Every finding on record at St James House of Baytown

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse, including mental, verbal, physical, and sexual abuse, as well as abuse involving the deprivation of goods and services by staff. This deficient practice was identified for one of five residents reviewed for abuse. Specifically, Resident #1 alleged that facility staff physically held his arm down while LVN S removed his personal cell phone without his consent. This deficient practice had the potential to result in psychosocial harm, including mental and verbal abuse, as well as deprivation of services by staff. Findings included: Record review of Resident #1's face sheet, dated 3/26/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included vitamin deficiency (not having enough nutrients that your body needs), pain, hypertensive heart disease (heart problems that occur due to high blood pressure over a long), type 2 diabetes (high blood sugar level) and muscle weakness. Record review of Resident #1's quarterly MDS assessment, dated 12/25/2025, revealed a BIMS score of 12 out of 15, which indicated moderately cognitive impairment. He required assistance from staff with activities of daily living care. Record review of Resident #1's care plan initiated on 4/28/2025 revealed he has potential risk for impaired cognitive function/dementia or impaired thought processes r/t Psychotropic druguse, History of Stroke, Mild Cognitive Impairment. Interventions were to use the Resident preferred name. Identify yourself at each interaction. Face the Resident when speaking and making eye contact. Reduce any distractions- turn off TV, radio, closed door etc. The Resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. cue, reorient and supervise as needed. Record review of the facility's PIR dated 3/25/2026, revealed the alleged incident occurred on 3/18/2026, at approximately 10:45 p.m. The report indicated the facility became aware of the incident on 3/19/2026. Further review of the investigation summary revealed LVN S was given a final written warning, and re-educated on the importance of timely reporting, notifying the chain of command, and escalating resident behavioral incidents. The report further indicated CNA Z was terminated following confirmation that the CNA Z restrained resident #1's arms and refused to assist the resident out of bed upon request. Additional review of the investigation findings confirmed the allegation. Review of the post-investigation actions revealed the facility planned to continue in-servicing staff on abuse and neglect, reporting requirements (including notification of the DON and Administrator, resident rights, customer service, and documentation. During interview with Resident #1 on 3/26/2026 at 11:15 a.m., Resident #1 recalled attempting to call 911 from his room due to the noise from outside his room. The resident stated that staff took his cell phone during the incident. He reported that while the cell phone was being taken, a staff member held his hands down, preventing him from moving freely. The resident stated that he felt physically restricted during this interaction. The resident also reported that his wheelchair was removed from his room and placed outside in the hallway. He stated that he requested assistance to be transferred into his wheelchair and to leave the room; however, staff refused his request. The resident stated that he felt he was being abused. He denied any physical injury or emotional distress. During interview with Administrator on 3/26/2026 at 10:25 a.m., the administrator reported that on 03/18/2026 at approximately 10:45 p. m., Resident #1 reportedly began calling 911 multiple times (approximately 14 calls within a 10-minute period) due to perceived loud noise in the hallway, which he stated was preventing him from sleeping. Staff members (identified as LVN S and CNA Z) responded to the room. According to the resident, during the encounter, one staff member held his arms down while the other removed his cell phone from his possession (from the front of his clothing). The resident stated the cell phone was taken to the nurse's station, and he was informed it would be returned in the morning due to repeated 911 calls. The resident further reported that he requested assistance to get out of bed and into his wheelchair; however, staff declined, instructing him to remain in bed due to the late hour. The resident indicated he was unable to get up independently, as he requires a two-person assistance, and noted that his wheelchair had been removed from his room and placed in the hallway. Further investigation confirmed that CNA Z held Resident #1's arms down and was not assisting him out of bed. This action was identified as a form of physical restraint. Additionally, the removal of the resident's wheelchair and refusal to assist with mobility contributed to the restriction of the resident's movement. Although no physical injuries were observed, the actions placed the residents at risk for emotional distress and potential trauma. Corrective action was taken, including termination of the CNA Z. LVN S was given a final written warning, and re-educated on the importance of timely reporting, notifying the chain of command, and escalating resident behavioral incidents. The facility has reinforced expectations regarding abuse prevention, proper reporting procedures, and resident rights with all staff. During interview with DON on 3/26/2026 at 12:25 p.m., she stated that the incident occurred during the night shift and that she was not notified at the time. She reported that the following morning, Resident #1 informed the Administrator that his phone had been taken. According to the DON, during the Administrator's interview, Resident #1 was unable to recall that he had been calling 911 multiple times. It was later identified that the resident had called 911 approximately 14 times, prompting law enforcement to contact the facility and request staff intervention. In response, LVN S and CNA Z went to Resident #1's room, removed the phone, and placed it at the nurse's station with the intention of returning it the following day. DON stated that CNA Z was terminated after admitting to holding the resident down while the phone was being taken. LVN S was given a final written warning, and re-educated on the importance of timely reporting, notifying the chain of command, and escalating resident behavioral incidents. DON stated that holding a resident down constitutes physical restraint and is considered abuse. DON stated the potential risks of abuse on the residents, was that residents may experience physical harm, emotional distress, withdrawal, and social isolation. During interview with LVN S on 3/26/2026 at 2:25 p.m., she stated that during the incident, Resident #1 was repeatedly calling 911, and she intervened in the direction of another nurse. She took the resident's phone and planned to return it the following morning. She reported that CNA Z assisted her by holding down the resident's hand to prevent him from hitting staff. LVN S stated that she did not physically harm the resident and initially did not consider the resident to be abused. She stated that taking the resident's phone without consent constitutes abuse, and she admitted that the resident was, in fact, abused by removal of property and restraint. She indicated that the potential risks of abuse include the resident losing rights, emotional distress, and continued abuse. During interview with CNA Z on 3/26/2026 at 3:12 p.m., she reported that during her shift, the resident was exhibiting behavioral issues. While she was conducting rounds, she observed Resident #1 sitting at the edge of the bed, she assisted Resident #1 back into bed. She stated that shortly after, the resident began repeatedly calling 911. Emergency services attempted to return the calls, but the resident did not answer. She continued to monitor the situation, until LVN S later responded to the room. CNA Z stated she and LVN S removed the phone from Resident #1. She stated that the resident was attempting to hit staff, and in response, she held the resident's hands while the nurse took the phone. She affirmed that holding a resident down to prevent the resident from leaving the bed constitutes abuse, and removing a resident's personal property, such as a phone, is also considered abuse. She also stated that she was no longer employed at the facility and believed her termination may be related to her involvement in the incident. She indicated that the potential risks of abuse on residents could result in psychological trauma. Record review of Employee Inservice/Training for Abuse/Neglect/Resident belongings revealed training was completed on 03/19/2026. Record review of Personnel Disciplinary Record dated 3/25/2026 for CNA Z revealed discharge due to confirmed abuse allegation. The Personnel Disciplinary Record was not signed by CNA Z with note employee refused to sign. Record review of a disciplinary form dated 3/25/2026, revealed LVN S received a final written warning. The documentation indicated that the LVN S failed to appropriately deescalate a resident's situation, inappropriately remove resident's cell phone, fail to document the incident, and failed to notify the DON/Administrator/RP regarding the incident that occurred on 3/18/2026. The LVN acknowledged and signed the disciplinary warning. Record review of facility's undated policy Abuse Prevention Investigation revealed; it is the policy of this facility to provide protection for the health, welfare and the rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident altercation. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident#1) reviewed for abuse, in that: The facility failed to ensure staff followed the abuse, neglect, and exploitation policy related to reporting, investigating, and responding to allegations of abuse. This failure could place residents at risk for abuse, neglect, and exploitation.The findings included:Record review of Resident #1's face sheet, dated 3/26/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included vitamin deficiency (not having enough nutrients that your body needs), pain, hypertensive heart disease (heart problems that occur due to high blood pressure over a long), type 2 diabetes (high blood sugar level) and muscle weakness. Record review of Resident #1's quarterly MDS assessment, dated 12/25/2025, revealed a BIMS score of 12 out of 15, which indicated moderately cognitive impairment. He required assistance from staff with activities of daily living care. Record review of Resident #1's care plan initiated on 4/28/2025 revealed he has potential risk for impaired cognitive function/dementia or impaired thought processes r/t Psychotropic druguse, history of stroke, mild cognitive impairment. Interventions were to use the Resident preferred name. Identify yourself at each interaction. Face the Resident when speaking and making eye contact. Reduce any distractions- turn off TV, radio, closed door etc. The Resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. cue, reorient and supervise as needed. During interview with Administrator on 3/26/2026 at 10:25 a.m., the administrator reported that; on 03/19/2026 at approximately 11:30 a.m. to 11:45 a.m., the resident requested the return of his cell phone. At that time, facility leadership became aware of the incident, as the incident had not been previously reported by staff to the administrator. The facility leadership immediately reported the allegation to Texas Health and Human Services, and investigation was initiated. Upon completion of the investigation the facility substantiated the allegation of abuse. The cell phone was retrieved from the nurse's station and returned to the resident immediately. Upon interview, the resident denied being tied down but stated he was unable to move due to needing assistance and reported that his arms were held down during the removal of his phone. The administrator stated that staff are trained monthly on abuse, neglect, and exploitation and are required to report any incidents immediately. In this case, LVN S failed to report the incident to the administrator, stating she forgot. Further investigation confirmed that CNA Z acknowledged holding the resident's arms down and not assisting him out of bed. This action was identified as a form of physical restraint. Additionally, the removal of the resident's wheelchair and refusal to assist with mobility contributed to the restriction of the resident's movement. She stated that failure to report any suspected/witnessed abuse would delay timely investigation and interventions, which could result in continued abuse, neglect, or misappropriation of resident property. During interview with Resident #1 on 3/26/2026 at 11:15 a.m., Resident #1 reported that two staff members were involved in the incident, stating that one staff member held his hand while another staff member removed his personal cell phone without his consent. The resident stated that his cell phone was not returned to him for the remainder of the night, and he was unable to call anyone until the following day. The resident further reported that no action was taken regarding the incident until the next day, at which time he reported the situation to the administrator. The resident stated that he informed the administrator that his cell phone had been taken the previous night and had not been returned, and that no staff had communicated with him regarding its whereabouts. During interview with DON on 3/26/2026 at 12:25 p.m., she stated that the incident occurred during the night shift and that she was not notified at the time. She reported that the following morning, Resident #1 informed the Administrator that his phone had been taken. She stated that any suspected abuse should be reported immediately to the Administrator. She stated that failure to report abuse could lead to continued harm to the residents, lack of timely intervention, and increased risk to other residents. During interview with LVN S on 3/26/2026 at 2:25 p.m., she stated that she took Resident #1's cell phone and planned to return it the following morning. LVN S stated that she did not physically harm the resident and initially did not consider the resident to be abused. She stated she did not notify the Administrator of the incident, as she did not initially think of it. She reported her last in-service on abuse occurred approximately 2-3 months ago, and she identified types of abuse as verbal, physical, mental, and isolation/seclusion. She stated that staff must report any suspected or witnessed abuse immediately to the Administrator, who serves as the abuse coordinator, and stated that failing to do so could result in continued resident harm and personal disciplinary consequences.During interview with CNA Z on 3/26/2026 at 3:12 p.m., she stated that the incident was not reported to the Administrator and she was unsure why it was not reported, noting that the nurse in charge was responsible for reporting. She stated that failure to report abuse could result in the incident continuing and could cause further harm to the residents. Record review of facility's undated policy Abuse Prevention and Investigation revealed; The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, Adult Protective Services and to all other required agencies within specified timeframes: a. immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review, the facility failed to ensure all alleged violations involving were reported immediately, but not later than 24 hours, to the administrator of the facility for 1 of 5 resident (Resident #1) reviewed for reporting. Resident #1 alleged that facility staff physically held his arm down while LVN S removed his personal cell phone without his consent, and this allegation was not reported to the administrator at the time it occurred. This failure had the potential to delay timely investigation and implementation of protective interventions, which could result in continued abuse, neglect, or misappropriation of resident property.Findings included: Record review of Resident #1's face sheet, dated 3/26/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included vitamin deficiency (not having enough nutrients that your body needs), pain, hypertensive heart disease (heart problems that occur due to high blood pressure over a long), type 2 diabetes (high blood sugar level) and muscle weakness.Record review of Resident #1's quarterly MDS assessment, dated 12/25/2025, revealed a BIMS score of 12 out of 15, which indicated moderately cognitive impairment. He required assistance from staff with activities of daily living care. Record review of Resident #1's care plan initiated on 4/28/2025 revealed he has potential risk for impaired cognitive function/dementia or impaired thought processes r/t Psychotropic druguse, history of stroke, mild cognitive impairment. Interventions were to use the Resident preferred name. Identify yourself at each interaction. Face the Resident when speaking and making eye contact. Reduce any distractions- turn off TV, radio, closed door etc. The Resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. cue, reorient and supervise as needed. During interview with Administrator on 3/26/2026 at 10:25 a.m., the administrator reported that; on 03/19/2026 at approximately 11:30 a.m. to 11:45 a.m., the resident requested the return of his cell phone. At that time, facility leadership became aware of the incident, as the incident had not been previously reported by staff to the administrator. The facility leadership immediately reported the allegation to Texas Health and Human Services, and investigation was initiated. Upon completion of the investigation the facility substantiated the allegation of abuse. The cell phone was retrieved from the nurse's station and returned to the resident immediately. Upon interview, the resident denied being tied down but stated he was unable to move due to needing assistance and reported that his arms were held down during the removal of his phone. The administrator stated that staff are trained monthly on abuse, neglect, and exploitation and are required to report any incidents immediately. In this case, LVN S failed to report the incident to the administrator, stating she forgot. Further investigation confirmed that CNA Z acknowledged holding the resident's arms down and not assisting him out of bed. This action was identified as a form of physical restraint. Additionally, the removal of the resident's wheelchair and refusal to assist with mobility contributed to the restriction of the resident's movement. She stated that failure to report any suspected/witnessed abuse would delay timely investigation and interventions, which could result in continued abuse, neglect, or misappropriation of resident property. During interview with Resident #1 on 3/26/2026 at 11:15 a.m., Resident #1 reported that two staff members were involved in the incident, stating that one staff member held his hand while another staff member removed his personal cell phone without his consent. The resident stated that his cell phone was not returned to him for the remainder of the night, and he was unable to call anyone until the following day. The resident further reported that no action was taken regarding the incident until the next day, at which time he reported the situation to the administrator. The resident stated that he informed the administrator that his cell phone had been taken the previous night and had not been returned, and that no staff had communicated with him regarding its whereabouts. During interview with DON on 3/26/2026 at 12:25 p.m., she stated that the incident occurred during the night shift and that she was not notified at the time. She reported that the following morning, Resident #1 informed the Administrator that his phone had been taken. She stated that any suspected abuse should be reported immediately to the Administrator. She stated that failure to report abuse could lead to continued harm to the residents, lack of timely intervention, and increased risk to other residents. During interview with LVN S on 3/26/2026 at 2:25 p.m., she stated that she took Resident #1's cell phone and planned to return it the following morning. LVN S stated that she did not physically harm the resident and initially did not consider the resident to be abused. She stated she did not notify the Administrator of the incident, as she did not initially think of it. She reported her last in-service on abuse occurred approximately 2-3 months ago, and she identified types of abuse as verbal, physical, mental, and isolation/seclusion. She stated that staff must report any suspected or witnessed abuse immediately to the Administrator, who serves as the abuse coordinator, and stated that failing to do so could result in continued resident harm and personal disciplinary consequences.During interview with CNA Z on 3/26/2026 at 3:12 p.m., she stated that the incident was not reported to the Administrator and she was unsure why it was not reported, noting that the nurse in charge was responsible for reporting. She stated that failure to report abuse could result in the incident continuing and could cause further harm to the residents. Record review of facility's undated policy Abuse Prevention and Investigation revealed; The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, Adult Protective Services and to all other required agencies within specified timeframes: a. immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 11 residents (Resident #88) whose records were reviewed for accuracy and completeness.MA A administered Losartan 25 mg give 1/2 tablet to equal 12.5mg by mouth daily to Resident #88 and documented they administered Losartan 100 mg give 1 tablet by mouth daily. This failure could place residents at risk for less than therapeutic benefits and/or not receiving ordered medications due to incomplete documentation. Findings include: Record review of Resident #88's admission Record dated 8/19/25 revealed he was an [AGE] year old male who admitted to the facility on [DATE] with some of the following diagnoses: acute respiratory failure with hypoxia, (a condition where the lungs cannot adequately oxygenate the blood leading to dangerously low levels of oxygen in the bloodstream), type 2 diabetes mellitus with diabetic nephropathy,(a chronic condition where the body does not produce or properly use insulin resulting in complications with damage to nerves throughout the body including the heart) chronic kidney disease, stage 3 (moderate kidney damage where the kidneys are not filtering waste and fluid as effectively as they should leading to build-up of waste products in the blood which can cause high blood pressure), and hypertensive heart disease without heart failure (a heart condition caused by long term high blood pressure, which can put extra strain on the heart increasing pressure in the arteries and or, over time, can lead to thickening of the heart muscle). Record review of Resident #88's admission Minimum Data Set (MDS) dated [DATE] revealed his Brief Interview for Mental Status (BIMS) (a score used to assess cognitive function) was 12 out of 15 indicating he had moderate cognitive impairment in decision making, had clear speech and was able to make himself understand and could understand others. The MDS also indicated he used a walker for mobility and required maximum assistance with bathing, dressing and personal hygiene and moderate assistance with toileting, bed mobility and transfers. Section I of the MDS for Active Diagnoses had him coded as having, 13. Medically Complex Conditions, and 10700. Hypertension. Continued record review of Resident #88's Quarterly MDS dated [DATE] revealed he had a BIMS score of 15 out of 15 indicating he was cognitively intact and Section I of the MDS for Active Diagnoses had him coded as having, 10700. Hypertension. Observation and interview with Resident #88 on 8/19/25 at 9:16 am in his room, during medication administration pass with MA A. Resident #88 was awake, alert, and oriented to person, place, and time. He was sitting upright in bed and was appropriately dressed in a tee shirt and pajama bottoms and appeared clean and groomed. Resident #88 said he had no care concerns at that time, and consented to the observation of his medication administration to be performed by MA A. Observation and interview with MA A on 8/19/25 at 9:16 am of Resident #88's morning medication administration pass. MA A was observed obtaining Resident #88's BP and HR, which he reported to surveyor as: BP=161/70 and HR=66. MA A stated, his blood pressure is a little high today. MA A did not say what Resident #88's regular BP readings were, and surveyor was able to view Resident #88's blood pressures in the EMR. MA A said that Resident #88 took BP medications that had parameters (specific instructions or measurable factors that guide the proper and safe administration of medications). Observed MA A remove multiple blister packets of medication from the MA cart he was using and proceeded to read his computer screen and place pills in a 30 ml clear plastic cup, passing the blister packet to surveyor after each pill was added to the cup. MA A passed surveyor a blister packet numbered 1-60 that read in part: Resident #88 .Pharmacy A. Losartan/POT TAB 25 MG. Give 1/2 tablet by mouth daily. Hold for SBP <110 or HR <60.30 Tabs 06/13/2025.Medical Director. and showed two 1/2 pill tablets remaining in blister packet. MA A proceeded to Resident #88's bedside with the small clear 30 ml plastic medication cup of pills and handed them to Resident #88 with one hand and handed Resident #88 a 6-8 oz clear plastic cup that contained a water mixture (mixed with a different dissolvable medication), with the other and said to Resident #88 that these were his morning medications and began naming some of the pills and what they were for. Resident #88 took all of the pills inside the 30 ml clear cup and drank all of the 6 oz water mixture and expressed no issues or concerns at that time. Record review of Resident #88's physician Order Summary Report dated Active Orders As Of: 08/01/2025 revealed Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse <60 .Order Status.Active.Order Date 01/08/2025.Start Date.01/09/2025 and had no end date. Record review of Resident #88's physician Order Summary Report dated Active Orders As Of: 01/01/2025 revealed Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 0.5 tablet by mouth one time a day related to Hypertensive Heart Disease Without Heart Failure.Give 1/2 a Tab to =12.5 MG. Hold for SBP<110 or HR<60. Order Status.Active.Order Date 12/26/2024.Start Date.12/27/2024 and had no end date. Record review of Resident #88's physician Order Summary Report dated Active Orders As Of: 02/01/2025 revealed Losartan Potassium Tablet 100 MG.Give 1 tablet by mouth one time a day for hypertension.hold if bp<110/60, pulse<60. Order Status.Active.Order Date 01/08/2025.Start Date.01/09/2025 and had no end date. Continued record reviews of Resident #88's physician Order Summary Reports dated Active Orders As Of: 03/01/2025, 04/01/2025, 06/01/2025 and 07/01/2025 all revealed the same order for Losartan Potassium Tablet 100 MG.Give 1 tablet by mouth one time a day for hypertension.hold if bp<110/60, pulse<60. Order Status.Active.Order Date 01/08/2025.Start Date.01/09/2025 and had no end date. A copy of Resident #88's physician Order Summary Report for May 2025 was also requested but was not received in scanned documents prior to facility exit. Record review of Resident #88's CMA MAR dated 8/1/205-8/31/2025 on 8/19/25 at 11:28 am revealed: Schedule for [DATE].Tue 19.Losartan Potassium Tablet 100 MG.Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse ,60. BP.160/70.Pulse.66.0900 and had a check mark symbol and was initialed NPe. Continued record review of the CMA MAR dated 8/1/205-8/31/2025 revealed Resident #88 was documented as having received Losartan Potassium Tablet 100 MG.Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse ,60, on the following dates, with the corresponding blood pressures:. Fri 1. BP.170/73.Pulse 62.0900 and had a check mark symbol and was initialed NPe.Mon 4.BP.124/69.Pulse.65.0900 and had a check mark symbol and was initialed NPe. Tue 5.BP.141/88.Pulse 74.0900 and had a check mark symbol and was initialed NPe. Sat 9.BP.179/82.Pulse 68.0900 and had a check mark symbol and was initialed NPe. Sun 10.BP.167/78.Pulse 62.0900 and had a check mark symbol and was initialed NPe. Wed 13.BP.173/79.Pulse.60.0900 and had a check mark symbol and was initialed NPe. Thu 14.BP.162/78.Pulse.64.0900 and had a check mark symbol and was initialed NPe. Fri 15.BP.111/72.Pulse.76.0900 and had a check mark symbol and was initialed NPe. Mon 18.BP.165/74.Pulse.66.0900' and had a check mark symbol and was initialed NPe. Follow-up interview and observation with MA A on 8/19/25 at 11:58 am regarding Resident #88's Losartan and review of blister packet revealed there were two 1/2 tablets out of 60 left in the blister packet. MA A said he realized after the medication administration pass with Resident #88 in the morning, that the order for his Losartan was incorrect and needed to be changed. MA A said he had not noticed the change in Resident #88's Losartan dose from 25mg, 1/2 tablet PO daily to 100mg, 1 tablet PO daily and thought he had been administering the correct medication and correct dosage. MA A said he let Resident #88's charge nurse know about the discrepancy and that Resident #88's order for Losartan needed to be clarified because Losartan/POT TAB 25 MG. Give 1/2 tablet by mouth daily. Hold for SBP <110 or HR <60, was the only Losartan blister pack and only Losartan medication on the medication aide cart for Resident #88. MA A said that LVN A was notified around 9:30 am about Resident #88 receiving the incorrect dose of medication and reviewed Resident #88's medications with LVN A at that time. MA A said LVN A told him she would notify Resident #88's physician and get a clarification of Resident #88's Losartan order. MA A said that a resident could potentially have low blood pressure if they did not receive enough medication or if they received an incorrect dose of medication and that he had been trained on the 6 rights of medication administration., he just did not recognize it was the wrong dose. Interview with MA A on 8/19/25 at 1:57 pm MA A said he did not know why he documented that he had given Losartan 100 mg 1 tab PO daily instead of Losartan 25 MG 1/2 tab PO daily. MA A said he was used to documenting at the time of the medication administration and had not really looked at the blister pack until after the medication administration pass with the surveyor that morning and had a chance to review it. MA A said he should not have documented incorrectly because there was no Losartan 100 mg on the cart for Resident #88 as ordered and he had given the Losartan 25 mg 1/2 tab instead. MA A said he was not sure how long he had incorrectly documented on Resident #88's MAR but corrected it today as soon as he recognized his error, by reporting it to LVN A who was Resident #88's charge nurse. MA A said he was unsure how long he had been giving Resident #88 Losartan 25 MG 1/2 tab PO, but said it was the only blister pack of Losartan on the cart for Resident #88. Interview with the DON on 8/19/25 at 3:12 pm she said LVN A contacted Pharmacy A today with the faxed order for Losartan 100 mg one tablet by mouth daily, as previously ordered in Resident #88's EMR from 1/8/25. The DON said a cart search for another blister pack of Resident #88's Losartan 100 mg tablets did not reveal any other Losartan medication for Resident #88 except the incorrect dose of Losartan 25 mg Give 1/2 tab PO daily that was removed from the cart after the morning medication administration pass. The DON said based on her audit of Pharmacy A delivery slips for Resident #88 since his admission to the facility in December 2024, she could only find pharmacy delivery slips for the month of June 2025. The DON said the only Losartan delivered for Resident #88 was on 6/13/25 for Losartan POT TAB 25 MG.Qty 30. The DON said MA A should not have been documenting that he administered the correct Losartan medication for Resident #88 because it was not the correct dose as ordered and that would be considered falsifying documentation. Interview with DON on 8/20/25 at 2:58pm and requested the CMA MAR signature page for Resident #88's [DATE] MAR. The DON advised surveyor there was no copy of any signature page for the CMA MAR. The DON was asked which staff members initials were NPe, she replied, MA A. When the DON was asked how she could tell which initials belong to which staff member, she said that NPe initials were MA A's and then said MA A and another MA were the only MA's who passed Resident #88's medications and worked that cart and hall. The DON then said that MA A was also the only MA who administered Resident #88's daytime medications on 8/19/25 and admitted to the medication error. Record review on 8/20/25 at 4:02pm of facility Medication Discrepancy Report dated 8/19/25 at 9:20 am revealed the following: Check items that are applicable: 3). Wrong Dose.Answer YES or NO 1. Was the order written correctly? Yes, was check marked.2. Did you follow the THREE RULES? -LOOK at the medicine as you removed it from the cart? .COMPARE it with the MAR? LOOK at it as you replaced it in the cart? NO was check marked as the answer to all three questions. 3. Was the order plainly written? NO was check marked.4. Was the order transcribed onto the MAR properly? YES, was check marked. Questions numbered 5, 6, 7, had been cut off in the photocopy. 8. Was attending physician notified? . If Yes: Date 8/18/25 at 12:13pm.9. Was family or responsible party notified? If yes: Date: 8/18/25 at 12:15 pm.Resident is own RP.Describe the incident.Order was written for Losartan 100 mg but Losartan 12.5mg was administered.Outcome to resident.There was no injury or distress noted B/P rechecked B/P 141/66.Corrective action taken.MD notified and orders are to administer 75 mg of Losartan, correct orders sent to pharmacy.Measures taken to prevent recurrence.CMA inserviced on proper medication administration rules and rights.Physician's response.Recheck residents B/P and administer 75mg of losartan X1 time, which MA A signed. Requested in-services with staff and any 1-to1 trainings of staff from DON on 8/19/25 at 12:33pm, and 3:12pm and again on 8/20/25 at 2:58 pm but did not receive them prior to facility exit. Record review of undated facility policy titled Medication-Documentation of Administration revealed in part: The facility shall maintain a medication administration record to document all medications administered .2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include as a minimum: a. Name and strength of drug; b. Dosage.f. Signature and title of the person administering the medication.

Based on observations, interviews, and record reviews the facility failed to ensure that residents were free from any significant medication errors for 1 (Resident #88) of 4 residents reviewed for pharmacy services.-The facility failed to ensure Losartan (a blood pressure (BP) medication given to lower high blood pressure and help protect the kidneys) was administered to Resident #88 per physician order from [DATE] through [DATE]. -The facility failed to ensure accurate reconciliation (a process of comparing and verifying a resident's current list of medications with all prescribed medications to ensure accuracy and safety), of Resident #88's Losartan medication. -MA A administered Losartan 25 mg give 1/2 tablet to equal 12.5mg by mouth daily to Resident #88 and documented they administered Losartan 100 mg give 1 tablet by mouth daily. These failures could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, adverse reactions and or decline in health. Findings included: Record review of Resident #88's admission Record dated [DATE] revealed he was an [AGE] year old male who admitted to the facility on [DATE] with some of the following diagnoses: acute respiratory failure with hypoxia, (a condition where the lungs cannot adequately oxygenate the blood leading to dangerously low levels of oxygen in the bloodstream), type 2 diabetes mellitus with diabetic nephropathy,(a chronic condition where the body does not produce or properly use insulin resulting in complications with damage to nerves throughout the body including the heart) chronic kidney disease, stage 3 (moderate kidney damage where the kidneys are not filtering waste and fluid as effectively as they should leading to build-up of waste products in the blood which can cause high blood pressure), and hypertensive heart disease without heart failure (a heart condition caused by long term high blood pressure, which can put extra strain on the heart increasing pressure in the arteries and or, over time, can lead to thickening of the heart muscle). Record review of Resident #88's admission MDS dated [DATE] revealed his BIMS (a score used to assess cognitive function) was 12 out of 15 indicating he had moderate cognitive impairment in decision making, had clear speech and was able to make himself understand and could understand others. The MDS also indicated he used a walker for mobility and required maximum assistance with bathing, dressing and personal hygiene and moderate assistance with toileting, bed mobility and transfers. Section I of the MDS for Active Diagnoses had him coded as having, 13. Medically Complex Conditions, and 10700. Hypertension. Continued record review of Resident #88's Quarterly MDS dated [DATE] revealed he had a BIMS score of 15 out of 15 indicating he was cognitively intact and Section I of the MDS for Active Diagnoses had him coded as having, 10700. Hypertension. Record review of Resident #88's physician Order Summary Report dated Active Orders As Of: [DATE] revealed Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse <60 .Order Status.Active.Order Date [DATE].Start Date.XXX[DATE] and had no end date. Record review of Resident #88's physician Order Summary Report dated Active Orders As Of: [DATE] revealed Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 0.5 tablet by mouth one time a day related to Hypertensive Heart Disease Without Heart Failure.Give 1/2 a Tab to =12.5 MG. Hold for SBP<110 or HR<60. Order Status.Active.Order Date [DATE].Start Date.XXX[DATE] and had no end date. Record review of Resident #88's physician Order Summary Report dated Active Orders As Of: [DATE] revealed Losartan Potassium Tablet 100 MG.Give 1 tablet by mouth one time a day for hypertension.hold if bp<110/60, pulse<60. Order Status.Active.Order Date [DATE].Start Date.XXX[DATE] and had no end date. Continued record reviews of Resident #88's physician Order Summary Reports dated Active Orders As Of: [DATE], [DATE], [DATE] and [DATE] all revealed the same order for Losartan Potassium Tablet 100 MG.Give 1 tablet by mouth one time a day for hypertension.hold if bp<110/60, pulse<60. Order Status.Active.Order Date [DATE].Start Date.XXX[DATE] and had no end date. A copy of Resident #88's physician Order Summary Report for [DATE] was also requested but was not received in scanned documents prior to facility exit. Record review of Resident #88's CMA MAR dated [DATE]-[DATE] on [DATE] at 11:28 am revealed: Schedule for [DATE].Tue 19.Losartan Potassium Tablet 100 MG.Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse ,60. BP.160/70.Pulse.66.0900 and had a check mark symbol and was initialed NPe. Continued record review of the CMA MAR dated [DATE]-[DATE] revealed Resident #88 was documented as having received Losartan Potassium Tablet 100 MG.Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse ,60, on the following dates, with the corresponding blood pressures:. Fri 1. BP.170/73.Pulse 62.0900 and had a check mark symbol and was initialed NPe.Mon 4.BP.124/69.Pulse.65.0900 and had a check mark symbol and was initialed NPe. Tue 5.BP.141/88.Pulse 74.0900 and had a check mark symbol and was initialed NPe. Sat 9.BP.179/82.Pulse 68.0900 and had a check mark symbol and was initialed NPe. Sun 10.BP.167/78.Pulse 62.0900 and had a check mark symbol and was initialed NPe. Wed 13.BP.173/79.Pulse.60.0900 and had a check mark symbol and was initialed NPe. Thu 14.BP.162/78.Pulse.64.0900 and had a check mark symbol and was initialed NPe. Fri 15.BP.111/72.Pulse.76.0900 and had a check mark symbol and was initialed NPe. Mon 18.BP.165/74.Pulse.66.0900' and had a check mark symbol and was initialed NPe. Observation and interview with Resident #88 on [DATE] at 9:16 am in his room, during medication administration pass with MA A. Resident #88 was awake, alert, and oriented to person, place, and time. He was sitting upright in bed and was appropriately dressed in a tee shirt and pajama bottoms and appeared clean and groomed. Resident #88 said he had no care concerns at that time, and consented to the observation of his medication administration to be performed by MA A. MA A was observed obtaining Resident #88's BP and HR, which he reported to surveyor as: BP=161/70 and HR=66. MA A stated, his blood pressure is a little high today. MA A did not say what Resident #88's regular BP readings were, and surveyor was able to view Resident #88's blood pressures in the EMR. MA A said that Resident #88 took BP medications that had parameters (specific instructions or measurable factors that guide the proper and safe administration of medications). Observed MA A remove multiple blister packets of medication from the MA cart he was using and proceeded to read his computer screen and place pills in a 30 ml clear plastic cup, passing the blister packet to surveyor after each pill was added to the cup. MA A passed surveyor a blister packet numbered 1-60 that read in part: Resident #88 .Pharmacy A. Losartan/POT TAB 25 MG. Give 1/2 tablet by mouth daily. Hold for SBP <110 or HR <60.30 Tabs [DATE].Medical Director. and showed two 1/2 pill tablets remaining in blister packet. MA A proceeded to Resident #88's bedside with the small clear 30 ml plastic medication cup of pills and handed them to Resident #88 with one hand and handed Resident #88 a 6-8 oz clear plastic cup that contained a water mixture (mixed with a different dissolvable medication), with the other and said to Resident #88 that these were his morning medications and began naming some of the pills and what they were for. Resident #88 took all of the pills inside the 30 ml clear cup and drank all of the 6 oz water mixture and expressed no issues or concerns at that time. Follow-up interview and observation with MA A on [DATE] at 11:58 am regarding Resident #88's Losartan and review of blister packet revealed there were two 1/2 tablets out of 60 left in the blister packet. MA A said he realized after the medication administration pass with Resident #88 in the morning, that the order for his Losartan was incorrect and needed to be changed. MA A said he had not noticed the change in Resident #88's Losartan dose from 25mg, 1/2 tablet PO daily to 100mg, 1 tablet PO daily and thought he had been administering the correct medication and correct dosage. MA A said he let Resident #88's charge nurse know about the discrepancy and that Resident #88's order for Losartan needed to be clarified because Losartan/POT TAB 25 MG. Give 1/2 tablet by mouth daily. Hold for SBP <110 or HR <60, was the only Losartan blister pack and only Losartan medication on the medication aide cart for Resident #88. MA A said that LVN A was notified around 9:30 am about Resident #88 receiving the incorrect dose of medication and reviewed Resident #88's medications with LVN A at that time. MA A said LVN A told him she would notify Resident #88's physician and get a clarification of Resident #88's Losartan order. MA A said that a resident could potentially have low blood pressure if they did not receive enough medication or if they received an incorrect dose of medication and that he had been trained on the 6 rights of medication administration., he just did not recognize it was the wrong dose. Interview and observation with LVN A on [DATE] at 12:00pm LVN A said MA A just told her earlier today around 10:00 am about the error in Resident #88's Losartan and she advised MA A at that time she would contact Resident #88's physician to clarify or change the order. When asked if she had already reached out Resident #88's physician about the error and order, as it was already lunchtime, LVN A said she would do it now. LVN A pulled up Resident #88's EMR on her computer screen on her nurse' cart and read the order for Losartan as Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse <60. LVN A said she did not see any blister pack or any other medication or pill bottle for Resident #88's Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse <60. LVN A said the only blister pack she saw was for Resident #88's resident's Losartan/POT TAB 25 MG. Give 1/2 tablet by mouth daily. Hold for SBP <110 or HR<60 and the MA's gave Resident #88 his daily blood pressure medications because the MAs gave the facility residents their scheduled medications. LVN A said she did not know what MA A had documented. LVN A said she was unsure who was responsible for verifying a residents physician order and usually it was the nurse who received the order from the physician. LVN A said she was unaware of who was responsible for monthly medication reconciliation at the facility and that she had been trained on the 6 Rights of Medication Administration. LVN A said a residents' blood pressure could bottom out or a resident could become dizzy or unresponsive if they were given the incorrect dose of blood pressure medication. Interview and observation with DON on [DATE] at 12:09 pm the DON said she first found out about the order discrepancy in Resident #88's Losartan order from her staff, LVN A and MA A. The DON confirmed that Resident #88's blister pack of Losartan revealed two (1/2) tablets left in blister pack that read Losartan Pot Tab 25 MG Give 1/2/Tablet by mouth Daily Hold for SBP<110 OR HR <60. Dated 30 TABS-delivered [DATE] and expired [DATE]. Record review with DON of Resident #88's EMR order for Losartan revealed Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for hypertension hold if bp <110/60, pulse <60.The DON said she would speak with Medical Director who was also Resident #88's attending physician and complete a facility medication error form, as the Medical Director was in the facility. The DON said the Medical Director would reevaluate and assess Resident #88, since he was in the building. The DON said the Pharmacy Consultant was the person responsible for reconciliation of all facility resident medications. The DON said the Pharmacy Consultant came to the facility monthly and completed resident medication reconciliations. The DON said that there was no in-house staff member in the facility, who was responsible for completing the monthly medication reconciliation reviews. The DON said that staff had been trained on the 6 rights of medication administration. The DON said she was still investigating and educating/reeducating staff. The DON said a resident could have increased blood pressure, or their blood pressure could not be controlled properly if they did not receive the correct dose of blood pressure medication. Interview with the Medical Director on [DATE] at 12:33 pm who was also the attending MD for Resident #88 said he had been notified by LVN A and MA A, a short while ago regarding Resident #88's Losartan order being incorrect. He said he had reviewed the residents file and found hospital records from an [DATE] hospitalization and readmission and said it looked like the Losartan medication dosage changed in [DATE] after Resident #88's readmission. The Medical Director said he was on his way to evaluate Resident #88 and further assess the situation. The DON was present and said she would be completing a facility medication error report, audit of at least Resident #88's orders and staff education/reeducation and would provide copies to surveyor once completed. In a follow-up interview with the Medical Director/MD for Resident #88, on [DATE] at 1:54 pm, he was notified by surveyor that upon continued record review, of Resident #88's CMA MARS from [DATE], through [DATE], and physician Order Summary Reports from [DATE], through [DATE], revealed Resident #88 had possibly received the incorrect dose of Losartan since [DATE]. The Medical Director said without actual medication packs and observations of the incorrect dose of Losartan being given to Resident #88 it would be difficult to definitively say the resident received the incorrect dose for the entire time. When asked if he considered that length of time to be a significant error, he said that sometimes Resident #88 had really good blood pressures and sometimes they were not good. He said he believed Resident #88 was stable, despite the error and was also taking Hydralazine (a medication primarily used to treat high blood pressure) if his blood pressure was up. The Medical Director also said he had requested a nephrology (branch of medicine that deals with the kidneys) consult for Resident #88 to ensure his kidneys were functioning ok and that Resident #88's laboratory test results so far were ok for the resident's kidney function. When asked who reconciled the medications for the facility monthly, he stated, as the Medical Director, I should have an answer for that, but I don't. The Medical Director said I should be reconciling the medications monthly, but to be honest, I usually just sign the orders. The Medical Director said he tried to make adjustments when he noticed changes or saw changes in medication orders but said he was not sure who at the facility actually completed the monthly medication reconciliation process, but they would be discussing and reviewing it. The Medical Director confirmed today ([DATE]) was the first day he was notified of the incorrect dose of Resident #88's Losartan and said the medication error was one of the good things to come out of the survey process, , was catching things that had been missed that would ultimately improve resident outcomes and thanked surveyor stating, good catch. The Medical Director said he had already reassessed Resident #88 and based on his blood pressure at that time, ordered a one-time does of Losartan. The Medical Director repeated that Resident #88 was stable, and he would be meeting with the administrative team at the facility to discuss, review and improve the medication reconciliation process. He said he had reviewed Resident #88's orders and found no other errors or discrepancies. Record review on [DATE] at 1:56 pm of copy of handwritten Medication Order for Resident #88 dated 8/19.Give Losartan 75 mg PO X 1 now. The order was signed by the Medical Director and there was no time or year indicated on the order. Interview with MA A on [DATE] at 1:57 pm MA A said he did not know why he documented that he had given Losartan 100 mg 1 tab PO daily instead of Losartan 25 MG 1/2 tab PO daily. MA A said he was used to documenting at the time of the medication administration and had not really looked at the blister pack until after the medication administration pass with the surveyor that morning and had a chance to review it. MA A said he should not have documented incorrectly because there was no Losartan 100 mg on the cart for Resident #88 as ordered and he had given the Losartan 25 mg 1/2 tab instead. MA A said he was not sure how long he had incorrectly documented on Resident #88's MAR but corrected it today as soon as he recognized his error, by reporting it to LVN A who was Resident #88's charge nurse. MA A said he was unsure how long he had been giving Resident #88 Losartan 25 MG 1/2 tab PO, but said it was the only blister pack of Losartan on the cart for Resident #88. Telephone interview with Pharmacy Consultant on [DATE] at 3:00pm said she was unaware of Resident #88's incorrect dose of Losartan. They said they had been the Pharmacy Consultant for about 6-7 years and conducted monthly consultations that included reconciliation of medications. They then said they did not conduct full MAR to MD order to cart type of medication reconciliations. The Pharmacy Consultant said they reconciled the orders at the facility. The Pharmacy Consultant said they did not understand how Resident #88''s Losartan 25 mg 1/2 tab to = 12.5 mg by mouth daily was still being delivered and said Pharmacy A should have the correct medication prescription and wondered aloud, how the incorrect medication dose continued to be delivered, stating, Why would Pharmacy A keep delivering the wrong medication?. When asked if they thought that Resident #88 potentially receiving the incorrect dose of Losartan since [DATE], the Pharmacy Consultant said Resident #88 's blood pressures looked good and had often had the medication held per parameters, so perhaps the Medical Director should look at the 100 mg dose because Resident #88 was being maintained on the lower 25 mg (1/2tab dose) per her own simultaneous, EMR record review. The Pharmacy Consultant said today was the first day they became aware of Resident #88's Losartan discrepancy and incorrect dose and said they did not remember doing a medication administration pass on Resident #88 but had done Medication pass/MAR to cart reviews in the past and facility staff had performed well. The Pharmacy Consultant said a possible outcome to the resident could be increased blood pressures if they did not receive the correct dose of medication. The Pharmacy Consultant stated, I really do not have an answer for how that happened and would be speaking with the facility about the incident. Record review of facility pharmacy review binder on [DATE] at 3:06pm for [DATE] through [DATE] revealed there were monthly pharmacy reviews conducted by Pharmacy Consultant, but there were no letters of recommendations or changes in medication reviews or orders for Resident #88. In a follow up interview with the DON on [DATE] at 3:12 pm she said the facility used Pharmacy A, but they were not fully integrated/computerized with Pharmacy A and still had to fax orders to the pharmacy. The DON said LVN A contacted Pharmacy A today with the faxed order for Losartan 100 mg one tablet by mouth daily, as previously ordered in Resident #88's EMR from [DATE]. The DON said a cart search for another blister pack of Resident #88's Losartan 100 mg tablets did not reveal any other Losartan medication for Resident #88 except the incorrect dose of Losartan 25 mg Give 1/2 tab PO daily that was removed from the cart after the medication administration pass. The DON said she had not completed her investigation as to how long Resident #88 had received the incorrect dose of Losartan but based on her audit of Pharmacy A delivery slips for Resident #88 since his admission to the facility in [DATE], she could only find pharmacy delivery slips for the month of [DATE]. The DON said the only Losartan delivered for Resident #88 was on [DATE] for Losartan POT TAB 25 MG.Qty 30. When asked if she thought Resident #88 potentially receiving Losartan 25 mg 1/2 tab since [DATE] was a significant medication error, the DON did not answer. The DON said MA A should not have been documenting that he administered the correct Losartan medication for Resident #88 because it was not the correct dose as ordered and that would be considered falsifying documentation. The DON said she was still conducting the medication error report and staff one to one education and reeducation and would provide copies of those records once completed. The DON said she had only been the DON at the facility since the end of [DATE] and had previously been the ADON at the facility. The DON said the Pharmacy Consultant was the person who completed the monthly medication reconciliations at the facility. Interview with the Administrator on [DATE] at 3:46 pm who said she the DON started in their roles at the facility around the same time, which was around the middle/end of [DATE]. The Administrator said the DON was responsible for facility resident monthly medication reconciliations along with the Pharmacy Consultant. The Administrator said she did not have anything to do with the medication reconciliation process at the facility and had nothing to do with residents' medications. The Administrator said the DON would be the on-site/in-house person responsible for monthly resident medication reconciliations and was not aware of any issues with Resident #88's blood pressure medication. The Administrator said she did not know anything about medications or risks. Interview with the DON on [DATE] at 2:58pm surveyor requested the CMA MAR signature page for Resident #88's [DATE] MAR. The DON advised surveyor there was no copy of any signature page for the CMA MAR. The DON was asked which staff members initials were NPe, she replied, MA A. When the DON was asked how she could tell which initials belong to which staff member, she said that NPe initials were MA A's and then said MA A and another MA were the only MA's who passed Resident #88's medications and worked that cart and hall. The DON then said that MA A was also the only MA who administered Resident #88's daytime medications on [DATE] and admitted to the medication error. Requested a copy of the staffing schedule from [DATE] and in-service trainings with staff. [DATE] at 3:10pm Telephone interview with Pharmacy A on [DATE] at 3:10 pm and spoke with Pharmacy Tech A who said the only order for Resident #88's Losartan 100 MG 1 tab PO Daily was from yesterday [DATE] and should have been delivered to the facility. Pharmacy Tech A said the only order they had for Resident #88 for Losartan before [DATE] were for Losartan 25 mg Give 1/2 tab to equal 12.5 mg PO daily and had been on the order log as active since [DATE]. Record review on [DATE] at 3:43 pm of staffing sheet dated [DATE] revealed MA A worked Days and Evenings on [DATE] and had signed his name and placed the initials NP next to his full name. Record review on [DATE] at 4:02pm of facility Medication Discrepancy Report dated [DATE] at 9:20 am revealed the following: Check items that are applicable: 3). Wrong Dose.Answer YES or NO 1. Was the order written correctly? Yes, was check marked.2. Did you follow the THREE RULES? -LOOK at the medicine as you removed it from the cart? .COMPARE it with the MAR? LOOK at it as you replaced it in the cart? NO was check marked as the answer to all three questions. 3. Was the order plainly written? NO was check marked.4. Was the order transcribed onto the MAR properly? YES, was check marked. Questions numbered 5, 6, 7, had been cut off in the photocopy. 8. Was attending physician notified? . If Yes: Date [DATE] at 12:13pm.9. Was family or responsible party notified? If yes: Date: [DATE] at 12:15 pm.Resident is own RP.Describe the incident.Order was written for Losartan 100 mg but Losartan 12.5mg was administered.Outcome to resident.There was no injury or distress noted B/P rechecked B/P 141/66.Corrective action taken.MD notified and orders are to administer 75 mg of Losartan, correct orders sent to pharmacy.Measures taken to prevent recurrence.CMA inserviced on proper medication administration rules and rights.Physician's response.Recheck residents B/P and administer 75mg of losartan X1 time, which MA A signed. Record review of facility Rx History Report on [DATE] at 4:04 pm revealed the following entry for Resident #88 [DATE] for Losartan POT TAB 25 MG.Qty 30. Requested in-services with staff and any 1-to1 trainings of staff from DON on [DATE] at 12:33pm, and 3:12pm and again on [DATE] at 2:58 pm but did not receive them prior to facility exit. Record review of undated facility policy titled Medications-Medication Regime Review revealed in part: Policy: It is this facilities policy to provide a Medication Regime Review (MRR) for all residents admitted to the nursing facility. Policy Explanation and Compliance Guidelines: 1. Medication Regime Review (MRR) is a thorough evaluation of the medication regime of a resident with the goal of promoting positive outcomes.The review included preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities and collaborating with ither members of the interdisciplinary team.15. The facility must (sic)insure that: b. Residents are free of any significant medication errors. Record review of undated facility policy titled Medication-Documentation of Administration revealed in part: The facility shall maintain a medication administration record to document all medications administered .2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include as a minimum: a. Name and strength of drug; b. Dosage.f. Signature and title of the person administering the medication.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 5 residents (CR#1) reviewed for physician notification. The facility failed to contact the physician for over 5 hours when CR#1 had shortness of breath and was gurgling. After approximately 5 hours, CR #1 was sent to the hospital via emergency transport and was admitted with Pneumonia, Acute Kidney Failure, and Septic Shock and expired 2 days later. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of corrective systems. This failure could place residents at risk of delayed treatment that has the propensity to lead to death. Findings include: Record review of CR #1 face sheet revealed a [AGE] year-old who was admitted to the facility on [DATE]. CR #1 had diagnoses which included Vascular Dementia (Occurs when blood vessels in the brain are damaged, reducing blood flow and brain function), Cerebral Infarction (Stroke), Cognitive Communication Deficit, Dysphagia (swallowing difficulties), Functional Dyspepsia (A chronic condition that causes pain or discomfort in the upper abdomen, often near the ribs), Anemia (lack of blood), Anxiety disorder, Hypoglycemia (low blood sugar), Unspecified Atrial Fibrillation (a heart condition), Neuromuscular dysfunction ( A group of diseases that affect the nerves and muscles that control movement in the body), Constipation and Type 2 diabetes. Record review of CR#1's Quarterly MDS, dated [DATE], revealed a BIMS score of 99, which indicated the resident was unable to complete the interview. Record review of CR#1's baseline care plan, dated [DATE] and revised on [DATE], revealed allowing residents to make decision regarding treatment, care and provide opportunities for resident to make choices. Communication: Resident has a communication problem related to minimal difficulty heating, history of stroke. Goal included: The resident will maintain current level of communication function through the review date. Interventions included: Anticipate and meet needs. Communication: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. Discuss with resident/ family concerns or feelings regarding communication difficulty. Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Monitor for/record confounding problems: decline in cognitive status, mood, decline in ADL, deterioration in respiratory status, oral motor function, hearing impairment (ear discharge and cerumen (wax) accumulation, poor fitting/missing dental appliances etc. Record review of NP note, completed on [DATE] at 10:18 PM, revealed LVN A reported change of condition; CR#1 had difficulty breathing and crackles in breathing sound. Order-Stat Chest X Ray, Duonebs Q4 prn X 5 days ordered. Record review of progress note, completed on [DATE], *late entry*, revealed resident noted with rattles and 96 % 02 sats. V/S ,d+[DATE]- BP, 97.6 Temp, 70, 26. On Call Physician notified change in condition. NP with orders for STAT Chest X Ray and Duonebs (a sterile inhalation solution containing a combination of albuterol and ipratropium). every 4 hours PRN X 5 Days. Duonebs administered. Resident rattles present O2 Sats at 89%. Resident noted responsive to tactile stimuli with cold clammy skin and hands. 911 called at 1105 to transfer resident to hospital. RP notified of change in condition and transfer to ER. Resident left facility at 1120PM. In an interview on [DATE] with LVN A at 2:08 PM, she stated she got a report from LVN D that she needed to go check on CR #1. She stated when she assessed CR #1, his breathing was not good. She described the resident as, just not being the same person. She stated she took his vital signs and contacted the on-call NP. She stated she received orders to do Stat Chest X ray and to put him in Duonebs. She stated she completed Duonebs for about 5 minutes and it appeared it was not helping and the resident was not getting better so she called 911 and they came immediately, and CR #1 was transported to the hospital. She stated the resident was still responsive when 911 arrived. She stated she contacted the RP of the change in condition and CR #1's transfer to the hospital. She stated the nurse that was assigned to CR#1 prior to her was LVN E. She stated she last worked with CR #1 2 days prior and she did not see any difficult changes with the resident when she worked with him. In an interview on [DATE] with CNA B at 3:07 PM, she stated she checked on CR #1 around 3:00 pm on [DATE] and he was complaining of pain. She stated she informed LVN E and LVN E informed she could not give the resident any medication because the nurse on the prior shift had already given him medication. She stated she checked on CR #1 between 4 and 4:30 PM and she noticed he sounded a little congested, as if he could have been coming down with a cold, she stated it sounded like something was in his chest (mucus) but his breathing did not sound gurgly but she could hear it (the mucus) whenever he yelled. She stated the resident did not really eat his dinner, it is unknown if it was common for the resident. She stated between 8:00 PM-8:30 PM, she provided incontinent care and the resident sounded gurgly, as if he had mucus in his throat or possibly needed to cough. (Initially CNA B stated she informed LVN E but in a later interview she stated she left the resident's room to wash her hands and when she returned, LVN E was already in the room checking on CR #1). She stated she left the room to wash her hands and when she returned LVN E was in the room checking on the resident, trying to get him to cough (telling the resident to try to cough it up). She stated she was unsure of what occurred after because she only peeked in to check on the resident and she did not remain in the room. In an interview on [DATE] with CNA C at 10:09 AM, she stated she worked with CR #1 on Christmas Day. She stated she worked the night shift. She stated she checked on the resident at the start of her shift and the resident was in bed. She stated CR #1 was not complaining of pain, but he was making noises(random noises). She stated CR #1 was not responding to questions. She stated she informed LVN A there was a concern with CR #1 and LVN A provided a breathing medicine and she called 911. In an interview on [DATE] with the MD at 10:19 AM, he stated he last saw CR #1 on Christmas eve and he assessed the resident due to being constipated. He stated he did not notice issues with breathing or congestion when CR #1 was assessed. He stated when there was a change in condition, the facility staff should call him or the call center. He stated they had a 24-hour call center. He stated whenever there was a change of condition, they were expected to call as quickly as they could, got vitals and pertinent information so the provider could make a judgement of the situation. The MD stated no one from the facility contacted him at the time of the change in condition. He stated the facility contacted the call center with CR#1's change in condition and the call that was placed the night of [DATE]. He stated that his expectation is that the facility either reaches out to him for a change in condition or if it is after hours, they are to reach out to the on call center. In an interview on [DATE] with the DON at 10:35AM, she stated she was not at the facility when the incident occurred. She stated the gurgling was not a common thing for CR #1. She stated the gurgling, and the shortness of breath would be considered a change in condition. If the resident would have had these symptoms earlier, the staff are expected to assess, call the physician, order labs and send out if needed. She stated once the patient is stable, they would notify the family. She stated whenever a resident had a change in condition, the staff would complete a S Bar (Communication tool used to share information about a resident's condition, used when a resident had a change in condition) for the resident and provide vitals to the physician. In an interview on [DATE] with LVN D at 12:30 PM, she stated she works the 2:00pm-10:00pm. She stated she worked on Christmas day and she worked station 3. She stated she did see CR #1 on Christmas day. She stated she happen to see CR #1 when she was walking down his hall. She stated the resident did not look right and she gave him a washcloth. When asked to elaborate on what that meant; she stated the resident looked like he was sweating a little. She stated she seen the resident around 9:30pm/10:00pm. She stated the resident sounded a little congested when she seen him. She stated CR #1 did not sound gurgly when she seen him. She stated the resident did not complain of pain when she seen him. She stated she informed the CNA B of the residents condition. She stated she does not know if the nurse assigned to the resident was notified. She stated the night nurse (LVN A) that she should go check on the resident because she did not know what was going on with him. She stated she went back into the room with LVN A to assist with the nebulizer machine but she left shortly after. In an interview on [DATE] with LVN E at 2:02 PM, she stated she noticed after dinner (exact time unknown) CR #1 appeared to be a little congested, but his breathing was not labored, she stated it sounded more like wheezing than congestion. She stated one of the previous aides (name unknown) informed her CR #1 had been sick. She stated she assessed the resident for pain and he was provided pain medication. She stated they repositioned CR #1, and it helped his congestion. She stated she checked CR #1's O2 stats and he was fine. She stated she did not observe anything imminent. She stated towards the end of her shift, she checked on the resident again and she tried to get him to cough. She stated the resident coughed up a little mucus and it helped. She stated LVN A came in for night shift around 10:00 PM and contacted the NP and got an order for the nebulizer and x ray and they sent the resident out. She stated the xray was not completed because the resident was sent out instead. She stated she did not contact the MD sooner because she did not think anything was imminent. She stated the resident appeared to be congested as if he was coming down with a cold. Record review of CR#1's hospital medical records, dated [DATE], revealed CR#1's admitting diagnosis was pneumonia and septic shock with low blood pressure and low blood sugar. CR #1 expired at [DATE]. Record review of the facility's, undated, policy Change in a Resident's Condition or Status, revealed Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 1. The Nurse Supervisor/Change Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . c. A significant change in the resident's physical/emotional/mental condition .g. A need to transfer the resident to a hospital/treatment center .i. Instructions to notify the physician of changes in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:34PM. The Administrator and DON were notified. The Administrator was provide with the IJ template on [DATE] at 4:38 PM. FACILITY'S PLAN OF REMOVAL DATED [DATE]. Introduction: On [DATE], at 4:35PM, an Immediate Jeopardy was identified due to failed to contact physician for over 5 hours when CR#1 had a change in condition in that he had shortness of breath and was gurgling. All current residents could be at risk of having a change of condition and have the potential to be impacted by this deficient practice. As a result of the IJ the facility has implemented the following. 1. Administrator, DON and ADON were in-serviced by Chief Nursing Officer as well as regional nurse: Healthcare regarding resident changes in condition, follow-up, staff reporting of incidents and changes in condition and notifying the medical director and or designated on call provider Admin, DON and ADON in-serviced on the need for increased staff education and monitoring including new hires and agency staff. All verbalized understanding. In service completed on [DATE]. 2. Facility reviewed policies and procedures prior to in-services. No changes were made to policies, as a result of the initial review. 3. Administrator, DON and ADON completed the following: a. The facility DON and ADON on [DATE] at 5:00 PM implemented the following: All on duty nursing staff were in-serviced on the following by DON and ADON. i. MD notification of change in condition, including change in mental status/alertness ii. Notification of DON/ Administrator of any change in condition. iii. Resident follow-up monitoring iv. Monitoring residents for change in condition. b. Signs/Symptoms of Resident change of condition to include but not limited to: i. mental status, ii. Changes in breathing iii. unarousable while sleeping, iv. changes to pupils v. inability to/or refusing to eat, drink or take medications. vi. Documentation 4. Facility also conducted additional in-services on: c. Abuse, neglect and exploitation. d. Documentation 5. Completion date [DATE] at 7am. 6. All other nurses will be in-serviced prior to starting their next scheduled shift. The DON, ADON or designee will in-service the nursing staff. 7. Additionally, DON/ADON may provide in-service training to charge nurses by phone prior to the start of their next shift. 8. Administrator, DON and or Designee will review all residents who have had a change in condition. An audit will be conducted on all residents with a change in condition to ensure compliance with the policy. Nurse's found to have not followed policy will be subjected to further training and/or disciplinary action up to and including termination of employment. This review has been added to the morning meeting packet and will be reviewed daily. 9. A reference binder has been set up for nursing staff to quickly access the policy on changes of condition. New Hires, Agency Staff and existing staff will be oriented to the location of the information and will be in-serviced by DON, ADON or Designee. The binder will be maintained at the Station 1 nurses station. This binder was placed at station 1 on [DATE]. 10. Staffing Coordinator was in-serviced by Corporate Administrator and DON. Staffing Coordinator was directed to make contact with all agency employees prior to their shift and provide direction on completing the required in-services and sign offs. A quick reference binder was developed and implemented for agency staff on [DATE]. 11. An Audit was conducted on [DATE]-[DATE] for residents having a change in condition, residents who were identified as having a change of condition in the past 30 days were reviewed. a. The facility Identified 43 residents with change of condition during the review period. b. Facility reviewed all 43 changes of condition; timely notification of medical director and/or designee was identified in 42 of 43 instances. 12. Agency LVN (LVN E) involved in CR#1s care was in-serviced on [DATE] by the DON. Agency nurse was added to the do not return to facility list on [DATE]. 13. CR #1 Passed away in the hospital on [DATE] 14. Administrator, DON/ADON will monitor this plan of removal and correction daily during morning meeting for the next 30 days. 15. The facility completed an ad-hoc QAPI, regarding the incident resulting in the IJ. QAPI Committee will add residents with change of condition to the agenda and will review data for 8 weeks. Additionally, any change of conditions will be reviewed in morning meeting. Monitoring of the POR included the following: Observation of nurses station 1, revealed the DON set up a reference binder for nurses to review when signing in for work. The reference binder included the change in condition policy. Observation of quick reference binder created for agency staff; the binder included an agency staff orientation training acknowledgement check off list and policies for Abuse, Resident Care, Effective Communication, Mechanical Lift, HIPAA/Privacy/Confidentiality, Notification of Change, Incidents/Accidents, Resident Rights, Med Pass/MISC (Nurses only), PPE and Handwashing. Interviews on [DATE] between 8:00AM and 4:00 PM with 17 staff across three shifts to include 6AM-2PM, 2PM-10PM & 10PM-6AM (RN's, LVN's, CNA's, ADON, DON, Staffing Coordinator, and Administrator) indicated they had been in-serviced on Urgency, Changes in Conditions , taking vitals and how to identify change in condition and who to immediately report changes to (the nurse, DON, ADON or MD) and the importance of documentation in the system immediately (to ensure the resident is getting proper care). During the interviews each staff member was asked to provide an example of what they felt was urgency and what they would do. All CNA's interviewed indicated they would immediately contact the RN or LVN if the vitals were too low, or the resident had a change in condition. They also indicated if necessary and they were unable to contact the RN/LVN they would contact the ADON or DON and then complete the appropriate documentation afterwards. The RN and LVN indicated the same. They also indicated it was imperative for them not to wait to document, but to document all occurrences. The DON will closely monitor changes in conditions with patients by completing an audit daily and reviewing all new physician orders from 30 days prior to present and foregoing. Record review of the Plan of Removal revealed each medical staff member (RN's, LVN's, CNA's, ADON, DON, Staffing Coordinator, and Administrator) were in-serviced, between [DATE] and [DATE] on Urgency in the notifications when resident vitals were abnormal, any changes in resident conditions, heart rate are out of the normal parameters or any changes in breathing an immediate notification to nursing and physician is required and documentation of date and time of the occurrence. Record review of audit completed by DON revealed all residents were audits for change in conditions (skin, falls, incidents with injury, antibiotics, hospitalization , change on 24-hour report, wounds, MD notifications) within the last 30 days. All residents were in stable condition. There was no concerns. Record review of the facility in-service documentation dated [DATE], revealed All Staff were in-serviced for Abuse and Neglect Policy, Change of Condition Policy, Documentation Policy, Change of condition-when to report to MD/NP/PA. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of corrective systems.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 3 residents (Residents #1 and #2) reviewed for respiratory care. 1. The facility failed to ensure the filter in Resident #1's oxygen concentrator was not dirty. 2. The facility failed to ensure Resident #1's portable oxygen cylinder was not empty while in use. 3. The facility failed to ensure Resident #2's oxygen cannula positioned in her nose for 2 hours. These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. Findings Included: Resident #1 Record review of Resident #1's face sheet dated 10/9/2024 revealed she was a [AGE] year-old female who was admitted to the facility originally on 12/12/2018 and most recently was admitted on [DATE]. Her diagnoses included, shortness of breath (difficulty breathing), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and heart failure. Record review of Resident #1's Admission MDS dated [DATE] revealed a BIMS (test used to measure cognitive decline) of 99, which indicated the resident was not able to complete the interview. Further review revealed Active Diagnoses - Debility, Cardiorespiratory conditions, Heart Failure, Hypertension (high blood pressure), Pulmonary - Asthma, Chronic Obstructive Pulmonary Disease . Section O - Respiratory treatments revealed Resident #1 had oxygen therapy. Record review of Resident #1's care plan dated 8/16/2024 revealed the following: Required Oxygen at 2-4 L per n/c daily continuous to maintain o2 sats greater than 95 Goal - Will maintain oxygen saturation levels Intervention - Administer oxygen as ordered Record review of Resident #1's Order Summary dated 10/9/2024 revealed the following in part: Oxygen at 2-4 liters PE Nasal cannula daily continuous to maintain 02 sat > [sic] 95% every shift for shortness of breath related to shortness of breath (start date 9/3/2024). Levalbuterol HCI (hydrochloric acid) solution nebulizer .63 mg/3ml. 1 vial inhale orally every 8 hours as needed for COPD (start date 9/3/2024) Record review of Resident #1's Admission MDS dated [DATE] revealed a BIMS of 99, which indicated the resident was not able to complete the interview. Further review revealed Active Diagnoses - Debility, Cardiorespiratory conditions, Heart Failure, Hypertension (high blood pressure), Pulmonary - Asthma, Chronic Obstructive Pulmonary Disease. Record review of Resident #1's nurses notes dated 10/9/2026 at 11:46 a.m., written by LVN A revealed the following: Changed O2 tank this AM [morning] Attempted to get O2 reading O2 machiene [sic] not reading attempted to warm ands [sic] and gave breathing treatment no distress noted. O2 reading 92% no distress noted at this time. Resident #2 Record Review of Resident #2's face sheet dated 10/9/2024 for revealed she was a [AGE] year-old, female who was admitted to the facility on [DATE]. Her diagnoses included Dementia (memory loss), shortness of breath (difficulty breathing), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), cerebral infarction (disrupted blood flow to the brain), and hypertension (high blood pressure). Record review of the physician's orders dated 10/7/2024 revealed Resident #2 had orders for the following: Oxygen at 2-4 liters per nasal cannula daily continuous to maintain o2 sats > 95% (order date 11/1/2022) to receive 02 at 2L/m via NC Continuously every shift. Additional order dated 6/4/24 revealed Oxygen at 2-4 LPM via nasal cannula continuously. Monitor 02 sat. every shift. Record review Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score 14 indicating the resident was cognitively intact. Review of Section O: Special treatment revealed the resident was coded as receiving respiratory treatments - continuous oxygen therapy. Record Review of Resident #2's care plan dated 8/29/2022 revealed the following: Required Oxygen: Continuous Start date 8/29/2022 - Status - Active Care plan Goal - Will maintain oxygen saturation levels. Intervention - Administer oxygen as ordered. Record review of the physician's orders dated 10/7/2024 revealed Resident #2 had orders for the following: Oxygen at 2-4 liters per nasal cannula daily continuous to maintain o2 sats > 95% (order date 11/1/2022) to receive 02 at 2L/m via NC Continuously every shift. Additional order dated 6/4/24 revealed Oxygen at 2-4 LPM via nasal cannula continuously. Monitor 02 sat. every shift. Observation on 10/9/2024 at 9:01 a.m. - 9:18 a.m. revealed Resident #1 was in her wheelchair, in a common area, with a portable O2 tank and cannula in her nose. The O2 gauge indicator was in the refill zone and the needle was on zero. An interview on 10/9/2024 at 9:02 a.m. was attempted. Resident #1 made a continuous moaning sound when asked if she had any shortness of breath . Resident #1 was not able to answer how she felt. Interview on 10/9/2024 at 9:03 a.m. CNA A said Resident #1 had been sitting in the common area for approximately 10-15 minutes. She said she had not checked Resident #1's oxygen gauge and the nurse was responsible. Interview on 10/9/2024 at 9:18 a.m. LVN A said she sat Resident #1 in the common area at approximately 8:45 a.m. She said the O2 gauge was close to the refill. She said she was completing other tasks for about 30 minutes. She said the gauge was in the refill zone, but it did not mean the resident was out of oxygen. She said she was not sure how long the gauge had been in the refill zone and the indicator was pointed to zero. She said the oxygen should be changed before it was empty. She said she was not able to determine if there was oxygen left in the tank and if the resident was receiving oxygen. Observation and interview on 10/9/2024 at 9:21 a.m. revealed LVN A attempted to measure Resident #1's oxygen saturations. LVN A rubbed Resident #1's hands with her hands for a minute. LVN A said Resident #1's hands were too cold for the pulse oximeter to get a reading. LVN A said she would give Resident #1 a breathing treatment because she was not sure if her 02 saturations were below her normal range. Observation and interview on 10/09/2024 at 9:25 a.m. with LVN A, in Resident #1's room, revealed the oxygen concentrator filter had a layer of light gray hairy substance. LVN A took Resident #1 into the room to give her a breathing treatment. LVN A said the nurses did not change the filters and she thought it was maintenance's responsibility. She said she was never told to clean the filters. Observation and interview on 10/09/2024 at 9:34 a.m., revealed Resident #2 was asleep in bed. Resident #2's concentrator was on and the tubing/cannula was on the floor next to the concentrator at the head of the bed. Interview on 10/9/2024 at 10:15 a.m. Maint. said he was not told to clean the oxygen concentrator filters. He said a previous DON cleaned the filters. Observation and interview on 10/09/2024 at 11:37 a.m., revealed Resident #2 was asleep in bed. Resident #2's concentrator and tubing/cannula was in the same position as the earlier observation revealed. Resident #2 was aroused when her name was called. Resident #2 touched on her chest and nose as she tried to find her oxygen. She said she did not know where the oxygen was and had not taken it off. She said she normally had it on. She said she could not remember if the nurse or aide came into her room. Interview and observation on 10/9/2024 at 11:39 a.m. CNA B said she was not aware the tubing for Resident #2's was on the floor. She said she had been in the resident's room but could not remember what time. She said she normally rounded every two hours. She said she was in another resident's room changing the sheets for the past several minutes. She said Resident #2 was supposed to have the oxygen on but was not sure if it was continuous or as needed. She said she had not placed the oxygen on Resident #2 at anytime during her shift . Interview on 10/9/2024 at 11:56 a.m. LVN B said she last checked on Resident #2 at 8:30 a.m. She said she was not aware Resident #2's oxygen cannula was not on. She said Resident #2 had a behavior of taking the oxygen off. LVN B said she normally made round to check on resident every two hours. She said Resident #2 could experience shortness of breath or low o2 saturations if she went without oxygen. Interview on 10/9/2024 at 12:35 p.m. the ADON said when a resident's portable oxygen tank was in the red refill zone, then the tank should be changed to a full tank. She said she expected the nurses to monitor the portable tank to ensure it was not empty. She said if the oxygen tank was empty, Resident #1 would not have received the therapeutic effect of the oxygen need to prevent shortness of breath. The ADON said she changed out Resident #2's cannula and ensured it was in place after it was found on the floor. The ADON said Resident #2 was care planned for taking the oxygen off . She said she was not able to explain why the cannula was in the same position on the floor for approximately two hours. Interview on 10/9/2024 at 1:49 p.m. the DON said nurse should check the portable oxygen tanks every shift. She said the nurses worked 6:30 a.m. - 2:30 p.m. The DON said possibly the tank was used yesterday (10/8/24) and it was not a full tank. She said normally the portable tanks were used for approximately 3 hours continuously before they are depleted. She said, If the gauge indicator is in the red (refill) section, the tank is empty. She said residents on continuous oxygen are at risk for lower oxygen saturations, confusion, and shortness of breath if they did not receive oxygen as ordered. The DON said she was not sure which staff changed out the concentrator filters and not instructed staff to do so . She said she was not sure how often the oxygen concentrator filters needed to be changed. She said the layer of gray matter that was on Resident #1's concentrator filter indicated the filter needed to be cleaned. She said the layer of gray matter could prevent the flow which could affect the resident. The DON said Resident #2 was on continuous o2 and the CNAs and nurses were responsible for ensuring Resident #2 had her oxygen on. She said Resident #2 could suffer from respiratory problems without the supplemental oxygen. Interview on 10/9/2024 at 2:08 p.m. the NP said he was notified approximately at 12:00 p.m. today about Resident #1's low o2 saturations (92%). He said because Resident #1 had COPD, any o2 saturations over 85% were good. He said the oxygen tank should have oxygen and not read zero. He said he was not sure if there was a risk to the resident, but there may not be efficient delivery flow of the oxygen if any was left in the tank. Interview on 10/9/2024 at 2:43 p.m. with the ADMIN, said he expected nurses to follow doctor's orders for oxygen administration. He said the DON and ADON were responsible for ensuring the oxygen tanks had adequate oxygen and were not empty. He said he monitored resident care by making rounds. The ADMIN said maintenance was responsible for checking the oxygen concentrator filters. He said he did not implement the process and it was prior to his hiring. He said he had not instructed maintenance to clean the oxygen concentrator filters. He said he was not aware of the risk and nursing would be better to ask what the risk was. Record review of facility policy Oxygen Administration not dated, reflected the following: Oxygen Administration Purpose - The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 3. Assemble the equipment and supplies as needed General Guidelines 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula . b. The nasal cannula is a tub that is placed approximately one-half inch into the resident nose. It is held in place by an elastic band placed around the resident head . Steps in Procedure 10. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order . 11. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . Record review of online source (https://my.clevelandclinic.org/health/treatments/25181-oxygen-tank) Respiratory When is an Oxygen Tank Empty? dated 8/4/2023 reflected the following: An oxygen tank is considered empty when the pressure gauge reads near zero, indicating that the volume of oxygen inside has been nearly or completely used up. However, it's vital never to let the tank reach absolute zero, especially in medical settings, to ensure patient safety and to maintain tank integrity. Record review of manufacture manual for the oxygen concentrator (model A-1025DS - copyright dated 2023) revealed the following: . Recommended cleaning interval- Air Filter - 7 days - cleaning method - mild dish soap and warm water.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #20) of 6 residents reviewed for quality of care in that: The facility failed to ensure Resident #20 received a weekly skin assessment by a licensed nurse between 12/27/22 - 6/26/24 in accordance with the facility policy and care plan. This failure could place residents at risk of unidentified skin breakdown. The findings include: Record review of Resident #20's face sheet dated 6/27/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included dementia, muscle wasting, heart failure, mild protein-calorie malnutrition, hypertension (high blood pressure), and major depressive disorders. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed the resident was unable to complete the brief interview for mental status. Staff assessed her mental status as severely impaired. She required assistance from staff with ADL care. She was at risk of developing pressure ulcers. Record review of Resident #20's care plan dated 6/27/24 revealed she would remain free from tissue injury through preventative nursing measures. Interventions included a weekly body audit by LN. Record review of Resident #20's quarterly Braden Risk Assessment (used to predict pressure sore risk) dated 6/18/24 by the ADON revealed she was at mild risk of developing pressure sores. Record review of Resident #20's Skin Inspection revealed the last documented inspection was conducted on 12/27/2022 by the previous wound care nurse. There was no documentation of a weekly body audit conducted by a nurse in the resident's clinical record since 12/2022. Record review of Resident #20's Skin Concern Roster dated 12/1/23 - 6/27/24 revealed she had no new skin concerns. The skin concern roster was completed by CNAs during baths and incontinent care. Record review of the facility's computer-generated skin Assessment Schedule for Thursday 6/27/24 - Wednesday 7/3/24 revealed Resident #20 was not listed on it. In an observation and attempted interview on 6/25/24 at 11:28 a.m., Resident #20 was lying on a couch in the common area, groomed, and not in distress. She did not respond to this Surveyor's greeting. Interview on 6/27/24 at 11:00 a.m., the ADON said the wound care nurse normally conducted the weekly skin assessments, but she stopped working at the facility one month ago. She said she and the charge nurses currently did the skin assessments and used a computer-generated list to know which residents to assess on the assigned day. She said she was unsure how Resident #20 fell off the list. She said CNAs conducted a daily skin check during showers and would report any issues to the nurse. She said nurses were trained to do the detailed head to toe skin assessment to ensure no skin deviations for the residents. She said she did monitor to ensure nurses completed the weekly skin assessments but because Resident #20 was not on the list, she was unable to verify that it was done in the system. She said she never had any concerns with Resident #20's skin. Interview on 6/27/24 at 12:02 p.m., the DON said there was a glitch in the computer system. He said all other residents were on the skin assessment list. He said the purpose of the weekly skin assessment, conducted by the nurse, was to check the whole body and ensure the skin was intact and nothing was missed. He said nurses did skin assessments according to facility's protocol. He said daily skin checks were done by CNAs who would report any skin changes. Interview on 6/27/24 at 1:46 p.m., the Regional Administrator said he would submit a ticket through the IT department to see when Residents #20 fell off the weekly skin assessment schedule generated by the system. He said he expected skin assessments to be done as planned and according to schedule. He said the purpose of the weekly skin assessment, conducted by the nurse, was to check for skin tears, injuries, and for the health and care of the resident. He said CNAs were trained to report anything seen to the nurse for a more thorough inspection. Interview on 6/27/24 at 2:40 p.m., the DON said he did not realize there was a glitch in the system. He said the ADON was responsible for reviewing the weekly skin audits and would refer any concerns to him. He said no concerns were identified. He said if nurse skin assessments were not done the residents could end up with unknown skin issues. Record review of the facility's undated Skin Program, Pressure Ulcers & Other Wounds policy read in part, .Prevention, Treatment, & Documentation . Risk Assessment & Routine Care for All Residents . 4. Nursing assistants will check all residents' skin during each episode of care, bathing, etc. Reddened areas will be reported to the licensed nurse . 6. Body Audits for impaired skin integrity will be performed weekly by a licensed nurse and findings will be documented in the medical record .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: -Food items were found in the kitchen with expired and beyond the use by date. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings include: Observation of the facility's kitchen and interview on [DATE] between 8:30 am and 8:45 am with the Dietary Cook A revealed the following: -A plastic container of Pimiento Cheese with a used by date [DATE] in the walk-in refrigerator. -A plastic container of sliced deli ham with a used by date [DATE] in the walk-in refrigerator. -A plastic container of American Sliced Cheese with a used by date [DATE] in the walk-in refrigerator. Interview with the Dietary Cook A on [DATE] at 8:35 AM, she said that the container of food items with expired used by date should have been used or discarded prior to the used by date. Interview with the Dietary Food Service Manager on [DATE] at 9:00 AM she said that the dietary staff Should have used or discarded the food prior to the used by date. Record review of facility's Policy on Food Storage dated [DATE] Read in part . Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within ,d+[DATE] days or discarded .

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 05-09-23 at 8:45 am, with Dietary Cook A revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster and the lid and door were open. Interview on 5-09-23, with Dietary Cook A she said that they were in-serviced that the Dumpster lids must be closed at all times when not in use. Interview on 5-10-23 at 10:00 am, with the Food Service Manager she said that the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Policy and Procedure for Food -Related Garbage and Rubbish Disposal read in part . 7. Outside dumpsters provided by garbage pick up services well be kept closed and free of surrounding litter .

Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 7 residents (CR #1) whose records were reviewed for accuracy and completeness in that: The facility failed to accurately document CR#1's regular diet on his dietary meal service admission order. This failure could place residents at risk of having inaccurate records and errors in care by staff. Findings include: Record review of CR#1's Face Sheet dated 2/25/23 revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, Essential Hypertension (abnormally high blood pressure that is not the result of a secondary medical condition), atrial fibrillation (an irregular, often very rapid heart rhythm that can lead to blood clots in the heart), pain, constipation (difficulty in emptying bowels, usually associated with hardened feces), gastro-esophageal reflux disease (condition that occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach (the esophagus) without esophagitis (inflammation that damages the esophagus/tube that connects the mouth and the stomach), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath, causing lung damage that cannot be reversed). Record review of CR#1's Admission MDS dated [DATE] revealed his BIMS was scored a 99 indicating the resident was unable to complete the interview for cognitive status. His SAMS was coded for Cognitive Skills for Daily Decision Making as being Moderately impaired. CR #1 was coded as requiring Limited assistance of one staff for his bed mobility, transfer, dressing, bathing, and locomotion on the unit. He required extensive assistance of one staff for toileting and personal hygiene. He was coded as requiring supervision, set-up assistance with eating. He was coded in section K, Swallowing/Nutritional Status, K0100. Swallowing Disorder .C. Coughing or choking during meals or when swallowing medications. C. Mechanically altered diet-require change in texture or food or liquids (e.g., pureed food, thickened liquids). Record review of discharge orders from Hospital A dated as signed on 6/1/22 revealed the following order: DIET Heart Healthy Dysphagia (sic) 5 moist/minced. Record review of undated Facility A nursing intake form read as follows, Diet Texture: dysphagia .Liquid: Thin liquid. Record review of CR#1's Physician/Prescriber .order sheet dated 6/1/22 revealed the following order: Admit to Facility A under the care of Physician A . Diet: regular with thin liquids. Telephone Order. Record review of CR #1's Comprehensive Risk assessment dated [DATE] read in part: Current Diet/Consistency/Tube Feeding order/Average Meal Intake: Pureed diet. and had been signed as completed by DM A. Interview with DM A on 3/8/23 at 9:44 am who said that she was the new Dietary Manager in June of 2022 and had just started. The DM said she could not recall who trained her. The DM said she could not recall if she worked the day CR #1 was served his lunch on 6/3/22, or if he had been served the appropriate or ordered diet, but she said that she had CR #1 listed as a pureed diet, so that would have been the diet CR #1 would have been served. She could not remember where she got the information regarding CR #1's diet. In an interview with the DON on 3/8/23 at 3:58pm who said that although he was the DON at the time of CR #1's admission to the facility, he did not remember what diet he was on or what diet CR #1 had been served during his stay. He said that the IDT met in or around 2/27/23 with Physician A and determined that the diet order for CR #1 was a transcription error. The DON said that the original physician order was for a regular diet and the DM A somehow documented a pureed diet in error. Telephone interview with Physician A on 3/8/23 at 4:18pm who said that he was the Physician for CR #1 and was asked recently by the facility to review CR #1's chart. He said he did not recall what CR #1's diet was without looking at it first, but whatever diet he wrote would have been the diet for CR#1. He said that the IDT at the facility met, and they all determined that there was a transcription error. He said that as far as he remembered, a DM could not write orders and believed the transcription error was with her. In a follow up interview with the DON on 3/8/23 at 4:22pm he said that the admitting nurse at that time, would have been the one responsible for CR #1's admission orders. He said that he and or the ADON should have checked the orders and did not know why or how they did not check CR #1's orders. He said he could not be 100% sure of what diet CR #1 was served but believed CR #1 had received the correct diet throughout his facility stay. Record review of undated facility policy and procedure titled Admission Orders read in part: 1. The written orders should include at a minimum a. Dietary .3. The orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. The policy and procedure did not contain any information on the accuracy or transcription of orders. Record review of undated facility policy and procedure titled Orders-Verbal /Telephone revealed the policy did not contain any information on the accuracy or transcription of orders.

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 7 of 7 residents (Resident #4, Resident 17, Resident #55, Resident #59, Resident #64, Resident #91, Resident #345) reviewed for quality of care. - The facility failed to set orders and to ensure that pre-prandial insulin, (insulin that should be administered within 5-20 minutes before meals) was administered at 6 AM, 2 hours before the breakfast meal for Resident #4 and Resident #64. - The facility failed to administer sliding scale insulin timely before meals as ordered by the physician for Resident #4, Resident #17, Resident #59, Resident #91, and Resident #345 by administering it before 6 AM, 2 hours before the breakfast meal. - The facility failed to administer Insulin as ordered by the physician to Resident #55 when her BG was greater than 200. - The facility failed to manage Resident #4, Resident #55, Resident #65 and Resident #91's pre-prandial insulin resulting in increase in HbA1c, a lab value that represents a 3 month average of blood glucose. These failures could place residents receiving insulin at risk for hypoglycemic episodes, increased HbA1c hospitalization , and/or death. Resident #4 Record review of Resident #4's face sheet dated 03/16/22 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, extensive assistance with most ADLs, and frequently incontinent of both bladder and bowel. Record review of Resident #4's Care Plan started 03/11/21 revealed, Area- diabetes type 2 uncontrolled blood sugars, Goal- A1c will by below 6, Intervention- Administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #4's A1c Lab results revealed: -04/21/21 was 8.7%, -08/17/21 was 8.4%, and -02/15/22 was 9.9%. Interview on 03/17/22 at 1:05 PM, Resident #4 said the nurses checked his blood sugar in the morning at 5:00 AM and gave him his insulin. He said his blood sugar went up to 600mg/dl before he came to the facility and he does not feel different, but it has been up to 500mg/dl when he was in the facility. Record review of Resident #4's Physician Order dated 01/20/22 revealed, Type 2 diabetes mellitus with diabetic [CONDITION(S)], accucheck (finger stick blood glucose reading) QAM with [MEDICATION(S)] [MEDICATION(S)] s/s, with administration time code of 5:30 AM. 0-200 = none, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD. Record review of Resident #4's January 2022 MAR for [MEDICATION(S)] revealed: 05:30 AM -01/21/22 BG-225, 2 units RLQ, 01/25/22 BG-335 6 units LUQ, 01/26/22 BG-450, 10 units LUARM. 01/27/22 BG-356, 8 units RUARM. 01/29/22 BG 353- 8 units LLQ. 01/30/21 BG-221, 2 units RLQ. Record review of Resident #4's February 2022 MAR for [MEDICATION(S)] revealed: 5:30 AM -02/02/22 BG-256, 4 RUQ. 02/06/22 BG 202, 2 units left thigh. 02/08/09 BG 240- 2 units right thigh. 02/09/22 BG-209, 2 units RLQ. 02/11/22 BG-397, 8 units LUQ. 02/15 BG-274, 4 units RUARM. 02/16/22 BG-301, 6 units LLQ. 02/18/22 BG-214, 2 units RLQ. 02/22 BG-279, 4 units LUQ. Record review of Resident #4's March 2022 MAR for [MEDICATION(S)] revealed, 5:30 AM -03/01/22 BG 202- 2 units RUQ. 03/02/22 BG-213, units unknown LLQ. 03/03/22 BG-320, 6 units LUARM. 03/4/22 BG-300, 4 units LUQ. 03/07/22 BG-361, 8 units LLQ. 03/08/22 BG-270, 4 units. 03/11/22 BG-324, 6 units RLQ, 03/11/22 BG-203, 2 units left mid-thigh, 03/12/22 BG-336, 6 units RUARM. 03/15/22 BG-391, 8 units LUQ. 03/16/22 BG-302, unknown units LLQ. Record review of Resident #4's Physician Order dated 01/20/22 revealed, [MEDICATION(S)] 100 unit/mL Kwikpen give 5 units SQ daily in AM Hold for BS <80 with administration time codes of 6 AM. Record review of Resident #4's January MAR for [MEDICATION(S)] Kwikpen revealed: Resident received 5 units at 6 AM on 01/03/22, 01/07/22, 01/08/22, 01/15/22 and 01/18/22, 01/21/22, 01/25/22, 01/26/22, 01/27/22, 01/29,22, 01/30/22, 01/31/22. Record review of Resident #4's February MAR for [MEDICATION(S)] revealed: Resident received 5 units at 6 AM on 02/02/22 to 02/11/22, 02/13/22, 02/15/22 to 02/19/22, 02/22/22 to 02/24/22, 02/26/22 and 02/27/22. Record review of Resident #4's February MAR for [MEDICATION(S)] revealed: Resident received 5 units at 6 AM on 03/02/22, 03/04/22, 03/06/22, 03/7/22, 03/11/22, 03/12/22, 03/15/22, 03/16/22. Resident #17 Record review of Resident # 17's face sheet dated 03/16/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #17's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, supervision with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #17's Care Plan with start date of 11/5/2019 revealed, Area- Diabetes Mellitus, Goal- will have blood glucose within normal range, Intervention- Administer insulin as ordered. Record review of Resident #17's A1c Labs revealed: -10/12/20 was 8.7%, 12/18/20 was 8.4%, 01/11/21 was 8.6%, 05/12/21 was 5.9%, 07/21/21 was 7.7%, 10/19/21 was 7.7%, and 01/18/22 was 7.5%. Record review of Resident #17's Physician Orders dated 08/16/21 revealed, Type 2 diabetes mellitus without complication accucheck twice daily with [MEDICATION(S)] 100 units/mL vial per s/s with administration time codes of 6AM and 4PM. 0-250 = 0 units, 251-400=3 units, >400= call MD for orders. Record review of Resident #17's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250. 4 PM- 01/02/22 BG-256, 3 units LLQ. 01/03/22 BG-342, 3 units RUARM. 01/09/22 BG-254, 3 units RUARM. 01/11/22 BG-280, 3 units LUARM. 01/18/22 BG-266, 3 units LUARM. 01/19/22 BG-251, 3 units RUARM. 01/21/22 BG-262, 3 units RUARM. 01/22/22 BG-251, 3 RUARM. 01/24/22 BG-311, 3 units RUARM. 01/25/22 BG-268, 3 units LUARM. 01/26/22 BG-252, 3 units RUARM, 01/31/22 BG-318, 3 units LLQ. Record review of Resident #17's February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250. 4 PM- 02/01/22 BG-275, 3 units RUARM. 02/11/22 BG-332, 3 units RUARM. Record review of Resident #17's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250. 4 PM- 03/04/22 BG-261, 3 units LLQ. Resident #55 Record review of Resident #55's face sheet dated 03/16/22 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #55's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #55's Care Plan with start date 11/22/21 revealed, Area- Diabetes Mellitus, Goal- A1c will be below 6 through next review, Intervention- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #55's A1c Labs revealed: 08/24/20 was 5.9%, 11/23/20 was 6%, 02/21/21 was 8.7%, 05/24/21 was 8.3%, 08/16/21 was 7.4%, and 02/21/22 was 9.5%. In an interview on 03/17/22 at 01:07 PM, Resident #55 said she did not receive any insulin. Record review of Resident #55's Physician Orders dated 12/02/19 revealed, type 2 diabetes mellitus without complications accucheck everyday with PRN [MEDICATION(S)] SQ per sliding scale. 0-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD Record review of Resident #55's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #55's February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55 did not receive any insulin per her sliding scale as ordered by her physician Record review of Resident #55's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55 did not receive any insulin per her sliding scale as ordered by her physician. Resident #59 Record review of Resident #59's face sheet dated 03/16/22 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #59's Quarterly MDS dated [DATE] revealed, moderately impaired cognition, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of Resident #59's Care Plan started 02/05/20 revealed, area- type 2 diabetes uncontrolled blood sugars, goal- A1c will be below 6% and have no complications through next review. Intervention- Administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #59's HgbA1c Labs revealed: 07/16/21 was 7.9%, 10/01/21 was 7.9%, and 01/07/22 was 7.9%. Record review of Resident #59's Physician Order dated 01/21/20 revealed, Type 2 diabetes with unspecified complications, Accucheck BID before meals with [MEDICATION(S)] 100 unit/ml vial per s/s with time codes for administration at 6 AM and 4 PM.0-60 0 units 60-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD Record review of Resident #59's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 4 PM 03/01/21 BG-229, 2 units RUARM. 03/06/21 BG-272, 4 units LUARM. 03/08/21 BG-217, 2 units LLQ. 03/14/22 BG-260, 4 units LLQ. Resident #64 Record review of Resident #64's face sheet dated 03/16/22 revealed, [AGE] year-old-female who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #64's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, limited assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of Resident #64's Care Plan started 10/12/21 revealed, area- diabetes, goal- A1c will be below 6%, intervention- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #64's HgbA1c Labs revealed: - 04/15/21 was 6.6%, - 08/02/21 was 10.3%, and - 02/07/22 was 11%. Record review of Resident #64's Physician Orders dated 02/06/22 revealed, [MEDICATION(S)] 100 units/mL. Give 12 units SQ BID. Hold for BS less than 80 with administration time codes of 6 AM and 6 PM. Record review of Resident #64's progress notes revealed, the resident had diabetic ulcers on both heels that were acquired in the facility. Record review of Resident #64's wound assessment report, dated 03/15/2022, stated, made aware of new skin concerns by staff . noted diabetic ulcer to right heel. Blood blistered site measures 2.0 cm by 3.5 cm, skin remains intact at this time . Noted diabetic ulcer to left heel. Area maroon in color. Site measures 3.0 cm by 2.5 cm, skin intact . Record review of Resident #64's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #91 Record review of Resident #91's face sheet dated 03/16/22 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #91's MDS dated [DATE] revealed, severely impaired cognition, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #91's Care Plan started 05/05/21 revealed, area- diabetes with diabetic polyneuropathy, goal- A1c will be below 6, intervention-administered oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #91's HgbA1c labs revealed: - 04/26/21 was 4.9% and - 02/08/22 was 7.1%. Record review of Resident #91's Physician Orders dated 02/04/22 revealed, Type 2 diabetes with diabetic polyneuropathy, Accucheck BID AC with [MEDICATION(S)] 100 unit/ml vial per s/s with time codes for administration at 6 AM and 4 PM. 60-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD. Record review of Resident #91's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 6AM 03/01/22 BG-221, 2 units right lower, 03/02/22 BG-266, 4 units LLQ, 03/03/22 BG- 215, 2 units RLQ, 03/04/22 BG-301, 6 units RLQ. 03/05/22 BG-266, 4 units RLQ, 03/06/22 BG-274, 4 units RLQ, 03/07/22 BG-362, 8 units RLQ, 03/08/22 BG-355, 8 units LLQ, 03/09/22 BG-318, 6 units RUARM, 03/10/22 BG- 319, 6 units LLQ, 03/11/22 BG-391, 8 units RLQ, 03/12/22 BG-350, 6 units RLQ. 03/13/22 BG-424, 10 units LUQ, 03/14/22 BG-286, 4 units LUQ. 03/15/22 BG-342- left thigh, 03/16/22 BG, 396 right thigh. 4PM- 03/01/22 BG-250, 2 right upper arm, 03/02/22 BG-203, 2 units LLQ, 03/03/22 BG- 305, 6 units LLQ, 03/04/22 BG-241, 2 units LLQ. 03/05/22 BG-316, 6 units LLQ, 03/06/22 BG-417, 10 units LLQ, 03/07/22 BG-321, 6 units RUARM, 03/08/22 BG-323, 84 units LUARM, 03/09/22 BG-324, 6 units RUARM, 03/10/22 BG- 319, 6 units LLQ, 03/11/22 BG-309, 6 units LLQ, 03/13/22 BG-308, 6 units RLQ, 03/14/22 BG-364, 8 units RUQ. Resident #345 Record review of Resident #345's face sheet dated 03/16/22 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #345's Admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 15, limited assistance for all ADLs and always continent of bladder and occasionally incontinent of bowel. Record review of Resident #345's Care Plan started 03/02/22 revealed, Area- diabetes Mellitus (type 2): uncontrolled blood sugar levels, goal- A1c ( a % that represents a 3 month average of blood sugars) will be below 6%, interventions- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #345's HgbA1c Lab revealed: - 03/16/22 was 8.8%. Record review of Resident #345's Physicians Orders dated 03/06/22 revealed, Accucheck BID AC with [MEDICATION(S)] 100 unit/mL vial per s/s with Time Codes of administration at 6 AM and 4 PM. 0-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD. Record review of Resident #345's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 6AM: 03/12/22 BG-215, 2 units Left thigh, 03/16/22 BG-209 2 units right upper quadrant. 4 PM: 03/07/22 BG-221 2 units, left upper arm. 03/08/22 BG-272, 4 units right lower quadrant. 03/09/22 BG-222, 2 units left upper arm. 03/10/22 BG-382, 8 units right upper quadrant. 03/12/22 BG-249 2 units, left lower quadrant. 03/13/22 BG-259, 4 units left lower quadrant. 03/14/22 288, 4 units left lower quadrant. An observation at 03/16/22 at 07:25 AM revealed, LVN D shadowing LVN N at the nursing cart. LVN N said that there were no sliding scale insulins to administer that morning because they were already completed by the night shift prior to the beginning of her shift at 6 AM. She said that this was the time morning insulin was always administered. An observation at 03/16/22 at 08:20 AM revealed, meal tray carts arriving on the 600 hall. In an interview on 03/16/22 at 07:30 AM, the ADON said that all morning insulin's including sliding scale and pre-prandial insulin were completed by the night shift and that insulin administration was not in relation to meals but was scheduled for 6AM and 4 PM. She said breakfast was normally around 8 am and that residents had snacks available to them between 6 am and 8 am. The ADON said that when administered insulin earlier than meals the expectation was for them to monitor the residents for signs and symptoms of [CONDITION(S)]. In an interview on 03/16/22 at 07:44 AM, LVN R said that she had no insulin to administer that morning because it was completed by the night shift prior to her arrival at 6 am. She said that this was the time morning insulin were always administered. In an interview on 03/16/22 at 08:25 AM, LVN D said that sliding scale insulin should be administered when you know the resident's tray is arriving and she would not administer them 2 hours before meals because it could place the resident at risk for [CONDITION(S)]. She said the facility had night shift nurses complete morning insulin administration before the morning shift started at 6 AM. In an interview on 03/16/22 at 11:22 AM, the Physician said that the facility night shift nurses had been administering pre-prandial insulin because it was easier to get it done. He said while there was a risk of [CONDITION(S)] if pre-prandial insulin was administered without a meal the facility used low sliding scale doses to avoid [CONDITION(S)], so they have had no problems. The Physician said that pre-prandial insulin should be administered closer to meals and not at 2 hours before a meal but would not give a narrower timeframe. He said for LTC patients his goal was for an A1C <8 % which is an average glucose around 183. In an interview on 03/16/22 at 02:00 PM, the DON said that pre-prandial insulin ([MEDICATION(S)] and [MEDICATION(S)]) are dosed per sliding scale in anticipation of increased blood glucose levels when a resident eats and that at most they should be administered close to a meal but no longer than 1 hour before. He said the risk of uncontrolled/ill managed blood sugars was [CONDITION(S)], impaired wound healing, and any condition which a consequence of uncontrolled blood sugars. In an interview on 03/18/2022 at 12:50 PM, the DON said [MEDICATION(S)] insulin peaks within 1 hour and continues to work within 2-4 hours, and if a resident had not eaten within that first hour, the resident would need to be watched for hypoglycemic effects such as nausea and vomiting and change in mental status. He said there was the need to balance the effect of the insulin with the timing of meals to keep blood glucose levels stable. He said each resident with diabetes is clinically different, some are stable, some are regular, for some insulin would need to be held if not eating, and some need to be monitored for symptoms. The DON said some people can become chronically hyperglycemic with the insulin. He said the goal was to keep resident blood glucose levels as normalized as possible to track trends and know when to adjust their diabetes management regimen and medication. The DON said those with diabetes generally have a risk for wounds and decreased healing abilities. Record review of the Package Insert for [MEDICATION(S)] revealed: Dosage and Administration- Subcutaneous injection: Inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm. Record review of the Package Insert for [MEDICATION(S)] revealed, Dosage and Administration- Subcutaneous injection: Administer [MEDICATION(S)] U-100 or U-200 by subcutaneous injection into the abdominal wall, upper arm or buttocks within 15 minutes before a meal or immediately after a meal. Record review of the facility posted Meal Times revealed: Hall Carts -Breakfast 07:15 AM, Lunch 11:15 AM, Dinner 05:15 PM Dining Room- Breakfast closed, Lunch 11:30 AM, Dinner 05:30 PM Not times for snacks were documented on the document. Record review of the facility policy titled Medications- Administering with no revision date revealed, 3- medications must be administered in accordance with the orders including any required time frame. 4- Medications must be administered within one(1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Record review of American Diabetes Association Standards of Medical Care in Diabetes-2021 revised 01/2021 revealed: 6- Glycemic Targets. Table 6.1-Estimated average glucose A1C (%) to mg/dL 5% ~ 97 (76-120) 6% ~ 126 (100-152) 7% ~ 154 (123-185) 8% ~ 183 (147-217) 9% ~ 212 (170-249) 10% ~ 240 (193-282) 11% ~ 269 (217-314) 12% ~ 298 (240-347) 12-Older Adults. Table 12.1 Patient Characteristic- Complex, Reasonable A1C goal <8.0% = Fasting or pre-prandial glucose goal of 90-150 mg/dL, bedtime glucose goal 100-180mg/dL.

Based on observation, record review, and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen, one standalone refrigerator, one walk in refrigerator, for reviewed for kitchen sanitation and storage. -The facility failed to ensure that open food and leftovers in the stand-alone refrigerator and walk in refrigerator were labeled, dated, and sealed. - Boxes of food items were observed on the floor outside of the freezer and in dry goods storage. - Boxes in walk-in freezer were crowded with no space for air circulation. - Food was not dated with an open date. - Two male staff did not wear beard and hair restraint. - Two staff did not wear PPE (mask) appropriately. -Two trash cans did not have lids. These deficient practices could place the residents who received meals from the kitchen at risk of a food-borne illness. Finding included: Observation on 3/15/2022 at 9:00 a.m. in the kitchen revealed the following: - Walk-in Freezer - 7 boxes of food were on the floor and stacked approximately 6 ft. high. - Kitchen hallway - food not refrigerated - 12 boxes of food with labels of Keep Frozen printed on them. - Dry pantry - 3 boxes of food on the floor. - Walk-in Refrigerator - wilted heads of romaine lettuce in cardboard box - not dated or sealed - Standalone Refrigerator - 2 salad dressing did not have open dates - 1 male cook staff did not have on a hair net, beard restraint and mask was not covering his nose and mouth. Interview on 3/15/2022 at 9:10 a.m. with Cook C said the facility had a food delivery at 5 a.m. Cook C said he and the two other staff had been too busy to put the food in its' appropriate place and not on the floor. Cook C said he did not wear a beard restraint because he forgot. He said he forgot his hair net too. Cook C said the food that was supposed to be frozen or refrigerated should not have been sitting in the hallway. Cook C said the food could spoil and be a danger to the residents. He said he had never worn a beard restraint. Cook C said the hair net would prevent cross-contamination. Cook C said he had his mask down below his chin because it was hot in the kitchen. Cook C said he had to wear the mask because of COVID-19 and the mask stopped spread. Observation on 3/15/2022 at 11:36 a.m. in the kitchen revealed the Dietary Manager and Cook C did not have a beard restraint on. The trash can in the kitchen near the door to exit into the dining room and the trash can next to the 3-compartment sink did not have a lid to cover the trash. Interview on 3/15/2022 at 11:37 a.m. with the Dietary Manager said all dietary staff should wear a hair nets if they have hair because it is the rule and prevents cross-contamination. The Dietary Manger said he and the other dietary staff had not worn beard restraints because they did not have any to use. He said he and the staff never used them. The Dietary Manager said Cook C had been trained to receive the food deliveries and the food should not have been stored on the kitchen floor. He said the food should be put in the freezer if it was to be kept frozen to prevent the food from spoiling and prevent cross contamination. He said the freezer should not be crowded and he had not had time to unpack the boxes. He said the overcrowding may not allow air to properly keep the freezer temperature. The Dietary Manager said all food should have an open date, label and sealed so that it can be discarded timely and prevent foodborne illnesses that could possibly harm residents. The Dietary Manager said all dietary staff have been trained to wear their mask to cover their mouth and nose. The Dietary Manager said a mask should be worn to prevent the spread of COVID-19. He said the trash can lids should be on to prevent pest and cross-contamination. Interview on 3/17/2022 at 11:35 a.m. with the DON said the kitchen staff should wear mask to prevent COVID-19. The DON said food should not be stored directly on the kitchen floor because it could cause cross-contamination. He said deliveries should be refrigerated as soon as possible. Interview on 3/17/2022 at 2:52 p.m. the Administrator said, she expected dietary staff to wear hair nets and beard restraints. She said beard restraints and hair nets are used to prevent cross-contamination. The Administrator said all staff have to wear mask when they are in the building. She said all staff wear mask to prevent the spread of COVID-19. The Administrator said the dietary staff should follow the rules of TFER related to food storage, trash containers and how to label/date/and seal food to prevent spoilage. She said food deliveries should be refrigerated soon after delivery to prevent bacteria or food spoilage. The Admistrator said these protocols prevent cross-contamination. Record review of TFER (Texas Food Establishment Rules) dated 10/2015 revealed the following in part: .§228.69§228.69 (c)§228.69. Preventing Contamination From the Premises. (a) Food storage. (1) Except as specified in paragraphs (2) and (3) of this subsection, food shall be protected from contamination by storing the food: (A) in a clean, dry location; (B) where it is not exposed to splash, dust, or other contamination; and (C) at least 15 cm (6 inches) above the floor. (n) Covering receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (1) inside the food establishment if the receptacles and units: (A) contain food residue and are not in continuous use; . with tight-fitting lids or doors if kept outside the food establishment. §228.43. Hair Restraints . food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. (g) Ready-to-eat, time/temperature controlled for safety food, date marking . (A) the day the original container is opened in the food establishment shall be counted as Day 1; and (B) the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (6) employees are verifying that foods delivered to the food establishment during non-operating hours are from approved sources and are placed into appropriate storage locations such that they are maintained at the required temperatures, protected from contamination, unadulterated and accurately presented; Record review of facility policy Storage Dry Food undated revealed the following in part: .1. Store dry foods . 6 off the floor . Record review of facility policy Storage: Freezer undated revealed the following in part: 1. Keep frozen foods at 1- to 0 degrees F. Record review of facility policy Storage: Refrigerator undated revealed the following in part: 1. Keep all perishable foods below 41 degrees F (7 degrees C). 2. Do not overcrowd refrigerator. Leave space between items so that cold air can circulate. 7. Keep refrigerated foods wrapped or covered and in sanitary containers.

Based on observation, interview and record review, the facility failed to ensure resident environment remained free of accidents in hazards for 3 of 16 residents (Resident #80, #16 and #68) and in 2 of 2 laundry rooms, in that: - The facility failed to place wet floor signs during and after mopping resident's hall and rooms. - The facility failed to ensure Resident #16 was out of her room or in a position free of walking on the wet floor prior to mopping resident's room. - The facility failed to ensure Resident #80 was free of paraphernalia (lighter and cigarettes) stored in her room. - The facility failed to ensure two laundry facilities for resident use, secured laundry detergent out of residents' reach. These failures could place all residents at risk for experiencing accidents/incidents resulting in possible injury or death. Findings included: Smoking Hazard Record review of Resident #80's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with Alzheimer's disease, heart failure and [CONDITION(S)]. Record review of Resident #80's care plan revealed the resident was an unsafe smoker and had the intervention of keeping all smoking paraphernalia at the nurses station and to educate resident and reinforce as needed the risk for injury related to [CONDITION(S)]. Record review of Resident #80's MDS, dated [DATE] revealed the resident had a BIMS score of 13 out of 15 indicating the resident cognition was intact. Record review of Resident #80's smoking assessments, dated 11/25/2021, revealed the resident was deemed and unsafe smoker and required constant supervision by staff for safety during smoking. Observations and interview on 03/17/2022 at 12:30PM, revealed Resident #80 feeding herself a lunch meal in her room. A lighter was observed on top of the resident's nightstand. Resident #80 stated she was unaware the lighter was there and it likely was left by her daughter who brought the lighter to her room instead of handing it off to the nurses' station. She stated the daughter forgets multiple times to give her paraphernalia to the nurses station. Observations and interview with Charge Nurse LVN N on 03/17/2022 at 1:11PM, revealed the LVN finding the lighter on Resident #80's nightstand and an open pack of cigarettes inside the resident's drawer. LVN N stated she was not aware there was paraphernalia kept in Resident #80's room. She stated she worked at the facility as an LVN on a part-time basis and was not too familiar with the resident. In an interview with CNA AO on 03/17/2022 at 1:30PM, she stated that just about everyday she has to check Resident #80's room for paraphernalia because the resident tends to keep her cigarettes and lighter after smoke breaks. She stated whenever she found the items, she confiscated and returned them to the nurses' station. In an interview with CNA AT on 03/17/ at 3:09PM, CNA AT stated that Resident #80 was capable of lighting a cigarette and smoking but required supervision. She stated according to facility's policy and procedures, the staff needed to be supervising the resident while outside smoking and the residents were not given more than 1 to 2 cigarettes to smoke during a smoke break. She stated the resident had the habit of sneaking cigarettes and lighters back to her room and all staff who normally work her are aware of that and know to check her room of paraphernalia. She stated if the resident was found with a whole pack in her room, then it is usually because her family member brought it directly to the resident instead of their nurses' station like they are supposed to. In an interview with the Regional Nurse and DON on 03/17/2022 at 3:53PM, the Regional Nurse stated if the resident was deemed a safe smoker, they were allowed to have possession of their own cigarettes as so long as they smoke only during the designated times and at the designated location. The DON stated they try to keep all paraphernalia checked in at the nurses station for added safety and that the risk of an unsafe smoker having possession of cigarettes and lighters was they could burn themselves or injure others. The DON said to monitor the resident, they have the CNA's checking on Resident #80 and just yesterday a pack of cigarettes were pulled from her room and he believed they were there because the family had brought them directly to the resident despite being educated multiple times to ensure paraphernalia were brought to the nurses station. Observation on 03/17/22 at 8:10 a.m. of the washer and dryer in the 500 hall with ADON. Revealed a liquid soap, (Straplus Odor Blaster, the bottle is blue with a purple top and the volume is 1.7 gallons), was in the cupboard under the sink and the cupboard was open. Interview on 03/17/22 at 8:14 a.m. with ADON, she said the laundry supervisor was off and the laundry supply should not be left in the closet that allows residents easy access. She said it will be hazardous for a resident if it is swallowed and stated she will call the administrator as she doesn't have anything to do with laundry. she came back at 8:21 a.m. and stated the administrator said the surveyor could speak to the laundry supervisor over the phone regarding any findings. Observation and interview on 03/17/22 at 8:25 a.m. of the washer and dryer in the 100 hall with ADON. Revealed there was an open box of laundry detergent, (Gain, 2.8-pound box, had about 25% of detergent). ADON stated the same thing applied to residents in 100 hall as it did 500 hall. Telephone interview on 03/17/22 at 8:40 a.m. with the laundry supervisor. She stated that the laundry rooms on the 100 and 500 halls are for resident and family members who prefer to do their own laundry and the laundry chemicals are kept in the main laundry room and it is supplied to resident or family members when they want to do their laundry. Laundry chemicals are not supposed to be where residents can reach or have access to because they could get sick if they eat or drink the laundry soap. She said that all the laundry and housekeeping staff do random sweeps of the laundry rooms on the 100 and 500 hall washer rooms to make sure there is no washing chemicals randomly and that since we the surveyor found some no one must have checked that area. She said the firs staff member comes at 6:00 a.m. and the last staff member leaves at 7:00 p.m. and she was not sure why they did make rounds to make sure chemicals were in the proper place. Record review of the facility round checklist read . there are no chemicals with resident reach - unlocked closets, unlocked supply room, resident room, housekeeping cart, shower rooms, whirlpools . Record review of the facility's policy on smoking, not dated, revealed, resident who are assessed as not being able to smoke safely will not be allowed to smoke without supervision . If a resident exhibits dangerous behaviors with smoking The resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for them at the nurses station or other specified location . All personnel caring for residents with smoking restrictions will be altered to the interventions . Fall Hazards Record Review Resident #16's Face Sheet revealed resident is diagnosed with major depressive disorder, recurrent sever without psycho features, anxiety disorder, unspecified, unspecified abnormalities of gait and mobility, muscle weakness, unspecified lack of coordination. Record Review Resident #16's Care Plan dated 02/02/22. Resident has difficulty with decision making resident is diagnosed with mild cognitive impairment, at risk for falls Record Review of the Incident and Accidents Report dated from 09/16/22 - 03/14/22 revealed the facility had 73 resident falls and 10 found on floor residents. Record Review of the Fall - Resident Policy undated contained no pertinent information pertaining to the prevent of falls and/or fall risks. Record Review of the housekeeping Operations Policy undated revealed The following operations re basic in proper housekeeping: Wet Mopping: It is extremely important that clean equipment be used, clean mop, clean bucket and clean water, using specified disinfectant. Usually, the water will need changing every (4) rooms. The mop should be wet, then squeezed damp dry. Mop thoroughly a portion of the floor, and then rinse the mop in the solution again. The wet mop heads should be cleaned thoroughly after each use by soaking in a bleach-cleaner solution for a least one hour, then rinsed thoroughly and allow to dry. In an observation on 03/15/22 at 10:11 a.m. Housekeeper D mopping Resident #16's room, no wet floor signs posted. Resident #68 sitting in wheelchair inside the room. In an observation on 03/15/22 at 10:37 a.m. wet floor in Resident #16's room with no wet floor sign posted. Resident #16 was dressed wearing laced shoestringed shoes and standing at the far end of resident's room. Resident began walking towards the door and grabbed the foot of her bed after her feet began to slip on the wet floor. Resident walked around her bed and sat on the end of her bed closest to the door. In an observation on 03/17/22 at 10:16 a.m. Housekeeper D mopping wing 2. 9 wet floor signs placed outside 9 resident rooms. In an interview on 03/15/22 at 10:02 a.m. Resident #394 stated to be careful, a housekeeper just mopped her room floor. In an interview on 03/15/22 at 10:12 a.m. Housekeeper D stated she works the 1st shift Monday through Friday. She is responsible for emptying trash, mopping, and sweeping unit halls and resident rooms once a day or more as needed, and dustings blinds and bed rails as needed on wings 2 and 3. There are a total of 5 housekeepers on shift per day. She stated she did not use the wet floor sign after mopping wing 2, but she should have used it. She stated if residents are in their room when she comes to clean, she asks the residents may she enter to clean their room. If the resident allows housekeeping to enter, residents should either step out of the room or be in a seated or lying down position. The risk of a resident not sitting or lying down could result in falls and injuries. The risk of not placing wet floor signs during and after mopping could result in resident, staff, and visitor falls. In an interview on 03/15/22 at 10:37 a.m. Resident #16 stated that housekeeping just left out of her room from mopping, the floor is slippery, and she better sit down so she does not fall. In an interview on 03/18/22 at 09:05 a.m. Housekeeping Supervisor stated that she has worked for the facility for 8 years. She stated that prior to cleaning a resident's room, housekeeping staff are to knock and ask if they can come in and clean their room. Residents not already lying-in bed or sitting are asked to have a seat or come out of the room and do an activity until the housekeeping mops and the floor dries. If resident's decline housekeeping's entry, the housekeeper is to circle back around and check in with the resident again. Wet floor signage is to be placed on the floor at all times during and right after mopping. Staff are to only mop half a hallway, allow it to dry and then mop the remaining half. She stated that the facility uses a mopping solution and disinfectant floor cleaner. It is label 200 produced by the company Autoclo. The standard practice and recommended use of the dispenser is predetermined. the staff push the mounted solution and place a hose in their mop bucket and the devise mixes the correct amount of solution to water mix. The staff do not control the water to solution ratios. She stated that the mopping solution once placed on the floor is very slick. The facility recently replaced tile with new floor planks. When the humidity in the air is high, the slickness of the floor is greater since the new floor planks have been placed. The Administrator has been made aware of the [NAME] than normal floors after mopping. In an interview on 03/18/22 at 01:48 p.m. Administrator stated that housekeeping is to announce to resident upon entering a resident's room that they are there to clean and mop. Administrator stated that no mopping is to take place if the resident is standing or walking around the room. The housekeeper should ask the resident to step out and asking nursing staff for assistance if the resident is uncooperative or has difficulty understanding. A resident is not to be in the room walking around while housekeeping is mopping. Otherwise, mopping is not permitted. Wet floor signs should be placed on the hall and in the freshly mopped rooms to alert residents and staff to be cautions and careful of the wet floor. Chemical Hazards Observation on 03/17/22 at 8:10 a.m. of the washer and dryer in the 500 hall with ADON, Revealed a liquid soap (Straplus Odor Blaster, the bottle is blue with a purple top and the volume is 1.7 gallons), was in the cupboard under the sink and the cabinet was open. Interview on 03/17/22 at 8:14 a.m. with ADON; she said the laundry supervisor was off and the laundry supply should not be left in the closet that allows residents easy access. She said it would be hazardous for a resident if it is swallowed and stated she would call the administrator as she doesn't have anything to do with laundry. She returned at 8:21 a.m. and stated the administrator said the surveyor could speak to the laundry supervisor over the phone regarding any findings. Observation and interview on 03/17/22 at 8:25 a.m. of the washer and dryer in the 100 hall with ADON, Revealed there was an open box of laundry detergent (Gain, 2.8-pound box, had about 25% of detergent). ADON stated the same thing applied to residents in 100 hall as it did 500 hall. Telephone interview on 03/17/22 at 8:40 a.m. with the laundry supervisor. She stated that the laundry rooms on the 100 and 500 halls are for residents and family members who prefer to do their laundry, and the laundry chemicals are kept in the main laundry room. It is supplied to assist residents or family members when they want to do their laundry. Laundry chemicals are not supposed to be where residents can reach or have access because they could get sick if they eat or drink the laundry soap. She said that all the laundry and housekeeping staff do random sweeps of the laundry rooms on the 100 and 500 hall washer rooms to make sure there are no washing chemicals randomly, and since the surveyor found some, it meant no one had checked that area. She said the first staff member comes at 6:00 a.m., and the last staff member leaves at 7:00 p.m. She was unsure when they made the previous rounds to ensure certain laundry chemicals were in the proper place. Record review of the facility round checklist read, . there are no chemicals with resident reach - unlocked closets, unlocked supply room, resident room, housekeeping cart, shower rooms, whirlpools .

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 7 of 7 residents (Resident #4, Resident 17, Resident #55, Resident #59, Resident #64, Resident #91, Resident #345) reviewed for quality of care. - The facility failed to set orders and to ensure that pre-prandial insulin, (insulin that should be administered within 5-20 minutes before meals) was administered at 6 AM, 2 hours before the breakfast meal for Resident #4 and Resident #64. - The facility failed to administer sliding scale insulin timely before meals as ordered by the physician for Resident #4, Resident #17, Resident #59, Resident #91, and Resident #345 by administering it before 6 AM, 2 hours before the breakfast meal. - The facility failed to administer Insulin as ordered by the physician to Resident #55 when her BG was greater than 200. - The facility failed to manage Resident #4, Resident #55, Resident #65 and Resident #91's pre-prandial insulin resulting in increase in HbA1c, a lab value that represents a 3 month average of blood glucose. These failures could place residents receiving insulin at risk for hypoglycemic episodes, increased HbA1c hospitalization , and/or death. Resident #4 Record review of Resident #4's face sheet dated 03/16/22 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: stage 2 CKD, type 2 diabetes with diabetic [CONDITION(S)](deterioration of kidney function). Record review of Resident #4's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, extensive assistance with most ADLs, and frequently incontinent of both bladder and bowel. Record review of Resident #4's Care Plan started 03/11/21 revealed, Area- diabetes type 2 uncontrolled blood sugars, Goal- A1c will by below 6, Intervention- Administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #4's A1c Lab results revealed: -04/21/21 was 8.7%, -08/17/21 was 8.4%, and -02/15/22 was 9.9%. Interview on 03/17/22 at 1:05 PM, Resident #4 said the nurses checked his blood sugar in the morning at 5:00 AM and gave him his insulin. He said his blood sugar went up to 600mg/dl before he came to the facility and he does not feel different, but it has been up to 500mg/dl when he was in the facility. Record review of Resident #4's Physician Order dated 01/20/22 revealed, Type 2 diabetes mellitus with diabetic [CONDITION(S)], accucheck (finger stick blood glucose reading) QAM with [MEDICATION(S)] [MEDICATION(S)] s/s, with administration time code of 5:30 AM. 0-200 = none, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD. Record review of Resident #4's January 2022 MAR for [MEDICATION(S)] revealed: 05:30 AM -01/21/22 BG-225, 2 units RLQ, 01/25/22 BG-335 6 units LUQ, 01/26/22 BG-450, 10 units LUARM. 01/27/22 BG-356, 8 units RUARM. 01/29/22 BG 353- 8 units LLQ. 01/30/21 BG-221, 2 units RLQ. Record review of Resident #4's February 2022 MAR for [MEDICATION(S)] revealed: 5:30 AM -02/02/22 BG-256, 4 RUQ. 02/06/22 BG 202, 2 units left thigh. 02/08/09 BG 240- 2 units right thigh. 02/09/22 BG-209, 2 units RLQ. 02/11/22 BG-397, 8 units LUQ. 02/15 BG-274, 4 units RUARM. 02/16/22 BG-301, 6 units LLQ. 02/18/22 BG-214, 2 units RLQ. 02/22 BG-279, 4 units LUQ. Record review of Resident #4's March 2022 MAR for [MEDICATION(S)] revealed, 5:30 AM -03/01/22 BG 202- 2 units RUQ. 03/02/22 BG-213, units unknown LLQ. 03/03/22 BG-320, 6 units LUARM. 03/4/22 BG-300, 4 units LUQ. 03/07/22 BG-361, 8 units LLQ. 03/08/22 BG-270, 4 units. 03/11/22 BG-324, 6 units RLQ, 03/11/22 BG-203, 2 units left mid-thigh, 03/12/22 BG-336, 6 units RUARM. 03/15/22 BG-391, 8 units LUQ. 03/16/22 BG-302, unknown units LLQ. Record review of Resident #4's Physician Order dated 01/20/22 revealed, [MEDICATION(S)] 100 unit/mL Kwikpen give 5 units SQ daily in AM Hold for BS <80 with administration time codes of 6 AM. Record review of Resident #4's January MAR for [MEDICATION(S)] Kwikpen revealed: Resident received 5 units at 6 AM on 01/03/22, 01/07/22, 01/08/22, 01/15/22 and 01/18/22, 01/21/22, 01/25/22, 01/26/22, 01/27/22, 01/29,22, 01/30/22, 01/31/22. Record review of Resident #4's February MAR for [MEDICATION(S)] revealed: Resident received 5 units at 6 AM on 02/02/22 to 02/11/22, 02/13/22, 02/15/22 to 02/19/22, 02/22/22 to 02/24/22, 02/26/22 and 02/27/22. Record review of Resident #4's February MAR for [MEDICATION(S)] revealed: Resident received 5 units at 6 AM on 03/02/22, 03/04/22, 03/06/22, 03/7/22, 03/11/22, 03/12/22, 03/15/22, 03/16/22. Resident #17 Record review of Resident # 17's face sheet dated 03/16/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes without complications. Record review of Resident #17's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, supervision with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #17's Care Plan with start date of 11/5/2019 revealed, Area- Diabetes Mellitus, Goal- will have blood glucose within normal range, Intervention- Administer insulin as ordered. Record review of Resident #17's A1c Labs revealed: -10/12/20 was 8.7%, 12/18/20 was 8.4%, 01/11/21 was 8.6%, 05/12/21 was 5.9%, 07/21/21 was 7.7%, 10/19/21 was 7.7%, and 01/18/22 was 7.5%. Record review of Resident #17's Physician Orders dated 08/16/21 revealed, Type 2 diabetes mellitus without complication accucheck twice daily with [MEDICATION(S)] 100 units/mL vial per s/s with administration time codes of 6AM and 4PM. 0-250 = 0 units, 251-400=3 units, >400= call MD for orders. Record review of Resident #17's January 2022 MAR revealed: 6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250. 4 PM- 01/02/22 BG-256, 3 units LLQ. 01/03/22 BG-342, 3 units RUARM. 01/09/22 BG-254, 3 units RUARM. 01/11/22 BG-280, 3 units LUARM. 01/18/22 BG-266, 3 units LUARM. 01/19/22 BG-251, 3 units RUARM. 01/21/22 BG-262, 3 units RUARM. 01/22/22 BG-251, 3 RUARM. 01/24/22 BG-311, 3 units RUARM. 01/25/22 BG-268, 3 units LUARM. 01/26/22 BG-252, 3 units RUARM, 01/31/22 BG-318, 3 units LLQ. Record review of Resident #17's February 2022 MAR revealed: 6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250. 4 PM- 02/01/22 BG-275, 3 units RUARM. 02/11/22 BG-332, 3 units RUARM. Record review of Resident #17's March 2022 MAR revealed: 6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250. 4 PM- 03/04/22 BG-261, 3 units LLQ. Resident #55 Record review of Resident #55's face sheet dated 03/16/22 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: [CONDITION(S)] of the left lower limb, type 2 diabetes without complications. Record review of Resident #55's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #55's Care Plan with start date 11/22/21 revealed, Area- Diabetes Mellitus, Goal- A1c will be below 6 through next review, Intervention- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #55's A1c Labs revealed: 08/24/20 was 5.9%, 11/23/20 was 6%, 02/21/21 was 8.7%, 05/24/21 was 8.3%, 08/16/21 was 7.4%, and 02/21/22 was 9.5%. In an interview on 03/17/22 at 01:07 PM, Resident #55 said she did not receive any insulin. Record review of Resident #55's Physician Orders dated 12/02/19 revealed, type 2 diabetes mellitus without complications accucheck everyday with PRN [MEDICATION(S)] SQ per sliding scale. 0-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD Record review of Resident #55's January 2022 MAR revealed, on 01/31/22 the resident had a BG of 233 but she did not receive 2 units of Insulin as ordered. Record review of Resident #55's February 2022 MAR revealed, on 02/07/22 BG of 204, 02/14/22 BG of 252, 02/21/22 BG of 220, 02/28/22 BG of 249. Resident #55 did not receive any insulin per her sliding scale as ordered by her physician Record review of Resident #55's March 2022 MAR revealed, on 03/07 BG of 250, 03/14/22 BG of 245. Resident #55 did not receive any insulin per her sliding scale as ordered by her physician. Resident #59 Record review of Resident #59's face sheet dated 03/16/22 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: polyneuropathy, type 2 diabetes with unspecified complications and [CONDITION(S)]. Record review of Resident #59's Quarterly MDS dated [DATE] revealed, moderately impaired cognition, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of Resident #59's Care Plan started 02/05/20 revealed, area- type 2 diabetes uncontrolled blood sugars, goal- A1c will be below 6% and have no complications through next review. Intervention- Administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #59's HgbA1c Labs revealed: 07/16/21 was 7.9%, 10/01/21 was 7.9%, and 01/07/22 was 7.9%. Record review of Resident #59's Physician Order dated 01/21/20 revealed, Type 2 diabetes with unspecified complications, Accucheck BID before meals with [MEDICATION(S)] 100 unit/ml vial per s/s with time codes for administration at 6 AM and 4 PM.0-60 0 units 60-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD Record review of Resident #59's March 2022 MAR revealed, 4 PM 03/01/21 BG-229, 2 units RUARM. 03/06/21 BG-272, 4 units LUARM. 03/08/21 BG-217, 2 units LLQ. 03/14/22 BG-260, 4 units LLQ. Resident #64 Record review of Resident #64's face sheet dated 03/16/22 revealed, [AGE] year-old-female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes with other diabetic neurological complications. Record review of Resident #64's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, limited assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of Resident #64's Care Plan started 10/12/21 revealed, area- diabetes, goal- A1c will be below 6%, intervention- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #64's HgbA1c Labs revealed: - 04/15/21 was 6.6%, - 08/02/21 was 10.3%, and - 02/07/22 was 11%. Record review of Resident #64's Physician Orders dated 02/06/22 revealed, [MEDICATION(S)] 100 units/mL. Give 12 units SQ BID. Hold for BS less than 80 with administration time codes of 6 AM and 6 PM. Record review of Resident #64's progress notes revealed, the resident had diabetic ulcers on both heels that were acquired in the facility. Record review of Resident #64's wound assessment report, dated 03/15/2022, stated, made aware of new skin concerns by staff . noted diabetic ulcer to right heel. Blood blistered site measures 2.0 cm by 3.5 cm, skin remains intact at this time . Noted diabetic ulcer to left heel. Area maroon in color. Site measures 3.0 cm by 2.5 cm, skin intact . Record review of Resident #64's March 2022 MAR revealed, resident received 10 units at 6 AM from 03/01/22 to 03/16/22 and 10 units at 4 PM from 03/01/22 to 03/15/22. Resident #91 Record review of Resident #91's face sheet dated 03/16/22 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: [CONDITION(S)] of the upper limb, hypertension, progressive [CONDITION(S)] (damage to one or more nerves that result in numbness, tingling, muscle weakness pain in the affected area) and type 2 diabetes with other circulatory complications. Record review of Resident #91's MDS dated [DATE] revealed, severely impaired cognition, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #91's Care Plan started 05/05/21 revealed, area- diabetes with diabetic polyneuropathy, goal- A1c will be below 6, intervention-administered oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #91's HgbA1c labs revealed: - 04/26/21 was 4.9% and - 02/08/22 was 7.1%. Record review of Resident #91's Physician Orders dated 02/04/22 revealed, Type 2 diabetes with diabetic polyneuropathy, Accucheck BID AC with [MEDICATION(S)] 100 unit/ml vial per s/s with time codes for administration at 6 AM and 4 PM. 60-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD. Record review of Resident #91's March 2022 MAR revealed: 6AM 03/01/22 BG-221, 2 units right lower, 03/02/22 BG-266, 4 units LLQ, 03/03/22 BG- 215, 2 units RLQ, 03/04/22 BG-301, 6 units RLQ. 03/05/22 BG-266, 4 units RLQ, 03/06/22 BG-274, 4 units RLQ, 03/07/22 BG-362, 8 units RLQ, 03/08/22 BG-355, 8 units LLQ, 03/09/22 BG-318, 6 units RUARM, 03/10/22 BG- 319, 6 units LLQ, 03/11/22 BG-391, 8 units RLQ, 03/12/22 BG-350, 6 units RLQ. 03/13/22 BG-424, 10 units LUQ, 03/14/22 BG-286, 4 units LUQ. 03/15/22 BG-342- left thigh, 03/16/22 BG, 396 right thigh. 4PM- 03/01/22 BG-250, 2 right upper arm, 03/02/22 BG-203, 2 units LLQ, 03/03/22 BG- 305, 6 units LLQ, 03/04/22 BG-241, 2 units LLQ. 03/05/22 BG-316, 6 units LLQ, 03/06/22 BG-417, 10 units LLQ, 03/07/22 BG-321, 6 units RUARM, 03/08/22 BG-323, 84 units LUARM, 03/09/22 BG-324, 6 units RUARM, 03/10/22 BG- 319, 6 units LLQ, 03/11/22 BG-309, 6 units LLQ, 03/13/22 BG-308, 6 units RLQ, 03/14/22 BG-364, 8 units RUQ. Resident #345 Record review of Resident #345's face sheet dated 03/16/22 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, hypertension and [CONDITION(S)] without behavioral disturbance. Record review of Resident #345's Admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 15, limited assistance for all ADLs and always continent of bladder and occasionally incontinent of bowel. Record review of Resident #345's Care Plan started 03/02/22 revealed, Area- diabetes Mellitus (type 2): uncontrolled blood sugar levels, goal- A1c ( a % that represents a 3 month average of blood sugars) will be below 6%, interventions- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin. Record review of Resident #345's HgbA1c Lab revealed: - 03/16/22 was 8.8%. Record review of Resident #345's Physicians Orders dated 03/06/22 revealed, Accucheck BID AC with [MEDICATION(S)] 100 unit/mL vial per s/s with Time Codes of administration at 6 AM and 4 PM. 0-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD. Record review of Resident #345's March 2022 MAR revealed: 6AM: 03/12/22 BG-215, 2 units Left thigh, 03/16/22 BG-209 2 units right upper quadrant. 4 PM: 03/07/22 BG-221 2 units, left upper arm. 03/08/22 BG-272, 4 units right lower quadrant. 03/09/22 BG-222, 2 units left upper arm. 03/10/22 BG-382, 8 units right upper quadrant. 03/12/22 BG-249 2 units, left lower quadrant. 03/13/22 BG-259, 4 units left lower quadrant. 03/14/22 288, 4 units left lower quadrant. An observation at 03/16/22 at 07:25 AM revealed, LVN D shadowing LVN N at the nursing cart. LVN N said that there were no sliding scale insulins to administer that morning because they were already completed by the night shift prior to the beginning of her shift at 6 AM. She said that this was the time morning insulin was always administered. An observation at 03/16/22 at 08:20 AM revealed, meal tray carts arriving on the 600 hall. In an interview on 03/16/22 at 07:30 AM, the ADON said that all morning insulin's including sliding scale and pre-prandial insulin were completed by the night shift and that insulin administration was not in relation to meals but was scheduled for 6AM and 4 PM. She said breakfast was normally around 8 am and that residents had snacks available to them between 6 am and 8 am. The ADON said that when administered insulin earlier than meals the expectation was for them to monitor the residents for signs and symptoms of [CONDITION(S)]. In an interview on 03/16/22 at 07:44 AM, LVN R said that she had no insulin to administer that morning because it was completed by the night shift prior to her arrival at 6 am. She said that this was the time morning insulin were always administered. In an interview on 03/16/22 at 08:25 AM, LVN D said that sliding scale insulin should be administered when you know the resident's tray is arriving and she would not administer them 2 hours before meals because it could place the resident at risk for [CONDITION(S)]. She said the facility had night shift nurses complete morning insulin administration before the morning shift started at 6 AM. In an interview on 03/16/22 at 11:22 AM, the Physician said that the facility night shift nurses had been administering pre-prandial insulin because it was easier to get it done. He said while there was a risk of [CONDITION(S)] if pre-prandial insulin was administered without a meal the facility used low sliding scale doses to avoid [CONDITION(S)], so they have had no problems. The Physician said that pre-prandial insulin should be administered closer to meals and not at 2 hours before a meal but would not give a narrower timeframe. He said for LTC patients his goal was for an A1C <8 % which is an average glucose around 183. In an interview on 03/16/22 at 02:00 PM, the DON said that pre-prandial insulin ([MEDICATION(S)] and [MEDICATION(S)]) are dosed per sliding scale in anticipation of increased blood glucose levels when a resident eats and that at most they should be administered close to a meal but no longer than 1 hour before. He said the risk of uncontrolled/ill managed blood sugars was [CONDITION(S)], impaired wound healing, and any condition which a consequence of uncontrolled blood sugars. In an interview on 03/18/2022 at 12:50 PM, the DON said [MEDICATION(S)] insulin peaks within 1 hour and continues to work within 2-4 hours, and if a resident had not eaten within that first hour, the resident would need to be watched for hypoglycemic effects such as nausea and vomiting and change in mental status. He said there was the need to balance the effect of the insulin with the timing of meals to keep blood glucose levels stable. He said each resident with diabetes is clinically different, some are stable, some are regular, for some insulin would need to be held if not eating, and some need to be monitored for symptoms. The DON said some people can become chronically hyperglycemic with the insulin. He said the goal was to keep resident blood glucose levels as normalized as possible to track trends and know when to adjust their diabetes management regimen and medication. The DON said those with diabetes generally have a risk for wounds and decreased healing abilities. Record review of the Package Insert for [MEDICATION(S)] revealed: Dosage and Administration- Subcutaneous injection: Inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm. Record review of the Package Insert for [MEDICATION(S)] revealed, Dosage and Administration- Subcutaneous injection: Administer [MEDICATION(S)] U-100 or U-200 by subcutaneous injection into the abdominal wall, upper arm or buttocks within 15 minutes before a meal or immediately after a meal. Record review of the facility posted Meal Times revealed: Hall Carts -Breakfast 07:15 AM, Lunch 11:15 AM, Dinner 05:15 PM Dining Room- Breakfast closed, Lunch 11:30 AM, Dinner 05:30 PM Not times for snacks were documented on the document. Record review of the facility policy titled Medications- Administering with no revision date revealed, 3- medications must be administered in accordance with the orders including any required time frame. 4- Medications must be administered within one(1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Record review of American Diabetes Association Standards of Medical Care in Diabetes-2021 revised 01/2021 revealed: 6- Glycemic Targets. Table 6.1-Estimated average glucose A1C (%) to mg/dL 5% ~ 97 (76-120) 6% ~ 126 (100-152) 7% ~ 154 (123-185) 8% ~ 183 (147-217) 9% ~ 212 (170-249) 10% ~ 240 (193-282) 11% ~ 269 (217-314) 12% ~ 298 (240-347) 12-Older Adults. Table 12.1 Patient Characteristic- Complex, Reasonable A1C goal <8.0% = Fasting or pre-prandial glucose goal of 90-150 mg/dL, bedtime glucose goal 100-180mg/dL.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6 %, based on two errors out of 32 opportunities, which involved 2 of 7 residents (Resident #6 and Resident #344); and 3 of 5 staff (RN L, MA C, MA S) reviewed for medication errors. The facility failed to ensure - LVN R did not administer medication [MEDICATION(S)] (PEG-3350), a stool softener, that was labeled for another resident . - CMA A administered the correct medication to Resident #344 by applying a [MEDICATION(S)] 5% patch instead of [MEDICATION(S)] 4% as ordered by the physicians These failures could place all residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Resident #6 Record review of Resident #6's face sheet dated 03/16/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognition skills, disorganized thinking, and always incontinent of both bladder and bowel. Record review of Resident #6's care plan dated 02/15/22 revealed, Area- experiencing constipation, always incontinent of bowel. Goal- will have a bowel movement every 1 to 3 days without complications, no skin breakdown from incontinence. Intervention- assess for constipation/impaction, assess for abdominal distention, administer [MEDICATION(S)] or stool softener as ordered. Record review of Resident #6's Physician Orders dated 10/27/21 revealed, [MEDICATION(S)] 17 gm- 1 capful, mix with 6 OZs of water by mouth twice daily. An observation on 03/16/22 at 07:44 AM, revealed LVN R preparing [MEDICATION(S)] and 5 solid form medication, capsules, and tablets for Resident #6. She retrieved a bottle of [MEDICATION(S)] labeled for another resident, measured 17 grams by pouring the powder into the cap, and emptied the contents of the cap into a cup. LVN R poured 6 ounces of water into the cup containing the powdered [MEDICATION(S)], dissolving the medication into the water. She crushed the pills and opened the capsule emptying its contents and mixed the medications in with pudding. LVN R retrieved the medications and began to enter into the resident's room before she was stopped by the surveyor. The surveyor asked LVN R if the bottle of [MEDICATION(S)] was for Resident #6 and she after inspecting the bottle said no that it belonged to another resident. She said that she thought the bottle she used was a stock bottle and did not belong to another resident. After confirming that the [MEDICATION(S)] she prepared was from another resident's prescription, LVN R entered into Resident #6's room and administered the crushed medications as well as the [MEDICATION(S)] dissolved in water that was made from a prescription bottle that did not belong to Resident #6. In an interview on 03/16/22 at 07:45 AM, LVN R said that staff should only administer medication from a resident's prescription bottle or a stock bottle and never from another resident's prescription bottle. She said that when she prepared the medication, she was using a facility stock bottle and she should have discarded the medication even though it was the same medication once she was alerted by the surveyor. LVN R said she should have reprepared the [MEDICATION(S)] from Resident #6's prescription bottle or the facility floor stock bottle if necessary. LVN R said administering medications from the wrong resident's prescription bottle placed residents at risk for medication errors due to administration of the wrong strength or wrong medication . Resident #344 Record review of Resident #344's face sheet dated 03/16/22 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #344's Admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 15, no behavioral symptoms, extensive assistance with most ADLs, always continent of bladder and always incontinent of bowel. Record review of Resident #344's Care Plan started 03/18/22 revealed, area- requires assistance with ADLs, goal- increased independence, intervention- refer to OT/PT/SF if needed. Record review of Resident #344's Physician Orders dated 02/28/22 revealed, [MEDICATION(S)] 4% patch apply one patch to lower back daily: on at 8AM off at 8PM. An observation on 03/16/22 at 09:50 AM revealed, CMA B preparing medication for administration to Resident #344. She retrieved a [MEDICATION(S)] 5% patch from a bag labeled with Resident #6's biographical information, she did not check the drug information against the MAR. CMA B entered into Resident #344's room and applied the [MEDICATION(S)] 5% patch to the residents lower back. In an interview on 03/16/22 at 12:52 PM, CMA B said prior to medication administration nursing staff should check the name, dosage, and medication against the resident's orders; and if the orders did not match the medication the resident's physician should be contacted to clarify the order. She said did not notice that the patch she applied was [MEDICATION(S)] 5% and not [MEDICATION(S)] 4% as ordered by Resident #344's physician. She said that she had non-prescription [MEDICATION(S)] 4% patches in her cart but the [MEDICATION(S)] 5% patch she applied was dispensed by the pharmacy specifically for Resident #344 and it must have been a filling error made by the pharmacy. CMA B said by administering the [MEDICATION(S)] 5% patch instead of the [MEDICATION(S)] 4% patch the resident was at risk of unwanted therapeutic effect . In an interview on 03/16/22 at 01:30 PM, the DON said that the nursing staff are expected to verify the resident's Physician Order prior to administration to make sure it is the right medication, right resident, right drug as well as assuring parameters of administration such as vitals are met. He said it is never appropriate to dispense medications labeled for one resident to another even if the medication is the same. The DON said administering residents the wrong strength of medication and medication from another resident's container are medication errors that can place residents at risk for cross contamination and adverse effects. Record review of the facility policy titled Medications- Administering with no revision date revealed, 3- Medications must be administered in accordance with the orders, including any required time frame.7- The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 19- Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 out of 3 medication carts ( Station 1 Nursing Cart, Station 1 Medication Aide Cart and Station 2 Medication Aide Cart) reviewed for medication storage. - The facility failed to ensure that the Station 1 Nursing Cart did not contain expired medication, and proteins supplements outside of the manufacturer's specified beyond use date. - The facility failed to ensure that the Station 1 Medication Aide Cart did not contain medication stored outside of manufacturers specified temperature ranges, medication with no visible expiration dates and expired protein supplements - The facility failed to ensure that the Station 2 Medication Aide Cart did not contain medications stored outside. These failures could place residents receiving medications at risk of adverse medication reactions. Findings include: Station 1 Nursing Cart In an observation and Interview on 03/16/22 at 12:30 PM, inventory of the Station 1 Nursing cart with LVN B revealed: - An open bottle of Liquid Protein with an open date of 10/10/21 with manufacturer instructions of 3-month shelf life from date opened (01/10/22). - An open and expired container of [MEDICATION(S)], a supplement used to increase the calorie and protein contents in most foods, with a manufacturer's expiration date of 02/01/22. LVN B said staff should check their carts daily for expired supplements and when supplements are expired they lose their efficacy so they should not be administered. She said all expired medications should be discarded in the drug disposal bin located in the medication storage room since the use of expired medications place resident's at risk for insufficient therapeutics. Station 1 Medication Aide Cart In an observation and Interview on 03/16/22 at 12:39 PM, inventory of the Station 1 Medication Aide Cart with CNA B revealed: - An open bottle of Acidophilus, a probiotic, at room temperature in the drawer with manufacturer instructions of Refrigerate After Opening. - An open bottle of Acetaminophen 500mg with no visible expiration date. - An open bottle of Aspirin 81mg with no visible expiration date. - An open bottle of Liquid Protein with an open date of 12/07/22 with manufacturer instructions of 3-month shelf life from date opened (03/07/22). CNA B said she did not know the bottle of Acidophilus had to be refrigerated and since it wasn't it could no longer be used. She said when refrigerated medication was left at room temperature it deteriorates and the bottles Acetaminophen and Aspirin did not have a visible expiration date she could not determine if they were expired so they could not be used. She said that all expired medications or medications without expiration medications should be discarded in the drug disposal bin located in the medication room since use of such medication places residents at risk of insufficient therapeutic effects. Station 2 Medication Aide Cart In an observation and interview on 03/16/22 at 12:47 PM, inventory of the Station 2 Medication Aide Cart with LVN N revealed: - An open bottle of Acidophilus, a probiotic, at room temperature in the drawer with manufacturer instructions of Refrigerate After Opening. LVN N said that nursing staff are expected to check their carts monthly for expired medications and medications stored outside of manufacturer specified temperature monthly. She said she did not know that the bottle of acidophilus had to be refrigerated and when refrigerated medication is stored at room temperature it can deteriorate so it could not be used. LVN N said that the bottle of acidophilus had to be discarded in the drug disposal bin located in medication room. In an Interview on 03/16/22 at 01:30 PM, the DON said that nursing staff are expected to check their carts on their shifts daily for loose pills, expired medications, inappropriately labeled medications and medications stored out of specified manufacturer temperature ranges. He said that all refrigerated medications should be stored as specified by the manufacture and that storage outside of the refrigerator could deteriorate. The DON said if a medication does not have a visible expiration date the assumption is that it is expired and all inappropriately labeled, expired or inappropriately stored medications should be immediately taken out of circulation and discarded in the drug disposal bin located in the Medication Storage room. He said when a medication expires or are stored at the wrong temperature they can deteriorate/experience a change in concentration and use places residents at risk for insufficient therapy. Record review of the facility policy titled Medications- Storage with no revision date revealed, 3- Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4- The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 9- Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 staff and 1 of 1 laundry rooms. The facility failed to ensure: - CNA AG, Cook C and Dietary Manager wore their face mask according to policy. - Cook C did not wear a hairnet or beard restraint according to policy. -- CNA AG followed proper hand hygiene and infection control precautions while she filled residents' water cups. - LVN R followed proper hand hygiene and infection control precautions while providing foley catheter flush and insertion for Resident #22. - Laundry Aide B demonstrated proper hand hygiene after loading dirty linen in the laundry. - Laundry Aide B did not place basket of dirty linen in the clean side of the laundry room. - staff did not place their personal items on the clean linen folding table. These failures could place residents at risk of cross contamination and infection. The finding included: Observation on 3/15/2022 at 9:00 a.m., Cook C did not have on a hair net or beard restraint. Cook C's mask was below his chin not covering his nose and mouth. Interview on 3/15/2021 at 9:10 a.m., Cook C said the hair net would prevent cross-contamination and he forgot to put it on. Cook C said he had his mask down below his chin because it was hot in the kitchen. Cook C said he had to wear the mask because of COVID-19 and the mask stopped the spread. He said he had never worn a beard restraint Observation on 3/15/2022 at 9:37 a.m., CNA AG wheeled a resident to a common area with her mask below her chin. Observation of 3/15/2022 at 9:39 a.m., CNA AG went into 3 different rooms (4 different cups) and filled the resident water cups. CNA AG did not wash her hands or sanitize her hands after touching multiple resident cups or as she went in and out of the ice chest to refill the cups. Interview on 3/15/2022 at 9:41 a.m., CNA AG said she was supposed to sanitize or wash her hands in between filling water cups or going in the ice chest. CNA AG said not sanitizing hands will lead to cross contamination. She said she had been trained on proper hand hygiene but forgot. Interview on 3/15/2022 at 11:37 a.m., the Dietary Manager said all dietary staff should wear a hair net if they have hair because it is the rule and prevents cross-contamination. The Dietary Manger said he and the other dietary staff had not worn beard restraints because they did not have any to use. He said he and the staff never used them. The Dietary Manager said all dietary staff have been trained to wear their mask to cover their mouth and nose. The Dietary Manager said a mask should be worn to prevent the spread of COVID-19. Interview on 3/17/2022 at 2:52 p.m., the Administrator said, she expected dietary staff to wear hair nets and beard restraints. She said beard restraints and hair nets are used to prevent cross-contamination. The Administrator said all staff have to wear a mask when they are in the building. She said all staff wear mask to prevent the spread of COVID-19. The Administrator said all staff are expected to perform hand hygiene when they have touched resident items. The Administrator said the staff should wash or sanitize their hands to prevent cross-contamination. Resident #22 Record review of Resident # 22's Face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #22's quarterly MDS dated [DATE] revealed a 99 (resident was unable to complete interview for mental status), and the resident required limited assist with one staff assistance. It also revealed the resident has indwelling foley catheter. Record review of Resident #22's care plan dated 10/23/20 revealed the resident had urinary indwelling catheter related to [CONDITION(S)] (urinary bladder problems due to disease or injury of the central nervous system ), and [CONDITION(S)] ([CONDITION(S)]). Interventions: assess color, clarity, character of urine and catheter care every shift. Record review of Resident #22's March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 03/15/21 at 1:40 p.m., LVN R was walking towards Resident #22 room she had a bottle of NS and 60 ML syringe in her hand. She then placed it in her uniform pocket. Observation and interview on 03/15/2 2 at 1:45 p.m., Resident #22's Foley flush provided by LVN R, she walked into the resident's room, took the NS and syringe from her uniform pocket, and placed it on the resident bedside table. She went into the resident restroom, took some gloves from the packet, and put it in her uniform pocket; on getting to the resident bed, she took a pair of gloves from her pocket and donned the gloves, and she did not wash her hands or sanitize her hand, she opened the syringe and NS, drew up 30 Milliliters. Observation on 03/15/22 at 2:05 p.m., LVN R carried the supplies in her two arms against her breast into the Resident #22's room. Observation and interview on 03/15/22 at 2:08 p.m., Resident #22 Foley catheter change provided by LVN R. she placed the supplies on the resident table without disinfecting the bedside table. Some part of the table was wet. She went to the resident restroom, took more gloves, and put them in her uniform pocket. She deflated the catheter in the resident, and she pulled it out, a long string of blood clots came out with the catheter, and she left it on the resident bed linen for 5 minutes before she placed it in the red bag. LVN R did not take off the gloves; she removed the catheter and put it in the trash bag before opening the new 16 French catheter. She left the room and came back to the room. She did not wash or sanitize her hands none of the four times she left and came back to the room. She donned the sterile gloves without washing her hands. While donning the gloves, she touched the outside of the sterile gloves instead of the inside. She took off her gloves after the procedure, washed her hands, and turned off the water faucet with her wet hands, she did not disinfect the resident table after use. Interview on 03/15/22 at 2:50 p.m., LVN R said she did not wash her hands when she went into the resident room and when she left Resident #22's room several times. LVN R said staff is supposed to wash or sanitize their hands upon entering and leaving the resident's room. She said she should have washed her hand when she donned the sterile gloves because the Foley insertion was an aseptic procedure, and the catheter was not supposed to touch the resident table because that part goes into the resident. She said she also did not disinfect the resident bedside table before and after use, and she did not place a barrier on the table before setting up her supplies. LVN R said she forgot to turn off the water tap with a dry paper towel instead of her wet hands. LVN R stated supplies for resident care are not carried on staff body or in staff uniform pocket, but in a clean trash bag. She also said gloves are not placed in a staff pocket or used during care, and all these mistakes were infection control issues because she could have transferred germ from her to the resident, and it could cause harm to the resident, such as [CONDITION(S)]. Interview on 03/16/22 at 2:08 p.m., ADON (RN) said LVN R should not have carried the supplies for a procedure in the staff uniform pocket or on her body. She said she should have washed her hands, introduced herself, and told the resident about the procedure. She should have disinfected the bedside table and placed a barrier on the table. LVN R should have taken off her gloves and washed her hands as many times as she left the room and came back. The ADON said LVN R should have washed her hand before she donned the sterile gloves because it was an aseptic procedure to prevent microorganism transmission to the resident bladder, which could cause [CONDITION(S)] and pain. She said when she washed her hands, she should have dried her hand and turned off the tap with a dry paper towel to prevent reinfection (cross-contamination) of her hand. She was supposed to wipe the resident's table and put it back where she found it. Interview on 03/17/22 at 8:50 a.m., the DON said LVN R should have washed her hands before trying to don the sterile gloves because it is a sterile technique, and she should have washed her hands when she entered the resident's room and when she left the room. He said nurses are not supposed to carry gloves in their uniform pockets or use them to provide care for residents. Also, water faucets are turned off after handwashing with a paper towel, not with a wet, washed hand. All these are done to prevent cross-contamination or transfer germs to the resident that may cause harm to the resident. Interview on 03/17/22 at 8:59 a.m., the corporate nurse said the nurse should wash her hands with soap and water or sanitize them before donning the sterile gloves to prevent contamination because it is a sterile procedure. By not washing her hands, she contaminated the aseptic procedure, which could transfer germs to the resident and lead to a [CONDITION(S)]. Observation on 03/16/21 at 1:30 p.m., Laundry Aide B demonstrated how to wash her hand after sorting and loading the washer with dirty linen in the dirty side of the laundry room. She washed her hand and turned off the water faucet with her wet hands, then dried her hand with a paper towel. Interview on 03/16/21 at 12:38 p.m., Laundry Aide B said she turned off the faucet with her wet hands. Laundry Aide B stated she should have turned it off with a dry paper towel because the tap was dirty, and she contaminated her hands when she turned the tap with her wet hand, which is an infection control issue. Observation on 03/16/222 at 12:43 p.m., revealed a cart with four trash bags filled with dirty linen in the clean section of the laundry room. Laundry Aide B pushed it over from the clean to the dirty and moved the dirty linen into another cart. Laundry Aide B washed her hand again and turned off the water faucet with her wet hands. Observation on 03/16/22 at 1:44 p.m., revealed the clean folding table had personal staff items, a box of cornflake cereal, four plates, a Ziploc bag of sugar, and bread wrapped in a foil, snuggle bottle, and they were touching a stack of face towels, (about 20). Interview on 03/16/22 at 12:45 a.m., Laundry Aide B said she was not supposed to put the dirty laundry in the clean section of the laundry room because of cross-contamination. She said she used the same basket for clean and dirty laundry and only sprayed it down after using it for dirty laundry. She stated the items on the table did not belong to her, and she did not know the staff was not supposed to put their things on the clean table used to fold clean clothes. Laundry Aide A said all those items were on the table when she folded the clean linen she delivered to the halls, and she was not sure how much of the clean linen touched the personal items. Interview on 01/16/22 at 12:51 p.m., the Housekeeping Supervisor stated Laundry Aide B should not have turned off the water faucet with her wet hands and should have dried her hands first and then used a dry towel to turn off the tap to prevent cross-contamination. She also stated that dirty laundry bags are never placed in the clean side of the laundry room because of cross-contamination. She said if the laundry aide uses the same cart for dirt and clean linen, the carts must be sanitized (Sprayed with approved chemical, left to sit for the approved contact time, 5 minutes, sprayed again, and wiped before it is used for clean laundry). She said the folding table in the clean area is only used for clean linens, and personal staff items should not be on the table because it can contaminate the clean linens, which may transfer germs to residents and become sick. Interview on 03/16/22 at 1:40 p.m., the Regional Administrator and Administrator said Laundry Aide B should use a paper towel to turn off the tap to prevent contamination of her hands. She said dirty laundry should not be on the clean side of the laundry to avoid cross-contamination. The Administrator stated personal staff items should not be on the clean linen table to prevent contaminating the clean linen, which may transfer germs to residents and cause the residents to be sick. The Regional Administrator said he agreed with the response given by the Administrator. Record review of the facility Hand Hygiene policy updated [DATE] read . staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident . Hand Hygiene Table: . before performing resident care procedures . after handing contaminated objects . before and after handling clean or soiled linen . Record review of the facility Laundry policy updated [DATE] read . it is the policy of this facility to follow infection control methods related to washing clothes . policy expectation and compliance guidelines: . # 3 . soiled laundry shall be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons . #10 Linens: a. laundry and direct care staff shall handle, store, process and transport lines so as to prevent spread of infection . Record review of facility in-service dated 2/15/2022 revealed the following in part: All staff wearing surgical mask at all time while in facility . Record review of TFER (Texas Food Establishment Rules) dated 10/2015 revealed the following in part: §228.43. Hair Restraints . food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 of 4 residents (Resident #22) reviewed for indwelling urinary catheters. The facility failed to ensure LVN R followed proper hand hygiene and infection control precautions while providing foley catheter flush and insertion for Resident #22. This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of developing or increased UTIs. The finding included: Record review of Resident #22's Face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #22's quarterly MDS dated [DATE] revealed 99 (resident was unable to complete interview for mental status), the resident required limited assist with one staff assistance, and the resident had an indwelling foley catheter. Record review of Resident #22's care plan dated 10/23/20 revealed the resident had a urinary indwelling catheter related to [CONDITION(S)], and [CONDITION(S)] ([CONDITION(S)]). Interventions: assess color, clarity, character of urine and catheter care every shift. Record review of Resident #22's March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility infection control log from 11/15/21 through 03/15/21 did not reveal Resident #22 had a [CONDITION(S)] (Urinary tract infection). Observation and interview on 03/15/21 at 1:30 p.m., Resident #22 said he is having pain in his lower abdomen, and his catheter was changed this morning (03/15/22). Resident #22 said he had no urine coming out but had only this, and he showed his catheter leg bag, which had bright red blood. He said the bag had not been drained, and he did not pull on it either. He said he told the nurse about 30 minutes ago, and she said she would come back, and she had not come back. Interview on 03/15/22 at 1:35 p.m., LVN R said she was the nurse for Resident #22, HHSC surveyor informed LVN R about the resident's complaint of pain and blood in his foley bag. LVN R said she went and assessed the resident and saw blood in his foley bag and called the NP, she said she is waiting for the NP to call her back. She also asked the aide if she drained the resident's catheter bag, and the aide said she had not drained the foley bag this shift. Observation and Interview on 03/15/21 at 1:40 p.m., with LVN R, was walking towards Resident #22 room she had a bottle of NS and 60 ML syringe in her hand. She then placed it in her uniform pocket. She said the NP (nurse practitioner) called back and said to flush the foley catheter with 30 ML (milliliter) of NS (normal saline) and monitor. Observation and interview on 03/15/22 at 1:45 p.m., of Resident #22's Foley flush provided by LVN R, she walked into the resident's room, took the NS and syringe from her uniform pocket, and placed it on the resident bedside table. She went into the resident restroom, took some gloves from the packet, and put it in her uniform pocket; upon getting to the resident bed, she took a pair of gloves from her pocket and donned the gloves, she did not wash her hands or sanitize her hand. She opened the syringe and NS, drew 30 Milliliters, disconnected the Foley tubing, placed it on the resident bed linen, and flushed the catheter. The residents doctor walked in and told her to change the catheter; she took off the gloves and left the resident room without washing or sanitizing her hands. Observation on 03/15/22 at 2:05 p.m., LVN R carried supplies on her two arms against her breast into Resident #22's room. Observation and interview on 03/15/22 at 2:08 p.m., of Resident #22's Foley catheter change provided by LNV R. LVN R placed the supplies (2- 10 ML syringes,16 French catheter, a leg bag, straight catheter kit) on the residents table without disinfecting the bedside table, parts of the table was wet. She went to the resident restroom, took more gloves, and put them in her uniform pocket. She deflated the bulb in Resident #22's catheter and pulled it out, a long string of blood clots came out with the catheter, and she left it on the residents bed linen for 5 minutes before she placed it in the red bag. LVN R did not take off the gloves before opening the new 16 French catheter, she tried to open the lubricant for the catheter, but she opened the [MEDICATION(S)] packet, and she trashed the kit and took off her gloves and left the resident room without washing or sanitizing her hands. LVN R left the room four times because each time she tried to put on the sterile gloves, they tore , and she went out to get another kit, she did not wash or sanitize her hands either time she left the room. LVN R donned the sterile gloves without washing her hands. While donning the gloves, she touched the outside of the sterile gloves instead of the inside. She did not drape the resident with the sterile drape from the kit, she squeezed the lubricant on the sterile paper and inserted the tip of the catheter in the lubricant, and the other parts of the catheter were touching the table. LVN R swabbed the residents penis with the [MEDICATION(S)] and inserted the catheter. She inflated the balloon with 10 ML of normal saline; without any urine return, she waited for about ten minutes, and she was asked when the balloon should be inflated. She said the balloon is inflated after you see urine return, she said she thought she saw urine return. When she deflated the balloon, she advanced the catheter, and 250 ML of urine returned within a few minutes, and the resident said he felt better now and had no more pain. The color of the urine changed from bright red blood to very light hues. She took off her gloves, washed her hands, and turned off the water faucet with her wet hands, she did not disinfect the resident table after use. Interview on 03/15/22 at 2:50 p.m., LVN R said she did not wash her hands when she came into the resident room and when she left the resident room several times. LVN R said staff is supposed to wash or sanitize their hands upon entering and leaving the resident's room. She said she should have washed her hands when she donned the sterile gloves because the Foley insertion was an aseptic procedure, and the catheter was not supposed to touch the resident table because that part goes into the resident. She said she also did not disinfect the resident bedside table before and after use, and she did not place a barrier on the table before setting up her supplies. LVN R said she forgot to turn off the water tap with a dry paper towel instead of her wet hands. she stated supplies for resident care are not carried on staff body or in staff uniform pocket, but in a clean trash bag. She also said gloves are not placed in a staff pocket or used during care, and all these mistakes were infection control issues because she could have transferred germs from her to the resident, and it could cause harm to the resident, such as [CONDITION(S)]. She said she had her skill checkoffs on Foley insertion, hand washing, and infection control in-service. Interview on 03/16/22 at 2:08 p.m., with ADON (RN); she said LVN R should not have carried the supplies for a procedure in the staff uniform pocket or on her body. She said she should have washed her hands, introduced herself, and told the resident about the procedure. She should have disinfected the bedside table and placed a barrier on the table. She said catheter insertion is an aseptic procedure, and if it is broken, she should have started all over again. LVN R should have taken off her gloves and washed her hands as many times as she left the room and came back. ADON said LVN R should have washed her hand before she donned the sterile gloves because it was an aseptic procedure to prevent microorganism transmission to the resident bladder, which could cause [CONDITION(S)] and pain. She said she should not have inflated the balloon without seeing any urine return, especially when the resident has complained of pain. She said when you see urine return, the catheter should be advanced a little more, inflate the balloon, and pull back to make sure the ball is in place to hold the catheter and allow the urine to drain appropriately. She said all nurses have skill checkoffs on Foley insertion before they start working on the floor by themselves and working with residents who have a Foley. She said when she washed her hands, she should have dried her hands and turned off the tap with a dry paper towel to prevent reinfection (cross-contamination) of her hands. She was supposed to wipe the resident's table and put it back where she found it. Interview on 03/17/22 at 8:50 a.m. with DON, he stated his expectations for the nurses were to follow the facility policy and protocol for Foley catheter insertion. He said LVN R should have washed her hands before trying to don the sterile gloves because it is a sterile technique, and she should have washed her hands when she entered the resident's room and when she left the room. He said nurses are not supposed to carry gloves in their uniform pockets or use them to provide care for residents. Also, water faucets are turned off after handwashing with a paper towel, not with a wet, washed hand. All these are done to prevent cross-contamination or transfer germs to the resident that may cause harm to the resident. He stated there should be a urine return before the nurse inflated the balloon on the catheter. Finally, he said all the nurses have skill checkoffs on Foley care before working by themselves on the floor. Interview on 03/17/22 at 8:59 a.m. with corporate nurse; she stated that sometimes you do not get a urine return before inflating the balloon depending on how long the Foley catheter has been off. She said the standard of care states that you should have a urine return before inflating the balloon on the catheter. She said the nurse should wash her hands with soap and water or sanitize them before donning the sterile gloves to prevent contamination because it is a sterile procedure. By not washing her hands, she contaminated the aseptic procedure, which could transfer germs to the resident and lead to a [CONDITION(S)]. She said the nurse could leave the resident's room without washing her hands but must use the hand sanitizer closest to the resident's room in the hallway. Record review of the facility charge nurse skills checklist for LVN R revealed indwelling bladder catheter assessment darted 11/29/21. Record review of undated facility policy on urinary catheter insertion, indwelling and intermittent read . steps in the procedure .#1 wash your hands thoroughly before beginning the procedure . #9 discard glove . wash hands . #11 open the catheter tray using sterile technique . #12 put on sterile gloves . for Male: . #26 insert the catheter gently into the meatus (approximately 5 - 7 inches) or until urine begins to flow from the bladder. When urine begins to flow advance the catheter another 2 inches. Inflate balloon and remove the syringe. Pull gently on catheter to check

Based on observation, interview, and record review the facility failed to ensure the provisions of self-administering medication were consistent with professional standards of practice for 2 of 18 residents sampled. -The facility failed to have physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could affect residents with medication needs to receive the level of quality of care necessary to maintain their quality of health. Findings included: Resident #14 Record Review of Resident #14 Face Sheet on 03/16/22 at 02:59 PM revealed resident has nausea with vomiting, unspecified, ulcerative (chronic) proctitis, pneumonitis due to inhalation of food and vomit, other recurrent depressive disorders and altered mental status. Record Review of Resident #14 Care plan dated 02/02/22. Resident has difficulty with decision making dementia and mild cognitive impairment. Record Review of Resident #14 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if SPS is <110 or Pulse <60. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for SBP <110, DBP 0 and HR <60. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #14 CMA EMAR dated 03/15/22 at 08:00 A.M. Aspirin 81mg Chewable tablet, 10:00 A.M. [MEDICATION(S)] 25mg, Multiple Vitamin w-mineral, Probiotic, Pepcid 20mg tablet, and [MEDICATION(S)] 10mg tablet and [MEDICATION(S)] 100mg capsule. Resident #16 Record Review of Resident #16 Face Sheet on 03/16/22 at 03:19 P.M. revealed resident is diagnosed with major depressive disorder, recurrent severe without psycho features and anxiety unspecified lack of coordination. Record Review of Resident #16 Care plan dated 02/02/22. Resident has difficulty with decision making resident is diagnosed with mild cognitive impairment. Record Review of Resident #16 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of Resident #16 CMA EMAR dated 03/15/22 revealed that the resident received a 08:00 A.M. dose of Tums tablet chewable give 2 tabs PO TID. DX: Indigestion administered by LVN H. Record Review of 03/15/22 Staffing Assignment revealed that CMA B, LVN B, and CNA R worked the day shift 6:00 A.M. to 02:00 P.M. on the 100 hall and LVN H worked the day shift 6:00 A.M. to 02:00 P.M on the 200 Hall. Each staff member initialed behind their name acknowledging they were on shift. Observation on 03/15/22 at 09:41 AM of 3 pills in a clear pill cup sitting on resident's bedside table. Resident #14 picked up pill cup, stirred the pills in the cup with her finger and placed back down on the bedside table. Observation on 03/15/22 at 10:37 AM of 2 stacked tums one pink and one yellow sitting on Resident #16 nightstand. Interview on 03/15/22 at 09:41 AM with Resident #14, who said on 3/14/22 sometime in the late evening, exact time unknown and she woke with an upset stomach and vomited. When the nurse whose name and description she could not provide, came around to pass out medication, her stomach was still feeling upset. The nurse left her medication so she could take her meds once her stomach settled. She was taking small bites of food: a cookie and a banana in between taking each pill as her stomach settled. She could not recall what medication she was taking or what the medication was prescribed for. She said that the nurse has not left medication for her to take without being present before. In an interview on 03/15/22 at 10:37 AM with Resident #16 who said she has acid reflux quite often. The tums on her nightstand was left by the nurse whose name and description she could not remember. She said that she felt good now, but that can change at any moment and she has the tums at beside in case her heartburn rises up. The nursing staff leave tums for her on the nightstand all the time to keep her from suffering until staff can bring her some when her acid reflux flares. She said LVN H was passing out meds. Interview on 03/15/22 at 10:59 AM with CNA R who said she does not administer medication, the nurses administering medication. She believes it ws LVN B and/or CMA B on shift today. Interview on 03/15/22 at 12:29 PM with Resident #14 who said that she took meds and was able to get them down okay. She said she takes her [CONDITION(S)] pill at 5 PM. She said she likes staff to leave meds so she can divide the meds out between food since she has a lot of pills to take. She said she does not know what all the pills are for, but believes the long capsule is for stomach. She avoids asking staff what meds she was taking because she will forget anyway, and she does not want to drive them up the wall asking the nurses every day. Interview on 03/16/22 at 01:32 PM with the DON who said the medication administration process requires a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff must ensure that the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff must determine if there is any special parameters needed such as: must be taking with water, juice, with food, and follow any crush, swallow, or chew orders. Then check policy to see if the resident requires the medication to be sprinkled into say apple sauce and spoon feed. Confirm with the resident that the medication is the right medications and once taken, the staff must sign off that the medication was administered. The facility has no residents with self-medication administration orders. A resident with a stomachache at the time of med pass and wishes not to take meds due to earlier vomiting should be held. Med Aides should loop back around and check back with the resident and attempt to administer later as long as the medication is giving within that medications time parameter. No medication should be left for the resident to take on their own and med Aides cannot leave medication with residents. The risk of leaving medication with residents are other residents, family members: children visiting could take the medication. The medication could be taken outside the time parameters, residents could forget to take medication thinking they had and had not and staff will not be able to accurately chart resident's medication intake. Interview on 03/17/22 at 09:39 AM with Resident #16, she no longer had the Tums as she took them. She tries to keep Tums for when she has heartburn or indigestion. Sometimes the facility runs out and then she does not get them when she really needs them. She said LVN H was passing out meds today. Interview on 03/18/22 at 02:59 PM with the Administration who said Resident #14 and Resident #16 do not have self-administrating medication orders. Interview on 03/22/22 at 4:02 PM with CMA B, she said she has worked for the Infacility for 7 years as a medication aide. Her shift is 6 AM to 2 PM. CMA B confirmed that she worked 3/15/22 from 6:00 A.M. to 02:00 P.M. on the 100 hall and confirmed that she initialed by her name on the Shift Assignment form acknowledging that she was on shift. She also confirmed that she administered to Resident #14 per the CMA EMAR record dated 03/15/22 at 08:00 A.M. Aspirin 81 mg Chewable tablet, 10:00 A.M. [MEDICATION(S)] 25 mg, Multiple Vitamin w-mineral, Probiotic, Pepcid 20 mg tablet, [MEDICATION(S)] 10 mg tablet ,and [MEDICATION(S)] 100 mg capsule. She said that the medication administration process requires a review of the medication and order to assure the right resident is receiving the right medication dose and times. Once matched, the mediation can be administered to the resident while she is present. She said that on 03/15/22 sometime during 10:00 A.M. med pass, Resident #14 had a nauseated stomach and refused to take all of her medication. Resident told CMA B she would take the medication once her stomach felt better. CMA B left [MEDICATION(S)] 25 mg and [MEDICATION(S)] 10 mg at beside for resident to take when her stomach felt better. CMA B told LVN B that resident did not take all her meds. LVN B told CMA B to hold the medication and loop back around and see if the resident was able to take the meds at a later time within the time parameters. CMA B then told LVN that the medication was left at the resident's bedside. LVN B told CMA B to go get the medication. CMA B did not go back right away. CMA B looped back around the resident still had her medication at bedside and still complained of stomach nausea. CMA B looped back around a third time she believes 15 minutes outside the medication's time parameter and the medication was gone. She assumed the resident had taken the meds. It is not med pass procedure to leave medication at bedside or with residents. Refused medication needs to be held within the allowed time parameters or discarded per medication discard procedure. The risk of leaving the medication with a resident is that staff are unable to assure the resident had taken the meds, residents could take the medication to close to other medication times and could affect the resident's condition, the meds could be taken by another resident or person and could harm those individuals. CMA B said she knows not to leave medication, it is not common practice, and is not supposed to be done. She said leaving the medication with resident was a poor decision and poor judgment on her part. She will not be leaving medication at bedside or with another resident in the future. Interview on 03/22/22 at 04:20 PM with LVN H who said she had worked at the facility 8 years. She confirmed that she worked 3/15/22 from 6:00 A.M. to 02:00 P.M. in the 200 hall and confirmed that she initialed by her name on the Shift Assignment Report acknowledging that she was on shift. LVN H confirmed that on 03/15/22 during 8:00 AM med pass, she administered to Resident #16 2 TUMS tablets chewable per the 3/2022f CMA EMAR report. She said that the medication procedure is to ensure that the medication is verified by checking that the right medication is being given to the right resident prior to the administering of the medication and stays in the room to assure the resident has taken the medication. On 3/15/22 during 6:00 A.M. medication pass she did not leave 2 Tum tablets with Resident #16. She does not recall seeing 2 Tum tablets on resident #16's bedside. LVN H has not left any medication or Tum tablets for Resident #16 in the past. She always waits for Resident to take her mediation and witnessed Resident #16 take her tum mediation on 03/15/22 during the 06:090 A.M. medication pass. The risk of leaving medications with residents could result in the resident's taking medication at the wrong time, being taking by the wrong resident, or missed by the resident. It is not common practice to leave medication or Tums with residents. She does not know how the medication was left with Resident #16 and does not know of any staff leaving meds with residents. Record Review Medications - Administering Policy undated revealed Policy Interpretation and Implementation. Licensed/Authorized Personnel 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications my do so. Supervision of Medication Administration Functions 2. The DON will supervise and direct all nursing personnel who administer medications and/or have related functions. In Accordance with Orders 3. Medication must be administered in accordance with the orders, including and required time frame. Medication Administration Timeframe 4. Medication must be administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Charting Withholding/Refusal of Medications on the [DATE]. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the mediation shall document this in the record. Self-Administration of Medication 20. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Record Review of the Fall - Resident Policy undated contained no pertinent information pertaining to the prevent of falls and/or fall risks.

Based on interview and record review the facility failed to implement their written policy and procedures that prohibit neglect for 1 of four residents, Closed Record (CR) #1 reviewed for neglect. CR#1 was not assessed or monitored after Certified Nursing Assistant (CNA) C informed Licensed Vocational Nurse (LVN) B that the resident was having difficulty breathing and gasping for air. The Director of Nursing (DON) left CR #1 unattended while she was in critical condition to assist Licensed Vocational Nurse (LVN) B call 911. CR #1 was transferred to the hospital where she expired four days later. Conditions of Immediate Jeopardy were identified for the days of February 15, 16, and 17, 2016, and the facility was notified on [DATE] after administrative review of the findings. While the IJ was removed on February 17, 2016, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. A Plan of Removal was not required as CR#1 was transported to the hospital by EMS for treatment; the resident was placed on a ventilator and died on [DATE]. These failures affected one resident with a [MEDICAL CONDITION] whose care was compromised due to staff neglecting to perform a thorough assessment, provide [MEDICAL CONDITION] care and monitor after a change in condition. Intake # 4 Findings Include: Record review of CR #1' s face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Interview on [DATE] at 2:05pm with the DON revealed the requested Minimum Data Set (MDS) was not available due to CR #1 had only been in the facility for 2 days before respiratory distress occurred and resident was transferred to the hospital. Record review of CR #1's initial care plan dated [DATE] revealed CR#1 was a Full Code. CR #1's Care Plan further revealed that she had a problem [MEDICAL CONDITION] Care but there were no goals or interventions listed on the care plan [MEDICAL CONDITION]. Record review of Admission Nursing Evaluation for CR#1 dated [DATE] revealed an admitting [DIAGNOSES REDACTED]. Further review of the Admission Nursing Evaluation did not identify CR#1 had [MEDICAL CONDITION] and was not signed by the nurse who completed the form. Record review of CR #1's CNA ' s Admission Record dated [DATE] revealed a temperature of 97.9, pulse 84, respirations of 18 and blood pressure of ,[DATE]. Area on form labeled, Condition On Admission was left blank. CR#1 ' [MEDICAL CONDITION] not identified and the form was not signed by CNA. Record review of MAR (medication administration record) for February 2016 revealed CR#1 ' [MEDICAL CONDITION] suctioned one time the day of [DATE] and one time on [DATE]. Time [MEDICAL CONDITION] was not provided on medication administration record. MAR further [MEDICAL CONDITION] was provided one time on [DATE] and [DATE]. No times provided. Record review of physician orders [REDACTED]. Record review of CR#1's Nurse ' s Notes dated [DATE] revealed the following: 7:15 pm revealed the nurse was called to CR#1's room. CR#1 was found to be sweaty. Oxygen saturation was 94%. CR#1 ' s face was cleansed with a cool wash cloth. The Supervisor was notified. 7:20 pm (late entry) breathing treatment given. O2 Sat 94% after breathing treatment. Suctioned x2. O2 Sat 96%. 7:45 pm revealed the Supervisor was in CR #1's room . An Accucheck was completed and blood sugar result was 374. Blood pressure was ,[DATE], pulse 59, temperature 101.5 and oxygen saturation was 94%-96%. Resident was a full code so 911 was called. At 8:05 pm paramedics arrived and 8:28 pm paramedics left with CR#1. In an interview with LVN B on [DATE] at 11:00 am, via phone, she said CR#1 had difficulty breathing and was sent out via 911. When asked to explain what happened regarding CR#1, LVN B became agitated and said she had already discussed this with the DON and another surveyor. LVN B further said that everything regarding CR#1 was documented in the chart. LVN B then said she had suctioned CR#1 at approximately 4:00 pm and CR#1 was fine. LVN B said CR#1 had oxygen on but was not sure of the rate. LVN B said at 7:00 pm she checked on CR#1 and she suctioned CR#1 ' [MEDICAL CONDITION] and was not able to get anything with the suction and about 10 minutes later she had respiratory distress. LVN B further said that she checks on [MEDICAL CONDITION] often. LVN B further said that CR#1 was only the second resident the facility has had with [MEDICAL CONDITION] a long while. Record review of EMS (Emergency Management System) report dated [DATE] read: Received call for breathing difficulty. Upon arrival we find [AGE] year old obese female sitting up in her bed staring off unresponsive in agonal respirations. O2 saturation was 64% with a blood pressure of ,[DATE], respiratory rate about 40 and shallow. At this point all we knew was she has [MEDICAL CONDITION] a stitched surgical incision to her left temporal area about 8 inches long. When we arrived to the room we found her on oxygen being supplied [MEDICAL CONDITION] with no attendant in the room. After a short wait while we were beginning treatment of [REDACTED]. No medical information was provided. We could not get a history or any information on the current condition. The statement that was provided was that they checked on her earlier and she was not this way. Upon further inspection we found a crusted mass around the interior of the Trach. Patient was placed on the electrocardiogram (ECG) monitor showing sinus brady and a set of vitals were obtained showing the above noted vitals. Patient was moved to the stretcher and [MEDICAL CONDITION] removed and replaced with a 5.5 endotracheal tube modified length inflated and secured with a pediatric tube tamer. There was condensation of the tube as well as negative epigastric sounds and clear bilateral breath sounds. EMS (emergency management system) record further said that CR#1 became pulseless during transport to hospital. CPR (cardiopulmonary resuscitation) was initiated. A defibrillator was used and cpr was continued until admission to the hospital. EMS staff stayed at hospital with CR#1 assisting staff until pulse returned. Record review of hospital emergency room report dated [DATE] at 8:44 pm revealed CR#1 presented to the emergency with cpr in progress and CR#1 had [MEDICAL CONDITION] a mucous plug. CR#1 received [MEDICATION NAME] and [MEDICATION NAME]. CPR continued for approximately 10 minutes until pulse was regained. CR#1 was unresponsive at that time and was admitted to hospital. Record review of hospital [MEDICAL CONDITION] consult dated [DATE] read: 1. Cardiorespiratory arrest. It seems that original cause of this cardiorespiratory arrest was a respiratory event, which apparently was related to ventilation issue through the [MEDICAL CONDITION]. 2. Acute [MEDICAL CONDITION]. I will not address the patient ' s [MEDICAL CONDITION] issue at this point. We will continue with endotracheal tube for the time being. 3. [MEDICAL CONDITIONS]. The patient is posturing. She has significant [MEDICAL CONDITION] [MEDICAL CONDITION]. Record review of hospital respiratory records revealed CR#1 was placed on ventilator on [DATE] and removed from ventilator on [DATE]. In an interview with LVN B on [DATE] at 1:30 pm when asked by surveyor how does she know when a resident with a [MEDICAL CONDITION] needs to be suctioned, she said, if a resident coughs you know to suction them and it comes out. She then said that she puts a pulse oximeter on the resident ' s finger and oxygen saturations should be 96%. In an interview with Supervisor on [DATE] at 10:38 am she said she had arrived to work on [DATE] between 7:15 pm and 7:30 pm and was standing at the nurses station speaking with the DON. Supervisor said a CNA came up to the nurses station and requested a nurse because CR#1 was in respiratory distress. Supervisor said 911 was called. She said upon entering the room she did not see any secretions and no suctioning of [MEDICAL CONDITION] done due to no secretions. Supervisor said she did not know much about the resident as she had been on vacation for 9 days prior. Supervisor said she filled out the paperwork for transport to the hospital and was not sure of vitals or oxygen saturation as she was documenting what a CNA had told her the vitals were. In an interview with CNA C on [DATE] at 10:40 am she said she and CNA D gave a bed bath to CR#1 about 3:00 pm. CNA C said at 3:30 pm CR#1 was sweaty and had difficulty breathing. She said it appeared that CR#1 was having difficulty breathing and was gasping for air. CNA C said she notified LVN B but is not sure what LVN B did. CNA C further said when she checked on CR#1 at 6:00 pm her O2 saturation was 40%. CNA C said she notified the DON and the Supervisor and 911 was called. CNA C said it looked like CR#1 was not getting any air and she was gasping for air. CNA C said she is not sure if anyone suctioned CR#1 ' [MEDICAL CONDITION] did not want to lie. In an interview with CNA D on [DATE] at 1:29 pm she said she kept a close eye on CR#1. CNA D said she always comes in to work at 3:00 pm and always checks on the residents first. CNA D said CR#1 would blink her eyes to communicate due to [MEDICAL CONDITION] the fact that she was non-verbal. CNA D said at 3:40 pm CR#1 blinked her eyes that she was alright. CNA D said at 4:45 pm the door to CR#1 ' s room was closed and she went in and LVN B was in the room with CR#1. LVN B requested she get a nurse to come assist her. CNA D said she was not sure what was going on or what had happened. At 5:30 pm CNA D checked on CR#1 and CR#1 was sweaty but responsive. CNA D notified LVN B and LVN B said to pull the covers back to cool CR#1 off. CNA D could not confirm if LVN B went to check on CR#1. CNA D said at 6:45 pm CR#1 didn ' t look right and was sweaty. LVN B was notified and LVN B asked if the covers had been removed earlier. CNA D said she knows the O2 Sats were low at 6:45 pm but could not remember the number. CNA D said CR#1 ' s temperature was 102.0 and she did not see LVN B [MEDICAL CONDITION] or suctioning of Trach. In an interview with the DON on [DATE] at 2:05pm a record of vital documentation from Care Tracker was requested from DON along with any other information regarding CR#1 on [DATE] at 2:05 pm. DON said she had looked for documentation on vitals and other documentation for CR#1 and there was none to be found. DON said vitals should have been put in the care tracker and is not sure why they were not. DON said she went to the room when CR#1 was having respiratory distress and knew the O2 sats were dropping but was not sure how low they dropped. DON said she did not stay in the room with CR#1 as she went out of the room to assist LVN B in calling 911. She said that she left the room to talk to the people at 911 because when the facility staff calls 911 the 911 staff will argue with them about whether the resident has a Do Not Resuscitate (DNR) status and whther they really need to be transferred to the hospital. She said she went to tell them that CR #1 was in distress and they needed to come get her now. The DON revealed that an in-service was done [MEDICAL CONDITION], as the facility rarely had residents with Trachs. When asked for in-service record [MEDICAL CONDITION], the DON said it was more of a huddle with the nurses done by the ADON and no records or sign in sheets were provided. DON further said that she was not happy with the documentation in CR#1 ' s chart but was happy that the nurses had attempted to start a care plan. In an interview with ADON (Assistant Director of Nurses) on [DATE] at 11:39 am she said the facility has had one [MEDICAL CONDITION] in recent years. ADON said she did an in-service with all the nurses before CR#1 arrived at facility. ADON could not provide in-service sign in sheet or documentation of in-service. Record review of policy and procedure for Care of [MEDICAL CONDITION] dated [DATE] with a revised date of [DATE] read: Keeping the [MEDICAL CONDITION] clean helps prevent infections and keeps [MEDICAL CONDITION] from plugging. A [MEDICAL CONDITION] is commonly known as [MEDICAL CONDITION]. You may have one tube (an outer cannula), or you may have two tubes (an outer and inner cannula). The inner cannula that fits inside the outer cannula is removed for cleaning or replacement. Follow your caregiver ' s directions as to how often you should change and clean [MEDICAL CONDITION]. [MEDICAL CONDITION] CARE: 1. Have all supplies ready and available. 2. Wash hands well. 3. Put on clean gloves. 4. Suction [MEDICAL CONDITION] as needed. 5. When suctioning is complete, remove [MEDICAL CONDITION], gloves, and suction catheter. Throw away the dressings and coiled catheter in the glove. To coil the catheter, roll the catheter around the fingers. Then, pull the glove off inside out so that catheter remains coiled in glove. 6. Wash hands well. 7. Put on sterile gloves. 8. Fill container 0.9% saline solution. 9. Give oxygen as needed. 10. Clean inner cannula. Conditions of Immediate Jeopardy were identified for the days of February 15, 16, and 17, 2016, and the facility was notified on [DATE] after administrative review of the findings. While the IJ was removed on February 17, 2016, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. A Plan of Removal was not required as CR#1 was transported to the hospital by EMS for treatment; the resident was placed on a ventilator and died on [DATE]. According to CMS-672 dated [DATE] listed no other residents with a [MEDICAL CONDITION] or requiring suctioning.

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of one residents reviewed (CR#1) for [MEDICAL CONDITION] care and suctioning. CR#1 was not assessed or monitored after Certified Nursing Assistant (CNA) C informed Licensed Vocational Nurse (LVN) B that the resident was having difficulty breathing and gasping for air, she developed a fever and her oxygen saturation was in the 40's. The Director of Nursing (DON) left CR #1 unattended while she was in critical condition to assist Licensed Vocational Nurse (LVN) B call 911. CR #1 was transferred to the hospital where she expired four days later. The facility failed to train nursing staff in proper care of a resident with a [MEDICAL CONDITION]. Conditions of Immediate Jeopardy were identified for the days of February 15, 16, and 17, 2016, and the facility was notified on [DATE] after administrative review of the findings. While the IJ was removed on February 17, 2016, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. A Plan of Removal was not required as CR#1 was transported to the hospital by EMS for treatment; the resident was placed on a ventilator and died on [DATE]. These deficient practices affected one resident with a [MEDICAL CONDITION] and required suctioning due to appropriate care not being provided regarding a change in condition, lack of documentation, and incomplete initial care plans. Intake # 4 Findings Include: Record review of CR #1' s face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Interview on [DATE] at 2:05pm with the DON revealed the requested Minimum Data Set (MDS) was not available due to CR #1 had only been in the facility for 2 days before respiratory distress occurred and resident was transferred to the hospital. Record review of CR #1's initial care plan dated [DATE] revealed CR#1 was a Full Code. CR #1's Care Plan further revealed that she had a problem [MEDICAL CONDITION] Care but there were no goals or interventions listed on the care plan [MEDICAL CONDITION]. Record review of Admission Nursing Evaluation for CR#1 dated [DATE] revealed an admitting [DIAGNOSES REDACTED]. Further review of the Admission Nursing Evaluation did not identify CR#1 had [MEDICAL CONDITION] and was not signed by the nurse who completed the form. Record review of CR #1's CNA ' s Admission Record dated [DATE] revealed a temperature of 97.9, pulse 84, respirations of 18 and blood pressure of ,[DATE]. Area on form labeled, Condition On Admission was left blank. CR#1 ' [MEDICAL CONDITION] not identified and the form was not signed by CNA. Record review of MAR (medication administration record) for February 2016 revealed CR#1 ' [MEDICAL CONDITION] suctioned one time the day of [DATE] and one time on [DATE]. Time [MEDICAL CONDITION] was not provided on medication administration record. MAR further [MEDICAL CONDITION] was provided one time on [DATE] and [DATE]. No times provided. Record review of physician orders [REDACTED]. Record review of CR#1's Nurse ' s Notes dated [DATE] revealed the following: 7:15 pm revealed the nurse was called to CR#1's room. CR#1 was found to be sweaty. Oxygen saturation was 94%. CR#1 ' s face was cleansed with a cool wash cloth. The Supervisor was notified. 7:20 pm (late entry) breathing treatment given. O2 Sat 94% after breathing treatment. Suctioned x2. O2 Sat 96%. 7:45 pm revealed the Supervisor was in CR #1's room . An Accucheck was completed and blood sugar result was 374. Blood pressure was ,[DATE], pulse 59, temperature 101.5 and oxygen saturation was 94%-96%. Resident was a full code so 911 was called. At 8:05 pm paramedics arrived and 8:28 pm paramedics left with CR#1. In an interview with LVN B on [DATE] at 11:00 am, via phone, she said CR#1 had difficulty breathing and was sent out via 911. When asked to explain what happened regarding CR#1, LVN B became agitated and said she had already discussed this with the DON and another surveyor. LVN B further said that everything regarding CR#1 was documented in the chart. LVN B then said she had suctioned CR#1 at approximately 4:00 pm and CR#1 was fine. LVN B said CR#1 had oxygen on but was not sure of the rate. LVN B said at 7:00 pm she checked on CR#1 and she suctioned CR#1 ' [MEDICAL CONDITION] and was not able to get anything with the suction and about 10 minutes later she had respiratory distress. LVN B further said that she checks on [MEDICAL CONDITION] often. LVN B further said that CR#1 was only the second resident the facility has had with [MEDICAL CONDITION] a long while. Record review of EMS (Emergency Management System) report dated [DATE] read: Received call for breathing difficulty. Upon arrival we find [AGE] year old obese female sitting up in her bed staring off unresponsive in agonal respirations. O2 saturation was 64% with a blood pressure of ,[DATE], respiratory rate about 40 and shallow. At this point all we knew was she has [MEDICAL CONDITION] a stitched surgical incision to her left temporal area about 8 inches long. When we arrived to the room we found her on oxygen being supplied [MEDICAL CONDITION] with no attendant in the room. After a short wait while we were beginning treatment of [REDACTED]. No medical information was provided. We could not get a history or any information on the current condition. The statement that was provided was that they checked on her earlier and she was not this way. Upon further inspection we found a crusted mass around the interior of the Trach. Patient was placed on the electrocardiogram (ECG) monitor showing sinus brady and a set of vitals were obtained showing the above noted vitals. Patient was moved to the stretcher and [MEDICAL CONDITION] removed and replaced with a 5.5 endotracheal tube modified length inflated and secured with a pediatric tube tamer. There was condensation of the tube as well as negative epigastric sounds and clear bilateral breath sounds. EMS (emergency management system) record further said that CR#1 became pulseless during transport to hospital. CPR (cardiopulmonary resuscitation) was initiated. A defibrillator was used and cpr was continued until admission to the hospital. EMS staff stayed at hospital with CR#1 assisting staff until pulse returned. Record review of hospital emergency room report dated [DATE] at 8:44 pm revealed CR#1 presented to the emergency with cpr in progress and CR#1 had [MEDICAL CONDITION] a mucous plug. CR#1 received [MEDICATION NAME] and [MEDICATION NAME]. CPR continued for approximately 10 minutes until pulse was regained. CR#1 was unresponsive at that time and was admitted to hospital. Record review of hospital [MEDICAL CONDITION] consult dated [DATE] read: 1. Cardiorespiratory arrest. It seems that original cause of this cardiorespiratory arrest was a respiratory event, which apparently was related to ventilation issue through the [MEDICAL CONDITION]. 2. Acute [MEDICAL CONDITION]. I will not address the patient ' s [MEDICAL CONDITION] issue at this point. We will continue with endotracheal tube for the time being. 3. [MEDICAL CONDITIONS]. The patient is posturing. She has significant [MEDICAL CONDITION] [MEDICAL CONDITION]. Record review of hospital respiratory records revealed CR#1 was placed on ventilator on [DATE] and removed from ventilator on [DATE]. In an interview with LVN B on [DATE] at 1:30 pm when asked by surveyor how does she know when a resident with a [MEDICAL CONDITION] needs to be suctioned, she said, if a resident coughs you know to suction them and it comes out. She then said that she puts a pulse oximeter on the resident ' s finger and oxygen saturations should be 96%. In an interview with Supervisor on [DATE] at 10:38 am she said she had arrived to work on [DATE] between 7:15 pm and 7:30 pm and was standing at the nurses station speaking with the DON. Supervisor said a CNA came up to the nurses station and requested a nurse because CR#1 was in respiratory distress. Supervisor said 911 was called. She said upon entering the room she did not see any secretions and no suctioning of [MEDICAL CONDITION] done due to no secretions. Supervisor said she did not know much about the resident as she had been on vacation for 9 days prior. Supervisor said she filled out the paperwork for transport to the hospital and was not sure of vitals or oxygen saturation as she was documenting what a CNA had told her the vitals were. In an interview with CNA C on [DATE] at 10:40 am she said she and CNA D gave a bed bath to CR#1 about 3:00 pm. CNA C said at 3:30 pm CR#1 was sweaty and had difficulty breathing. She said it appeared that CR#1 was having difficulty breathing and was gasping for air. CNA C said she notified LVN B but is not sure what LVN B did. CNA C further said when she checked on CR#1 at 6:00 pm her O2 saturation was 40%. CNA C said she notified the DON and the Supervisor and 911 was called. CNA C said it looked like CR#1 was not getting any air and she was gasping for air. CNA C said she is not sure if anyone suctioned CR#1 ' [MEDICAL CONDITION] did not want to lie. In an interview with CNA D on [DATE] at 1:29 pm she said she kept a close eye on CR#1. CNA D said she always comes in to work at 3:00 pm and always checks on the residents first. CNA D said CR#1 would blink her eyes to communicate due to [MEDICAL CONDITION] the fact that she was non-verbal. CNA D said at 3:40 pm CR#1 blinked her eyes that she was alright. CNA D said at 4:45 pm the door to CR#1 ' s room was closed and she went in and LVN B was in the room with CR#1. LVN B requested she get a nurse to come assist her. CNA D said she was not sure what was going on or what had happened. At 5:30 pm CNA D checked on CR#1 and CR#1 was sweaty but responsive. CNA D notified LVN B and LVN B said to pull the covers back to cool CR#1 off. CNA D could not confirm if LVN B went to check on CR#1. CNA D said at 6:45 pm CR#1 didn ' t look right and was sweaty. LVN B was notified and LVN B asked if the covers had been removed earlier. CNA D said she knows the O2 Sats were low at 6:45 pm but could not remember the number. CNA D said CR#1 ' s temperature was 102.0 and she did not see LVN B [MEDICAL CONDITION] or suctioning of Trach. In an interview with the DON on [DATE] at 2:05pm a record of vital documentation from Care Tracker was requested from DON along with any other information regarding CR#1 on [DATE] at 2:05 pm. DON said she had looked for documentation on vitals and other documentation for CR#1 and there was none to be found. DON said vitals should have been put in the care tracker and is not sure why they were not. DON said she went to the room when CR#1 was having respiratory distress and knew the O2 sats were dropping but was not sure how low they dropped. DON said she did not stay in the room with CR#1 as she went out of the room to assist LVN B in calling 911. She said that she left the room to talk to the people at 911 because when the facility staff calls 911 the 911 staff will argue with them about whether the resident has a Do Not Resuscitate (DNR) status and whther they really need to be transferred to the hospital. She said she went to tell them that CR #1 was in distress and they needed to come get her now. The DON revealed that an in-service was done [MEDICAL CONDITION], as the facility rarely had residents with Trachs. When asked for in-service record [MEDICAL CONDITION], the DON said it was more of a huddle with the nurses done by the ADON and no records or sign in sheets were provided. DON further said that she was not happy with the documentation in CR#1 ' s chart but was happy that the nurses had attempted to start a care plan. In an interview with ADON (Assistant Director of Nurses) on [DATE] at 11:39 am she said the facility has had one [MEDICAL CONDITION] in recent years. ADON said she did an in-service with all the nurses before CR#1 arrived at facility. ADON could not provide in-service sign in sheet or documentation of in-service. Record review of policy and procedure for Care of [MEDICAL CONDITION] dated [DATE] with a revised date of [DATE] read: Keeping the [MEDICAL CONDITION] clean helps prevent infections and keeps [MEDICAL CONDITION] from plugging. A [MEDICAL CONDITION] is commonly known as [MEDICAL CONDITION]. You may have one tube (an outer cannula), or you may have two tubes (an outer and inner cannula). The inner cannula that fits inside the outer cannula is removed for cleaning or replacement. Follow your caregiver ' s directions as to how often you should change and clean [MEDICAL CONDITION]. [MEDICAL CONDITION] CARE: 1. Have all supplies ready and available. 2. Wash hands well. 3. Put on clean gloves. 4. Suction [MEDICAL CONDITION] as needed. 5. When suctioning is complete, remove [MEDICAL CONDITION], gloves, and suction catheter. Throw away the dressings and coiled catheter in the glove. To coil the catheter, roll the catheter around the fingers. Then, pull the glove off inside out so that catheter remains coiled in glove. 6. Wash hands well. 7. Put on sterile gloves. 8. Fill container 0.9% saline solution. 9. Give oxygen as needed. 10. Clean inner cannula. Conditions of Immediate Jeopardy were identified for the days of February 15, 16, and 17, 2016, and the facility was notified on [DATE] after administrative review of the findings. While the IJ was removed on February 17, 2016, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. A Plan of Removal was not required as CR#1 was transported to the hospital by EMS for treatment; the resident was placed on a ventilator and died on [DATE]. According to CMS-672 dated [DATE] listed no other residents with a [MEDICAL CONDITION] or requiring suctioning.

Based on record review and interview the facility failed to consult with the physician when there was a change in condition for 1 of 13 residents (CR #1) who were reviewed for physician's consultations. CR #1 experienced a change in condition on 08/08/15 at 4:45 am after she fell in her bedroom. She had a change in her neurological (neuro) status. The physician was not notified of the change in CR#1 ' s neuro status for seven hours after the fall and she was not sent to the hospital for evaluation. She had a large hematoma on the left side of her forehead and was taking anticoagulant (blood thinning) medication.CR #1 was found on the floor of her bathroom and was pronounced dead on 08/08/15 at 9:10pm. An IJ was identified on 08/14/15. While the IJ was removed on 08/17/15 the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed an additional 45 residents taking anticoagulant medications at risk of not receiving care and services, delay in treatment, complications, hospitalization , or death. # 1 and # 2. Findings Include: Record review of CR # 1's Face Sheet revealed she was [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 13 which indicated CR #1 was cognitively intact. CR #1 required limited assistance of one staff for bed mobility and supervision with setup help for ambulation and toileting. She was assessed as not steady but able to stabilize without staff assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer and used a wheelchair. Record review of CR #1 ' s consolidated physician orders [REDACTED]. Record review of CR#1 ' s Medication flow sheet dated 08/01/15-08/31/15 revealed CR# 1 received both her aspirin and [MEDICATION NAME] from 08/01/15-08/08/15. Record review of CR #1 ' s care plan dated 06/19/15 to reflect a fall while transferring self to bathroom. The goal falls will be reduced with no occurrence or injury over the next 90 days; Approaches included encourage resident to ask for assistance from staff, place call light within reach and answer promptly, anticipate the resident ' s needs and provide prompt assistance, assure adequate lighting in room and that room is free from clutter, therapy to evaluate and treat as needed, encourage socialization and activity attendance as tolerated, high raised toilet seat and bed in lowest position, the approaches physical and occupational therapy to screen, move refrigerator across the room (these two approaches were discontinued on 06/25/15 due to resident refused). Have resident call for assistance with transfers . bed in lowest position . non-skid socks while in bed. There was a review date of 07/09/15 with no new problems, goals or approaches were added. There was a date of 08/08/15 with the problem of fall while transferring self from bed to chair. There were no new goals or approaches added with this fall. Record review of facility incident report dated 08/08/15 revealed CR # 1 was observed on the floor at the foot of the bed with her head under a chair lying on her left side. CR #1 had an abrasion to both knees and a large hematoma to the left side of her head. CR#1 did not have on her shoes or non-skid socks as care planned but had on regular socks. Record review of nurse ' s notes dated 08/08/15 at 4:45am (signed by RN C) read in part, Resident on floor of bed with her head under a chair lying on her left side .Resident said she was getting up from her bed going to the bathroom and fell . Resident did not have on her shoes or non-skid socks (as care planned) but had on regular socks. Resident had a large hematoma to the left side of her forehead, abrasions on both knees. Neuros in progress, head to toe assessment done. Physician group called and talked with NP. New orders carried out . Cool compress applied to left forehead .vital sign 167\58, 59, 20, &97 .Left pupil pin point Right eye pupil shaped of a cat pupil . resident on [MEDICATION NAME] and aspirin. Record review of CR #1's clinical record revealed there was no docmentation of the facility reporting the change in CR#1's neurological status to the physician. Record review of CR #1 ' s clinical record revealed there was no further documentation in CR #1 ' s nurse ' s notes until 08/08/15 at 7:00pm. The documentation revealed CR #1 denied pain, Neuros in progress and intact, pupils were equal and reactive to light. Assistance f one person with ADLS and transfers.7:45 pm vital sign 150\77 65, 18, 97.1 Neuro ' s in tacked (Sic). Record review of CR #1 ' s Neurological Evaluation Flow Sheet dated 08/08/15 revealed from 04:30am (prior to the time documented for the fall) until 11:45am CR #1 was assessed has follows: right pupil was five millimeters and had a sluggish reaction to light and the left pupil was one millimeter and brisk reaction to light. Under the section for best verbal response she was assessed as a four, which is listed as confused, from 4:30am until the last neuro check conducted at 7:45pm. Her total Glasgow Coma Scale (GCS) score was between 13 and 14 throughout the day from 4:30am until 7:45pm. A score of 13-14 on GCS indicates mild [MEDICAL CONDITION] according to the instructions on the back of the form. Also as part of the instructions for best verbal response, confused is defined as .the individual cannot answer the questions regarding name, place and date accurately but is still capable of producing phrases, sentences or conversation exchanges. Record review of CR #1 ' s nurse ' s notes dated 08/08/15 at 9:10pm read in part . upon entering room, CR#1 was noted lying on her back on floor of her bathroom with her back against the bathroom wall. No noted pulse, no spontaneous respirations and no heart rate on auscultation. There was no response to painful application. The physician and family were notified .time of death 9:10pm. Record review of Facility ' s investigation summary dated 08/09/15 at 12:00am revealed CR #1 was getting up to the restroom when she fell . Neuros were done. The physician and responsible party were notified. The intervention was to have on non-skid socks while in bed to prevent slipping when getting up. RN B called time of death at 9:10pm. Record review of this investigation report did not include resident change of condition as indicated on her neuros checks and physician orders [REDACTED]. Record review of CR #1 ' s physician ' s telephone order dated 08/08/15 revealed the following: 1. Neuros, 2. Cool compresses time four as needed, 10 minutes each time while awake for 24 hours.3. Abrasions clean with normal saline (NS), pat dry, triple antibiotic ointment and leave open to air. This order was signed as taken by RN C. In an interview with the Director of Nursing (DON) on 08/13/15 at 3:24pm, she said CR #1 ' s physician was called and a verbal order was given. She said all physician orders [REDACTED].#1 ' s forehead, she said CR #1 ' s physician told her that he did not perform a CAT Scan on all residents with a bump on the head. Record review of an email from the physician ' s group to the DON dated 08/14/15 at 1:42pm (requested by Surveyor) revealed the call log from RN C ' s call to report CR #1 ' s fall. It read in part, Reported: fall, unwitnessed no nek (Sic)/body pain . no neuro deficits .abrasions to both knees, hematoma left forehead, vital signs stable, taking aspirin 81mg and [MEDICATION NAME]. Orders: has Tylenol . Verbal orders given per fall SDO (standing orders):x-ray affected area and position for comfort, may use cool application as needed four times for 24 hours for 10 minutes while awake, Tylenol 650 milligrams (mg) by mouth every six hours as needed for pain time 72 hours, not to exceed three grams per 24 hours, monitor for pain, bruising, vital signs, neuro checks every four hours times 24 hours the every shift times 48 hours, make note in communication book . In an interview with the facility DON on 08/14/15 at 1:00pm she said RN C did not follow physician's order [REDACTED]. In an interview on 08/14/15 at 1:30 pm the facility administrator said RN C was terminated because she did not follow facility's protocol and physician orders. Attempt was made to contact with RN C on 08/14/15, 08/15/15 and 08/16/15. Message was left phone calls was not returned. In an interview on 08/17/15 at 2:45pm, LVN B who worked 6:00am-2:00pm on 08/08/15 said when she saw CR #1 ' s eyes, she asked the outgoing nurse (RN C) about CR #1 ' s look and she was told that Resident #1' s eyes were usually like that. She said she had not worked with CR# 1 and was not familiar with her look. She said the right side of her face was purple looking as a result of the fall. She said she spoke to CR #1 at about 10:30am and she replied that she was doing fine; she said she offered her midday snack but refuse. She said her family was around her for a while. She said CR# 1 was alright when she left. Record review of CR #1 ' s previous Neurological Evaluation Flow Sheet dated 06/19/15 revealed the pupils were 3 mm in size and had a brisk reaction to light. She was assessed with [REDACTED]. In an interview on 08/17/15 at 3:00pm, with the Medical Director who was also CR #1 ' s attending physician said the fall happened on a weekend. He said the first call came to the call center at about 4:50 am and standing orders per protocol describing CR #1 ' s fall and injuries were given. He said the person on call gave the appropriate orders based on the report that was given at the time of fall. He said the next call received was about her (CR #1) being found dead at about 9:10-9:15pm. Record review of the facility ' s 24 hour report/change of condition report dated 08/08/15 revealed there was no documentation regarding CR #1 ' s fall or change in neuro status. The only documentation was she passed at 9:10pm. Record review of the Facility ' s Abuse and Neglect Policy and Procedure dated 04/01/14 read in part .residents has the right to be free of abuse .neglect .f. neglect is the failure to provide goods and services necessary to avoid physical harm . i. Possible signs of neglect .5. Untreated medical conditions .II. Reporting and Responding to Resident Abuse .b. investigation of alleged abuse. I The Abuse Coordinator or designee will interview: 1. The person reporting the incident. 2. Any witnesses to the incident .4. All employees on all shifts who have had contact with the resident 24 hours before and after the time of alleged incident . Record review of the facility ' s Anticoagulation Clinical Protocol dated October 2010 revealed it did not address if a Resident on anticoagulation has a fall with a head injury. Record review of the facility ' s Assessing Falls and Their Causes Policy dated October 2010 read in part .1. After a fall .d .When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Record review of the facility ' s Falling Stars Clinical Protocol dated March 30, 2015 revealed that it did not address when to send a resident out for evaluation and treatment after a fall with head injury. An immediate jeopardy (IJ) was identified on 08/14/15 at 12:33pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 08/14/15 at 4:48pm and after several revisions were made it was accepted on 08/17/15 at 8:30am. The POR included in part: 1. Immediate Corrective action was RN C was terminated. 2. Corrective action for additional residents: a. All residents on anticoagulation medication where identified and medical records were reviewed for changes in neurological changes. b. Falling Stars Clinical Protocol and the Anticoagulation Clinical Protocol were changed to address a resident with a fall and possibly sustaining a head injury will be sent to the emergency room immediately for evaluation and treatment. 3. Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change regarding the fall and anticoagulant policies on 08/14/15 by 3:00pm by the Assistant Director of Nursing (ADON.) b. The night shift supervisor will in-service the night shift nurses on the policy change regarding the fall and anticoagulant policies on 08/14/15, 08/15/15 and 08/16/15. c. No nurse will begin working with resident until they have been educated on anticoagulant and fall policies. d. All currently active licensed staff will have been trained by the end of the day on 08/17/15.Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 08/14/15. 4. Incident and accident monitoring began on 08/14/15 and will be reviewed for the changes in policy. The night supervisor will monitor all care plans to ensure new approach for sending residents to the ER for evaluation and treatment after a fall with a head injury has been added. 5. The DON will be responsible for corrective action and completion date for all actions will be 08/17/15. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 08/14/15 until 08/17/15. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment, Falling star program and any resident on anticoagulant medication. Observations were made from 08/14/15 until 08/17/15 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 08/15/15 until 08/17/15 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 08/17/15 at 3:00pm that the IJ was lowered; however the facility remained out of compliance at a isolated level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. Facility 672 dated 08/13/15 listed 45 residents on anticoagulant medication.

Based on observations, interviews and record reviews the facility failed to implement their policy and procedures that prohibit mistreatment and neglect and abuse for 1 of 13 residents (Closed Records CR #1) reviewed for incident and accidents and care. This was evidenced by: CR #1 experienced a change in condition on 08/08/15 at 4:45 am after she fell in her bedroom. She had a change in her neurological (neuro) status. The physician was not notified of the change in CR#1 ' s neuro status for seven hours after the fall and she was not sent to the hospital for evaluation. She had a large hematoma on the left side of her forehead and was taking anticoagulant (blood thinning) medication.CR #1 was found on the floor of her bathroom and was pronounced dead on 08/08/15 at 9:10pm. An IJ was identified on 08/14/15. While the IJ was removed on 08/17/15 the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed an additional 45 residents taking anticoagulant medications at risk of not receiving care and services, delay in treatment, complications, hospitalization , or death. # 1 and # 2. Findings Include: Record review of CR # 1's Face Sheet revealed she was [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 13 which indicated CR #1 was cognitively intact. CR #1 required limited assistance of one staff for bed mobility and supervision with setup help for ambulation and toileting. She was assessed as not steady but able to stabilize without staff assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer and used a wheelchair. Record review of CR #1 ' s consolidated physician orders [REDACTED]. Record review of CR#1 ' s Medication flow sheet dated 08/01/15-08/31/15 revealed CR# 1 received both her aspirin and [MEDICATION NAME] from 08/01/15-08/08/15. Record review of CR #1 ' s care plan dated 06/19/15 to reflect a fall while transferring self to bathroom. The goal falls will be reduced with no occurrence or injury over the next 90 days; Approaches included encourage resident to ask for assistance from staff, place call light within reach and answer promptly, anticipate the resident ' s needs and provide prompt assistance, assure adequate lighting in room and that room is free from clutter, therapy to evaluate and treat as needed, encourage socialization and activity attendance as tolerated, high raised toilet seat and bed in lowest position, the approaches physical and occupational therapy to screen, move refrigerator across the room (these two approaches were discontinued on 06/25/15 due to resident refused). Have resident call for assistance with transfers . bed in lowest position . non-skid socks while in bed. There was a review date of 07/09/15 with no new problems, goals or approaches were added. There was a date of 08/08/15 with the problem of fall while transferring self from bed to chair. There were no new goals or approaches added with this fall. Record review of facility incident report dated 08/08/15 revealed CR # 1 was observed on the floor at the foot of the bed with her head under a chair lying on her left side. CR #1 had an abrasion to both knees and a large hematoma to the left side of her head. CR#1 did not have on her shoes or non-skid socks as care planned but had on regular socks. Record review of nurse ' s notes dated 08/08/15 at 4:45am (signed by RN C) read in part, Resident on floor of bed with her head under a chair lying on her left side .Resident said she was getting up from her bed going to the bathroom and fell . Resident did not have on her shoes or non-skid socks (as care planned) but had on regular socks. Resident had a large hematoma to the left side of her forehead, abrasions on both knees. Neuros in progress, head to toe assessment done. Physician group called and talked with NP. New orders carried out . Cool compress applied to left forehead .vital sign 167\58, 59, 20, &97 .Left pupil pin point Right eye pupil shaped of a cat pupil . resident on [MEDICATION NAME] and aspirin. Record review of CR #1's clinical record revealed there was no docmentation of the facility reporting the change in CR#1's neurological status to the physician. Record review of CR #1 ' s clinical record revealed there was no further documentation in CR #1 ' s nurse ' s notes until 08/08/15 at 7:00pm. The documentation revealed CR #1 denied pain, Neuros in progress and intact, pupils were equal and reactive to light. Assistance f one person with ADLS and transfers.7:45 pm vital sign 150\77 65, 18, 97.1 Neuro ' s in tacked (Sic). Record review of CR #1 ' s Neurological Evaluation Flow Sheet dated 08/08/15 revealed from 04:30am (prior to the time documented for the fall) until 11:45am CR #1 was assessed has follows: right pupil was five millimeters and had a sluggish reaction to light and the left pupil was one millimeter and brisk reaction to light. Under the section for best verbal response she was assessed as a four, which is listed as confused, from 4:30am until the last neuro check conducted at 7:45pm. Her total Glasgow Coma Scale (GCS) score was between 13 and 14 throughout the day from 4:30am until 7:45pm. A score of 13-14 on GCS indicates mild [MEDICAL CONDITION] according to the instructions on the back of the form. Also as part of the instructions for best verbal response, confused is defined as .the individual cannot answer the questions regarding name, place and date accurately but is still capable of producing phrases, sentences or conversation exchanges. Record review of CR #1 ' s nurse ' s notes dated 08/08/15 at 9:10pm read in part . upon entering room, CR#1 was noted lying on her back on floor of her bathroom with her back against the bathroom wall. No noted pulse, no spontaneous respirations and no heart rate on auscultation. There was no response to painful application. The physician and family were notified .time of death 9:10pm. Record review of Facility ' s investigation summary dated 08/09/15 at 12:00am revealed CR #1 was getting up to the restroom when she fell . Neuros were done. The physician and responsible party were notified. The intervention was to have on non-skid socks while in bed to prevent slipping when getting up. RN B called time of death at 9:10pm. Record review of this investigation report did not include resident change of condition as indicated on her neuros checks and physician orders [REDACTED]. Record review of CR #1 ' s physician ' s telephone order dated 08/08/15 revealed the following: 1. Neuros, 2. Cool compresses time four as needed, 10 minutes each time while awake for 24 hours.3. Abrasions clean with normal saline (NS), pat dry, triple antibiotic ointment and leave open to air. This order was signed as taken by RN C. In an interview with the Director of Nursing (DON) on 08/13/15 at 3:24pm, she said CR #1 ' s physician was called and a verbal order was given. She said all physician orders [REDACTED].#1 ' s forehead, she said CR #1 ' s physician told her that he did not perform a CAT Scan on all residents with a bump on the head. Record review of an email from the physician ' s group to the DON dated 08/14/15 at 1:42pm (requested by Surveyor) revealed the call log from RN C ' s call to report CR #1 ' s fall. It read in part, Reported: fall, unwitnessed no nek (Sic)/body pain . no neuro deficits .abrasions to both knees, hematoma left forehead, vital signs stable, taking aspirin 81mg and [MEDICATION NAME]. Orders: has Tylenol . Verbal orders given per fall SDO (standing orders):x-ray affected area and position for comfort, may use cool application as needed four times for 24 hours for 10 minutes while awake, Tylenol 650 milligrams (mg) by mouth every six hours as needed for pain time 72 hours, not to exceed three grams per 24 hours, monitor for pain, bruising, vital signs, neuro checks every four hours times 24 hours the every shift times 48 hours, make note in communication book . In an interview with the facility DON on 08/14/15 at 1:00pm she said RN C did not follow physician's order [REDACTED]. In an interview on 08/14/15 at 1:30 pm the facility administrator said RN C was terminated because she did not follow facility's protocol and physician orders. Attempt was made to contact with RN C on 08/14/15, 08/15/15 and 08/16/15. Message was left phone calls was not returned. In an interview on 08/17/15 at 2:45pm, LVN B who worked 6:00am-2:00pm on 08/08/15 said when she saw CR #1 ' s eyes, she asked the outgoing nurse (RN C) about CR #1 ' s look and she was told that Resident #1' s eyes were usually like that. She said she had not worked with CR# 1 and was not familiar with her look. She said the right side of her face was purple looking as a result of the fall. She said she spoke to CR #1 at about 10:30am and she replied that she was doing fine; she said she offered her midday snack but refuse. She said her family was around her for a while. She said CR# 1 was alright when she left. Record review of CR #1 ' s previous Neurological Evaluation Flow Sheet dated 06/19/15 revealed the pupils were 3 mm in size and had a brisk reaction to light. She was assessed with [REDACTED]. In an interview on 08/17/15 at 3:00pm, with the Medical Director who was also CR #1 ' s attending physician said the fall happened on a weekend. He said the first call came to the call center at about 4:50 am and standing orders per protocol describing CR #1 ' s fall and injuries were given. He said the person on call gave the appropriate orders based on the report that was given at the time of fall. He said the next call received was about her (CR #1) being found dead at about 9:10-9:15pm. Record review of the facility ' s 24 hour report/change of condition report dated 08/08/15 revealed there was no documentation regarding CR #1 ' s fall or change in neuro status. The only documentation was she passed at 9:10pm. Record review of the Facility ' s Abuse and Neglect Policy and Procedure dated 04/01/14 read in part .residents has the right to be free of abuse .neglect .f. neglect is the failure to provide goods and services necessary to avoid physical harm . i. Possible signs of neglect .5. Untreated medical conditions .II. Reporting and Responding to Resident Abuse .b. investigation of alleged abuse. I The Abuse Coordinator or designee will interview: 1. The person reporting the incident. 2. Any witnesses to the incident .4. All employees on all shifts who have had contact with the resident 24 hours before and after the time of alleged incident . Record review of the facility ' s Anticoagulation Clinical Protocol dated October 2010 revealed it did not address if a Resident on anticoagulation has a fall with a head injury. Record review of the facility ' s Assessing Falls and Their Causes Policy dated October 2010 read in part .1. After a fall .d .When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Record review of the facility ' s Falling Stars Clinical Protocol dated March 30, 2015 revealed that it did not address when to send a resident out for evaluation and treatment after a fall with head injury. An immediate jeopardy (IJ) was identified on 08/14/15 at 12:33pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 08/14/15 at 4:48pm and after several revisions were made it was accepted on 08/17/15 at 8:30am. The POR included in part: 1. Immediate Corrective action was RN C was terminated. 2. Corrective action for additional residents: a. All residents on anticoagulation medication where identified and medical records were reviewed for changes in neurological changes. b. Falling Stars Clinical Protocol and the Anticoagulation Clinical Protocol were changed to address a resident with a fall and possibly sustaining a head injury will be sent to the emergency room immediately for evaluation and treatment. 3. Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change regarding the fall and anticoagulant policies on 08/14/15 by 3:00pm by the Assistant Director of Nursing (ADON.) b. The night shift supervisor will in-service the night shift nurses on the policy change regarding the fall and anticoagulant policies on 08/14/15, 08/15/15 and 08/16/15. c. No nurse will begin working with resident until they have been educated on anticoagulant and fall policies. d. All currently active licensed staff will have been trained by the end of the day on 08/17/15.Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 08/14/15. 4. Incident and accident monitoring began on 08/14/15 and will be reviewed for the changes in policy. The night supervisor will monitor all care plans to ensure new approach for sending residents to the ER for evaluation and treatment after a fall with a head injury has been added. 5. The DON will be responsible for corrective action and completion date for all actions will be 08/17/15. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 08/14/15 until 08/17/15. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment, Falling star program and any resident on anticoagulant medication. Observations were made from 08/14/15 until 08/17/15 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 08/15/15 until 08/17/15 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 08/17/15 at 3:00pm that the IJ was lowered; however the facility remained out of compliance at a isolated level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. Facility 672 dated 08/13/15 listed 45 residents on anticoagulant medication.

Based on interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 1 of 13 residents reviewed for accidents and supervision, following physician orders [REDACTED]. (Close record (CR #1) The Administrator failed to: -- implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent neglect. --implement the facility fall policies and protocols to prevent residents from falling. --supervise the DON to ensure nursing staff transcribed correct telephone orders as expected by physicians. --supervise the DON to ensure that nursing staff were trained on fall prevention and fall management programs. --supervise the DON to ensure that nursing staff put into place effective interventions for fall prevention for Residents on anticoagulants medications. The DON failed to: --train staff to care for and monitor residents with falls resulting in injuries and to recognize and report a change in condition to the physician. --monitor Nursing staff to make sure they were correctly transcribing and following physician's orders [REDACTED]. An IJ was identified on 08/14/15. While the IJ was removed on 08/17/15 the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failure affected 1 resident and placed 45 others residents taking anticoagulant at risk of not receiving needed care and services according to their plan of care. Findings include: CR #1 was found on the floor of her bedroom on 08/08/15 at 4:45am. She told staff that she was getting out of bed to go to the bathroom and fell . She had a large hematoma to her left forehead and abrasions to both knees. The staff conducted neurological checks on CR #1 and from 4:30am until 11:45am it was documented that CR#1's left eye was pinpoint (1mm in size). It was also documented that she was confused. According to assessment prior to the fall she was assessed as coginitvely intact. RN C called the physician's group after the fall and spoke with the NP. RN C then transcribed verbal orders to include cool compress as needed, tylenol for pain and treatment for [REDACTED]. RN C also did not notify the physician or the NP of the changes in CR #1's neurological status. She had a large hematoma on the left side of her forehead and was taking anticoagulant medications. CR #1 was found on the floor of her bathroom and was pronounced dead on 08/08/15 at 9:10pm. In an interview on 08/14/15 1:00 pm the Administrator looked at presented change of condition report for CR # 1- resident on anticoagulant medication, had an injury from a fall and said he would investigate. He said he monitored staff, including the DON, by using the Care Tracker system, annual competency/skills were monitored and performance reviews were used to provide his expectations for the employees. When asked why he thought this Immediate Jeopardy and Substandard Quality of Care happened he said The RN on duty did not followed physician orders [REDACTED]. Interview on 8/14/15 at 4:00pm with the Administrator he said RN C that found CR #1 the first time on the floor with hematoma was terminated. He explained that she did not follow physician's order [REDACTED]. In an interview on 08/13/15 at 3:50pm the Director of Nursing (DON) said the nurses had the following training regarding falls: reviewing the policy and procedure, the CMS definition of falls, seven day assessments, resident's care plan, and communication. When asked how she ensured the nurses were competent in their skill for caring for residents with injuries and are on anticoagulant medication, she said through assessment, monitoring, and following physician's order [REDACTED]. The DON said she thought the IJ and Sub Standard Quality of Care (SQC) happened due to staff not following physician's order [REDACTED]. She said she would have in-service with all staff regarding anticoagulant medication and falls\injuries. In an interview with the DON on 08/13/15 at 3:24pm, she said CR #1 ' s physician was called and a verbal order was given. She said all physician orders [REDACTED]. told her that he does not perform a cat scan on all residents with a bump on the head. Record review of physician orders [REDACTED]. apap 650 mg by mouth and as needed for pain. Follow facility ' s protocol. In an interview with the facility DON on 08/14/15 at 1:00pm she said the nurse on duty RN C did not follow physician orders. She said RN C initially found resident on the floor, did the initial assessment and called physician but did not follow physician's orders [REDACTED]. In an interview on 08/14/415 at 1:30 pm the facility administrator said RN C was terminated because she did not followed facility's protocol and physician orders. Attempt was made to contact with RN C on 08/14/15, 08/15/15 and 08/16/15. Message was left phone calls was not returned. In an interview on 08/17/15 at 2:45pm, LVN B who worked 6:00-2:00pm shift on 08/08/15 said when she saw CR #1 ' s eyes, she asked the outgoing nurse about CR #1 ' s look and she was told that Resident #1' s eyes are usually like that. She said she had not worked with CR# 1 and was not familiar with her look. She said the right side of her face was purple looking as a result of the fall. She said she spoke to CR #1 at about 10:30am and she replied that she was doing fine; she said she offered her midday snack but refuse. She said her family was around her for a while. She said CR# 1 was alright when she left. In an interview on 08/17/15 at 3:00pm, the facility Medical Director also CR#1 ' s attending physician said the fall happen on a weekend. He said the first call came to the call center at about 4:50 am he said standing orders per protocol describing CR #1 ' s fall and injuries were given. He said base on what was said to the physician on call, an x-ray and as needed medication were ordered. He said the next call received was about her being found dead at about 9:10-9:15pm indicating that CR #1 was found on the floor non responsive pronuanced dead at 9:10pm. He said the person on call gave the appropriate orders based on the report that was given at the time of fall. He said base on what was reported he gave the appropriate orders. He said that was a stand by the order. An immediate jeopardy (IJ) was identified on 08/14/15 at 12:33pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 08/14/15 at 4:48pm and after several revisions were made it was accepted on 08/17/15 at 8:30am. The POR included in part: 1. Immediate Corrective action was RN C was terminated. 2. Corrective action for additional residents: a. All residents on anticoagulation medication where identified and medical records were reviewed for changes in neurological changes. b. Falling Stars Clinical Protocol and the Anticoagulation Clinical Protocol were changed to address a resident with a fall and possibly sustaining a head injury will be sent to the emergency room immediately for evaluation and treatment. 3. Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change on fall and anticoagulant policies on 08/14/15 by 3:00pm by the Assistant Director of Nursing (ADON.) b. The night shift supervisor will in-service the night shift nurses on the policy change on fall and anticoagulant policies on 08/14/15, 08/15/15 and 08/16/15. c. No nurse will begin working with resident until they have been educated on anticoagulant and fall policies. d. All currently active licensed staff will have been trained by the end of the day on 08/17/15.Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 08/14/15. 4. Incident and accident monitoring began on 08/14/15 and will be reviewed for the changes in policy. The night supervisor will monitor all care plans to ensure new approach for sending residents to the ER for evaluation and treatment after a fall with a head injury has been added. 5. The DON will be responsible for corrective action and completion date for all actions will be 08/17/15. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 08/14/15 until 08/17/15. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment, Falling star program and any resident on anticoagulant medication. Observations were made from 08/14/15 until 08/17/15 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 08/15/15 until 08/17/15 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 08/17/15 at 3:00pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. Facility 672 dated 08/13/15 listed 45 residents on anticoagulant medication.

Based on observations, interviews and record reviews the facility failed to implement their written policy and procedures that prohibit mistreatment and neglect and abuse for 1 of 13 residents (Closed Records CR #1) reviewed for incident and accidents and care. This was evidenced by: CR #1 experienced a change in condition on 08/08/15 at 4:45 am after she fell in her bedroom. She had a change in her neurological (neuro) status. The physician was not notified of the change in CR#1 ' s neuro status for seven hours after the fall and she was not sent to the hospital for evaluation. She had a large hematoma on the left side of her forehead and was taking anticoagulant (blood thinning) medication.CR #1 was found on the floor of her bathroom and was pronounced dead on 08/08/15 at 9:10pm. An IJ was identified on 08/14/15. While the IJ was removed on 08/17/15 the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed an additional 45 residents taking anticoagulant medications at risk of not receiving care and services, delay in treatment, complications, hospitalization , or death. # 1 and # 2. Findings Include: Record review of CR # 1's Face Sheet revealed she was [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 13 which indicated CR #1 was cognitively intact. CR #1 required limited assistance of one staff for bed mobility and supervision with setup help for ambulation and toileting. She was assessed as not steady but able to stabilize without staff assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer and used a wheelchair. Record review of CR #1 ' s consolidated physician orders [REDACTED]. Record review of CR#1 ' s Medication flow sheet dated 08/01/15-08/31/15 revealed CR# 1 received both her aspirin and [MEDICATION NAME] from 08/01/15-08/08/15. Record review of CR #1 ' s care plan dated 06/19/15 to reflect a fall while transferring self to bathroom. The goal falls will be reduced with no occurrence or injury over the next 90 days; Approaches included encourage resident to ask for assistance from staff, place call light within reach and answer promptly, anticipate the resident ' s needs and provide prompt assistance, assure adequate lighting in room and that room is free from clutter, therapy to evaluate and treat as needed, encourage socialization and activity attendance as tolerated, high raised toilet seat and bed in lowest position, the approaches physical and occupational therapy to screen, move refrigerator across the room (these two approaches were discontinued on 06/25/15 due to resident refused). Have resident call for assistance with transfers . bed in lowest position . non-skid socks while in bed. There was a review date of 07/09/15 with no new problems, goals or approaches were added. There was a date of 08/08/15 with the problem of fall while transferring self from bed to chair. There were no new goals or approaches added with this fall. Record review of facility incident report dated 08/08/15 revealed CR # 1 was observed on the floor at the foot of the bed with her head under a chair lying on her left side. CR #1 had an abrasion to both knees and a large hematoma to the left side of her head. CR#1 did not have on her shoes or non-skid socks as care planned but had on regular socks. Record review of nurse ' s notes dated 08/08/15 at 4:45am (signed by RN C) read in part, Resident on floor of bed with her head under a chair lying on her left side .Resident said she was getting up from her bed going to the bathroom and fell . Resident did not have on her shoes or non-skid socks (as care planned) but had on regular socks. Resident had a large hematoma to the left side of her forehead, abrasions on both knees. Neuros in progress, head to toe assessment done. Physician group called and talked with NP. New orders carried out . Cool compress applied to left forehead .vital sign 167\58, 59, 20, &97 .Left pupil pin point Right eye pupil shaped of a cat pupil . resident on [MEDICATION NAME] and aspirin. Record review of CR #1's clinical record revealed there was no docmentation of the facility reporting the change in CR#1's neurological status to the physician. Record review of CR #1 ' s clinical record revealed there was no further documentation in CR #1 ' s nurse ' s notes until 08/08/15 at 7:00pm. The documentation revealed CR #1 denied pain, Neuros in progress and intact, pupils were equal and reactive to light. Assistance f one person with ADLS and transfers.7:45 pm vital sign 150\77 65, 18, 97.1 Neuro ' s in tacked (Sic). Record review of CR #1 ' s Neurological Evaluation Flow Sheet dated 08/08/15 revealed from 04:30am (prior to the time documented for the fall) until 11:45am CR #1 was assessed has follows: right pupil was five millimeters and had a sluggish reaction to light and the left pupil was one millimeter and brisk reaction to light. Under the section for best verbal response she was assessed as a four, which is listed as confused, from 4:30am until the last neuro check conducted at 7:45pm. Her total Glasgow Coma Scale (GCS) score was between 13 and 14 throughout the day from 4:30am until 7:45pm. A score of 13-14 on GCS indicates mild [MEDICAL CONDITION] according to the instructions on the back of the form. Also as part of the instructions for best verbal response, confused is defined as .the individual cannot answer the questions regarding name, place and date accurately but is still capable of producing phrases, sentences or conversation exchanges. Record review of CR #1 ' s nurse ' s notes dated 08/08/15 at 9:10pm read in part . upon entering room, CR#1 was noted lying on her back on floor of her bathroom with her back against the bathroom wall. No noted pulse, no spontaneous respirations and no heart rate on auscultation. There was no response to painful application. The physician and family were notified .time of death 9:10pm. Record review of Facility ' s investigation summary dated 08/09/15 at 12:00am revealed CR #1 was getting up to the restroom when she fell . Neuros were done. The physician and responsible party were notified. The intervention was to have on non-skid socks while in bed to prevent slipping when getting up. RN B called time of death at 9:10pm. Record review of this investigation report did not include resident change of condition as indicated on her neuros checks and physician orders [REDACTED]. Record review of CR #1 ' s physician ' s telephone order dated 08/08/15 revealed the following: 1. Neuros, 2. Cool compresses time four as needed, 10 minutes each time while awake for 24 hours.3. Abrasions clean with normal saline (NS), pat dry, triple antibiotic ointment and leave open to air. This order was signed as taken by RN C. In an interview with the Director of Nursing (DON) on 08/13/15 at 3:24pm, she said CR #1 ' s physician was called and a verbal order was given. She said all physician orders [REDACTED].#1 ' s forehead, she said CR #1 ' s physician told her that he did not perform a CAT Scan on all residents with a bump on the head. Record review of an email from the physician ' s group to the DON dated 08/14/15 at 1:42pm (requested by Surveyor) revealed the call log from RN C ' s call to report CR #1 ' s fall. It read in part, Reported: fall, unwitnessed no nek (Sic)/body pain . no neuro deficits .abrasions to both knees, hematoma left forehead, vital signs stable, taking aspirin 81mg and [MEDICATION NAME]. Orders: has Tylenol . Verbal orders given per fall SDO (standing orders):x-ray affected area and position for comfort, may use cool application as needed four times for 24 hours for 10 minutes while awake, Tylenol 650 milligrams (mg) by mouth every six hours as needed for pain time 72 hours, not to exceed three grams per 24 hours, monitor for pain, bruising, vital signs, neuro checks every four hours times 24 hours the every shift times 48 hours, make note in communication book . In an interview with the facility DON on 08/14/15 at 1:00pm she said RN C did not follow physician's order [REDACTED]. In an interview on 08/14/15 at 1:30 pm the facility administrator said RN C was terminated because she did not follow facility's protocol and physician orders. Attempt was made to contact with RN C on 08/14/15, 08/15/15 and 08/16/15. Message was left phone calls was not returned. In an interview on 08/17/15 at 2:45pm, LVN B who worked 6:00am-2:00pm on 08/08/15 said when she saw CR #1 ' s eyes, she asked the outgoing nurse (RN C) about CR #1 ' s look and she was told that Resident #1' s eyes were usually like that. She said she had not worked with CR# 1 and was not familiar with her look. She said the right side of her face was purple looking as a result of the fall. She said she spoke to CR #1 at about 10:30am and she replied that she was doing fine; she said she offered her midday snack but refuse. She said her family was around her for a while. She said CR# 1 was alright when she left. Record review of CR #1 ' s previous Neurological Evaluation Flow Sheet dated 06/19/15 revealed the pupils were 3 mm in size and had a brisk reaction to light. She was assessed with [REDACTED]. In an interview on 08/17/15 at 3:00pm, with the Medical Director who was also CR #1 ' s attending physician said the fall happened on a weekend. He said the first call came to the call center at about 4:50 am and standing orders per protocol describing CR #1 ' s fall and injuries were given. He said the person on call gave the appropriate orders based on the report that was given at the time of fall. He said the next call received was about her (CR #1) being found dead at about 9:10-9:15pm. Record review of the facility ' s 24 hour report/change of condition report dated 08/08/15 revealed there was no documentation regarding CR #1 ' s fall or change in neuro status. The only documentation was she passed at 9:10pm. Record review of the Facility ' s Abuse and Neglect Policy and Procedure dated 04/01/14 read in part .residents has the right to be free of abuse .neglect .f. neglect is the failure to provide goods and services necessary to avoid physical harm . i. Possible signs of neglect .5. Untreated medical conditions .II. Reporting and Responding to Resident Abuse .b. investigation of alleged abuse. I The Abuse Coordinator or designee will interview: 1. The person reporting the incident. 2. Any witnesses to the incident .4. All employees on all shifts who have had contact with the resident 24 hours before and after the time of alleged incident . Record review of the facility ' s Anticoagulation Clinical Protocol dated October 2010 revealed it did not address if a Resident on anticoagulation has a fall with a head injury. Record review of the facility ' s Assessing Falls and Their Causes Policy dated October 2010 read in part .1. After a fall .d .When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Record review of the facility ' s Falling Stars Clinical Protocol dated March 30, 2015 revealed that it did not address when to send a resident out for evaluation and treatment after a fall with head injury. An immediate jeopardy (IJ) was identified on 08/14/15 at 12:33pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 08/14/15 at 4:48pm and after several revisions were made it was accepted on 08/17/15 at 8:30am. The POR included in part: 1. Immediate Corrective action was RN C was terminated. 2. Corrective action for additional residents: a. All residents on anticoagulation medication where identified and medical records were reviewed for changes in neurological changes. b. Falling Stars Clinical Protocol and the Anticoagulation Clinical Protocol were changed to address a resident with a fall and possibly sustaining a head injury will be sent to the emergency room immediately for evaluation and treatment. 3. Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change regarding the fall and anticoagulant policies on 08/14/15 by 3:00pm by the Assistant Director of Nursing (ADON.) b. The night shift supervisor will in-service the night shift nurses on the policy change regarding the fall and anticoagulant policies on 08/14/15, 08/15/15 and 08/16/15. c. No nurse will begin working with resident until they have been educated on anticoagulant and fall policies. d. All currently active licensed staff will have been trained by the end of the day on 08/17/15.Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 08/14/15. 4. Incident and accident monitoring began on 08/14/15 and will be reviewed for the changes in policy. The night supervisor will monitor all care plans to ensure new approach for sending residents to the ER for evaluation and treatment after a fall with a head injury has been added. 5. The DON will be responsible for corrective action and completion date for all actions will be 08/17/15. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 08/14/15 until 08/17/15. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment, Falling star program and any resident on anticoagulant medication. Observations were made from 08/14/15 until 08/17/15 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 08/15/15 until 08/17/15 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 08/17/15 at 3:00pm that the IJ was lowered; however the facility remained out of compliance at a isolated level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. Facility 672 dated 08/13/15 listed 45 residents on anticoagulant medication.

Based on interview and record review, the facility failed to provide services in accordance with the written Plan of Care for 1 of 13 residents (CR#1) reviewed for compliance with physician's orders [REDACTED]. CR #1 had a change of condition after a fall and physician orders [REDACTED]. CR#1 did not have her non-skid socks on while in bed to prevent further falls as per her care plan.CR #1 was found on the floor of her bathroom and was pronounced dead on 08/08/15 at 9:10pm. An IJ was identified on 08/14/15. While the IJ was removed on 08/17/15 the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed 45 other residents receiving anticoagulant medication at risk of not receiving safe effective nursing care and services as planned. # 1 and # 2. Findings Include: Record review of CR # 1's Face Sheet revealed she was [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 13 which indicated CR #1 was cognitively intact. CR #1 required limited assistance of one staff for bed mobility and supervision with setup help for ambulation and toileting. She was assessed as not steady but able to stabilize without staff assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer and used a wheelchair. Record review of CR #1 ' s consolidated physician orders [REDACTED]. Record review of CR#1 ' s Medication flow sheet dated 08/01/15-08/31/15 revealed CR# 1 received both her aspirin and [MEDICATION NAME] from 08/01/15-08/08/15. Record review of CR #1 ' s care plan dated 06/19/15 to reflect a fall while transferring self to bathroom. The goal falls will be reduced with no occurrence or injury over the next 90 days; Approaches included encourage resident to ask for assistance from staff, place call light within reach and answer promptly, anticipate the resident ' s needs and provide prompt assistance, assure adequate lighting in room and that room is free from clutter, therapy to evaluate and treat as needed, encourage socialization and activity attendance as tolerated, high raised toilet seat and bed in lowest position, the approaches physical and occupational therapy to screen, move refrigerator across the room (these two approaches were discontinued on 06/25/15 due to resident refused). Have resident call for assistance with transfers . bed in lowest position . non-skid socks while in bed. There was a review date of 07/09/15 with no new problems, goals or approaches were added. There was a date of 08/08/15 with the problem of fall while transferring self from bed to chair. There were no new goals or approaches added with this fall. Record review of facility incident report dated 08/08/15 revealed CR # 1 was observed on the floor at the foot of the bed with her head under a chair lying on her left side. CR #1 had an abrasion to both knees and a large hematoma to the left side of her head. CR#1 did not have on her shoes or non-skid socks as care planned but had on regular socks. Record review of nurse ' s notes dated 08/08/15 at 4:45am (signed by RN C) read in part, Resident on floor of bed with her head under a chair lying on her left side .Resident said she was getting up from her bed going to the bathroom and fell . Resident did not have on her shoes or non-skid socks (as care planned) but had on regular socks. Resident had a large hematoma to the left side of her forehead, abrasions on both knees. Neuros in progress, head to toe assessment done. Physician group called and talked with NP. New orders carried out . Cool compress applied to left forehead .vital sign 167\58, 59, 20, &97 .Left pupil pin point Right eye pupil shaped of a cat pupil . resident on [MEDICATION NAME] and aspirin. Record review of CR #1's clinical record revealed there was no docmentation of the facility reporting the change in CR#1's neurological status to the physician. Record review of CR #1 ' s clinical record revealed there was no further documentation in CR #1 ' s nurse ' s notes until 08/08/15 at 7:00pm. The documentation revealed CR #1 denied pain, Neuros in progress and intact, pupils were equal and reactive to light. Assistance f one person with ADLS and transfers.7:45 pm vital sign 150\77 65, 18, 97.1 Neuro ' s in tacked (Sic). Record review of CR #1 ' s Neurological Evaluation Flow Sheet dated 08/08/15 revealed from 04:30am (prior to the time documented for the fall) until 11:45am CR #1 was assessed has follows: right pupil was five millimeters and had a sluggish reaction to light and the left pupil was one millimeter and brisk reaction to light. Under the section for best verbal response she was assessed as a four, which is listed as confused, from 4:30am until the last neuro check conducted at 7:45pm. Her total Glasgow Coma Scale (GCS) score was between 13 and 14 throughout the day from 4:30am until 7:45pm. A score of 13-14 on GCS indicates mild [MEDICAL CONDITION] according to the instructions on the back of the form. Also as part of the instructions for best verbal response, confused is defined as .the individual cannot answer the questions regarding name, place and date accurately but is still capable of producing phrases, sentences or conversation exchanges. Record review of CR #1 ' s nurse ' s notes dated 08/08/15 at 9:10pm read in part . upon entering room, CR#1 was noted lying on her back on floor of her bathroom with her back against the bathroom wall. No noted pulse, no spontaneous respirations and no heart rate on auscultation. There was no response to painful application. The physician and family were notified .time of death 9:10pm. Record review of Facility ' s investigation summary dated 08/09/15 at 12:00am revealed CR #1 was getting up to the restroom when she fell . Neuros were done. The physician and responsible party were notified. The intervention was to have on non-skid socks while in bed to prevent slipping when getting up. RN B called time of death at 9:10pm. Record review of this investigation report did not include resident change of condition as indicated on her neuros checks and physician orders [REDACTED]. Record review of CR #1 ' s physician ' s telephone order dated 08/08/15 revealed the following: 1. Neuros, 2. Cool compresses time four as needed, 10 minutes each time while awake for 24 hours.3. Abrasions clean with normal saline (NS), pat dry, triple antibiotic ointment and leave open to air. This order was signed as taken by RN C. In an interview with the Director of Nursing (DON) on 08/13/15 at 3:24pm, she said CR #1 ' s physician was called and a verbal order was given. She said all physician orders [REDACTED].#1 ' s forehead, she said CR #1 ' s physician told her that he did not perform a CAT Scan on all residents with a bump on the head. Record review of an email from the physician ' s group to the DON dated 08/14/15 at 1:42pm (requested by Surveyor) revealed the call log from RN C ' s call to report CR #1 ' s fall. It read in part, Reported: fall, unwitnessed no nek (Sic)/body pain . no neuro deficits .abrasions to both knees, hematoma left forehead, vital signs stable, taking aspirin 81mg and [MEDICATION NAME]. Orders: has Tylenol . Verbal orders given per fall SDO (standing orders):x-ray affected area and position for comfort, may use cool application as needed four times for 24 hours for 10 minutes while awake, Tylenol 650 milligrams (mg) by mouth every six hours as needed for pain time 72 hours, not to exceed three grams per 24 hours, monitor for pain, bruising, vital signs, neuro checks every four hours times 24 hours the every shift times 48 hours, make note in communication book . In an interview with the facility DON on 08/14/15 at 1:00pm she said RN C did not follow physician's order [REDACTED]. In an interview on 08/14/15 at 1:30 pm the facility administrator said RN C was terminated because she did not follow facility's protocol and physician orders. Attempt was made to contact with RN C on 08/14/15, 08/15/15 and 08/16/15. Message was left phone calls was not returned. In an interview on 08/17/15 at 2:45pm, LVN B who worked 6:00am-2:00pm on 08/08/15 said when she saw CR #1 ' s eyes, she asked the outgoing nurse (RN C) about CR #1 ' s look and she was told that Resident #1' s eyes were usually like that. She said she had not worked with CR# 1 and was not familiar with her look. She said the right side of her face was purple looking as a result of the fall. She said she spoke to CR #1 at about 10:30am and she replied that she was doing fine; she said she offered her midday snack but refuse. She said her family was around her for a while. She said CR# 1 was alright when she left. Record review of CR #1 ' s previous Neurological Evaluation Flow Sheet dated 06/19/15 revealed the pupils were 3 mm in size and had a brisk reaction to light. She was assessed with [REDACTED]. In an interview on 08/17/15 at 3:00pm, with the Medical Director who was also CR #1 ' s attending physician said the fall happened on a weekend. He said the first call came to the call center at about 4:50 am and standing orders per protocol describing CR #1 ' s fall and injuries were given. He said the person on call gave the appropriate orders based on the report that was given at the time of fall. He said the next call received was about her (CR #1) being found dead at about 9:10-9:15pm. Record review of the facility ' s 24 hour report/change of condition report dated 08/08/15 revealed there was no documentation regarding CR #1 ' s fall or change in neuro status. The only documentation was she passed at 9:10pm. Record review of the Facility ' s Abuse and Neglect Policy and Procedure dated 04/01/14 read in part .residents has the right to be free of abuse .neglect .f. neglect is the failure to provide goods and services necessary to avoid physical harm . i. Possible signs of neglect .5. Untreated medical conditions .II. Reporting and Responding to Resident Abuse .b. investigation of alleged abuse. I The Abuse Coordinator or designee will interview: 1. The person reporting the incident. 2. Any witnesses to the incident .4. All employees on all shifts who have had contact with the resident 24 hours before and after the time of alleged incident . Record review of the facility ' s Anticoagulation Clinical Protocol dated October 2010 revealed it did not address if a Resident on anticoagulation has a fall with a head injury. Record review of the facility ' s Assessing Falls and Their Causes Policy dated October 2010 read in part .1. After a fall .d .When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Record review of the facility ' s Falling Stars Clinical Protocol dated March 30, 2015 revealed that it did not address when to send a resident out for evaluation and treatment after a fall with head injury. An immediate jeopardy (IJ) was identified on 08/14/15 at 12:33pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 08/14/15 at 4:48pm and after several revisions were made it was accepted on 08/17/15 at 8:30am. The POR included in part: 1. Immediate Corrective action was RN C was terminated. 2. Corrective action for additional residents: a. All residents on anticoagulation medication where identified and medical records were reviewed for changes in neurological changes. b. Falling Stars Clinical Protocol and the Anticoagulation Clinical Protocol were changed to address a resident with a fall and possibly sustaining a head injury will be sent to the emergency room immediately for evaluation and treatment. 3. Training and Education a. All licensed nurses on day and evening shift were in-serviced in policy change regarding the fall and anticoagulant policies on 08/14/15 by 3:00pm by the Assistant Director of Nursing (ADON.) b. The night shift supervisor will in-service the night shift nurses on the policy change regarding the fall and anticoagulant policies on 08/14/15, 08/15/15 and 08/16/15. c. No nurse will begin working with resident until they have been educated on anticoagulant and fall policies. d. All currently active licensed staff will have been trained by the end of the day on 08/17/15.Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 08/14/15. 4. Incident and accident monitoring began on 08/14/15 and will be reviewed for the changes in policy. The night supervisor will monitor all care plans to ensure new approach for sending residents to the ER for evaluation and treatment after a fall with a head injury has been added. 5. The DON will be responsible for corrective action and completion date for all actions will be 08/17/15. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 08/14/15 until 08/17/15. The topics included in part: Fall prevention; Fall Precaution, Fall Assessment, Falling star program and any resident on anticoagulant medication. Observations were made from 08/14/15 until 08/17/15 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 08/15/15 until 08/17/15 between 10:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 08/17/15 at 3:00pm that the IJ was lowered; however the facility remained out of compliance at a isolated level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. Facility 672 dated 08/13/15 listed 45 residents on anticoagulant medication.

Based on observaton, interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 3 of 7 residents reviewed for accidents and supervision. (Residents # 3, #21 and #22) , for 2 of 2 residents (Resident #23 and Resident #24) that were reviewed for feeding assistance and to have a Qualified Activity Director. The Administrator failed to: -- implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent neglect. --implement the facility fall policies and protocols to prevent residents from falling. --supervise the DON to ensure nursing staff completed accurate care plans to address resident's with falls. --supervise the DON to ensure that nursing staff were trained on fall prevention and fall management programs. --supervise the DON to ensure that nursing staff put into place effective interventions for fall prevention for Residents with dementia. --failed to ensure staff was trained and able to care for residents with falls. --to ensure that the facility had a Qualified Activity Director --ensure that Residents with swallowing difficulties were assisted with feeding by qualified staff. Housekeeping was feeding staff without adequate training. The DON failed to: Monitor and supervise the development of resident care plans for falls. Train staff to be able to identify residents' at risk for falls. Train and monitor the staff on Fall Prevention and Fall Management Program Train and monitor the nursing staff on revising care plans with effective interventions for residents at risk for falls or had actually fallen. Ensure that Residents with swallowing difficulties were assisted with feeding by qualified staff. Housekeeping was feeding staff without adequate training. These failures affected 5 residents and placed 90 residents at risk for falls, injury, inadequate food intake, decline in health status and a decreased quality of life. Findings include: Interview on 05/27/15 at 11:30am the Administrator said the facility has several processes and procedures to ensure that the residents' needs were being met. He said the family and resident could be interviewed to find out preferences and then the employees would be informed of their care needs. He said he monitored staff, including the DON, by using the CareTracker system, annual competency/skills were monitored and performance reviews were used to provide his expectations for the employees. When asked why he thought this Immediate Jeopardy and Substandard Quality of Care happened he said the residents' care plan was not being used to provide their care. Interview on 05/27/15 at 2:00pm the DON said the nurses had the following training regarding falls: reviweing the policy and procedure, the CMS definition of falls, seven day assessments, resident's care plan, and communication. When asked how she ensured the nurses were competent in their skilld for caring for residents with falls she said through assessment and monitoring and communication. The DON said the plan that was in place for falls was that since she had started working at the facility she had started a Care Resource Team that met weekly. She said she thought the IJ and SQC happened due to staff failed to document inteventions on the care plans. In an interview on 05/21/15 at 4:00pm the facility administrator said the activity director left few months ago and he was in the process of looking for a qualified Activity Director. Interview on 5/25/2015 at 1:30 pm the DON said they did not have any paid feeding assistants and that all residents being assisted have been okay by speech therapy to be feed by staff. All of our staff is trained to feed residents that are dependent and who have swollowing difficulities. Interview on 05/26/15 at 1:00pm with the Administrator and DON revealed that the facility did allow housekeepers that had been through training to feed the residents. When asked if the housekeepers should be feeding residents with swaloowing difficulties the Administrator said no, they should only assist resident that need cuing and help physically raising the utensil to their mouths. He also said the the housekeepers that were feeding residents had been through a training program that was comparable to the State training. Interview on 05/26/15 at 2:15pm with the DON and ADON revealed that the documentation of training for the housekeepers could not be located as it was not in their files. Interview on 5/27/2015 at 3:00 pm the administrator said that the feeding program at the facility was instituted by the previous administrators; he was not aware that the practice was still in effect however, the practice would cease immediately. Resident #3 Review of Resident #3 ' s Face Sheet revealed she was [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #3 had multiple falls that included a fall that led to a hospital stay and fracured skull. When Resident #3 returned to the facility there were no effective measures put in place to prevent further falls. The resident was observed wearing inappropriate foot wear (one sock on one foot only and no shoes) and had another fall after she returned from the hospital. Observation on 05/20/15 at 10:00am revealed resident #1 was lying down on her bed in her room. Observation revealed her bed was in the highest position. In an interview at this time CNA G said the bed was supposed to be in low position. She said the person who made the bed might have forgotten to lower it down. In an interview on 05/20/15 at 3:00pm Assistant Director of Nursing (ADON) said Resident # 3 had multiple falls and her care plan would be updated to reflect her current condition. Observation on 05/21/15 at 8:40am revealed Resident # 3 sitting in the dining area conversing with herself. Observation revealed she had socks on one leg (her right leg) and none on her left leg. Resident was not interviewable. She was alert and awake but not oriented. Further observation revealed one CNA in the dining area attending to a resident in the bathroom. In an interview on 05/22/15 at 11:00am, the DON said she was reviewing all residents with fall to address the situation. She said residents ' plan of care should reflect their condition. Resident #21 Review of Resident #21's Face Sheet revealed the [AGE] year old male was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #21had a fall that led to laceration to the left side forehead, an abrasion to the left elbow and left thumb and a swollen left wrist. There were no revison of his care plan and no effective measures put in place to prevent him from further falls. Review of Resident #21 ' s nurse ' s notes dated 5/14/2015 documented that he fell in the dining room sustaining a laceration to the left side of his forehead, an abrasion to the left elbow and left thumb. No other documentation was provided concerning the fall. Record review of the facility's incident reports from March 2015 to May 2015 revealed there was not an incident report completed for Resident #21's fall on 05/14/15. Observation on 05/24/2015 at 1:24 PM revealed Resident # 21 lying in bed. Resident # 21 was awake and his left wrist did show some slight swelling but no bruising was noted. Resident #21 was able to move his wrist. Interview on 5/24/2015 at 1:30 pm Resident # 21 said another resident was kicking him so he tried to get away from him by getting out of his wheelchair. The Resident said he stood up trying to move away and lost his balance and fell hitting his head against the table and landed on his wrist trying to break the fall. Resident #21 said he did not remember much after that but woke up in his room. Interview on 5/24/2015 at 2:00 pm with Licensed Vocational Nurse (LVN) C who said the reason Resident # 21 had x-rays done was because he was complaining of pain and cried out when his left wrist was touched. At the time of the fall his left wrist was swollen and had some bruising. LVN C said Resident # 21 said he could not remember what happened. She said she was not at work on the day the Resident had the fall but in report was told to monitor him. Interview on 5/25/2015 at 12:30 pm with the DON she said she was unable to find the incident report concerning the fall of Resident # 21 and would have to look into the matter to ascertain what actions the staff took to care for the Resident. Resident # 22 Review of Resident # 22's Face Sheet revealed the [AGE] year old male was admitted to the facility on [DATE]. Resident # 22's [DIAGNOSES REDACTED]. Observation on 05/22/2015 at 11:24 am Resident # 22 was sitting at dining table on the memory care unit alert and oriented to name only although relating well with others residents sitting at his table. The Resident had multiple ecchymosis (bleeding from broken vessels underneath the skin) areas to his forehead and one large band aid to his left thumb. Interview on 5/22/2015 at 11:30 am with Resident # 22 he said he was doing well. Resident #22 was unable to explain how he obtained his injuries. Interview on 5/23/2015 with at 12:15 pm LVN E who said the reason Resident # 22 had a witnessed fall near his room. LVN E was not sure what day it happened. She said she was given report that he had fallen and sustained injuries. She said an incident report should have been completed after the fall but she did not know if one was done or not. We do not keep any records on the unit about falls. The incidents are given to the DON or ADONs. From there she did not know what happened to them but she did know that there was an incident book. Interview on 5/25/2015 at 1:30 pm with the DON who said she was unable to find the incident report concerning the fall of Resident # 22 and would have to look into the matter to ascertain what actions the staff took to care for the resident. Follow up interview 5/25/2015 at 3:00 pm with DON who said she looked in the matter but was unable to find the incident report. The state was unable to remember any details of the accident. Resident #23 Record review of Resident # 23's face sheet revealed a [AGE] year old male who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #23's care plan dated 4/2/15 read in part, Problem: Swallowing dificulty related to condition associated with [MEDICAL CONDITION] for thick liquids and puree diet.Approach: Serve foods in safest form for consumption. Feeding assistant at meals. Review of Comprehensive care plan dated 04/02/15 did not address non-nursing staff feeding resident. Observation on 5/24/2015 at 12:30 pm HK K was feeding Resident #23 his lunch. Obersvation on 5/25/2015 at 12:25 revealed Resident #23 was having difficulties swallowing while being fed by CNA F. Interview on 5/23/2015 at 11:45 am Resident ' s #23 ' s family members said that they had observed the housekeepers feeding Resident # 23. They said that the housekeeper mixed all of the Resident ' s pureed food together in one heaping pile and feed the resident so fast that the resident started choking. The resident was choking so severely that he started to turn a different color. In an interview on 5/24/2015 at 12:00 pm HK K said that she received training for assisting residents with eating about two years ago when she started working for the facility; the class that was provided was a part of their skills check list and they had to watch a video on feeding resident at that time. In an interview on 05/24/15 at 1:40pm HK M said that she did feed residents and most of the time she would feed Resident #23. Resident #24 Record review of Resident # 24's face sheet revealed a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A ' gitans, altered mental status, dementia with behavior disturbances and muscle wasting and disuse. Resident #24 was being fed by HK L. Resident #224 had difficulty swallowing and HK L did not have training in assisting resident with eating. He also had documented weight loss. Record review of Resident #24's care plan dated 01/2915 read in part, Problem.swallowing difficulty related to condition associated with [MEDICAL CONDITION]: provide food safely.Approaches: 1) Provide feeding assist at meals, 2) serve diet as tolerated, 3) monitor intake, weights. Observation on 5/24/2015 at 12:30 pm HK L was feeding Resident #24 his lunch. Interview on 5/27/2015 at 1:35 pm housekeeper L said she had been trained to feed dependent residents. That she had taken the course two years ago at the facility. She further added the training was provided by video for one hour. She also said that she did not have a copy of the feeding training. Interview on 5/25/2015 at 12:00 pm LVN C said that the housekeepers could feed residents as long as they had been trained. All of the staff feeding the residents now have all been trained to do so. Interview on 5/27/2015 at 1:35 pm housekeeper L said she had been trained to feed dependent residents. That she had taken the course two years ago at the facility. She further added the training was provided by video for one hour. She also said that she did not have a copy of the feeding training. Activity director Observation on 05/19/15 between 9:00am and 2:00pm revealed multiple small group activities going on at different station of the facility. Groups were supervised by restorative aids and CNAs Interview on 05/20/15 at 9:30 in an attempt to schedule resident ' s group meetings, CNA H said the facility does not have an activity director. She said she put the activity colander together and the facility administrator and the social worker reviewed it for approval. She said the activity director left few months ago. Record review of facility ' s pay records for the activity director, revealed her last day at the facility was 10/24/14. In an interview on 05/21/15 at 4:00pm the facility administrator said the activity director left few months ago and he was in the process of looking for a qualified Activity Director. No further information was provided prior to exit on 05/27/15. An IJ was identified on 05/22/15 at 10:40am and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 05/25/25 at 5:00 pm and after several revisions were made it was accepted on 05/27/15 at 3:40pm. The POR included in part: 1. Immediate corrective action for Resident #3 a. Resident is to sit while being showered. b. Walkway to be cleared and cluttered. c. Evaluation of medications. d. Remove wet floor sign when floor is dry. e. Updated Resident #3 ' s care plan to include all interventions listed above on 05/22/15. f. On 5/23/15 Received new shoes. g. On 05/24/15 Resident #3 ' s care plan was updated to include the following interventions: i. Resident to use new shoes. ii. Resident will be allowed her preference to sleep in and be social during the evening and night. iii. All staff will be required to log in to the CareTracker system at the beginning of their shift to receive messages regarding Resident #3 ' s care. The DON will be responsible for this corrective action. 2. Corrective Action for Residents identified as having a fall are as follows: a. A review of all Incident and Accident reports since February were reviewed to identify residents at risk for falls. This was completed on 05/22/15. b. On 05/24/15 communication to all staff was placed in the resident ADL and Assessment Documentation system (CareTracker). All staff must log into CareTracker at the beginning of their shift and read all communication for change in residents ' plan of care. The CareTracker records time and date when staff view this communication. 3. Training and Education a. All Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 05/22/15. b. The Charge Nurse on each shift will educate the RNs, LVNs, CMAs, and CNAs on each relieving shift on following the resident Care Plan. This was completed by 05/26/15. c. All licensed nursing staff at St James House on duty on 5/22/2015 were educated and trained by the DON regarding: i. Completion of a Fall Risk Evaluation Form upon admission and implementation of risk interventions. ii. Documentation and communication required post fall. iii. CareTracker was reviewed to ensure that all staff had access. This was completed on 05/26/15. d. All employees were trained before returning to work. The DON and ADON is responsible for this action. 4. Beginning 05/22/15 the night supervisor will ensure that all new admissions have a Fall Risk Evaluation and that all documentation is done for residents post fall. 5. The Care Resource Team will review all falls weekly, will make recommendations and report to the QAPI Committee. 6. On 05/26/15 the CRT team reviewed all falls since February 2015. The team made recommendations and implemented those on the care plans of the identified residents. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 05/25/15 until 05/27/15.The topics included in part: Fall prevention; Fall Precaution, Fall Assessment and Falling star program. Interviews conducted from 05/25/15 until 05/27/15 between 9:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 05/27/15 at 4:00pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. Record review of facility ' s policy dated 04/01/14 read in part .residents has the right to be free of .neglect .f. Neglect is the failure to provide goods and services necessary to avoid physical harm .i. Possible signs of neglect .3. Inadequate clothing . The Form CMS 672 listed a census of 95 residents.

Based on observation, interview and record review the facility failed to ensure 3 of 20 residents (Residents #3, #21 and #22) reviewed for accidents and supervision received adequate supervision to prevent a fall with injury. Resident #3 had 4 falls from March 2015 to May 2015. On 04/19/15 she had a fall where she suffered a skull fracture and required a hospital stay. The facility did not revise her care plan and put in place effective interventions to prevent further falls. Resident #3 had another fall on 05/01/15 after returning to the facility from the hospital. Resident #21 had a fall on 05/14/15 that resulted in minor injuries. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. Resident #22 had a fall on 05/12/15 with minor injuries. There was no incident report completed An IJ was identified on 05/22/15. While the IJ was removed on 05/27/15 the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 3 residents and placed 92 residents at risk of injury from lack of proper and adequate supervision. Findings Include: Resident #3 Record review of Resident #3's Face Sheet revealed the [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3 ' s admission Minimum Data Set ((MDS) dated [DATE] revealed Brief Intervention for Mental Status (BIMS) of 03 which indicates severe cognitive impairment. Record review of Care Assessment Area (CAA) summary revealed resident was triggered for cognitive loss, visual function and falls. Resident #3 was assessed at needing limited assistance of one staff member for all ADLs. Walking in room was assessed as needing the supervision of one staff member. She was coded as not steady but able to stabilize without staff assistance for moving from seated to standing position, walking, turning around, and surface-to-surface transfers. She had no history of falls. Record review of Resident #3's Care plan dated 07/16/14 read in part, Problem: Resident has a history of falls and is at risk for increased falls and fractures as evidenced by cognitive impairment and unsteady gait.Goal: Dignity will be maintained and falls will be reduced and occurrence of injury will occur over the next 90 days. Approaches. Encourage resident to ask for assistance of staff. Ensure call light is in reach and answer promptly.Anticipate needs, provide prompt assistance.assure lighting is adequate and areas are free of clutter.low bed.floor mat. (The last two interventions were written in the care plan with no date of when they were added.) There were review dates listed as 10/14/14, 01/15/15, 04/14/15 and 05/05/15. Record review of the facility's Accident and Incident Reports from March 2015 to May 2015 revealed that Resident #3 had 6 falls. The fall on 04/19/15 resulted in skull fracture, intracerebral hemorrhage and a hospital stay. Record review of Resident #3's Incident Report dated 04/19/15 at 4:00am -Resident #3 was found on the floor on her left side in her room. She was bleeding from her left eyebrow. The intervention listed was change in activities. It was documented as Resident #3 had a one inch laceration to her left eyebrow area with a hematoma forming. Her blood pressure was 160/100. She was sent to the local Hospital at 4:20am. Record review of the Facility ' s investigation of the incident dated 04/19/15 read in part . It was documented that Resident #3 was ambulatory and there was no change in ambulation or medication .There was a chair in her path in her room .[DIAGNOSES REDACTED]. Record review of the witness statement for the incident dated 04/19/15 revealed that staff heard a noise when Resident #3 fell but none of the staff witnessed the fall. Record review of Resident #3 ' s Nurse ' s notes dated 04/19/15 at 4:00am read in part, the Nurse was called to Resident #3 ' s room. She was on the floor and bleeding from the left side of her head near her eyebrow. Pressure was applied to the wound, vital signs were taken with her blood pressure being 160/100 .the physician was notified and order was received to send Resident #3 to the hospital .she was sent to the ER at 4:20am. Record review of Resident #3's hospital records dated 04/19/15 revealed admitting [DIAGNOSES REDACTED]. The CT scan of the head revealed that she had a right occipital skull fracture with no displacement as well as bilateral subdual effusion and multiple intraparenchymal hemorrhages (bleeding in the main part of the brain) bin bilateral frontal lobes, largest being approximately 0.9cm in the left frontal lobe .She was transferred to local hospital for higher level of care. Record review of Resident #3 ' s Nurse ' s note dated 04/22/15 read in part, Resident readmitted to facility .Head to toe assessment done .right second and third finger had purple discolorations and red dots .Left leg has a purple and yellow discoloration on outer aspect of leg, yellow discoloration to left knee, discoloration to outer aspect of right knee, purple discoloration on left hip and two areas of purple discoloration on upper right arm. There was a skin tear located on Resident #3 ' s left elbow, a scab to her left eye, yellowish discoloration to the left side of her face and purplish discoloration on her left chin area. Record review of Resident #3 ' s Nurse ' s note dated 04/27/15 at 12:35pm read in part . status [REDACTED]. She had an unsteady gait and continues to favor right hip, she has a discoloration under left eye and the left side of her face and left hip. She has a scabbed area located on the back of her head. Observation of Resident #3 throughout the survey from 05/19/15 to 05/27/15 in the Secure Unit revealed resident was walking around without assistance. Observation and interview on 05/20/15 at 10:00am revealed Resident #3 was lying down on her bed. Her bed was in the highest position. In an interview at this time Certified Nursing Assistant (CNA) G said the bed should be in the low position. She said the person who made the bed might have forgotten to lower it back down. In an interview on 05/20/15 at 3:00pm Assistant Director of Nursing (ADON) said Resident # 3 had multiple falls and her care plan would be updated to reflect her current condition. Interview with the ADON on 05/21/15 at 4:30pm revealed she reviewed and signed all care plans but had not revised them; including Resident #3's care plan. Record review of Resident #3 ' s Accident/Incident Reports revealed the following: 03/05/15- Resident #3 had a fall in the bathroom, intervention have resident seated while in shower. 03/18/15- Resident #3 was found sitting upright on the floor. She was confused. The intervention listed was make frequent rounds. 04/13/15 at 10:00am- Resident #3 was found on the floor in the lobby of the secure unit. It stated that there was wound care but does not describe the wound. Interventions taken to prevent recurrence were keep walkway clear and uncluttered and that this was an isolated incident. Record review of facility ' s investigation of the incident dated 04/13/15 read in part . resident was ambulatory and had not had a change in ambulation or medication .staff described most recent transfer of the Resident as independently transfers .[DIAGNOSES REDACTED]. Record review of witness statement dated 04/13/15 read in part .a staff member was in another resident ' s room administering medication when she heard a big noise and came out to the lobby area to find Resident #3 on the floor . 04/16/15 at 4:00am- Resident #3 was yelling out for help. She was found on the floor, lying face up legs extended toward her bed. She was confused and unable to describe event. Resident #3 had a skin tear located on her left forearm. It was documented that Resident #3 had a triangle shape open area under her left eye and one centimeter laceration under left eye. It was also documented that her right eye was bleeding. The intervention was provide adequate lighting, evaluate medication and bed checks every 30 minutes to an hour. Record review of the facility ' s investigation of the incident dated 04/16/15 read in part . Resident #3 was ambulatory, there had been a change in her ambulation and her medication .Her Depakote was decreased from 500mg to 250mg one by mouth twice a day . The most recent transfer was described staff as Resident #3 required assistance related to an unsteady gait at times .[DIAGNOSES REDACTED]. Record review of the witness statement dated 04/16/15 read in part .the staff member heard someone yelling and .Resident #3 was on the floor in her room lying on her side in front of the night stand. Record review of physician's order [REDACTED]. Start date on order was 04/22/15. 05/01/15 at 3:00pm- Resident #3 was discovered lying on the floor in the hallway of the secure unit. The Resident was unable to recall what happened. She was confused. Interventions were to in-service housekeeping on removing the wet floor signs, Occupational therapy to evaluate shoes Resident #3 ' s shoes and to replace glasses as her old glasses where left at the hospital. Record review of Facility ' s Investigation of the Incident dated 05/01/15 (no time provided) read in part .2. The Resident was ambulatory and the Resident had experienced a change in ambulation. There was no recent change in the Resident ' s medication .[DIAGNOSES REDACTED]. Observation on 05/21/15 at 8:40am revealed Resident #3 was sitting in the dining area conversing with herself. She had a sock on her right foot and none on her left foot. She did not have any shoes on at this time. Resident #3 was not interviewable due to her cognitive status. She was alert and awake but not oriented. Further observation revealed one CNA in the secured unit attending to a resident in the bathroom. There was no other staff visible at this time. In an interview on 05/22/15 at 11:00am, the Director of Nursing (DON) said she was reviewing all residents with falls to address the situation. She said the resident ' s care plan should reflect their condition. In an interview on 05/22/15 at 8:40am, CNA H said Resident #3 was confused and would take off her socks sometimes. She said the Resident did not have shoes and her family was supposed to get her some. She said Resident #3 has had multiple falls. Resident #21 Review of Resident #21's Face Sheet revealed the [AGE] year old male was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident's # 21 ' s Quarterly MDS assessment dated [DATE] revealed a BIMS of 12. The resident ' s functional status according to MDS reports extensive assistance to provide weight bearing support. Review of the assessment reflected Resident # 21 required extensive assistance of one person for bed mobility, transfer and toileting use and one person for bathing and currently utilizes a wheelchair. Review of Resident #21 ' s nurse ' s notes dated 5/14/2015 documented that he fell in the dining room sustaining a laceration to the left side of his forehead, an abrasion to the left elbow and left thumb. No other documentation was provided concerning the fall. Review of Resident # 21's Comprehensive Care Plan dated 05/14/2015 did not reflect his fall with injuries on 5/14/2015 at 3:15 pm. The care plan was not revised to include effective interventions to prevent the Resident from further falls. Record review of the facility's incident reports from March 2015 to May 2015 revealed there was not an incident report completed for Resident #21's fall on 05/14/15. Record review of Resident #21's physician's orders [REDACTED]. Observation on 05/24/2015 at 1:24 PM revealed Resident # 21 was lying in bed. He was awake and his left wrist did show some slight swelling but no bruising was noted. Resident #21 was able to move his wrist. Interview on 5/24/2015 at 1:30 pm Resident # 21 said another resident was kicking him so he tried to get away from him by getting out of his wheelchair. The Resident said he stood up trying to move away and lost his balance and fell hitting his head against the table and landed on his wrist trying to break the fall. Resident #21 said he did not remember much after that but woke up in his room. Interview on 5/24/2015 at 2:00 pm with Licensed Vocational Nurse (LVN) C she said the reason Resident # 21 had x-rays done was because he was complaining of pain and cried out when his left wrist was touched. At the time of the fall his left wrist was swollen and had some bruising. LVN C said Resident # 21 said he could not remember what happened. She said she was not at work on the day the Resident had the fall but in report was told to monitor him. Interview on 5/25/2015 at 12:30 pm with the DON she said she was unable to find the incident report concerning the fall of Resident # 21 and would have to look into the matter to ascertain what actions the staff took to care for the Resident. Resident # 22 Review of Resident # 22's Face Sheet revealed the [AGE] year old male was admitted to the facility on [DATE]. Resident # 22's [DIAGNOSES REDACTED]. Record review of Resident #22's care plan dated 03/04/14 read in part, Problem: Resident has a history of falls and is at risk for increased falls and fractures. Goal.incidence of falls will be reduced and no occurrence of injury over next 90 days. Approach.encourage resident to ask for assistance from staff.ensure call light is in reach, answer promptly.anticipate needs, provide prompt assistance. assure lighting is adequate and areas are free from clutter.bright color tape on breaks for visual cues, review of medication. (The last two interventions were added 05/14/15.) Record review of Resident #22's incident report dated 5/12/2015 read in part the physician was notified concerning the injury of Resident # 22. According to the incident report the resident fell at 7:45 pm in his room. resident sustained [REDACTED]. It was reported that the Resident was alert but very confused. The fall was unwitnessed and he was not sent to hospital for mental confusion status [REDACTED]. Record review of Resident #22 ' s treatment records revealed 05/12/15-Cleanse skin tear to right palm with normal saline dry and apply dressing continue until resolved. Record review of Resident #22's Radiology report dated 5/16/2015 revealed x-ray of left hip and femur status [REDACTED]. Review of the facility's accident/incident reports revealed Resident # 22 had two other documented falls on: 2/9/2015: Resident # 22 at 6:45 am was found in his room on the floor beside his wheelchair. The fall was unwitnessed. No injuries were sustained. 4/13/2015 at 2:00 pm resident # 22 was found on floor in hallway by medication aide who said resident's wheelchair was a few feet away from the resident. Resident was alert to person only. Incident report read resident had some discoloration on his body but the report does not indicate the locations of bruises. Observation on 05/22/2015 at 11:24 am Resident # 22 was sitting at dining table on the memory care unit alert and oriented to name only although relating well with others residents sitting at his table. The Resident had multiple ecchymosis (bleeding from broken vessels underneath the skin) areas to his forehead and one large band aid to his left thumb. Interview on 5/22/2015 at 11:30 am with Resident # 22 he said he was doing well. Resident #22 was unable to explain how he obtained his injuries. Interview on 5/23/2015 with at 12:15 pm LVN E who said Resident # 22 had a witnessed fall near his room. LVN E was not sure what day it happened. She said she was given report that he had fallen and sustained injuries. She said an incident report should have been completed after the fall but she did not know if one was done or not. We do not keep any records on the unit about falls. The incidents are given to the DON or ADONs. From there she did not know what happened to them but she did know that there was an incident book. Interview on 5/25/2015 at 1:30 pm the DON said she was unable to find the incident report concerning the fall of Resident # 22 and would have to look into the matter to ascertain what actions the staff took to care for the resident. Follow up interview 5/25/2015 at 3:00 pm the DON said she looked in the matter but was unable to find the incident report. The staff was unable to remember any details of the accident. Falling stars clinical protocol: Goal: 1-Prevent falls and serious injury 2-Recognize multifactorial risk and courses of falls in older adult. 3- Institute recommendations for falls prevention and management consist with clinical guidelines and standard of care. Steps; Assessments. Assess and document resident care environment routinely for extrinsic risk factors to the fall and institute corrective action; An IJ was identified on 05/22/15 at 10:40am and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 05/25/25 at 5:00 pm and after several revisions were made it was accepted on 05/27/15 at 3:40pm. The POR included in part: 1. Immediate corrective action for Resident #3 a. Resident is to sit while being showered. b. Walkway to be cleared and cluttered. c. Evaluation of medications. d. Remove wet floor sign when floor is dry. e. Updated Resident #3 ' s care plan to include all interventions listed above on 05/22/15. f. On 5/23/15 Received new shoes. g. On 05/24/15 Resident #3 ' s care plan was updated to include the following interventions: i. Resident to use new shoes. ii. Resident will be allowed her preference to sleep in and be social during the evening and night. iii. All staff will be required to log in to the CareTracker system at the beginning of their shift to receive messages regarding Resident #3 ' s care. The DON will be responsible for this corrective action. 2. Corrective Action for Residents identified as having a fall are as follows: a. A review of all Incident and Accident reports since February were reviewed to identify residents at risk for falls. This was completed on 05/22/15. b. On 05/24/15 communication to all staff was placed in the resident ADL and Assessment Documentation system (CareTracker). All staff must log into CareTracker at the beginning of their shift and read all communication for change in residents ' plan of care. The CareTracker records time and date when staff view this communication. 3. Training and Education a. All Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 05/22/15. b. The Charge Nurse on each shift will educate the RNs, LVNs, CMAs, and CNAs on each relieving shift on following the resident Care Plan. This was completed by 05/26/15. c. All licensed nursing staff at St James House on duty on 5/22/2015 were educated and trained by the DON regarding: i. Completion of a Fall Risk Evaluation Form upon admission and implementation of risk interventions. ii. Documentation and communication required post fall. iii. CareTracker was reviewed to ensure that all staff had access. This was completed on 05/26/15. d. All employees were trained before returning to work. The DON and ADON are responsible for this action. 4. Beginning 05/22/15 the night supervisor will ensure that all new admissions have a Fall Risk Evaluation and that all documentation is done for residents post fall. 5. The Care Resource Team will review all falls weekly, will make recommendations and report to the QAPI Committee. 6. On 05/26/15 the CRT team reviewed all falls since February 2015. The team made recommendations and implemented those on the care plans of the identified residents. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 05/25/15 until 05/27/15.The topics included in part: Fall prevention; Fall Precaution, Fall Assessment and Falling star program. Observations were made from 05/25/15 until 05/27/15 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 05/25/15 until 05/27/15 between 9:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 05/27/15 at 4:00pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The CMS 672 listed 90 resident needing assistance with transfers.

Based on Record review and interview the facility failed to develop and implement written policies and procedures that prohibit neglect, and abuse of residents for 3 of 20 residents (Resident #3, #21 and #22) reviewed for abuse and neglect. Resident #3 had 4 falls from March 2015 to May 2015. On 04/19/15 she had a fall where she suffered a skull fracture and required a hospital stay. The facility did not revise her care plan and put in place effective interventions to prevent further falls. Resident #3 had another fall on 05/01/15 after returning to the facility from the hospital. Resident #21 had a fall on 05/14/15 that resulted in minor injuries. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. Resident #22 had a fall on 05/12/15 with minor injuries. There was no incident report completed An IJ was identified on 05/22/15. While the IJ was removed on 05/27/15 the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 3 residents and placed 92 residents at risk of injury from lack of proper and adequate supervision. Findings Include: Record review of facility ' s policy dated 04/01/14 read in part: Title Abuse and Neglect policy and procedure reporting procedure no page . ii Complete an incident report iii Call the Texas Department of Aging and Disability Services at . Resident #3 Record review of Resident #3's Face Sheet revealed the [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3 ' s admission Minimum Data Set ((MDS) dated [DATE] revealed Brief Intervention for Mental Status (BIMS) of 03 which indicates severe cognitive impairment. Record review of Care Assessment Area (CAA) summary revealed resident was triggered for cognitive loss, visual function and falls. Resident #3 was assessed at needing limited assistance of one staff member for all ADLs. Walking in room was assessed as needing the supervision of one staff member. She was coded as not steady but able to stabilize without staff assistance for moving from seated to standing position, walking, turning around, and surface-to-surface transfers. She had no history of falls. Record review of Resident #3's Care plan dated 07/16/14 read in part, Problem: Resident has a history of falls and is at risk for increased falls and fractures as evidenced by cognitive impairment and unsteady gait.Goal: Dignity will be maintained and falls will be reduced and occurrence of injury will occur over the next 90 days. Approaches. Encourage resident to ask for assistance of staff. Ensure call light is in reach and answer promptly.Anticipate needs, provide prompt assistance.assure lighting is adequate and areas are free of clutter.low bed.floor mat. (The last two interventions were written in the care plan with no date of when they were added.) There were review dates listed as 10/14/14, 01/15/15, 04/14/15 and 05/05/15. Record review of the facility's Accident and Incident Reports from March 2015 to May 2015 revealed that Resident #3 had 6 falls. The fall on 04/19/15 resulted in skull fracture, [MEDICATION NAME] hemorrhage and a hospital stay. Record review of Resident #3's Incident Report dated 04/19/15 at 4:00am -Resident #3 was found on the floor on her left side in her room. She was bleeding from her left eyebrow. The intervention listed was change in activities. It was documented as Resident #3 had a one inch laceration to her left eyebrow area with a hematoma forming. Her blood pressure was 160/100. She was sent to the local Hospital at 4:20am. Record review of the Facility ' s investigation of the incident dated 04/19/15 read in part . It was documented that Resident #3 was ambulatory and there was no change in ambulation or medication .There was a chair in her path in her room .[DIAGNOSES REDACTED]. Record review of the witness statement for the incident dated 04/19/15 revealed that staff heard a noise when Resident #3 fell but none of the staff witnessed the fall. Record review of Resident #3 ' s Nurse ' s notes dated 04/19/15 at 4:00am read in part, the Nurse was called to Resident #3 ' s room. She was on the floor and bleeding from the left side of her head near her eyebrow. Pressure was applied to the wound, vital signs were taken with her blood pressure being 160/100 .the physician was notified and order was received to send Resident #3 to the hospital .she was sent to the ER at 4:20am. Record review of Resident #3's hospital records dated 04/19/15 revealed admitting [DIAGNOSES REDACTED]. The CT scan of the head revealed that she had a right occipital skull fracture with no displacement as well as bilateral subdual effusion and multiple intraparenchymal hemorrhages (bleeding in the main part of the brain) bin bilateral frontal lobes, largest being approximately 0.9cm in the left frontal lobe .She was transferred to local hospital for higher level of care. Record review of Resident #3 ' s Nurse ' s note dated 04/22/15 read in part, Resident readmitted to facility .Head to toe assessment done .right second and third finger had purple discolorations and red dots .Left leg has a purple and yellow discoloration on outer aspect of leg, yellow discoloration to left knee, discoloration to outer aspect of right knee, purple discoloration on left hip and two areas of purple discoloration on upper right arm. There was a skin tear located on Resident #3 ' s left elbow, a scab to her left eye, yellowish discoloration to the left side of her face and purplish discoloration on her left chin area. Record review of Resident #3 ' s Nurse ' s note dated 04/27/15 at 12:35pm read in part . status [REDACTED]. She had an unsteady gait and continues to favor right hip, she has a discoloration under left eye and the left side of her face and left hip. She has a scabbed area located on the back of her head. Observation of Resident #3 throughout the survey from 05/19/15 to 05/27/15 in the Secure Unit revealed resident was walking around without assistance. Observation and interview on 05/20/15 at 10:00am revealed Resident #3 was lying down on her bed. Her bed was in the highest position. In an interview at this time Certified Nursing Assistant (CNA) G said the bed should be in the low position. She said the person who made the bed might have forgotten to lower it back down. In an interview on 05/20/15 at 3:00pm Assistant Director of Nursing (ADON) said Resident # 3 had multiple falls and her care plan would be updated to reflect her current condition. Interview with the ADON on 05/21/15 at 4:30pm revealed she reviewed and signed all care plans but had not revised them; including Resident #3's care plan. Record review of Resident #3 ' s Accident/Incident Reports revealed the following: 03/05/15- Resident #3 had a fall in the bathroom, intervention have resident seated while in shower. 03/18/15- Resident #3 was found sitting upright on the floor. She was confused. The intervention listed was make frequent rounds. 04/13/15 at 10:00am- Resident #3 was found on the floor in the lobby of the secure unit. It stated that there was wound care but does not describe the wound. Interventions taken to prevent recurrence were keep walkway clear and uncluttered and that this was an isolated incident. Record review of facility ' s investigation of the incident dated 04/13/15 read in part . resident was ambulatory and had not had a change in ambulation or medication .staff described most recent transfer of the Resident as independently transfers .[DIAGNOSES REDACTED]. Record review of witness statement dated 04/13/15 read in part .a staff member was in another resident ' s room administering medication when she heard a big noise and came out to the lobby area to find Resident #3 on the floor . 04/16/15 at 4:00am- Resident #3 was yelling out for help. She was found on the floor, lying face up legs extended toward her bed. She was confused and unable to describe event. Resident #3 had a skin tear located on her left forearm. It was documented that Resident #3 had a triangle shape open area under her left eye and one centimeter laceration under left eye. It was also documented that her right eye was bleeding. The intervention was provide adequate lighting, evaluate medication and bed checks every 30 minutes to an hour. Record review of the facility ' s investigation of the incident dated 04/16/15 read in part . Resident #3 was ambulatory, there had been a change in her ambulation and her medication .Her [MEDICATION NAME] was decreased from 500mg to 250mg one by mouth twice a day . The most recent transfer was described staff as Resident #3 required assistance related to an unsteady gait at times .[DIAGNOSES REDACTED]. Record review of the witness statement dated 04/16/15 read in part .the staff member heard someone yelling and .Resident #3 was on the floor in her room lying on her side in front of the night stand. Record review of physician's order [REDACTED]. 05/01/15 at 3:00pm- Resident #3 was discovered lying on the floor in the hallway of the secure unit. The Resident was unable to recall what happened. She was confused. Interventions were to in-service housekeeping on removing the wet floor signs, Occupational therapy to evaluate shoes Resident #3 ' s shoes and to replace glasses as her old glasses where left at the hospital. Record review of Facility ' s Investigation of the Incident dated 05/01/15 (no time provided) read in part .2. The Resident was ambulatory and the Resident had experienced a change in ambulation. There was no recent change in the Resident ' s medication .[DIAGNOSES REDACTED]. Observation on 05/21/15 at 8:40am revealed Resident #3 was sitting in the dining area conversing with herself. She had a sock on her right foot and none on her left foot. She did not have any shoes on at this time. Resident #3 was not interviewable due to her cognitive status. She was alert and awake but not oriented. Further observation revealed one CNA in the secured unit attending to a resident in the bathroom. There was no other staff visible at this time. In an interview on 05/22/15 at 11:00am, the Director of Nursing (DON) said she was reviewing all residents with falls to address the situation. She said the resident ' s care plan should reflect their condition. In an interview on 05/22/15 at 8:40am, CNA H said Resident #3 was confused and would take off her socks sometimes. She said the Resident did not have shoes and her family was supposed to get her some. She said Resident #3 has had multiple falls. Resident #21 Review of Resident #21's Face Sheet revealed the [AGE] year old male was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident's # 21 ' s Quarterly MDS assessment dated [DATE] revealed a BIMS of 12. The resident ' s functional status according to MDS reports extensive assistance to provide weight bearing support. Review of the assessment reflected Resident # 21 required extensive assistance of one person for bed mobility, transfer and toileting use and one person for bathing and currently utilizes a wheelchair. Review of Resident #21 ' s nurse ' s notes dated 5/14/2015 documented that he fell in the dining room sustaining a laceration to the left side of his forehead, an abrasion to the left elbow and left thumb. No other documentation was provided concerning the fall. Review of Resident # 21's Comprehensive Care Plan dated 05/14/2015 did not reflect his fall with injuries on 5/14/2015 at 3:15 pm. The care plan was not revised to include effective interventions to prevent the Resident from further falls. Record review of the facility's incident reports from March 2015 to May 2015 revealed there was not an incident report completed for Resident #21's fall on 05/14/15. Record review of Resident #21's physician's orders [REDACTED]. Observation on 05/24/2015 at 1:24 PM revealed Resident # 21 was lying in bed. He was awake and his left wrist did show some slight swelling but no bruising was noted. Resident #21 was able to move his wrist. Interview on 5/24/2015 at 1:30 pm Resident # 21 said another resident was kicking him so he tried to get away from him by getting out of his wheelchair. The Resident said he stood up trying to move away and lost his balance and fell hitting his head against the table and landed on his wrist trying to break the fall. Resident #21 said he did not remember much after that but woke up in his room. Interview on 5/24/2015 at 2:00 pm with Licensed Vocational Nurse (LVN) C she said the reason Resident # 21 had x-rays done was because he was complaining of pain and cried out when his left wrist was touched. At the time of the fall his left wrist was swollen and had some bruising. LVN C said Resident # 21 said he could not remember what happened. She said she was not at work on the day the Resident had the fall but in report was told to monitor him. Interview on 5/25/2015 at 12:30 pm with the DON she said she was unable to find the incident report concerning the fall of Resident # 21 and would have to look into the matter to ascertain what actions the staff took to care for the Resident. Resident # 22 Review of Resident # 22's Face Sheet revealed the [AGE] year old male was admitted to the facility on [DATE]. Resident # 22's [DIAGNOSES REDACTED]. Record review of Resident #22's care plan dated 03/04/14 read in part, Problem: Resident has a history of falls and is at risk for increased falls and fractures. Goal.incidence of falls will be reduced and no occurrence of injury over next 90 days. Approach.encourage resident to ask for assistance from staff.ensure call light is in reach, answer promptly.anticipate needs, provide prompt assistance. assure lighting is adequate and areas are free from clutter.bright color tape on breaks for visual cues, review of medication. (The last two interventions were added 05/14/15.) Record review of Resident #22's incident report dated 5/12/2015 read in part the physician was notified concerning the injury of Resident # 22. According to the incident report the resident fell at 7:45 pm in his room. resident sustained [REDACTED]. It was reported that the Resident was alert but very confused. The fall was unwitnessed and he was not sent to hospital for mental confusion status [REDACTED]. Record review of Resident #22 ' s treatment records revealed 05/12/15-Cleanse skin tear to right palm with normal saline dry and apply dressing continue until resolved. Record review of Resident #22's Radiology report dated 5/16/2015 revealed x-ray of left hip and femur status [REDACTED]. Review of the facility's accident/incident reports revealed Resident # 22 had two other documented falls on: 2/9/2015: Resident # 22 at 6:45 am was found in his room on the floor beside his wheelchair. The fall was unwitnessed. No injuries were sustained. 4/13/2015 at 2:00 pm resident # 22 was found on floor in hallway by medication aide who said resident's wheelchair was a few feet away from the resident. Resident was alert to person only. Incident report read resident had some discoloration on his body but the report does not indicate the locations of bruises. Observation on 05/22/2015 at 11:24 am Resident # 22 was sitting at dining table on the memory care unit alert and oriented to name only although relating well with others residents sitting at his table. The Resident had multiple ecchymosis (bleeding from broken vessels underneath the skin) areas to his forehead and one large band aid to his left thumb. Interview on 5/22/2015 at 11:30 am with Resident # 22 he said he was doing well. Resident #22 was unable to explain how he obtained his injuries. Interview on 5/23/2015 with at 12:15 pm LVN E who said Resident # 22 had a witnessed fall near his room. LVN E was not sure what day it happened. She said she was given report that he had fallen and sustained injuries. She said an incident report should have been completed after the fall but she did not know if one was done or not. We do not keep any records on the unit about falls. The incidents are given to the DON or ADONs. From there she did not know what happened to them but she did know that there was an incident book. Interview on 5/25/2015 at 1:30 pm the DON said she was unable to find the incident report concerning the fall of Resident # 22 and would have to look into the matter to ascertain what actions the staff took to care for the resident. Follow up interview 5/25/2015 at 3:00 pm the DON said she looked in the matter but was unable to find the incident report. The staff was unable to remember any details of the accident. Falling stars clinical protocol dated 03/30/15 Goal: 1-Prevent falls and serious injury 2-Recognize multifactorial risk and courses of falls in older adult. 3- Institute recommendations for falls prevention and management consist with clinical guidelines and standard of care. Steps; Assessments. Assess and document resident care environment routinely for extrinsic risk factors to the fall and institute corrective action; An IJ was identified on 05/22/15 at 10:40am and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 05/25/25 at 5:00 pm and after several revisions were made it was accepted on 05/27/15 at 3:40pm. The POR included in part: 1. Immediate corrective action for Resident #3 a. Resident is to sit while being showered. b. Walkway to be cleared and cluttered. c. Evaluation of medications. d. Remove wet floor sign when floor is dry. e. Updated Resident #3 ' s care plan to include all interventions listed above on 05/22/15. f. On 5/23/15 Received new shoes. g. On 05/24/15 Resident #3 ' s care plan was updated to include the following interventions: i. Resident to use new shoes. ii. Resident will be allowed her preference to sleep in and be social during the evening and night. iii. All staff will be required to log in to the CareTracker system at the beginning of their shift to receive messages regarding Resident #3 ' s care. The DON will be responsible for this corrective action. 2. Corrective Action for Residents identified as having a fall are as follows: a. A review of all Incident and Accident reports since February were reviewed to identify residents at risk for falls. This was completed on 05/22/15. b. On 05/24/15 communication to all staff was placed in the resident ADL and Assessment Documentation system (CareTracker). All staff must log into CareTracker at the beginning of their shift and read all communication for change in residents ' plan of care. The CareTracker records time and date when staff view this communication. 3. Training and Education a. All Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 05/22/15. b. The Charge Nurse on each shift will educate the RNs, LVNs, CMAs, and CNAs on each relieving shift on following the resident Care Plan. This was completed by 05/26/15. c. All licensed nursing staff at St James House on duty on 5/22/2015 were educated and trained by the DON regarding: i. Completion of a Fall Risk Evaluation Form upon admission and implementation of risk interventions. ii. Documentation and communication required post fall. iii. CareTracker was reviewed to ensure that all staff had access. This was completed on 05/26/15. d. All employees were trained before returning to work. The DON and ADON are responsible for this action. 4. Beginning 05/22/15 the night supervisor will ensure that all new admissions have a Fall Risk Evaluation and that all documentation is done for residents post fall. 5. The Care Resource Team will review all falls weekly, will make recommendations and report to the QAPI Committee. 6. On 05/26/15 the CRT team reviewed all falls since February 2015. The team made recommendations and implemented those on the care plans of the identified residents. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 05/25/15 until 05/27/15.The topics included in part: Fall prevention; Fall Precaution, Fall Assessment and Falling star program. Observations were made from 05/25/15 until 05/27/15 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 05/25/15 until 05/27/15 between 9:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 05/27/15 at 4:00pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The CMS 672 listed a census of 95 residents.

Based on observations, interviews and record reviews the facility failed to implement their written policy and procedures that prohibit mistreatment and neglect and abuse for 3 of 20 residents (Residents #3, #21 and #22) reviewed for incident and accidents and care. This was evidenced by: Resident #3 had 4 falls from March 2015 to May 2015. On 04/19/15 she had a fall where she suffered a skull fracture and required a hospital stay. The facility did not revise her care plan and put in place effective interventions to prevent further falls. Resident #3 had another fall on 05/01/15 after returning to the facility from the hospital. Resident #21 had a fall on 05/14/15 that resulted in minor injuries. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. Resident #22 had a fall on 05/12/15 with minor injuries. There was no incident report completed An IJ was identified on 05/22/15. While the IJ was removed on 05/27/15 the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 3 residents and placed 92 residents at risk of injury from lack of proper and adequate supervision. Findings Include: Resident #3 Record review of Resident #3's Face Sheet revealed the [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3 ' s admission Minimum Data Set ((MDS) dated [DATE] revealed Brief Intervention for Mental Status (BIMS) of 03 which indicates severe cognitive impairment. Record review of Care Assessment Area (CAA) summary revealed resident was triggered for cognitive loss, visual function and falls. Resident #3 was assessed at needing limited assistance of one staff member for all ADLs. Walking in room was assessed as needing the supervision of one staff member. She was coded as not steady but able to stabilize without staff assistance for moving from seated to standing position, walking, turning around, and surface-to-surface transfers. She had no history of falls. Record review of Resident #3's Care plan dated 07/16/14 read in part, Problem: Resident has a history of falls and is at risk for increased falls and fractures as evidenced by cognitive impairment and unsteady gait.Goal: Dignity will be maintained and falls will be reduced and occurrence of injury will occur over the next 90 days. Approaches. Encourage resident to ask for assistance of staff. Ensure call light is in reach and answer promptly.Anticipate needs, provide prompt assistance.assure lighting is adequate and areas are free of clutter.low bed.floor mat. (The last two interventions were written in the care plan with no date of when they were added.) There were review dates listed as 10/14/14, 01/15/15, 04/14/15 and 05/05/15. Record review of the facility's Accident and Incident Reports from March 2015 to May 2015 revealed that Resident #3 had 6 falls. The fall on 04/19/15 resulted in skull fracture, [MEDICATION NAME] hemorrhage and a hospital stay. Record review of Resident #3's Incident Report dated 04/19/15 at 4:00am -Resident #3 was found on the floor on her left side in her room. She was bleeding from her left eyebrow. The intervention listed was change in activities. It was documented as Resident #3 had a one inch laceration to her left eyebrow area with a hematoma forming. Her blood pressure was 160/100. She was sent to the local Hospital at 4:20am. Record review of the Facility ' s investigation of the incident dated 04/19/15 read in part . It was documented that Resident #3 was ambulatory and there was no change in ambulation or medication .There was a chair in her path in her room .[DIAGNOSES REDACTED]. Record review of the witness statement for the incident dated 04/19/15 revealed that staff heard a noise when Resident #3 fell but none of the staff witnessed the fall. Record review of Resident #3 ' s Nurse ' s notes dated 04/19/15 at 4:00am read in part, the Nurse was called to Resident #3 ' s room. She was on the floor and bleeding from the left side of her head near her eyebrow. Pressure was applied to the wound, vital signs were taken with her blood pressure being 160/100 .the physician was notified and order was received to send Resident #3 to the hospital .she was sent to the ER at 4:20am. Record review of Resident #3's hospital records dated 04/19/15 revealed admitting [DIAGNOSES REDACTED]. The CT scan of the head revealed that she had a right occipital skull fracture with no displacement as well as bilateral subdual effusion and multiple intraparenchymal hemorrhages (bleeding in the main part of the brain) bin bilateral frontal lobes, largest being approximately 0.9cm in the left frontal lobe .She was transferred to local hospital for higher level of care. Record review of Resident #3 ' s Nurse ' s note dated 04/22/15 read in part, Resident readmitted to facility .Head to toe assessment done .right second and third finger had purple discolorations and red dots .Left leg has a purple and yellow discoloration on outer aspect of leg, yellow discoloration to left knee, discoloration to outer aspect of right knee, purple discoloration on left hip and two areas of purple discoloration on upper right arm. There was a skin tear located on Resident #3 ' s left elbow, a scab to her left eye, yellowish discoloration to the left side of her face and purplish discoloration on her left chin area. Record review of Resident #3 ' s Nurse ' s note dated 04/27/15 at 12:35pm read in part . status [REDACTED]. She had an unsteady gait and continues to favor right hip, she has a discoloration under left eye and the left side of her face and left hip. She has a scabbed area located on the back of her head. Observation of Resident #3 throughout the survey from 05/19/15 to 05/27/15 in the Secure Unit revealed resident was walking around without assistance. Observation and interview on 05/20/15 at 10:00am revealed Resident #3 was lying down on her bed. Her bed was in the highest position. In an interview at this time Certified Nursing Assistant (CNA) G said the bed should be in the low position. She said the person who made the bed might have forgotten to lower it back down. In an interview on 05/20/15 at 3:00pm Assistant Director of Nursing (ADON) said Resident # 3 had multiple falls and her care plan would be updated to reflect her current condition. Interview with the ADON on 05/21/15 at 4:30pm revealed she reviewed and signed all care plans but had not revised them; including Resident #3's care plan. Record review of Resident #3 ' s Accident/Incident Reports revealed the following: 03/05/15- Resident #3 had a fall in the bathroom, intervention have resident seated while in shower. 03/18/15- Resident #3 was found sitting upright on the floor. She was confused. The intervention listed was make frequent rounds. 04/13/15 at 10:00am- Resident #3 was found on the floor in the lobby of the secure unit. It stated that there was wound care but does not describe the wound. Interventions taken to prevent recurrence were keep walkway clear and uncluttered and that this was an isolated incident. Record review of facility ' s investigation of the incident dated 04/13/15 read in part . resident was ambulatory and had not had a change in ambulation or medication .staff described most recent transfer of the Resident as independently transfers .[DIAGNOSES REDACTED]. Record review of witness statement dated 04/13/15 read in part .a staff member was in another resident ' s room administering medication when she heard a big noise and came out to the lobby area to find Resident #3 on the floor . 04/16/15 at 4:00am- Resident #3 was yelling out for help. She was found on the floor, lying face up legs extended toward her bed. She was confused and unable to describe event. Resident #3 had a skin tear located on her left forearm. It was documented that Resident #3 had a triangle shape open area under her left eye and one centimeter laceration under left eye. It was also documented that her right eye was bleeding. The intervention was provide adequate lighting, evaluate medication and bed checks every 30 minutes to an hour. Record review of the facility ' s investigation of the incident dated 04/16/15 read in part . Resident #3 was ambulatory, there had been a change in her ambulation and her medication .Her [MEDICATION NAME] was decreased from 500mg to 250mg one by mouth twice a day . The most recent transfer was described staff as Resident #3 required assistance related to an unsteady gait at times .[DIAGNOSES REDACTED]. Record review of the witness statement dated 04/16/15 read in part .the staff member heard someone yelling and .Resident #3 was on the floor in her room lying on her side in front of the night stand. Record review of physician's order [REDACTED]. 05/01/15 at 3:00pm- Resident #3 was discovered lying on the floor in the hallway of the secure unit. The Resident was unable to recall what happened. She was confused. Interventions were to in-service housekeeping on removing the wet floor signs, Occupational therapy to evaluate shoes Resident #3 ' s shoes and to replace glasses as her old glasses where left at the hospital. Record review of Facility ' s Investigation of the Incident dated 05/01/15 (no time provided) read in part .2. The Resident was ambulatory and the Resident had experienced a change in ambulation. There was no recent change in the Resident ' s medication .[DIAGNOSES REDACTED]. Observation on 05/21/15 at 8:40am revealed Resident #3 was sitting in the dining area conversing with herself. She had a sock on her right foot and none on her left foot. She did not have any shoes on at this time. Resident #3 was not interviewable due to her cognitive status. She was alert and awake but not oriented. Further observation revealed one CNA in the secured unit attending to a resident in the bathroom. There was no other staff visible at this time. In an interview on 05/22/15 at 11:00am, the Director of Nursing (DON) said she was reviewing all residents with falls to address the situation. She said the resident ' s care plan should reflect their condition. In an interview on 05/22/15 at 8:40am, CNA H said Resident #3 was confused and would take off her socks sometimes. She said the Resident did not have shoes and her family was supposed to get her some. She said Resident #3 has had multiple falls. Resident #21 Review of Resident #21's Face Sheet revealed the [AGE] year old male was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident's # 21 ' s Quarterly MDS assessment dated [DATE] revealed a BIMS of 12. The resident ' s functional status according to MDS reports extensive assistance to provide weight bearing support. Review of the assessment reflected Resident # 21 required extensive assistance of one person for bed mobility, transfer and toileting use and one person for bathing and currently utilizes a wheelchair. Review of Resident #21 ' s nurse ' s notes dated 5/14/2015 documented that he fell in the dining room sustaining a laceration to the left side of his forehead, an abrasion to the left elbow and left thumb. No other documentation was provided concerning the fall. Review of Resident # 21's Comprehensive Care Plan dated 05/14/2015 did not reflect his fall with injuries on 5/14/2015 at 3:15 pm. The care plan was not revised to include effective interventions to prevent the Resident from further falls. Record review of the facility's incident reports from March 2015 to May 2015 revealed there was not an incident report completed for Resident #21's fall on 05/14/15. Record review of Resident #21's physician's orders [REDACTED]. Observation on 05/24/2015 at 1:24 PM revealed Resident # 21 was lying in bed. He was awake and his left wrist did show some slight swelling but no bruising was noted. Resident #21 was able to move his wrist. Interview on 5/24/2015 at 1:30 pm Resident # 21 said another resident was kicking him so he tried to get away from him by getting out of his wheelchair. The Resident said he stood up trying to move away and lost his balance and fell hitting his head against the table and landed on his wrist trying to break the fall. Resident #21 said he did not remember much after that but woke up in his room. Interview on 5/24/2015 at 2:00 pm with Licensed Vocational Nurse (LVN) C she said the reason Resident # 21 had x-rays done was because he was complaining of pain and cried out when his left wrist was touched. At the time of the fall his left wrist was swollen and had some bruising. LVN C said Resident # 21 said he could not remember what happened. She said she was not at work on the day the Resident had the fall but in report was told to monitor him. Interview on 5/25/2015 at 12:30 pm with the DON she said she was unable to find the incident report concerning the fall of Resident # 21 and would have to look into the matter to ascertain what actions the staff took to care for the Resident. Resident # 22 Review of Resident # 22's Face Sheet revealed the [AGE] year old male was admitted to the facility on [DATE]. Resident # 22's [DIAGNOSES REDACTED]. Record review of Resident #22's care plan dated 03/04/14 read in part, Problem: Resident has a history of falls and is at risk for increased falls and fractures. Goal.incidence of falls will be reduced and no occurrence of injury over next 90 days. Approach.encourage resident to ask for assistance from staff.ensure call light is in reach, answer promptly.anticipate needs, provide prompt assistance. assure lighting is adequate and areas are free from clutter.bright color tape on breaks for visual cues, review of medication. (The last two interventions were added 05/14/15.) Record review of Resident #22's incident report dated 5/12/2015 read in part the physician was notified concerning the injury of Resident # 22. According to the incident report the resident fell at 7:45 pm in his room. resident sustained [REDACTED]. It was reported that the Resident was alert but very confused. The fall was unwitnessed and he was not sent to hospital for mental confusion status [REDACTED]. Record review of Resident #22 ' s treatment records revealed 05/12/15-Cleanse skin tear to right palm with normal saline dry and apply dressing continue until resolved. Record review of Resident #22's Radiology report dated 5/16/2015 revealed x-ray of left hip and femur status [REDACTED]. Review of the facility's accident/incident reports revealed Resident # 22 had two other documented falls on: 2/9/2015: Resident # 22 at 6:45 am was found in his room on the floor beside his wheelchair. The fall was unwitnessed. No injuries were sustained. 4/13/2015 at 2:00 pm resident # 22 was found on floor in hallway by medication aide who said resident's wheelchair was a few feet away from the resident. Resident was alert to person only. Incident report read resident had some discoloration on his body but the report does not indicate the locations of bruises. Observation on 05/22/2015 at 11:24 am Resident # 22 was sitting at dining table on the memory care unit alert and oriented to name only although relating well with others residents sitting at his table. The Resident had multiple ecchymosis (bleeding from broken vessels underneath the skin) areas to his forehead and one large band aid to his left thumb. Interview on 5/22/2015 at 11:30 am with Resident # 22 he said he was doing well. Resident #22 was unable to explain how he obtained his injuries. Interview on 5/23/2015 with at 12:15 pm LVN E who said Resident # 22 had a witnessed fall near his room. LVN E was not sure what day it happened. She said she was given report that he had fallen and sustained injuries. She said an incident report should have been completed after the fall but she did not know if one was done or not. We do not keep any records on the unit about falls. The incidents are given to the DON or ADONs. From there she did not know what happened to them but she did know that there was an incident book. Interview on 5/25/2015 at 1:30 pm the DON said she was unable to find the incident report concerning the fall of Resident # 22 and would have to look into the matter to ascertain what actions the staff took to care for the resident. Follow up interview 5/25/2015 at 3:00 pm the DON said she looked in the matter but was unable to find the incident report. The staff was unable to remember any details of the accident. Record review of facility ' s policy dated 04/01/14 read in part: Title Abuse and Neglect policy and procedure reporting procedure no page . ii Complete an incident report iii Call the Texas Department of Aging and Disability Services at . Falling stars clinical protocol dated 03/30/15 Goal: 1-Prevent falls and serious injury 2-Recognize multifactorial risk and courses of falls in older adult. 3- Institute recommendations for falls prevention and management consist with clinical guidelines and standard of care. Steps; Assessments. Assess and document resident care environment routinely for extrinsic risk factors to the fall and institute corrective action; An IJ was identified on 05/22/15 at 10:40am and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 05/25/25 at 5:00 pm and after several revisions were made it was accepted on 05/27/15 at 3:40pm. The POR included in part: 1. Immediate corrective action for Resident #3 a. Resident is to sit while being showered. b. Walkway to be cleared and cluttered. c. Evaluation of medications. d. Remove wet floor sign when floor is dry. e. Updated Resident #3 ' s care plan to include all interventions listed above on 05/22/15. f. On 5/23/15 Received new shoes. g. On 05/24/15 Resident #3 ' s care plan was updated to include the following interventions: i. Resident to use new shoes. ii. Resident will be allowed her preference to sleep in and be social during the evening and night. iii. All staff will be required to log in to the CareTracker system at the beginning of their shift to receive messages regarding Resident #3 ' s care. The DON will be responsible for this corrective action. 2. Corrective Action for Residents identified as having a fall are as follows: a. A review of all Incident and Accident reports since February were reviewed to identify residents at risk for falls. This was completed on 05/22/15. b. On 05/24/15 communication to all staff was placed in the resident ADL and Assessment Documentation system (CareTracker). All staff must log into CareTracker at the beginning of their shift and read all communication for change in residents ' plan of care. The CareTracker records time and date when staff view this communication. 3. Training and Education a. All Registered Nurses (RN), Licensed Vocational Nurses (LVN), Medication Aides, CNAs and Neighborhood Leaders were educated by the DON of following Falls Clinical Protocol Policy on 05/22/15. b. The Charge Nurse on each shift will educate the RNs, LVNs, CMAs, and CNAs on each relieving shift on following the resident Care Plan. This was completed by 05/26/15. c. All licensed nursing staff at St James House on duty on 5/22/2015 were educated and trained by the DON regarding: i. Completion of a Fall Risk Evaluation Form upon admission and implementation of risk interventions. ii. Documentation and communication required post fall. iii. CareTracker was reviewed to ensure that all staff had access. This was completed on 05/26/15. d. All employees were trained before returning to work. The DON and ADON are responsible for this action. 4. Beginning 05/22/15 the night supervisor will ensure that all new admissions have a Fall Risk Evaluation and that all documentation is done for residents post fall. 5. The Care Resource Team will review all falls weekly, will make recommendations and report to the QAPI Committee. 6. On 05/26/15 the CRT team reviewed all falls since February 2015. The team made recommendations and implemented those on the care plans of the identified residents. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 05/25/15 until 05/27/15.The topics included in part: Fall prevention; Fall Precaution, Fall Assessment and Falling star program. Observations were made from 05/25/15 until 05/27/15 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate and Residents had on proper foot wear. Interviews conducted from 05/25/15 until 05/27/15 between 9:00 am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 05/27/15 at 4:00pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The CMS 672 listed a census of 95 residents.