saw her on [DATE]. The family member said CR #1 could not breathe and the nurse (RN #1) could not tell something was wrong with the resident and did not know how long she had been that way. The family member said she demanded that RN #1 call 911 and have CR #1 transferred to the hospital immediately. The family member said when the Administrator came into CR #1's room and saw the resident she also told him they needed to call 911 and have CR #1 transferred to the hospital and he agreed. The family member said CR #1 died during the early hours of [DATE] in the intensive care unit. Interview on [DATE] at 10:05a.m., Facility Supply Staff said when he got information about CR #1 coming in, he got the room ready and told the DON that the facility's only working [MEDICAL CONDITION] machine was in use by another resident. The DON told him she would rent a [MEDICAL CONDITION] machine from an outside rental company for CR #1. Interview on [DATE] at 10:40a.m., the DON said when CR #1 admitted on [DATE], she was aware CR #1 needed a [MEDICAL CONDITION] machine. The DON further said the hospital record indicated it should be used as needed. The DON said she could not recall where she saw this order in the resident's record. The DON also said the order for the [MEDICAL CONDITION] stated it was to be used at bedtime only. When asked where she saw the order for the [MEDICAL CONDITION] to be used at bedtime, the DON was unable to find it. The DON said CR #1 was provided a [MEDICAL CONDITION] machine upon admission, which was placed in her room. She also said she called the facility's contracted respiratory therapist who came out and set-up the [MEDICAL CONDITION] machine according to CR#1's orders. Interview on [DATE] at 1:10p.m., the Facility Supply Staff said he now recalled that a [MEDICAL CONDITION] machine was rented from the outside company was in the CR#1's room on [DATE]. He also brought in an oxygen concentrator and a welcome basket. Interview on [DATE] at 1:23p.m., LVN #1 said on [DATE] after the LVN #3 completed CR #1's admission, CR #1's family asked her about the [MEDICAL CONDITION] machine. LVN #1 said she checked CR #1's admission orders [REDACTED]. LVN #1 said the [MEDICAL CONDITION] was not available throughout [DATE]. LVN #1 said on [DATE] CR #1 had therapy and was then encouraged to go to the dining room. She said CR #1 was very weak and did not speak English, but she had orders to eat in the dining room. While CR #1 was in the dining room for lunch, LVN #1 said she was called because the resident appeared very weak and pale. LVN #1 said she did not remember if the resident had oxygen on at that time. CR #1 was moved to her room where her oxygen saturation and other vital signs were checked, and her oxygen saturation was low. LVN #1 said she increased the liters of oxygen and CR #1's oxygen saturation came up. CR #1 came back to her previous self and was no longer pale. LVN #1 said CR #1 was supposed to be on a [MEDICAL CONDITION] according to her admission notes, but the [MEDICAL CONDITION] was not available throughout her shift on [DATE]. Interview on [DATE] at 2:37p.m., Unit Manager #1 said she received the rented [MEDICAL CONDITION] machine during the ,[DATE] shift on [DATE] but was unsure the exact time it was delivered. Unit Manager #1 said the machine was placed in CR #1's room. She said she presumed the company preset the machine before the delivery but was not sure. She said no training was given to staff upon delivery of the [MEDICAL CONDITION]. Interview on [DATE] at 3:45p.m., RN #1 said she worked the morning shift on [DATE]. She said upon duty assumption, the night nurse did not tell her about any incidents regarding CR #1. RN #1 said she did not know CR #1 had a change in condition as she had not worked with the resident before. RN #1 said CR #1 was newly admitted so she did not know her baseline. When asked if the resident showed any signs of distress RN #1 said no. RN #1 said in the morning she attempted putting the [MEDICAL CONDITION] on CR #1, but could not because the [MEDICAL CONDITION] mask was too small and did not fit CR #1's face. RN #1 said she was not trained on how to use the machine and did not ask anyone how the machine should be used. RN #1 further said the resident's family wanted her to go out to the hospital, so she called 911. Interview on [DATE] at 9:37a.m., CR #1's NP said she saw CR #1 the morning of [DATE], which was a Friday. She said CR #1 was advanced in age and had aspirational pneumonia. Upon observation she appeared to be in hypo-active [MEDICAL CONDITION] with stable vital signs. The NP said CR #1 did not speak English but she followed gestures. The NP said she was not notified on the resident's oxygen desaturation on [DATE] but was told she de-saturated on [DATE]. The NP said she was notified on [DATE] they could not bring CR #1's oxygen level up so the facility sent her to the hospital. The NP said CR #1 was sick and believed she may have been sent to the facility in an unstable condition. Interview on [DATE] at 10:30a.m., the Facility Respiratory Therapist said he was out of town when this incident occurred with CR #1 and would not have been reached by any facility staff because his work phone was off. He denied any knowledge of the incident and said he did not speak to the DON regarding any [MEDICAL CONDITION] set up. He had no knowledge of CR #1. Interview on [DATE] at 11: 35a.m., the Administrator said he did not know much about CR #1 because CR #1 had just admitted . He stated he was in the facility in the morning of [DATE] when the resident's family member came up to the front office and expressed concern about the resident, he went down to her room with the family member to see the resident. After seeing the resident, he immediately told someone to call 911. The Administrator said he had no prior knowledge of any incident that happened days ago. Interview on [DATE] at 2:15p.m., LVN #1 said she did not notify the physician of CR #1's change in condition on [DATE] because the resident came back to her normal self and it was around shift change. She further explained she continued to monitor the resident and reported this to the next nurse to continue to monitor the resident. Interview on [DATE] at 3:34p.m., LVN #3 said he admitted CR #1 on [DATE]. LVN #3 said CR #1's family member reported the resident needed a [MEDICAL CONDITION] because CR #1 had respiratory problems and used the [MEDICAL CONDITION] in the hospital. LVN #3 said he checked the resident's record and saw an order for [REDACTED]. Interview on [DATE] at 3:53p.m., LVN #2 said when she worked the ,[DATE] shift on [DATE], LVN #1 did not tell her about CR #1's incident during shift change. She said she did not know about CR #1's desaturation. She recalled administering a Nebulizer treatment to CR #1. She also said the resident had a [MEDICAL CONDITION] machine at beside. LVN #2 said the [MEDICAL CONDITION] machine had a mask which covered CR #1's face, but she struggled to use the machine and the mask. LVN #2 said she was not trained on how to use the machine and did not ask anyone how the machine should be used. Interview on [DATE] at 4:32p.m., the Facility Admission Marketer said she saw CR #1 in the hospital prior to her admission to the facility. She further said she was told by the hospital case manager that CR #1 would need a [MEDICAL CONDITION] to be on stand by and used as needed. She said all of this was communicated to the facility and paperwork was also sent for review prior to CR #1's admission on [DATE]. Record review of the Facility's policy on significant change in patient status, which was not dated, revealed .a significant change in patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions or in incidents of clinical complication. Scope and severity, example of life-threatening conditions include but are limited to cardiovascular or respiratory changes Etc. As a significant change in patient's conditions occurs; the charge nurse will notify the physician, family or other appropriate person/agency of the significant change immediately. Complete interact SBAR form for non-emergent changes in condition . Record review of the Facility's policy on physician notification, which was not dated, revealed .it is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment. The nurse will recognize the change, complete interact SBAR, monitor the patient of any changes in condition and document communication and response with the physician in the clinical record . Record review of the Facility's policy on assessments, dated [DATE] revealed .a Situation, Background, Assessment and Request (SBAR) communication form and progress notes must be completed upon a patient's change in condition and prior to contacting the attending physician, the SBAR communication form can replace a nurse's note and is filled in the patient's medical record . Record review of the Facility's policy on reporting guidelines for shift change, which was not dated, revealed .all staff coming on duty are to be present for report, report the condition of each patient, list and report elevated temperatures or abnormal vital signs and the last time checked. Report the last dose of any PRN medications administered and effectiveness, report any condition change or follow-up on any condition change of any patient, reports incidents, status of patients, orders to be followed, report all equipment or supplies needed and report on status of staffing for the following shift, report status of all calls to physicians, pending labs, X-rays, or test results-why call was placed, name of patients, when call was last placed . The facility's policy on Residents rights requested from the DON, but was not provided. The Administrator was notified on [DATE] at approximately 11:30a.m., of an Immediate Jeopardy of the above failures. Interview on [DATE] at 4:11p.m., the Administrator, who was the abuse coordinator, said he was not aware of any of CR #1's incidents prior to [DATE]. He said he believed the facility was in an IJ situation because of a lack of communication between nurses and with CR #1's physician. He said he found out about CR #1's incidents after the surveyor initiated the investigation, and from asking staff about CR #1. He said he met the family briefly on [DATE] and when they came to him asking for help. The Administrator said he went to CR #1's room and saw her in her room. Interview on [DATE] at 4:40p.m., the DON said she believed the facility's immediate jeopardy occurred because staff failed to properly use the facility's system of notifying CR #1's physician of changes, 24 hour reporting and staff communication and documentation. She expected staff to notify the Resident's physician of a change in condition and to report to the on-coming nurse to continue to monitor residents and to follow up with physicians if there was no response from the physician. She said the staff should report to on-coming staff during shift change all changes that occurred the past shift for continued monitoring. The DON agreed staff should be trained on newly rented equipment for proper use and that equipment needed by residents should be available for their use upon admission. The DON also said the [MEDICAL CONDITION] machine rented for CR#1 was delivered with a nasal mask only. A plan of removal for the IJ was submitted on [DATE] at 3:52 p.m. After three revisions, the plan of removal was accepted on [DATE] at 5:01 p.m. The following steps are the facility's plan to remove the Immediate Jeopardy. Plan to remove immediacy: Immediate Jeopardy Plan of Removal [DATE] Systematic Approach 1. Notification of Physicians: a. The facility has begun to conduct in-services to licensed nursing staff on notification of physicians per the facility policy. The facility policy includes conditions which may arise from as well as the nurses' responsibility to act. These include: Altered Mental Status, Bleeding, Chest Pain, Diarrhea, [MEDICAL CONDITION], Emesis, Falls, Family Concerns, G- Tubes Complications, Medication Error, Pressure Sores, [MEDICAL CONDITION], Shortness of Breath, (if changes in orders for treatment is required), skin rash, Vital Sign Changes, and Laboratory Values. The most common condition changes are listed. If changes that warrant a change in treatment exist, the physician is to be notified, as well as the responsible person, if indicated. For new patients, information is obtained from the referral information as well as the admission assessment which may include interviews as indicated with the family and patient. Significant variances from that of the admission assessment and the referring facility information, the physician will be notified. The in-services began on [DATE] and will be completed [DATE]. b. The facility has begun to conduct in-services to facility staff on the interact process. The interact Process is a systematic approach by which each facility staff member is assigned the responsibility of notifying nursing of any change in condition. The electronic medical record has been set up to include the systematic forms utilized in the process with automatic triggers to nursing staff once the form is completed. In-services on the Interact process began on [DATE] and will be completed by [DATE]. The in-services began on [DATE] and will be completed [DATE]. c. The Facility immediately conducted an evaluation, to include record auditing on those Patients with special needs equipment. The Facility ensured that all equipment needs were addressed, to include operation of equipment. This was completed on [DATE]. d. The facility shall use both the Interact process and the 24 hour Electronic report to verify action on change of status. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the tour of duty. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Changes from non-nursing staff shall be accomplished through the Interact Process. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The in-services began on [DATE] and will be completed [DATE]. e. The facility will document monitoring of change of status on the change of status log. f. As a systematic change, monitoring of admission assessments and clinical needs will be conducted by a Registered Nurse no later 24 hours after admission. This review will include verification of the care needs carried forward to the C.N.A. care card as this is how communication to the C.N.A.'s is accomplished. g. No facility staff will be allowed to return to active duty until such a time as the education described above is completed. h. Results of all monitoring shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. i. Changes identified by non-nursing staff will be communicated using the Interact Process. j. Completion Date: [DATE] 2. 24 Hour Reporting: a. The facility has begun reeducating the staff on 24 hour reporting utilizing the electronic 24 hour report. b. The 24 hour report will be reviewed by Unit Managers, Weekend Supervisors and the Director of Nursing daily to ensure that appropriate information is communicated to the proper individual. c. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Changes from non-nursing staff shall be accomplished through the Interact Process. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The in-services began on [DATE] and will be completed [DATE]. d. Monitoring of 24 hour report handoff between shifts will occur randomly by the Unit Manager, Weekend Supervisor or the Director of Nursing and a daily review of the 24 hour electronic report will be conducted by the Director of Nursing or her designee to ensure appropriate follow through occurs on any resident need. This tool can be used by all staff as a means to identify resident needs when a patient admits to the facility. e. No licensed nurse shall return to active duty until such a time as they have been in-serviced on the 24 hour report. f. The results of all 24 hour monitoring shall be brought to the Quality Assessment and Assurance Committee and the committee's recommendations acted upon. g. Completion Date: [DATE] 3. Special Needs Equipment: a. The facility will address the needs of special equipment through the admission process by review of the Referral information, admission nursing assessment, as well as physician or nurse practitioner assessment. Once the facility has identified the need, the equipment will be provided. If this equipment is noted in the referral information, it will be provided before the patient is admitted . Any identified equipment needs will be obtained and checked by the Director of Nursing or designee for functionality prior to providing the equipment of the resident. It shall be the responsibility of the charge nurse to ensure that equipment remains functional to patient needs throughout the stay. The Director of Nursing, Unit Managers as well as the weekend Nursing Supervisor shall be responsible for routine monitoring of equipment functionality. 4. Non- English Speaking Patients: a. Patients who do not speak English shall be communicated with utilizing facility staff who do speak the language, if available, or patient family members. b. Care cards indicating needs will be established for the resident allowing for identified needs to be communicated to staff. The facility also, if needed will establish a letter board to allow the resident to effectively communicate with staff. New patients will not be admitted until such a time as a mode of communication has been established. c. The Patient's language needs are assessed on admission and will be communicated though staff through the medical record alerts C.N.A. care cards as well as the Patient's Plan of Care. d. These processes were initiated on [DATE], to be completed on [DATE]. Monitoring The surveyor monitored the plan to remove the immediate jeopardy on [DATE] through [DATE] as follows: On [DATE], and [DATE] LVNs and RNs on all three shifts were interviewed on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Record review of the facility In-Services revealed: [DATE]: 28 nursing staff members were trained on communication: 24 hour reporting. [DATE]: facility initiated facility audit to rule out no resident had a change in condition that was not identified. [DATE]: 28 nursing staff members were trained on proper way of notifying/consulting the resident's physician, identifying a significant change in status, report guideline for change of shift and facility's medical director and to call 911 if no response was received from the physicians; and staff were to notify the DON or designee of any identified changes in condition. [DATE]: 27 staff members were trained on documentation of changes of condition, documenting SBAR, and following up documentation for monitoring and giving change of shift reports. [DATE]: 39 staff members were trained on use of communication boards. Established an audit tool for 24 hour reporting and change in condition. All equipment in the facility was checked by staff to ensure they were in good working condition. Observation on [DATE] revealed all 6 Non-English speaking residents in the facility had a communication book in their room and staff were aware of how to use them. On [DATE] through [DATE], 16 RNs and LVNs received respiratory training which included Tracheal suctioning, [MEDICAL CONDITION] care with returned demonstration. Facility had [MEDICAL CONDITION]/[MEDICAL CONDITION] training set up in the future. Observation on [DATE] at 10:00a.m., revealed one resident in the facility who used a [MEDICAL CONDITION] machine. His [MEDICAL CONDITION] was a personal one and was already set-up for him prior to admission. Resident was able to use this [MEDICAL CONDITION] machine by himself. [DATE]: more than 60% of the facility's nursing staff members were trained on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes in condition among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Interview on [DATE] at 10:02a.m., the DON stated she completed chart audits, evaluated all residents in the facility for changes in condition and found that staff were implementing the appropriate and current plan. Record review of in-services, dated [DATE] through [DATE] revealed the DON and Unit Managers trained all staff scheduled to work ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE] on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes in condition among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Interviews with 5 CNAs on [DATE] between 2:25 p.m. and 5:40 p.m., and on [DATE] between 8:00a.m. and 10:00a.m. revealed they received training on how to identify abuse and neglect, when to notify a charge nurse of anything usual noted about any patient. Record review of the in-service forms provided by the DON dated ,[DATE], ,[DATE] and ,[DATE] revealed on-going in-services concerning resident assessments, physicians' consultation, and communication. Interview on [DATE] at 4:11p.m., the Administrator stated he would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. He further reported he would continue to monitor the facility approved plan of removal to ensure the safety of the residents. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 10:06a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of a pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following changes in condition, proper assessment , establishing a baseline vital signs for newly admitted residents, communication of changes among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. According to the facility's check list of equipment, 23 residents required special respiratory equipment.

Based on interview and record review, the facility failed to develop and implement policies and procedures that prohibit neglect of residents for one of 13 residents (CR#1) reviewed for neglect. The facility failed to promptly provide a [MEDICAL CONDITION] machine for CR #1 for two days and failed to ensure staff were trained to use the machine when it was provided. The facility failed to seek medical consultation for CR #1 when she experienced a change in condition on [DATE] and [DATE]. The facility failed to continue to monitor, assess, and provide medical interventions to CR #1 after she was assessed as having experienced a change in condition on [DATE]; and a change in condition on [DATE] that was not identified or addressed until a family member requested for 911 to be called. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of a pattern. The facility needed additional time to evaluate the effectiveness of their plan. These failures affected one resident who died in the hospital on [DATE] following a transfer for change in status and placed 22 other residents at risk of not receiving services necessary to prevent complications which could lead to a decline in their health, or death. Findings include: Intake # 0 CR #1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 was transferred to theER on [DATE] at 1:30 p.m. Record review of CR #1's discharge hospital record dated [DATE] revealed the following Diagnoses: [REDACTED]. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's Hospital discharge order for [MEDICAL CONDITION] dated [DATE] at 1:06p.m., revealed the following setting [MEDICAL CONDITION] for routine use, frequency -RQ4H, PAP mode (cm H20) -12, EPAP mode (cm h20)- 5, mode of operation -spontaneous, B.P.M-12, and FI02 -35. Record review of the facility invoice for [MEDICAL CONDITION] rental revealed the equipment was ordered from an outside company on [DATE] and delivered sometime during the ,[DATE] shift on [DATE]. Equipment delivery was signed by Unit Manager #1. Record review of CR #1's facility clinical notes report dated [DATE] at 6:32p.m. written by LVN #3 revealed assessment admitted [AGE] years old female to the facility she was transferred from hospital she does not speak English and cannot communicate, she appears to be very anxious and restless at this time . heart rate irregular, lungs wheezing bilaterally, both legs are swollen from knees to feet she does not show any non-verbal signs of pain at this time admitted to hospital for respiratory problems, found to have pneumonia [MEDICAL CONDITION]. Presently on intravenous antibiotics, she is confused and is total care at this time. Record review of CR #1's facility clinical note report dated [DATE] at 4:58p.m. written by LVN #1 revealed patient continues with [MEDICATION NAME] intravenous first dose this AM. Peripheral intravenous central catheter on the right upper arm. Patient tolerated well. Patient went to dining room for lunch and sat on the wheel chair. Patient was lethargic and was not eating. Patient's face started to be pale, they rushed patient to her room. Nurse came to patient's room and assessed her. Oxygen saturation ,[DATE]% at 2 liters was elevated to 5 liters and the oxygen saturation started to be increased to ,[DATE]%. Patient requested some thicken water and it was given to her, Nurse also fed some pureed meat and vegetable to her. Patient became alert and was trying to smile and talk to the nurse. patient ate all the chocolate pudding, head of bed elevated and pillows were placed under both legs, will continue to monitor. Record review of the facility's 24 hour report for the ,[DATE] shift on [DATE] revealed no documentation of the incident or of CR #1. There was no further documentation about CR #1 on the facility's 24 hour report until her transfer toER on [DATE]. None was provided as requested. Record review of CR #1's facility clinical notes report dated [DATE] at 11:00p.m., written by RN #1 revealed 7a.m.- resident in bed with oxygen ,[DATE] liters nasal cannula 90%. PICC line to the right arm double lumen, both ports patent dressing clean and intact. Assisted to feed for breakfast, tolerated only ¼ of share. Head of bed elevated 45 degrees. At 9a.m., intravenous [MEDICATION NAME] infused. At 11:00a.m., try to fit [MEDICAL CONDITION], oxygen saturation at 88% to 90%. Change nasal cannula to non-rebreather mask, resident's family concerned about condition, DON and administrator aware, called 911, NP notified, transfer to ER at 1:30p.m. Record review of CR #1's MAR indicated [REDACTED]. Order was signed by the DON as implemented on [DATE] and [DATE]. Interview on [DATE] at 3:30p.m., CR #1's family members said CR #1 admitted to the facility on [DATE] and was not properly cared for. She was not provided a [MEDICAL CONDITION] which she needed for breathing due to her [MEDICAL CONDITION]. This family member said CR #1 used a [MEDICAL CONDITION] while in the hospital and was discharged with an order to continue using it. The family member said the facility did not have the [MEDICAL CONDITION] for two days and when it came, staff did not know how to use it. The family member said the facility did not notify them about any change the resident may have had prior to their visit on [DATE] about midday when they found CR #1 half naked in bed, with half of her body hanging off the bed. The family member said CR #1 was very weak, could not be understood, did not know family and was not herself since they last saw her on [DATE]. The family member said CR #1 could not breathe and the nurse (RN #1) could not tell something was wrong with the resident and did not know how long she had been that way. The family member said she demanded that RN #1 call 911 and have CR #1 transferred to the hospital immediately. The family member said when the Administrator came into CR #1's room and saw the resident she also told him they needed to call 911 and have CR #1 transferred to the hospital and he agreed. The family member said CR #1 died during the early hours of [DATE] in the intensive care unit. Interview on [DATE] at 10:05a.m., Facility Supply Staff said when he got information about CR #1 coming in, he got the room ready and told the DON that the facility's only working [MEDICAL CONDITION] machine was in use by another resident. The DON told him she would rent a [MEDICAL CONDITION] machine from an outside rental company for CR #1. Interview on [DATE] at 10:40a.m., the DON said when CR #1 admitted on [DATE], she was aware CR #1 needed a [MEDICAL CONDITION] machine. The DON further said the hospital record indicated it should be used as needed. The DON said she could not recall where she saw this order in the resident's record. The DON also said the order for the [MEDICAL CONDITION] stated it was to be used at bedtime only. When asked where she saw the order for the [MEDICAL CONDITION] to be used at bedtime, the DON was unable to find it. The DON said CR #1 was provided a [MEDICAL CONDITION] machine upon admission, which was placed in her room. She also said she called the company's contracted respiratory therapist who came out and set-up the [MEDICAL CONDITION] machine according to CR#1's orders. Interview on [DATE] at 1:10a.m., the Facility Supply Staff said he now recalled that a [MEDICAL CONDITION] machine was rented from the outside company was in the CR#1's room on [DATE]. He also brought in an oxygen concentrator and a welcome basket. Interview on [DATE] at 1:23p.m., LVN #1 said on [DATE] after LVN #3 completed CR #1's admission, CR #1's family asked her about the [MEDICAL CONDITION] machine. LVN #1 said she checked CR #1's admission orders [REDACTED]. LVN #1 said the [MEDICAL CONDITION] was not available throughout [DATE]. LVN #1 said on [DATE] CR #1 had therapy and was then encouraged to go to the dining room. She said CR #1 was very weak and did not speak English, but she had orders to eat in the dining room. While CR #1 was in the dining room for lunch, LVN #1 said she was called because the resident appeared very weak and pale. LVN #1 said she did not remember if the resident had oxygen on at that time. CR #1 was moved to her room where her oxygen saturation and other vital signs were checked, and her oxygen saturation was low. LVN #1 said she increased the liters of oxygen and CR #1's oxygen saturation came up. CR #1 came back to her previous self and was no longer pale. LVN #1 said CR #1 was supposed to be on a [MEDICAL CONDITION] according to her admission notes, but the [MEDICAL CONDITION] was not available throughout her shift on [DATE]. Interview in [DATE] at 2:37p.m., Unit Manager #1 said she received the rented [MEDICAL CONDITION] machine during the ,[DATE] shift on [DATE] but was unsure the exact time it was delivered. Unit Manager #1 said the machine was placed in CR #1's room. She said she presumed the company preset the machine before the delivery but was not sure. She said no training was given to staff upon delivery of the [MEDICAL CONDITION]. Interview on [DATE] at 3:45p.m., RN #1 said she worked the morning shift on [DATE]. She said upon duty assumption, the night nurse did not tell her about any incidents regarding CR #1. RN #1 said she did not know CR #1 had a change in condition as she had not worked with the resident before. RN #1 said CR #1 was newly admitted so she did not know her baseline. When asked if the resident showed any signs of distress RN #1 said no. RN #1 said in the morning she attempted putting the [MEDICAL CONDITION] on CR #1, but could not because the [MEDICAL CONDITION] mask was too small and did not fit CR #1's face. RN #1 said she was not trained how to use the machine and did not ask anyone how the machine should be used. RN #1 further said the resident's family wanted her to go out to the hospital, so she called 911. Interview on [DATE] at 9:37a.m., CR #1's NP said she saw CR #1 the morning of [DATE], which was a Friday. She said CR #1 was advanced in age and had aspirational pneumonia. Upon observation she appeared to be in hypo-active [MEDICAL CONDITION] with stable vital signs. The NP said CR #1 did not speak English but she followed gestures. The NP said she was not notified on the resident's oxygen desaturation on [DATE] but was told she de-saturated on [DATE]. The NP said she was notified on [DATE] they could not bring CR #1's oxygen level up so the facility sent her to the hospital. The NP said CR #1 was sick and believed she may have been sent to the facility in an unstable condition. Interview on [DATE] at 10:30a.m., the Facility Respiratory Therapist said he was out of town when this incident occurred with CR #1 and would not have been reached by any facility staff because his work phone was off. He denied any knowledge of the incident and said he did not speak to the DON regarding any [MEDICAL CONDITION] set up. He had no knowledge of CR #1. Interview on [DATE] at 11: 35a.m., the Administrator said he did not know much about CR #1 because CR #1 had just admitted . He stated he was in the facility in the morning of [DATE] when the resident's family member came up to the front office and expressed concern about the resident, he went down to her room with the family member to see the resident. After seeing the resident, he immediately told someone to call 911. The Administrator said he had no prior knowledge of any incident that happened days ago. Interview on [DATE] at 2:15p.m., LVN #1 said she did not notify the physician of CR #1's change in condition on [DATE] because the resident came back to her normal self and it was around shift change. She further explained she continued to monitor the resident and reported this to the next nurse to continue to monitor the resident. Interview on [DATE] at 3:34p.m., LVN #3 said he admitted CR #1 on [DATE]. LVN #3 said CR #1's family member reported the resident needed a [MEDICAL CONDITION] because CR #1 had respiratory problems and used the [MEDICAL CONDITION] in the hospital. LVN #3 said he checked the resident's record and saw an order for [REDACTED]. Interview on [DATE] at 3:53p.m., LVN #2 said when she worked the ,[DATE] shift on [DATE], LVN #1 did not tell her about CR #1's incident during shift change. She said she did not know about CR #1's desaturation. She recalled administrating a Nebulizer treatment to CR #1. She also said the resident had a [MEDICAL CONDITION] machine at beside. LVN #2 said the [MEDICAL CONDITION] machine had a mask which covered CR #1's face, but she struggled to use the machine and the mask. LVN #2 said she was not trained how to use the machine and did not ask anyone how the machine should be used. Interview on [DATE] at 4:32p.m., the Facility Admission Marketer said she saw CR #1 in the hospital prior to her admission to the facility. She further said she was told by the hospital case manager that CR #1 would need a [MEDICAL CONDITION] to be on stand by and used as needed. She said all of this was communicated to the facility and paperwork was also sent for review prior to CR #1's admission on [DATE]. Record review of Facility policy on abuse and neglect dated [DATE] revealed .our facility will not condone patient abuse, neglect mistreatment or misappropriation of patient property by anyone, including staff members, other patients, consultants, volunteers, guardians and sponsors, friends and other individuals. The following definitions are provided to assist our facility's staff members in recognizing incidents of patients abuse; .deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being . Record review of the Facility's policy on significant change in patient status, which was not dated, revealed .a significant change in patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions or in incidents of clinical complication. Scope and severity, example of life-threatening conditions include but are limited to cardiovascular or respiratory changes Etc. As a significant change in patient's conditions occurs; the charge nurse will notify the physician, family or other appropriate person/agency of the significant change immediately. Complete interact SBAR form for non-emergent changes in condition . Record review of the Facility's policy on physician notification, which was not dated, revealed .it is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment. The nurse will recognize the change, complete interact SBAR, monitor the patient of any changes in condition and document communication and response with the physician in the clinical record . Record review of the Facility's policy on assessments, dated [DATE] revealed .a Situation, Background, Assessment and Request (SBAR) communication form and progress notes must be completed upon a patient's change in condition and prior to contacting the attending physician, the SBAR communication form can replace a nurse's note and is filled in the patient's medical record . Record review of the Facility's policy on reporting guidelines for shift change, which was not dated, revealed .all staff coming on duty are to be present for report, report the condition of each patient, list and report elevated temperatures or abnormal vital signs and the last time checked. Report the last dose of any PRN medications administered and effectiveness, report any condition change or follow-up on any condition change of any patient, reports incidents, status of patients, orders to be followed, report all equipment or supplies needed and report on status of staffing for the following shift, report status of all calls to physicians, pending labs, X-rays, or test results-why call was placed, name of patients, when call was last placed . The facility's policy on Residents rights requested from the DON, but was not provided. Facility Census dated [DATE] listed 84 residents. The Administrator was notified on [DATE] at approximately 11:30a.m., of an Immediate Jeopardy of the above failures. Interview on [DATE] at 4:11p.m., the Administrator, who was the abuse coordinator, said he was not aware of any of CR #1's incidents prior to [DATE]. He said he believed the facility was in an IJ situation because of a lack of communication between nurses and with CR #1's physician. He said he found out about CR #1's incidents after the surveyor initiated the investigation, and from asking staff about CR #1. He said he met the family briefly on [DATE] and when they came to him asking for help. The Administrator said he went to CR #1's room and saw her in her room. Interview on [DATE] at 4:40p.m., the DON said she believed the facility's immediate jeopardy occurred because staff failed to properly use the facility's system of notifying CR #1's physician of changes, 24 hour reporting and staff communication and documentation. She expected staff to notify the Resident's physician of a change in condition and to report to the on-coming nurse to continue to monitor residents and to follow up with physicians if there was no response from the physician. She said the staff should report to on-coming staff during shift change all changes that occurred the past shift for continued monitoring. The DON agreed staff should be trained on newly rented equipment for proper use and that equipment needed by residents should be available for their use upon admission. The DON also said the [MEDICAL CONDITION] machine rented for CR#1 was delivered with a nasal mask only. A plan of removal for the IJ was submitted on [DATE] at 3:52 p.m. After three revisions, the plan of removal was accepted on [DATE] at 5:01 p.m. The following steps are the facility's plan to remove the Immediate Jeopardy. Immediate Jeopardy Plan of Removal [DATE] Systematic Approach 1. Notification of Physicians: a. The facility has begun to conduct in-services to licensed nursing staff on notification of physicians per the facility policy. The facility policy includes conditions which may arise from as well as the nurses' responsibility to act. These include: Altered Mental Status, Bleeding, Chest Pain, Diarrhea, [MEDICAL CONDITION], Emesis, Falls, Family Concerns, G- Tubes Complications, Medication Error, Pressure Sores, [MEDICAL CONDITION], Shortness of Breath, (if changes in orders for treatment is required), skin rash, Vital Sign Changes, and Laboratory Values. The most common condition changes are listed. If changes that warrant a change in treatment exist, the physician is to be notified, as well as the responsible person, if indicated. For new patients, information is obtained from the referral information as well as the admission assessment which may include interviews as indicated with the family and patient. Significant variances from that of the admission assessment and the referring facility information, the physician will be notified. The in-services began on [DATE] and will be completed [DATE]. b. The facility has begun to conduct in-services to facility staff on the interact process. The interact Process is a systematic approach by which each facility staff member is assigned the responsibility of notifying nursing of any change in condition. The electronic medical record has been set up to include the systematic forms utilized in the process with automatic triggers to nursing staff once the form is completed. In-services on the Interact process began on [DATE] and will be completed by [DATE]. The in-services began on [DATE] and will be completed [DATE]. c. The Facility immediately conducted an evaluation, to include record auditing on those Patients with special needs equipment. The Facility ensured that all equipment needs were addressed, to include operation of equipment. This was completed on [DATE]. d. The facility shall use both the Interact process and the 24 hour Electronic report to verify action on change of status. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the tour of duty. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Changes from non-nursing staff shall be accomplished through the Interact Process. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The in-services began on [DATE] and will be completed [DATE]. e. The facility will document monitoring of change of status on the change of status log. f. As a systematic change, monitoring of admission assessments and clinical needs will be conducted by a Registered Nurse no later 24 hours after admission. This review will include verification of the care needs carried forward to the C.N.A. care card as this is how communication to the C.N.A.'s is accomplished. g. No facility staff will be allowed to return to active duty until such a time as the education described above is completed. h. Results of all monitoring shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. i. Changes identified by non-nursing staff will be communicated using the Interact Process. j. Completion Date: [DATE] 2. 24 Hour Reporting: a. The facility has begun reeducating the staff on 24 hour reporting utilizing the electronic 24 hour report. b. The 24 hour report will be reviewed by Unit Managers, Weekend Supervisors and the Director of Nursing daily to ensure that appropriate information is communicated to the proper individual. c. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Changes from non-nursing staff shall be accomplished through the Interact Process. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The in-services began on [DATE] and will be completed [DATE]. d. Monitoring of 24 hour report handoff between shifts will occur randomly by the Unit Manager, Weekend Supervisor or the Director of Nursing and a daily review of the 24 hour electronic report will be conducted by the Director of Nursing or her designee to ensure appropriate follow through occurs on any resident need. This tool can be used by all staff as a means to identify resident needs when a patient admits to the facility. e. No licensed nurse shall return to active duty until such a time as they have been in-serviced on the 24 hour report. f. The results of all 24 hour monitoring shall be brought to the Quality Assessment and Assurance Committee and the committee's recommendations acted upon. g. Completion Date: [DATE] 3. Special Needs Equipment: a. The facility will address the needs of special equipment through the admission process by review of the Referral information, admission nursing assessment, as well as physician or nurse practitioner assessment. Once the facility has identified the need, the equipment will be provided. If this equipment is noted in the referral information, it will be provided before the patient is admitted . Any identified equipment needs will be obtained and checked by the Director of Nursing or designee for functionality prior to providing the equipment of the resident. It shall be the responsibility of the charge nurse to ensure that equipment remains functional to patient needs throughout the stay. The Director of Nursing, Unit Managers as well as the weekend Nursing Supervisor shall be responsible for routine monitoring of equipment functionality. 4. Non- English Speaking Patients: a. Patients who do not speak English shall be communicated with utilizing facility staff who do speak the language, if available, or patient family members. b. Care cards indicating needs will be established for the resident allowing for identified needs to be communicated to staff. The facility also, if needed will establish a letter board to allow the resident to effectively communicate with staff. New patients will not be admitted until such a time as a mode of communication has been established. c. The Patient's language needs are assessed on admission and will be communicated though staff through the medical record alerts C.N.A. care cards as well as the Patient's Plan of Care. d. These processes were initiated on [DATE], to be completed on [DATE]. Monitoring The surveyor monitored the plan to remove the immediate jeopardy on [DATE] through [DATE] as follows: On [DATE], and [DATE] LVNs and RNs on all three shifts were interviewed on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Record review of the facility In-Services revealed: [DATE]: 28 nursing staff members were trained on communication: 24 hour reporting. [DATE]: facility initiated facility audit to rule out no resident had a change in condition that was not identified. [DATE]: 28 nursing staff members were trained on proper way of notifying/consulting the resident's physician, identifying a significant change in status, report guideline for change of shift and facility's medical director and to call 911 if no response was received from the physicians; and staff were to notify the DON or designee of any identified changes in condition. [DATE]: 27 staff members were trained on documentation of changes of condition, documenting SBAR, and following up documentation for monitoring and giving change of shift reports. [DATE]: 39 staff members were trained on use of communication boards. Established an audit tool for 24 hour reporting and change in condition. All equipment in the facility was checked by staff to ensure they were in good working condition. Observation on [DATE] revealed all 6 Non-English speaking residents in the facility had a communication book in their room and staff were aware of how to use them. On [DATE] through [DATE], 16 RNs and LVNs received respiratory training which included Tracheal suctioning, [MEDICAL CONDITION] care with returned demonstration. Facility had [MEDICAL CONDITION]/[MEDICAL CONDITION] training set up in the future. Observation on [DATE] at 10:00a.m., revealed one resident in the facility who used a [MEDICAL CONDITION] machine. His [MEDICAL CONDITION] was a personal one and was already set-up for him prior to admission. Resident was able to use this [MEDICAL CONDITION] machine by himself. [DATE]: more than 60% of the facility's nursing staff members were trained on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes in condition among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Interview on [DATE] at 10:02a.m., the DON stated she completed chart audits, evaluated all residents in the facility for changes in condition and found that staff were implementing the appropriate and current plan. Record review of in-services, dated [DATE] through [DATE] revealed the DON and Unit Managers trained all staff scheduled to work ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE] on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes in condition among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Interviews with 5 CNAs on [DATE] between 2:25 p.m. and 5:40 p.m., and on [DATE] between 8:00a.m. and 10:00a.m. revealed they received training on how to identify abuse and neglect, when to notify a charge nurse of anything usual noted about any patient. Record review of the in-service forms provided by the DON dated ,[DATE], ,[DATE] and ,[DATE] revealed on-going in-services concerning resident assessments, physicians' consultation, and communication. Interview on [DATE] at 4:11p.m., the Administrator stated he would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. He further reported he would continue to monitor the facility approved plan of removal to ensure the safety of the residents. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 10:06a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of a pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following changes in condition, proper assessment , establishing a baseline vital signs for newly admitted residents, communication of changes among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. According to the facility's check list of equipment, 23 residents required special respiratory equipment.

Based on interview, and record review, the facility failed to immediately consult with the physician, and notify the resident's legal representative or an interested family member of incidents involving one of 13 residents (CR #1) who were reviewed for notifications of changes in condition. The facility failed to immediately consult CR #1's physician on [DATE] when a significant change in respiratory status had been assessed. The facility failed to notify CR #1's family member on [DATE] when a significant change in condition had been assessed. The facility failed to immediately consult CR #1's physician on [DATE] when she was found in bed lethargic, confused and in respiratory distress, by a family member who demanded 911 be called and CR #1 be transferred to ER. CR #1 died the next day. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of a pattern. The facility needed additional time to evaluate the effectiveness of their plan. These failures affected one resident who died in the hospital on [DATE] following a transfer for change in status and placed 22 other residents at risk of not receiving services necessary to prevent complications which could lead to a decline in their health, or death. Findings include: Intake # 0 CR #1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 was transferred to theER on [DATE] at 1:30 p.m. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's MAR indicated [REDACTED]. Order was signed by DON as implemented on [DATE] and [DATE]. Record review of CR #1's facility clinical notes report dated [DATE] at 6:32pm written by LVN #3 revealed assessment .admitted [AGE] years old female to the facility she was transferred from hospital she does not speak English and cannot communicate, she appears to be very anxious and restless at this time .heart rate irregular, lungs wheezing bilaterally, both legs are swollen from knees to feet she does not show any non-verbal signs of pain at this time admitted to hospital for respiratory problems, found to have pneumonia [MEDICAL CONDITION]. Presently on intravenous antibiotics, she is confused and is total care at this time. Record review of CR #1's facility clinical notes report dated [DATE] at 4:58pm written by LVN #1 revealed patient continues with [MEDICATION NAME] intravenous first dose this AM. Peripheral intravenous central catheter on the right upper arm. Patient tolerated well. Patient went to dining room for lunch and sat on the wheel chair. Patient was lethargic and was not eating. Patient's face started to be pale, they rushed patient to her room. Nurse came to patient's room and assessed her. Oxygen saturation ,[DATE]% at 2 liters was elevated to 5 liters and the oxygen saturation started to be increased to ,[DATE]%. Patient requested some thicken water and it was given to her, Nurse also fed some pureed meat and vegetable to her. Patient became alert and was trying to smile and talk to the nurse. Patient ate all the chocolate pudding, head of bed elevated and pillows were placed under both legs, will continue to monitor. Record review of the facility's 24 hour report for ,[DATE] shift on [DATE] revealed no documentation of CR #1's incident. Record review of CR#1's facility clinical notes report dated [DATE] at 11:00p.m., written by RN #1 revealed 7am- resident in bed with oxygen ,[DATE] liters nasal cannula 90%. PICC line to the right arm double lumen, both ports patent dressing clean and intact. Assisted to feed for breakfast, tolerated only ¼ of share. Head of bed elevated 45 degrees. At 9am, intravenous [MEDICATION NAME] infused. At 11:00a.m., try to fit [MEDICAL CONDITION], oxygen saturation at 88% to 90%. Change nasal cannula to non-rebreather mask, resident's family concerned about condition, DON and administrator aware, called 911, NP notified, transfer to ER at 1:30p.m. Interview on [DATE] at 3:30p.m., CR #1's family members said CR #1 admitted to the facility on [DATE] and was not properly cared for. She was not provided a [MEDICAL CONDITION] which she needed for breathing due to her [MEDICAL CONDITION]. This family member said CR #1 used a [MEDICAL CONDITION] while in the hospital and was discharge with an order to continue using it. The family member said the facility did not have the [MEDICAL CONDITION] for two days and when it came, staff did not know how to use it. The family member said the facility did not notify them about any change the resident may have had prior to their visit on [DATE] about midday when they found CR #1 half naked in bed, with half of her body hanging off the bed. The family member said CR #1 was very weak, could not be understood, did not know family and was not herself since they last saw her on [DATE]. The family member said CR #1 could not breathe and the nurse (RN#1) could not tell something was wrong with the resident and did not know how long she had been that way. The family member said she demanded that RN #1 call 911 and have CR #1 transferred to the hospital immediately. The family member said when the Administrator came into CR #1's room and saw the resident she also told him they needed to call 911 and have CR #1 transferred to the hospital and he agreed. The family member said CR #1 died during the early hours of [DATE] in the intensive care unit. Interview on [DATE] at 3:45p.m., RN #1 said she worked the morning shift on [DATE]. She said upon duty assumption, she was not told of any incidents regarding CR #1 from the night nurse. RN #1 said she did not know CR #1 had a change in condition as she had not worked with the resident before. RN #1 said CR #1 was newly admitted so she did not know her baseline. When asked if the resident showed any signs of distress she said no. RN #1 said in the morning she attempted putting the [MEDICAL CONDITION] on CR #1, but could not because the [MEDICAL CONDITION] mask was too small and did not fit CR #1's face. RN #1 said she was not trained on how to use the machine and did not ask anyone how the machine should be used. RN #1 further said the resident's family wanted her to go out to the hospital, so she called 911. Interview on [DATE] at 9:37a.m., CR #1's NP said she saw CR #1 the morning of [DATE], which was a Friday. She said CR #1 was advanced in age and had aspirational pneumonia. Upon observation she appeared to be in hypo-active [MEDICAL CONDITION] with stable vital signs. The NP said CR #1 did not speak English but she followed gestures. The NP said she was not notified on the resident's oxygen desaturation on [DATE] but was told she de-saturated on [DATE]. The NP said she was notified on [DATE] they could not bring CR #1's oxygen level up so the facility sent her to the hospital. The NP said CR #1 was sick and believed she may have been sent to the facility in an unstable condition. Interview on [DATE] at 1:23p.m., LVN #1 said on [DATE] CR #1 had therapy and was then encouraged to go to the dining room. She said CR #1 was very weak and did not speak English, but she had orders to eat in the dining room. While CR #1 was in the dining for lunch, LVN#1 said she was called because the resident appeared very weak and pale. LVN #1 said she did not remember if the resident had oxygen on at that time. CR #1 was moved to her room where her oxygen saturation and other vital signs were checked, and her oxygen saturation was low. LVN #1 said she increased the liters of oxygen and CR #1's oxygen saturation came up. CR #1 came back to her previous self and was no longer pale. LVN #1 said the resident was supposed to be on [MEDICAL CONDITION] according to admission notes. Interview on [DATE] at 11: 35a.m., the Administrator said he did not know much about CR #1 because CR #1 had just admitted . He stated he was in the facility in the morning of [DATE] when the resident's family member came up to the front office and expressed concern about the resident, he went down to her room with the family member to see the resident. After seeing the resident, he immediately told someone to call 911. The Administrator said he had no prior knowledge of any incident that happened days ago. Interview on [DATE] at 2:15p.m., LVN #1 said she did not notify the physician or CR #1's family of CR #1's change in condition on [DATE] because the resident came back to her normal self and it was around shift change. She further explained she continued to monitor the resident and reported this to the next nurse to continue to monitor the resident. Interview on [DATE] at 3:53p.m., LVN #2, who worked the ,[DATE] shift on [DATE], said LVN #1 did not tell her about CR #1's incident during shift change. She said she did not know about CR #1's desaturation. She recalled administering a Nebulizer treatment to the resident. She also said the resident had a [MEDICAL CONDITION] machine at beside. LVN #2 said the [MEDICAL CONDITION] machine had a mask which covered the residents face, but struggled to use the machine and the mask. LVN #2 said she was not trained on how to use the machine and did not ask anyone how the machine should be used. Interview on [DATE] at 4:40p.m., the DON said she expected staff to notify the Resident's physician of a change in condition and to report this to the on-coming nurse. She further said the on-coming nurse should continue to monitor the resident and follow-up with the physician if there was no response from the physician. Record review of Facility's policy on significant change in patient status, which was not dated, revealed .a significant change in patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions or in incidents of clinical complication. Scope and severity, example of life threatening conditions include but are limited to cardiovascular or respiratory changes Etc. As a significant change in patient's condition occurs; the charge nurse will notify the physician, family or other appropriate person/agency of the significant change immediately. Complete interact SBAR form for non-emergent changes in condition. Record review of Facility's policy on physician notification, which was not dated, revealed .it is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment. The nurse will recognize the change, complete interact SBAR, monitor the patient of any changes in condition and document communication and response with the physician in the clinical record. The facility's policy on Residents rights requested from the DON, but not provided. The Administrator was notified on [DATE] at approximately 11:30a.m., of an Immediate Jeopardy of the above failures. Interview on [DATE] at 4:11p.m., the Administrator, who was the abuse coordinator, said he was not aware of any of CR #1's incidents prior to [DATE]. He said he believed the facility was in an IJ situation because of a lack of communication between nurses and with CR #1's physician. He said he found out about CR #1's incidents after the surveyor initiated the investigation, and from asking staff about CR #1. He said he met the family briefly on [DATE] and when they came to him asking for help. The Administrator said he went to CR #1's room and saw her in her room. Interview on [DATE] at 4:40p.m., the DON said she believed the facility's immediate jeopardy occurred because staff failed to properly use the facility's system of notifying CR #1's physician of changes, 24 hour reporting and staff communication and documentation. She expected staff to notify the Resident's physician of a change in condition and to report to the on-coming nurse to continue to monitor residents and to follow up with physicians if there was no response from the physician. She said the staff should report to on-coming staff during shift change all changes that occurred the past shift for continued monitoring. The DON agreed staff should be trained on newly rented equipment for proper use and that equipment needed by residents should be available for their use upon admission. The DON also said the [MEDICAL CONDITION] machine rented for CR#1 was delivered with a nasal mask only. A plan of removal for the IJ was submitted on [DATE] at 3:52 p.m. After three revisions, the plan of removal was accepted on [DATE] at 5:01 p.m. The following steps are the facility's plan to remove the Immediate Jeopardy. Immediate Jeopardy Plan of Removal [DATE] Systematic Approach 1. Notification of Physicians: a. The facility has begun to conduct in-services to licensed nursing staff on notification of physicians per the facility policy. The facility policy includes conditions which may arise from as well as the nurses' responsibility to act. These include: Altered Mental Status, Bleeding, Chest Pain, Diarrhea, [MEDICAL CONDITION], Emesis, Falls, Family Concerns, G- Tubes Complications, Medication Error, Pressure Sores, [MEDICAL CONDITION], Shortness of Breath, (if changes in orders for treatment is required), skin rash, Vital Sign Changes, and Laboratory Values. The most common condition changes are listed. If changes that warrant a change in treatment exist, the physician is to be notified, as well as the responsible person, if indicated. For new patients, information is obtained from the referral information as well as the admission assessment which may include interviews as indicated with the family and patient. Significant variances from that of the admission assessment and the referring facility information, the physician will be notified. The in-services began on [DATE] and will be completed [DATE]. b. The facility has begun to conduct in-services to facility staff on the interact process. The interact Process is a systematic approach by which each facility staff member is assigned the responsibility of notifying nursing of any change in condition. The electronic medical record has been set up to include the systematic forms utilized in the process with automatic triggers to nursing staff once the form is completed. In-services on the Interact process began on [DATE] and will be completed by [DATE]. The in-services began on [DATE] and will be completed [DATE]. c. The Facility immediately conducted an evaluation, to include record auditing on those Patients with special needs equipment. The Facility ensured that all equipment needs were addressed, to include operation of equipment. This was completed on [DATE]. d. The facility shall use both the Interact process and the 24 hour Electronic report to verify action on change of status. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the tour of duty. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Changes from non-nursing staff shall be accomplished through the Interact Process. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The in-services began on [DATE] and will be completed [DATE]. e. The facility will document monitoring of change of status on the change of status log. f. As a systematic change, monitoring of admission assessments and clinical needs will be conducted by a Registered Nurse no later 24 hours after admission. This review will include verification of the care needs carried forward to the C.N.A. care card as this is how communication to the C.N.A.'s is accomplished. g. No facility staff will be allowed to return to active duty until such a time as the education described above is completed. h. Results of all monitoring shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. i. Changes identified by non-nursing staff will be communicated using the Interact Process. j. Completion Date: [DATE] 2. 24 Hour Reporting: a. The facility has begun reeducating the staff on 24 hour reporting utilizing the electronic 24 hour report. b. The 24 hour report will be reviewed by Unit Managers, Weekend Supervisors and the Director of Nursing daily to ensure that appropriate information is communicated to the proper individual. c. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Changes from non-nursing staff shall be accomplished through the Interact Process. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The in-services began on [DATE] and will be completed [DATE]. d. Monitoring of 24 hour report handoff between shifts will occur randomly by the Unit Manager, Weekend Supervisor or the Director of Nursing and a daily review of the 24 hour electronic report will be conducted by the Director of Nursing or her designee to ensure appropriate follow through occurs on any resident need. This tool can be used by all staff as a means to identify resident needs when a patient admits to the facility. e. No licensed nurse shall return to active duty until such a time as they have been in-serviced on the 24 hour report. f. The results of all 24 hour monitoring shall be brought to the Quality Assessment and Assurance Committee and the committee's recommendations acted upon. g. Completion Date: [DATE] 3. Special Needs Equipment: a. The facility will address the needs of special equipment through the admission process by review of the Referral information, admission nursing assessment, as well as physician or nurse practitioner assessment. Once the facility has identified the need, the equipment will be provided. If this equipment is noted in the referral information, it will be provided before the patient is admitted . Any identified equipment needs will be obtained and checked by the Director of Nursing or designee for functionality prior to providing the equipment of the resident. It shall be the responsibility of the charge nurse to ensure that equipment remains functional to patient needs throughout the stay. The Director of Nursing, Unit Managers as well as the weekend Nursing Supervisor shall be responsible for routine monitoring of equipment functionality. 4. Non- English Speaking Patients: a. Patients who do not speak English shall be communicated with utilizing facility staff who do speak the language, if available, or patient family members. b. Care cards indicating needs will be established for the resident allowing for identified needs to be communicated to staff. The facility also, if needed will establish a letter board to allow the resident to effectively communicate with staff. New patients will not be admitted until such a time as a mode of communication has been established. c. The Patient's language needs are assessed on admission and will be communicated though staff through the medical record alerts C.N.A. care cards as well as the Patient's Plan of Care. d. These processes were initiated on [DATE], to be completed on [DATE]. Monitoring The surveyor monitored the plan to remove the immediate jeopardy on [DATE] through [DATE] as follows: On [DATE], and [DATE] LVNs and RNs on all three shifts were interviewed on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Record review of the facility In-Services revealed: [DATE]: 28 nursing staff members were trained on communication: 24 hour reporting. [DATE]: facility initiated facility audit to rule out no resident had a change in condition that was not identified. [DATE]: 28 nursing staff members were trained on proper way of notifying/consulting the resident's physician, identifying a significant change in status, report guideline for change of shift and facility's medical director and to call 911 if no response was received from the physicians; and staff were to notify the DON or designee of any identified changes in condition. [DATE]: 27 staff members were trained on documentation of changes of condition, documenting SBAR, and following up documentation for monitoring and giving change of shift reports. [DATE]: 39 staff members were trained on use of communication boards. Established an audit tool for 24 hour reporting and change in condition. All equipment in the facility was checked by staff to ensure they were in good working condition. Observation on [DATE] revealed all 6 Non-English speaking residents in the facility had a communication book in their room and staff were aware of how to use them. On [DATE] through [DATE], 16 RNs and LVNs received respiratory training which included Tracheal suctioning, [MEDICAL CONDITION] care with returned demonstration. Facility had [MEDICAL CONDITION]/[MEDICAL CONDITION] training set up in the future. Observation on [DATE] at 10:00a.m., revealed one resident in the facility who used a [MEDICAL CONDITION] machine. His [MEDICAL CONDITION] was a personal one and was already set-up for him prior to admission. Resident was able to use this [MEDICAL CONDITION] machine by himself. [DATE]: more than 60% of the facility's nursing staff members were trained on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes in condition among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Interview on [DATE] at 10:02a.m., the DON stated she completed chart audits, evaluated all residents in the facility for changes in condition and found that staff were implementing the appropriate and current plan. Record review of in-services, dated [DATE] through [DATE] revealed the DON and Unit Managers trained all staff scheduled to work ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE] on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes in condition among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Interviews with 5 CNAs on [DATE] between 2:25 p.m. and 5:40 p.m., and on [DATE] between 8:00a.m. and 10:00a.m. revealed they received training on how to identify abuse and neglect, when to notify a charge nurse of anything usual noted about any patient. Record review of the in-service forms provided by the DON dated ,[DATE], ,[DATE] and ,[DATE] revealed on-going in-services concerning resident assessments, physicians' consultation, and communication. Interview on [DATE] at 4:11p.m., the Administrator stated he would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. He further reported he would continue to monitor the facility approved plan of removal to ensure the safety of the residents. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 10:06a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of a pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following changes in condition, proper assessment , establishing a baseline vital signs for newly admitted residents, communication of changes among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. According to the facility's check list of equipment, 23 residents required special respiratory equipment.

Based on interview and record review, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to attain or maintain the highest practicable physical well-being of one of 13 residents (CR #1) reviewed for quality of care. The Administrator failed to oversee and assist with the development and implementation of effective policies and procedures on identifying changes in condition, promptly consulting with the physician and preventing neglect. The Administrator failed to supervise the DON on training and monitoring the nursing staff to assess, and consult physicians concerning residents' changes of condition. The DON failed to ensure ordered equipment ([MEDICAL CONDITION] machine) was ordered and made available to residents for prompt and immediate use. The DON failed to ensure staff were trained to monitor, assess, and consult physicians timely concerning changes in residents' conditions. The DON failed to ensure staff were trained on new, rented or purchased equipment. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern. The facility needed additional time to evaluate the effectiveness of their plan. These failures affected one resident who died in the hospital on [DATE] following a transfer for change in status and placed 22 other residents at risk of not receiving services necessary to prevent complications which could lead to a decline in their health, or death. Findings include: Intake # 0 CR #1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 was transferred to theER on [DATE] at 1:30 p.m. Record review of CR #1's discharge hospital record dated [DATE] revealed the following Diagnoses: [REDACTED]. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's Hospital discharge order for [MEDICAL CONDITION] dated [DATE] at 1:06p.m., revealed the following setting [MEDICAL CONDITION] for routine use, frequency -RQ4H, PAP mode (cm H20) -12, EPAP mode (cm h20)- 5, mode of operation -spontaneous, B.P.M-12, and FI02 -35. Record review of the facility invoice for [MEDICAL CONDITION] rental revealed the equipment was ordered from an outside company on [DATE] and delivered sometime during the ,[DATE] shift on [DATE]. Equipment delivery was signed by Unit Manager #1. Record review of CR #1's facility clinical notes report dated [DATE] at 6:32p.m. written by LVN #3 revealed assessment admitted [AGE] years old female to the facility she was transferred from hospital she does not speak English and cannot communicate, she appears to be very anxious and restless at this time . heart rate irregular, lungs wheezing bilaterally, both legs are swollen from knees to feet she does not show any non-verbal signs of pain at this time admitted to hospital for respiratory problems, found to have pneumonia [MEDICAL CONDITION]. Presently on intravenous antibiotics, she is confused and is total care at this time. Record review of CR #1's facility clinical note report dated [DATE] at 4:58p.m. written by LVN #1 revealed patient continues with [MEDICATION NAME] intravenous first dose this AM. Peripheral intravenous central catheter on the right upper arm. Patient tolerated well. Patient went to dining room for lunch and sat on the wheel chair. Patient was lethargic and was not eating. Patient's face started to be pale, they rushed patient to her room. Nurse came to patient's room and assessed her. Oxygen saturation ,[DATE]% at 2 liters was elevated to 5 liters and the oxygen saturation started to be increased to ,[DATE]%. Patient requested some thicken water and it was given to her, Nurse also fed some pureed meat and vegetable to her. Patient became alert and was trying to smile and talk to the nurse. patient ate all the chocolate pudding, head of bed elevated and pillows were placed under both legs, will continue to monitor. Record review of the facility's 24 hour report for the ,[DATE] shift on [DATE] revealed no documentation of the incident or of CR #1. There was no further documentation about CR #1 on the facility's 24 hour report until her transfer toER on [DATE]. None were provided as requested. Record review of CR #1's facility clinical notes report dated [DATE] at 11:00p.m., written by RN #1 revealed 7a.m.- resident in bed with oxygen ,[DATE] liters nasal cannula 90%. PICC line to the right arm double lumen, both ports patent dressing clean and intact. Assisted to feed for breakfast, tolerated only ¼ of share. Head of bed elevated 45 degrees. At 9a.m., intravenous [MEDICATION NAME] infused. At 11:00a.m., try to fit [MEDICAL CONDITION], oxygen saturation at 88% to 90%. Change nasal cannula to non-rebreather mask, resident's family concerned about condition, DON and administrator aware, called 911, NP notified, transfer to ER at 1:30p.m. Record review of CR #1's MAR indicated [REDACTED]. Order was signed by the DON as implemented on [DATE] and [DATE]. Interview on [DATE] at 3:30p.m., CR #1's family members said CR #1 admitted to the facility on [DATE] and was not properly cared for. She was not provided a [MEDICAL CONDITION] which she needed for breathing due to her [MEDICAL CONDITION]. This family member said CR #1 used a [MEDICAL CONDITION] while in the hospital and was discharged with an order to continue using it. The family member said the facility did not have the [MEDICAL CONDITION] for two days and when it came, staff did not know how to use it. The family member said the facility did not notify them about any change the resident may have had prior to their visit on [DATE] about midday when they found CR #1 half naked in bed, with half of her body hanging off the bed. The family member said CR #1 was very weak, could not be understood, did not know family and was not herself since they last saw her on [DATE]. The family member said CR #1 could not breathe and the nurse (RN #1) could not tell something was wrong with the resident and did not know how long she had been that way. The family member said she demanded that RN #1 call 911 and have CR #1 transferred to the hospital immediately. The family member said when the Administrator came into CR #1's room and saw the resident she also told him they needed to call 911 and have CR #1 transferred to the hospital and he agreed. The family member said CR #1 died during the early hours of [DATE] in the intensive care unit. Interview on [DATE] at 10:05a.m., Facility Supply Staff said when he got information about CR #1 coming in, he got the room ready and told the DON that the facility's only working [MEDICAL CONDITION] machine was in use by another resident. The DON told him she would rent a [MEDICAL CONDITION] machine from an outside rental company for CR #1. Interview on [DATE] at 10:40a.m., the DON said when CR #1 admitted on [DATE], she was aware CR #1 needed a [MEDICAL CONDITION] machine. The DON further said the hospital record indicated it should be used as needed. The DON said she could not recall where she saw this order in the resident's record. The DON also said the order for the [MEDICAL CONDITION] stated it was to be used at bedtime only. When asked where she saw the order for the [MEDICAL CONDITION] to be used at bedtime, the DON was unable to find it. The DON said CR #1 was provided a [MEDICAL CONDITION] machine upon admission, which was placed in her room. She also said she called the facility's contracted respiratory therapist who came out and set-up the [MEDICAL CONDITION] machine according to CR#1's orders. Interview on [DATE] at 1:10p.m., the Facility Supply Staff said he now recalled that a [MEDICAL CONDITION] machine was rented from the outside company was in the CR#1's room on [DATE]. He also brought in an oxygen concentrator and a welcome basket. Interview on [DATE] at 1:23p.m., LVN #1 said on [DATE] after the admission nurse completed CR #1's admission, CR #1's family asked her about the [MEDICAL CONDITION] machine. LVN #1 said she checked CR #1's admission orders [REDACTED]. LVN #1 said the [MEDICAL CONDITION] was not available throughout [DATE]. LVN #1 said on [DATE] CR #1 had therapy and was then encouraged to go to the dining room. She said CR #1 was very weak and did not speak English, but she had orders to eat in the dining room. While CR #1 was in the dining room for lunch, LVN #1 said she was called because the resident appeared very weak and pale. LVN #1 said she did not remember if the resident had oxygen on at that time. CR #1 was moved to her room where her oxygen saturation and other vital signs were checked, and her oxygen saturation was low. LVN #1 said she increased the liters of oxygen and CR #1's oxygen saturation came up. CR #1 came back to her previous self and was no longer pale. LVN #1 said CR #1 was supposed to be on a [MEDICAL CONDITION] according to her admission notes, but the [MEDICAL CONDITION] was not available throughout her shift on [DATE]. Interview on [DATE] at 2:37p.m., Unit Manager #1 said she received the rented [MEDICAL CONDITION] machine during the ,[DATE] shift on [DATE] but was unsure the exact time it was delivered. Unit Manager #1 said the machine was placed in CR #1's room. She said she presumed the company preset the machine before the delivery but was not sure. She said no training was given to staff upon delivery of the [MEDICAL CONDITION]. Interview on [DATE] at 3:45p.m., RN #1 said she worked the morning shift on [DATE]. She said upon duty assumption, the night nurse did not tell her about any incidents regarding CR #1. RN #1 said she did not know CR #1 had a change in condition as she had not worked with the resident before. RN #1 said CR #1 was newly admitted so she did not know her baseline. When asked if the resident showed any signs of distress RN #1 said no. RN #1 said in the morning she attempted putting the [MEDICAL CONDITION] on CR #1, but could not because the [MEDICAL CONDITION] mask was too small and did not fit CR #1's face. RN #1 said she was not trained how to use the machine and did not ask anyone how the machine should be used. RN #1 further said the resident's family wanted her to go out to the hospital, so she called 911. Interview on [DATE] at 9:37a.m., CR #1's NP said she saw CR #1 the morning of [DATE], which was a Friday. She said CR #1 was advanced in age and had aspirational pneumonia. Upon observation she appeared to be in hypo-active [MEDICAL CONDITION] with stable vital signs. The NP said CR #1 did not speak English but she followed gestures. The NP said she was not notified on the resident's oxygen desaturation on [DATE] but was told she de-saturated on [DATE]. The NP said she was notified on [DATE] they could not bring CR #1's oxygen level up so the facility sent her to the hospital. The NP said CR #1 was sick and believed she may have been sent to the facility in an unstable condition. Interview on [DATE] at 10:30a.m., the Facility Respiratory Therapist said he was out of town when this incident occurred with CR #1 and would not have been reached by any facility staff because his work phone was off. He denied any knowledge of the incident and said he did not speak to the DON regarding any [MEDICAL CONDITION] set up. He had no knowledge of CR #1. Interview on [DATE] at 11: 35a.m., the Administrator said he did not know much about CR #1 because CR #1 had just admitted . He stated he was in the facility in the morning of [DATE] when the resident's family member came up to the front office and expressed concern about the resident, he went down to her room with the family member to see the resident. After seeing the resident, he immediately told someone to call 911. The Administrator said he had no prior knowledge of any incident that happened days ago. Interview on [DATE] at 2:15p.m., LVN #1 said she did not notify the physician of CR #1's change in condition on [DATE] because the resident came back to her normal self and it was around shift change. She further explained she continued to monitor the resident and reported this to the next nurse to continue to monitor the resident. Interview on [DATE] at 3:34p.m., LVN #3 said he admitted CR #1 on [DATE]. LVN #3 said CR #1's family member reported the resident needed a [MEDICAL CONDITION] because CR #1 had respiratory problems and used the [MEDICAL CONDITION] in the hospital. LVN #3 said he checked the resident's record and saw an order for [REDACTED]. Interview on [DATE] at 3:53p.m., LVN #2 said when she worked the ,[DATE] shift on [DATE], LVN #1 did not tell her about CR #1's incident during shift change. She said she did not know about CR #1's desaturation. She recalled administering a Nebulizer treatment to CR #1. She also said the resident had a [MEDICAL CONDITION] machine at beside. LVN #2 said the [MEDICAL CONDITION] machine had a mask which covered CR #1's face, but she struggled to use the machine and the mask. LVN #2 said she was not trained how to use the machine and did not ask anyone how the machine should be used. Interview on [DATE] at 4:32p.m., the Facility Admission Marketer said she saw CR #1 in the hospital prior to her admission to the facility. She further said she was told by the hospital case manager that CR #1 would need a [MEDICAL CONDITION] to be on stand by and used as needed. She said all of this was communicated to the facility and paperwork was also sent for review prior to CR #1's admission on [DATE]. Record review of Facility policy on abuse and neglect dated [DATE] revealed .our facility will not condone patient abuse, neglect mistreatment or misappropriation of patient property by anyone, including staff members, other patients, consultants, volunteers, guardians and sponsors, friends and other individuals. The following definitions are provided to assist our facility's staff members in recognizing incidents of patients abuse; .deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being . Record review of the Facility's policy on significant change in patient status, which was not dated, revealed .a significant change in patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions or in incidents of clinical complication. Scope and severity, example of life-threatening conditions include but are limited to cardiovascular or respiratory changes Etc. As a significant change in patient's conditions occurs; the charge nurse will notify the physician, family or other appropriate person/agency of the significant change immediately. Complete interact SBAR form for non-emergent changes in condition . Record review of the Facility's policy on physician notification, which was not dated, revealed .it is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment. The nurse will recognize the change, complete interact SBAR, monitor the patient of any changes in condition and document communication and response with the physician in the clinical record . Record review of the Facility's policy on assessments, dated [DATE] revealed .a Situation, Background, Assessment and Request (SBAR) communication form and progress notes must be completed upon a patient's change in condition and prior to contacting the attending physician, the SBAR communication form can replace a nurse's note and is filled in the patient's medical record . Record review of the Facility's policy on reporting guidelines for shift change, which was not dated, revealed .all staff coming on duty are to be present for report, report the condition of each patient, list and report elevated temperatures or abnormal vital signs and the last time checked. Report the last dose of any PRN medications administered and effectiveness, report any condition change or follow-up on any condition change of any patient, reports incidents, status of patients, orders to be followed, report all equipment or supplies needed and report on status of staffing for the following shift, report status of all calls to physicians, pending labs, X-rays, or test results-why call was placed, name of patients, when call was last placed . The facility's policy on Residents rights requested from the DON, but was not provided. The Administrator was notified on [DATE] at approximately 11:30a.m., of an Immediate Jeopardy of the above failures. Interview on [DATE] at 4:11p.m., the Administrator, who was the abuse coordinator, said he was not aware of any of CR #1's incidents prior to [DATE]. He said he believed the facility was in an IJ situation because of a lack of communication between nurses and with CR #1's physician. He said he found out about CR #1's incidents after the surveyor initiated the investigation, and from asking staff about CR #1. He said he met the family briefly on [DATE] and when they came to him asking for help. The Administrator said he went to CR #1's room and saw her in her room. Interview on [DATE] at 4:40p.m., the DON said she believed the facility's immediate jeopardy occurred because staff failed to properly use the facility's system of notifying CR #1's physician of changes, 24 hour reporting and staff communication and documentation. She expected staff to notify the Resident's physician of a change in condition and to report to the on-coming nurse to continue to monitor residents and to follow up with physicians if there was no response from the physician. She said the staff should report to on-coming staff during shift change all changes that occurred the past shift for continued monitoring. The DON agreed staff should be trained on newly rented equipment for proper use and that equipment needed by residents should be available for their use upon admission. The DON also said the [MEDICAL CONDITION] machine rented for CR#1 was delivered with a nasal mask only. A plan of removal for the IJ was submitted on [DATE] at 3:52 p.m. After three revisions, the plan of removal was accepted on [DATE] at 5:01 p.m. The following steps are the facility's plan to remove the Immediate Jeopardy. Plan to remove immediacy: Immediate Jeopardy Plan of Removal [DATE] Systematic Approach 1. Notification of Physicians: a. The facility has begun to conduct in-services to licensed nursing staff on notification of physicians per the facility policy. The facility policy includes conditions which may arise from as well as the nurses' responsibility to act. These include: Altered Mental Status, Bleeding, Chest Pain, Diarrhea, [MEDICAL CONDITION], Emesis, Falls, Family Concerns, G- Tubes Complications, Medication Error, Pressure Sores, [MEDICAL CONDITION], Shortness of Breath, (if changes in orders for treatment is required), skin rash, Vital Sign Changes, and Laboratory Values. The most common condition changes are listed. If changes that warrant a change in treatment exist, the physician is to be notified, as well as the responsible person, if indicated. For new patients, information is obtained from the referral information as well as the admission assessment which may include interviews as indicated with the family and patient. Significant variances from that of the admission assessment and the referring facility information, the physician will be notified. The in-services began on [DATE] and will be completed [DATE]. b. The facility has begun to conduct in-services to facility staff on the interact process. The interact Process is a systematic approach by which each facility staff member is assigned the responsibility of notifying nursing of any change in condition. The electronic medical record has been set up to include the systematic forms utilized in the process with automatic triggers to nursing staff once the form is completed. In-services on the Interact process began on [DATE] and will be completed by [DATE]. The in-services began on [DATE] and will be completed [DATE]. c. The Facility immediately conducted an evaluation, to include record auditing on those Patients with special needs equipment. The Facility ensured that all equipment needs were addressed, to include operation of equipment. This was completed on [DATE]. d. The facility shall use both the Interact process and the 24 hour Electronic report to verify action on change of status. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the tour of duty. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Changes from non-nursing staff shall be accomplished through the Interact Process. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The in-services began on [DATE] and will be completed [DATE]. e. The facility will document monitoring of change of status on the change of status log. f. As a systematic change, monitoring of admission assessments and clinical needs will be conducted by a Registered Nurse no later 24 hours after admission. This review will include verification of the care needs carried forward to the C.N.A. care card as this is how communication to the C.N.A.'s is accomplished. g. No facility staff will be allowed to return to active duty until such a time as the education described above is completed. h. Results of all monitoring shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. i. Changes identified by non-nursing staff will be communicated using the Interact Process. j. Completion Date: [DATE] 2. 24 Hour Reporting: a. The facility has begun reeducating the staff on 24 hour reporting utilizing the electronic 24 hour report. b. The 24 hour report will be reviewed by Unit Managers, Weekend Supervisors and the Director of Nursing daily to ensure that appropriate information is communicated to the proper individual. c. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any conditions, phone calls out to physicians, outstanding tests or labs or any outstanding need a patient may have. Changes from non-nursing staff shall be accomplished through the Interact Process. Random monitoring of this will be accomplished through Unit Managers, Weekend Supervisors and the Director of Nursing verifying changes of status in the 24 hour report or the clinical record and ensuring that these changes are reported to the appropriate practitioner timely. The in-services began on [DATE] and will be completed [DATE]. d. Monitoring of 24 hour report handoff between shifts will occur randomly by the Unit Manager, Weekend Supervisor or the Director of Nursing and a daily review of the 24 hour electronic report will be conducted by the Director of Nursing or her designee to ensure appropriate follow through occurs on any resident need. This tool can be used by all staff as a means to identify resident needs when a patient admits to the facility. e. No licensed nurse shall return to active duty until such a time as they have been in-serviced on the 24 hour report. f. The results of all 24 hour monitoring shall be brought to the Quality Assessment and Assurance Committee and the committee's recommendations acted upon. g. Completion Date: [DATE] 3. Special Needs Equipment: a. The facility will address the needs of special equipment through the admission process by review of the Referral information, admission nursing assessment, as well as physician or nurse practitioner assessment. Once the facility has identified the need, the equipment will be provided. If this equipment is noted in the referral information, it will be provided before the patient is admitted . Any identified equipment needs will be obtained and checked by the Director of Nursing or designee for functionality prior to providing the equipment of the resident. It shall be the responsibility of the charge nurse to ensure that equipment remains functional to patient needs throughout the stay. The Director of Nursing, Unit Managers as well as the weekend Nursing Supervisor shall be responsible for routine monitoring of equipment functionality. 4. Non- English Speaking Patients: a. Patients who do not speak English shall be communicated with utilizing facility staff who do speak the language, if available, or patient family members. b. Care cards indicating needs will be established for the resident allowing for identified needs to be communicated to staff. The facility also, if needed will establish a letter board to allow the resident to effectively communicate with staff. New patients will not be admitted until such a time as a mode of communication has been established. c. The Patient's language needs are assessed on admission and will be communicated though staff through the medical record alerts C.N.A. care cards as well as the Patient's Plan of Care. d. These processes were initiated on [DATE], to be completed on [DATE]. Monitoring The surveyor monitored the plan to remove the immediate jeopardy on [DATE] through [DATE] as follows: On [DATE], and [DATE] LVNs and RNs on all three shifts were interviewed on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Record review of the facility In-Services revealed: [DATE]: 28 nursing staff members were trained on communication: 24 hour reporting. [DATE]: facility initiated facility audit to rule out no resident had a change in condition that was not identified. [DATE]: 28 nursing staff members were trained on proper way of notifying/consulting the resident's physician, identifying a significant change in status, report guideline for change of shift and facility's medical director and to call 911 if no response was received from the physicians; and staff were to notify the DON or designee of any identified changes in condition. [DATE]: 27 staff members were trained on documentation of changes of condition, documenting SBAR, and following up documentation for monitoring and giving change of shift reports. [DATE]: 39 staff members were trained on use of communication boards. Established an audit tool for 24 hour reporting and change in condition. All equipment in the facility was checked by staff to ensure they were in good working condition. Observation on [DATE] revealed all 6 Non-English speaking residents in the facility had a communication book in their room and staff were aware of how to use them. On [DATE] through [DATE], 16 RNs and LVNs received respiratory training which included Tracheal suctioning, [MEDICAL CONDITION] care with returned demonstration. Facility had [MEDICAL CONDITION]/[MEDICAL CONDITION] training set up in the future. Observation on [DATE] at 10:00a.m., revealed one resident in the facility who used a [MEDICAL CONDITION] machine. His [MEDICAL CONDITION] was a personal one and was already set-up for him prior to admission. Resident was able to use this [MEDICAL CONDITION] machine by himself. [DATE]: more than 60% of the facility's nursing staff members were trained on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes in condition among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Interview on [DATE] at 10:02a.m., the DON stated she completed chart audits, evaluated all residents in the facility for changes in condition and found that staff were implementing the appropriate and current plan. Record review of in-services, dated [DATE] through [DATE] revealed the DON and Unit Managers trained all staff scheduled to work ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE] on physician notification of change in status, proper assessment, establishing a baseline on vital signs for newly admitted residents, communication of changes in condition among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. Interviews with 5 CNAs on [DATE] between 2:25 p.m. and 5:40 p.m., and on [DATE] between 8:00a.m. and 10:00a.m. revealed they received training on how to identify abuse and neglect, when to notify a charge nurse of anything usual noted about any patient. Record review of the in-service forms provided by the DON dated ,[DATE], ,[DATE] and ,[DATE] revealed on-going in-services concerning resident assessments, physicians' consultation, and communication. Interview on [DATE] at 4:11p.m., the Administrator stated he would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. He further reported he would continue to monitor the facility approved plan of removal to ensure the safety of the residents. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 10:06a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of a pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, establishing a baseline vital signs for newly admitted residents, communication of changes among nursing staff, providing ordered equipment promptly, training staff on new equipment and communication with Non-English speaking residents. According to the facility's check list of equipment, 23 residents required special respiratory equipment.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest physical well-being of one of six residents (Resident #3) reviewed for care and services to address pain. -Resident #3, who had a stage IV pressure sore, was not assessed for pain prior, during or after the wound dressing change. This failure affected one resident and could place the other two residents receiving wound care at risk for experiencing pain unnecessarily. Findings include: Record review of Resident #3's face sheet revealed Resident #3 was [AGE] years old. She was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's care plan reviewed 8/22/14 revealed Potential for pain/discomfort related to recent surgery(right above knee amputation), wounds, osteo[DIAGNOSES REDACTED] right leg. Unable to express. Resident #3 is not able to adequately express pain due to cognitive deficits, no speech. Approach: Observe for signs and symptoms of increased pain/discomfort, observe for non-verbal signs and symptoms of pain/discomfort, administer pain medications as ordered, as needed. Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed under Hearing, Speech and Vision: Resident #3 had unclear speech, had highly impaired vision and had adequate hearing. She was coded as "rarely/never understood" in her ability to express ideas and wants. She was also coded as "rarely/never understands" in her understanding verbal content. Resident #3's cognitive skills were severely impaired. Resident #3 was dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene and bathing. Resident #3 was incontinent of bowel and had an indwelling catheter. Resident #3 was coded as not on any scheduled pain medication regimen and had not received any PRN pain medications. The resident had also not received non-medication intervention for pain. Indicators of Pain or Possible Pain in the last 5 days revealed that Resident #3 was coded as having no signs of non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements of postures observed. Resident #3 had a Stage IV pressure ulcer that was present on admission. The Stage IV pressure ulcer measured 2.4 cm x 1.0 cm x 0.1 cm. Record review of the wound assessment sheet for Resident #3 dated 9-10-2014 revealed the Stage IV pressure sore was located on the right ischium and was 3 cm. x 2.0 cm. x 0.6 cm. Record review of Resident #3's summary of physician's orders [REDACTED]. - cleanse right ischium with Normal Saline, Pat dry. Apply alginate and dry dressing every day. -[MEDICATION NAME] 5-325 mg every 6 hours as needed for pain. -Tylenol 325 mg two tabs every 6 hours as needed for pain. Observation on 9/12/2014 at 11:30 a.m. revealed LVN A was doing wound care on Resident #3's right ischium (lower buttock area). During the wound care, Resident #3 yelled out "ayyyy" with facial grimacing and jerking when LVN A first wiped the wound with a gauze. LVN A continued with the wound care while Resident #3 continued to grimace and yell out again "ayyyyy" and said in Spanish "duele" (hurts) as LVN A wiped the outside of the Stage IV pressure ulcer. CNA B was assisting LVN A during the wound care. An interview with Resident #3 was attempted on 9/12/14 at 11:44 am; however, the resident was non-responsive to the questions. In an interview on 9/12/2014 at 11:46 a.m., LVN A stated that Resident #3 was able only to speak small phrases in Spanish but was unable to have a conversation and further stated "I have known her for long time". Record review of Resident #3's MAR for September 2014 revealed she had received the pain medication only one time on September 2, 2014. The resident had not received any pain medication and/or other pain interventions prior to the wound care on 9/12/14. Even after Resident #3 yelled out two times during wound care on 9/12/14 no pain medication or pain intervention was provided. In an interview with LVN A on 9/12/14 at 1:40 p.m., she stated she would assess for pain before wound care. She stated Resident #3 was not able to communicate pain, so she would go by her facial expressions. Surveyor asked LVN A if she assessed Resident #3 for pain before and during wound care and LVN A replied "she (the resident) would not answer you". LVN A was asked about the observation during wound care of Resident #3 yelling out 2 times and verbalizing in Spanish pain and LVN A replied "probably I need to give her something 30 minutes before wound care". In an interview on 9/12/2014 at 3:55 p.m. the DON, stated if a resident was verbal, staff would ask about pain and if a resident was non-verbal, they would look for facial grimaces to assess the resident for pain. Record review of the facility's Policy and procedure on Pain Management, revised March 2013, read in part: " ...2. Every patient must be assessed for pain utilizing the faces/PAINAD (form 16-2) based on a pain intensity score of 0-10 or by observing for non-verbal/non-cognitive signs of pain: c) prior to and immediately following any invasive procedure, including dressing changes utilizing the weekly head to toe skin record. 4.- If a Patient's pain intensity score is > 1 or has been assessed with [REDACTED]." Record review of the facility's Policy and procedure on "skin", dated June 2011, read in part: " .....8. A pain assessment must be completed and documented prior to and after each dressing change utilizing the Wong-Baker Scale or by observing for non-verbal/non-cognitive signs of pain on the Weekly Head to Toe Skin Record. If the assessment reveals the Patient is having pain; the nurse must administer pain medication(s), per physician orders [REDACTED]." The facility's Centers for Medicare and Medicaid Services (CMS) Form 672 dated 09/06/2014, indicated 3 residents with pressure ulcers (exclude stage 1).