Every finding on record at The Broadmoor at Creekside Park

Based on observation, record review, and interviews, the facility failed to ensure residents received adequate supervision for 1 of 7 residents (CR #1) reviewed for quality of care.CR #1 eloped from the facility on 02/23/2026 from an unwitnessed point of exit, and was located at the rear of the property at a school.The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 02/23/2026 and ended on 02/23/2026. The facility corrected the non-compliance before the investigation on 03/10/2026. The IJ template was provided to the Administrator on 03/12/2026 at 2:02pm.This failure could place the residents with exit seeking behaviors at risk for injury or death.Findings included:Record review of CR #1's undated face sheet, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnosis of unsteadiness on his feet, vascular dementia (decline in mental abilities), urine retention (buildup of urine), infection and inflammatory reaction due to indwelling urethral catheter (bacteria or germs have entered the urinary tract through the tube causing sickness and irritation). He was discharged to the hospital.Record review of CR #1's admission assessment dated [DATE] revealed in the category of Elopement Risk Evaluation, he was not bedfast, non-ambulatory, or unable to self-propel in a wheelchair independently. CR #1 did not have history of elopement at home or had made attempts to leave the facility without informing staff. CR#1 was not seen packing belonging to go home without a discharge plan in place. CR #1 did not wander with a specific destination in mind, attempted to open secured doors, or tried to leave the facility to go home.Record review of CR #1's admission MDS assessment dated [DATE] revealed a BIMS score of 07 of 15 was indicative of severe cognitive impairment, and significantly impaired cognitive functioning. CR #1 was assessed as not exhibiting behaviors for wandering. He had impairment of the lower extremities (hip, knee, ankle, foot) and no impairment of his upper extremities (shoulder, elbow, wrist, hand). He utilized a walker and a wheelchair for mobility.Record review of CR #1's Care Plan dated 02/23/2026 revealed he was at risk for elopement as evidenced by history/attempt to leave facility. Interventions put into place included distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, assist to ambulate or wheel resident outside as needed to ease restlessness, check on resident frequently, and one-to-one monitoring until acute condition improves.Record review of CR #1's Incident Report dated 02/23/2026 at 11:01am read incident description as, CR#1 was found wandering in back of facility, unable to give description, and the incident was not witnessed. Immediate action taken by the facility read, CR #1 was redirected and brought inside, head to toe assessment and skin assessment was done and resident placed on one to one monitoring and he was not taken to the hospital. There were no injuries observed or noted and no pain. Predisposing physiological factors read impaired memory and recent change in condition. Predisposing situation factors read CR #1 used a walker and was a wander.Record review of CR#1's Progress Note dated 02/23/2026 at 11:33 am by the Administrator revealed CR #1 was going for a walk when asked what he was doing outside of the facility. CR #1 stated the door alarm did sound off when he walked out.During an interview on 03/10/2026 at 3:42 pm, the family member of CR #1 stated that CR #1 had dementia ,and is in very poor health. She reported that he has no prior history of elopement and believes he attempted to go outside because she had taken him out earlier in the week. She said that on 02/23/2026, the day he exited the facility, CR #1 told her he put on his own shoes, which is unusual for him. She explained that after she arrived at the facility and learned of the elopement, his condition deteriorated within a few hours, prompting staff to call an ambulance. The hospital later confirmed that CR #1 had a urinary tract infection.During an interview on 03/11/2026 at 12:15pm, LVN M stated she was not aware that CR #1 had eloped until the unit manager informed her that the resident returned to the building. LVN M completed a head-to-toe assessment and checked the resident for injury and pain. At the time of the assessment, LVN M observed that CR #1 was agitated and appeared confused, and based on her previous interactions with him, he was not himself. LVN M reported that she completed an SBAR for change in condition and notified the nurse practitioner, who ordered a urine sample, and blood work. She stated the last elopement training occurred on 02/23/2026, which included information on residents who wandered or exhibited exit-seeking behaviors. She explained that the facility maintains pictures of all residents at risk for wandering or elopement at the nurse's station. She stated the protocol for elopement requires staff to respond to exit door alarms by immediately checking on their residents and ensure all individuals are accounted for before the alarm is turned off. The risk of elopement is the potential for resident harm by becoming lost or being struck by a vehicle.During an interview with the SW on 03/11/2026 at 1:13pm, she stated she did not witness CR #1's elopement but did confirm seeing him earlier that day in passing. She reported that she was informed of the elopement after leaving a meeting and subsequently conducted a BIMS assessment. She stated the resident had demonstrated severely impaired cognition from admission to the present, with his score deceasing from 9 to 7 on the day of the incident. She stated during her assessment, he did not exhibit any noticeable changes in his behavior. She explained that the protocol when a resident attempts to leave the facility is to notify the administrator, nursing staff, and the family to ensure all residents can be accounted for.During an interview with LVN O on 03/11/2026 at 2:47pm stated she witnessed CR #1 attempt to leave the facility earlier in the day at the 100-hall exit. She observed the resident using his walker to push on the exit door, which triggered the alarm. LVN O stated the other staff members redirected him away from the door, but she was unsure where he was taken afterward. She stated she could not confirm whether an assessment was completed following this initial wandering attempt. LVN O stated she was later notified by a phone call from the Administrator that CR #1 had successfully eloped from the facility, and had been found on the school property connected to the facility grounds. She stated that the protocol for residents who were wandering or attempting to elope, is to conduct an immediate assessment, and ensure the resident's picture is posted at each nurse's station. She stated the resident is then to be placed on one-to-one Supervision by facility staff. LVN O also stated she did not inform the DON after witnessing CR #1's first attempt to leave the facility, but wishes she had, so that all parties could have been more involved.During an interview with the DON on 03/11/2026 at 3:26pm stated she reported that staff informed her CR #1 went to the exit door, but was redirected back to his room, which was located near the door. She stated redirection involved engaging the resident, and that its effectiveness depends on the resident's cognitive status. The DON stated the facility's wandering and elopement policy is once a resident is identified as wandering, staff should notify management, complete a reassessment, and add the resident to the elopement program. She stated that the initial redirection attempt was brought to her attention during the investigation. The DON stated she learned during the investigation the facility received a call from a nearby school reporting a resident on their property, who was found to be CR #1. She stated the teacher that observed CR #1 on the school playground appeared disoriented. The DON stated she observed the resident once he returned to the facility with the assistance of the Administrator and facility receptionist. She stated CR #1 was assessed from head to toe and appeared to be tired but was talking and did not appear to be confused. The DON stated CR #1 told her he went outside when the alarm sounded, and said he was trying to go home. She stated the staff are trained to immediately report elopement incidents, notify the DON, and implement one-to-one supervision. She stated she would have assessed the resident, determined his intent, and ensured close supervision. The DON stated that no staff admitted to turning off the exit door alarm, the alarms were checked, and she believed the alarm may have been manually turned off by unknown staff.This was determined to be a Past Non-Compliance Immediate Jeopardy on 03/12/2026 at 1:45pm. The Administrator and the DON were notified on 03/12/2026 at 2pm. The Administrator was provided with the IJ Template on 03/12/2026 at 2:02pm. The facility took the following action to correct the non-compliance prior to the investigation:Record review of CR #1's Elopement Risk Evaluation dated 02/23/2026 at 12:10pm revealed a score of 1, indicating CR#1 was a high risk of elopement and action items must be implemented to include, alert Administrator and DON immediately, obtain resident photo and place in elopement prevention system, place on 1:1 monitoring until alternate setting is located and resident is transferred, and implement or update element risk care plan.Record review of facility's Ad Hoc QAPI meeting dated 02/23/2026 at 3:30pm revealed CR #1 was placed on one-to-one supervision with nursing staff, with additional support from family. Facility staff received education on elopement prevention. Laboratory tests were ordered for CR #1, and care plans for residents identified as risk for elopement were reviewed.Record review of CR #1's Physician Order dated 02/23/2026 reflected culture, urine uncollected 5:28pm by LVN M.Record review of the Elopement Audit revealed there were no residents at risk for wandering or elopement.Record review of In-Service Education dated 02/23/2026 for Elopement, Abuse and Neglect, and Behaviors for all and signed by 59 staff members. A brief outline of the in-service included, defining elopement and wandering per CMS guidelines, identifying risk factors, identify strategies and tools for prevention, identifying person-centered interventions to prevent unsafe wandering and elopement, and identify the appropriate response for a missing resident. Staff were also in-service on abuse, neglect, and exploitation which included the welfare and rights of each resident developed and implemented for prevention of the allegation.Record review of Fire Equipment Invoice dated 02/24/2026 revealed reprogramming of all exit door keypads was completed, and the fire exit inspection and tamper switch reset were also performed.Record review of the facility's policy and procedures on Elopements and Wandering revised on 12/01/2025 read in part: Policy:This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless.Monitoring and Managing Residents at Risk for Elopement or Unsafe WanderingResidents will be assessed for risk of elopement and unsafe wandering upon admission, readmission, quarterly, and upon change of condition throughout their stay by the interdisciplinary care plan team.During an interview with CNA R on 03/12/2026 at 7:15am stated she reported she was not working the day CR #1 eloped. She stated that residents identified as being at risk for elopement have photographs posted at the nurses' station, and this information was also communicated through reports, or by the charge nurse. CNA R stated the residents may also be assigned a sitter if needed. She stated the elopement protocol as keeping the resident within staff line of sight. She stated she never personally experienced an elopement, and reported that it has not occurred on her shift, to her knowledge. She stated the most recent elopement in-service occurred approximately two weeks prior. However, she was unable to clearly recall the specific procedures. She stated that if a resident is found to be missing, staff are to notify the charge nurse and alert other staff members. She stated that residents cannot exit the building without triggering an alarm. She stated if an alarm sounded, she would respond to investigating the situation. She stated if a resident attempted to leave the building, she would notify the charge nurse and attempt to distract the resident from exiting further but would not physically restrain the resident. She stated she accounts for residents by completing rounds at the beginning of her shift, and conducting rounds at least every two hours, or more frequently, for residents with increased care needs. She identified the risks associated with elopement as potential kidnapping, falls, and sustaining injuries.During an interview with the Maintenance Director on 03/12/2026 at 7:25am stated that when CR #1 eloped, he checked all exit doors throughout the facility to confirm the alarms were sounding. The Maintenance Director stated alarms may be silenced using a key or keypad code by the Administrator, DON, Unit Manager, ADON, and himself. However, it could only occur after staff verified all residents are safe. Each nurse's station is equipped with a keypad system that illuminates to indicate which exit door has been opened and where the alarm is sounding. The Maintenance Director stated the potential risks associated with elopement included injury or death. During an interview with LVN S on 03/12/2026 at 7:33am stated she was not working at the time CR #1 eloped. She stated the most recent elopement in service occurred approximately two weeks prior. She stated that residents at risk for wandering or elopement were identified by the interdisciplinary team, which informs staff and updates the resident's care plan accordingly. She stated her role consists of completing angel rounds only. She stated the elopement protocol as initiating a text message alert to staff. She stated staff on the unit are notified, a code is announced, and staff respond by checking resident rooms, obtaining a census sheet, and ensuring all residents are accounted for within the building. She stated if a resident attempts to leave the building, she stated she would attempt to redirect the resident through verbal interaction, walk with the resident, and request assistance from an aide. She reported that if an exit door alarm sounded, she would immediately respond to the door that is activating. She identified the risks associated with elopement as the resident being injured by landscaping or bushes, entering the street and being struck by a vehicle, or falling and sustaining injury.During an interview with LVN T on 03/12/2026 at 7:42am stated she was not present at the time CR #1 eloped. She stated the most recent elopement in service occurred approximately two weeks prior. She stated that if a resident was not observed, she would immediately alert management and staff to initiate a room to room search. She stated if the resident is not located within the building, staff would expand the search to the exterior grounds. She stated that no formal code is announced; instead, staff verbally inform one another. She stated that once the resident is located, an assessment is completed, and the resident's photograph is posted at each nurse's station as well as at the front of the facility. She stated if a resident attempts to leave the building, she would attempt to redirect the resident to their room or the nurses' station and notify both the physician and management. She stated if the resident was not previously identified as being at risk for elopement, she would complete an SBAR. She identified changes in condition as exit seeking behaviors, pacing, and entering other residents' rooms. She stated if an exit alarm sounded, she would check the alarm panel to identify which door was activated and determine whether anyone exited the building. LVN T stated she would notify maintenance and management to deactivate the alarm once all residents have been accounted for. She stated that residents are accounted for using the census and through rounds conducted at the beginning of her shift and continuous throughout the day. She identified the risks associated with elopement as significant danger due to a nearby pond and roadway, placing residents at risk of becoming lost or being struck by a vehicle.During an interview with the Administrator on 03/12/2026 at 9:57am, she reported that central supply received a call at the front desk regarding the CR#1. The Administrator stated she located CR #1 at the edge of the parking lot near the school and returned him to the facility in a wheelchair. She stated upon returning to his room, the resident's family member was present. The Administrator stated CR #1 stated he had gone for a walk and reported no injuries or falls while using his walker for assistance. She stated a skin assessment was completed with no injuries noted, and laboratory work was ordered. She stated CR #1 was placed on one-to-one supervision by staff or family and if the family were not available, they would need to inform her immediately to ensure he is accompanied by staff. She stated as part of QAPI, the facility conducted in-service training on abuse, neglect, and elopement and reviewed residents for potential elopement risk. The Administrator stated she was not aware of the resident's initial elopement attempt, but believed when CR #1 successfully eloped from the facility he went out the exit door on the 100 hall. The Administrator reported CR #1 was outside of the facility for approximately 12 minutes.During an interview with LVN P on 03/12/2026 at 3:03pm stated she was not working the day CR #1 eloped, but her most recent elopement in-service occurred approximately two weeks ago. She stated residents identified as being at risk of wandering or elopement were verified through photographs posted at each unit nurses' station. She stated the facility's elopement protocol requires staff to immediately alert other staff and notify the administrator. She stated staff are to first attempt to locate the resident as quickly as possible. She stated if a resident attempted to leave, staff would redirect the resident back to their room, offer snacks a calming intervention, implement one-to-one supervision, complete an assessment, and notify all appropriate parties. She stated when an exit alarm sounds, staff are to locate the exit door and determine who exited the area. She stated she accounts for her residents by conducting counts and performing rounds at least two hours, with additional rounds as needed. She stated the identified risks associated with elopement include the resident becoming lost or sustaining injury.During an interview with CNA N on 03/12/2026 at 3:16pm stated she was present on the day CR #1 eloped. She stated her office was located near the 100 hall. She stated she observed CR #1 push open the exit door, which activated the alarm. She stated she redirected him to his room, where he sat in a chair for approximately two to three minutes. At that time, he did not appear agitated or confused and appeared curious about the outside area. She stated when CR #1 successfully eloped from the facility, she was in the dining room assisting with resident trays for lunch. She stated the most recent elopement training occurred approximately two weeks prior. She stated the elopement protocol is to notify the Administrator and DON, search the facility both inside and outside, and contact 911 if the resident is not located. She stated the risks of elopement as falling, particularly due to ponds located behind the facility, and the possibility of the resident not being found.During an interview with CNA Q on 03/12/2026 at 3:29pm stated she was not working the day CR #1 eloped. She stated her most recent elopement in service occurred at the end of the previous month. She stated that when an elopement occurs, staff were required to notify the administrator and Director of Nursing, conduct a search of the facility both inside and outside, and contact law enforcement if the resident is not located. She stated if a resident attempts to leave the facility, staff are to notify appropriate personnel and attempt redirection through verbal engagement. She stated she would walk with the resident and would not leave them unattended, and that management would assign one to one supervision until the resident is deemed safe and all required assessments are completed. She stated if an exit alarm sounded, she would respond to the door, initiate a search, and account for all residents. She stated she accounts for residents through frequent rounds. She stated the risks associated with elopement as being struck by a vehicle or potential harm from wildlife due to the wooded area surrounding the facility.An observation was conducted on 03/11/2026 at 3:49pm with the Maintenance and DON to verify that all exit door alarms were functioning properly and activated when tested.

Based on observation, record review, and interviews, the facility failed to carry out activities of daily living necessary services to maintain grooming and personal hygiene reviewed for 2 of 7 residents (Resident #34 and Resident #123).The facility failed to ensure Resident #34 and Resident #123 received scheduled showers/bathing as required.This failure could result in skin breakdown, decreased self-esteem and quality of life.Findings included:Record review of Resident #34's undated face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing (healing fracture of right hip), falls, and muscle weakness.Record review of Resident #34's admission MDS assessment dated [DATE] revealed her BIMS score of 10 out of 15 indicated moderate cognitive impairment. Functional Abilities for Shower/bath and toileting hygiene revealed she required partial/ moderate assistance from staff to help lift, hold, and support.Record review of Resident #34's Care Plan dated 02/28/2026 revealed she required assistance of 1 or 2 staff to move between surfaces. This may fluctuate with weakness, fatigue, or weight bearing status. There were no additional interventions regarding bathing or ADL deficit.Record review of Resident #34's Progress Notes dated 02/28/2026 to 03/13/2026 revealed no documentation of refused showers.Record review of Resident #34's Kardex initiated on 02/28/2026 revealed a bathing schedule of every day, any time of the day with a CNA. Check marks were entered under the Not Applicable column for shower/bath/bed bath from 02/28/2026 through 03/06/2026.Record review of Resident #34's Bathing Documentation revealed:02/28/2026-03/06/2026 Not ApplicableDuring an interview on 03/10/2026 with Resident #34 at 12:55pm, she reported she had one shower since being admitted into the facility on [DATE]. She stated that she tries not to feel some way about not having a shower because she knows the staff were too busy with other residents when she asks for assistance with bathing.2. Record review of Resident #123's undated face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis are displaced fracture of lower end of right humerus, subsequent encounter for fracture with routine healing (healing fracture of the right elbow/upper arm), depression, and anxiety.Record review of Resident #123's admission MDS assessment dated [DATE] revealed her BIMS score of 12 out of 15 indicated noticeable memory and thinking difficulties. Functional Abilities for Shower/bathe self and toileting revealed she required substantial/maximal assistance from staff to help lift, hold, and support.Record review of Resident #123's Care Plan dated 03/07/2026 revealed she had limited physical mobility with no interventions, and she had an ADL self-care performance deficit and there were no interventions listed.Record review of Resident #123's undated Kardex revealed no specifications for ADL- bathing.Record review of Resident #123's Bathing Documentation revealed:03/06/2026 at 8:02 pm shower by CNA W03/07/2026 at 12:28 pm bed bath by CNA X ; 9:03 pm shower by CNA Y.03/08/2026 at 5:17 pm shower by CNA XNo checkmarks for 03/09, 03/10, 03/11, and 03/12.Record review of Resident #123's Progress Notes dated 03/06/2026 to 03/13/2026 did not reveal documentation of refused showers.Record review on 03/13/2026 of Shower Sheets for all halls revealed no documentation of showers or baths for Resident #34 and Resident #123 from 02/25/2026 through the date of review. An interview and observation on 03/10/2026 with Resident #123 revealed she hasn't had a shower since being admitted into the facility, and it makes her feel nasty. Resident #123's hair was observed to be extremely oily. She stated that she is supposed to get a shower that day, but it has not been confirmed yet and doesn't want the staff to feel that she is asking for too much when it's also other residents in the building.An interview on 03/13/2026 at 2:50 pm with CNA U stated she did not recall bathing Resident #34. She stated no one has access to her log in besides her. She stated that she is temporary staff, and she verifies when a resident needs a shower by the schedule on the nurse's desk. It is the resident's choice if they want to shower, and it is encouraged. The risk of showers not being provided as scheduled could result in distress and decreased quality of life.During an interview on 03/13/2026 at 3:11 pm, CNA V stated, upon reporting to work, she checked on residents and asks whether they would like to receive a shower. She reported that showers may be provided daily. However, the facility follows a schedule in which residents on the odd side of the building receive showers on Mondays, Wednesdays, and Fridays, and residents on the even side receive showers on Tuesdays, Thursdays, and Saturdays. CNA V indicated she was familiar with Resident #123 and stated she would not have documented a shower in the electronic health record unless she personally provided the shower and no one has access to her login information for the electronic health record. She identified the risk of showers not being received would cause potential frustration, also stating that residents have the right to accept or refuse bathing care.During an interview on 03/13/2026 at 3:38 pm, CNA X stated that residents received showers based on a scheduled rotation, with residents on the even side of the building scheduled for showers on Mondays, Wednesdays, and Fridays, and residents on the odd side scheduled for Tuesdays, Thursdays, and Saturdays. She reported that she is not assigned to a specific hallway, and shower assignments are pre-determined and documented in a shower book, which has been in use since she begun employment. She stated that completed or refused showers are documented in the electronic health record by checking the appropriate entry. CNA X reported that she worked with Resident #34. However, she does not recall providing a shower to the resident on 03/01/2026, and does not believe the resident was on her assigned shower list. She further stated that she is not scheduled to provide showers for Resident #123. She confirmed that no one has access to her PCC login information other than herself. She identified the risk of showers not being received would cause an increased risk of infection, including bacterial infection.During an interview on 03/13/2026 at 4:07 pm, the DON stated following attendance at training, she implemented the use of shower sheets after corporate provided clarification of purpose. She reported that staff should not use the electronic health record and shower sheets as documentation methods, and shower sheets are intended to be the sole method of documenting showers. She explained that the shower sheets are used to identify and verify any skin concerns observed during bathing. The DON reported that she is not familiar with the facility's shower/bathing policy. She stated residents should receive showers as often as they desire. However, the facility follows a schedule in which residents are typically provided with showers three times per week. To ensure showers are being completed, the DON stated she relies on observation and communication, including noting whether residents have fresh linens, appear groomed (such as shaved), and verbally report having received a shower. She reported that she has not audited the shower sheets, and unit managers are responsible for auditing them, with nursing staff expected to review and sign off. The DON identified the risks of showers not being received would cause a bacterial buildup, skin breakdown, and unpleasant odors.During an interview on 03/13/2026 at 5:10 pm, CNA W stated that she identified residents who required showers by reviewing the shower book, which outlined the schedule as Mondays, Wednesdays, and Fridays for residents on the odd-numbered side of the building and Tuesdays, Thursdays, and Saturdays for residents on the even-numbered side. She reported that shower assignments are determined by the scheduler who posts a schedule identifying the rooms assigned to each staff member and the designated shower days for residents. She stated that when a shower is refused, she would notify the nurse. She used paper shower sheets to document showers and informed the nurse if she is unable to provide a scheduled shower. She reported that she does not routinely document completed showers herself, as nursing staff review and verify the showers afterward. Regarding Resident #134, she stated that she does not recall providing the resident with a shower on the date in question and indicated that she would have documented the shower in the electronic health record had she provided it. She identified the risks of showers not being received would cause a skin breakdown and other related concerns, and stated without regular bathing, changes in skin condition may go unnoticed.Record review of facility policy for Activities of Daily Living implemented on 12/01/2025 read.Policy:The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living:Bathing, dressing, grooming and oral care;Transfer and ambulation;Toileting;Eating to include meals and snacks; andUsing speech, language or other functional communication systems.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #40 and Resident #68) and one of three medication carts (300 hall nurse cart) reviewed for storage of medications.1. The facility failed to keep Resident #40's medications secured. Eight unidentified medication tablets were found in a medication cup inside Resident #40's mini refrigerator. Resident #40 did not have orders to self-administer medications.2. The facility failed to keep Resident #68's medications secured. One albuterol solution was found in the resident's purse. Resident #68 did not have orders to self-administer medications.3. An unlocked and unattended medication cart was observed in a hallway in front of a resident room.The deficient practice could place residents at risk of not receiving the therapeutic benefit of medications, infection, drug diversion or ingestion of unprescribed medications to residents, staff, and visitorsFindings included:Record review of Resident #40's face sheet dated 03/11/26 revealed a [AGE] year-old admitted to the facility on [DATE]. His diagnoses included Parkinson's disease (a nervous system disorder), Diabetes (a chronic condition that occurs when blood glucose levels are too high), falls, hypertension (elevated blood pressures), Dementia (a general term for a group of symptoms that cause a loss of cognitive functioning) and depression.Record review of Resident #40's annual MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. Resident #40 required set up assistance for all ADLs and he used a wheelchair for mobility.Record review of Resident #40's undated care plan (downloaded on 3/11/26 at 10:10 AM) included: Focus - Resident #40 had behavior problems AEB: keeps medications at bedside, non-compliant with education on walking with stand by assistance with use of walker, uses another resident's walker without assistance r/t dementia, Parkinson's. Date initiated 02/10/25, revised on 03/10/26. Goal - Resident #40 will have fewer episodes of behaviors, revised on 02/05/26. Interventions included - Explain all procedures to the resident before starting and allow the resident to adjust to changes, revised on 12/10/25. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, revised on 12/10/25. Focus - Resident #40 was resistive to care refusing medications just don't want to take them, date initiated 06/10/25, revised on 07/24/25. Goal - Resident #40 will cooperate with care through next review date, revised on 02/05/26. Interventions included - Educate resident/family/caregivers of the possible outcome (s) of not complying with treatment of care, revised on 06/10/25. The resident's triggers for resisting care are (not liking the way he feels). The resident's behavior is de-escalating by (one on one) (follow up with psychologist noted), revised on 06/10/25. Further review revealed no care plan for self-administration.Record review of Resident #40's active physician orders as of 03/11/26 revealed the following scheduled medications in whole tablet form: Amlodipine 5mg tablet daily for HTN, Atenolol 50mg tablet daily for HTN, Cyclobenzaprine 5mg tablet for muscle spasms, Eliquis 5mg tablet BID for stroke prevention, Famotidine 20mg tablet BID for vitamin deficiency, Gabapentin 600mg tablet at bedtime for diabetic neuropathy, Jardiance 25mg tablet daily for diabetes, Lisinopril 40mg tablet daily for HTN, Memantine HCL 10mg tablet BID for dementia, Methimazole 5mg tablet daily for hypothyroidism, Mirabegron ER 25mg tablet daily for bladder spasms, and Tylenol 325 mg 2 tablets in the morning for pain. Further review revealed there was no order for self-administration of medications. Record review of Resident #68's undated face sheet revealed an [AGE] year-old female who admitted into the facility on [DATE]. She had diagnoses of paroxysmal atrial fibrillation (heartbeat that suddenly starts and stops on its own), obesity, kidney disease, diabetes, and epilepsy. There was no diagnosis related to the use of albuterol sulfate.Record review of Resident #68's admission MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. There were no behaviors identified and the use of a walker and wheelchair for mobility devices to assist with walking. There are no impairments for upper and lower extremities.Record review of Resident #68's active physician orders as of 03/13/2026 revealed the following scheduled medications for inhalation form: Arformoterol Tartrate Inhalation Nebulization Solution 15 MCG/2ML for congestive heart failure, and Budesonide Suspension 0.5 MG/2ML for congestive heart failure.In an interview and observation on 03/10/2026 at 10:53am, Resident #68 stated she was using oxygen at night for the diagnoses of congestive heart failure and emphysema. This surveyor observed Resident #68's beige purse on her lap, open, revealed Albuterol Sulfate 90 mcg. Resident #68 stated that she uses Albuterol Sulfate when she is wheezing or coughing and the staff is aware she has it.Observation and interview on 03/10/26 at 11:30 AM, Resident #40 was awake, alert and lying on his left side on the bed. Surveyor asked permission to look in the refrigerator and freezer to check thermometer temperatures. Resident #40 stated, go ahead. Inside the mini-refrigerator door compartment was a clear plastic 30ml medication cup with 8 pills of various shape and size: 2 large round white tablets, one oblong pale-yellow tablet, one medium sized round pale-yellow tablet, one medium sized round white tablet, one small round tablet, one small round yellow tablet and one pink tablet. When asked about the pills, Resident #40 stated he would take them later. In an interview on 03/10/26 at 11:45 AM, LVN F stated she was assigned to Resident #40, and said the Medication Aides administered most of the oral pills, and she did not know why or who would have put the medications in the refrigerator. LVN F stated the medications should not be in the fridge and expected medication aides to watch and make sure Resident #40 swallowed medications when given. LVN F then entered Resident #40's room. Resident #40 was heard yelling at LVN F. LVN F exited the room and stated Resident #40 grabbed the medication cup, told her he would take them later then cursed at her.In an interview on 03/11/26 at 12:00 PM, MA J stated she had not worked with Resident #40 in a while and would never leave medications with a resident.In an interview on 03/11/26 at 12:20 PM, MA G stated she was familiar with Resident #40 and would always make sure he swallowed his medications in front of her and would never leave a medication cup with pills in his room. MA G stated it was important not to have medications in the fridge because other residents might enter their room, find them and ingest medications that did not belong to them.In an interview and observation on 03/11/26 at 2:10PM, the Regional Corporate Nurse stated the facility conducted an investigation into the medications that were found in Resident #40's refrigerator. Resident #40 was unable to state why they were there, where they came from, or the length of their stay. The Regional Corporate Nurse stated that Resident #40's family members visited and that the medications could have originated from the family. The Regional Corporate Nurse and MA G assisted in trying to identify the pills from the photo taken by the Surveyor comparing them to Resident #40's medications stored in the medication cart. MA G stated the 2 large white pills were 325mg Tylenol, the small pink tablet was a multivitamin, and the oblong pale-yellow tablet was Jardiance. The remaining tablets could not be identified.In an interview on 03/11/26 at 2:20 PM, the DON stated she expected the staff to watch the resident consume the medication when passing medications to residents. The DON stated the medications should not be left for residents to self-administer and residents should not be holding on to medications given to them. In an interview on 03/11/26 at 4:40 PM, MA H stated she worked the 2:00 PM to 10:00PM shift, and was familiar with Resident #40. MA H stated Resident #40 did not have a lot of medications to give on her shift, and would refuse the 6:00 AM medications because of the time. MA H stated she would return at Resident #40's preferred time after breakfast at 9:00 AM when he would accept the medications. MA H stated she would never leave medications with Resident #40 and walk away. MA H stated the risk for Resident #40 was that he could choke on the medications and no one would be around to help him. MA H stated it was facility procedure to always watch the residents consume the medications before walking away.In an interview on 03/11/26 at 4:45 PM, MA I worked the 2:00 PM to 10:00 PM shift, and stated Resident #40 always refused his medications. MA I stated she would try again and return when Resident #40 was in the right mood, then he would accept the medications. MA I stated she always watched to make sure Resident #40 swallowed the medications. MA I stated she would never leave medications with Resident #40 for him to take later. MA I stated the risks would be that he would forget to take them, missing a dose and the timing of the medications would be off schedule. MA I stated she received in-services on medication administration yearly and several times in between.Observation on 03/13/2026 at 2:03 p.m. revealed an unlocked/unattended medication cart in front of room [ROOM NUMBER] on [NAME] Lane. The cart was facing outward, with the drawers accessible to passersby. One staff member was observed cleaning the carpet in a room across the hall. At the time of the initial observation, he was the only person within sight of the cart. During the 8-minute observation, several staff and one unidentified resident walked past the cart. None of the staff appeared to look at the cart. Continuous observation revealed several times no staff were within line of sight of the cart. A second Surveyor stood next to the cart for several minutes. The second Surveyor then left to find the nurse.Continued observation at 2:13 p.m. revealed LVN L was walking in the hallway. The Surveyor asked LVN L if she knew who was responsible for the medication cart. She said it was the nurse's cart. LVN L then locked the cart. Continued observation at 2:20 p.m. revealed LVN K arrived at the cart. When the surveyor informed her the cart was unlocked, LVN K replied, It's habit. She said anyone could have gotten into the cart and taken the medications. She said the narcotics were locked in a separate compartment. In an interview on 03/13/2026 at 2:35 p.m., the DON said if the cart was in within view of the nurse, it did not need to be locked. If the nurse is unable to see the cart, it would need to be locked. She said if a cart was unlocked, a resident or someone else could 'go inside the cart.' She said if a resident got meds it would be possible for them to have an allergic reaction or could cause harm. She said LVN K had been called away from the cart by a surveyor. The DON was informed that the surveyor she was referring to had also stood by the unlocked/unattended medication cart for several minutes.Observation on 03/13/2026 at 2:46 p.m. revealed LVN K at the same medication cart. Observation of the contents revealed medication bubble packs, nebulizer treatments, and other prescription medications as well as over the counter medications and supplements. She said the cart was for the 300 and 400 halls.In an interview on 03/13/2026 at 4:25 pm, the DON stated , for emergency purposes, no residents are permitted to keep medications for self-administration. All medications are expected to be stored in the designated areas, with medications carts and the medication room always secured. Failure to do so poses a risk of potential harm to residents if they gain access to the medications.In an interview on 03/13/2026 at 6:15 p.m., the Administrator said medication carts should be locked if unattended. She said if a resident accessed the medications, it could cause injury.Record review of the facility's policy for medication storage dated 12/01/25 read in part: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper . security.1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observations, interviews, and record review, the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident # 124) reviewed for quality of care. The facility failed to ensure Resident #124's transportation arrangements were made for a dialysis (a medical procedure used to remove waste products and excess fluid from the blood when the kidneys are not functioning properly) appointment as physician ordered. Resident #124 missed a dialysis treatment on 3/10/26.This failure could affect residents who received transportation services for appointments, and place them at risk of complications and not receiving proper care and treatment to meet their needs. Findings included:Record review of Resident #124's face sheet dated 03/12/26 revealed she was admitted to the facility from the hospital on [DATE]. Her diagnoses included acute osteomyelitis of the right ankle and foot (an infection of the bone that develops quickly), liver disease, acute kidney failure (an abrupt decrease in kidney function), heart failure, COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), Diabetes (a chronic condition that occurs when blood glucose levels are too high), acquired absence of right great toe, and hypertension (elevated blood pressure).Record review of Resident #124's admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognition. She required substantial assistance with showering and dressing. She required partial assistance with toileting. She required set-up assistance with eating and personal hygiene. She used a wheelchair for mobility. She was always continent of bowel and bladder. Resident #124 had functional limitations to one side of the upper extremity and had impairment to both sides of the lower extremities.Record review of Resident #124's undated care plan report revealed: Focus - Resident #124 needed dialysis - Planning to be temporary. Goal - The resident will have no s/sx of complications from dialysis through the review date. Interventions included: Encourage resident to go for scheduled dialysis appointments, monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report PRN new/worsening peripheral edema.Record review of Resident #124's active physician orders revealed an order for dialysis at the outpatient clinic every Tuesday, Thursday and Saturday. Dialysis will start on Tuesday 03/10/26 at 3:30PM. The order was dated 03/07/26; Record review of Resident #124's welcome letter from the dialysis center dated 03/06/26 revealed the first dialysis treatment was scheduled for Tuesday March 10 at 3:30 PM.Record review of Resident #124's general note dated 03/06/26 at 7:58 PM written by LVN A read in part: admitted to the facility from the hospital.Dialysis usually Tuesday/Thursday and Saturday but resident stated it had been switched to Monday/Wednesday/Friday for another week or two.Observation and interview on 03/12/26 at 9:30 AM, Resident #124 was sitting in a wheelchair, and visiting her family in the resident's room. Resident #124 stated she was supposed to have dialysis on Tuesday 3/10/26, but there was a transportation problem. Resident #124 stated the facility was supposed to make the transportation arrangements and was not too concerned about the mix-up with transportation. Resident #124 stated the last time she had dialysis was on Friday 03/06/26, while in hospital. Resident #124 stated currently her legs felt tight and heavy and that she had pain d/t the amputation on the right foot. Resident #124 was wearing tight-fitting leggings. She was in no respiratory distress and had no difficulty with speech. Resident #124 stated she began making urine again about 2 weeks ago. Resident #124 stated she could not complete PT yesterday (3/11/26) d/t trouble bending her legs.In an interview on 03/12/26 at 9:45 AM, LVN A stated she was assigned to Resident #124. LVN A stated she notified the NP when Resident #124 missed dialysis on 3/10/26. When asked the question, why did Resident #124 miss dialysis, LVN A replied that there was an issue with transportation and the resident's schedule had changed when she was in the hospital, so she went back to her original dialysis schedule. In an interview on 3/12/26 at 10:25 AM, the Unit Manager stated she was familiar with Resident #124 and was aware she needed dialysis. The Unit Manager stated she expected the nurse who took the order for dialysis to follow up by ordering transportation and contacting the dialysis center to confirm the appointment. The Unit Manager stated the facility provided in-house transportation as well as the use of outside transportation companies for resident appointments. The Unit Manager checked the her, and stated that it was LVN A who took the order for dialysis. The Unit Manager stated she was unaware that Resident #124 missed the dialysis appointment on 3/10/26. The Unit Manager stated when Resident #124 missed the dialysis appointment, and if she was the nurse responsible for the resident, she would have called the doctor, contacted the dialysis center to see if there were any available spots to make up the missed dialysis. The Unit Manager stated if Resident #124 had dialysis on 03/06/26, missed a scheduled dialysis on 03/10/26, and then scheduled for dialysis 03/12/26, she would have gone for at least 5 days without dialysis which could lead to anything such as the risk of fluid retention.In an interview on 3/12/26 at 10:40 AM, LVN A stated when she notified the NP that Resident #124 missed a dialysis treatment, the instructions were to monitor the resident, and the NP would be in to see the resident after dialysis on 3/12/26. LVN A stated the risks to any resident if they did not get dialysis depended on the diagnosis, maybe weight gain, and fluid retention. LVN A stated if Resident #124 did not get dialysis the risks would be SOB, CHF, aspiration and weight gain. In an interview on 3/12/26 at 10:45 AM, PTA B stated she worked with Resident #124 on 03/10/26 on balance and strengthening exercises. PTA B stated Resident #124 completed the 30-minute session and did c/o fatigue. PTA B stated Resident #124 participated in breathing exercises for core strengthening without any problems. PTA B stated she worked with Resident #124 again on 3/12/26 for the 30-minute-long session which Resident #124 completed. PTA B stated on 3/12/26 Resident #124 c/o fatigue, tightness to the right leg and pain to the right toe where she had the amputation. PTA B stated Resident #124 completed breathing exercises, did well overall and that her participation during the session was no different than the session on 3/10/26. In an interview on 03/12/26 at 10:55 AM, PTA C stated she worked with Resident #124 on 03/11/26. PTA C stated Resident #124 completed the 30-minute therapy session. PTA C stated Resident #124 was participatory with frequent rest breaks. PTA C stated Resident #124's leg was bothering her, particularly her right leg. PTA C stated she did not notice any SOB, nor did she see any other signs or symptoms that she would need to report.In an interview on 3/13/26 at 11:55 AM, Receptionist D stated she received an acknowledgment on Friday 3/06/26 that Resident #124 was arriving at the facility that day, but she did not put in the dialysis transportation because she was unsure if the resident would admit to the facility or not. She said she then got busy and forgot to arrange the dialysis transportation. She said she was notified on Tuesday 3/10/26 that Resident #124 did not make it to her dialysis appointment. She called the dialysis facility on Tuesday to arrange transportation; dialysis said that Wednesday was full, but it was ok for Resident #124 to attend dialysis on Thursday at an earlier chair time. She said she was responsible for setting up transportation and had received training. She said she would now arrange transportation regardless of whether the resident being admitted to the facility or not and she would report missed dialysis appointments to the DON or Administrator.In a telephone interview on 03/12/26 at 12:49PM, the Dialysis Nurse at the outpatient Dialysis Center stated that on Monday 3/09/26 she did not receive any phone calls from the facility to confirm Resident #124's dialysis appointment for 3/10/26 at 3:30 PM. The Dialysis Nurse stated she was unaware the resident was residing at the facility until she contacted Resident #124 directly via telephone on 03/09/26. The Dialysis Nurse stated that on 03/09/26 she spoke with the receptionist at the facility, then spoke with a nurse and learned that the facility was aware of Resident #124's appointment on 3/10/26 and was informed that transportation had been set up with an outside transportation company. The Dialysis Nurse stated she did not have the names of staff she spoke with. The Dialysis Nurse stated that on 3/11/26 when the resident did not arrive for the 3:30 PM appointment she called the facility and was told Resident #124 was waiting outside for the ride. The Dialysis Nurse called Resident #124 and confirmed she was outside the facility awaiting transportation. The Dialysis Nurse contacted the outside transportation company and learned Resident #124 was not booked to be picked up for the 3/10/26 3:30 PM appointment. The Dialysis Nurse contacted a second outside transportation company that was commonly used and learned Resident #124 was also not booked for transportation. The Dialysis Nurse stated she contacted someone at the facility and was told the facility would set up the ride for Thursday's appointment. The Dialysis Nurse stated she contacted the same transportation company and booked a ride for Thursday 3/12/26 11:45 AM appointment to ensure Resident #124 would not miss the appointment then contacted Resident #124 to confirm the appointment. The Dialysis Nurse stated Resident #124 was currently on dialysis and doing fine. In an interview on 3/12/26 at 2:15 PM, the NP said Resident #124 admitted to the facility on Friday of last week (3/06/26) and was dialyzed on that day. She said she saw Resident #124 on Monday (3/10/26) and she was ok and completed therapy with no swelling. She said Resident #124 was supposed to be dialyzed on Tuesday, but she received a call from LVN A that Resident #124 missed dialysis due to transportation issues. She informed LVN A to monitor the resident for fluid overload and to call her back if there was shortness of breath or lower extremity swelling. On Wednesday, she only received a call about the resident having pain. She said she received a call from a nurse today, 3/12/26 and was informed that the resident had lower extremity swelling. The NP said she told the nurse to ensure Resident #124 went to dialysis today. The NP said the risks of not getting dialysis would be edema, weight gain, and if it was really bad, then maybe SOB. The NP said the s/sx of hyperkalemia (elevated blood potassium levels, dialysis aids in regulating potassium levels for individuals who do not have adequate kidney function) would be muscle weakness, cramps, numbness and N/V. The NP stated she would not normally check labs if someone missed dialysis but would first look for s/sx such as edema, weight gain and SOB. She said she expected the facility to follow up and arrange transportation to ensure everything was done appropriately for the residents because that is their life.In an interview on 3/13/26 at 6:00 PM, the DON said the receptionist was designated to arrange dialysis transportation. She said her understanding was that the ball was dropped on the Receptionist's end, and transportation was not arranged. She said if a dialysis appointment was missed, nursing should immediately notify the NP or MD, family, and obtain any orders; put assessment pieces in place, monitor weights, and implement fluid restrictions until the resident could get dialysis. She said Resident #124 was on fluid restriction. Record review of the facility's policy for Hemodialysis dated 10/01/2025 read in part: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.7. The facility will assure that arrangements are made for safe transportation to and from the dialysis facility

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 1 of 6 residents (Resident #100) reviewed for pharmacy services. The facility failed to account for one of Resident #100's Alprazolam 0.5 mg tablets from 3/11/26 - 3/13/26.This failure could place residents at risk for drug diversion and/or duplicate therapy.Findings included: Record review of Resident #100's face sheet dated 3/13/26 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnosis included anxiety disorder, fracture of right pubis, and depression. Record review of Resident #100's admission MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 which indicated intact cognition. Record review of Resident #100's Medication Administration Record for March 2026 revealed Alprazolam 0.5 mg was scheduled for 1 tablet every 8 hours as needed for pain, start date 3/6/26. The medication was documented as administered one time between 3/11/26 and 3/13/26 on 3/11/26 at 1:32 p.m. Record review of Resident #100's undated Narcotic Record for Alprazolam 0.5 mg revealed there were 4 entries documented between 3/11/26 and 3/13/26. One tablet was documented as administered on 3/11/26 at 8:00 p.m., 3/12/26 at 2 p.m. and 3/12/26 at 9 p.m. On 3/12/26 at 9:00 p.m. there were 66 tablets remaining. On the next entry, dated 3/13/26 at 3 p.m. there were 65 tablets remaining with the word correction written in parenthesis and one nurse signature (LVN K). There was no explanation of what happened to the unaccounted for tablet. In an observation and interview on 3/13/26 at 3:41 p.m. of the 400-hall nurses' cart, LVN K counted Resident #100's Alprazolam tablets and said there were 65 tablets remaining. She said she was unsure what happened to the missing tablet and said someone might have forgotten to sign it out on the narcotic record. She said she was coming on to work and LVN D was getting off work. She and LVN D conducted a narcotic count during shift change around 6:15 a.m. and tried to find out what happened to the tablet at that time. She said LVN D did not sign as the second nurse on the narcotic sheet because she got busy. She said she and LVN D would try and figure out what happened when LVN D arrived for her shift that evening. She said they did not report the missing tablet at the time because they wanted to see if they could find the error before escalating the situation. In an interview on 3/13/26 at 4:48 p.m., the Regional Director of Clinical Services said he expected nursing staff to account for the narcotics. He said anytime there was a narcotic missing, nursing staff should notify the DON and Administrator, the facility would interview the nurses and if they were unable to state where the tablet was, they would conduct a further investigation. He said the oncoming nurse should not have taken the keys to the nurse cart if she knew the count was inaccurate during the shift count. He said if they took the keys, they were held responsible for the narcotics. In an interview on 3/13/26 at 4:52 p.m., the Unit Manager said when administering medications, nursing staff should read the order three times and sign before giving the medication, and ensure there were no holes in the documentation. She said nursing staff should sign as they go. She said it was important to document, especially for narcotics, because they were controlled medications. She said she was not aware of any missing tablets for Resident #100. In an interview on 3/13/26 at 5:46 p.m., the DON said nursing staff should count the narcotics to keep track of the medication, and if there were any discrepancies, staff should notify her. She said she was not informed of any narcotic discrepancies by the night nurse (LVN D), and the night nurse administered the medication (to Resident #100), but did not sign it. She said staff were trained on controlled substances and were educated in school. She said the risk of an inaccurate narcotic counts could be that the residents may not receive their medication.In an interview on 3/13/26 at 6:51 p.m., LVN D said she and LVN K counted the narcotics this morning and compared each narcotic to the name and number in the narcotic book. She said, during shift change, they thought there were 66 Alprazolam tablets for Resident #100, but that was an error. She said she thought the count was correct, and was notified later by LVN K that the count was off and needed to be corrected. She said she was unsure if anyone else was notified at that time. She said if the count was off nursing staff normally notified the DON and checked with the nurses. She said she did not notice any discrepancy with the Alprazolam until today and did not notice a discrepancy yesterday when she arrived at work. She said she was trained on controlled substances which included counting each narcotic before and after the shift and reporting any discrepancies. In an interview on 3/13/26 at 7:02 p.m., LVN K said she did some digging (research) and saw where she administered one Alprazolam 0.5 mg to Resident #100 on 3/11/26 (but did not document it on the narcotic sheet). She said there was no discrepancy of count noted on 3/11/26 after her shift. She said her main focus was documenting the administration on the computer, but she should document in the computer, and also turn to the right to document in the narcotic book, to ensure accuracy. She said if the administration was not documented in the narcotic book, it would throw the count off and confuse the other nurses.Record review of the facility's Medication Storage policy dated 12/1/25 read in part, .2. Narcotics and Controlled Substances. c. any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy, and possibly the State Licensure Board for Nursing Home Administrators. d. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. Record review of the facility's Medication Administration policy revised on 12/1/25 read in part, .20. If medication is a controlled substance, sign narcotic book.

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 7%, based on 2 errors out of 27 opportunities, which involved 1 of 6 residents (Resident #48) and 1 of 5 staff (MA G) reviewed for medication administration.MA G administered two anti-hypertensives, Amlodipine and Lisinopril, (medications that reduce blood pressure) to Resident #48 without checking her blood pressure according to MD orders, the pharmacy label, and facility policy on 3/11/26. This failure could place residents at risk of low blood pressure and hospitalization. Findings include:Record review of Resident #48's admission record dated 3/11/26 revealed an [AGE] year-old female who admitted on [DATE]. Her diagnoses included hypertension (high blood pressure), Alzheimer's disease, kidney failure, and hypertensive heart disease without heart failure (a condition caused by prolonged high blood pressure, leading to damage to the heart).Record review of Resident #48's quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15 which indicated severe cognitive impairment. She required set-up or clean-up assistance from staff with ADL care.Record review of Resident #48's care plan revealed she had hypertension related to hypertensive heart disease, revised on 7/21/25. Interventions were to give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure when standing up) and increased heart rate and effectiveness. Record review of Resident #48's Order Summary Report revealed orders for:Lisinopril 20 mg give 1 tablet orally one time a day for hypertension hold for SBP <110 or DBP < 60, order date 2/9/26;Amlodipine 5 mg give 1 tablet orally one time a day for hypertension hold for SBP < 110, pulse <60, order date 10/29/25.An observation and interview on 3/11/26 at 8:03 a.m., during medication pass, revealed MA G prepared Resident #48's medication for administration. She prepared Amlodipine 5 mg, Lisinopril 20 mg, Anastrozole 1 mg, Vitamin D 5000 IU, and Memantine 5 mg. The pharmacy labels for Amlodipine and Lisinopril read .Check patient's parameters before administering. MA G entered Resident #48's room and administered all medications to Resident #48 without taking her blood pressure. MA G said she did not take Resident #48's blood pressure because the eMAR did not have a heart symbol next to the medication name, which would prompt her to take the blood pressure. She said there was no prompt for her to enter the resident's vitals. She said Resident #48's blood pressure medications, Amlodipine and Lisinopril had hold orders and the pharmacy label also read to check parameters prior to administering. She said the directions had been in place, but she was new and still learning. She said if she did not check the blood pressure, the resident could go into cardiac arrest and be sent out to the hospital. An observation on 3/11/26 at 8:13 a.m. of Resident #48's eMAR revealed her last recorded blood pressure was on 3/10/26 at 9:04 p.m. Her blood pressure at that time was 123/77 with a pulse of 75. (Normal blood pressure vitals range from 90-120/60-80 and pulse range from 60-100).In an interview on 3/11/26 at 8:55 a.m. MA G said she checked on Resident #48 after the medication pass and said her blood pressure was 130/72 with a pulse of 72. In an interview on 3/11/26 at 3:09 p.m., the Unit Manager said medication aides and nurses were trained to take the blood pressure prior to administering blood pressure medications. She said when nursing staff entered blood pressure medication orders, they selected a box to include the supplementary documentation that would cause the heart symbol to pop up next to the medication. (The supplementary documentation would prompt staff to enter the residents' vitals such as blood pressure and pulse). She said there was no reason for the supplementary documentation to be deleted off Resident #48's Amlodipine and Lisinopril. She said she did change the administration time on those two medications, but did not change the supplementary documentation requirement. She said no one brought it to her attention that the supplementary documentation was not included in the orders. In an interview on 3/11/26 at 4:56 p.m., LVN F said she was unsure what MA G told her about Resident #48 earlier, but she took Resident #48's blood pressure at 8:30 a.m. and documented it.In an interview on 3/13/26 at 5:32 p.m., the DON said the blood pressure should be taken prior to administration. She said you do not want to give a blood pressure reduction medication because the blood pressure could be low and the resident could bottom out (occurs when the blood pressure has dropped to a very low level, which can reduce blood flow to vital organs) if the blood pressure was not checked. She said there were several ways that nursing staff were alerted to take the blood pressure prior to administration which included supplemental orders in the computer system. She said nursing staff were also taught in school to check the blood pressure prior to administering the blood pressure medication. She said parameter orders could also be listed in the orders. She expected nursing staff to complete their checks during medication pass which included following the instructions on the pharmacy cards and following the MD orders. Record review of Resident #48's nursing note dated 3/11/26 at 8:30 a.m. written by LVN F read in part, Patient BP 130/72 HR 72. Due medications administered as ordered by medication aide, no adverse reactions noted.Record review of the facility's Medication Administration policy revised 12/1/25 read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Medication requiring vital signs prior to administration: .Anti-Hypertensives.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for one out two dumpsters observed for garbage disposal.One facility dumpster lid was open and unsecured.This failure placed residents at risk of infection and a decreased quality of life due to having an exterior environment which could attract flying pests, rodents and other animals.Findings include:In an observation on 03/13/26 at 12:08 pm, the surveyor and the Dietary Manager observed the facility dumpster area, which was in the lot behind the dietary department. There were two commercial-sized dumpsters. The lid of the dumpster located on the left side was open (the dumpster was located inside a gate).In an interview on 03/13/26 at 12:09 pm with the Dietary Manager, she stated everyone (Kitchen, Nurses and Laundry) were responsible for closing the dumpster lids. She stated it should be closed after each use, but she thought it was okay for the lid to be open as long as the gate was closed (the dumpster was located inside a gate). She stated she was not sure who was the last person to use the dumpster. She stated the risk of leaving the dumpster open could be raccoons.In an interview on 03/13/26 at 6:09 pm with the Administrator, she stated the staff checked the outside dumpster throughout the day regularly, and it should have been closed. She stated dietary, maintenance and housekeeping were responsible for ensuring the dumpsters were closed. She stated the risk of the dumpster lid not being closed was pest. She stated the Dietary Manager was aware that the dumpster had to always be closed so she wasn't sure why she said it could be open if the gate was closed. Record review of the facility's Dumpster and Waste Disposal policy dated 12/01/25 reflected, 1. Prior to disposal, all waste shall be kept in a leak proof, non-absorbent, fireproof containers that are covered. 2. These containers are emptied as often as necessary throughout the day. Trash bags shall be sealed prior to removing from the facility. Trash will be deposited into the sealed container outside the premises.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for residents, staff, and the public for 2 (CR #1, Resident #1) of 5 residents and 2 (vacant room A, vacant room B) of 5 vacant rooms reviewed for sanitary conditions. 1. CR#1 was admitted on [DATE] into a room that had urine-stained sheets, brown fecal matter on the toilet seat and toilet bowl, and inside closet was wheelchair equipment left over from a previous resident. 2. Resident #1 had small black bugs crawling on the counter of the kitchenette inside her room on 12/12/25. 3. Vacant Room A had spider webs along the based boards, a urine stain on the fitted sheet, and dried fecal matter splatter inside of the toilet bowl on 12/12/25. 4. Vacant Room B had over 30 short black hairs found on the fitted sheet and hairballs and food particles along the baseboards on 12/12/25. These failures could pose a concern for infection control, sanitation, affect resident's quality of life. Findings included:Record review of CR#1's facesheet reviewed on 12/12/25 revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were spinal stenosis of the lumbar region with neurogenic claudication (the space in your lower spine (lumbar region) narrowed) and fusion of the spine in the lumbar sacral region (a surgical procedure that permanently joins two or more vertebrae in the lower back (lumbar) and the triangular bone at the base of the spine (sacrum) into a single, solid bone). CR#1's facesheet revealed that she was discharged on 11/8/25 at 11:24 a.m. A record review was attempted on 12/12/25 to review CR#1's care plan. CR#1 resided in the facility for 17 hours. There was not a care plan available to review. Record review of CR#1's progress note dated 11/7/25 at 5:07 p.m. revealed that CR#1 was AO (alert and oriented) x4 (alert to person, place, time, and event). and was admitted from the hospital with a diagnosis of spinal stenosis. Note stated that during the admission process, CR#1 decided to leave AMA (against medical advice). Record review of the facility's grievance log revealed a grievance was made by CR#1 on 11/7/25. CR#1 reported that her room was not clean, and the action taken was staff immediately changed linens, offered different comforters, and eventually moved CR#1 to another room. HKM also met with CR#1 on 11/8/25 to ensure that she was satisfied but she still decided to discharge AMA. In an observation of vacant room A on 12/12/25 at 11:10 a.m., the room was empty of personal belongings and appeared to be vacant but there was a resident's name on the door. An aide walked past and stated that the resident had gone to the hospital sometime last week and the facility held the room based off their insurance. Inside of the room, there were spider webs in a corner to the left side of the bed. Inside of the spider web was a dead centipede curled up into the web. With the covers on the bed pulled back, a faint urine stain could be seen on the fitted sheet. Inside of the bathroom, there were fecal splatters inside the back of the toilet bowl. In an observation of vacant room B on 12/12/25 at 11:20 a.m., hairballs and residue from food could be seen along the floor baseboards. With the bed sheets pulled back, over 30 strands of short black hair were observed on the fitted sheets. In an interview on 12/12/25 at 1:07 p.m. with CR#1 she stated that she found the facility to be unsanitary upon admittance. She stated that the room was so gross that her family had to clean it up for her. Her family member informed her that the bed was dirty, and she saw urine stains on the sheets. The nurse on shift helped her change the sheets and eventually moved her into another room. She was admitted to the facility around 4/5 p.m. and after several mishaps, she decided that she wanted to return home. CR#1 informed the surveyor that she took pictures of the room, and they were sent to the surveyor for evidence. In an observation of the photographs taken by CR#1 on 11/7/25, the following could be seen:Photo 1: brown fecal matter located on the bottom of the toilet set inside the bathroomPhoto 2: brown fecal matter on toilet, directly underneath the toilet seat inside the bathroomPhoto 3: short black hair in the soap dish inside of the bathroomPhoto 4: inside the closet, leg rest for a wheelchair were left on the floor Record review of Resident #1's facesheet reviewed on 12/12/25 revealed a [AGE] year-old woman who was admitted on [DATE]. Her admitting diagnoses were noninfective gastroenteritis and colitis (inflammation in the digestive tract) and perforation of the intestine (a hole or tear formed in the wall of the gastrointestinal (GI) tract (esophagus, stomach, small or large intestine), allowing its contents (food, digestive fluids, bacteria, stool) to leak into the sterile abdominal cavity). Record review of Resident #1's care plan dated 12/8/25 revealed that she had an ADL self-care performance deficit related to activity intolerance and impaired balance due to declined health. In an interview on 12/12/25 at 11:37 a.m. with Resident #1's family member, she stated that her mother moved into the facility two weeks ago and the move in process went fine, however, there were a lot of bugs by the kitchenette sink and counter. By the kitchenette, several small black bugs (type unknown) could be seen crawling all over the counter and inside of plastic bag with a cookie inside. When asked how long the bugs had been seen inside the room, the family member stated that the bugs had been seen inside of the room for a while (length of time undisclosed). In an interview on 12/12/25 at 11:48 a.m. with HK C, she stated that she had worked at the facility for 1 year. Some of her duties in housekeeping were to dust, wipe, disinfect, mop, clean beds, showers, make sure nothing was on the walls, and vacuum. These tasks were done in the rooms of current residents as well as inside the vacant room for future guests. She stated she had gotten complaints about bugs inside the facility, but she had not seen any bug while cleaning up on her assigned halls. HKM oversaw all housekeeping practices, but he was currently out of the facility at a doctor's appointment. In an interview on 12/12/25 at 11:56 a.m. with CNA D, she stated that she had been working at the facility since August 2025. She stated that the laundry aides brought the linens to the resident rooms and CNA's made them up on the residents' beds. She stated that some of the sheets she received had been stained really bad, but she would throw them back into dirty linen because the residents would not want them. She explained that the facility used white sheets, and it was hard to keep them clean and some of the sheets were stained with BM (bowel movement). She had received complaints from residents regarding bugs and the types of bugs she had seen were roaches. In an interview on 12/12/25 at 12:03 p.m. with CNA E, she stated that she had worked at the facility for over a year. She explained she received the linens from the laundry aides, and she made up the residents' beds. When asked to describe the cleanliness of the linens, she stated that she could not rate how clean the linen was, but she personally would not want to sleep on them and described the stains to be from urine. She stated that she had gotten complaints from residents about the linen being dirty and she had not received any complaints regarding there being bugs found inside of the residents' rooms, but she had found a roach in the hallway. In an interview on 12/12/25 at 12:11 p.m. with LA F, she stated that she had worked at the facility for over 5 years and typically worked the morning shift. She stated that before she brought the soiled linen into the laundry room, she separated them out in the linen rooms on the hall. If she saw items that looked runny (loose or watery substance) or had #2 (bowel movement) on them, she would place them in the infection control pile and wash them separately. She stated that if she saw the sheets were dirty after they were washed or still had an odor to it, she would toss it back into the washing machine and double wash those linens. She felt that some of the laundry staff did not do this, however, she had washed items up to 3 times to make sure they were clean and fresh for residents. If she could not get a stain out after 3 washes, she would inform the HKM. She stated that she had received complaints from staff that the linen had stains on them but felt they were referencing other laundry staff and not herself. In an interview with the DON on 12/12/25 at 3:01 p.m., she stated that she had been working at the facility since July. She explained that when there was a new admit of when a resident was discharged , housekeeping was supposed to clean the room. If a resident was sent out of the facility but not discharged , housekeeping would do a deep clean to the room, their items would be boxed up and put away, and maintenance would be notified through a secure text to prepare the room for a new admit. DON stated that she remembered CR#1 and said that she was very dissatisfied with different cosmetic things about her room. She explained that CR#1 thought a few things about her room were dirty but they were wear and tear. DON stated that her expectation of the rooms for a new admit would be a deep clean and the harm in someone admitting into an environment that was not clean would be infection control. Record review of the facility policy titled Homelike Environment revised February 2021 revealed the policy statement was: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Interpretation and implementation:1. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:1. clean, sanitary and orderly environment;2. comfortable (minimum glare) yet adequate (suitable to the task) lighting;3. inviting colors and decor;4. personalized furniture and room arrangements;5. clean bed and bath linens that are in good condition;6. pleasant, neutral scents;7. plants and flowers, where appropriate;8. comfortable and safe temperatures (71 F - 81 F); and9. comfortable sound levels.

Based on 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 of 6 residents (CR #1) reviewed for quality of care.-The facility failed to ensure a thorough head to toe skin assessment was completed on CR #1 on 8/29/25. CR #1 was discharged to an acute care hospital on 8/30/25 and was diagnosed with a left groin abscess.This failure could place residents at risk of delayed treatment, pain and infection.Findings Include:Record review of CR #1's admission record dated 11/10/25 revealed a [AGE] year-old male who admitted on [DATE] and discharged on 8/30/25 to an acute care hospital. His diagnosis included in part, Alzheimer's disease, pain, basal cell carcinoma of skin of left upper limb, and basal cell carcinoma of skin of right upper limb. (Basal cell carcinoma is a type of skin cancer).Record review of CR #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 out of 15 which indicated severe cognitive impairment. He required supervision or touching assistance and setup or clean-up assistance with ADL care. He did not exhibit behaviors of rejection of care during the assessment period.Record review of CR #1's care plan revealed he had impaired urinary elimination related to obstruction of urinary flow secondary to enlarged prostate gland. Interventions were to assess and monitor urinary incontinence and skin condition, assess and monitor urinary status and signs/symptoms of infection, perineal care, date initiated 5/28/25. CR #1 was at risk for pressure ulcer related to decreased mobility, incontinent of bowel and bladder, use of right ankle brace, use of CPAP at bedtime, CR #1 reluctant to allow staff to assist with peri care and/or ADL care, date initiated 12/1/24 and revised on 9/5/25. Interventions were to check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown, date initiated 1/3/25. Record review of CR #1's Order Summary Report dated 11/20/25 indicated an order for Weekly Head to Toe Skin Assessment every day shift every Friday, N=new, E=existing skin alteration, C= clear, order date 1/7/25.Record review of CR #1's nursing note dated 8/27/25 written by LVN F read in part, Resident's sitter reported to this writer about 1030 hrs (10:30 a.m.) that resident's pullup had what appears to be a little bit of blood-tinged urine in it. This writer monitored resident for other bleeding the rest of the shift and none was seen. Provider notified of isolated incident and order was given for UA with C&S. [family members] notified.Record review of CR #1's SBAR dated 8/27/25 completed by LVN F revealed the resident had blood in urine and a skin evaluation was not clinically applicable to the change in condition being reported.Record review of CR #1's MAR for August 2025 indicated on 8/29/25 a weekly head to toe skin assessment was documented as completed by LVN J. There was an e documented which indicated existing skin alteration. Record review of CR #1's nursing note dated 8/29/25 written by LVN J read in part, .late entry. skin assessment completed, noted with existing upper back skin abnormalities. No s/s of redness/infection noted to right shoulder biopsy site. Skin intact. Resident schedule for DERM appointment today.Record review of CR #1's nursing note dated 8/30/25 written by LVN F read in part, Resident noted with what appears to be an abscess to the left groin area, between the crease of the left leg and the pubic area. Abscess was draining and had a real foul odor. Resident groaned in pain when palpated (examined by touch). [Family member] at bedside. Vitals stable. NPs of MD J was notified, and they ordered for him to be sent to the ED for further evaluation.Record review of CR #1's hospital records dated 9/4/25 indicated CR #1 was admitted from the ED on 8/30/25 and on 8/31/25 had an incision and drainage of left groin. The infectious disease progress note revealed a 3.6 x 2.3 cm medial (middle) left groin abscess adjacent to hip adductors (a group of muscles located in the medial compartment of the thigh). Assessment/plan: polymicrobial (several types of microorganisms) left inguinal (groin) abscess with enteric flora (bacteria that exist in the intestines of animals and humans) status post-surgical I&D with clinical improvement. CT of the abdomen and pelvis with IV contrast completed on admission without evidence of any perineal or GI tract pathology to explain abscess formation. Exam on admission did show evidence of skin breakdown in the area with 2 wounds which could have led to contamination with enteric flora due to its location and eventual abscess formation.In an interview on 11/18/25 at 2:26 p.m. LVN F said CR #1 had a private sitter and a few days before he was sent out to the hospital the sitter said there was a little bit of blood in his pull up. She said she and another staff did a skin check on CR #1 (on 8/27/25) and did not see any open areas. She said there was no pain or odor. She said she tried to look in the creases but did not pry because CR #1 would not allow it, refused to be touched and was not easy to redirect. CR #1 said no stop, and zipped up his pants. She said she reported to the NP that she did not see any bleeding, no odor, and there was no sign of anything being there. She said she got an order for a UA and thought the blood was coming from his urine. She said the urinalysis was collected 2 days later because CR #1's dementia was bad, and he did not know what to do when staff tried to collect the urine. She said when she returned to work on Saturday 8/30/25 CR #1's family member found an open area on him that looked like an abscess. She said she lifted up his penis and the abscess was in the fold and crease. She said the abscess was oozing and the odor was really bad and foul and he was in pain. In an interview on 11/19/25 at 11:13 a.m. CR #1's family member said she knew there was something going on with CR #1 because he had blood in his pull up. She said she arrived at the facility on Saturday morning, 8/30/25, and there was blood all over his chair and bed. She said she had CR #1 lay down so she could examine him, and the smell was unholy. She made the facility call 911 and get CR #1 into an ambulance. She said she believed the abscess had been there for weeks and had gone internally. In an interview on 11/19/25 at 12:33 p.m. CR #1's private sitter said one day she took CR #1's pants down and there was blood in his pull up and on the side which was unusual. She said she took a picture and notified the nurse who said they would do a urinary tract test. She said she assisted him with a bath on that day, and he pushed her hand away when she tried to assist him. She said every day was different with showers because of his dementia, and CR #1 would usually say he would wash himself. She said CR #1 had a doctor's visit on 8/29/25 and the facility bathed him. She said she did not recall seeing any blood spots or anything unusual on that day. She described the abscess as a huge hole in the groin with pus and said you could not see it unless you put your face under his groin. In an interview on 11/19/25 at 1:40 p.m. LVN J said on 8/29/25 she completed a head-to-toe assessment on CR #1 but did not look at his groin area and did not lift his balls because he did not complain of discomfort, there was no blood anywhere including the pull up, and she did not suspect anything. She said the only areas she did not lift during the assessment were his scrotum/balls area. She said when she returned to work it was reported that the abscess was found in that area. She said during a head-to-toe skin assessment you have to check and look at everything. She said she was trained on head-to-toe skin assessments and should look at the person and review for any abnormalities or anything suspected. She said the purpose of the head-to-to-toe skin assessment was to prevent any open areas, which would be reported to the supervisor and wound care nurse. She was unsure of what could happen if every part of the resident's body was not examined during a head-to-toe skin assessment. In an interview on 11/19/25 at 1:52 p.m. the DON said they believed CR #1's tinge of blood was a UTI but found out he had an abscess that had not ruptured yet. She said the facility staff had not seen an abscess on CR #1. She said nurses should look at the creases, moist areas, folds, and every inch of the body during a head-to-toe skin assessment. She said those areas of the body were more susceptible to bacteria. She said as a result of the incident with CR #1, the facility conducted in-services, conducted a QAPI, PIP and a very thorough skin sweep. She said the ADON, wound care nurse, and unit managers were overseeing the skin assessments.In an interview on 11/19/25 at 2:15 p.m. the Administrator said the facility was treating CR #1's small blood as a possible UTI and a UA was ordered. She said the area was a boil and the resident would not allow the staff to wash him. She said during his shower there was nothing on the washcloth. She said the facility always investigated concerns and 99% of the time she would take the time and re-educate staff. She said head to toe assessments were conducted on all residents and the facility QAPI'd the incident. She said the conclusion of their investigation was that something may have been festering but the abscess just popped out. She said head to toe skin assessments should be completed regularly and were based on the patients' behavior and compliance. In an interview on 11/19/25 at 3:33 p.m. CR #1's MD J said an abscess just popped up on CR #1 and CR #1's family member noticed it. He said the abscess was in the groin area and if it was small, it could be hard to feel. He said an abscess could absolutely pop up overnight and the resident would show signs that something was there. He said signs and symptoms of an abscess could be fever, pain, and being uncomfortable.In an interview on 11/20/25 at 10:35 a.m. CNA S said she assisted CR #1 with a shower on 8/29/25. She said CR #1 washed in between his private area and underneath his balls (testicles) and there was no blood on the white bath towel or in his pull up. He dried the front and back of his body with no concerns and no pain expressed. She said she did not see his private area. She said CR #1's sitter rechanged his pull up, dressed him, and took him to a doctor's appointment. CR #1 did not complain of any pain to her on Friday 8/29/25. She said she would have reported any areas of concern to the nurse. Record review of the facility's Skin Assessment policy dated 10/1/25 read in part, . policy: it is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. 2. Procedure. e. begin head to toe, thoroughly examining the resident's skin for condition. Pay close attention to pressure points, bony prominences, and underneath medical devices.Record review of the facility's Ad Hoc QAPI Plan dated 9/4/25 read in part, Problem: External reportable to HHSC for allegation of neglect. Abscess to resident groin. Resident refuses care and toilets himself. Facility action: patient safe surveys on interviewable patients, safe survey follow up if appropriate, head to toe assessments, in-service on ANE, in-service on skin, Inservice on continence, in-service on ADLs and dealing with difficult residents, medical director notification, psychosocial well being assessment if resident returns to the facility, accident/incident report, pain monitoring audit, head to toe evaluations audit.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 out of 6 residents (Resident #40) reviewed for ADL care. - The facility staff failed to provide scheduled showers/baths to Resident #40 on 12/7/24 and 12/14/24. - The facility failed to change Resident #40's shirt for 3 days (12/15/24, 12/16/24, and 12/17/24) when there was debris and stains on it. These failures could place residents at risk of a decline in ADL's. Findings include: Record review of Resident #40's undated face sheet revealed he was a [AGE] year-old male originally admitted to the facility on [DATE], with the most recent admitted [DATE]. He had diagnoses of kidney failure (kidneys stop filtering the blood), dementia neurological conditions that cause a decline in mental abilities that affects daily life), hemiplegia (paralysis) and hemiparesis (numbness) following a stroke, heart failure, diabetes mellitus (body does not produce insulin or resists it), major depression, aphasia (trouble speaking), weakness, convulsions (seizures), and muscle wasting and atrophy. Record review of Resident #40's Annual MDS assessment from 12/10/24 revealed he had a BIMS score of 8 out of 15, which indicated he had moderately impaired cognition. The resident had impairment on one side of his upper and lower extremities. According to the MDS, the resident was dependent (the helper does all of the effort and resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the activity) for showers/baths, toileting hygiene, and lower body dressing. The resident was substantial/max assist (helper does more than half the effort) with oral hygiene, upper body dressing, putting on/taking off footwear, and personal hygiene. According to the MDS, the resident was always incontinent of bowel and bladder. Record review of Resident #40's medical record revealed his care plan was not completed. Record review performed on 12/15/24, of the facility's shower schedule, revealed Resident #40's shower days were Tuesday, Thursday, and Saturday morning. In an interview and observation on 12/15/24 at 11:22am with Resident #40 and family, the resident was observed laying on his back in bed. The resident had white debris all over the top part of his shirt, near his collar, and his hair appeared greasy looking. The resident and family revealed he had not had a shower for the past two Saturdays (12/14/24 and 12/7/24). In an interview and observation on 12/16/24 at 1:15pm, Resident #40 said he had just got back from dialysis. His shirt still had not been changed and he had white debris near the collar of his shirt. The resident said the staff did not help him brush his teeth or clean his face. In an interview and observation on 12/17/24 at 10:29am, Resident #40 had the same shirt on with debris near his collar. He said he had asked for his shower when he woke up at 6:10am, but he still had not received it yet. In an interview with CNA J on 12/17/24 at 10:53am, she said she had not given Resident #40 a shower yet, but she would before her shift was over. She said this was the first day she worked the hall the resident was on, and she would have changed his shirt before today if there was debris on it. CNA J said she did not know if the CNAs on that hall brushed the resident's teeth, but Resident #40 would normally ask for a warm cloth for his face if he wanted one. CNA J said there was a binder at the nursing station that had the shower schedules for each resident and they knew how much assistance was needed by looking in the resident's chart and through report handoff. In an interview with the Administrator on 12/16/24 at 1:45pm, she said there were no shower sheets in the EMR because she had not had time to implement it yet. She said she would have to ask the DON who gave showers on 12/7/24 and 12/14/24. In an interview with the DON on 12/17/24 at 11:15am, she said CNA C was supposed to have showered Resident #40 on 12/14/24. She said she did not know she was supposed to check who gave showers for 12/7/24. She said she spoke to CNA J, and she was going to make sure to shower the resident today (12/17/24). She said she would pop in more often on the weekends to ensure showers were given. If showers were not given it could cause infections. Record review of the facility's policy and procedure on Activities of Daily Living (ADL), Supporting (Revised March 2018) read in part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible, and systematically organized for 3 of 6 residents (Resident #151, Resident #18, and Residetn #27) reviewed for medical records. - The facility failed to document Resident #151's treatments into his electronic record from 12/14/24 to 12/15/24. - The facility failed to have current care plans for Resident #18 and Resident #27 in the electronic health system. This failure could cause missed treatments and a decline in health. Findings included: 1. Record review of Resident #151's face sheet dated 12/17/24 revealed a [AGE] year-old male who readmitted on [DATE]. His diagnosis included convulsions (rapid involuntary muscle contractions), malnutrition, and benign prostatic hyperplasia (an enlarged prostate). Record review of Resident #151's undated baseline care plan indicated he was lethargic and cognitively impaired. He had a history of skin integrity issues. Record review of Resident #151's Braden scale for predicting pressure ulcer risk evaluation dated 12/13/24 revealed a score of 11 which indicated he was high risk. Record review of Resident #151's paper Physician's Telephone/Verbal Order dated 12/13/24 revealed the following order: Wound is almost healed; please keep clean and cover with provided bordered gauze dressing, order date 12/13/24. Record review of Resident #151's nursing note dated 12/13/24 (unknown author) read in part, .Residents arrive to facility via [name] transport . bed bound. Total care . R thumb laceration cleaned .R/L thigh wounds cleaned w/NS and dressed w/border gauze. Record review of Resident #151's nursing note dated 12/14/24 (unknown author) read in part, .LATE ENTRY: resident received wound care with dry dressing to left hip, right hip, and right hand. No s/s of pain noted. Notified [hospice] for clarification on wound care was told a nurse would be in to visit to clarity [sic] orders. Record review of Resident #151's nursing notes revealed there was no documentation of treatments on 12/15/24. Record review of Resident #151's nursing note dated 12/16/24 (unknown author) read in part, .notified [name], nurse with [name] Hospice, need for nurses visit for clarity of orders. Record review of Resident #151's order summary report dated 12/17/24 revealed the following treatment orders were entered 3 days after admission: -Wound treatment - dry dressing every day shift cleanse wound to left hip with normal saline or skin cleanser. Pat dry. Cover with dry dressing, order date 12/16/24 -Wound treatment - dry dressing every day shift cleanse wound to right hip with normal saline or skin cleanser. Pat dry. Cover with dry dressing, order date 12/16/24. In an observation on 12/15/24 at 12:04 p.m. Resident #151 was lying in bed with towels in both hands. He did not respond to this Surveyor's questions. In an observation on 12/16/24 at 9:37 a.m. Resident #151 was lying in bed. His right hand was wrapped and dated 12/16/24. In an interview on 12/16/24 at 3:02 p.m. LVN G said she worked with Resident #151 on 12/13/24. She said she did his head-to-toe skin assessment and LVN S helped her do the wound care. She said he had a shunt on the left side that went to his stomach, two red areas on the inside of his knees, an area to his right thumb, and a pressure sore to the left thigh/hip. She said the areas did not look infected, only red and they applied a simple dry dressing change and left it open. She said he was admitted from the hospital, and they did not send any orders for his wounds and was not alerted to any wounds. She said she could not remember if she contacted anyone about his wound orders. She said she would normally contact hospice about the wounds and treatments and hospice would send orders over. She said she reported the areas to the Unit Manager who said she would help her put the orders in. LVN G said she was not able to put the orders in because she got busy. She said whatever they do not complete they pass on to the next nurse. She said she notified the next nurse about the wounds and that there were no orders for them yet. She said she was trained on admissions and entering orders into the system. In an interview on 12/16/24 at 3:19 p.m. LVN V said she worked with Resident #151 on 12/14/24. She said she did a full body assessment, changed his bandage on his hand, hip, and sacrum, and documented the wound care on a note. She said his hospice orders were in the medical records bin and posted in his room, but the order did not specify the areas. She said she received report from the night nurse on Saturday morning and was informed how to do the wound care for the resident. She said the orders were normally in the system, but the facility recently changed to a new electronic record system, and it was acting up. She said she called hospice to determine the wounds and orders but did not get a response. She said she did not document the notification. She said the orders should be inputted in the system during admission and if the orders were not in the system the facility should check with the MD. She said she did not put the actual order in the system because it was not specific, and hospice did not answer back. In an interview on 12/17/24 at 9:17 a.m. the Wound Care Nurse said she was notified of Resident #151's wounds on 12/16/24 by the floor nurse. She said he had a left and right hip wound and scar tissue/redness to the sacrum. She said the areas did not look infected and there were dressings on all the areas from the previous day. She said Resident #151 had a note, but the order was confusing and not specific to the resident. She said the floor nurse verified the order with hospice and they wanted the facility to clean the areas and cover with dry dressing. She said everything had to be verified with Hospice and if hospice could not be reached, clean the areas and cover with a dry dressing. She said the order would have to be in the system because it was an order and nursing staff would either document in a nursing note and sign out in the MAR/TAR. In an interview on 12/17/24 at 9:57 a.m. LVN S said she conducted a head-to-toe assessment on Resident #151 with LVN G on 12/13/24. She said she identified a wound to the left hip/thigh, a small rash to the right side of leg, redness behind the knee, and a right laceration from piercing his thumb. She said the hospice nurse put orders on the resident's wall for normal saline and dry dressing. She said she was training LVN G and assumed LVN G put the orders in the system for the wound. LVN S said she should have checked behind LVN G to ensure the orders were in the system. She said orders should be in the system so the next nurse and wound care nurse would know what to look for. She said she received an in-service on putting orders into system and had been trained before. In an interview on 12/17/24 at 10:55 a.m. the DON said the staff questioned the orders for Resident #151, so they did not enter them in the system. She said the Hospice orders were posted on the wall, staff saw the orders, did the actual treatment, and communicated through shift change but were waiting for clarification from hospice. She said orders should be in the system when the order is obtained and if hospice did not respond within the hour, staff should go up the chain of command. She said the orders should have been put in the system even if staff were waiting for clarification so they could follow the order. She said the ADON put the orders in on Sunday 12/15/24. She said there was always a chance to miss treatment orders if the order was not in the system. She said staff were trained on order entry and in serviced prior to her coming. She said the floor staff and managers were responsible for ensuring orders were in the system. In an attempted interview on 12/17/24 at 11:27 a.m. with Resident #151's hospice nurse was unsuccessful. In an interview on 12/17/24 at 1:17 p.m. Unit Manager D said she put Resident #151's treatment orders in the system on 12/15/24. She said she called the NP and was instructed to continue orders as directed which was: Clean and cover with dry dressing. In an interview on 12/17/24 at 1:51 p.m. the Administrator said she spoke with Resident #151's Hospice nurse about tightening up the process for implementation of orders. She said the order provided by Hospice was the way family and hospice did the treatment and clarification was needed. She said the order should have been in the system to ensure the service was not missed, and to document what service was done. She said the DON provided reeducation. Record review of Resident #151's hospice clinical charts note dated 12/17/24 written by Resident #151's hospice nurse revealed a skilled nurse daily visit was made for respite care. Respite stay from 12/13 - 12/18. Patient lying in hospital bed with head of bed elevated. Dressing is clean, dry and intact. Pressure wound to left hip is improving dramatically since the use of low air loss mattress. Wound still has some slough and mild drainage with no odor. Wound is 75% smaller now than at time of injury. Patient resting comfortably. Showing no signs of pain or discomfort at this time. Spoke with facility staff who report no unmanaged issues at this time. Updated facility staff on plan of care and encouraged them to call with any questions, concerns, change in patient condition or falls. 2. Record review of Resident #18's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of a sacral pressure ulcer (pressure injury on the lower back and tailbone), diabetes mellitus (body does not produce insulin or resists it), quadriplegia (paralysis to all 4 extremities), colostomy (opening in the colon, or large intestine, through the abdomen), neuromuscular dysfunction of the bladder (inability to properly control urination), anemia, and anxiety. Record review of Resident #18's Quarterly MDS assessment from 11/6/24 revealed a BIMS score of 10 out of 15, which indicated moderately impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent (the helper does all of the effort and resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the activity) with all ADLs. Resident #18 had an indwelling catheter (a tube into the bladder to drain urine) and a colostomy. The MDS revealed he had a diagnosis of neurogenic bladder, which required the indwelling catheter. The resident was on Hospice care. According to the MDS, the resident had 5 Stage 4 (tissue loss with exposed bone, tendon or muscle) pressure ulcers. Record review of Resident #18's History and Physical from MD L on 10/8/24 revealed the resident had a foley catheter, a colostomy, Hospice services, and pressure ulcers. Record review of Resident #18's medical record revealed a Wound Evaluation and Management Summary from 11/22/24 from MD T, which indicated he had 5 pressure ulcers. Record review of Resident #18's medical record on 12/17/24, revealed his foley catheter, colostomy, hospice, and pressure ulcers were not care planned . In an observation and interview with Resident #18 on 12/17/24 at 9:00am, the resident was laying on his back in bed with no obvious foley catheter or colostomy visible. The resident said he did have a foley catheter and a colostomy. 3. Record review of Resident #87's undated face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (inability to properly control urination), paraplegia (paralysis of either the upper or lower extremities), sepsis (infection throughout body), schizophrenia (mental illness that affects how a person thinks, feels, and behaves), pressure ulcer of the sacrum (pressure injury on the lower back and tailbone), muscle weakness, and muscle wasting and atrophy. Record review of Resident #87's Quarterly MDS assessment from 11/20/24 revealed a BIMS score of 10 out of 15, which indicated moderately impaired cognition. The resident had impairment on both sides of his lower extremities. According to the MDS the resident was substantial/max assist with toileting hygiene (helper does more than half the effort). Resident #87 had an indwelling catheter. The MDS revealed he had a diagnosis of neurogenic bladder, which required the indwelling catheter. Resident #87 had a Stage 4 pressure ulcer. Record review of Resident #87's medical record revealed his foley catheter, pressure ulcer, and wound vac (treatment that uses suction to help heal wounds) were not care planned. Record review of Resident #87's order summary report dated 12/01/24-12/17/24 revealed the following orders: - Wound Vac-Placement and Patency Check, every shift. Wound Vacuum @ 125mmHg, Check placement and ensure patency. If dislodged, re-enforce dressing or change if necessary. Ordered on 12/1/24. - Wound Treatment: Cleanse Sacrum Wound with wound cleanser or normal saline; pat dry cover with calcium alginate (type of wound treatment) and collagen sheet (type of wound treatment). Cover with Island Gauze w/ border dressing-PRN when wound vac is not in use, as needed for wound healing. Ordered on 12/1/24. - Wound Vac -Apply to Sacrum- M-W-F at -125mmhg; Cleanse with wound cleanser or normal saline; pat dry; apply wound vac foam dressing and cover with film when vac not in use refer to PRN Wound Care Order, every shift Cleanse wound with Normal Saline or Skin Cleanser. Pat dry. Apply Wound Vacuum Dressing as instructed. Apply Wound Vacuum @-125 mmHg. Ordered on 12/1/24. In an observation on 12/15/24 at 12:59pm, Resident #87 was lying on his back in bed and had a foley catheter clipped to the side of the bed. In an observation on 12/16/24 at 1:00pm, Resident #87 was lying on his back in bed and had a wound vac draining bloody drainage from his pressure ulcer to his sacrum. In an interview on 12/17/2024 at 12:45pm with RN S, he said he was responsible for completing the entrance and discharge care plans for the long-term care side and stated if the resident's care plan was not updated, the resident would fall through the cracks and proper care would not be provided. RN S also stated the annual, admissions, and discharge care plans were the responsibility of the MDS nurse. He said the acute care plans were the responsibility of the ADON and unit manager. In an interview on 12/17/2024 at 1:10pm with LVN A, she said she assisted with care plans, but it had not been further discussed and was something they had not been trained in the past to do. LVN A also stated if a care plan was not updated or completed timely something would be missed such as daily ADLs for a resident or the treatment could not be completed. Staff was made aware of care plan changes by the morning huddle and nurses pulled a report that would verify any changes to inform other staff members who also provided care to residents. LVN A said if the Care Plans were not up to date, the expectation was to meet with the DON, MDS Nurse, and the Unit Manager to develop a plan on how the care plans would be brought up to compliance. In an interview on 12/17/2024 at 1:24pm with the ADON, she stated if a care plan was not updated for a resident, the resident would fall by the wayside and would miss the opportunity to receive appropriate care. She said the care plans were updated by herself. The ADON said there had not been a chance to view the care plans and training had not been provided, since the position was just filled two weeks ago. She said the training would to be given by the DON in the upcoming weeks. As of right now, the ADON said during the transition of roles and new staff, MDS was supposed to update and complete care plans. Record review of the facility's policy on, Care Plans, Comprehensive Person-Centered, updated, March 2022 revealed, 2. The comprehensive, person-centered plan is developed within (7) days of the completion of the required MDS assessments (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 6. If the participation of the resident and his/her representative in developing the residents care plan is determined to not be practicable, an explanation is documented in the residents' medical record. The explanation should include what steps were taken to include the resident or representative in the process. 7e. The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just the symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record review of the facility's Patient Care Management System 1, Skin policy dated July 2022 read in part, .1. A head-to-toe skin assessment will be completed on day of admission and documented by the Admitting Nurse upon admission (including re-admission) of every patient. In addition, the Admitting Nurse will notify the physician and patient representative of any identified areas, implement treatment/interventions and document in Electronic Medical Record (EMR). Record review of the facility's Charting and Documentation policy dated July 2017 read in part, .all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . Policy Interpretation and Implementation . 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: . b. medications administered; c. treatments or services performed . Record review of the facility's Physician Orders dated January 2020 read in part, .all physicians' order shall be recorded on the patients medical record and must be signed electronically by the attending/prescribing physician . 4.The admission physician order will remain in the patient's chart at all times . 47722

Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 2 of 6 residents (Resident #18 and Resident #87) reviewed for catheter care. - The facility failed to ensure physician orders for catheter care were entered into the system for Resident #18 and Resident #87 and staff were unable to document care provided from 12/1/24 to 12/17/24. This failure could place residents with foley catheters at risk for urinary tract infections and skin break down. Findings included: 1. Record review of Resident #18's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of a sacral pressure ulcer (pressure injury on the lower back and tailbone), diabetes mellitus (body does not produce insulin or resists it), quadriplegia (paralysis of upper and lower extremities), colostomy (an opening in the colon, or large intestine, through the abdomen), neuromuscular dysfunction of the bladder (inability to properly control urination), anemia, and anxiety. Record review of Resident #18's Quarterly MDS assessment from 11/6/24 revealed a BIMS score of 10 out of 15, which indicated moderately impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent (the helper does all of the effort and resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the activity) with all ADLs. Resident #18 had an indwelling catheter and a colostomy. The MDS revealed he had a diagnosis of neurogenic bladder, which required the indwelling catheter. Record review of Resident #18's medical record revealed a foley catheter was not care planned. Record review of Resident #18's History and Physical from MD L on 10/8/24 revealed the resident had a foley catheter. Record review of Resident #18's order summary report dated 12/01/24-12/17/24 revealed no orders for a foley catheter. Record review of Resident #18's medical record on 12/17/24, revealed no documentation of foley catheter care. In an observation and interview with Resident #18 on 12/17/24 at 9:00am, the resident was lying on his back in bed with no obvious foley catheter or colostomy visible. The resident said he had a foley catheter and a colostomy. 2. Record review of Resident #87's undated face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (inability to properly control urination), paraplegia (paralysis of both upper or lower extremities), sepsis (infection throughout body), schizophrenia (mental illness that affects how a person thinks, feels, and behaves), pressure ulcer of the sacrum (pressure injury on the lower back and tailbone), muscle weakness, and muscle wasting and atrophy. Record review of Resident #87's Quarterly MDS assessment from 11/20/24 revealed a BIMS score of 10 out of 15, which indicated moderately impaired cognition. The resident had impairment on both sides of his lower extremities. According to the MDS the resident was substantial/max assist with toileting hygiene (helper does more than half the effort). Resident #87 had an indwelling catheter. The MDS revealed he had a diagnosis of neurogenic bladder, which required the indwelling catheter. Record review of Resident #87's medical record revealed a foley catheter was not care planned. Record review of Resident #87's order summary report dated 12/01/24-12/17/24 revealed no orders for a foley catheter. Record review of Resident #87's medical record on 12/17/24, revealed no documentation of foley catheter care. In an observation on 12/15/24 at 12:59pm, Resident #87 was lying on his back in bed and had a foley catheter clipped to the side of the bed. In an interview and observation with Unit Manager D on 12/17/24 at 10:35am, she checked Resident #18 and Resident #87's medical record for a foley catheter or foley care order and there were none. She said they were still trying to fix orders that did not come over correctly or that were missed all together since they switched to a new EMR on 12/1/24. In an interview with the DON on 12/17/24 at 11:15am, she said the orders should have been in the system when the order was obtained. The staff should have reviewed the orders with the provider and then the provider verified the orders. She said there was always a chance to miss treatment if the order was not in the system. She said staff were trained on order entry and in-serviced prior to her coming. She said the ADON and Unit Manager conducted 24-hour chart checks to verify orders. She said the floor staff and managers were responsible for ensuring orders were in the system. The DON said the orders for the foley catheter and the foley care should have been in the EMR. She said the nursing staff should have seen the resident had a foley catheter and noticed there were no orders for it, then asked the MD to put orders in. She said if there were no orders, care could be missed. In an interview with LVN S on 12/17/24 at 11:29am she said Resident #18 and #87 both had foley catheters. She said she had not provided foley care yet, but she was going to before her shift was over. She said she knew to provide foley care because she had had the residents for a while before. She said this was her first day back with them, so she did not know if the nurses before her provided foley care. She said if the nurse did provide foley care and there were no orders, there would not be a place to document that it was done, and no one would know if the care was done or not. Record review of the facility's policy and procedure on Catheter Care (Revised March 2019) read in part: .Cleanse area at catheter insertion well, taking care not to pull on catheter or advance further into urethra. All debris must be removed from catheter at insertion site .Ensure leg strap in place to secure tubing .Date, time, procedure, condition of the perineum and catheter insertion site .signature and title. Record review of the facility's policy and procedure on Charting and Documentation (Revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record: .Treatments or services performed .Documentation of procedures and treatments will include care-specific details, including: the date and time of the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment .the signature and title of the individual documenting . Record review of the facility's policy and procedure on Physician Orders (Revised January 2020) read in part: It is the policy of the facility that physician orders are maintained per state and federal regulations. All physicians' orders shall be recorded on the Patients Medical Record and must be signed electronically by the attending/prescribing physician .Physician orders include: .Treatments .Special medical procedures required for the safety and well being of the Patient .Others as necessary and appropriate .Medications, diets, therapy, or any treatment may not be administered to the Patient without a written order from the attending physician.

Based on observation, interview, and record review the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice for 1 of 6 residents (Resident #18) reviewed for ostomies (surgical opening from an area inside the body to the outside). - The facility failed to ensure physician orders for colostomy care were entered into the system for Resident #18 and staff were unable to document care provided from 12/1/24 to 12/17/24. This failure could place residents at risk of infection, skin break down, or discomfort. Findings included: Record review of Resident #18's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of a sacral pressure ulcer (pressure injury on the lower back and tailbone), diabetes mellitus (body does not produce insulin or resists it), quadriplegia (paralysis of upper and lower extremities), colostomy (an opening in the colon, or large intestine, through the abdomen), neuromuscular dysfunction of the bladder (inability to properly control urination), anemia, and anxiety. Record review of Resident #18's Quarterly MDS assessment from 11/6/24 revealed a BIMS score of 10 out of 15, which indicated moderately impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent (the helper does all of the effort and resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the activity) with all ADLs. Resident #18 had a colostomy. Record review of Resident #18's medical record revealed a colostomy was not care planned. Record review of Resident #18's History and Physical from MD L on 10/8/24 revealed the resident had a colostomy. Record review of Resident #18's order summary report dated 12/01/24-12/17/24 revealed no orders for a colostomy. Record review of Resident #18's medical record on 12/17/24, revealed no documentation of colostomy care. In an observation and interview with Resident #18 on 12/17/24 at 9:00am, the resident was lying on his back in bed with no obvious foley catheter or colostomy visible. The resident said he had a foley catheter and a colostomy. In an interview with Unit Manager D on 12/17/24 at 10:35am, she checked Resident #18's medical record for a colostomy or colostomy care order and said there were none. She said they were still trying to fix orders that did not come over correctly or that were missed all together since they switched to a different EMR on 12/1/24. In an interview with the DON on 12/17/24 at 11:15am, she said the orders should have been in the system when the orders were obtained. The staff should have reviewed the orders with the provider and then the provider verified the orders. She said there was always a chance to miss treatment if the order was not in the system. She said staff were trained on order entry and in-serviced prior to her coming. She said the ADON and Unit Manager conducted a 24-hour chart check to verify orders. She said the floor staff and managers were responsible for ensuring orders were in the system. The DON said the orders for the colostomy/colostomy care should have been in the EMR. She said the nursing staff should have seen the resident had a colostomy and noticed there were no orders for it and asked the MD to put orders in. She said if there were no orders, care could be missed. In an interview with LVN S on 12/17/24 at 11:29am she said Resident #18 had a colostomy. She said she had not provided colostomy care yet, but she was going to before her shift was over. She said she knew to provide colostomy care because she had had the resident for a while before. She said this was the first day back with him, so she did not know if the prior nurses provided colostomy care. She said if the nurse did provide colostomy care and there were no orders, there would not be a place to document it was done, and no one would know if the care was done or not. Record review of the facility's policy and procedure on Colostomy/Ileostomy Care (Revised October 2010) read in part: The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter .Remove drainage bag .Cleanse skin .Evaluate skin .Replace drainage bag .The following information should be recorded in the resident's medical record: The date and time the colostomy/ileostomy care was provided. The name and title of the individual(s) who provided the colostomy/ileostomy care. Any breaks in resident's skin, signs of infection .or excoriation of skin .The signature and title of the person recording the data . Record review of the facility's policy and procedure on Charting and Documentation (Revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record: .Treatments or services performed .Documentation of procedures and treatments will include care-specific details, including: the date and time of the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment .the signature and title of the individual documenting . Record review of the facility's policy and procedure on Physician Orders (Revised January 2020) read in part: It is the policy of the facility that physician orders are maintained per state and federal regulations. All physicians' orders shall be recorded on the Patients Medical Record and must be signed electronically by the attending/prescribing physician .Physician orders include: .Treatments .Special medical procedures required for the safety and well being of the Patient .Others as necessary and appropriate .Medications, diets, therapy, or any treatment may not be administered to the Patient without a written order from the attending physician.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #59) reviewed for pharmaceutical services. - The facility failed to ensure Resident #59's order for Potassium Chloride was accurately transcribed when the order was entered as unsupervised self-administration. Staff documented the medication as unsupervised self-administration from 12/07/24-12/17/24 although Resident #59 did not self administer Potassium Chloride. This failure could place the resident at risk of not receiving their medication or receiving the medication more than once. Findings included: Record review of Resident #59's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of kidney failure (kidney stops filtering the blood), cardiac arrhythmia (heart does not beat regularly), respiratory failure (not enough oxygen in the blood), pneumonia (infection in the lungs), and heart failure. Record review of Resident #59's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15, which indicated severely impaired cognition. The resident was supervision and set up with all ADLs. Resident #59 was frequently incontinent of urine and always continent of bowel. The resident did not have any pressure ulcers or skin issues. Record review of Resident #59's medical record revealed her Potassium Chloride was not care planned. Record review of Resident #59's order summary report dated 12/01/24-12/17/24 revealed an order for Potassium Chloride Capsule 10meq ER, Give 1 tablet orally QD, unsupervised self-administration. Do not crush, dissolve in water. Ordered on 12/6/24. Record review of Resident #59's December 2024 MAR revealed from 12/7/24-12/17/24 the Potassium Chloride 10meq was signed off as U-SA by several different staff members. Record review of Resident #59's medical record on 12/17/24 revealed there were no assessments performed for self-administration of medication. In an observation on 12/16/24 at 8:29am Med Aide G gave Resident #59 her morning medications which were Norco, Eliquis, Spironolactone, and Pantoprazole, but not the Potassium Chloride. In an interview on 12/17/24 at 8:30am with Resident #59, she said she did not take any medications on her own and she only took whatever the staff gave her. She did not take her own Potassium Chloride. In an interview on 12/17/24 at 8:35am with Med Aide K she said she did not know the Potassium Chloride order said unsupervised self-administration and she did not question the order. She said the medication popped up on her MAR and she gave it to the resident. She did not question the resident about taking Potassium Chloride on her own or ensure she did not give the resident a double dose. In an interview and observation on 12/17/24 at 10:35am with Unit Manager D, she said they did not give unsupervised medications for self-administration. She said Resident #59's Potassium Chloride order was wrong, and someone must have checked the wrong box for self-administration on accident when they received the order. Unit Manager D was observed as she fixed the order. She said they were still trying to go through all the orders to ensure they were correct, from the old EMR to the new one that occurred on 12/1/24. In an interview with the DON on 12/17/24 at 11:15am, she said the orders should have been in the system when the orders were obtained. The staff should have reviewed the orders with the provider and then the provider verified the orders. She said there was always a chance to miss treatment if the order was not in the system. She said staff were trained on order entry and in-serviced prior to her coming. She said the ADON and Unit Manager conducted a 24-hour chart check to verify orders. She said the floor staff and managers were responsible for ensuring orders were in the system. The DON said the Potassium Chloride was on the Med Aide and the Nurse's orders so either one could have given the medication. She said on 12/16/24 the nurse had already given the medication to the resident. Record review of the facility's policy and procedure on Pharmacy Services Overview (revised April 2019) read in part: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications .Pharmaceutical services consist of: the process of receiving and interpreting prescriber's orders; .dispensing .distributing, administering .using and/or disposing of all medications .Medications are .administered .according to all applicable state and federal laws and consistent with standards of practice. Record review of the facility's policy and procedure on Physician Orders (revised January 2020) read in part: It is the policy of this Facility that physician orders are maintained per state and federal regulations. All physicians' orders shall be recorded on the Patients Medical Record and must be signed electronically by the attending/prescribing physician. Verbal or telephone orders are considered to be in writing when dictated by the attending physician and later signed by him/her electronically once the Licensed nurses enter the order into the EMR. Orders must be signed electronically within a timely manner. Physician orders include: All medications .

Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 residents (Resident #18) reviewed for hospice services, in that: - The facility failed to ensure Resident #18's Hospice order was in the EMR from 12/1/24-12/17/24. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care, coordination of care and communication of resident needs. Findings included: Record review of Resident #18's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of a sacral pressure ulcer (pressure injury on the lower back and tailbone), diabetes mellitus (body does not produce insulin or resists it), quadriplegia (paralysis of upper and lower extremities), colostomy (an opening in the colon, or large intestine, through the abdomen), neuromuscular dysfunction of the bladder (inability to properly control urination), anemia, and anxiety. Record review of Resident #18's Quarterly MDS assessment from 11/6/24 revealed a BIMS score of 10 out of 15, which indicated moderately impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent (the helper does all of the effort and resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the activity) with all ADLs. Resident #18 had an indwelling catheter (a tube into the bladder to drain urine) and a colostomy. The MDS revealed the resident was on Hospice care. Record review of Resident #18's medical record revealed hospice was not care planned. Record review of Resident #18's History and Physical from MD L on 10/8/24 revealed the resident was on hospice. Record review of Resident #18's order summary report dated 12/01/24-12/17/24 revealed no orders for hospice. In an interview with Unit Manager D on 12/17/24 at 10:35am, she checked Resident #18's medical record for a hospice order and said there was not one. She said she knew the resident was on hospice and looked in the previous EMR. She said the order was in the previous EMR for hospice services. The Unit Manager said they were still trying to fix orders that did not come over correctly or that were missed all together since they switched to a different EMR on 12/1/24. In an interview with the DON on 12/17/24 at 11:15am, she said the orders should have been in the system when the orders were obtained. The staff should have reviewed the orders with the provider and then the provider verified the orders. She said there was always a chance to miss treatment if the order was not in the system. She said staff were trained on order entry and in-serviced prior to her coming. She said the ADON and Unit Manager conducted a 24-hour chart check to verify orders. She said the floor staff and managers were responsible for ensuring orders were in the system. Record review of the facility's policy and procedure on Hospice Services (dated November 2016) read in part: It's the policy of this facility to provide hospice services through an agreement with one or more Medicare-certified hospices .The facility must meet the following requirements: .Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the facility before hospice care is furnished to any resident. The written agreement must set out at least the following: The services the hospice will provide. The hospice's responsibilities for determining the appropriate hospice plan of care. The services the facility will continue to provide based on each resident's plan of care. A communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the Patient/Resident are addressed and med 24 hours per day .Obtain the following information from the hospice: The most recent hospice plan of care specific to each patient/resident. Hospice election form. Physician certification and recertification of the terminal illness specific to each patient/resident. Names and contact information for hospice personnel involved in hospice care of each patient/resident. Instructions on how to access the hospice's 24-hour on-call system. Hospice medication information specific to each patient/resident. Hospice physician and attending physician (if any) orders specific to each patient/resident . Record review of the facility's policy and procedure on Charting and Documentation (Revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record: .Treatments or services performed .Documentation of procedures and treatments will include care-specific details, including: the date and time of the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment .the signature and title of the individual documenting . Record review of the facility's policy and procedure on Physician Orders (Revised January 2020) read in part: It is the policy of the facility that physician orders are maintained per state and federal regulations. All physicians' orders shall be recorded on the Patients Medical Record and must be signed electronically by the attending/prescribing physician .Physician orders include: .Treatments .Special medical procedures required for the safety and well being of the Patient .Others as necessary and appropriate .Medications, diets, therapy, or any treatment may not be administered to the Patient without a written order from the attending physician.

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 1 of 6 residents (Resident #23) reviewed for Infection Control. Med Aide G failed to sanitize the blood pressure cuff between residents on 12/16/24. The blood pressure cuff was used on a Resident #250 who was on EBP and then placed on Resident #23 without being sanitized first. - This failure could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #250's undated face sheet, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of extradural and subdural abscess (types of brain infections), bacterial meningitis (infection around the brain and spinal cord), MSSA (bacterial infection that can range from mild skin infections to more serious conditions), hemiplegia (paralysis) affecting right side following a stroke, aphasia (trouble speaking), dysphasia (trouble swallowing), neurofibromatosis (genetic disorder that causes tumors to grow in the nervous system), endocarditis (infection of the heart), epilepsy (seizures), and TIA (mini strokes). Record review of Resident #250's Admission MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. The resident had impairment on both sides of his lower extremities and one side of his upper extremities. According to the MDS, the resident was substantial/max assist with all ADLs (helper does more than half the effort). Resident #250 was always incontinent of bowel and bladder. The MDS had diagnoses of bacterial meningitis, and MSSA. The resident had an unhealed Stage 2 (shallow open ulcer with a red or pink wound bed, without debris or intact/open blister.) pressure ulcer, according to the MDS. Resident #250 was also receiving IV antibiotics. Record review of Resident #250's medical record revealed his EBP and IV antibiotics were not care planned. Record review of Resident #250's History and Physical dated 12/9/24 from NP N, revealed the resident was at the hospital on 11/18/24 for a subdural empyema (brain infection) and had an evacuation with CSF (removal of spinal fluid) which was growing MSSA, and had endocarditis. The resident was going to need 6wks of IV antibiotics starting 11/22/24. Record review of the facility's Resident Matrix, printed on 12/15/24, revealed Resident #250 was on IV antibiotics. In an observation on 12/16/24 at 8:48am, Resident #250 had an EBP sign outside of his room. Med Aide G was observed as she took Resident #250's blood pressure with an electronic blood pressure cuff on his left wrist. She then took the blood pressure cuff and set it on the medication cart without cleaning it. 2. Record review of Resident #23's undated face sheet revealed she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of altered mental status, anxiety, urinary tract infection, atrial fibrillation (heart does not beat regularly), and type 2 diabetes mellitus (body does not produce insulin or resists it). Record review of Resident #23's Admission MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated moderately impaired cognition. The resident was supervision and set up with all ADLs. Resident #23 was always continent of bowel and bladder. According to the MDS, she had no pressure ulcers or skin issues. She was receiving PT/OT and was at the facility for rehabilitation after getting weak from a UTI. In an observation on 12/16/24 at 8:51am, Med Aide G was observed applying the blood pressure cuff on Resident #23's left wrist without disinfecting it first. In an interview on 12/16/24 at 9:11am with Med Aide G, she said she forgot to clean the blood pressure cuff. She said without cleaning the blood pressure cuff, it could cause cross contamination. In an interview on 12/16/24 at 9:15am with RN K, she said Resident #250 was on EBP and the blood pressure cuff should have been disinfected after each use to prevent cross contamination and for infection control. In an interview on 12/16/24 at 3:00pm with the DON, she said she in-serviced Med Aide G on infection control. She said the blood pressure cuff should have been cleaned and staff had just been in-serviced a few days earlier on EBP. Record review of the facility policy, Infection Control dated November 2017 read in part, .1. The facility must establish an infection prevention and control program (IPCP) that must include: a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all patients, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment .If there are signs and/or symptoms of an infection or positive culture, standard and transmission-based precautions must be put into place to prevent the spread of infection .

Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 3 residents (Resident #2, #3) reviewed for ADL care. The facility failed to provide timely incontinence care to Resident #2 and Resident #3. The noncompliance was identified as PNC. The noncompliance began on 4/6/24 and ended on 11/11/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for poor hygiene, diminished quality of life, and possible skin infections. The findings included: Record review of Resident #2's face sheet, dated 12/12/2024, reflected a [AGE] year-old female resident initially admitted on , 01/22/2024 with diagnoses including diarrhea, abnormalities of gait and mobility, epileptic seizure related to external causes, dementia (group of neurological conditions that cause a decline in mental abilities that affects daily life), disorder of urinary system, and cognitive communication deficit (communication difficulty caused by a cognitive impairment). Record review of Resident #2's MDS Assessment, dated 12/12/2024, reflected Resident #2 had a BIMS score of 9, suggesting moderate impairment. Resident #2 has been diagnosed with dementia, although the diagnosis was not present on the MDS assessment. Resident #2 MDS assessment indicated that Resident #2 was fully dependent for assistance with toileting hygiene and shower/bathe. Record review of Resident #2's Care Plan, updated, reflected interventions stating the resident had an ADL self-care performance deficit related to diagnosis of disorder of urinary system, abnormalities of gait and mobility, and diarrhea. In a telephone interview with Resident #2's family member on, 12/12/2024 at 12:31pm, he said he witnessed the facility being short staffed, which was why Resident #2's brief would constantly be soiled. The family member said he always had to find staff to change Resident #2 because they did not check on her often, and she was non-verbal and did not understand what the call light was for. Record review of Resident #3's undated face sheet revealed she was admitted to the facility on [DATE] with diagnoses of acute respiratory failure (not enough oxygen in the lungs), hemiplegia (paralysis) affecting right side from a stroke, stroke, dementia (group of neurological conditions that cause a decline in mental ability), weakness, and macular degeneration (disease that damages part of the retina that controls central vision). Record review of Resident #3's Quarterly MDS assessment from 11/28/24 revealed a BIMS of 11 out of 15, which indicated moderately impaired cognition. Resident #7 had impairment on one side of their upper and lower extremities and used a wheelchair. According to the MDS, the resident was dependent with toileting hygiene, showers/baths, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #7 was always incontinent of bowel and bladder. Record review of Resident #3's Care Plan dated 12/4/22 revealed Resident required extensive assistance with ADLs and mobility. Goal: Resident would maintain dignity by being clean, dry, and odor free for the next 90 days. Interventions: Assist with ADLs as needed. On 12/11/24 at 11:18am, the previous DON was called but he did not answer, and he never called back. In an interview with LVN V on 12/11/24 at 2:05pm, she said she had been with the facility for about 4 months. She said since the new Administration started, she had not found any resident soiled. She said they had enough staff to complete all their daily tasks. LVN V said they had in-services on customer service, call lights, and incontinence care. In an interview with LVN N on 12/12/24 at 8:57am, she said she had been with the facility for the past 2 years. She said the facility was short staffed previously and she would come to her shift at 6am and find residents completely soiled. She said the staffing is much better now with the new Administration. LVN V said they had in-services on customer service, call lights, and incontinence care. Record review performed on 12/12/24 of in-services provided by the DON on 11/18/24 revealed Customer Service, Call Lights, Incontinence Care, ANE, and Infection Control. In an interview with Resident #3 on 12/12/24 at 12:49pm, she said earlier in the year she had to wait several hours to be changed. She said she never had any skin breakdown from it. She said she would always have to wait to be changed, they would not answer call lights or the telephone. She said it was starting to get better with the new Administration. In an interview with LVN N on 12/12/24 at 8:57am, she said the facility was short staffed earlier in the year, and she would come on to her shift at 6am and find residents who were soiled and not changed. She said the staffing was much better now and she could go home on time now at 6pm. She said the new Administration had helped so much already. In an interview with the DON on 12/12/24 at 11:15am, she said she started at the facility on 11/11/24. She said she was not sure what was going on prior to her being there or what the staffing was like. She said her expectations were that staff were to put their eyes on the residents at least every 2hrs. She expected everyone to answer call lights, even housekeeping because everyone could help the resident. The DON said if a CNA was busy and could not assist the resident, then she expected someone else to help because the resident's come first. She said she in-serviced all the staff on call lights, customer service, and incontinence care on 11/18/24. The DON said to ensure the residents were taken care of she had open communication with the residents/families, she would make herself available, make rounds, call families, and be present. She said she would come to the facility on off hours as well to check on staff and residents. In a telephone interview with EMS K on, 12/12/2024 at 12:12pm he said he had responded to multiple calls for the Nursing Facility. EMS K stated he had witnessed on several occasions residents that were soiled because they were unable to get in contact with staff, so they would call 911 for help. EMS K stated when he arrived on the scene he would have to search for staff. He said he would ask the staff why residents were not being changed in a timely manner, and staff would answer that they were short staffed, or they had just changed shifts. EMS K stated the majority of the calls he responded to from the facility, were from 11pm to 1am. In a telephone interview with Chief H on 12/14/2024 at 9:46am he said he had been to the facility several times. Chief H stated he saw residents who had soiled through their adult diaper, and he had to track down staff to assist the residents. Record review of the facility's policy and procedure on Activities of Daily Living (ADL), Supporting (Revised March, 2018) read in part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care) .elimination (toileting) .

Based on interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility's assessment tool for 5 of 6 days (2/14/24, 2/15/24, 4/6/24, 4/7/24, and 4/9/24) reviewed for sufficient staff. The facility failed to have adequate staff to provide appropriate care to residents, resulting in multiple complaints of residents sitting in soiled briefs for 4-5 hours on 2/14/24, 2/15/24, 4/6/24, 4/7/24, and 4/9/24. The noncompliance was identified as PNC. The noncompliance began on 2/14/24 and ended on 11/18/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of skin breakdown, pain, and infection. Findings included: Record review of Resident #3's undated face sheet revealed she was admitted to the facility on [DATE] with diagnoses of acute respiratory failure (not enough oxygen in the lungs), hemiplegia (paralysis) affecting right side from a stroke, stroke, dementia (group of neurological conditions that cause a decline in mental ability), weakness, and macular degeneration (disease that damages part of the retina that controls central vision). Record review of Resident #3's Quarterly MDS assessment from 11/28/24 revealed a BIMS of 11 out of 15, which indicated moderately impaired cognition. Resident #7 had impairment on one side of their upper and lower extremities and used a wheelchair. According to the MDS, the resident was dependent with toileting hygiene, showers/baths, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #7 was always incontinent of bowel and bladder. Record review of Resident #3's Care Plan dated 12/4/22 revealed a Focus: Resident required extensive assistance with ADLs and mobility. Goal: Resident would maintain dignity by being clean, dry, and odor free for the next 90 days. Interventions: Assist with ADLs as needed. Focus: Resident requires extensive assistance with toileting. Goal: Resident would have toileting needs met with the assistance of 1-2 people. Interventions: Provide hygiene after urinating/having a BM. Focus: Resident was always incontinent of bowel. Goal: Resident would have incontinence managed over the next 90 days. Interventions: Patients who are incontinent of bladder and/or bowel will have incontinent care provided every 2 hours as needed. Focus Resident was always incontinent of urine. Goal: Resident would have intact skin for the next 90 days. Interventions: Check for incontinence and change if wet or soiled. Record review of the facility's most recent assessment tool, performed on 12/31/22 revealed staffing ratios were 4 nurses during the day and 4 nurses at night. The staffing ratios for CNAs were 7 during the day and 5 at night. Record review of the electronic clock-ins conducted on 12/12/24, for 2/14/24, 2/15/24, 4/6/24, 4/7/24, and 4/9/24 revealed the following information: - 2/14/24 day shift had 4 CNAs. Night shift had 4 CNAs and 3 nurses. The census for 2/14/24 was 103. - 2/15/24 day shift had 5 CNAs. - 4/6/24 day shift had 5 CNAs and 3 nurses. - 4/7/24 day shift had 6 CNAs and 3 nurses. - 4/9/24 day shift had 5 CNAs. Record review of the staff schedules for 12/10/24 and 12/11/24 revealed the following: - 12/10/24 day shift had 8 CNAs and 4 nurses. Night shift had 7 CNAs and 5 nurses. The census was 92. - 12/11/24 day shift had 8 CNAs and 5 nurses. Night shift had 7 CNAs and 5 nurses. The census was 92. Record review performed on 12/12/24 of in-services provided by the DON on 11/18/24 revealed Customer Service, Call Lights, Incontinence Care, ANE, and Infection Control. In an interview with the Senior ED on 12/11/24 at 2:43pm, he said the facility assessment was the one that was used for staffing from December 12/31/22 until the most recent one completed with the new administration. He said there could be potential negative outcomes if they had less than the number of staff they should have. He said he was not aware of any staff shortages. In an interview with LVN V on 12/11/24 at 2:05pm, she said she had been with the facility for about 4 months. She said since the new Administration started, she had not found any resident soiled. She said they had enough staff to complete all their daily tasks. LVN V said they had in-services on customer service, call lights, and incontinence care. In an interview with LVN N on 12/12/24 at 8:57am, she said she had been with the facility for the past 2 years. She said the facility was short staffed previously and she would come to her shift at 6am and find residents completely soiled. She said the staffing is much better now with the new Administration. LVN V said they had in-services on customer service, call lights, and incontinence care. In an interview with the DON on 12/12/24 at 11:35am, she said she started on 11/11/24 and immediately started implementing new policies and education. She said on 11/18/24 she gave in-services to the whole facility on infection control, customer service, incontinence care, and several others. She said she would schedule 4-5 nurses per shift and 6-7 CNAs per shift, depending on the census and the acuity of the residents. The DON said she expected her staff to call her if someone called in or they felt they were short staffed so she could fix the situation, because if she did not know she could not fix the problem. She said she would work the floor if they were short staffed. The DON said to ensure the residents were taken care of she had open communication with the residents/families, she would make herself available, make rounds, call families, and be present. She said she would come to the facility on off hours as well to check on staff and residents. In an interview with EMS K on 12/12/24 at 12:12pm, he said he did not specifically remember the time from 3/26/24 when the resident called due to not being changed because there were numerous times he would come out and find residents soiled in their briefs. He said there were numerous complaints from residents when he would respond, about the staff and not being changed. EMS K said he asked staff why residents were not changed timely, and they would tell him they were short staffed. He said he had been reassigned and did not go to the facility anymore, so he did not know if it had gotten better or not. In an interview with Resident #3 on 12/12/24 at 12:49pm, she revealed she used to have to wait several hours to be changed. The resident stated it has gotten better since the new administration started. She said she never received any skin breakdown or sores from not being changed. In an interview with Chief H on 12/13/24 at 9:46am, he said he had been to the facility many times. He said it was common for residents to call 911 when they needed assistance because they could not get a staff member to help them. He said it was always hard to find staff at the facility and they were short staffed. Record review of the facility's policy and procedure on Staffing (revised April 2007) read in part: Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan .

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 9 residents reviewed for misappropriation of property. (Resident #1) The facility failed to ensure Resident #1 was free from misappropriation of property when Housekeeper A gave Resident #1's purse to an unidentified individual. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: Record review of Resident #1's face sheet, printed on 10/31/24, indicated she was a [AGE] year-old female with diagnoses including fracture of fourth lumbar vertebra (break in the vertebrae that extends from the hips to the chest), major depressive disorder, hyperlipidemia (high cholesterol), and COPD (progressive lung disease that makes it difficult to breathe). Resident #1 is her own responsible party. Record review of Resident #1's resident assessment and care screening MDS dated [DATE] indicated Resident #1 had a BIMS score of 15, which indicated cognitively intact. She exhibited some disorganized thinking. Resident #1 required minimal assistance with ADL care. Record review of facility's typed investigation summary dated 10/31/24 revealed Incident: Misappropriation; On the morning of 10/29/24, Senior ED was notified of an allegation of a missing purse belonging to patient Resident #1. Facility immediately launched investigation into allegation. Resident #1 was discharged to the hospital per physician order on the late evening of 10/23/24. Facility investigation notes Housekeeper A was assigned to deep clean Resident #1's room due to her discharge to the hospital. Housekeeping Supervisor noted seeing Housekeeper A holding the purse and the purse was bagged and tagged to identify it belonged to Resident #1 then placed in the Admissions Coordinators office for patient or family to retrieve. On the evening of 10/25/24 Admissions Coordinator stated employee Housekeeper A came to her office and requested the purse because the family was at the facility asking for it. Housekeeper A's statement confirms she retrieved the purse to give to the family of Resident #1. Housekeeper A then stated she gave to a resident accidentally. Facility suspended Housekeeper A pending investigation. Upon notification of missing purse, facility immediately notified the Local Police. Officer spoke to Housekeeper A, who stated the same story. Officer stated case would remain open. Facility leadership searched facility and was unable to locate the purse. SR ED spoke to patients family member who stated she did not have the purse and was unsure last time it was seen, but confirmed no usage on Resident #1's debit card since purse was missing. Facility investigation shows while employee Housekeeper A was the last facility employee in possession of the purse, there has been no indication her story of giving it to the wrong person is not true. However employee Housekeeper A was on a final write up for excessive tardiness and subsequently terminated 10/30.24. Facility investigation concludes allegation of misappropriation inconclusive. In an interview on 12/10/24 at 10:19 a.m. with Resident #1 she said she remembered her purse missing. She said she found the purse. She said the purse was left in the van (ambulance) she said her went to pick it up yesterday. She laughed and said don't quote me on that. Sometimes she cannot tell the difference in reality or dreams. In an interview on 12/10/24 at 10:25 a.m. with Housekeeping Supervisor, he said the purse was sent to the front of the building. When they discharged a resident, they take personal belongings to the front. He told surveyor she could get more information about the purse from the office staff. Housekeeper A was terminated due to attendance and tardiness not for the purse. He did not know if the purse was found later. It was bagged and tagged and taken to front. They searched for it and never found it. In a telephone interview on 12/10/24 at 2:17 pm with Housekeeper A, she said she found the purse in Resident #1's room and bagged the purse up and signed it and took to admissions front desk. About 2 or 3 weeks later the purse was still with the Admissions Coordinator and she saw a random lady she thought it was Resident #1's mother because she looked like Resident #1. Well, come to find out I gave the purse to another resident at the facility. Housekeeper A said she was so anxious to go back and get the clothes that belonged to Resident #1 to give to this lady, but when she came back the lady was gone. She said she gave it to resident name who was a resident. The room was searched and come to find out she had Dementia and the purse was nowhere to be found. She wrote her statement down. In an interview on 12/11/24 at 12:41 p.m. with current Administrator she said that the general policy and expectation, if the resident was a long-term care person, they try not to send personal valuables, unless residents want them, such as glasses, teeth, hearing aids, and purses to the hospital. Things were always lost in the ER. If they were a long-term care patient they did a bed hold and held all their stuff, if they were not returning, the resident and/or family would have to pick up their stuff. If they had valuables, they could lock it up. She did not want to be responsible for their stuff. She said she was not employed at the facility when this incident occurred and did not know any details. In an interview on 12/11/24 at 1:36 p.m. with Receptionist she stated that she was unaware of where Resident #1's purse is. She said that the family would call the facility looking for Resident #1's purse often. In an interview on 12/11/24 at 2:18 p.m. with Senior ED he said typically when someone discharged the building, and it depended on if they would come back, personal valuables were bagged and tagged until family came and picked them up. The valuables were kept in a locked closet. Identity of the person picking up items should be checked. He said it did not appear that there was any identification checked before giving Resident #1's purse to anyone. He stated that it was never recovered. If he correctly remembers correctly, Housekeeper A wrote in statement that she gave it to someone. In an interview on 12/12/24 at 1:53 p.m. with the Admissions Coordinator, she stated that the Housekeeping Supervisor came to her office and handed her the purse and the purse was wrapped up with a name tag and he asked to keep it in her office and she placed it in the closet. It was maybe a day or two later, she cannot remember how long, she thinks it was a Friday when Housekeeper A asked if anyone had seen the blue purse and Admissions Coordinator stated that she had it and the Housekeeper A said the family was there for it. She handed it over to Housekeeper A. She did not normally store the valuables in her office. Her office was at the front behind reception desk so Housekeeping Supervisor felt it was a safe place to keep it. She said she did not know if the purse was ever found. She did not know what Housekeeper A did, she just gave it to the family member asking for it. She did not really know for sure if identity should be checked. That was the first time she held valuables and had not done it since. In an interview on 12/12/ 24 at 6:16 p.m. with Resident #1 family member she said Resident #1 was concerned about not being able to find her purse. So, family member called the facility and according to the director of the facility, he said they remembered seeing the purse after leaving for the hospital and someone had asked for it and they gave it to them. He said a girl from housekeeping gave it to the female person asking for the purse. Family member also stated that Resident #1 told her later that someone contacted her and that they found her purse and it was going to be in the lost and found. The facility also called police and filed police report. Family member called the hospital and called the facility and she talked to the head of housekeeping, and he said that some housekeeper gave it to someone. She called the main transportation company that the facility used, and they did not have it. She called the receptionist at the facility and the receptionist said she would find out if the main transportation company used another service because sometimes, they had contracts . In the purse she knew for sure was Resident #1's driver's license, debit card and credit card. Family member was able to get into Resident #1's email and call the bank to let them know her purse was missing. She got a daily report from the bank via email and there had been no fraudulent charges. This made family member believe that Resident #1 was not dreaming and that someone did actually call, and the purse was sitting somewhere in a lost and found. The only family Resident #1 had was herself and her half-brother. No one went to the facility asking for the purse. Record review of revised abuse policy dated April 2019 revealed The Patient has the right to be free from Abuse, neglect, mistreatment of resident property, and exploitation.Misappropriation of Patient property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Patient's belongings or money without the Patient's consent.

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 one of three residents (Resident #4) reviewed for Infection Control. 1.The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #4 on 12/12/2024. This failure could place residents at risk of cross-contamination and development of infections. Findings include: Record review of Resident #4's Face Sheet dated 12/12/2024 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnosis included hemiplegia following cerebral infarction (one-sided paralysis or weakness following a stroke), type 2 diabetes (body does not produce insulin or resists it), and major depressive disorder. Record review of Resident #4's quarterly MDS assessment, dated 11/12/2024, revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. She was always incontinent of both bowel and bladder and required substantial/maximal assistance from staff with toileting hygiene. In an observation and interview on 12/12/24 at 1:17 p.m. with CNA D as she performed incontinence care on Resident #4. CNA D was observed not doing any hand hygiene prior to care. She gathered one pair of gloves and entered the Resident #4's room. She used one pair of gloves during the entire incontinence care for Resident #4. She applied barrier cream, moved pillows on the bed, adjusted the sheets and the resident using the same pair of dirty gloves. She used water to wet the wipes and said it helped get the barrier cream off the resident better. She left the resident and sheets wet. In an interview on 12/12/24 at 1:32 p.m. CNA D said she normally changed her residents every 2 hours or more frequently if needed or if they ask. She acknowledged that she did not change her gloves throughout incontinent care. She said the Surveyor made her nervous and that was not her normal practice. She said she would change her gloves after touching any bowel or if the gloves got dirty. She said she received training on the floor and on the computer about one week ago. She said she did train with two other CNAs, and someone watched her do an incontinent care on a resident about two weeks ago. In an interview on 12/12/24 at 2:02 p.m. the DON said when providing incontinent care, hand hygiene should be done first, gather all the supplies, glove up, and provide privacy for the resident. The next step is to provide the incontinent care, wash hands again, change gloves, and put on a clean brief. She said to apply barrier cream if needed. She said staff should see if the resident is soiled and move through the task from clean to dirty. She said CNA D was a newer CNA and did receive training. She said infection control was important because it may put the resident at risk for infection such as an UTI. She said all staff were responsible for infection control. Record review of the facility's Incontinent Care Skills Checklist dated 12/12/24 read in part, .4. wash hands; apply gloves .6. Assist patient to supine position and remove soiled clothing and/or brief, if needed clean soiled areas first by wiping off fecal material with dry wipes .7. remove gloves, sanitize hands and apply new gloves .Female perineal care . 2. Clean outwards from front to side . 5. Wash labia major and skin folds . 9. Wash, wiping from vagina toward rectum with one stoke, front to back, repeat, if necessary, with a new wipe as all feces must be cleaned off . 11. Wash/sanitize hands. Apply clean gloves. 12. Position new brief under patient. Apply barrier cream to perineal and buttock area, position and fasten clean brief under patient and adjust clothing . Record review of the facility policy, Infection Control dated November 2017 read in part, .1. The facility must establish an infection prevention and control program (IPCP) that must include: a. a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all patients, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment .

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 care plan, and the residents' choices based on the comprehensive assessment of resident (Resident #1) 1 of 6 residents reviewed for quality of care. -The facility failed to ensure staff remained with Resident #1 after Resident #1 was found on the floor, bleeding from his head. -The facility failed to complete an appropriate assessment for Resident #1 after an unwitnessed fall, where a laceration to the head and skin tear to the shoulder were sustained. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs. Findings include: 1. Record review of Resident #1's face sheet dated 04/16/24, revealed he was admitted to the facility on [DATE] with diagnoses of idiopathic peripheral autonomic neuropathy (peripheral nerve damage); malignant neoplasm of head, face and neck (head and neck cancer); right clavicle fracture (broken right collar bone), unsteadiness on feet; abnormalities of gait and mobility (weakness of and lower extremity muscles); chronic pain (unspecified, localized pain); and, muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record review of Resident #1's MDS dated [DATE], revealed the resident's BIMS score was 7, which indicated severe cognitive impairment. Resident #1 used a wheelchair and required maximum assistance with transferring to and from a bed to a wheelchair; moderate assistance with bathing, upper body dressing and personal hygiene; and supervision or touching assistance with eating and oral hygiene. Record review of Resident #1's care plan revealed he was at risk for fall related to decreased mobility and frequent falls at home prior to admission. Further review indicated the resident had potential for injury due to unsafe independent transfers. Interventions included assisting the resident with wearing non-slick footwear; monitoring the resident for increases in pain, redness and warmth of the legs; educating and encouraging the resident to use the call light for help with tasks requiring balance and standing positions; ensuring the resident's call light was within reach; and, transfers with assist of one to two staff with a gait belt or stand aid or, two or more staff with a mechanical lift. Record Review of Resident #1's electronic health record, revealed the following: Fall Risk Assessment on 04/14/24, the resident was considered a high fall risk and experienced 1 to 2 falls in the past 3 months; no recent changes in medication; suffered from dizziness, joint pain, and Parkinson's Disease; fall prevention protocol and care plan updated. The resident was not experiencing pain at this time but was at risk for pain due to current cancer diagnosis, history of chronic pain and previous injury. Further review revealed pain medication was administered. Record Review of Resident #1's SBAR on 04/14/24, revealed the following: The SBAR, completed by LVN A, did not reveal results of his range of motion assessment; the size, depth and amount of bleeding or drainage from Resident #1's laceration; nor, the size, amount and color/discoloration of his observed hematoma on his head. SBAR on 04/14/24, BP:109 54 Pulse:58 Respiratory Rate:18 Temperature:97.6 Oximetry %:96. No changes observed with the resident's mental status, behavioral, respiratory, cardiovascular, abdominal/GI, urine, and neurological evaluations. The resident's functional status was noted as general weakness compared to his baseline. Abrasion, laceration, skin tear and wound noted during skin evaluation. Further review of the SBAR revealed, Patient was on the floor bleeding from a hematoma to the forehead. There was also a small skin tear on the back of the right shoulder. Patient was awake, alert and oriented x 4. Talking. could recount what happened and how he fell . Trying to transfer from bed to wheelchair and lost balance. NP noted to have been notified at 4:30 PM on 04/14/24. Record Review of Resident #1's clinical notes on 04/14/24, revealed the following: The clinical note did not reveal Resident #1's pain using the 0-10 pain scale; results of Resident #1's range of motion assessment; the size, depth and amount of bleeding or drainage from Resident #1's laceration; nor, the size, amount and color/discoloration of his observed hematoma on his head. LVN A wrote, CNA responded to yelling coming from patient's room. Patient was observed on the floor adjacent to his bed bleeding from his head. Write did full head to toe assessment. Patient was alert and oriented x4. Only injuries noted was a knot above the right eyebrow on his forehead and small skin tear on the back of his right shoulder. First aid was done and TAO and dressing was applied. PRN Norco 10-325mg was also administered at this time. He reported that he was trying to get into his wheel chair to come out of the room and ask for help. SN reeducated the patient on the importance of using the call light and he verbalized understanding. Neuro check have been started and all responsible parties (RP, MD, UM & DON) were notified of incident. Care ongoing. Resident is listed as his own RP. Record Review of Resident #1's Treatment Notes, revealed the following: An order for neuro checks every 15 minutes for 1 hour; every 30 minutes for 2 hours; every hour for 5 hours; and, every 4 hours for 24 hours began on 04/14/24 at 4:15 PM. LVN A recorded Resident #1's Blood Pressure 109/54, Pulse 58, Respiration 18, Temperature 97.6, equal hand grasps, and normal motor function on 04/14/24 at 4:15 PM, 4:30 PM, 5:00 PM, 5:30 PM and 6:00 PM. Further review of Resident #1's Treatment Notes, revealed RN A recorded Blood Pressure 140/64, Pulse 64, Respiration 18, Temperature 97.6, equal hand grasps, and normal motor function on 04/14/24 at 6:30 PM; Blood Pressure 174/78, Pulse 60, Respiration 18, Temperature 97.6, equal hand grasps, and normal motor function on 04/14/24 at 7:00 PM; Blood Pressure 134/80, Pulse 62, Respiration 18, Temperature 97.8, equal hand grasps, and normal motor function on 04/14/24 at 8:00 PM. Further review of Resident #1's Treatment Notes revealed, neuro checks were not completed for Resident #1 between 8:00 PM on 04/14/24 through 8:00 AM on 04/15/24 while the resident was sent out to the hospital. Further review of clinical notes on 04/14/24, revealed: at 9:57 PM, RN A wrote, The pt was received resting in bed, alert and able to make his needs known. Outgoing nurse reported pt had a fall at about 4 pm today and had sustained head injury to the right side of his forehead with skin tear, bruising and swelling on the forehead. The nurse also reported NP was notified and had given order to monitor pt and to send pt to hospital for any change in his condition, pt on neuro-checks. The nurse also reported she had given the pt pain medication for the pain to his forehead. At about 7:30 PM neuro-checks was done, pt c/o headache to the forehead, the site of the injury, swelling to the forehead looked increased, vitals T 97.6 R 18 BP 174/78, P 60, O2 sats on room air 87-90%, initiated O2 2L via N/C, sats 95%, NP notified, order was received to send the pt to ER for evaluation. Pt. was notified, he requested to be sent to the hospital in The Woodlands, Pt was picked up by EMS at about 20:48, vitals at the time he was leaving the unit-by EMS equipment BP 197/88, R 18 P 63 O2 on room air 88-90%. This nurse attempted to reach family on the phone few times without success; .Pt alert and able to make his needs known at the time of his p/u at about 20:48, DON and ED were notified. Record Review of Resident #1's hospital records revealed the following: On 04/14/24 an MD noted the resident's CT scan results to have an age-indeterminate (timeframe not precisely determined or established) nondisplaced (broken bone not moved far enough during the break to be out of alignment) fracture at the right inferior pubic ramus (right pelvic fracture). The MD discussed resident remaining in the hospital for three days for observation. The resident preferred returning to the nursing facility for physical therapy and follow up with orthopedic surgery. The MD instructed the resident to provide the facility with pelvic fracture paperwork. Record Review of Resident #1's hospital discharge paperwork, revealed the following: On 04/14/24, the resident was diagnosed with a fall, scalp hematoma, multiple abrasions, and pelvic fracture. Record Review of Resident #1's clinical notes on 04/15/24, revealed: at 7:17 AM RN A wrote, DON was notified of pt's return and diagnosis from the ER visit. At 7:18 AM RN A wrote, Pt returned back from the hospital at about 0615 am, alert and able to make his needs known. The hospital reported diagnosis from the visit: Fall, scalp hematoma, multiple abrasions, pelvic fracture. NP notified. Vitals T 97.6 R 18 BP 150/70 O2 96% on room air. At 7 am he was given PRN pain med as per order for c/o pain on the head; endorsed to morning nurse. Further review of the treatment notes did not reveal, results of blood pressure, pulse, respiration, or temperature for Resident #1 on 04/15/24 at 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM by LVN B and 12:00 AM on 04/16/24 by LVN E. Treatment notes revealed equal hand grasps and normal motor function for Resident #1 recorded by LVN B on 04/15/23 at 8:00 AM, 12:00 PM, 8:00 PM and 12:00 AM by LVN E. In an interview with LVN B on 04/16/2024 at 1:32 PM, She said she began working at the facility on December 11, 2023, as a Unit Manager. She said on 04/14/24 at 4:33 PM, she got a text from LVN A regarding Resident #1's unwitnessed fall. She said LVN A told her the resident had a knot on top of his right eye, and skin tear on his shoulder. She said she instructed LVN A to complete an SBAR and incident/accident report in Resident #1's electronic health record, call the DON and the resident's doctor. She said she has reviewed the SBAR, and the incident/accident report completed by LVN A in Resident #1's electronic health record. She said the LVN A carried out her directives and responded to the incident with Resident #1 appropriately. She said LVN A and LVN C helped Resident #1 get back into the bed after the fall. She said it was her expectation of any nurse to assess a resident before they moved them. She said once the nurse determined it was safe to move the resident, the nurse should help get the resident into a safe place, whether that is back into a chair or wheelchair, or back into bed. She said it was not necessary for her to do much follow up with her nurses, because her staff were astute. She said it was her expectation of a CNA that found a resident on the floor to press the call light, and if no one comes to follow up or assist, call for help down the hallway to get the resident some assistance. She said once the nurse arrived and assessed the resident, the CNA could help the nurse get the resident up and into a safe place. In an interview with LVN A on 04/16/24 at 1:53 PM, she said she had worked at the facility for a year. She said she was the charge nurse for 500 hall and was the nurse on duty when Resident #1 had an unwitnessed fall. She said one of the CNA's walked into Resident #1's room and found him on the floor. She said the CNA asked LVN A to come into the resident's room. She said assessed him and saw the resident had a hematoma on the top of his forehead, and a skin tear on his shoulder. She said Resident #1 said everything was fine, and did not complain of pain, but he had a head injury, so she gave him pain medication. She said the resident asked for pain medication once or twice a day and had a PRN pain medication. She said she cleaned the resident's wounds and put bandages on them. She said LVN C, from another hall, helped her get the resident back in the bed. She said when a resident had a fall, whether it was witnessed or unwitnessed, a nurse was supposed to do a head-to-toe assessment, pain assessment, and any first aid the resident needed . She said after they got the resident back into his bed, she put the bed in the lowest position, performed a fall risk assessment, pain assessment, completed an SBAR, notified the resident's nurse practitioner, DON, administrator, and the resident's responsible party. She said she documented the assessments and everything she did for the resident in his electronic health record. She said when she notified the nurse practitioner of Resident #1's fall, the nurse practitioner asked about the size of the resident's hematoma, and whether he was on blood thinners, or not. She said she told the nurse practitioner the resident was not prescribed a blood thinner but was prescribed aspirin. She said the nurse practitioner told to her Resident #1 needed to be monitored for changes and ordered neuro checks for 72 hours . She said the Resident was fine throughout the rest of her shift. She said Resident #1's change of condition did not happen on her shift, but she knew the resident was sent out to the hospital. In an interview with CNA A on 04/16/24 at 2:32 PM, she said worked at the facility for four and a half years and worked with Resident #1 the three and a half years he had been living at the facility. She said the resident was very particular about the care he received from staff and would walk them through how he preferred to receive care. She said she was not the aide responsible for working on Resident #1's hall on 04/14/24. She said she walked over to the [NAME] unit to put out the schedules for the week when she heard yelling coming from a resident's room. She said LVN A, CNA B and CNA C were sitting at the nurse's station near where the yelling was coming from. She said she asked them who was yelling, and why. She said LVN A and CNA B told her Resident #1 was being demanding, yelling, screaming, and kicking at staff all day. She said she could not remember the exact time this occurred, but knew it was after lunch time. She said CNA B and LVN A told her they had already checked on the resident and that he was okay. She said she decided to go check on him because he was still yelling and screaming. She said she opened the door to the resident's room; she saw the resident on the floor next to his bed and saw blood on his forehead. She said she immediately went to go get LVN A from the nurse's station. She said once the nurse returned to Resident #1's room with her, the nurse got the resident into a sitting position on the floor. She said she was not sure what all LVN A did to assess the resident. She said the resident was not complaining about pain, but LVN A gave him pain medication. She said she did not stay with LVN A the whole time because she was not the aide responsible for the hall at that time and had other tasks to complete. She said she went back to the nurses station and told CNA B to go to Resident #1's room to assist LVN A. In an interview with CNA B on 04/14/24 at 2:49, she said she began working at the facility in January 2024, and had become a PRN staff as of 03/29/24. She said Resident #1 was very verbally aggressive towards women. She said Resident #1 called her stupid, ugly, and told her she had no class. She said the resident would also tell her to 'get the fuck out of his room.' She said she worked 9:00 AM to 6:00 PM on 04/14/24. She said there was another CNA, and LVN A sitting at the nurses station with her, when CNA A came and told LVN A Resident #1 was on the floor in his room. She said LVN A went to go check on Resident #1. She said she went to Resident #1's room also. She said she did not know exactly what LVN A did with Resident #1 as far as assessing him after his unwitnessed fall. She said she knew LVN A cleaned up the resident's wounds, gave him pain medication, and another nurse came and helped LVN A get the resident back into his bed. She said shortly after all of this she believed she left work for the day. In an interview with Resident #1 on 04/16/24 at 3:25 PM, he said he wasn't in the mood to be answering too many questions. He said before he fell , he was really upset, and wanted to go out into the hallway and get help. He said he did not know what he was thinking. He said he was trying to get out of his bed and into his wheelchair. He said he sat up and was sitting on his bed and the next thing, he was on the floor. He said he did not press his call light before he tried to get out of bed. He said he was just so mad, he did not think about it. He said he was just upset and wanted to talk to the nurse. He said his wheelchair was in the same spot it is currently in (about five feet away from the end of his bed, against the wall), when he fell . He said he just could not get off the floor on his own. He said now he had a whole new set of health issues and injuries to worry about. He said he was getting upset all over again. He said he no longer wanted to speak about the incident. In an interview with LVN D on 04/16/24 at 4:38 PM , she said she was familiar and had worked with Resident #1 before. She said if she had found or been notified to respond to Resident #1 being found on the floor, she would have assessed the resident first. She said she would do a visual assessment for visible injuries, make note of their size, color, amount of bleeding, etc. She said Resident #1 was alert and oriented times three, so she would have asked him about the locations of his pain, if he had any pain at all, and level of pain using the 0-10 scale. She said she would assess the resident's range of motion by having him flex his lower extremities and instructing him to grab onto her arm with his hands. She said she would check his pupils, temperature, blood pressure, pulse, and any other necessary vital sign. She said everything she observed and everything she did with the resident would be documented on an SBAR, Pain Assessment, Fall Assessment, Incident Report, and clinical notes in the resident's electronic health record. She said she would also make notifications to the doctor, DON, Administrator, and the responsible party; and document the attempts in the resident's electronic health record. She said a nurse was supposed to use their best judgment in the moment to prevent injury to the patient, but also to prevent injury to themselves. She said Resident #1 was a bigger buy, and if she assessed him after a fall, witnessed or unwitnessed, and determined it was safe to move him, she would have gotten another nurse to assist her in using a mechanical lift to get him off the floor and back into his bed. She said she would begin closely monitoring the resident for changes, follow any orders given by the physician and start neuro-checks on the resident every 15 minutes, 30 minutes, 1 hour, 2 hours, etc. for the necessary 72-hour period. She said if she was the nurse to respond to any resident who suffered an unwitnessed fall and had any sort of head injury, she would err on the side of caution and call 911. In an interview with LVN C on 4/17/24 at 9:57 AM, she said on she worked on 04/14/24, the day Resident #1 had an unwitnessed fall. She said she was coming out of room [ROOM NUMBER], LVN A was coming out of Resident #1's room and were both headed towards the nurse's station. She said LVN A asked her to help get Resident #1 off the floor in his room. She said when they went back to the resident's room, LVN A was carrying a blood pressure cuff. She said she was not sure whether LVN A had completed her assessment on Resident #1 at that point. She said when she went into the room, the resident was on the floor sitting straight up, with his legs sort of crossed. She said she did not observe any blood or active bleeding on the resident. She said the resident had a bandage on his head. She said the resident never complained about pain. She said LVN A asked Resident #1 if he was in pain before they got him up off the floor, and after they got him back into his bed. She said both times Resident #1 said he was fine. She said once they got Resident #1 back into his bed, LVN A helped her with the resident while she put briefs back on the resident. She said when Resident #1 went to turn over to the right, on the left side of his body, he could not do that on his own, so LVN A helped her turn him during putting on the briefs. She said she was not sure whether the resident being able to turn on his side was a baseline behavior for him or not. She said after they put the briefs on, the resident asked to be adjusted and scooted down in his bed. She said she asked LVN A if she needed anything else, and LVN A said no. She said she went back to working on things for her residents, LVN A stayed behind and was in Resident #1's room a little bit longer. She said she knew LVN A notified Resident #1's doctor because she heard LVN A read the message from the provider out loud, which said to monitor the resident and send him out if he had any changes in condition. In an interview with the DON on 04/17/24 at 10:45 AM, he said he had worked at the facility for four months. He said based on what he reviewed regarding the incident with Resident #1, the care Resident #1 received from staff after his unwitnessed fall was appropriate. He said if a CNA found a resident on the floor, it was his expectation for the CNA to call out for help. He said the aide could press the call light, or yell for help, but the CNA was supposed to stay with the resident until the nurse arrived to give directives. He said once the nurse arrived, the nurse was supposed to begin doing assessments and observations on the resident. He said for any fall, a nurse needed to do a visual assessment to look for obvious injuries and a head-to-toe assessment. He said a head-to-toe assessment consisted of checking neuro status by checking the patient's pupils, having them perform hand grips with the nurse and looking for any slurred speech . He said the nurse needed to identify any head trauma; look to see if the resident was on an anticoagulant or aspirin; check for abrasions and any obvious deformities on the body; and assess the resident's pain. He said a pain assessment should be done using the 0-10 scale unless the resident was could not verbalize discomfort. He said then, the nurse needed to look for signs of pain from the resident, like grimacing of the face. He said the nurse would need to notify the physician and treat the resident according to the physician's orders. He said if a resident had a head injury after any fall, they would call 911 and the resident would be sent out to the hospital. He said that nurses were also trained to use their best judgement. He said LVN A performed her assessments, spoke with the resident and the resident's doctor and the doctor gave an order to monitor the resident and send him out to the hospital if there were any changes in condition. He said the resident experienced a change in condition when he complained of pain on the next nurse's shift, the physician was notified, and the resident was sent to the hospital. He said, according to the inservices he conducted with staff yesterday, a resident who suffered a fall, had a visible fracture, or was expressing pain was not supposed to be moved by staff, instead call 911 and notify the physician. He said yesterday, the entire staff was inserviced on fall management. He said Resident #1 never complained about pain during his assessments with LVN A. He said staff were also doing extra rounding on Resident #1 to make sure he was not in any pain. He said he reviewed all the documentation completed by LVN A on 04/14/24, and she did everything right. He said he was not sure if he saw any documentation completed by LVN A regarding assessing Resident #'1 range of motion. He said he did not ask LVN A whether she assessed the resident's range of motion before moving him, but he was sure LVN A assessed his range of motion. He said if LVN A performed range of motion on the resident at the time of her assessment, it would have been documented in the clinical notes with the rest of the information assessed by the nurse. He said when documenting range of motion, the nurse needed to describe whether the resident had full or limited range of motion and the location on the resident's body. He said he would have to review the resident's electronic health record to see what LVN A documented for Resident #1's range of motion. He said he reviewed LVN A's documentation and agreed she did not document Resident #1's range of motion after his unwitnessed fall. He said not performing or not documenting a resident's range of motion could put a resident at risk of further injury or not receiving the appropriate care. Record Review of Inservice, dated 04/17/24, revealed the following: The inservice did not reveal moving residents after a fall with a head injury as a topic of discussion. All staff from all departments were trained by the administrator about falls, in that; any staff that finds a resident that has a fall, witnessed or unwitnessed, will remain with the resident until a nurse arrives to assess and give directives. In an interview with the Regional Director of Clinical Services and the Administrator on 04/19/24 at 8:55 AM, The Regional Director of Clinical Services said if a CNA or Medication Aide found a resident on the floor, they were not to touch the resident until an assessment had been completed by nurse. She said finding a resident on the floor or any other medical emergency, could have been a case-by-case scenario where staff would have to use their best judgement to get the resident the help they needed. She said sometimes, pressing the call light or calling out for help may not get help for the resident quick enough. She said the staff may have to stick their head out in the hall and yell for help. She said it was not acceptable for any staff to leave a resident with obvious injuries, especially to the head, or after an unwitnessed fall. She said however, if the staff had yelled for help to the best of their ability, and no one responded they may have to physically step away from the resident to alert the nearest staff. She said if any resident had a fall and complained of pain to the head, the resident would be sent out to the hospital. She said a resident who had an unwitnessed fall might need to be evaluated on a different level. She said the nurses used their best judgement, but ultimately the results of the nurse's neuro assessment determined whether a resident who suffered an unwitnessed fall needed to be sent to the hospital. She said her expectations of an assessment completed by a nurse after a resident had an unwitnessed fall included checking vitals (such as, blood pressure, heart rate, temperature, and respiration) checking pupils, asking the resident if they were experiencing pain. She said the resident was not able to verbalize pain, look for grimacing and wincing. She said as far as pain assessment, the nurses should have used the pain scale and documented the numerical representation of the pain level on the incident/accident report and the resident's TAR. She said nurses were also supposed to document the location of the pain. She said as far as range of motion, the nurse needed to document whether the resident had full or limited range of motion. She said for the nurse to assess range of motion they needed to slowly move all extremities and look for resident responses to those movements. She said the nurse could also do slow movements of the pelvis to assess range of motion. She said range of motion should be documented whether the resident's fall was witnessed or unwitnessed. The Clinical Director and the Administrator agreed they were unsure as to whether LVN A assessed Resident #1's range of motion after his unwitnessed fall. The administrator agreed LVN A did not document the resident's range of motion. The Clinical Director said once a nurse decided it was safe to move a resident after a fall, they needed to get assistance from at least one other staff to get the resident off the floor. She said the nurses needed to use their best judgement and help the resident with a two-person assist, a mechanical lift, or even placing a sheet underneath the resident to get them up. The Administrator said from what he read, there were improvements the nurses and the rest of the staff could make in responding to and documenting a resident incident. He said this incident highlighted that while the nurses know what to do in the moment, they were not documenting the necessary details. Record Review of Inservice, dated 04/19/24, revealed the following: All staff from all departments were trained by the administrator on the subject of falls, in that; any staff that finds a resident that has a fall, witnessed or unwitnessed, will remain with the resident until a nurse arrives to assess and give directives; and, an RN or LVN must document vital signs, neuro checks, pain using the 0-10 pain scale, range of motion, skin integrity (bruising, cuts, lacerations, hematomas, abrasions), resident interview as part of a head to toe assessment. Record review of the policy, dated November 2022, titled, Fall Management Guidelines revealed the following: 1. Definition: Unintentional change in position coming to rest on the ground, floor or onto the next lower surface .Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .3. Complete the Intervention Checklist for Patient .6. When the Patient experiences a fall: Licensed nurse will assess the Patient. Before moving the patient, check for injury. Stabilize the Patient and provide immediate treatment if necessary. If the Patient has a serious injury, do not move the Patient. Inform the Physician, Responsible Party and call 911 for ambulance. Obtain vital signs (Temperature, Pulse, Respiration, Blood Pressure). A Head-to-Toe Assessment will be performed at the time of the fall .Document a clinical note in the electronic health record .The DON and/or Unit /Manager will ensure the Intervention Checklist, Fall Risk Care Plan and Daily Care Guide were updated as needed. Record review of the policy, revised January 2024, titled, Follow-Up for Potential Head Injury revealed the following: Responsibility Licensed Nurse Purpose To observe, record and report any condition change to the attending physician so proper treatment will be implemented .Procedure Following any head trauma, monitor the following: Observe for lacerations; if present, clean apply dry, sterile dressing. Note size, depth, and amount of bleeding or drainage. Observe for swelling and discoloration; if present, chart size, site, amount and color .Observe and inquire if patient has headache or pain .Observe for sensory weakness. Observe for generalized weakness .Observe for proper reflexes .Have someone stay with the patient while the charge nurse notifies the physician on call .Complete an incident/accident report if applicable .Documentation Date, time condition change was identified .Emergency care provided . Record review of the policy, dated November 2015, titled, Change in a Resident's Condition or Status revealed the following: 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; and, d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii) .3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (Interact Version 4.0) Communication Form. Policy Interpretation and Implementation 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the r[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure pain management was provided to and monitored for 2 of 4 residents (Resident #128 and Resident #228), in that: -Resident #128 experienced pain after admission without her ordered Oxycodone available for use. -Resident #228 verbalized pain that without and pharmacological or non-pharmacological treatment offered to him. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #128 and #228 to experience pain that went unmanaged and placed additional residents at risk for experiencing unmanaged pain. Findings include: Resident #128 Record review of Resident #128's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] and was diagnosed with anxiety disorder, dementia, and the presence of an artificial left hip joint. Record review of Resident #128's hospital discharge 7-day medication summary, dated 09/23/2023, revealed the resident was ordered Oxycodone 2 - 5mg tablets every 4 hours PRN for pain score 7-10 starting on 09/21/2023 with her last dose given in the hospital by 09/23/2023 at 11:52AM. Record review of Resident #128's physician's orders revealed the resident was ordered: 1. Acetaminophen 2-500 mg tablets every 6 hours on 09/04/2023 at 7AM. 2. PRN Oxycodone 5mg tablet every 4 hours as needed for pain score 7-10 starting 09/24/2023 at 7AM. 3. Tramadol 50mg tablet one time daily only one time on 09/25/23 at 11:59PM. 4. pain assessment every shift starting on 09/24/2023 Record review of Resident #128's TAR revealed the resident had orders for a pain scale assessment every shift starting on 09/24/2023. LVN J checked off that pain assessment was done on 09/24/2023 but did not document a number on the scale of 0 - 10. Record review of Resident #128's clinical note, dated 09/23/2023 11:34PM, revealed LVN H noted Resident #128, . arrived to facility via EMS . Left hip replacement. Uses walker to ambulate, Not happy about her pain meds being unavailable and wanting to go back to the hospital until we get her pain meds. Stable. Pain 10/10. Surgical wound to left hip. Resting in bed with call light within reach . Record review of Resident #128's clinical notes, revealed in September 2023, there were no other notes about the resident's pain aide from her admission note on 09/23/2023 at 11:34PM. Record review of the Resident #128's progress note, dated 09/25/2025, written by NP D, revealed he documented, . Patient is a [AGE] year-old female with past medical history of significant for longstanding left hip and back pain. She presented for elective hip surgery . Patient is seen and evaluated today while laying in bed. She is complaining of pain to left hip. Given Tylenol but not effective. Declined to attend therapy session until stronger pain medication was administered . Record review of Resident #128's hospital discharge 7-day medication summary, dated 09/23/2023, revealed the resident was ordered Oxycodone 2 - 5mg tablets every 4 hours PRN for pain score 7-10 starting on 09/21/2023 with her last dose given in the hospital by 09/23/2023 at 11:52AM. Observation of Resident #128 on 09/26/2023 at 10:52AM, revealed the resident sitting up on the side of her bed wearing a hospital gown. Interview with the Resident #128 on 09/26/2023 at 10:52AM, she said she was dumped there from the hospital on Saturday 09/23/23 where there was no in-house pharmacy to access her Oxycodone. She said .why put me here if her medications would not be here? She said she needed her pain medications to allow her to move and get physically fit enough to discharge from the nursing home. She said she was in absolute tears and in excruciating pain over the weekend from her hip replacement and all they had to offer her was Tylenol, but she kept refusing it because it did not work for her. She said they gave her some other unknown medication recently, but she was not sure if it worked because it put her to sleep shortly after. She said she rather go back to the hospital at this point to get her pain medication. Record review of Resident #128's physician's orders revealed the resident was ordered: 1. Acetaminophen 2-500 mg tablets every 6 hours on 09/04/2023 at 7AM. 2.1. PRN Oxycodone 5mg tablet every 4 hours as needed for pain score 7-10 starting 09/24/2023 at 7AM. 3.1. Tramadol 50mg tablet one time daily only one time on 09/25/23 at 11:59PM. 4.1. pain assessment every shift starting on 09/24/2023 Record review of Resident #128's clinical note, dated 09/23/2023 11:34PM, revealed LVN H noted Resident #128, . arrived to facility via EMS . Left hip replacement. Uses walker to ambulate, Not happy about her pain meds being unavailable and wanting to go back to the hospital until we get her pain meds. Stable. Pain 10/10. Surgical wound to left hip. Resting in bed with call light within reach . Record review of Resident #128's TAR revealed the resident had orders for a pain scale assessment every shift starting on 09/24/2023. LVN J checked off that pain assessment was done on 09/24/2023 but did not document a number on the scale of 0 - 10. Record review of Resident #128's clinical notes, revealed in September 2023, there were no other notes about the resident's pain aide from her admission note on 09/23/2023 at 11:34PM. Record review of the Resident #128's progress note, dated 09/25/2025, written by NP D, revealed he documented, . Patient is a [AGE] year-old female with past medical history of significant for longstanding left hip and back pain. She presented for elective hip surgery . Patient is seen and evaluated today while laying in bed. She is complaining of pain to left hip. Given Tylenol but not effective. Declined to attend therapy session until stronger pain medication was administered . In a phone interview with a Pharmacist on 09/26/23 at 2:10PM, he stated he had just received the electronic script from the doctor less than an hour ago. He said Oxycodone is a CII medication, if there was no script for it, it could not be sent out to the nursing home, and the admission nurse should have known this. If the script was sent upon admission, then the medication could have been delivered the same day. Interview with the DON on 09/26/2023 at 2:34PM, she reported that acquiring medication had been an ongoing problem since she started working in the facility in July 2023. She said she could not say how quickly she expected the scripts to be sent but the admitting nurses were responsible for calling the pharmacy and following up if a medication was needed stat. She said the situation involving Resident #128 was never brought to her attention until then. Interview with LVN Q on 09/26/2023, she said she called the pharmacy on 09/26/23 at 11:27 AM that morning. She said she worked with Resident #128 for the first time on Monday, 09/25/23. She revealed she texted the NP on 9/25/23 at 8:47AM reminding him to send a triplicate for the resident's medication, but she believed the doctor forgot to send it. She said there were orders to check Resident #128's pain level every shift but she never performed or documented pain assessments because whenever she went in her room, Resident #128 would all already be complaining of her pain. Interview with NP D, on 09/26/23 at 3:00 PM, he said he was messaged by LVN Q yesterday about Resident #128's oxycodone. He said he sent the script out on 09/25/23 but there could have been an issue with the system if the pharmacy did not receive it then. He said he was not reminded by the nurse again until that morning, on 09/26/23. He said the resident reported to him in the morning on 09/26/2023 that her pain was still at a 10/10 and the Oxycodone had been ordered today and was in route to arrive in the facility by tonight. He stated the risks of delayed acquiring of pain medication is the resident remaining in pain. Interview with LVN Q on 09/27/2023 at 1:46 PM, she said Resident #128 did not perform a pain scale assessment on 09/24/23 because the resident did not complain of pain to her only tenderness during her shift. In a phone interview with LVN H on 09/27/2023 at 2:06PM, she stated she was the admitting nurse for Resident #128 who came into the facility around 7:00PM on 09/23/2023. She stated she texted the Physician the resident's hospital discharge medication list. She said the Physician approved her to fax the medication list to the pharmacy but she did not follow up to see if the pharmacy received the fax. She said she did not bother to follow up because it typically took two days to receive ordered medications from the pharmacy over the weekends. Interview with LVN H, on 09/29/2023 at 6:22PM, she said she gave Resident #128 gabapentin and Tylenol on 09/23/2023 after she made complaints about her pain. She said when she went back an hour later to follow up with the resident, she was sleeping. She said on Sunday she reported to LVN J, the day nurse, that Resident #128 refused to take her pain meds in the morning of 09/24/2023. She said the order she received, was supposed to be faxed the pharmacy with state written on the list printed directly from the system. She said she did not call to follow up with the pharmacy and verify the fax was received. She said because it usually took days to get ordered medication in general, she did not think about acquiring the Oxycodone as soon as possible especially after Resident #128 did not have any additional complaints of pain on Sunday, 09/24/2023. Record review of Resident #128's TAR, dated September 2023, revealed resident's first dose of Oxycodone in the facility was not administered until 09/26/2023 at 8:00 PM. Resident #228 Record Review of Resident #228's Face Sheet revealed a [AGE] year-old male with a diagnosis of Acute Kidney Failure. Other diagnoses were Pain, Constipation, and other General Symptoms. Record Review of Resident # 228's Care Plan dated 9/26/2023 to present read in part . PROBLEMS . Pain Management (Acute) (Chronic) STATUS: Active (Current) . will achieve an acceptable level of pain control. Record review of Resident #228's nursing notes dated 9/23/2023 6:09pm revealed Resident #228 was admitted from hospital to facility on 9/23/2023 with diagnosis of Obstructive Uropathy (Blocked Urinary Flow), Benign Prostatic Hypertrophy (Enlarged Prostate), and Foley Catheter. Notes reveal resident had pain of 7 out of 10 under his left knee. On 9/26/2023 10:00 am Surveyor observed Resident #228 in bed moaning. Interview on 9/26/2023 at 10:01am with Resident #228 he said he was in pain and the only medication they gave him was acetaminophen and it did not work for him. He said they should have known he was in pain. On 9/26/2023 at 11:03am surveyor reviewed nursing notes dated 9/24/2023 at 11:08am for Resident #228, resident requested pain medication from nursing and was administered acetaminophen. Resident #228 had become upset when acetaminophen was offered for pain. Resident was informed acetaminophen was the only medication prescribed for his pain and resident informed nursing the acetaminophen was not enough medication to control his pain. LVN J outreached physicians phone number and was informed they do not prescribe pain medications over the weekend and the resident would have to wait until Monday when he would be seen by the physician. Resident was informed of this answer. Record review on 9/26/2023 at 2:00 pm revealed no documented follow up for Resident #228's pain control. Interview on 9/26/2023 at 4:00pm with LVN Q she said it was not relayed to her in report that Resident #228 needed something other than acetaminophen for pain over the weekend. She said the resident rating for pain on the pain scale was an 8 today and she had administered acetaminophen. Interview on 9/27/2023 at 9:03am with LVN J she said she had been a nurse for about a year and had worked at the facility since February, she said she called the NP on Sunday 9/24/2023 and spoke with two different people to get pain medication for Resident #228. She said she called more than once. She said they could not initially find Physician #1 in the system. She said they could not prescribe the resident anything and they would have to talk to the doctor on Monday. LVN J said the NP was on call the past weekend on Sunday 9/24/23. She said they told her he would not be able to call back until Monday 9/25/2023. She said the facility referred to all the nurses as charge nurses on the weekend. LVN J said there was no charge nurse or manager on the weekend. She said the DON and ADON were on call over the weekend and she did not call them because they could not do anything to help. She said when she was hired, she was not oriented to the facility and had never been in-serviced on pain management. Interview on 9/27/2023 at 9:08:am with the Unit Manager she said the nurses were in charge over the weekend. She said there was a manager on duty as well. She said she and the DON were on call over the weekend and they were in the process of hiring an ADON. She said the process for narcotics was the on-call physician prescribed narcotics over the weekend. She said the nurses go to the physician's binder and get the on-call number for the weekend. They get the order and put it in the computer, print the order, fax the order to pharmacy and do a follow up phone call. The Unit Manager said they did have some narcotics in their lock box. She said if nurses could not get pain management, they are supposed to call the DON and they would call the Medical Director. She said she had been a nurse for [AGE] years and had worked at the facility since July of 2023. She said the last in-service on pain management was yesterday 9/26/2023 after the surveyors arrived. She said there were no in-services on pain management prior to the surveyors arriving. She said prior to that they went by word of mouth or did a one-to-one conference. Record review of the facility's policy on pain management, dated March 2016, stated: .5. A Pain Assessment must be completed for a Patient upon admission, including re-admission, the onset or an increase in Pain, quarterly and with any significant change in the Patient's condition. 6. Every Patient must be assessed for pain utilizing the Pain Intensity Scale (Faces/ 0-10) or PAINAD for the non-verbal, cognitively impaired patient. a) Every shift 7. If a Patient's Pain intensity score is 1 or has been assessed with non-verbal/non-cognitive signs of Pain; the Pain must be addressed through pharmacological and/or non-pharmacological Pain interventions and documented. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15 PM. On 09/27/2023 at 4:20PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 09/28/2023 at 5:12 PM. The POR revealed: F-697 Pain Management Systematic Approach: Assessment Resident #128 did not receive pain management on 9-23-23. Resident has orders for Acetaminophen 500mg 2 tablets every 6 hours as needed and Oxycodone 5mg tablet every 4 hours as needed. Resident #128 was offered Acetaminophen but she refused. Oxycodone 5mg was not available. Facility received Oxycodone on afternoon of 9/26/23. Resident received Oxycodone at 8:00pm 9/26/23. Oxycodone order verified Q4hrs x 7 day. On 9/27/23 at 4:30pm Resident immediately assessed for pain, pain level noted at 0. Care plan reviewed, no changes needed. The Director of Nursing notified the facility Medical Director of the Immediate Jeopardy on 9/27/23 at 4:30 pm. All residents pain medication will be audited by the Director of Nursing, Unit Manager, Treatment Nurse and/or Patient Care Coordinator by 9/27/2023 to identify any current residents that are missing their pain medication. After completion of pain medication audit, no other residents were found to be missing pain medication. The pain medication audit includes the following information: Checking the pain medication order against the medication in the cart. The pain medication audit is to determine if any resident is missing pain medication. Who will be responsible: Nurse Managers. Who Will monitor: Director of Nursing/Regional Director of Clinical Services. Completion Date: By 9/27/23 and ongoing thereafter. Actions Actions taken for the incident involving Resident #128 include the following: All resident's were assessed for pain as of 9/27/2023 and for any for pain medication needs by the RDCS/DON/Nurse. The result of this reflected no other residents were identified with pain that was not being managed. All facility licensed nursing staff (RNs and LVNs) have received in services on pain assessments and pain management on 9/27/2023. All licensed nurses will be required to complete the in service prior to working their next shift for those who are not present in the facility on 9/27/2023. All new licensed nurses will receive the in services on pain assessments and pain management as part of the onboarding orientation process. The in-services will be completed before the employee works with residents. All newly admitted residents will have a medication review reports daily Monday - Friday during morning clinical stand-up meeting, and Wknd Supervisor and/or designee will review Saturday and Sunday to ensure pain medication that is needed has been ordered and delivered to prevent neglect related to pain management. In-Services All licensed nurses were educated on pain assessments and pain management and to notify the Physician and Director of Nursing immediately of residents' with any pain that is not being managed. This education was provided by the Regional Director of Clinical Services and/or designee by 9/28/2023. All licensed nurses will not be allowed to begin their shift until the education has been completed. The DON and RDCS will be responsible to ensure education has been completed. Each licensed nurse completed a post-test after their education was completed to ensure staff were able to identify pain management needs. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested . In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). Who will be responsible: Nurse Managers Who Will monitor: Director of Nursing. Completion Date: 9/28/2023 Policy and Procedures Policy and procedures were reviewed by Senior [NAME] President of Operations, [NAME] President of Clinical Services, Regional Director of Clinical Services, Senior Executive Director and Director of Nursing. These policies included Neglect, Pain Management and Pharmacy Services. No policies needed any revisions. Monitoring: Record review of six sampled residents revealed pain assessments were completed by 09/27/2023. Record review of six sampled residents' clinical records revealed for all six residents, their pain medications were reconciled from hospital discharge order records, and residents had orders in place for pain scale assessments every shift. Observations of the med carts revealed that all ordered medication for six sampled residents were on the carts. Record review of in-services on 09/29/2023 revealed all nurses who worked since 09/27/2023 were trained on pain management policy and controlled substance policy, including how to order a script. Trainings were conducted by the RN, RDSC for LVNs, RNs, CMAs and the DON. 10 of 10 post-tests completed and passed. Interview with day shift nurse, LVN S and Unit Manager, on 09/29/2023 at 5:00 PM, she said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. She said pain intensity scores of at least 1 should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. She said if she was unable to obtain and order from the doctor, that she would notify the DON. Interview with day shift nurse, LVN J, on 09/29/2023 at 5:05 PM, she said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. She said pain intensity scores of at least 1 should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. She said if she was unable to obtain and order from the doctor, that she would notify the DON. Interview with day shift nurse, LVN L, on 09/29/2023 at 5:08 PM he said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. He said pain intensity scores of at least oned should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. He said if he was unable to obtain and order from the doctor, that he would notify the DON. Interview with the DON on 09/29/2023 at 5:30PM, she said on the weekends, or any time, the manager on duty was in the building was to assist the nurse in acquiring scripts for the pharmacy for new and current residents. She said the pain intensity scale should be done by nurses every shift and they address the pain as ordered. If there was no ordered pain medicine, they needed to contact the physician. She said examples of non-pharmacological pain management strategies included music, distraction, repositioning, and conversation. She said a pain scale was to be assessed when the complaint was made, as well as intensity and location, and after PRN meds are administered, the system would trigger to document follow up pain assessment for effectiveness. She said new orders came from the clinician (MD or NP), and if no order was provided upon request by nurse and manager on duty, they should contact DON to escalate this issue again to the doctor. She said if pain remained unresolved after all attempts, they would have conversation to with clinician to have the resident sent out to the hospital for care. Interview with day shift nurse, RN D, on 09/29/2023 at 5:53 PM, she said to acquire and order for new medication, you could always reach an NP in the case there was no on-call doctor. She said she can also utilized the E-kit for narco, tramadol, Tylenol 3 or morphine if ordered stat. She said if nothing could be done for the patient, they would send them out to ER for pain management. She said scripts were called in by the doctor by phone, and nurses sent the fax of the script request. She said she would follow up daily with the pharmacy and doctor to ensure a script was received. Interview with day shift nurse, LVN Q, on 09/29/2023 at 6:01 PM, she said new orders were called in over the phone by the doctor and faxed orders are printed of from their system. She said a text message was not acceptable for ordering medication. Interview with night shift nurse, LVN P, on 09/29/2023 at 6:13 PM, she said she received training on pain management and was taught to assess for resident's pain every shift. She said in response to pain complaints, she would administer scheduled or PRN medications. She said she could utilize e-kit if doctor gave a new order. After the pain medication was administered, she would follow up with patient 30 minutes to an hour to reassess if pain was alleviated. She said she would offer residents needing pain management pharmacological and non-pharmacological methods to manage pain. She said to obtain an order and send a script to the pharmacy, she would call the doctor, medical director and DON if there was a failure to reach any of them, and she would call to follow up to ensure order was received. Verbal orders were put into the computer and then faxes of scripts were sent by them. Interview with night shift nurse, LVN H, on 09/29/2023 at 6:22 PM, she said she received training on pain management and was taught to notify the DON in the case she has trouble obtaining orders for pain management. She said pain assessments are to be every shift and when pain medication is administered, a pain assessment should be done within the hour afterwards to ensure medication managed the pain. The immediate Jeopardy (IJ)was lowered on 09/29/2023 at 6:37 PM. While the IJ was removed 09/29/2023 at 6:37PM, the facility remained out of compliance at a scope of actual harm. 47531

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the resident needs when the facility did not acquire the prescribed pain medications for 2 of 4 residents (Resident #128 and Resident #228) reviewed for medication administration, in that: -Resident #128 experienced pain after admission when her ordered Oxycodone was not available for use at the facility. -Resident #228 verbalized pain and was not offered pharmacological or non-pharmacological treatment to relieve his discomfort. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #128 and #228 to experience pain that went unmanaged and placed additional residents at risk for experiencing unmanaged pain. Findings include: Resident #128 Record review of Resident #128's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] and was diagnosed with anxiety disorder, dementia, and the presence of an artificial left hip joint. Record review of Resident #128's hospital discharge 7-day medication summary, dated 09/23/2023, revealed the resident was ordered Oxycodone 2 - 5mg tablets every 4 hours PRN for pain score 7-10 starting on 09/21/2023 with her last dose given in the hospital by 09/23/2023 at 11:52 AM. Record review of Resident #128's physician's orders revealed the resident was ordered: 1. Acetaminophen 2-500 mg tablets every 6 hours on 09/04/2023 at 7 AM. 2. PRN Oxycodone 5 mg tablet every 4 hours as needed for pain score 7-10 starting 09/24/2023 at 7 AM. 3. Tramadol 50mg tablet one time daily only one time on 09/25/23 at 11:59 PM. 4. pain assessment every shift starting on 09/24/2023 Record review of Resident #128's TAR revealed the resident had orders for a pain scale assessment every shift starting on 09/24/2023. LVN J checked off that pain assessment was done on 09/24/2023 but did not document a number on the scale of 0 - 10. Record review of Resident #128's clinical note, dated 09/23/2023 11:34 PM, revealed LVN H noted Resident #128, . arrived to facility via EMS . Left hip replacement. Uses walker to ambulate, Not happy about her pain meds being unavailable and wanting to go back to the hospital until we get her pain meds. Stable. Pain 10/10. Surgical wound to left hip. Resting in bed with call light within reach . Record review of Resident #128's clinical notes, revealed in September 2023, there were no other notes about the resident's pain aide from her admission note on 09/23/2023 at 11:34 PM. Record review of the Resident #128's progress note, dated 09/25/2025, written by NP D, revealed he documented, . Patient is a [AGE] year-old female with past medical history of significant for longstanding left hip and back pain. She presented for elective hip surgery . Patient is seen and evaluated today while laying in bed. She is complaining of pain to left hip. Given Tylenol but not effective. Declined to attend therapy session until stronger pain medication was administered . Record review of Resident #128's hospital discharge 7-day medication summary, dated 09/23/2023, revealed the resident was ordered Oxycodone 2 - 5mg tablets every 4 hours PRN for pain score 7-10 starting on 09/21/2023 with her last dose given in the hospital by 09/23/2023 at 11:52 AM. Observation of Resident #128 on 09/26/2023 at 10:52 AM, revealed the resident sitting up on the side of her bed wearing a hospital gown. Interview with the Resident #128 on 09/26/2023 at 10:52 AM, she said she was dumped there from the hospital on Saturday 09/23/23 where there was no in-house pharmacy to access her Oxycodone. She said .why put me here if her medications would not be here? She said she needed her pain medications to allow her to move and get physically fit enough to discharge from the nursing home. She said she was in absolute tears and in excruciating pain over the weekend from her hip replacement and all they had to offer her was Tylenol, but she kept refusing it because it did not work for her. She said they gave her some other unknown medication recently, but she was not sure if it worked because it put her to sleep shortly after. She said she rather go back to the hospital at this point to get her pain medication. In a phone interview with a Pharmacist on 09/26/23 at 2:10 PM, he said he had just received the electronic script from the doctor less than an hour ago. He said Oxycodone is a CII medication, if there was no script for it, it could not be sent out to the nursing home, and the admission nurse should have known this. If the script was sent upon admission, then the medication could have been delivered the same day. Interview with the DON on 09/26/2023 at 2:34 PM, she reported that acquiring medication had been an ongoing problem since she started working in the facility in July 2023. She said she could not say how quickly she expected the scripts to be sent but the admitting nurses were responsible for calling the pharmacy and following up if a medication was needed stat. She said the situation involving Resident #128 was never brought to her attention until then. Interview with LVN Q on 09/26/2023, she said she called the pharmacy on 09/26/23 at 11:27 AM that morning. She stated she worked with Resident #128 for the first time on Monday, 09/25/23. She revealed she texted the NP on 9/25/23 at 8:47 AM reminding him to send a triplicate for the resident's medication, but she believed the doctor forgot to send it. She said there were orders to check Resident #128's pain level every shift but she never performed or documented pain assessments because whenever she went in her room, Resident #128 would all already be complaining of her pain. Interview with NP D, on 09/26/23 at 3:00P M, he said he was messaged by LVN Q yesterday about Resident #128's oxycodone. He said he sent the script out on 09/25/23 but there could have been an issue with the system if the pharmacy did not receive it then. He said he was not reminded by the nurse again until that morning, on 09/26/23. He said the resident reported to him in the morning on 09/26/2023 that her pain was still at a 10/10 and the Oxycodone had been ordered today and is in route to arrive in the facility by tonight. He said the risks of delayed acquiring of pain medication is the resident remaining in pain. Interview with LVN Q on 09/27/2023 at 1:46 PM, she said Resident #128 did not perform a pain scale assessment on 09/24/23 because the resident did not complain of pain to her only tenderness during her shift. In a phone interview with LVN H on 09/27/2023 at 2:06 PM, she said she was the admitting nurse for Resident #128 who came into the facility around 7:00 PM on 09/23/2023. She said she texted the Physician the resident's hospital discharge medication list. She said the Physician approved her to fax the medication list to the pharmacy but she did not follow up to see if the pharmacy received the fax. She said she did not bother to follow up because it typically took two days to receive ordered medications from the pharmacy over the weekends. Interview with LVN H, on 09/29/2023 at 6:22 PM, she said she gave Resident #128 gabapentin and Tylenol on 09/23/2023 after she made complaints about her pain. She said when she went back an hour later to follow up with the resident, she was sleeping. She said on Sunday she reported to LVN J, the day nurse, that Resident #128 refused to take her pain meds in the morning of 09/24/2023. She said the order she received, was supposed to be faxed the pharmacy with state written on the list printed directly from the system. She said she did not call to follow up with the pharmacy and verify the fax was received. She said because it usually took days to get ordered medication in general, she did not think about acquiring the Oxycodone as soon as possible especially after Resident #128 did not have any additional complaints of pain on Sunday, 09/24/2023. Record review of Resident #128's TAR, dated September 2023, revealed resident's first dose of Oxycodone in the facility was not administered until 09/26/2023 at 8:00 PM. Resident #228 Record Review of Resident #228's Face Sheet revealed a [AGE] year-old male with a diagnosis of Acute Kidney Failure. Other diagnoses were Pain, Constipation, and other General Symptoms. Record Review of Resident # 228's Care Plan dated 9/26/2023 to present read in part . PROBLEMS . Pain Management (Acute) (Chronic) STATUS: Active (Current) . will achieve an acceptable level of pain control. Record review of Resident #228's nursing notes dated 9/23/2023 6:09 pm revealed Resident #228 was admitted from hospital to facility on 9/23/2023 with diagnosis of Obstructive Uropathy (Blocked Urinary Flow), Benign Prostatic Hypertrophy (Enlarged Prostate), and Foley Catheter. Notes reveal resident had pain of 7 out of 10 under his left knee. On 9/26/2023 10:00 am Surveyor observed Resident #228 in bed moaning. Interview on 9/26/2023 at 10:01 am with Resident #228 he said he was in pain and the only medication they gave him was acetaminophen and it did not work for him. He said they should have known he was in pain. On 9/26/2023 at 11:03 am surveyor reviewed nursing notes dated 9/24/2023 at 11:08am for Resident #228, resident requested pain medication from nursing and was administered acetaminophen. Resident #228 had become upset when acetaminophen was offered for pain. Resident was informed acetaminophen was the only medication prescribed for his pain and resident informed nursing the acetaminophen was not enough medication to control his pain. LVN J outreached physicians phone number and was informed they do not prescribe pain medications over the weekend and the resident would have to wait until Monday when he would be seen by the physician. Resident was informed of this answer. Record review on 9/26/2023 at 2:00 pm revealed no documented follow up for Resident #228's pain control. Interview on 9/26/2023 at 4:00 pm with LVN Q she said it was not relayed to her in report that Resident #228 needed something other than acetaminophen for pain over the weekend. She said the resident rating for pain on the pain scale was an 8 today and she had administered acetaminophen. Interview on 9/27/2023 at 9:03 am with LVN J she said she had been a nurse for about a year and had worked at the facility since February, she said she called the NP on Sunday 9/24/2023 and spoke with two different people to get pain medication for Resident #228. She said she called more than once. She said they could not initially find Physician #1 in the system. She said they could not prescribe the resident anything and they would have to talk to the doctor on Monday. LVN J said the NP was on call the past weekend on Sunday 9/24/23. She said they told her he would not be able to call back until Monday 9/25/2023. She said the facility referred to all the nurses as charge nurses on the weekend. LVN J said there was no charge nurse or manager on the weekend. She said the DON and ADON were on call over the weekend and she did not call them because they could not do anything to help. She said when she was hired, she was not oriented to the facility and had never been in-serviced on pain management. Interview on 9/27/2023 at 9:08 am with the Unit Manager she said the nurses were in charge over the weekend. She said there was a manager on duty as well. She said she and the DON were on call over the weekend and they were in the process of hiring an ADON. She said the process for narcotics was the on-call physician prescribed narcotics over the weekend. She said the nurses go to the physician's binder and get the on-call number for the weekend. They get the order and put it in the computer, print the order, fax the order to pharmacy and do a follow up phone call. The Unit Manager said they did have some narcotics in their lock box. She said if nurses could not get pain management, they are supposed to call the DON and they would call the Medical Director. She said she had been a nurse for [AGE] years and had worked at the facility since July of 2023. She said the last in-service on pain management was yesterday 9/26/2023 after the surveyors arrived. She said there were no in-services on pain management prior to the surveyors arriving. She said prior to that they went by word of mouth or did a one-to-one conference. Record review of the facility's policy on pain management, dated March 2016, stated: .5. A Pain Assessment must be completed for a Patient upon admission, including re-admission, the onset or an increase in Pain, quarterly and with any significant change in the Patient's condition. 6. Every Patient must be assessed for pain utilizing the Pain Intensity Scale (Faces/ 0-10) or PAINAD for the non-verbal, cognitively impaired patient. a) Every shift 7. If a Patient's Pain intensity score is 1 or has been assessed with non-verbal/non-cognitive signs of Pain; the Pain must be addressed through pharmacological and/or non-pharmacological Pain interventions and documented. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15PM. On 09/27/2023 at 4:20PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 09/28/2023 at 5:12PM. The POR revealed: F-697 Pain Management Systematic Approach: Assessment Resident #128 did not receive pain management on 9-23-23. Resident has orders for Acetaminophen 500mg 2 tablets every 6 hours as needed and Oxycodone 5mg tablet every 4 hours as needed. Resident #128 was offered Acetaminophen but she refused. Oxycodone 5mg was not available. Facility received Oxycodone on afternoon of 9/26/23. Resident received Oxycodone at 8:00pm 9/26/23. Oxycodone order verified Q4hrs x 7 day. On 9/27/23 at 4:30pm Resident immediately assessed for pain, pain level noted at 0. Care plan reviewed, no changes needed. The Director of Nursing notified the facility Medical Director of the Immediate Jeopardy on 9/27/23 at 4:30 pm. All residents pain medication will be audited by the Director of Nursing, Unit Manager, Treatment Nurse and/or Patient Care Coordinator by 9/27/2023 to identify any current residents that are missing their pain medication. After completion of pain medication audit, no other residents were found to be missing pain medication. The pain medication audit includes the following information: Checking the pain medication order against the medication in the cart. The pain medication audit is to determine if any resident is missing pain medication. Who will be responsible: Nurse Managers. Who Will monitor: Director of Nursing/Regional Director of Clinical Services. Completion Date: By 9/27/23 and ongoing thereafter. Actions Actions taken for the incident involving Resident #128 include the following: All resident's were assessed for pain as of 9/27/2023 and for any for pain medication needs by the RDCS/DON/Nurse. The result of this reflected no other residents were identified with pain that was not being managed. All facility licensed nursing staff (RNs and LVNs) have received in services on pain assessments and pain management on 9/27/2023. All licensed nurses will be required to complete the in service prior to working their next shift for those who are not present in the facility on 9/27/2023. All new licensed nurses will receive the in services on pain assessments and pain management as part of the onboarding orientation process. The in-services will be completed before the employee works with residents. All newly admitted residents will have a medication review reports daily Monday - Friday during morning clinical stand-up meeting, and Wknd Supervisor and/or designee will review Saturday and Sunday to ensure pain medication that is needed has been ordered and delivered to prevent neglect related to pain management. In-Services All licensed nurses were educated on pain assessments and pain management and to notify the Physician and Director of Nursing immediately of residents' with any pain that is not being managed. This education was provided by the Regional Director of Clinical Services and/or designee by 9/28/2023. All licensed nurses will not be allowed to begin their shift until the education has been completed. The DON and RDCS will be responsible to ensure education has been completed. Each licensed nurse completed a post-test after their education was completed to ensure staff were able to identify pain management needs. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested . In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). Who will be responsible: Nurse Managers Who Will monitor: Director of Nursing. Completion Date: 9/28/2023 Policy and Procedures Policy and procedures were reviewed by Senior [NAME] President of Operations, [NAME] President of Clinical Services, Regional Director of Clinical Services, Senior Executive Director and Director of Nursing. These policies included Neglect, Pain Management and Pharmacy Services. No policies needed any revisions. Monitoring: Record review of six sampled residents revealed pain assessments were completed by 09/27/2023. Record review of six sampled residents' clinical records revealed for all six residents, their pain medications were reconciled from hospital discharge order records, and residents had orders in place for pain scale assessments every shift. Observations of the med carts revealed that all ordered medication for six sampled residents were on the carts. Record review of in-services on 09/29/2023 revealed all nurses who worked since 09/27/2023 were trained on pain management policy and controlled substance policy, including how to order a script. Trainings were conducted by the RN, RDSC for LVNs, RNs, CMAs and the DON. 10 of 10 post-tests completed and passed. Interview with day shift nurse, LVN S and Unit Manager, on 09/29/2023 at 5:00 PM, she said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. She said pain intensity scores of at least 1 should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. She said if she was unable to obtain and order from the doctor, that she would notify the DON. Interview with day shift nurse, LVN J, on 09/29/2023 at 5:05 PM, she said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. She said pain intensity scores of at least 1 should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. She said if she was unable to obtain and order from the doctor, that she would notify the DON. Interview with day shift nurse, LVN L, on 09/29/2023 at 5:08 PM he said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. He said pain intensity scores of at least oned should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. He said if he was unable to obtain and order from the doctor, that he would notify the DON. Interview with the DON on 09/29/2023 at 5:30 PM, she said on the weekends, or any time, the manager on duty was in the building was to assist the nurse in acquiring scripts for the pharmacy for new and current residents. She said the pain intensity scale should be done by nurses every shift and they address the pain as ordered. If there was no ordered pain medicine, they needed to contact the physician. She said examples of non-pharmacological pain management strategies included music, distraction, repositioning, and conversation. She said a pain scale was to be assessed when the complaint was made, as well as intensity and location, and after PRN meds are administered, the system would trigger to document follow up pain assessment for effectiveness. She stated new orders came from the clinician (MD or NP), and if no order was provided upon request by nurse and manager on duty, they should contact DON to escalate this issue again to the doctor. She said if pain remained unresolved after all attempts, they would have conversation to with clinician to have the resident sent out to the hospital for care. Interview with day shift nurse, RN D, on 09/29/2023 at 5:53 PM, she said to acquire and order for new medication, you could always reach an NP in the case there was no on-call doctor. She said she can also utilized the E-kit for narco, tramadol, Tylenol 3 or morphine if ordered stat. She said if nothing could be done for the patient, they would send them out to ER for pain management. She said scripts were called in by the doctor by phone, and nurses sent the fax of the script request. She said she would follow up daily with the pharmacy and doctor to ensure a script was received. Interview with day shift nurse, LVN Q, on 09/29/2023 at 6:01 PM, she said new orders were called in over the phone by the doctor and faxed orders are printed of from their system. She said a text message was not acceptable for ordering medication. Interview with night shift nurse, LVN P, on 09/29/2023 at 6:13 PM, she said she received training on pain management and was taught to assess for resident's pain every shift. She said in response to pain complaints, she would administer scheduled or PRN medications. She said she could utilize e-kit if doctor gave a new order. After the pain medication was administered, she would follow up with patient 30 minutes to an hour to reassess if pain was alleviated. She said she would offer residents needing pain management pharmacological and non-pharmacological methods to manage pain. She said to obtain an order and send a script to the pharmacy, she would call the doctor, medical director and DON if there was a failure to reach any of them, and she would call to follow up to ensure order was received. Verbal orders were put into the computer and then faxes of scripts were sent by them. Interview with night shift nurse, LVN H, on 09/29/2023 at 6:22 PM, she said she received training on pain management and was taught to notify the DON in the case she has trouble obtaining orders for pain management. She said pain assessments are to be every shift and when pain medication is administered, a pain assessment should be done within the hour afterwards to ensure medication managed the pain. The immediate Jeopardy (IJ)was lowered on 09/29/2023 at 6:37 PM. While the IJ was removed 09/29/2023 at 6:37PM, the facility remained out of compliance at a scope of actual harm. 43049

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 7 residents (Resident #1, #2, #3, and #4) reviewed for infection control. -CNA A failed to perform hand hygiene during incontinent care for Resident #1 and Resident #2. -The facility failed to provide incontinent care for Resident #2 for more than 2 hours. Resident #2's brief was saturated with urine and soaked through her pants and onto the wheelchair pad. -CNA A failed to cleanse Resident #3's buttocks area completely by not washing off the white cream that was over a reddened area. -CNA B failed to perform hand hygiene during incontinent care for Resident #4 - CNA B failed to cleanse between labia folds and proximal end of the urinary catheter during female incontinent care for Resident #4. These failures could place the remaining 77 residents who required incontinent care at risk for cross contamination, infection, delay in treatment and hospitalization . Findings included: Resident #1: Record review of Resident #1 face sheet printed on 06/02/2022 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the significant change Minimum Data Set (MDS) resident assessment date completed on 5/04/2022 revealed Resident #1 had a BIMS score of 9 indicating she had moderate cognitive impairment. Resident #1 required total assistance of two staff for her bed mobility and transfers. She required total assistance of one staff person for dressing, toilet use and personal hygiene. She was always incontinent of urine and bowel. Record review of Resident #1's care plan effective date 12/11/2018 to present revealed in part; -Problems: Resident #1 is diabetic and at risk for frequent infections -Interventions included: Monitor for skin changes, redness, circulatory problems, breakdown, report to MD, RP. -Problem Resident #1 is at risk for skin breakdown . -Interventions included: Monitor for incontinence, every 2hours and as needed, change promptly. Apply moisturizing lotion, give meds per order, use non-irritating soaps. -Problems: Pressure ulcer prevention -Interventions included: turn ever 2hours, skin protocols, barrier cream. Observation and interview on 5/18/2022 at 2:33 PM, Resident #1 was in bed. CNA A was performing incontinent care, assisted by CNA D. CNA A had clean gloves on and the needed supplies were on the overbed table. CNA A wiped the left groin, then wiped the right groin and passed over the vagina. Resident #1was turned to her left side. CNA A wiped the perianal area from vagina to rectum and removed the feces. The dressing on the sacrum was loose and was stained brown on one edge. CNA A removed the soiled brief and placed in trash bag. CNA A touched clean brief and positioned beneath Resident #1 fastened the brief and touched gown and bed linen. CNA A then touched Resident #1's personal items on the overbed table. CNA A removed gloves and walked out of room saying she would return and would let the nurse know about the soiled dressing. CNA A said when using cleansing wipes, can be folded and use clean side to clean another area. CNA A said she would not clean from groin to vagina in order to prevent spreading infection, and that she would change gloves when they are visibly dirty. CNA A said the gloves are dirty after cleaning the resident and she should have removed them hand sanitized and put on clean gloves. CNA A said this is to prevent cross-contamination and for infection control. CNA A said she realized gloves should have been changed and hand sanitized before touching items on the bedside table because, the gloves were dirty and used when cleaning feces. CNA A said she did spread the labia and cleaned area in the beginning. Interview on 5/18/2022 at 2:53 PM the DON stated when performing incontinent care, she would hand sanitize, put on clean gloves and start with wipes, making sure not to go from back to front or reuse wipe over another area. She would hand sanitize between dirty and clean procedure. She said always hand sanitize don clean gloves and then apply barrier cream. Typically, she would teach CNAs to get another clean wipe so not to bring contaminants into the new area. This is to prevent infection. DON plan was to in-service the staff, especially the 2 CNAs who performed incontinent care for Resident #1. DON said a big in-service including incontinent care was done within the last month, so she was surprised this happened. Interview on 5/18/2022 at 3:57 PM, CNA A she didn't wash her hands before leaving Resident#1 room because she was nervous. Resident #2: Record review of Resident #2 face sheet printed on 06/02/2022 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual Minimum Data Set (MDS) resident assessment date completed on 10/22/2021 revealed Resident #2 had no speech, rarely made self-understood and usually understood others. She had long-term memory problems and her cognitive skills for daily decision making was moderately impaired. She was totally dependent on one staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. She used a wheelchair for mobility. She was always incontinent of urine and bowel. Record review of Resident #2's care plan effective date 06/24/2016 to present revealed in part; -Problems: Resident #2 is at risk for falls related to impaired mobility -Interventions included: respond promptly to calls for assistance to the toilet -Problems: Resident #2 is always incontinent of bowel movement and bladder. -Interventions included: apply moisture barrier to buttocks, check for incontinence, clean and dry skin if wet or soiled, document when incontinent, perform complete skin assessment, use pads/briefs to manage incontinence -Problems: Resident #2 is at risk for skin breakdown, related to impaired mobility and incontinence -Interventions included: check skin for redness, skin tears, pressure areas, report any signs of skin breakdown. Record review of Resident #2's June 2022 physician orders revealed an order Proactive Health Check to determine early changes in order to proactively monitor and treat as appropriate, start date 08/09/2020. Weekly head-to-toe (skin assessment), start date 02/03/2022. Observation and interview on 5/29/2022 at 6:00 PM Resident #2 was sitting in a wheelchair and visiting with family in her room. The Family said the staff did not check on her often enough. The family had been at the facility since around 3:30 PM and stated no one has come by to check her. The family stated they have in the past seen the staff change Resident #2 and put her right back into the wet chair and that was just not right. The family assisted Resident #2 to a standing position. Her pants had large dark wet stain. The pad on the wheelchair was wet. The family turned the call light on and requested staff to change Resident #2. Observation and interview on 5/29/2022 at 6:30 PM, CNA A prepared a clean work area for incontinent care for Resident #2. CNA A donned clean gloves and transferred Resident #2 from the wheelchair to the bed. She removed Resident #2's pants and unfastened the adult brief. There was a strong urine odor and the brief was supersaturated with urine. CNA A used cleansing wipe to the left groin a second wipe to the right groin. CNA A spread the labia and with a new cleansing wipe she cleansed the vulva. Resident assisted to turn onto her left side. With a clean wipe she cleansed the buttocks, perianal area. She then doffed the gloves, donned clean gloves, positioned, and secured the clean adult brief and doffed gloves. She said the pants were clean and will assist resident to put them on. Surveyor asked if the pants were wet or not. CNA A said they were not. She then donned clean gloves and closely inspected the pants and said they were wet. CNA A got dry pants from the closet and assisted the resident with putting them on. She was just about to transfer Resident #2 back into the wheelchair. The Surveyor asked about the possible wet wheelchair pad. CNA A said she usually wipes down the wheelchair. She wiped it down with clean cleansing wipes then transferred the resident into the wheelchair. CNA A gathered the garbage, left the room, and walked to the dirty utility room, she sanitized her hands using dispenser outside the dirty utility room. She said she should have sanitized between glove changes to help prevent cross contamination. Record review of Resident #2 nursing clinical notes written by LVN D on 06/03/2022 at 3:41 PM read in part .During head-to-toe skin assessment .incontinent care was provided the patient does have a foul urine odor. Waiting on new orders . Record review of Resident #2 nursing clinical notes written by LVN D on 06/08/2022 at 8:49 AM read in part .Patient's urine results are in. Her urine was cloudy and she had moderate leukocyte esterase (white blood cells in the urine indicating possible infection) .notified NP. No new orders at the time. Record review of Resident #2's nursing clinical notes written by LVN D on 06/10/2022 at 9:23 AM read in part .Per NP, patient to take [MEDICATION(S)] 100 mg via PEG BID for 7 days for [CONDITION(S)] . Resident #3: Record review of Resident #3 face sheet printed on 06/02/2022 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) resident assessment date completed on 04/25/2022 revealed Resident #3 had unclear speech, usually made self-understood and usually understood others. She was totally dependent on one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. She used a wheelchair for mobility. She was always incontinent of urine and bowel. Record review of Resident #3's care plan effective date 04/07/2022 to present, revealed in part; -Problems: Resident #3 is at risk for falls related to right sided [CONDITION(S)] (weakness from a stroke) and dementia. -Interventions included: respond promptly to calls for assistance to the toilet -Problems: Resident #3 is at risk for pressure ulcer development due to risk factors identified in the Braden Scale. -Interventions included: turn every 2 hours, skin protocols, barrier cream. Record review of Resident #3's June 2022 physician orders revealed an order Proactive Health Check to determine early changes in order to proactively monitor and treat as appropriate, start date 04/06/2022. Weekly head-to-toe (skin assessment), start date 04/06/2022. Wound treatment - Barrier cream, apply after each incontinent episode starting 05/29/2022. Observation and interview on 5/29/2022 at 7:15 PM, Resident #3's family member came to the nurse station asking CNA A to change Resident #3 as it had been several hours since anyone changed her. CNA A went into Resident #3 room and began to set up a clean work area, donned clean gloves, assisted Resident #3 to remove her pajama bottom, unfastened the brief, cleansing wipe to the left groin, folded wipe, and cleansed right groin. CNA A spread Resident #3's labia and with a clean wipe cleansed the vulva are once. CNA A turned resident to her right side. Observed the skin on buttocks to be a deep maroon color and the area on the left buttocks had a white patch. The family stated this was the start of a pressure sore. CNA A cleansed the perianal area and with a new wipe she cleansed the right buttocks circling around the white patch. CNA A cleansed the left buttocks with a fresh wipe. The family applied a cream and moisturizer. CNA A removed the gloves, washed hands at the sink in the room. CNA A donned clean gloves, positioned and secured the adult brief. She assisted Resident #3 to put on the pajama bottoms and adjusted bed linens. CNA A put away clean supplies, gathered the trash, doffed the gloves, walled out of the room to the dirty utility room. The hand sanitizer dispenser outside the dirty utility room was empty. CNA A washed hands at the sink in the small kitchenette. CNA A stated she cleansed the groin area before the vulva area because the groin is a clean area and did not want to cross contaminate from vulva to groin. CNA A stated this is how she was taught in school and did not know what the facility policy and procedure was. CNA A stated she did cleanse the white patch on Resident #3's buttocks. CNA A stated she did not hand sanitize prior to entering the resident room because she had just sanitized when she was outside the dirty utility room. She stated sometimes there would not be any soap in the resident bathrooms, so she sanitizes her hands after taking the trash to the dirty utility room. Interview on 5/29/2022 at 8:00 PM, LVN D stated hand hygiene is always done prior to entering the resident room for infection control and she expected the nursing staff to do this. She said she would work from the groin to one side of the vulva and then the other side of the vulva with a new cleansing wipe each time. When done cleaning the front area she would perform hand hygiene, don clean gloves, and then clean the perianal area from front to back. With a new wipe she would clean the buttocks and surrounding skin. She would doff gloves, wash hands, don clean gloves then position the clean brief and bed linens. She would wash hands, gather trash, use a glove to touch trash and carry to the dirty utility room then sanitize hands. Interview on 6/02/2022 at 12:45 PM, LVN D stated barrier cream should be applied after each incontinent episode for preventative measure to serve as a barrier to protect skin from breakdown. She stated that residents should be checked for incontinence typically every 2 hours depending on the resident. It works out to every hour when the nurses are also checking every 2 hours. She stated the reason for performing hand hygiene during incontinent care, between glove changes, before starting the care and before exiting the resident room is to help prevent the spread of infection. She stated she tries to educate the night staff about cleaning dirty or wet wheelchairs and when the resident is visibly soiled if the pants are soaked. Therapy or central supply inspect the cushions if soiled. LVN D did not state how often cushions were inspected by therapy or central supply. It could cause wounds or skin breakdown if a resident remains seated in wet clothes and cushions. If severe enough the resident should shower or have a bed bath. Redness to the skin on a resident's buttocks could be from sitting in urine or fecal matter and some people's skin are easily irritated. Resident #4: Record review of Resident #4's face sheet printed on 5/19/2022 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) resident assessment date completed on 05/05/2022 revealed Resident #4 had a BIMS score of 14 indicating her cognition was intact. She required extensive assistance with one person for bed mobility, transfers, dressing, toilet use and personal hygiene. She used a wheelchair for mobility. She had a urinary catheter, and she was always incontinent of bowel. Record review of Resident #4's care plan effective date 04/28/2022 to present, revealed in part; -Problems: Resident #4 requires extensive assistance to total assistance with ADLs and functional mobility. -Interventions included: set-up, assist, give shower, shave, oral, hair, nail care on schedule and as needed. -Problems: Resident #4 is at risk for skin breakdown related to incontinence, impaired mobility, fragile skin, diabetes. -Interventions included: Monitor for incontinence every 2 hours and as needed, change promptly, apply moisturizing lotion, monitor for skin breakdown and report to MD, assess skin weekly and record findings, turn, and reposition every 2 hours, use non-irritating soaps -Problems: Resident #4 stage 2 pressure ulcer to buttocks. -Interventions included: check for incontinence, clean and dry skin if wet or soiled, perform complete skin assessment and record, provide care according to the protocol for stage 1 pressure ulcer -Problems: Resident #4 was totally dependent on the staff. -Interventions included: bathe/shower 3 times a weekly. -Problems: Resident #4 was always incontinent of bowel movement. -Interventions included: apply moisture barrier to buttocks, document when incontinent. -Problems: Resident #4 has history of [CONDITION(S)] within the last 30days (effective 5/18/2022) -Interventions included: monitor for burning/painful urination. -Problems: Resident #4 is at risk of pressure ulcer related to history of pressure ulcers/impaired mobility. -Interventions included: check skin for redness, skin tears, swelling or pressure areas. Report any signs of skin breakdown -Problems: Resident #4 is at risk for infection related to indwelling catheter -Interventions included: clean around catheter with soap and water or may use wipes as appropriate/desired by patient; keep tubing below level of bladder and fee of kinks or twists; report any signs of infection, wash hands before and after procedure. Interview on 5/19/2022 at 11:15 AM, Resident #4 was lying in bed on her back. She was alert, oriented and said she always has back pain. She prefers to have bed baths right now due to back pain. She was wearing adult brief and foley catheter was hanging of the side of the bed below the resident. There was yellow urine in the tubing and bag She had been very itchy in the perineal area and gets sores when sitting in feces for hours. She said she was changed before 8:30 AM. She stated this has been an issue of not receiving a thorough clean up ever. She stated she had a bath on Monday and thinks she is supposed to get them weekly. Observation on 5/19/2022 at 11:32 AM, with the help of CNA C, Resident #4's skin was observed. The entire perineal area: groin folds, labia area, extending to the buttocks was a diffused deep red color. There were multiple scattered red bumps along abdominal folds, left hip, buttocks, and groin area. The left upper outer hip had a long bright red, shiny area where the elastic of the brief contacts the skin. The foley catheter was secured onto the right thigh with a stat lock secure device. Interview on 5/19/2022 at 1:00 PM, Resident #4 stated prior to admitting to the facility she did not have any redness or itching. The itching started about one week ago. Prior to Monday's bath she had not had a bath for 3 weeks. Interview on 6/02/2022 at 3:00 PM, LVN D stated she did a head-to- toe skin assessment on Resident #4 on 5/19/2022 after Surveyor assessed Resident #4's skin. LVN D was unable to recall anything else about the resident's skin condition other than a wound to the right buttocks that had a dressing. LVN D noted on a body form drawing that Resident #4 had discoloration to the left arm, a foley catheter and wound on the right buttocks. LVN D's assessment of Resident #4's skin condition was unlike the Surveyor's assessment. Record review of Resident #4 nursing clinical notes dated 6/04/2022 at 12:48 PM and written by LVN E read in part: The family .requested that Resident #4 be sent to the hospital because her [CONDITION(S)] has worsened .orders received to send the resident to the ER for evaluation and treatment . Record review of Resident #4's hospital records dated 6/04/2022 at 7:43 PM read in part .the resident was admitted to the ICU with suspected [CONDITION(S)] . Record review of Resident #4's hospital MD progress note dated 06/09/2022 at 1:37 PM read in part .1. Altered mental status . acute metabolic [CONDITION(S)] likely due to urinary tract infection .4. Complicated [CONDITION(S)], due to chronic indwelling Foley catheter, urine culture positive for [CONDITION(S)] pneumonia, ESBL and E. coli . Record review of Resident #4 hospital discharge papers indicated she was transferred back to the facility on [DATE]. Observation on 6/15/2022 at 2:10 PM of incontinent care for Resident #4. There was a very strong odor in the room. There was no PPE cart or contact isolation signage. The resident was awake and slightly confused. CNA B assembled clean supplies on the bedside table, donned clean gloves and explained to the resident that she was going to clean her up. The foley bag had 350cc of amber urine. The bag was dated 6/15/22. CNA B moved the foley bag and placed it on top of the bed sheet to the right of the resident's legs. She unfastened the brief. Resident #4's groin, labia, entire perineal area had widespread redness. There were faded red spots beneath the abdominal pannus. Both hip areas were clear with small amounts of flaky skin. CNA B cleanses the right groin with a wipe, folded the wipe and cleansed the left groin. She assisted the resident to roll to the right side in order to change the bed linen. She removed the linen and replaced with clean linen. CNA B removed the soiled brief. The brief had serosanguineous drainage. She placed in the trash bag. Resident #4's skin on her bottom had areas that were open and bleeding. There was no dressing. The surrounding skin was red, excoriated, widespread from vagina, across buttocks and up to lower lumbar region. The edges of the red area on lower back was dry and flaky. RN A entered the room with a measuring hat, box of clean gloves and privacy cover for the foley bag then left the room. CNA E entered room and assisted. CNA E washed hands at the bathroom sink and donned clean gloves and assisted by keeping the resident turned to her right side. CNA B cleaned the perianal area with a wipe starting from front to back, folded the wipe and cleansed the perianal area again, there was some stool, folded and wiped the sacral area. CNA B removed gloves and donned clean gloves. The foley catheter anchoring device was wrapped and stuck around the foley catheter very close to the vagina area. CNA E gently removed the adhesive anchor device. The resident said ouch once. CNA B used one wipe to cleanse the lower vagina region moving from front to back, folded the wipe and cleansed the same area again. The resident said ow, you don't listen. With the same gloves CNA B applied the [MEDICATION(S)] lotion to the buttocks and lower lumbar region then removed the gloves. CNA B started to don a new pair of gloves when CNA E reminded she needed to wash her hands first. CNA B washed her hands at the bathroom sink. CNA B donned clean gloves, positioned the clean brief under the resident and turned resident onto her back. There was white substance visible in the folds of the vagina. The foley bag was moved to the left side of the resident on the bed. The resident was turned to her left side. Red excoriated skin was visible on right buttocks and lumbar region. CNA B applied [MEDICATION(S)] cream to inside groin areas and skin over the vulva. She removed gloves, washed hands, donned new gloves. Without first spreading the labia, CNA B cleaned the foley catheter, starting from the patient outward with a cleansing wipe. She then secured the brief: opened brief again, repositioned the catheter and secured brief again. CNA B removed Resident #4 soiled gown and dressed the resident in a clean gown. The resident was turned to her left side a wedge placed under her back and linen adjusted. The foley tubing and bag was hung on bed frame to the left and below the resident then CNA B removed gloves. Foley bag had approximately 700cc urine. Interview on 6/15/2022 at 3:00 PM CNA B stated she was taught to fold the wipes and use a second time, by the State and that this was facility policy. When asked why she did not spread the labia and clean within the folds, she stated she did spread the labia and wiped inside. When asked why she applied cream before cleaning the catheter she stated she did not want to get cream onto the catheter. When asked why she did not sanitize hands between glove changes she stated she did wash her hands three times and the reason for hand washing or hand sanitizing was for infection control. When asked, what did she do to prevent urine from backing up into the resident and help prevent a [CONDITION(S)] she stated she made sure to straighten the catheter and tubing prior to placing it on the bed. CNA B said she planned to empty but will need alcohol pad first. She said she would notify the nurse that Resident #4 will need a new anchor device for the foley catheter. Interview on 6/15/2022 at 4:22 PM, the DON was notified of Resident #4's incontinent care performed by CNA B. DON stated during peri care she preferred to use one cleansing wipe per area. She expects the nursing staff to hook the foley bag to the same side of the bed the resident is turned to so not to cross over the leg during incontinent care. The foley bag is always positioned below the patient to prevent backflow of urine and prevent infection. The foley bag and tubing should never be placed on the bed due to the risk of urine backflow into the resident. She stated to prevent infection, hand sanitizing is performed after changing gloves, any time the gloves are visibly soiled, when entering and exiting a resident room, after removing the soiled brief and prior to and after applying barrier cream. The stat lock is used all the time to prevent tugging of the foley catheter, to maintain position, to avoid trauma which could lead to pain. LVN D is responsible for checking microorganisms and isolation depends on the microorganism and resistance to antibiotics. She stated everyone can report signs and symptoms of urinary infection such as burning, frequency, discoloration, nausea, and odors. The DON stated she will start in-services specifically covering UTIs and that spot checks are done by the nurses to watch how the CNAs are performing incontinent care. She stated spot checks will need to be done daily. Interview on 6/16/2022 at 2:00 PM, the Regional Clinical Services Director stated Resident #4 did readmit with a [CONDITION(S)]. Contact isolation is used for residents with C-diff or multidrug resistant bacteria ESBL (extended spectrum beta-lactamase) for example. Resident #4 will be put into contact isolation right away because of the ESBL in her urine. The Regional Clinical Service Director also said he would have to research regarding the discrepancies on the weekly skin assessment descriptions, that the facility was aware the wounds are not descriptive and had hired a new wound care nurse. Interview on 6/16/2022 at 2:00 PM the Administrator stated he spoke with CNA B after performing incontinent care for Resident #4 on 6/15/2022 at 2:00 PM and said that CNA B did use gloves when emptying the foley bag. Record review of the facility policy and procedure titled Catheter Care, Cantex Continuing Care Network, updated March 2019 read in part: Responsibility - Licensed Nurse and Nursing Assistant. Purpose - To prevent infection and to reduce irritation Procedure - wash your hands, gather equipment, and take to bedside .put on gloves, cleanse perineal area with warm wash towel. Wash perineum well with soap and warm water, taking care to wash from front to back. May use wipes in place of soap and water .Cleanse area at catheter insertion well .pat dry gently with clean towel .discard disposable equipment properly. Ensure leg strap in place to secure tubing .wash your hands . Record review of the facility policy and procedure titled Handwashing, Cantex Continuing Care Network, revised March 2019 read in part: Guidelines, Standards of Practice/Hand washing - Hand washing is the single most important means of preventing the spread of infection After Patient contact wash hands with soap and running water May use hand sanitizing gel in place of soap and water. Record review of facility policy and procedure titled Perineal Care Protocol, Cantex Continuing Care Network, February 2022 read in part: .Cleansing the perineal area between showers or baths help prevent irritation, infection and skin breakdown as well as keeping the patient comfortable Assemble equipment and supplies on bedside .will need .hand sanitizer .Wash hands; apply gloves .remove soiled clothing and/or brief, if needed clean soiled areas first by wiping off fecal material with wipes. Remove gloves, sanitize hands, and apply new gloves Using a new wipe, wash, beginning from center of abdomen, and clean outwards from front to side separate labia with hand to expose urethral meatus. Use one stroke method to clean front to back. Wash labia major and skin folds Using a wipe, cleanse the inside of the first groin area then get a new wipe and cleanse the other groin area .Ask patient .assume side lying position .Using a new wipe, wash from vagina toward rectum with one stroke, front to back, repeat if necessary with a wipe as all feces must be cleaned off. With new wipe, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock. Wash/sanitize hands. Apply clean gloves .Report any skin concerns to Charge Nurse . Record review of CNA A's staff competency check list for incontinent care dated 4/26/2022 and CNA B's staff competency check list for incontinent care dated 5/20/2022, read in part: .3. Assemble equipment and supplies on bedside .4. Wash hands and apply gloves .6. Assist patient to supine position and remove soiled clothing and/or brief .7. Remove gloves, sanitize hands, and apply new gloves .Female Perineal Care .2. Wash, beginning from center of abdomen and clean outwards from front to side. Use new wipe per area .3. Wash from front towards rectum .using clean stroke. Never wipe back and forth from the back to the top .4. Separate labia with and to expose urethral meatus. Use one stroke method to clean front to back. 5. Wash labia major and skin folds 6. Cleanse inside of the first groin area downward from top to bottom, then get a new wipe and cleanse the other groin area .7. If catheter present, stabilize the catheter, then gently wipe the catheter tubing with new wipe from the meatus outward .10. With new wipe, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock .11. Wash/sanitize hands. Apply clean gloves 12. Position brief under patient. Apply barrier cream to perineal and buttock area .fasten clean brief .13 wash hands. Record review of the facility policy and procedure titled Quick Reference for isolation Precautions, Cantex Continuing Care Network, Revised March 2019 read in part: .Contact Precautions, In addition to Standard Precautions, Use Contact Precautions for Patients known or suspected to have serious illnesses easily transmitted by direct Patient contact or by contact with items in the Patient's environment. Examples of such illnesses include: .skin, wound infections or colonization with multidrug-resistant bacteria by the infection control program, based on current state, regional or national recommendations, to be of special clinical and epidemiologic si [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for 5 of 6 residents (Resident #2, #4, #9, Anonymous and CR #1) reviewed for ADLs. 1. The facility failed to provide incontinent care for Resident #2 for more than 2 hours. Resident #2's brief was saturated with urine and soaked through her pants and onto the pad of the wheelchair. 2. The facility failed to provide showers to Resident #4, Resident #9, Anonymous, and CR #1, in compliance with the shower schedule. This deficient practice could place residents at risk of a decline in their sense of well-being, level of satisfaction with life, at risk for skin breakdown and infection. Findings include: Resident #2: Record review of Resident #2 face sheet printed on 06/02/2022 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual Minimum Data Set (MDS) resident assessment date completed on 10/22/2021 revealed Resident #2 had no speech, rarely made self-understood and usually understood others. She had long-term memory problems and her cognitive skills for daily decision making was moderately impaired. She was totally dependent on one staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. She used a wheelchair for mobility. She was always incontinent of urine and bowel. Record review of Resident #2's care plan effective date 06/24/2016 to present revealed in part; -Problems: Resident #2 is at risk for falls related to impaired mobility -Interventions included: respond promptly to calls for assistance to the toilet -Problems: Resident #2 is always incontinent of bowel movement and bladder. -Interventions included: apply moisture barrier to buttocks, check for incontinence, clean and dry skin if wet or soiled, document when incontinent, perform complete skin assessment, use pads/briefs to manage incontinence -Problems: Resident #2 is at risk for skin breakdown, related to impaired mobility and incontinence -Interventions included: check skin for redness, skin tears, pressure areas, report any signs of skin breakdown. Observation and interview on 5/29/2022 at 5:30 PM Resident#2 sitting in a wheelchair, in her room and visiting with family. Resident #2 was alert and non-verbal. The family stated the staff did not check on her often enough. The family had been at the facility since around 3:30 PM and stated no one has come by to check her. The family stated they have seen the staff change Resident #2 and put her right back into the wet chair and that was just not right. The family then assisted Resident #2 to a standing position. Her pants had a large dark wet stain. The family stated the pad on the wheelchair was also wet. The family turned the call light on and requested staff to change Resident #2. Observation and interview on 5/29/2022 at 6:30 PM CNA A removed Resident #2's pants, unfastened the adult brief. There was a strong urine odor, and the brief was saturated with yellow urine. After incontinent care, CNA said the pants were clean and ready to put back on the resident. The Surveyor asked if the pants were wet or not. CNA A looked closer and said they were wet. After Resident #2 was dressed, with clean dry pants, CNA A was just about to transfer Resident #2 back into the wheelchair. The Surveyor asked about the possible wet wheelchair pad. CNA A said she should and would usually wipe down the wheelchair. Then she wiped it down with clean cleansing wipes and transferred the resident into the wheelchair. CNA A stated Resident #2's skin was red and was probably from sitting a long time. Interview on 6/02/2022 at 12:45 PM, LVN D stated residents should be checked for incontinence typically every 2 hours, depending on the resident. It worked out to every hour when the nurses also check every 2 hours. LVN D stated wheelchairs are cleaned on the night shift. She stated she thought she had educated the night staff about cleaning dirty or wet wheelchairs as well as when the resident is visibly soiled and if the pants are soaked. Therapy or central supply inspect the cushions if soiled. LVN D did not state how often cushions were inspected by therapy or central supply. It could cause wounds or skin breakdown if a resident remains seated in wet clothes and cushions. If severe enough, the resident should shower or have a bed bath. Redness to the skin on a resident's buttocks could be from sitting in urine or fecal matter and some people's skin are easily irritated. Resident #4: Record review of Resident #4's face sheet printed on 5/19/2022 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) resident assessment date completed on 05/05/2022 revealed Resident #4 had a BIMS score of 14 indicating her cognition was intact. She required extensive assistance with one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of Resident #4's care plan effective date 04/28/2022 to present, revealed in part; -Problems: Resident #4 requires extensive assistance to total assistance with ADLs and functional mobility. -Interventions included: set-up, assist, give shower, shave, oral, hair, nail care on schedule and as needed. -Problems: Resident #4 was totally dependent on the staff. -Interventions included: bathe/shower 3 times a weekly. Record review of facility's shower schedule indicated Resident #4 was scheduled for showers every Tuesdays, Thursdays, and Saturdays at 6:00 AM to 2:00 PM. Record review of Resident #4's ADL Verification Worksheet for dates 4/26/2022 to 5/19/2022 revealed the resident received bathing on 5/06/2022, 5/09/2022 and 5/16/2022. Observation and interview on 5/19/2022 at 11:15 AM, Resident #4 was lying in bed on her back. She was alert, oriented and said she always had back pain, she preferred to have bed baths instead of showers at that time. She had been very itchy in the perineal area and got sores when sitting in feces for hours. She stated she never had itching or redness prior to admission to the facility. She stated she had a bath on Monday 5/16/2022 and thought she was supposed to get them only weekly. She was unaware of the three times per week shower schedule. Interview on 5/19/2022 at 1:00 PM, Resident #4 stated, prior to admitting to the facility, she did not have any redness or itching. The itching started about one week ago. She stated prior to Monday's (5/16/2022) bath she had not been offered a bath for 3 weeks. She preferred to not have waited for 3 weeks before getting a bath. Observation on 5/19/2022 at 11:32 AM, with assistance from CNA C, Resident #4's skin was assessed. Resident #4's entire perineal area: groin folds, labia area, extending to the buttocks was a diffused deep red color. There were multiple scattered red bumps along abdominal folds, left hip, buttocks, and groin area. The left upper, outer hip had a long bright red, shiny raw area where the elastic of the brief contacted the skin. Interview and record review on 06/02/2022 at 3:00 PM, LVN D stated she conducted a head-to-toe skin assessment on 5/19/2022 after the Surveyor visited Resident #4. LVN D stated Resident #4 had a dressing over a wound to the right buttocks and was unable to recall anything else about the skin. LVN D noted on a body form drawing that Resident #4 had discoloration to the left arm, a foley catheter and wound on the right buttocks. LVN D's assessment of Resident #4's skin condition was unlike the Surveyor's assessment. Record review of Resident #4's clinical notes dated 05/19/2022 at 5:33 PM written by LVN D read in part: .performed head to toe skin assessment. Patient has a wound to her right buttocks. In addition, she has some scattered bruises to her upper extremities . Resident #9: Record review of Resident #9's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's quarterly Minimum Data Set (MDS) resident assessment completed on date 03/22/2022 revealed a BIMS score of 14 indicating she was cognitively intact. She required limited assistance of one staff for bed mobility, transfers, locomotion both on and off the unit; dressing, toilet use and personal hygiene. She used a wheelchair for mobility. Record review of the facility shower schedule indicated Resident #9 was scheduled Mondays, Wednesday, and Fridays from 2:00 PM to 10:00 PM. Record review of Resident #9's ADL Verification Worksheet for Bathing on dates 3/30/2022 to 4/26/2022, printed on 5/19/2022 at 10:27 AM revealed inconsistencies compared to ADL Verification Worksheet for Bathing on same date range of 3/30/2022 to 4/26/2022, printed on 4/27/2022 at 12:10 PM. The worksheet printed on 5/19/2022 indicated that on 04/05/2022 at 5:03 AM the resident was bathed, at 12:59 PM the resident was not bathed, and at 5:14 PM the resident was bathed. The worksheet printed on 4/27/2022 indicated on 04/05/2022 at 5:03 AM, 12:57 PM and 5:12 PM the bathing did not occur. The worksheet printed on 4/27/2022 indicated care was provided for showers or bed baths on all dates except for 4/05/2022, 4/15/22, 4/17/22, 4/18/22 and 4/26/22. This information did not match the information on the worksheet printed on 5/19/2022. Record review of Resident #9's Skin Monitoring: Comprehensive CNA Shower Review sheets revealed showers were given on 2/14/22, 2/21/2022 and 3/14/2022. There were no other shower sheets for Resident #9. In an interview on 4/27/2022 at 10:20 AM, Resident #9 stated her skin had been itchy and she never experienced this before. She said it may be due to staying in wet briefs for a long time and not getting showers. She stated she had to ask for medication for the itching in the middle of the night so she could sleep. At home she would shower every night. On Monday mornings, she would start asking about showers. She told the staff she would like a shower anytime it was available and would be lucky to get one shower a week. In an interview on 4/27/2022 at 11:20 AM, LVN F stated she ensured residents received showers by checking in with the residents and a shower schedule is located at each nurses' station that nursing staff should be following. The residents should get showers three times a week. In an observation and interview on 04/27/2022 at 11:33 AM, Resident #9 was helped to the toilet by LVN H. Resident #9's skin on her buttocks was pink. Resident #9 stated the area that itched the most was her front and skin folds where the pull-ups contact the skin. In an interview on 4/27/2022 at 11:40 AM, LVN H stated she had a list of scheduled showers and this is how she knew who needed them. She stated the frequency of showers/baths depends on the resident condition and she ensured residents received their showers/baths by rounding and talking with the CNAs. LVN H did not state how often per week residents were scheduled for showers/baths. LVN H stated she was aware Resident #9 had orders for itch medication that she had been receiving this. In an interview on 4/28/2022 at 11:57 AM, CNA G stated shower sheets were supposed to be filled out every shower day. The CNA's responsibilities was to sign the sheet, notify the nurse then the nurse will talk with the resident if they refuse. Resident #9 was limited assistance with showers, incontinent care should be on another screen on the computer and not documented under bathing. The questions in the bathing section in Resident #9's chart may not be answered correctly. Anonymous: In an interview and observation during the investigation, Anonymous stated, the changing of adult briefs was done timely during the day but not at night. At night, the adult brief would be totally soaked. Anonymous was, swimming in it and sometimes they won't come for a very long time to change the brief. They don't do a thorough job cleaning either. Other times all they do is change the wet brief and not wash the skin. Anonymous stated their private areas had been very itchy. Red scratch marks were present on the right thigh. Bilateral inner groin and inner thighs had large areas of diffused (spread over a wide area) reddish-brown skin. The right buttocks had red area at the gluteal cleft. Flakes of white substance was clinging to the skin. Record review of the Bathing ADL Verification Worksheet for Anonymous revealed there were only two days during the month of May 2022 that bathing was provided in a 10-day period. Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 06/16/2022 at 2:00 PM, the Regional Director of Clinical Services stated if the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 4/28/2022 at 12:20 PM, the DON stated residents were given showers/baths three times per week. The use of shower sheets was new and was intended to catch skin issues. She stated she did not know exactly when the use of shower sheets began. The DON stated she was aware if residents were receiving showers three times a week or not when doing rounds and during report. During rounds and report she expected the nurses to question the CNAs about any skin issues noted during resident care and of any refusals to bathe. She stated the plan was for CNAs to be in-serviced on ADL documentation in the computer becauseaccuracy was a problem. She stated the aides may have clicked through the sections very quickly without reading and there were many new staff in orientation who were not familiar with documentation. CR #1: Record review of CR#1's face sheet printed on 5/19/2022 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on 4/29/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1 admission Minimum Data Set (MDS) resident assessment completed on date 4/07/2022 revealed CR#1 had a BIMS score of 6 indicating she had severe cognitive impairment. She had clear speech, had the ability to make self-understood and had the ability to understand others. CR#1 required extensive assistance of two staff for her bed mobility and toilet use. The resident required extensive assistance of one staff for transfers and dressing. The resident required limited assistance from one staff for walking and personal hygiene. The resident used a walker or wheelchair. The resident was always incontinent of bowel and always incontinent of urine. The resident was at risk of developing pressure ulcers or skin injuries. The resident had a surgical wound and required wound care. Record review of CR#1's care plan effective 3/24/22 revealed in part: -Problems: CR#1 was diabetic and at risk for frequent infections. -Interventions included: Monitor skin for changes, redness, circulatory problems, breakdown and report to MD and RP -Problems: CR #1required the use of an Ostomy as evidenced by a [CONDITION(S)]. -Interventions included: provide ostomy care; monitor site for swelling, pain, redness. -Problems: CR#1 had current skin concerns: excoriation (stripped of skin) to sacral area, effective date 4/26/2022. -Interventions included: incontinent care; turn and reposition; perform treatments per order, if no improvement in 2 weeks then report to MD; monitor areas for increased breakdown, s/s of infection and report to MD .keep MD and RP. -Problems: CR#1 required extensive assistance for toileting, effective date 4/7/2022. -Interventions included: provide hygiene after voiding/bowel movements to prevent skin breakdown. Apply moisture barriers; select clothing easily removed and change incontinence pad/brief. -Problems: CR#1 is always incontinent of bowel movement (no episodes of continent bowel movements) -Interventions included: Apply moisture barrier to buttocks; check for incontinence-clean and dry skin if wet or soiled; document when CR#1 is incontinent; perform complete assessment of skin and note areas of redness; use pads/briefs to manage incontinence. -Problems: Urinary continence - CR#1 is always incontinent. -Interventions included: Apply moisture barrier to buttocks; check for incontinence-clean and dry skin if wet or soiled; document when CR#1 is incontinent; perform complete assessment of skin and note areas of redness; use pads/briefs to manage incontinence; check for incontinence and change if wet/soiled; clean skin with mild soap and water; apply moisture barrier; check skin for areas of redness and report any changes to the nurse. Turn/reposition. Use pads/briefs to manage incontinence. -Problems: CR#1 is at risk of pressure ulcer. - Interventions included: Check skin for redness, skin tears, swelling or pressure areas. Report any signs of skin breakdown. Use pillows, pads, or wedges to reduce pressure on heals and pressure points. Turn/reposition. Do not massage skin over pressure areas. -Problems: CR#1 was on antibiotics and at risk for adverse reactions to IV [MEDICATION(S)] x 14 days, effective 3/24/22 - 4/26/2022. -Interventions included: Monitor resident for adverse reactions specific to the medication. Follow universal/standard precaution to prevent cross contamination and spread of infection. -Problems: CR#1's ADL functions: extensive assist with ADLs and functional mobility. -Interventions included: set-up assistance: give shower, shave, oral, hair, nail care on schedule and PRN. Record review of CR #1's ADL verification worksheet for bathing revealed between 3/23/2022 and 4/29/2022, CR#1 was bathed 4 times: 4/12/2022, 4/18/2022, 4/26/2022 and 4/28/2022. In an interview on 5/26/2022 at 1:15 PM the first hospital nurse stated that on 4/30/2022 at approximately 1:53 AM, CR#1's was received on her unit. She conducted a full body assessment. The sacrum had a pressure ulcer, multiple skin tears and bruises. The nurse stated the family was concerned. The second hospital nurse stated she also saw CR#1 in the morning of Saturday 4/30/2022 and gave CR#1 a bath. The pressure ulcer was at least a stage 2. There was large excoriation up her back side, groin, and thigh. The wounds were red, very excoriated over the entire buttocks area, including folds of thigh, groin, and labia. The TV remote was found on CR#1's back under her clothing. The family was looking for the remote the previous Tuesday or Wednesday. The second nurse said she assumed the patient had not been changed at the facility. The patient had a skin tear to the right hip fold crease. This area was red and raw and the scabs were red. The first hospital nurse confirmed that on 4/30/2022 at 10:00 AM or 11:00 AM, she was with CR#1 when the family took pictures of CR#1's skin. The second hospital nurse said CR#1 had a [CONDITION(S)] and the urine was orange and fuzzy. An external female catheter with low suction was used to collect urine in a clear canister by the bedside. The first hospital nurse stated CR#1 was not making urine at first. Then IV fluids were started, and the urine output increased. The sacral pressure ulcer was weeping. The first hospital nurse and the hospital quality director stated the skin condition of CR#1 could be caused by lack of turning, not keeping the skin clean, poor hygiene, poor nutritional support, not washing the skin, not using skin barrier cream, wearing adult briefs versus leaving open to air and all of these could possibly lead to moisture associated skin disorder. If the patient had a [CONDITION(S)] then it would be possible that the urine could cause a fungal skin infection. The hospital patient safety specialist stated the pressure ulcer had yellow slough and therefore was unstageable. The first and second hospital nurse confirmed the body skin assessment drawing tool used was the correct description of CR#1's condition. They stated the skin tool was signed by two nurses and used when entering data into the electronic health records. The nurse stated lab results indicated pseudomonas in the urine. Interview on 6/16/2022 at 2:00 PM, the Regional Clinical Services Director stated he would have to research regarding the discrepancies on the weekly skin assessment descriptions, that the facility was aware the wounds are not descriptive and had hired a new wound care nurse. Record review of the facility's policy and procedure titled Activities of Daily Living, Cantex Continuing Care Network, March 2013 read in part: 1. Every effort must be made to assure that assignments of nurses and nurse aides to Patients are as consistent as possible. 2. A Daily Care Guide must be prepared from the electronic medical record (EMR) to assist direct care staff in providing assistance to Patients in their activities of daily living. The Daily Care guide for each Patient must be updated at least on admission, readmission and upon any change in condition affecting activities of daily living Record review of the facility's policy and procedure titled Bath-Bed-Shower, Cantex Continuing Care Network, March 2013 read in part: Responsibility-Licensed Nurse and Nursing Assistant. Purpose-To cleanse, refresh, and soothe the patient, to stimulate circulation and to inspect the body . Record review of facility policy and procedure titled Perineal Care Protocol, Cantex Continuing Care Network, February 2022 read in part: .Cleansing the perineal area between showers or baths help prevent irritation, infection and skin breakdown as well as keeping the patient comfortable

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan and the residents' choices for 2 of 10 residents (CR #1 and Resident #8) reviewed for quality of care. 1. The facility failed to properly identify a change in condition for CR#1 who developed [CONDITION(S)] to skin secondary to a fungal infection. 2. The facility failed to timely transport Resident #8 to the hospital following a fall that resulted in a right humeral neck (the top of the upper arm bone at the shoulder joint) fracture. This failure could place residents at risk for unidentified changes in condition, delay of treatment, infection, decline in health and hospitalization . Findings Include: CR #1 Record review of CR#1's face sheet printed on 5/19/2022 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on 4/29/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1 admission Minimum Data Set (MDS) resident assessment completed on 4/07/2022 revealed CR#1 had a BIMS score of 6 indicating she had severe cognitive impairment. She had clear speech, had the ability to make self-understood and had the ability to understand others. CR#1 required extensive assistance of two staff for her bed mobility and toilet use. The resident required extensive assistance of one staff for transfers and dressing. The resident required limited assistance from one staff for walking and personal hygiene. The resident used a walker or wheelchair. The resident was always incontinent of bowel and always incontinent of urine. The resident was at risk of developing pressure ulcers or skin injuries. The resident had a surgical wound and required wound care. Record review of CR#1's care plan effective 3/24/22 revealed in part: -Problems: CR#1 was diabetic and at risk for frequent infections. -Interventions included: Monitor skin for changes, redness, circulatory problems, breakdown and report to MD and RP -Problems: CR #1required the use of an Ostomy as evidenced by a [CONDITION(S)]. -Interventions included: provide ostomy care; monitor site for swelling, pain, redness. -Problems: CR#1 had current skin concerns: excoriation (stripped of skin) to sacral area, effective date 4/26/2022. -Interventions included: incontinent care; turn and reposition; perform treatments per order, if no improvement in 2 weeks then report to MD; monitor areas for increased breakdown, s/s of infection and report to MD .keep MD and RP. -Problems: CR#1 required extensive assistance for toileting, effective date 4/7/2022. -Interventions included: provide hygiene after voiding/bowel movements to prevent skin breakdown. Apply moisture barriers; select clothing easily removed and change incontinence pad/brief. -Problems: CR#1 is always incontinent of bowel movement (no episodes of continent bowel movements) -Interventions included: Apply moisture barrier to buttocks; check for incontinence-clean and dry skin if wet or soiled; document when CR#1 is incontinent; perform complete assessment of skin and note areas of redness; use pads/briefs to manage incontinence. -Problems: Urinary continence - CR#1 is always incontinent. -Interventions included: Apply moisture barrier to buttocks; check for incontinence-clean and dry skin if wet or soiled; document when CR#1 is incontinent; perform complete assessment of skin and note areas of redness; use pads/briefs to manage incontinence; check for incontinence and change if wet/soiled; clean skin with mild soap and water; apply moisture barrier; check skin for areas of redness and report any changes to the nurse. Turn/reposition. Use pads/briefs to manage incontinence. -Problems: CR#1 is at risk of pressure ulcer. - Interventions included: Check skin for redness, skin tears, swelling or pressure areas. Report any signs of skin breakdown. Use pillows, pads, or wedges to reduce pressure on heals and pressure points. Turn/reposition. Do not massage skin over pressure areas. -Problems: CR#1 was on antibiotics and at risk for adverse reactions to IV [MEDICATION(S)] x 14 days, effective 3/24/22 - 4/26/2022. -Interventions included: Monitor resident for adverse reactions specific to the medication. Follow universal/standard precaution to prevent cross contamination and spread of infection. -Problems: CR#1's ADL functions: extensive assist with ADLs and functional mobility. -Interventions included: set-up, assist, give shower, shave, oral, hair, nail care schedule and PRN. Record review of CR#1's April 2022 physician orders revealed, in part; an order to apply moisturizer cream: apply skin barrier to sacrum every day until resolved, start date 3/23/2022. Weekly head-to-toe assessments once a week starting 3/24/2022. Order to discontinue the foley catheter on date 4/6/2022. Wound treatment-[MEDICATION(S)] 3 times a daily; cleanse sacrum may use wipes and apply barrier cream until redness resolves starting 4/13/2022. Apply [MEDICATION(S)] to inner thighs for preventative treatment once a day starting 4/16/2022. Wound treatment - collagen once daily: clean sacrum with normal saline, pat dry, apply collagen and cover with dry dressing starting on 4/27/2022. Record review of hospital records revealed on 3/22/2022 at 4:24 AM prior to admission to the facility on [DATE], CR#1 had a stage 2 pressure injury to the sacrum. Record review of CR#1's nursing note dated 3/23/2022 at 3:35 PM written by LVN B revealed in part .an admission skin assessment, .Multiple bruises also on bilateral lower legs, different stages of healing, [CONDITION(S)] site to the left side of abdomen. Drainage tubes to the left upper and mid lower abdomen .PICC line to the inner right arm .Sacrum has peeling and red area . Record review of CR#1's nursing note dated 03/24/2022 at 2:30 PM, LVN A wrote in part .resident has a stage 2 sacral wound . Record review of CR#1's wound assessment dated [DATE] (no time) written by LVN C revealed a non-pressure-moisture associated skin damage(excoriation) located on the sacrum was identified in-house and the date of onset was 4/12/2022. It was 4 x 4 cm in length and width. There was scant amount of exudate (drainage). The exudate was described as serosanguineous (composed of red blood cells and serous fluid). Surrounding skin color was bright red. The wound appearance was redness. The surrounding tissue had maceration (oversaturation of skin due to prolonged exposure to moisture). Treatments: barrier cream. Record review of CR#1's wound assessment dated [DATE] (no time) written by LVN C revealed a non-pressure-moisture associated skin damage (excoriation) located on the sacrum was identified in-house on 4/12/2022. It was 3.5 x 3 cm in length and width. Surrounding skin color was bright red. The wound's appearance was redness. Treatments: barrier cream. Record review of CR#1's wound assessment dated [DATE] (no time) written by LVN C revealed a non-pressure-moisture associated skin damage (excoriation) located on the sacrum was identified in-house on 4/12/2022. It was 3.5 x 4 cm in length and width. There was small amount of exudate. Surrounding skin color was bright red. The wound appearance was redness. The surrounding tissue had maceration. Further investigation of wound care notes revealed there were no assessments related to the multiple bruising to the lower legs mentioned in the 3/22/2022 admission skin assessment nursing notes. Record review of the 2022 weekly head to toe skin assessments revealed on 3/30/2022, 4/06/2022 and 4/13/2022 CR#1's skin condition was noted as non-pressure. On 4/20/22 and 4/27/2022 the skin condition was noted as clear. Record review of CR #1's ADL verification worksheet for bathing between 3/23/2022 and 4/29/2022, revealed evidence that CR#1 was bathed only 4 times: 4/12/2022, 4/18/2022, 4/26/2022 and 4/28/2022. There was no documentation for the 12 other dates the resident was scheduled for bathing. Record review of the facility's undated shower schedule revealed residents were to be showered three times per week. Record review of a nursing clinical note on 4/29/2022 at 4:53 PM, written by LVN D revealed in part .Family requested that the patient be sent out to hospital for evaluation and treatment because she was acting abnormal . Record review of ambulance run sheet revealed on 4/29/2022 at 6:09 PM the ambulance arrived at the facility and transported CR#1's to the hospital on 4/29/2022 at 6:46 PM. The acute symptoms listed were abnormal breathing, hypoxemia (low blood oxygen levels), confusion/disorientation, altered mental status, weakness, malaise, and fatigue/lethargy. Interview on 5/18/2022 at 1:32 PM, LVN C stated CR#1's initially had excoriation on her bottom and she did not have a pressure ulcer. She remembered educating the Admission nurse (LVN A no longer employed at the facility) regarding staging because they (the hospital) staged it as a 2. MASD and excoriation did not get better. She did not have a stage 2 when admitted . She did end up with a stage 2. Her MASD was clearing up pretty well but got worse when she did not see her over the weekend (04/23/2022 and 4/24/2022) and it was a stage 2 the week she discharged . She put in a request to see the wound care doctor that week but she discharged before then. Excoriated area was more reddened. It was not wide-spread on her buttocks, it was just the area immediately around the sacrum. She was informed by way of Stop and Watch that the sacrum got worse and did not know the reporting nurse's name. LVN C stated a cause of MASD could be from declining health or being in wet or soiled brief too long. She was on antibiotics. So loose stools could lead to skin breakdown. As far as she knew she was getting sufficient incontinence care. LVN C did not mention the condition of the skin as described by the hospital nurses and described in the hospital notes when the resident was admitted on [DATE]. In an interview on 5/26/2022 at 1:15 PM the first hospital nurse stated that on 4/30/2022 at approximately 1:53 AM, CR#1's was received on her unit. She conducted a full body assessment. The sacrum had a pressure ulcer, multiple skin tears and bruises. The nurse stated the family was concerned. The second hospital nurse stated she also saw CR#1 in the morning of Saturday 4/30/2022 and gave CR#1 a bath. The pressure ulcer was at least a stage 2. There was large excoriation up her back side, groin, and thigh. The wounds were red, very excoriated over the entire buttocks area, including folds of thigh, groin, and labia. The TV remote was found on CR#1's back under her clothing. The family was looking for the remote the previous Tuesday or Wednesday. The second nurse said she assumed the patient had not been changed at the facility. The patient had a skin tear to the right hip fold crease. This area was red and raw and the scabs were red. The first hospital nurse confirmed that on 4/30/2022 at 10:00 AM or 11:00 AM, she was with CR#1 when the family took pictures of CR#1's skin. The second hospital nurse said CR#1 had a [CONDITION(S)] and the urine was orange and fuzzy. An external female catheter with low suction was used to collect urine in a clear canister by the bedside. The first hospital nurse stated CR#1 was not making urine at first. Then IV fluids were started, and the urine output increased. The sacral pressure ulcer was weeping. The first hospital nurse and the hospital quality director stated the skin condition of CR#1 could be caused by lack of turning, not keeping the skin clean, poor hygiene, poor nutritional support, not washing the skin, not using skin barrier cream, wearing adult briefs versus leaving open to air and all of these could possibly lead to moisture associated skin disorder. If the patient had a [CONDITION(S)] then it would be possible that the urine could cause a fungal skin infection. The hospital patient safety specialist stated the pressure ulcer had yellow slough and therefore was unstageable. The first and second hospital nurse confirmed the body skin assessment drawing tool used was the correct description of CR#1's condition. They stated the skin tool was signed by two nurses and used when entering data into the electronic health records. The nurse stated lab results indicated pseudomonas in the urine. Interview on 06/02/2022 at 12:40PM, LVN D said CR#1 had a PICC line to the upper right arm, a [CONDITION(S)] on the right side of abdomen, two drainage tubes on the left side of abdomen and no signs of infection to the sacral area. She illustrated these areas by drawing on a body form sheet. There was no mention of the unstageable pressure ulcer to the coccyx, the wide-spread excoriation to the buttocks, perineal area, perianal area, multiple skin tears and bruises that were noted in the interview and record review of CR #1's admission to the hospital on 4/30/2022. Interview on 06/16/2022 at 2:00 PM, the Administrator stated the risks of not performing incontinent care for any resident requiring assistance was skin breakdown, poor hygiene, infection and [CONDITION(S)]. Interview on 6/16/2022 at 2:00 PM, the Regional Clinical Services Director stated he would have to research regarding the discrepancies on the weekly skin assessment descriptions, that the facility was aware the wounds are not descriptive and had hired a new wound care nurse. In a telephone interview on 06/17/2022 at 4:45 PM the family stated CR#1 passed away at home on 06/02/2022. Record review of hospital records revealed on 4/30/2022 at 2:20 AM, CR#1 had multiple scattered scabs to both lower legs and a skin tear on the right upper-outer left hip CR#1 had an unstageable pressure injury to the coccyx which was present on admission, excoriation to bilateral gluteal fold and the surrounding tissue was also excoriated. - CR#1 also had excoriation, [CONDITION(S)] (redness) and non-blanchable (skin that did not lose redness with pressure) skin to bilateral groin area. Record review of CR#1's body form skin assessment drawing, which was not a part of the patient's medical records dated 4/30/2022 and signed by two hospital nurses reflected the written description of the wounds. Record review of CR#1's wound evaluation written by the hospital wound care nurse dated 5/02/2022 at 10:30 AM revealed in part: . Wound to right and left lower medial buttocks, gluteal cleft, perianal area, perineum and both labia: [CONDITION(S)] secondary to fungal rash .Sacrum: unstageable pressure injury, 3 cm diameter, wound bed is 100% yellow slough, scant serosanguinous drainage, peri wound: [CONDITION(S)]. Right and left groin and beneath pannus (dense layer of abdominal fatty tissue): partial thickness fissures and [CONDITION(S)] . Recommendations: 1. Apply [MEDICATION(S)] powder twice daily to right and left lower medial buttocks, gluteal cleft, perianal area, perineum, bilateral groin and both labia Record review of CR#1's hospital records revealed microbiology results dated 5/02/22 at 12:18 PM that the urine culture collected on 4/29/22 at 10:57 PM results were Pseudomonas aeruginosa (a multidrug resistant pathogen). Record review of CR#1's hospital records revealed on 4/30/2022 at 2:54 AM, a physician order read in part .Female External Urinary Catheter .set wall suction at low continuous suction, Incontinence Associated [CONDITION(S)] . Record review of CR#1's hospital records dated 4/30/2022 at 3:10 AM revealed the History and Physical written by the physician, read in part: .Chief Complaint: .family states patient is more lethargic, weakness and increased AMS .Assessment/Plan: Pelvic abscess-start antibiotic, IR ([MEDICATION(S)] radiology) consulted for drain, surgery and ID (infectious disease) consulted; Perforated viscus (internal organs); [CONDITION(S)] (urinary tract infection)-continue antibiotic; [CONDITION(S)] (below normal levels of oxygen)-chest x-ray show questionable pulmonary [CONDITION(S)] (fluid accumulates in lung tissue) vs interstitial pneumonitis ([CONDITION(S)] lung disease affecting the connective tissue of the lung) .[CONDITION(S)] (low blood potassium level); type 2 diabetes; CAD(coronary artery disease); hypertension (elevated blood pressure); sacral ulcer . Record review of photos the family submitted to TULIP revealed CR#1 had widespread redness to the sacral and buttocks areas. The sacral wound had a dressing with exudate from the dressing. A red, shiny area along the upper inner groin of the left hip. A portion of the female external catheter was visible in the photos. The collection canister had cloudy, frothy fluid. There were 36 photos submitted. Resident #8 Record review of Resident #8 face sheet printed 06/16/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Quarterly MDS dated [DATE] revealed extensive assistance with most activities of daily living, short-term memory problem, long-term memory problem, no recall ability of the current season, location of own room, staff names and faces or that she was in a nursing home. The resident had moderately impaired cognitive skills for daily decision making, used a wheelchair and was always incontinent of both bladder and bowel. Record review of Resident #8's Care Plan printed 06/16/22 at 09:32 AM revealed, problem- at risk for falls related to cognitive impairment and generalized weakness, intervention- keep areas free of obstructions to reduce the risk of falls or injury, resident returned from ER with right arm sling placed and antibiotics for [CONDITION(S)]. An observation on 06/16/22 at 09:43 AM revealed, Resident #8 lying in bed asleep. The resident was well groomed, well dressed, appeared in no immediate distress, and had no visible bruising and injuries. Record review of Resident # 8's Progress Notes dated 05/07/22 at 9:34 PM revealed, at around 4:15 pm, CNA resident reported that resident was lying beside her bed on the mat face down . Resident was alert and responsive to verbal stimuli. Resident obtained a small scratch to her outer right eyebrow . denies pain. Record review of Resident #8's Progress Notes dated 05/08/22 at 08:05 AM revealed, correction: incident occurred at 01:45 Pm on 05/07/22. Record review of Resident #8's Progress Notes dated 05/08/22 at 09:34 AM revealed, Resident noted to be favoring her right shoulder. Bruising to right shoulder and upper arm noted this morning post fall. Resident able to mover her fingers and elbow but is complaining of pain to her right upper should. Called Provider, awaiting on return call. Record review of Resident #8's Progress Notes dated 05/08/22 at 09:43 AM revealed, NP returned call, informed her that resident had a fall yesterday with no apparent injuries except a small scratch to the right side of her eyebrow. However today she is complaining of pain to her right shoulder and has bruising down her right shoulder to her upper arm . New order received an xray of right should and right arm to rule out fracture. Record review of Resident #8's Physician Orders from 05/07/22 to 05/09/22 revealed , no new orders received for pain medication for the residents suspected injury. Record review of Resident #8's radiology report dated 05/08/22 at 11:55 AM revealed, Impression: displaced right humeral neck fracture. Record review of Resident #8's Progress Notes dated 05/08/22 at 4:25 PM revealed, spoke with hospice nurse at 2:52 PM (over 3 hours after the results of were released) regarding x-ray results, informed x-ray shows a right shoulder fracture. New order received to send resident to urgent care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #8's Progress Notes dated 05/08/22 at 5:12 PM (over 2 hours after the order was given to send the resident out and 5 hours after the results of the fracture was released) revealed, ambulance here to transport the resident to the hospital ER for evaluation and treatment. In an interview on 06/15/22 at 04:35 PM, the DON said once an order was placed to send a resident to the hospital, they should be sent out quickly. If the scheduled transport did not arrive promptly, the staff should call 911. She said residents should not wait for up to 1 hour to be transported to the hospital. In an interview on 06/16/22 at 11:06 the MD said, any findings of acute fracture require the resident to be sent out to the hospital in a timely manner and without approval from the NP/MD because his providers could not handle orthopedic issues. In an interview on 06/16/22 at 01:32 PM, the Administrator said that nursing staff were expected to act on providers orders to send residents in a timely fashion, and it should take no longer than 30-45minutes from the order being given to the resident leaving the facility. He said it was not appropriate for Resident #8 to wait for almost 2 hours to leave for the hospital after the order was given. The Administrator said that failure to send residents out to the hospital in a timely fashion, placed residents at risk of delayed treatment and pain. Record review of the facility's policy and procedure titled Patient Care Management System 1 - Skin, Cantex Continuing Care Network, April 2022 read in part: .1. A head-to-toe skin assessment must be completed and documented by the Admitting Nurse upon admission .of every patient 2. The treatment nurse/designee must complete a head-to-toe assessment and document in the EMR to validate the findings of the initial skin assessment 3. A Braden Scale must be completed the day of admission .once weekly for a minimum of four weeks and quarterly thereafter .7. A wound assessment must be completed by the treatment nurse/designee and a narrative of each site must be documented weekly for any pressure injury and non-pressure skin condition, including but not limited to Arterial Ulcers, Diabetic [CONDITION(S)] Ulcers, [CONDITION(S)] Ulcers, Bruises, Skin Tears, and surgical Wounds .9. A certified Nurse Aide will notify the treatment nurse or charge nurse of any newly identified skin issues .13. Timely and appropriate incontinent care will be provided to all incontinent Patients. The Facility must ensure that all licensed staff and nurse aides are consistently in-serviced on the provision of proper incontinent care Record review of the facility policy and procedure titled Patient Care Management System 12, Assessments, Cantex Continuing Care Network dated November 2017 read in part .4. A Baseline, Person-centered Plan of Care for each patient that includes the instructions needed to provide effective and person-centered care of the patient that meet professional standards of quality care. Record review of facility policy and procedure titled Patient Care Management System 18 - Interact, Cantex Continuing Care Network dated March 2016 read in part .1. The Stop and Watch Early Warning Tool must be initiated upon the first signs of a Patient presenting with a change in condition and the nurse notified immediately. 2. A Care Path Form .must be used as a guide when a Patient presents with a change in condition. 3. A Situation, Background, Assessment and Request (SBAR) Communication Form and Progress Note must be completed upon a Patient's change in condition .The SBAR Communication Form can replace a nurse's note The staff in-service dated on 4/15/2022 at 2:00 PM included change in condition and was conducted by the DON. Record review of the facility policy and procedure titled Bath-Bed, Nursing Policy & Procedure, Personal Care-Section 11; Cantex Continuing Care Network March 2013 read in part .Responsibility: Licensed Nurse and Nursing Assistant, Purpose: To cleanse, refresh, and soothe the Patient; to stimulate circulation and to inspect the body .

Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical procedures for notification of the ordering physician orders for 2 of 10 resident (Resident #7, Resident #8) reviewed for diagnostic services. - The facility failed to timely report Resident #7's radiology findings of an acute left [CONDITION(S)] resulting in a delay of surgical treatment in the hospital by over 32 hrs. - The facility failed to timely report Resident #8's radiology findings of resulting in a delay of treatment These failures could place residents at risk for delayed identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: Resident #7 Record review of Resident #7's face sheet revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's Admission MDS dated [DATE] revealed, moderately impaired vision with the use of corrective lenses, short term memory problem, long-term memory problem, moderately impaired cognitive skills for daily decision making and extensive assistance with most activities of daily living, ambulation with a walker, history of a fall with fracture in the 6 months prior to admission. Record review of Resident #7's Care Plan dated 06/15/22 revealed, Problem- as risk for falls related to history of falls, intervention- keep areas free of obstruction to reduce the risk of falls or injury, non-skid footwear, call bell/light within easy reach. An observation on 04/27/22 at 10:40 AM revealed, Resident #7 walking in the hallway with non-skid socks on. The resident appeared well groomed, well dressed in no immediate distress, he had no visible injuries. Resident #7 was unable to be interviewed due to limited English proficiency. Record review of Resident #7's Progress Notes dated 04/12/22 at 03:05 PM revealed, CNA reported to nurse that patient was on the floor. Patient's vitals were within range for patient. However, patient had some pain to his left knee, NP notified and ordered a 2-view x-ray of the left knee due to fall and complaints of pain Patient was assisted back into bed by CNA and nurse. Record review of Resident #7's Radiology Report dated 04/13/22 at 01:30 AM revealed, Left Femur X-ray Impression: Acute Left [CONDITION(S)]. Record review of Resident #7's Progress Notes dated 04/14/22 at 10:45 AM (over 24 hours after a fracture was identified ) signed by NP #2 revealed, x-ray of left knee and left femur reviewed on 04/14/22, resulted on 04/13/22. Send patient to hospital for Ortho evaluation . NP #2 ordered to send the patient to ER for evaluation and treatment. Record review of Resident #7's Progress Notes dated 04/14/22 at 11:10 AM revealed, Xray results received from patient's fall. There is an acute fracture of the left hip Patient is alert, now in café. NP #2 ordered to send the patient to ER for evaluation and treatment. Record review of Resident #7's EHR revealed, no pain assessments or head to toe assessment was documented between 04/12/22 and 04/14/22. Record review of Resident #7's Hospital Procedure Notes dated 04/15/22 revealed, Procedure Performed: left hip intramedullary nailing, a surgery to repair a broken bone and keep it stable by inserting a permanent nail or rod into the center of the bone. Resident #8 Record review of Resident #8 face sheet printed 06/16/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Quarterly MDS dated [DATE] revealed extensive assistance with most activities of daily living, short-term memory problem, long-term memory problem, no recall ability of the current season, location of own room, staff names and faces or that she was in a nursing home. The resident had moderately impaired cognitive skills for daily decision making, used a wheelchair and was always incontinent of both bladder and bowel. Record review of Resident #8's Care Plan printed 06/16/22 at 09:32 AM revealed, problem- at risk for falls related to cognitive impairment and generalized weakness, intervention- keep areas free of obstructions to reduce the risk of falls or injury, resident returned from ER with right arm sling placed and antibiotics for [CONDITION(S)]. An observation on 06/16/22 at 09:43 AM revealed, Resident #8 lying in bed asleep. The resident was well groomed, well dressed, appeared in no immediate distress, and had no visible bruising and injuries. Record review of Resident # 8's Progress Notes dated 05/07/22 at 9:34 PM revealed, at around 4:15 pm, CNA resident reported that resident was lying beside her bed on the mat face down . Resident was alert and responsive to verbal stimuli. Resident obtained a small scratch to her outer right eyebrow . denied pain. Record review of Resident #8's Progress Notes dated 05/08/22 at 08:05 AM revealed, correction: incident occurred at 01:45 Pm on 05/07/22. Record review of Resident #8's Progress Notes dated 05/08/22 at 09:34 AM revealed, Resident noted to be favoring her right shoulder. Bruising to right shoulder and upper arm noted this morning post fall. Resident able to move her fingers and elbow but is complained of pain to her right upper shoulder. Called Provider, awaiting on return call. Record review of Resident #8's Progress Notes dated 05/08/22 at 09:43 AM revealed, NP returned call, informed her that resident had a fall yesterday with no apparent injuries except a small scratch to the right side of her eyebrow. However today she is complaining of pain to her right shoulder and has bruising down her right shoulder to her upper arm . New order received an x-ray of right shoulder and right arm to rule out fracture. Record review of Resident #8's Physician Orders revealed, no new orders received for pain medication for the residents suspected injury. Record review of Resident #8's radiology report dated 05/08/22 at 11:55 AM revealed, Impression: displaced right humeral neck fracture. Record review of Resident #8's Progress Notes dated 05/08/22 at 4:25 PM revealed, spoke with hospice nurse at 2:52 PM (over 3 hours after the results of were released) regarding x-ray results, informed x-ray shows a right shoulder fracture. New order received to send resident to urgent care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #8's Progress Notes dated 05/08/22 at 5:12 PM (over 2 hours after the order was given to send the resident out and 5 hours after the results of the fracture was released) revealed, ambulance here to transport the resident to the hospital ER for evaluation and treatment. In an interview on 06/15/22 at 04:35 PM, the DON said once an order is placed to send a resident to the hospital, they should be sent out quickly and if the scheduled transport did not arrive promptly the staff should call 911. She said residents should not wait for up to 1 hour to be transported to the hospital In an interview on 06/16/22 at 11:06 the MD said, any findings of acute fracture required the resident to be sent out to the hospital in a timely manner and without approval from the NP/MD because his providers could not handle orthopedic issues. In an interview on 06/15/22 at 02:26 PM, NP #3 said it was the nursing staff's responsibility to notify the NP/MD of any acute fractures and once identified resident's must be sent out immediately because they need assessment from an orthopedic specialist. She said that she was not informed of Resident #7's acute fracture that was identified on 04/13/22 but she happened to review his lab records on 04/14/22 and immediately sent the resident out to the hospital. In an interview on 06/15/22 at 04:35 PM, the DON said that if a lab or x-ray service identifies an acute fracture or critical labs, a fax is sent to the facility and they are also called. She said the nursing staff have access to the labs at the nursing stations from the providers portal, and it was every nurse's responsibility to check the fax and the portals multiple times during their shift. The DON said if there was an outstanding lab, nursing staff should continuously check for the results. She said she did not know why the facility had a delayed response to Resident #7's acute fracture, but it was not appropriate for his treatment to be delayed by over 24 hours. The DON said she was unaware of the over 3 hour delay in notification of Resident #8's acute fracture and did not know why the findings were not communicated immediately to the NP. She could not identify who was responsible for following up on Resident #7 and Resident #8's pending lab results or account for the delayed physician notification. In an interview on 06/16/22 at 01:32 PM, the Administrator said significant x-ray findings should be reported to the NP/MD immediately and failure to report significant x-ray findings such as acute fractures could place residents at risk of pain, adverse events, and delayed treatment. Record review of the facility policy titled Physician Notification revised 03/2019 revealed, the types of condition which arise frequently are listed . laboratory values. It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment. The Physician, PA, NP, or clinical nurse specialist is to be promptly notified of the results of the radiology, lab and other diagnostic tests ordered.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 17 residents (CR #1) reviewed for quality of care. The facility failed to assess CR #1's Neurological Vital Signs (NVS) (assessment to detect neurological disease or injury and monitor the progression of an injury) after she was found on the floor in her room twice on [DATE], which resulted in a delay in treatment. CR #1 was admitted to the hospital's intensive care unit and diagnosed with subarachnoid hemorrhage (brain bleed) and closed fracture of skull on [DATE], the resident died three days later. This failure could place residents at risk for having unidentified changes in condition, decline in health, and hospitalization . Findings include: Record review of CR #1's admission face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She went to the hospital on [DATE] for a laminetomy; returning to the facility on [DATE]. She was discharged to the hospital on [DATE]. Record review of CR #1's quarterly MDS assessment, dated [DATE] revealed she usually makes herself understood to others and was usually able to understand others. She had a BIMS score of 10 (moderate cognitive impairment) and exhibited no behaviors. CR #1 required limited assistance from one staff with bed mobility, transfers, walking in room, walking in corridor, locomotion on and off unit, dressing, toileting, and personal hygiene, she had limitation to her functional range of motion to one side of her lower extremity, she was always continent of bowel and bladder. Section J Health Conditions revealed the resident had no falls and had major spinal surgery. Record review of CR #1's care plan dated [DATE] revealed: Problem: Resident was a full code Interventions: Monitor for decrease in change of condition. Problem: Resident is at risk for increased bleeding/bruising related to blood thinning agent Intervention: Monitor for side effects Protect from bruising self Bleeding precautions Problem: Resident is at risk for falls related to decreased mobility. Interventions included: Keep area free of obstruction to reduce the risk of falls or injury. Remind resident to call for assistance before moving from bed to chair Record review of CR #1's Hospital Transfer Order Summary dated [DATE] medication orders revealed start taking these medications [MEDICATION(S)] ([MEDICATION(S)]) 75 mg one tablet by mouth daily. Start taking [DATE]. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 revealed [MEDICATION(S)] 75 mg one tablet by mouth start [DATE]. Order dated [DATE]. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's clinical nurses notes dated [DATE] at 9:45 AM, written by LVN C revealed the resident was found sitting on the floor at the bedside. Bed was in lowest position. When asked about falling, CR #1 angrily answered, hell no I didn't fall, don't ask me more, how dare you. Nurse practitioner (NP) was notified. There was no documentation of NVS. There were not additional nurses notes. Record review of CR #1's clinical nurses notes dated [DATE] at 11:05AM, written by LVN C revealed resident was observed on the floor at foot of bed in supine position with legs in upright position. Assessed resident at this time for pain or injury. When asked what happened, CR #1 said she did not fall, she was not in pain, she was ok. Bed down to lowest position. NP asked to see resident. There was no documentation of NVS. Record review of CR #1's Emergency Medical Services (EMS) Incident Report dated [DATE] at 3:57 PM, altered mental status, delirious, not violent, uncooperative, has poor hand-eye coordination, cannot or will not follow instructions. Record review of CR #1's clinical nurses notes dated [DATE] at 4:05 PM, revealed 911 emergency medical here to transfer resident to hospital emergency room for further evaluation. She was combative, refusing to be transferred by staff. Family member was called to encourage the resident to comply. There was no documentation of NVS. There was no documentation of CR #1's condition since her last fall. Record review of CR #1's NP progress notes dated [DATE] at 4:52 PM, revealed late entry resident seen today after found lying on the floor twice in a six-hour period. Resident's denotation progressively worsening, sent to hospital for further evaluation. There was no documentation of NVS assessment completed. Record review of CR #1's communication form SBAR dated [DATE] at 5:08 PM PM revealed: Situation: Started on [DATE]. Since it started the symptoms have gotten worse; Resident Evaluation: 1. Mental Status: Increased confusion or disorientation; 2. Functional Status Changes: Falls, Weakness; 3. Behavior: Verbal aggression, physical aggression, personality changes; 10. Neurological: Abnormal speech, dizziness or unsteadiness and other Neurological symptoms. There was no documentation of NVS assessment. Record review of CR #1's hospital emergency department admission record dated [DATE] at 5:00 PM, revealed her hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical Exam revealed Head; left skin bruise Record review of Hospital CAT SCAN dated [DATE] at 6:56 PM, Impression: Multiple intracranial hemorrhages. Interview on [DATE] at 11:34 AM, CR #1's family member stated CR #1 passed away from injuries she received on [DATE]. She stated she had a head injury and had to be put on palliative care because there was nothing that could be done for her. Record review of External Examination Report dated [DATE] revealed Cause of Death: [MEDICATION(S)] head trauma with skull fracture, subdural hemorrhage, subarachnoid hemorrhage and brain contusion. Interview on [DATE] at 8:17 AM, LVN A stated if a resident was found on the floor and it was undetermined what happened we always do a neurological assessment by doing NVS to make sure there was no head injury or other life-threatening injury. NVS were an important assessment tool to watch for changes. LVN #A stated [MEDICATION(S)] increases a resident's chance for bleeding, those residents must be monitored closely. Interview on [DATE] at 8:21 AM, the Corporate RN stated for any resident found on the floor and we do not know what happened we must do NVS, since we do not know if they hit their head NVS could help identify any injury. Interview on [DATE] 8:50 AM, the Unit Manager LVN #B stated if we find a resident on the floor, we must do NVS to assess for possible injuries. She stated when a resident was on [MEDICATION(S)] it increases the risk for bleeding. Interview on [DATE] at 12:03 PM, the DON stated she looked, and she was unable to find any completed NVS for CR #1 dated [DATE]. The DON stated it was the current practice if any resident was found on the floor NVS were to be done. NVS were important especially if the resident was not observed because we do not know if they fell and if they hit their head. There could be trauma to the brain. She stated we also do NVS for a witnessed fall if it was suspected they did hit their head. The DON stated [MEDICATION(S)] interferes with the clotting and causes bleeding, especially bleeding and bruising anywhere. Interview on [DATE] at 1:09 PM, the NP stated CR #1's mental baseline was she was alert and oriented to person and place but, it could vary and some days would be better than other days. She stated residents on [MEDICATION(S)] have an increased risk of bleeding. The NP stated on [DATE] CR #1 was found on the floor in the morning (9:45 AM) and the nurse asked her to come and see CR #1. At the time she was found on the floor the first time, she was assessed and there was no injury. The NP said CR #1 said she did not fall, she crawled out of bed. She was put back to bed. The NP stated she did not do NVS that was the nurse's responsibility to do. She stated nursing facilities have protocols in place to do NVS after any fall to make sure there was no head injury or damage to the head that we may not be able to see. The NVS will show slurred speech, changes in pupil size and reaction to light, dizziness, mental confusion, weakness which could all indicate a head injury. The NP stated she went back to see CR #1 later in the afternoon after the second time she was found on the floor. Her mental state was deteriorating she had increased confusion from her baseline. She did not know who she was and where she was, she was agitated and combative. When her rapid decline was identified she was sent out to the hospital by 911 ambulance. Interview on [DATE] at 2:00 PM, the Executive Director stated current practice was to do NVS on all residents who were found on the floor or for those residents who had a witnessed fall and may have hit their head. Record review of the facility policy titled Patient Care Management System 3 Accidents/Incidents dated [DATE] revealed in part: .13. A neurological assessment must be immediately initiated and maintained for at least 72 hours following each accident/incident involving an injury of any kind to the head or any unwitnessed fall. Record review of the facility policy titled Anticoagulation Therapy dated [DATE] revealed in part: side effects monitoring was done every shift in the electronic medical record.

Based on observation, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services for four (Resident #7, #10, #8 and #2) of ten residents reviewed for incontinent care, in that: - CNA A failed to ensure Resident #7 received appropriate care during incontinent care resulting in Resident #7 moaning, screaming and flinching. -The facility staff failed to provide timely incontinent care to Resident #10. Resident #10 was found screaming complaining of itchiness to her buttocks. -The facility staff failed to provide timely incontinent care to Resident #8 and her brief was heavily wet with urine and stool. -The facility staff failed to provide timely incontinent care to Resident #2 and her brief was saturated with urine and stool. These failures affected 4 residents who required assistance with incontinence care at risk for discomfort, pain, skin breakdown, cross contamination and urinary tract infections. Findings include: Intakes TX 363/ Intake # and TX 817/ Intake # Resident #7 Record review of Resident #7's face sheet revealed that he was a [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's Quarterly MDS (Minimum Data Set) dated 10/24/18 revealed that he had a BIMS score of 10 out of a possible 15 indicating he had moderate cognitive impairment. Resident #7 required limited assistance of one person physical assist for bed mobility, transfer, dressing and personal hygiene. He required extensive assistance of one person for toilet use. He was totally dependent for bathing. He was frequently incontinent of bladder and bowel. Record review of Resident #7's care plan with effective date of 02/2/2017 revealed in part; -Problems: Resident #7 is at risk for skin breakdown related to bowel and bladder. He has current skin concerns to groin and buttocks - rash ongoing. Incontinence. -Interventions: Monitor for incontinence. Change promptly. Observe for skin breakdown, report to MD. Apply skin barrier creams as ordered. Keep fingernails clipped/ groomed to prevent scratching/ injuring self. Observation on 11/8/2018 at 11:22 a.m. during incontinent care, CNA A washed her hands and donned clean gloves. Further observation revealed that Resident #7 had bright redness around his scrotum and inner thighs. His brief was wet. CNA A then began to clean Resident #7's genitalia area. Resident #7 started to scream and moaned ayayayayay, it hurts as CNA A continued wiping Resident #7's scrotum area. Further observation at that time, CNA A assisted Resident #7 to his side and removed the soiled brief and the soiled underneath sheet. CNA A then grabbed a clean brief and a clean draw sheet with the same gloves and placed the clean brief and clean draw sheet underneath Resident #7 without wiping the buttocks of the Resident. CNA A then applied skin protectant ointment to Resident #7's back area (Resident #7 had redness to his lower back) and assisted Resident #7 to his back. CNA A then continued cleaning Resident #7's scrotum area while Resident #7 flinched his body and screamed loud easy, easy, ayayayaya as CNA A continued wiping Resident #7's scrotum area and genitals. Continued observation and interview on 11/8/2018 at 11:26 a.m. CNA A then closed the brief and removed her gloves after procedure. CNA A then donned new gloves without washing or sanitizing her hands and told Resident #7 that she was going to come back later in the day with some cream for his genitals because they were all red. She then covered Resident #7 with a blanket. Observation on 11/8/2018 at 11:30 a.m. CNA A removed her gloves and walked out of the room without washing her hands. She was holding a plastic bag with soiled linen and said she was going to the soiled room that was next to the nurses station. Observation on 11/8/2018 at 11:31 a.m. CNA A entered the soiled room and immediately came out of room and said she had already finished and needed to continued making rounds. In an interview on 11/8/2018 at 11:32 a.m. with CNA A, she stated that staff was trained to wash their hands upon entrance to a resident's room and upon leaving. When asked about the time she washed or sanitized her hands during Resident #7's incontinent care, CNA A said I did wash my hands upon entrance to his room. I didn't wash my hands on his room at the end of the procedure, but I just washed them when I dropped the soiled linen. CNA A then said I did sanitize my hands when I changed gloves. I am not lying. Further interview on 11/8/2018 at 11:38 a.m. when asked regarding Resident #7's discomfort during incontinent care, CNA A said I would stop the procedure if a Resident complaints of pain. Resident #7's scrotum area was red and it will hurt regardless. It was really red. CNA A then said I am sorry if I forgot something today. I do apologize. I have 24 residents today. I am trying to do as much as possible. Today is my birthday. I wasn't supposed to be here, but they were short. I am responsible for all 200 Hall. The nurse, LVN A, said she was going to helped me but she has her own work. That's why I am back and forth. Continued interview on 11/8/2018 at 11:43 a.m. CNA A stated I haven't done some of the Residents. I don't know how many anymore. I am just so busy. I just happened to be on the cross fire. In an interview on 11/8/2018 at 3:29 p.m. with LVN A, she stated that she was not made aware of Resident #7's redness to scrotum area or pain during incontinent care. In an interview on 11/8/2018 at 3:35 p.m. with the Wound Care Nurse, she stated that Resident #7 had chronic condition of redness to his back and buttocks. When asked if she was made aware of Resident #7's redness to groin/genital area and inner thighs, The Wound Care Nurse said will check, don't remember. In an interview on 11/9/2018 at 1:21 p.m. the Acting DON stated that staff should washed their hands when changing gloves during incontinent care. She further said Hand washing should be prior care and prior leaving the room of the Resident after care. Further interview at that time, the Acting DON stated that when CNA's provided care to the Residents and the Residents complained of pain during care, the staff were supposed to stop the care and get the charge nurse right away and then said Charge nurses need to come and see the Resident in real time and assess the condition. Resident #10 Record review of Resident #10's face sheet revealed that she was a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #10's Admission MDS (Minimum Data Set) dated 10/23/18 revealed that she had a BIMS score of 2 out of a possible 15 indicating she had severe cognitive impairment. Resident #10 required extensive assistance of one person physical assist for bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. She was totally dependent for bathing. She was frequently incontinent of bladder and occasionally incontinent of bowel. Resident #10 was at risk of developing pressure ulcers/injuries and had one Stage 1 pressure injury. Record review of Resident #10's care plan with effective date of 10/17/2018 revealed in part; -Problems: Resident #10 requires staff assist with ADL's. Resident #10 is at risk for skin breakdown related to impair mobility and incontinence. admitted with Stage 1 to buttocks (resolved). readmitted with suspected deep tissue injury to bilateral buttocks. (Resolved 11/6/2018). -Goals: Will maintain a sense of dignity by being clean, dry, odor free and well groomed. Skin will remain clean, dry and intact without evidence of new breakdown. -Interventions: Assist with ADL's as needed. Monitor for incontinence every 2 hours and as needed. Change promptly. Blanchable redness to buttocks. Record review of Resident #10's Clinical Notes Report dated 11/6/2018 at 2:07 p.m. revealed in part; Upon skin assessment discoloration to buttocks has resolved. Blanchable redness noted. Barrier cram applied to buttocks . In an observation on 11/8/2018 at 1:07 p.m. Staff noted passing lunch trays by Resident #10's room. Further observation and interview revealed that Resident #10 was heard from the hallway screaming loudly help me, help me. I am itching, help me, help me. As surveyor entered the room. Resident #10 was noted in bed with the head of the bed elevated at 45 degrees. There was a strong urine odor in her room. Resident #10 stated as Surveyor entered the room I am itching, help me please and pointed at her buttocks. There was a strong urine odor on her room. Surveyor went outside of Resident #10's room and found CNA B who was by the lunch trays. When asked about Resident #10, CNA B stated I just came in, they called me to come and help. I am working 2 to 10 shift. CNA C is assigned to Resident #10, but I can go and help. CNA B then said This Hall is almost full (400 Hall), when is this full, the facility usually has 2 CNA's on this hall. Today is only CNA C. Further observation on 11/8/2018 at 1:11 p.m. with CNA B revealed that Resident #10's brief was saturated with urine. There was a large dried yellow urine stained circle on her draw sheet where the Resident was lying that had been saturated in urine and left to dried. Resident #10 had redness/rash on her buttocks and she was screaming and crying that her buttocks were itching. CNA B then said as she looked at Resident #10 I will go and shower her because she is so soiled. Resident #10 continued screaming my skin is itching, my buttocks, it's terrible. CNA B said she was going to get the shower chair. In an interview on 11/8/2018 at 1:17 p.m. with Resident #10, she stated I am surprised they left me this long, they missed something here. Resident #10 then continued to scream on and off while waiting for CNA B to bring the shower chair my skin, it itches, my buttocks. Resident #10 then said The Captain promised he would come and help me but .(silence) . After few minutes Resident #10 said I am tired of this and continued screaming loud that her skin itches. Continued observation on 11/8/2018 at 1:20 p.m. CNA B arrived to Resident #10's room with the shower chair and Resident #10 screamed again please help me, oh dear. Observation and interview on 11/8/2018 at 1:28 p.m. LVN B entered Resident #10's room to assist with Resident #10. Resident #10 then said to him Where have you been?, why it took you so long? Further observation revealed that LVN B did not respond. Resident #10 was then assisted to the shower by CNA B. In an interview on 11/8/2018 at 1:40 p.m. with CNA C, she stated that she was assigned to Resident #10. She then said that the last time she checked on the Resident, was at 9:00 a.m. CNA C then said we are supposed to check the Residents every 2 hours but we are short and I had been doing showers and making beds. CNA C further said that when she saw Resident #10 at 9:00 a.m. she provided incontinent care and that the Resident #10 did not have any redness on her buttocks. In an interview on 11/8/2018 at 2:15 p.m. with the Wound Care Nurse, she stated that Resident #10 was admitted to the facility with deep tissue injury to bilateral buttocks and then said Resident #10 is better now. Her buttocks has some redness now. I just saw her. We put barrier cream. I put her on the watch list. I think her bottom is bothering her. She is at high risk to develop pressure sores. In an interview on 11/8/2018 at 2:51 p.m. with LVN B, he stated that he was the charge nurse for the 400 Hall (Hall of Resident #10) and then said I monitor the care of my Residents by making rounds. I try to do them every 2 hours but 1 nurse has 25 Residents. I have the 300 and 400 Halls. These are skilled Halls, the acuity is higher on those Residents. When asked when was the last time he saw Resident #10, LVN B stated that he saw Resident #10 in the morning and that Resident #10 was assisted to bed at around 10:00 a.m. and further said I probably popped my head to her room twice after she was assisted to bed because Resident #10 tends to scream help, help. LVN B continued saying that Resident #10 was pretty much alert and that she was able to verbalize her needs. LVN B then said She knows my name. But she did not ask me for help earlier or told me that she was wet. CNA B told me that Resident #10 was very dirty and soiled and that Resident #10 had dark brown rings on her linen. CNA B called the Wound Care Nurse to report the condition of Resident #10's buttocks. In an interview on 11/9/2018 at 1:00 p.m. with the Acting DON, she stated, they told me that Resident #10 was in bed with brown rings, that she was heavily soiled. I noticed that they had to give her a shower. I saw Resident #10's buttocks and they had a deep red color and Resident #10 said the area was itching. Resident #10 is really bony, we talked about positioning frequently. Residents are supposed to be checked for incontinence every 2 hours and as needed. Resident #8 Record review of Resident #8's face sheet revealed that she was a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's Admission MDS (Minimum Data Set) dated 10/05/18 revealed that her cognitive skills for daily decision making were severely impaired. Resident #8 required extensive assistance of two person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. She was totally dependent for bathing. She was frequently incontinent of bladder and bowel. Resident #8 had impairments on both of her lower extremities. Resident #8 was at risk of developing pressure ulcers/injuries. Record review of Resident #8's care plan with effective date of 09/28/2018 revealed in part; -Problems: Resident #8 requires staff assist with ADL's. Resident #8 is at risk for skin breakdown related to impair mobility and incontinence. Resident #8 is frequently incontinent of bowel and bladder. -Goals: Skin will remain clean, dry and intact without evidence of new breakdown. Will maintain a sense of dignity by being clean, dry, odor free and well groomed over next 90 days. -Interventions: Monitor for incontinence every 2 hours and as needed. Change promptly. Clean skin with mild soap and water. Apply moisture barrier. Assist with ADL's as needed. In an observation on 11/8/2018 at 11:45 a.m. Resident #8's room was closed. Surveyor knocked and entered the room. The room was dark and had a strong foul odor that was coming from inside the room. Resident #8 was in her bed with the head of the bed elevated at 45 degrees. [MEDICATION NAME] 1.5 Cal feeding tube was running via pump at 50 ml per hour. Feeding bottle was dated 11/8/2018 at 8:00 a.m. When asked Resident #8 if she had been provided incontinent care, Resident #8 shook her head indicating no. In an interview on 11/8/2018 at 11:47 a.m. with LVN A, she stated that she was the Staff Development coordinator but there was a call off and she was called to work on the floor and she was assigned to Resident #8. She then said that CNA A was assigned to Resident #8 and that she was not sure when Resident #8 had incontinent care last and then said I am not sure when Resident #8 was last changed but rounds had been done. In an interview on 11/8/2018 at 11:49 a.m. with the Wound Care Nurse, she stated that Resident #8 did not have wounds. Further observation and interview at that time during skin assessment, the Wound Care Nurse stated as she touched Resident #8's covers and opened the brief. Resident #8 is wet, she is soiled. I need help. The Wound Care Nurse then said as she pointed to a pile of linen on the room There is some linen here. The CNA probably was ready to do incontinent care. Wound Care Nurse then exited the room. Observation and interview on 11/8/2018 at 11:53 a.m. CNA A stated as she opened Resident #8's blankets Oh yes, it feels wet (the linen). LVN A said she did incontinent care earlier, but she is really wet. Further observation and interview as CNA A opened Resident #8's brief Resident #8 is really wet. LVN A did not do incontinent care. Continued observation at that time revealed that Resident #8's brief was heavily wet with dark yellow/brownish colored urine and had stool. Underneath the draw sheet had a yellow urine stained circle and the blankets that were covering the Resident were wet. There was a strong urine smell. Observation and interview on 11/8/2018 at 12:05 p.m. CNA A said as she removed all the linen off Resident #8's bed All linen is wet. I need to change everything. I have 23 patients. Look how Resident #8 was. They were supposed to have 2 aides on this Hall. It's only me here. This Hall is very hard. In an interview on 11/8/2018 at 12:13 p.m. with CNA A after the procedure, she stated I am sorry but I was moving fast. Resident #8 was very soiled and she needed help fast. In an interview on 11/8/2018 at 12:30 p.m. with the Acting DON, she stated that CNA A was not working alone on the 200 Hall and then said that CNA F was supposed to help CNA A on the 200 Hall and that CNA F was assigned Resident #8. When asked to speak to CNA F, the Acting DON brought surveyor to the other side of the building to speak to CNA F. In an interview on 11/9/2018 at 1:00 p.m. with the Acting DON, she stated, I heard that Resident #8 was wet and soiled but they didn't go into details. CNA A did say that she had to change the linen, from there you could see it was soaked through. Residents are supposed to be check for incontinence every 2 hours and as needed. Resident #2 Record review of Resident #2's face sheet revealed that she was a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Admission MDS (Minimum Data Set) dated 10/15/18 revealed that she had a BIMS score of 15 out of a possible 15 indicating she was cognitively intact. Resident #2 required extensive assistance of two person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. She was totally dependent for bathing. She was frequently incontinent of bladder and bowel. Resident #2 was at risk of developing pressure ulcers/injuries and had one Stage 2 pressure injury that was present upon admission. Record review of Resident #2's care plan with effective date of 10/08/2018 revealed in part; -Problems: Resident #2 requires staff assist with ADL's. Resident #2 is at risk for skin breakdown related to impair mobility and incontinence. admitted with Stage 2 to sacrum. barrier cream. Pressure ulcer prevention. -Goals: Will maintain a sense of dignity by being clean, dry, odor free and well groomed. Skin will remain clean, dry and intact without evidence of new breakdown. -Interventions: Assist with ADL's as needed. Monitor for incontinence every 2 hours and as needed. Change promptly. Record review of Resident #2's Weekly Head to Toe assessment dated [DATE] revealed that Resident #2's skin was clear. In an observation and interview on 11/9/2018 at 10:41 a.m. Resident #2 was up on her chair. Her chair had a pillow where the Resident was seated. Resident #2's FM was at the bedside. FM stated that she visited Resident #2 every day and that in the last 3 weeks in the facility, Resident #2 had only one shower a while back. Resident #2 agreed to the statement by nodding her head up and down. Resident #2 then said Staff don't come and do incontinent care either. Had incontinent care at around 7:00 a.m. today and they won't come anymore. Resident #2's FM member said I am usually with her until 2:00 p.m. everyday. In an interview and observation on 11/9/2018 at 1:50 p.m. Resident #2 was in her bed. Resident #2 stated that a Therapist had just assisted her to bed. Resident #2 then said They haven't done incontinent care since this morning at 7:00 a.m. Resident #2's FM then said Nobody has come. I don't even know who the aide for this room was. I came at 9:00 a.m. today and nobody has showed up in this room to offer care to Resident #2. Further observation at that time revealed that the pillow where Resident #2 had been seated in her chair had a large wet area. The room had a strong urine odor. Resident #2 pushed her call light on. Observation on 11/9/2018 at 1:57 p.m. CNA D came to Resident #2's room and said will do incontinent care to Resident #2. Further observation on 11/9/2018 at 2:00 p.m. LVN A entered Resident #2's room to assist with incontinent care. Both staff washed their hands. CNA D then opened Resident #2's brief. The brief was saturated with urine and stool. CNA D then started wiping the front perineal area. CNA D then removed her gloves and donned clean gloves without washing or sanitizing her hands. Resident#2 is then assisted to her side. CNA D then removed the soiled brief. Observation on 11/9/2018 at 2:06 p.m. Resident #2's buttocks and rectal area noted excoriated and red. The draw sheet where the Resident was lying had had also a wet area on the direction of the brief. CNA D proceeded to clean the rectal and buttocks area. Resident #2 started complaining of discomfort ay ay ay while CNA D was cleaning the buttocks. LVN A then asked CNA D if she had already reported the excoriation to the charge nurse and CNA D said Yes, this morning. CNA D then continued cleaning Resident #2's bowel movement from the buttocks area. Further observation, CNA D removed her gloves and donned clean gloves without washing or sanitizing her hands. CNA D then said The sheet is wet, has a yellow stain. I will remove it. CNA D then placed new brief and applied a white ointment to Resident #2's buttocks. Resident #2 stated It hurts a lot while CNA D was placing a white ointment to her buttocks. CNA D and LVN A washed hands at the end of the procedure. In an interview on 11/9/2018 at 2:16 p.m. with CNA D, she stated that staff was supposed to checked for incontinent care every 1 to 2 hours. When asked when was the last time Resident #2 was checked for incontinent care, CNA D responded I don't know the real time because it's been fast pace today but it was around 11:00 a.m. , but I also did incontinent care at 7:00 a.m. Resident #2's FM was not there on either times. In an interview on 11/9/2018 at 2:25 p.m. with LVN A, she stated that she noticed that CNA D did not wash or sanitize her hands during incontinent care to Resident #2. She then said that she had been the Staff Development and Staffing Coordinator since (MONTH) and that staff was supposed to be trained annually and quarterly for incontinent care procedures including infection control. When asked if she had checked the Skills for CNA's including CNA A and CNA D, LVN A responded Ideally, I would want to have a skills fair but I had been doing Unit Manager duties, we don't have Unit Manager for 200, 300 and 400 Halls. I had been doing Charge Nurse duties as well, there is a lot that needs to be done. That's the goal. Further interview at that time, LVN A stated that CNA A did not report to her that Resident #7 had any redness to his scrotum on 11/8/2018. LVN A then said that staff was supposed to checked residents for incontinent care at least every 2 hours and then said that 11/8/2018 was a challenging day because she had to work on the floor instead of doing her Staff Development and Staffing duties. In an interview on 11/9/2018 at 3:45 p.m. with the Executive Administrator, he stated that he had only been working 2 weeks in the facility and then said Charge nurses are supposed to monitor the care provided to the Residents. Every night time, we do a meeting with the Staff Development and review the staffing for the next day. I am here every morning at 5:30 a.m. 7 days a week. If someone calls in sick, we call everybody on the list. The Unit Manager monitors the staff and answers call lights. The CNA of the 300 Hall (CNA E) was supposed to help CNA A from the 200 Hall on 11/8/2018. Yesterday, 11/8/2018 we were supposed to be 1/15 for staffing and today we are 1/10. I am working on staffing. I am here to get the best quality of care, we will improve, I promise. Record review of the facility Policy and Procedure Perineal Care Protocol dated (MONTH) 2013 revealed in part; .Cleansing the perineal area between showers or baths, helps prevent irritation, infection, and skin breakdown as well as keeping the Patient comfortable .

Based on observation, interview and record review, the facility failed to ensure that Residents received treatment and care in accordance with professional standards of practice for two of ten (Resident #7 and #10) residents reviewed for quality of care. -CNA A failed to report Resident #7's pain during incontinent care resulting in Resident #7 moaning, screaming and flinching. -The facility staff failed to provide timely incontinent care to Resident #10. Resident #10 was found seated in a heavily wet brief screaming and complaining of itchiness to her buttocks. These failures affected two residents by placing them at risk for a decline in their physical, mental and psychosocial wellbeing. Findings included: Resident #7 Record review of Resident #7's face sheet revealed that he was a [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's Quarterly MDS (Minimum Data Set) dated 10/24/18 revealed that he had a BIMS score of 10 out of a possible 15 indicating he had moderate cognitive impairment. Resident #7 required limited assistance of one person physical assist for bed mobility, transfer, dressing and personal hygiene. He required extensive assistance of one person for toilet use. He was totally dependent for bathing. He was frequently incontinent of bladder and bowel. Record review of Resident #7's care plan with effective date of 02/2/2017 revealed in part; -Problems: Resident #7 is at risk for pain related to impaired mobility. He has current skin concerns to groin and buttocks - rash ongoing. Incontinence. -Goal: Resident #7's caregiver will actively participate in assessment of pain. -Interventions: Assess Resident #7 to determine if experiencing pain. If pain is present, conduct and document pain assessment particularly location, nature, intensity and duration of pain. Observation on 11/8/2018 at 11:22 a.m. during incontinent care, CNA A washed her hands and donned clean gloves. Further observation revealed that Resident #7 had bright redness around his scrotum and inner thighs. His brief was wet. CNA A then began to clean Resident #7's genitalia area. Resident #7 started to scream and moaned ayayayayay, it hurts as CNA A continued wiping Resident #7's scrotum area. Further observation at that time, CNA A assisted Resident #7 to his side. and removed the soiled brief and the soiled underneath sheet. CNA A then grabbed a clean brief and a clean draw sheet with the same gloves and placed the clean brief and clean draw sheet underneath Resident #7 without wiping the buttocks of the Resident. CNA A then applied skin protectant ointment to Resident #7's back area (Resident #7 had redness to his lower back) and assisted Resident #7 to his back. CNA A then continued cleaning Resident #7's scrotum area while Resident #7 flinched his body and screamed loud easy, easy, ayayayaya as CNA A continued wiping Resident #7's scrotum area and genitals. Continued observation and interview on 11/8/2018 at 11:26 a.m. CNA A then closed the brief and removed her gloves after procedure. CNA A then donned new gloves without washing or sanitizing her hands and told Resident #7 that she was going to come back later in the day with some cream for his genitals because they were all red. She then covered Resident #7 with a blanket. In an interview on 11/8/2018 at 11:38 a.m. with CNA A, when asked regarding Resident #7's discomfort during incontinent care, CNA A said I would stop the procedure if a Resident complaints of pain. Resident #7's scrotum area was red and it will hurt regardless. It was really red. CNA A then said I am sorry if I forgot something today. I do apologize. I have 24 residents today. I am trying to do as much as possible. Today is my birthday. I wasn't supposed to be here, but they were short. I am responsible for all 200 Hall. The nurse, LVN A, said she was going to help me but she has her own work. That's why I am back and forth. In an interview on 11/8/2018 at 3:29 p.m. with LVN A, who was the Charge nurse for Resident #7, she stated that she was not made aware of Resident #7's redness to scrotum area or pain during incontinent care. In an interview on 11/8/2018 at 3:35 p.m. with the Wound Care Nurse, she stated that Resident #7 had chronic condition of redness to his back and buttocks. When asked if she was made aware of Resident #7's redness to groin/genital area and inner thighs, The Wound Care Nurse said will check, don't remember. In an interview on 11/9/2018 at 1:21 p.m. the Acting DON, she stated that when CNA's provided care to the Residents and the Residents complained of pain during care, the staff were supposed to stop the care and get the charge nurse right away and then said Charge nurses need to come and see the Resident in real time and assess the condition. Resident #10 Record review of Resident #10's face sheet revealed that she was a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #10's Admission MDS (Minimum Data Set) dated 10/23/18 revealed that she had a BIMS score of 2 out of a possible 15 indicating she had severe cognitive impairment. Resident #10 required extensive assistance of one person physical assist for bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. She was totally dependent for bathing. She was frequently incontinent of bladder and occasionally incontinent of bowel. Resident #10 was at risk of developing pressure ulcers/injuries and had one Stage 1 pressure injury. Record review of Resident #10's care plan with effective date of 10/17/2018 revealed in part; -Problems: Resident #10 requires staff assist with ADL's. Resident #10 is at risk for skin breakdown related to impair mobility and incontinence. admitted with Stage 1 to buttocks (resolved). readmitted with suspected deep tissue injury to bilateral buttocks. (Resolved 11/6/2018). -Goals: Will maintain a sense of dignity by being clean, dry, odor free and well groomed. Skin will remain clean, dry and intact without evidence of new breakdown. -Interventions: Assist with ADL's as needed. Monitor for incontinence every 2 hours and as needed. Change promptly. Blanchable redness to buttocks. Record review of Resident #10's Clinical Notes Report dated 11/6/2018 at 2:07 p.m. revealed in part; Upon skin assessment discoloration to buttocks has resolved. Blanchable redness noted. Barrier cram applied to buttocks . In an observation on 11/8/2018 at 1:07 p.m. Staff noted passing lunch trays by Resident #10's room. Further observation and interview revealed that Resident #10 was heard from the hallway screaming loudly help me, help me. I am itching, help me, help me. As surveyor entered the room. Resident #10 was noted in bed with the head of the bed elevated at 45 degrees. There was a strong urine odor in her room. Resident #10 stated as Surveyor entered the room I am itching, help me please and pointed at her buttocks. There was a strong urine odor on her room. Surveyor went outside of Resident #10's room and found CNA B who was by the lunch trays. When asked about Resident #10, CNA B stated I just came in, they called me to come and help. I am working 2 to 10 shift. CNA C is assigned to Resident #10, but I can go and help. CNA B then said This Hall is almost full (400 Hall), when is this full, the facility usually has 2 CNA's on this hall. Today is only CNA C. Further observation on 11/8/2018 at 1:11 p.m. with CNA B revealed that Resident #10's brief was saturated with urine. There was a large dried yellow urine stained circle on her draw sheet where the Resident was lying that had been saturated in urine and left to dried. Resident #10 had redness/rash on her buttocks and she was screaming and crying that her buttocks were itching. CNA B then said as she looked at Resident #10 I will go and shower her because she is so soiled. Resident #10 continued screaming my skin is itching, my buttocks, it's terrible. CNA B said she was going to get the shower chair. In an interview on 11/8/2018 at 1:17 p.m. with Resident #10, she stated I am surprised they left me this long, they missed something here. Resident #10 then continued to scream on and off while waiting for CNA B to bring the shower chair my skin, it itches, my buttocks. Resident #10 then said The Captain promised he would come and help me but .(silence) . After few minutes Resident #10 said I am tired of this and continued screaming loud that her skin itches. Continued observation on 11/8/2018 at 1:20 p.m. CNA B arrived to Resident #10's room with the shower chair and Resident #10 screamed again please help me, oh dear. Observation and interview on 11/8/2018 at 1:28 p.m. LVN B entered Resident #10's room to assist with Resident #10. Resident #10 then said to him Where have you been?, why it took you so long? Further observation revealed that LVN B did not respond. Resident #10 was then assisted to the shower by CNA B. In an interview on 11/8/2018 at 1:40 p.m. with CNA C, she stated that she was assigned to Resident #10. She then said that the last time she checked on the Resident, was at 9:00 a.m. CNA C then said we are supposed to check the Residents every 2 hours but we are short and I had been doing showers and making beds. CNA C further said that when she saw Resident #10 at 9:00 a.m. she provided incontinent care and that the Resident #10 did not have any redness on her buttocks. In an interview on 11/8/2018 at 2:15 p.m. with the Wound Care Nurse, she stated that Resident #10 was admitted to the facility with deep tissue injury to bilateral buttocks and then said Resident #10 is better now. Her buttocks has some redness now. I just saw her. We put barrier cream. I put her on the watch list. I think her bottom is bothering her. She is at high risk to develop pressure sores. In an interview on 11/8/2018 at 2:51 p.m. with LVN B, he stated that he was the charge nurse for the 400 Hall (Hall of Resident #10) and then said I monitor the care of my Residents by making rounds. I try to do them every 2 hours but 1 nurse has 25 Residents. I have the 300 and 400 Halls. These are skilled Halls, the acuity is higher on those Residents. When asked when was the last time he saw Resident #10, LVN B stated that he saw Resident #10 in the morning and that Resident #10 was assisted to bed at around 10:00 a.m. and further said I probably popped my head to her room twice after she was assisted to bed because Resident #10 tends to scream help, help. LVN B continued saying that Resident #10 was pretty much alert and that she was able to verbalize her needs. LVN B then said She knows my name. But she did not ask me for help earlier or told me that she was wet. CNA B told me that Resident #10 was very dirty and soiled and that Resident #10 had dark brown rings on her linen. CNA B called the Wound Care Nurse to report the condition of Resident #10's buttocks. In an interview on 11/9/2018 at 1:00 p.m. with the Acting DON, she stated, they told me that Resident #10 was in bed with brown rings, that she was heavily soiled. I noticed that they had to give her a shower. I saw Resident #10's buttocks and they had a deep red color and Resident #10 said the area was itching. Resident #10 is really bony, we talked about positioning frequently. Residents are supposed to be checked for incontinence every 2 hours and as needed. Record review of the facility Policy and Procedure dated (MONTH) (YEAR) Pain Management revealed in part; .Every Patient must be assessed for pain utilizing the FACES/PAINAD based on a pain intensity score of 0-10 or by observing for non-verbal/non-cognitive signs of pain: a) Every shift . Record review of the facility Policy and Procedure Perineal Care Protocol dated (MONTH) 2013 revealed in part; .Cleansing the perineal area between showers or baths, helps prevent irritation, infection, and skin breakdown as well as keeping the Patient comfortable .

Based on interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 1 of 6 residents (CR #1) reviewed for neglect in that; -RN A gave CR #1 100 mg of [MEDICATION NAME] sulfate sublingual (under the tongue) which was 19 times more than he should have received per his physician order. -RN A failed to follow physician's orders [REDACTED].#1. This failure affected one former resident and could affect all 80 residents who receive medication by placing them at risk for neglect. The findings include: Complaint # 9 Incident # 6 Record review of CR #1's face sheet revealed that he was an [AGE] year old male who was admitted on [DATE] at 6:45 pm with [DIAGNOSES REDACTED]. He was DNR. He was pronounced dead on [DATE] at 2:55 am. Record review of CR #1's Nursing Admission assessment dated [DATE] at 9:21 am revealed that he was admitted for hospice services. In the neurological section it was revealed that he was alert and oriented x 3. His mental status review revealed that he did not display periods of altered perception or awareness of his surroundings and periods of lethargy did not occur. His vital signs were: BP ,[DATE], respiratory rate 14, pulse 68. His pain assessment revealed that his pain at time of assessment (using a scale from ,[DATE] with 0 being no pain and 10 worst possible pain), was 0. His worst pain was at level 5. Record review of CR #1's Baseline Care Plan and Daily Care Guide did not include pain management. Record review of CR #1's consolidated physicians orders revealed he had an order for [REDACTED]. The order began on [DATE] and was discontinued on [DATE] at 5:04 pm. Record review of CR #1's Controlled Drug Disposition Form revealed that on [DATE] at 5:50 pm RN A signed that she gave 5 ml (100 mg of [MEDICATION NAME]) and that 9.5 ml of [MEDICATION NAME] remained. No more [MEDICATION NAME] was signed out after that dose. Record review of CR #1's pharmacy label on his bottle of [MEDICATION NAME] revealed that he was to receive 0.25 ml (5 mg) by mouth or under his tongue every 3 hours as needed for pain or shortness of breath. Record review of CR #1's MAR (Medication Administration Record [REDACTED]=5mg as needed every 3 hours. Order begun on [DATE] and stopped on [DATE]. RN A gave a dose on [DATE] at 6:00 pm and charted that the results were effective at 7:00 pm. Record review of CR #1's clinical notes report dated [DATE] was a late entry for [DATE] which RN A wrote that CR #1 was agitated and screaming in pain. [MEDICATION NAME] is given at 1730 (5:30pm), At 1800 (6:00pm) patient was resting with eyes close, chest is raising up and down, respiration is 16 per minute, 02 = 76% on 5L, p=84. Family by the bedside. Record review of another clinical note by staff on [DATE] at 1939 revealed that per hospice nurse, reported today that patient received an extra dose of [MEDICATION NAME] on [DATE]. Patient assessed for signs of adverse effects, Vitals WDL for patient. MD, Family , supervisor , and hospice notified. [MEDICATION NAME] and [MEDICATION NAME] orders discontinued until further notice. Record review of another note on [DATE] at 6:08 pm revealed that CR #1 was resting in bed. Head of bed elevated. O2 via nasal cannula at 3 L/min, family at bedside. Resident sleeping and did not consume any of his evening meal. O2 Sat at 77, blood pressure at ,[DATE], respirations 18, pulse 55. Record review of the facility's grievance report dated [DATE] at 12:34 pm revealed CR #1's RP, filed a grievance report with the DON. Facility follow up action revealed that the incident report was completed, physician notified, and nurse was terminated. Under comments the facility met with the family to discuss the resolution. It further revealed that they explained that they contacted the physician with no new orders as well as completing a medication incident report and that they terminated the nurse. Record review of the written statement from RN A read in part; On Sunday [DATE] at about 1730 (5:30pm) the family members of CR #1 in room [ROOM NUMBER]A came to the nurse station asking me to help the patient because he is screaming in pain. I went to the patient room and patient was agitated and screaming, nurse asked the patient where your pain is I hurting all over family members were crying and told me he need medicine. I went to the cart and open patient chart to check PRN orders then I saw the [MEDICATION NAME] order as 5 ml instead of 5 mg at the beginning I did not feel comfortable giving this high dose but his niece came to me crying to hurry and help him. I took the [MEDICATION NAME] box from the cart to the patient room with the 1 ml syringe that comes with the [MEDICATION NAME] in the box and I gave him 2 ml and told the family to give the medicine about 15 to 20 minutes to start to work and I went back to the nurses station. In less than 5 minutes later (two other family members) came back to the nurse station and said the medicine is not working and he need more he is still screaming in pain. I went again to the cart I took the [MEDICATION NAME] bottle went to the room patient was still screaming and agitated all family were crying and asked me to give him some more medicine. I gave the patient 3 more ml of [MEDICATION NAME]. After 30 minutes patient was resting with eyes closed, chest is raising up and down, respiration is 16 per minutes, O2 =76% on 5L, P=84. Record review of the Internal Investigation dated [DATE] revealed in part .that on [DATE], CR #1 appearing drowsy and sleeping. Family voiced concerns to Hospice Nurse . Hospice nurse made nurse aware of medication error. The hospice nurse spoke with DON to make her aware of medication error. Record review of CR #1's SBAR dated [DATE] at 6:12 pm was signed by the DON, which revealed that vital signs were taken (no time given), Blood Pressure ,[DATE], Temp 97, P 58, Respiratory Rate 14, no pulse oximetry done. Mental status changes were compared to baseline and found to have decreased level of consciousness. He also had decreased urinary output. In an interview on [DATE] at 8:15 am with the DON, she stated that the family of CR #1 , one was a nurse and saw RN A administer 5 syringes of pain medication on Sunday evening. She also stated that each syringe held 1 ml of [MEDICATION NAME]. The police were not notified. The facility does check off's for medication administration at hire and also does random medication administration checks. She stated that RN A came in and wrote her statement, and that same day RN A was terminated. In a telephone interview on [DATE] at 11:00 am with RN A the nurse who gave an overdose of [MEDICATION NAME] to CR #1, she stated that she wrote everything in the statement at the facility. She further stated that if the surveyor had any more questions , that they could speak to her lawyer. RN A did not provide the name of her lawyer at that time. In a telephone interview on [DATE] at 10:15 am with the Nurse Practitioner she stated that the facility called her around ,[DATE] pm on [DATE] and let her know CR #1 had been given an overdose of [MEDICATION NAME]. She stated that she did not consider [MEDICATION NAME] (an opioid antagonist used for the complete or partial reversal of opioid overdose, including respiratory depression. [MEDICATION NAME] is also used for [DIAGNOSES REDACTED].) because she was told he was stable. She further stated that she asked how he was and was told that he was stable.His blood pressure was lower than previously but not much lower. She also stated that she held the [MEDICATION NAME] and anxiety medication at that time. She stated that after CR #1 died , no toxicology blood work was done. In an interview on [DATE] at 10:30 am with the Administrator, she stated that she was the Abuse Prevention Coordinator. She stated that she did not report the overdose of [MEDICATION NAME] related to resident CR #1 immediately because there was no negative outcome. She further stated that she filed a report after CR #1 died . Review of the facility's policy Abuse Protocol dated (MONTH) (YEAR) revealed in part 1. The patient/resident has the right to be free from abuse, neglect, mistreatment of [REDACTED]. 7. The following definitions are provided to assist our Facility's staff members in recognizing incidents of Patient/Resident Abuse: i. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a patient/resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incidents of Patient/Resident Abuse as required un application regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours)after forming the suspicion to The Department of Aging and Disability Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance. Record review of the facility's policy for Administering Medications, Nursing Services Policy and Procedure Manual for Long-Term Care, 2001 Med-Pass, Inc (Revised (MONTH) 2012) read in part; Policy Statement - Medications shall be administered in a safe and timely manner, and as prescribed.3. Medications must be administered in accordance with the orders, including any required time frame.5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. Information on the 672 provided by the DON revealed that there were 80 residents in the facility.

Based on observation, interview, and record review, the facility failed ensure that residents were free of any significant medication errors for 2 of 6 residents (CR #1 and Resident #2) reviewed for medication errors, in that; -RN A failed to follow physicians orders for CR #1 and she gave him 100 mg of [MEDICATION NAME] sulfate, 19 times more than ordered. -LVN B gave Resident #2 [MEDICATION NAME] without a physicians order. These failures affected 1 former resident and 1 current resident and could affect the remaining 79 residents and could cause serious health issues i.e. bleeding, decreased respirations, and even death. The findings include: P1 Complaint 9 P1 Incident 6 CR #1 Record review of CR #1's face sheet revealed that he was an [AGE] year old male who was admitted on [DATE] at 6:45 pm with [DIAGNOSES REDACTED]. He was DNR. He was pronounced dead on [DATE] at 2:55 am. Record review of CR #1's Nursing Admission assessment dated [DATE] at 9:21 am revealed that he was admitted for hospice services. In the neurological section it was revealed that he was alert and oriented x 3. His mental status review revealed that he did not display periods of altered perception or awareness of his surroundings and periods of lethargy did not occur. His vital signs were: BP ,[DATE], respiratory rate 14, pulse 68. His pain assessment revealed that his pain at time of assessment (using a scale from ,[DATE] with 0 being no pain and 10 worst possible pain), was 0. His worst pain was at level 5. Record review of CR #1's Baseline Care Plan and Daily Care Guide did not include pain management. Record review of CR #1's consolidated physicians orders revealed he had an order for [REDACTED]. The order began on [DATE] and was discontinued on [DATE] at 5:04 pm. Record review of CR #1's Controlled Drug Disposition Form revealed that on [DATE] at 5:50 pm RN A signed that she gave 5 ml (100 mg of [MEDICATION NAME]) and that 9.5 ml of [MEDICATION NAME] remained. No more [MEDICATION NAME] was signed out after that dose. Record review of CR #1's pharmacy label on his bottle of [MEDICATION NAME] revealed that he was to receive 0.25 ml (5 mg) by mouth or under his tongue every 3 hours as needed for pain or shortness of breath. Record review of CR #1's MAR (Medication Administration Record [REDACTED]=5mg as needed every 3 hours. Order begun on [DATE] and stopped on [DATE]. RN A gave a dose on [DATE] at 6:00 pm and charted that the results were effective at 7:00 pm. Record review of CR #1's clinical notes report dated [DATE] was a late entry for [DATE] which RN A wrote that CR #1 was agitated and screaming in pain. [MEDICATION NAME] is given at 1730 (5:30pm), At 1800 (6:00pm) patient was resting with eyes close, chest is raising up and down, respiration is 16 per minute, 02 = 76% on 5L, p=84. Family by the bedside. Record review of another clinical note by staff on [DATE] at 1939 revealed that per hospice nurse, reported today that patient received an extra dose of [MEDICATION NAME] on [DATE]. Patient assessed for signs of adverse effects, Vitals WDL for patient. MD, Family , supervisor , and hospice notified. [MEDICATION NAME] and [MEDICATION NAME] orders discontinued until further notice. Record review of another note on [DATE] at 6:08 pm revealed that CR #1 was resting in bed. Head of bed elevated. O2 via nasal cannula at 3 L/min, family at bedside. Resident sleeping and did not consume any of his evening meal. O2 Sat at 77, blood pressure at ,[DATE], respirations 18, pulse 55. Record review of the facility's grievance report dated [DATE] at 12:34 pm revealed CR #1's RP, filed a grievance report with the DON. Facility follow up action revealed that the incident report was completed, physician notified, and nurse was terminated. Under comments the facility met with the family to discuss the resolution. It further revealed that they explained that they contacted the physician with no new orders as well as completing a medication incident report and that they terminated the nurse. Record review of the written statement from RN A read in part; On Sunday [DATE] at about 1730 (5:30pm) the family members of CR #1 in room [ROOM NUMBER]A came to the nurse station asking me to help the patient because he is screaming in pain. I went to the patient room and patient was agitated and screaming, nurse asked the patient where your pain is I hurting all over family members were crying and told me he need medicine. I went to the cart and open patient chart to check PRN orders then I saw the [MEDICATION NAME] order as 5 ml instead of 5 mg at the beginning I did not feel comfortable giving this high dose but his niece came to me crying to hurry and help him. I took the [MEDICATION NAME] box from the cart to the patient room with the 1 ml syringe that comes with the [MEDICATION NAME] in the box and I gave him 2 ml and told the family to give the medicine about 15 to 20 minutes to start to work and I went back to the nurses station. In less than 5 minutes later (two other family members) came back to the nurse station and said the medicine is not working and he need more he is still screaming in pain. I went again to the cart I took the [MEDICATION NAME] bottle went to the room patient was still screaming and agitated all family were crying and asked me to give him some more medicine. I gave the patient 3 more ml of [MEDICATION NAME]. After 30 minutes patient was resting with eyes closed, chest is raising up and down, respiration is 16 per minutes, O2 =76% on 5L, P=84. Record review of the Internal Investigation dated [DATE] revealed in part .that on [DATE], CR #1 appearing drowsy and sleeping. Family voiced concerns to Hospice Nurse . Hospice nurse made nurse aware of medication error. The hospice nurse spoke with DON to make her aware of medication error. Record review of CR #1's SBAR dated [DATE] at 6:12 pm was signed by the DON, which revealed that vital signs were taken (no time given), Blood Pressure ,[DATE], Temp 97, P 58, Respiratory Rate 14, no pulse oximetry done. Mental status changes were compared to baseline and found to have decreased level of consciousness. He also had decreased urinary output. In an interview on [DATE] at 8:15 am with the DON, she stated that the family of CR #1 , one was a nurse and saw RN A administer 5 syringes of pain medication on Sunday evening. She also stated that each syringe held 1 ml of [MEDICATION NAME]. The police were not notified. The facility does check off's for medication administration at hire and also does random medication administration checks. She stated that RN A came in and wrote her statement, and that same day RN A was terminated. In a telephone interview on [DATE] at 11:00 am with RN A the nurse who gave an overdose of [MEDICATION NAME] to CR #1, she stated that she wrote everything in the statement at the facility. She further stated that if the surveyor had any more questions , that they could speak to her lawyer. RN A did not provide the name of her lawyer at that time. In a telephone interview on [DATE] at 10:15 am with the Nurse Practitioner she stated that the facility called her around ,[DATE] pm on [DATE] and let her know CR #1 had been given an overdose of [MEDICATION NAME]. She stated that she did not consider [MEDICATION NAME] (an opioid antagonist used for the complete or partial reversal of opioid overdose, including respiratory depression. [MEDICATION NAME] is also used for [DIAGNOSES REDACTED].) because she was told he was stable. She further stated that she asked how he was and was told that he was stable.His blood pressure was lower than previously but not much lower. She also stated that she held the [MEDICATION NAME] and anxiety medication at that time. She stated that after CR #1 died , no toxicology blood work was done. In an interview on [DATE] at 10:30 am with the Administrator, she stated that she was the Abuse Prevention Coordinator. She stated that she did not report the overdose of [MEDICATION NAME] related to resident CR #1 immediately because there was no negative outcome. She further stated that she filed a report after CR #1 died . Resident #2 Record review of Resident #2's facesheet revealed that she was an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS (Minimum Data Set) dated [DATE] revealed that she was understood by others and that she usually understood. Her cognitive function section revealed that she had a score of 7 out of 15 on her BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment. Review of her medications revealed that she had taken anticoagulants all 7 days during look back. Record review of Resident #2's Care Plan revealed in part . that one of her Problems: Resident #2 was at risk for increased bleeding related to the use of blood thinning agent. Her goal was to not have side effects from medication and interventions included to administer meds as ordered and observe for side effects. Record review of Resident #2's consolidated Physicians Orders for (MONTH) (YEAR) revealed that she had an order for [REDACTED]. Record review of Resident #2's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the facility's Accident/Incident report dated [DATE] revealed during chart audits that Resident #2 received a dose of [MEDICATION NAME] 2.5 mg and that she did not have an order for [REDACTED]. Employee (LVN B) was educated on 5 rights of medication and in-servicing on proper medication administration was done. In an interview on [DATE] at 10:50 am with the DON, she stated that LVN B received the [MEDICATION NAME] order and gave it to the wrong resident. The DON further stated that there were two residents with the same last name. She stated that LVN B pulled up the wrong resident on the electronic record, started the new medication and placed the medication order into the wrong residents electronic MAR. She also stated that each MAR indicated [REDACTED]. Record review of the facility's policy for Administering Medications, Nursing Services Policy and Procedure Manual for Long-Term Care, 2001 Med-Pass, Inc (Revised (MONTH) 2012) read in part; Policy Statement - Medications shall be administered in a safe and timely manner, and as prescribed.3. Medications must be administered in accordance with the orders, including any required time frame.5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. Information on the 672 provided by the DON revealed that there were 80 residents in the facility.

Based on observation, interview and record review, the facility failed to provide services in accordance with each resident's written plan of care for two of six residents (CR #1 and #2) reviewed for care plans. -RN A gave CR #1 100 mg of [MEDICATION NAME] sulfate sublingual (under the tongue) which was 19 times more than he should have received per his physician order. -RN A failed to follow physician's orders [REDACTED].#1. -LVN B gave Resident #2 [MEDICATION NAME] without a physicians order. These failures affected one former resident and one current resident and had the potential to affect the remaining 79 residents at the facility and place them at risk of not receiving the care and services ordered by the physician or receiving medications not ordered for them and could result in an over dose and result in a decline in their health status. The findings include: P1 Complaint 9 P1 Incident 6 CR #1 Record review of CR #1's face sheet revealed that he was an [AGE] year old male who was admitted on [DATE] at 6:45 pm with [DIAGNOSES REDACTED]. He was DNR. He was pronounced dead on [DATE] at 2:55 am. Record review of CR #1's Nursing Admission assessment dated [DATE] at 9:21 am revealed that he was admitted for hospice services. In the neurological section it was revealed that he was alert and oriented x 3. His mental status review revealed that he did not display periods of altered perception or awareness of his surroundings and periods of lethargy did not occur. His vital signs were: BP ,[DATE], respiratory rate 14, pulse 68. His pain assessment revealed that his pain at time of assessment (using a scale from ,[DATE] with 0 being no pain and 10 worst possible pain), was 0. His worst pain was at level 5. Record review of CR #1's Baseline Care Plan and Daily Care Guide did not include pain management. Record review of CR #1's consolidated physicians orders revealed he had an order for [REDACTED]. The order began on [DATE] and was discontinued on [DATE] at 5:04 pm. Record review of CR #1's Controlled Drug Disposition Form revealed that on [DATE] at 5:50 pm RN A signed that she gave 5 ml (100 mg of [MEDICATION NAME]) and that 9.5 ml of [MEDICATION NAME] remained. No more [MEDICATION NAME] was signed out after that dose. Record review of CR #1's pharmacy label on his bottle of [MEDICATION NAME] revealed that he was to receive 0.25 ml (5 mg) by mouth or under his tongue every 3 hours as needed for pain or shortness of breath. Record review of CR #1's MAR (Medication Administration Record [REDACTED]=5mg as needed every 3 hours. Order begun on [DATE] and stopped on [DATE]. RN A gave a dose on [DATE] at 6:00 pm and charted that the results were effective at 7:00 pm. Record review of CR #1's clinical notes report dated [DATE] was a late entry for [DATE] which RN A wrote that CR #1 was agitated and screaming in pain. [MEDICATION NAME] is given at 1730 (5:30pm), At 1800 (6:00pm) patient was resting with eyes close, chest is raising up and down, respiration is 16 per minute, 02 = 76% on 5L, p=84. Family by the bedside. Record review of another clinical note by staff on [DATE] at 1939 revealed that per hospice nurse, reported today that patient received an extra dose of [MEDICATION NAME] on [DATE]. Patient assessed for signs of adverse effects, Vitals WDL for patient. MD, Family , supervisor , and hospice notified. [MEDICATION NAME] and [MEDICATION NAME] orders discontinued until further notice. Record review of another note on [DATE] at 6:08 pm revealed that CR #1 was resting in bed. Head of bed elevated. O2 via nasal cannula at 3 L/min, family at bedside. Resident sleeping and did not consume any of his evening meal. O2 Sat at 77, blood pressure at ,[DATE], respirations 18, pulse 55. Record review of the facility's grievance report dated [DATE] at 12:34 pm revealed CR #1's RP, filed a grievance report with the DON. Facility follow up action revealed that the incident report was completed, physician notified, and nurse was terminated. Under comments the facility met with the family to discuss the resolution. It further revealed that they explained that they contacted the physician with no new orders as well as completing a medication incident report and that they terminated the nurse. Record review of the written statement from RN A read in part; On Sunday [DATE] at about 1730 (5:30pm) the family members of CR #1 in room [ROOM NUMBER]A came to the nurse station asking me to help the patient because he is screaming in pain. I went to the patient room and patient was agitated and screaming, nurse asked the patient where your pain is I hurting all over family members were crying and told me he need medicine. I went to the cart and open patient chart to check PRN orders then I saw the [MEDICATION NAME] order as 5 ml instead of 5 mg at the beginning I did not feel comfortable giving this high dose but his niece came to me crying to hurry and help him. I took the [MEDICATION NAME] box from the cart to the patient room with the 1 ml syringe that comes with the [MEDICATION NAME] in the box and I gave him 2 ml and told the family to give the medicine about 15 to 20 minutes to start to work and I went back to the nurses station. In less than 5 minutes later (two other family members) came back to the nurse station and said the medicine is not working and he need more he is still screaming in pain. I went again to the cart I took the [MEDICATION NAME] bottle went to the room patient was still screaming and agitated all family were crying and asked me to give him some more medicine. I gave the patient 3 more ml of [MEDICATION NAME]. After 30 minutes patient was resting with eyes closed, chest is raising up and down, respiration is 16 per minutes, O2 =76% on 5L, P=84. Record review of the Internal Investigation dated [DATE] revealed in part .that on [DATE], CR #1 appearing drowsy and sleeping. Family voiced concerns to Hospice Nurse . Hospice nurse made nurse aware of medication error. The hospice nurse spoke with DON to make her aware of medication error. Record review of CR #1's SBAR dated [DATE] at 6:12 pm was signed by the DON, which revealed that vital signs were taken (no time given), Blood Pressure ,[DATE], Temp 97, P 58, Respiratory Rate 14, no pulse oximetry done. Mental status changes were compared to baseline and found to have decreased level of consciousness. He also had decreased urinary output. In an interview on [DATE] at 8:15 am with the DON, she stated that the family of CR #1 , one was a nurse and saw RN A administer 5 syringes of pain medication on Sunday evening. She also stated that each syringe held 1 ml of [MEDICATION NAME]. The police were not notified. The facility does check off's for medication administration at hire and also does random medication administration checks. She stated that RN A came in and wrote her statement, and that same day RN A was terminated. In a telephone interview on [DATE] at 11:00 am with RN A the nurse who gave an overdose of [MEDICATION NAME] to CR #1, she stated that she wrote everything in the statement at the facility. She further stated that if the surveyor had any more questions , that they could speak to her lawyer. RN A did not provide the name of her lawyer at that time. In a telephone interview on [DATE] at 10:15 am with the Nurse Practitioner she stated that the facility called her around ,[DATE] pm on [DATE] and let her know CR #1 had been given an overdose of [MEDICATION NAME]. She stated that she did not consider [MEDICATION NAME] (an opioid antagonist used for the complete or partial reversal of opioid overdose, including respiratory depression. [MEDICATION NAME] is also used for [DIAGNOSES REDACTED].) because she was told he was stable. She further stated that she asked how he was and was told that he was stable.His blood pressure was lower than previously but not much lower. She also stated that she held the [MEDICATION NAME] and anxiety medication at that time. She stated that after CR #1 died , no toxicology blood work was done. In an interview on [DATE] at 10:30 am with the Administrator, she stated that she was the Abuse Prevention Coordinator. She stated that she did not report the overdose of [MEDICATION NAME] related to resident CR #1 immediately because there was no negative outcome. She further stated that she filed a report after CR #1 died . Resident #2 Record review of Resident #2's facesheet revealed that she was an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS (Minimum Data Set) dated [DATE] revealed that she was understood by others and that she usually understood. Her cognitive function section revealed that she had a score of 7 out of 15 on her BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment. Review of her medications revealed that she had taken anticoagulants all 7 days during look back. Record review of Resident #2's Care Plan revealed in part . that one of her Problems: Resident #2 was at risk for increased bleeding related to the use of blood thinning agent. Her goal was to not have side effects from medication and interventions included to administer meds as ordered and observe for side effects. Record review of Resident #2's consolidated Physicians Orders for (MONTH) (YEAR) revealed that she had an order for [REDACTED]. Record review of Resident #2's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the facility's Accident/Incident report dated [DATE] revealed during chart audits that Resident #2 received a dose of [MEDICATION NAME] 2.5 mg and that she did not have an order for [REDACTED]. Employee (LVN B) was educated on 5 rights of medication and in-servicing on proper medication administration was done. In an interview on [DATE] at 10:50 am with the DON, she stated that LVN B received the [MEDICATION NAME] order and gave it to the wrong resident. The DON further stated that there were two residents with the same last name. She stated that LVN B pulled up the wrong resident on the electronic record, started the new medication and placed the medication order into the wrong residents electronic MAR. She also stated that each MAR indicated [REDACTED]. Record review of the CDC website on an article, Adverse Drug Events in Adults, revealed that an adverse drug event (ADE) is when someone is harmed by a medicine. Older adults ([AGE] years or older) visit emergency departments almost 450,000 times each year, more than twice as often as younger persons. Older adults are nearly seven times more likely than younger persons to be hospitalized after an emergency visit, but most of these hospitalization s are due to just a few drugs that should be monitored carefully to prevent problems. Blood thinners (such as [MEDICATION NAME]), diabetes medications (such as insulin), [MEDICAL CONDITION] medications (such as [MEDICATION NAME]), and opioid [MEDICATION NAME] are some examples of these medications. Record review of the facility's policy for Administering Medications, Nursing Services Policy and Procedure Manual for Long-Term Care, 2001 Med-Pass, Inc (Revised (MONTH) 2012) read in part; Policy Statement - Medications shall be administered in a safe and timely manner, and as prescribed.3. Medications must be administered in accordance with the orders, including any required time frame.5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. Information on the 672 provided by the DON revealed that there were 80 residents in the facility.

Based on interview, and record review, the facility failed to implement their written policies and procedures that prohibit neglect for one of nine Residents (CR #4) reviewed for neglect. -The facility failed to provide CR#4 with a Hoyer lift transfer as ordered, resulting in a fall where the resident sustained [REDACTED]. -CNA A, CNA B and CNA C failed to notify the nurse that Resident CR#4 fell during the transfer and put her back to bed. These failures affected one former resident and had the potential to place eight current residents at the facility who require Hoyer lift transfers at risk of physical harm, pain, not receiving care and services, delay in treatment, complications, hospitalization or mental anguish. Findings include: Compliant Intake # 2/TX 134 Incident Intake # 5/TX 266 Record review of CR #4's face sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident CR#4 ' s electronic care plan dated [DATE] revealed the following: -Problem: CR #4 requires staff assistance with activities of daily living (ADL ' s) related to right [MEDICAL CONDITION] with decreased range of motion (ROM) -decreased ROM to bilateral lower extremities -Interventions: assist with transfer as needed by Hoyer lift Record review of Resident CR#4 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 2 out of 15 which indicted her cognition was impaired. The resident required extensive assistance from two staff for her bed mobility, transfers, dressing, toilet use and personal hygiene and extensive assistance from one staff for eating. Continued review of the MDS revealed the resident had limitations in her range of motion to her bilateral lower extremities and one side of her upper extremities. Record review of Resident CR#4 ' s electronic care plan dated [DATE] and updated on [DATE] revealed the following: -Problem: At risk for falls related to impaired mobility, generalized muscle weakness, deconditioning. Requires staff assistance for all transfers, right [MEDICAL CONDITION]-Reported to charge nurse CNA ' s dropped Resident CR#4 during her transfer for a bath. The resident complained of right lower extremity pain, swelling, sent to local hospital for X-ray/Doppler to right lower extremity to rule out fracture. Record review of Resident CR#4 ' s verbal physician order sheet dated [DATE] revealed the following orders: -Doppler right lower extremity-venous; -Bilateral lower extremity x-rays hip to ankle -Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and [MEDICATION NAME] time / International normalized ratio (PT/INR). (Blood tests to monitor for blood clotting). Record review of Resident CR#4 ' s electronic physician ' s order dated [DATE] revealed -Transfer to hospital -unplanned. Record review of Resident CR#4 ' s electronic clinical note report dated [DATE] revealed: Resident reported aides dropped her during a transfer for bath, then placed her back in bed and gave her a bed bath. The resident ' s responsible party and physician were notified. Continued review of the clinical notes revealed the revealed the facility was unable to get a mobile X-ray due to resident not being able to straighten her leg. Physician was notified and ordered to send to local hospital. Resident was transferred by transport ambulance. Record review of the facility grievance /complaint report dated [DATE] revealed Resident CR#4 ' s family member/ resident ' s representative met with the facility administrator and director of nurses (DON) . Documentation of grievance/complaint .to discuss the incident that occurred with Resident (CR#4) . Documentation of Facility Follow up .explained to family member the incident was reported to Texas Department of Aging and Disability Services (TDADS) and it was being investigated . Record review of the facility accident/incident report dated [DATE] Resident CR#4 had a witnessed fall due to improper transfer. Continued review of the report revealed the following . While being transferred inappropriately Resident CR#4 was put on the side of the bed in an attempt to slide her to the shower chair utilizing Resident CR#4 ' s brief to lift her. Resident CR#4 ' s legs gave out and she was lowered to her side on the floor. The CNA lowered the bed as low as possible lifted the resident back into the bed. The CNAs continued with a bed bath without notifying anyone of the incident. Resident was sent to the hospital for suspected fracture. It was reported to DADS. Record review of the facility coaching and counseling record dated [DATE] revealed the following for CNA A, CNA B and CNA C: - Supervisor remarks: Employee failed to follow the facility transfer guidelines and protocols in relation to transfers and reporting incidents and accidents to the Licensed Nurses in order to prevent patients from undue distress. Employee has had several education and training sessions on transfer, abuse and neglect, reporting incidents and accessing the daily care guide for patient information. ---Action taken revealed: Due to the egregious nature of the incident as well as recent training and failure to comply with the facility standards and protocols the employee has been terminated for not complying. Continued review revealed CNA A and CNA B signed the record CNA C refused to sign the form. Record review of Resident CR#4's Daily Care Guide with the following dates: [DATE], [DATE] and [DATE] revealed the following: Transfer Status Mechanical (Hoyer) lift-assist by 2 (or more . In an interview on [DATE] at 9:15am the administrator stated all the staff involved in the incident involving Resident CR#4 was fired. They all were caught lying it was really bad. She stated the staff did not report what happened. In an interview on [DATE] at approximately 11:30am DON stated these were three staff who knew better and knew what they did was wrong. Two CNAs (CNA A and CNA B) tried to transfer Resident CR#4 by using her brief rather than the Hoyer lift. The resident ' s legs gave out and they lowered her to the floor. They found the third CNA (CNA C) and they all put Resident CR#4 back to bed, tucked her in and never told anyone about it. The resident ' s transfer method was on the daily care guide that is reviewed daily before working with the residents. The resident told her daughter the CNAs dropped her and she had pain, the nurse was notified by the daughter who notified the DON. In an interview on [DATE] at 9:05am the DON stated LVN A ( former employee) who was caring for Resident CR#4 was told the resident was having pain and she thought it was her hand because that was where she normally has pain. LVN A repositioned the resident ' s arm and hand then asked her if that was alright the resident answered her in Spanish that it was all right. Then the resident ' s daughter came in and told LVN A the resident ' s pain was in her leg due to a fall, LVN A did not know of a fall, she assessed the resident, notified the physician, medicated the resident for pain and notified me that she believed something happened to Resident CR#4 during her transfer. In a phone interview on [DATE] at 2:34pm CNA C stated she was not in the room when Resident CR#4 was transferred and fell . She stated CNA A came out in the hall and asked her to help them get the resident in to bed. She did help put the resident to bed. CNA C stated she was told if anyone asked if Resident #4 fell say no. CNA C stated she panicked and lied and said the resident did not fall. The CNA stated the three CNA ' s put a sheet under the resident while she was on the floor and lifted her into bed. They gave her a bed bath and did not report it. CNA C stated she was notified the next day the resident broke her hip. In a phone interview on [DATE] at 9:05am with Resident CR#4 ' s family member, she stated the CNAs caused the resident to fall. She said the resident was sent back out to the hospital and she just died . She said this was all a result of the fall. The family member stated a fourth staff member was involved but she did not know who. In a phone interview on [DATE] at 9:35am former employee LVN A stated she was not notified of Resident CR#4 ' s fall. The resident had pain but was better after she supported the resident ' s arm and hand. The LVN stated the resident ' s daughter came in and notified her of the resident ' s fall. She stated she immediately notified the doctor, we did test for clots because she has a history of blood clots. We needed to send her to the hospital because we could not complete the X-ray here and she did have a fracture. In an interview on [DATE] at 10:40am The DON stated the resident and family reported there was four staff but our investigation determined the three staff who we already identified. Record review of the facility policy titled Patient Care Management system 18 dated February 2015 revealed .1. The stop and watch early warning tool must be completed upon the first signs of a patient presenting with a change in condition. The completed tool must be presented to the licensed nurse immediately . Record review of the facility policy titled Abuse Protocol .1. Our facility will not condone abuse, neglect, mistreatment or misappropriation of patient property by anyone including staff members . 4. The abuse prevention coordinator will assure that all facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment . 5.Our facility will not retaliate againist any person who in good faith reports an allegation. Accidents and incidents must be reported both internally and externally in accordance with the Reportable Incident Protocol .b. All persons who report an allegation of abuse or neglect will be kept confidential by the abuse prevention coordinator. A policy for Hoyer (mechanical) lift was requested but not provided prior to exit. The facility DON identified 8 residents transferred by Hoyer lift transfers.

Based on interview and record review the facility failed to provide necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for 1 resident (CR #4) of nine residents reviewed for quality of care and neglect. -The facility failed to transfer CR#4 using the required Hoyer lift and CR#4 had a fall during the inappropriate transfer which resulted in a [MEDICAL CONDITION], resulting in hospitalization ; -The facility staff failed to notify the nurse that Resident CR#4 fell during the transfer and put her back to bed. These failures affected one former resident and had the potential to place eight current residents at the facility who require Hoyer lift transfers at risk of physical harm, pain, and/or hospitalization . Findings include: Complaint Intake # 2 /Incident Intake # 5 CR#4 Record review of CR #4's face sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident CR#4 ' s electronic care plan dated [DATE] revealed the following: -Problem: CR #4 requires staff assistance with activities of daily living (ADL ' s) related to right [MEDICAL CONDITION] with decreased range of motion (ROM) -decreased ROM to bilateral lower extremities -Interventions: assist with transfer as needed by Hoyer lift Record review of Resident CR#4 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 2 out of 15 which indicted her cognition was impaired. The resident required extensive assistance from two staff for her bed mobility, transfers, dressing, toilet use and personal hygiene and extensive assistance from one staff for eating. Continued review of the MDS revealed the resident had limitations in her range of motion to her bilateral lower extremities and one side of her upper extremities. Record review of Resident CR#4 ' s electronic care plan dated [DATE] and updated on [DATE] revealed the following: -Problem: At risk for falls related to impaired mobility, generalized muscle weakness, deconditioning. Requires staff assistance for all transfers, right [MEDICAL CONDITION]-Reported to charge nurse CNAs dropped Resident CR#4 during her transfer for a bath. The resident complained of right lower extremity pain, swelling, sent to local hospital for X-ray/Doppler to right lower extremity to rule out fracture. Record review of Resident CR#4 ' s verbal physician order sheet dated [DATE] revealed the following orders: -Doppler right lower extremity-venous; -Bilateral lower extremity x-rays hip to ankle -Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and [MEDICATION NAME] time / International normalized ratio (PT/INR). (Blood tests to monitor for blood clotting). Record review of Resident CR#4 ' s electronic physician ' s order dated [DATE] revealed -Transfer to hospital -unplanned. Record review of Resident CR#4 ' s electronic clinical note report dated [DATE] revealed: Resident reported aides dropped her during a transfer for bath, then placed her back in bed and gave her a bed bath. The resident ' s responsible party and physician were notified. Continued review of the clinical notes revealed the revealed the facility was unable to get a mobile X-ray due to resident not being able to straighten her leg. Physician was notified and ordered to send to local hospital. Resident was transferred by transport ambulance. Record review of the facility grievance /complaint report dated [DATE] revealed Resident CR#4 ' s family member/ resident ' s representative met with the facility administrator and director of nurses (DON) . Documentation of grievance/complaint .to discuss the incident that occurred with Resident CR#4 . Documentation of Facility Follow up .explained to family member the incident was reported to Texas Department of Aging and Disability Services (TDADS) and it was being investigated . Record review of the facility accident/incident report dated [DATE] Resident CR#4 had a witnessed fall due to improper transfer. Continued review of the report revealed the following . While being transferred inappropriately Resident CR#4 was put on the side of the bed in an attempt to slide her to the shower chair utilizing Resident CR#4 ' s brief to lift her. Resident CR#4 ' s legs gave out and she was lowered to her side on the floor. The CNA lowered the bed as low as possible lifted the resident back into the bed. The CNAs continued with a bed bath without notifying anyone of the incident. Resident was sent to the hospital for suspected fracture. It was reported to DADs. Record review of the facility coaching and counseling record dated [DATE] revealed the following for CNA A, CNA B and CNA C: - Supervisor remarks: Employee failed to follow the facility transfer guidelines and protocols in relation to transfers and reporting incidents and accidents to the Licensed Nurses in order to prevent patients from undue distress. Employee has had several education and training sessions on transfer, abuse and neglect, reporting incidents and accessing the daily care guide for patient information. ---Action taken revealed: Due to the egregious nature of the incident as well as recent training and failure to comply with the facility standards and protocols the employee has been terminated for not complying. Continued review revealed CNA A and CNA B signed the record CNA C refused to sign the form. Record review of Resident CR#4's Daily Care Guide with the following dates: [DATE], [DATE] and [DATE] revealed the following: Transfer Status Mechanical (Hoyer) lift-assist by 2 (or more . In an interview on [DATE] at 9:15am the administrator stated all the staff involved in the incident involving Resident CR#4 was fired. They all were caught lying it was really bad. She stated the staff did not report what happened. In an interview on [DATE] at approximately 11:30am DON stated these three staff who knew better and knew what they did was wrong. Two CNAs (CNA A and CNA B) tried to transfer Resident CR#4 by using her brief rather than the Hoyer lift. The resident ' s legs gave out and they lowered her to the floor. They found the third CNA (CNA C) and they all put Resident CR#4 back to bed, tucked her in and never told anyone about it. The resident ' s transfer method was on the daily care guide that is reviewed daily before working with the residents. The resident told her daughter the CNAs dropped her and she had pain, the nurse was notified by the daughter who notified the DON. In an interview on [DATE] at 9:05am the DON stated LVN A ( a former employee) who was caring for Resident CR#4 was told the resident was having pain and she thought it was her hand because that was where she normally has pain. LVN A repositioned the resident ' s arm and hand then asked her if that was alright the resident answered her in Spanish that it was all right. Then the resident ' s daughter came in and told LVN A the resident ' s pain was in her leg due to a fall, LVN A did not know of a fall, she assessed the resident, notified the physician, medicated the resident for pain and notified me that she believed something happened to Resident CR#4 during her transfer. In a phone interview on [DATE] at 2:34pm CNA C stated she was not in the room when Resident CR#4 was transferred and fell . She stated CNA A came out in the hall and asked her to help them get the resident in to bed. She did help put the resident to bed. CNA C stated she was told if anyone asked if Resident #4 fell say no. CNA C stated she panicked and lied and said the resident did not fall. The CNA stated the three CNAs put a sheet under the resident while she was on the floor and lifted her into bed. They gave her a bed bath and did not report it. CNA C stated she was notified the next day the resident broke her hip. In a phone interview on [DATE] at 9:05am with Resident CR#4 ' s family member, she stated the CNAs caused the resident to fall. She siad the resident was sent back out to the hospital and she just died . She said this was all a result of the fall. The family member stated a fourth staff member was involved but she did not know who. In a phone interview on [DATE] at 9:35am former employee LVN A stated she was not notified of Resident CR#4 ' s fall. The resident had pain but was better after she supported the resident ' s arm and hand. The LVN stated the resident ' s daughter came in and notified her of the resident ' s fall. She stated she immediately notified the doctor, we did test for clots because she has a history of blood clots. We needed to send her to the hospital because we could not complete the X-ray here and she did have a fracture. In an interview on [DATE] at 10:40am The DON stated the resident and family reported there was four staff but our investigation determined the three staff who we already identified. Record review of the facility policy titled Patient Care Management system 18 dated February 2015 revealed .1. The stop and watch early warning tool must be completed upon the first signs of a patient presenting with a change in condition. The completed tool must be presented to the licensed nurse immediately . A policy for Hoyer (mechanical) lift was requested, but not provided prior to exit. The facility roster identified 8 residents transferred by Hoyer lift transfers.

Based on interview and record review, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of four residents (CR #1) reviewed for catheter care. The facility failed to consult with the MD changes of CR #1's urine color. CR #1 was admitted to a local hospital and was diagnosed with [REDACTED]. This failure affected one former resident and had the potential to place 5 residents at the facility with indwelling or external catheters at risk of not receiving care and services, delay in treatment, complications, and hospitalization . Findings include: Record review of CR #1's face sheet revealed he was [AGE] years old. He was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR #1 was admitted to a local hospital and was diagnosed with [REDACTED]. Record review of CR #1's MD orders dated 7/8/2016 revealed the following: -Change foley catheter every month on the 10th of each month. Current size 16 FE with 10cc for [DIAGNOSES REDACTED]. Record review of CR #1's care plan with effective date of 7/8/2016 revealed the following: -Problem: CR #1 has a foley catheter related to [DIAGNOSES REDACTED]. -Interventions: Observe urine for odor, color, sediments and amount of urine and report abnormalities to MD per facility policy. Record review of CR #1's Admission Assessment MDS dated [DATE] revealed CR #1 was cognitively intact with a BIMS score of 14 out of a possible 15. He required extensive assistance of two persons for bed mobility and transfer and extensive assistance of one person for locomotion, dressing, toilet use and personal hygiene. CR #1 was total dependent for bathing. He was frequent incontinent of bowel and had an indwelling catheter. Record review of CR#1's Clinical Notes Report revealed the following: -8/1/2016 at 1:39 p.m. CR#1 has a foley in place which is draining clear yellow urine . -8/3/2016 at 9:59 a.m. .foley catheter draining slightly reddish/yellow urine . -8/3/2016 at 4:23 p.m. .foley catheter draining slightly reddish/yellow urine . -8/7/2016 at 10:38 a.m. .foley catheter draining slightly cloudy yellow urine . -8/8/2016 at 12:49 p.m. foley catheter draining slightly cloudy yellow urine . -8/9/2016 at 5:18 p.m. Foley catheter draining cloudy yellow urine -8/10/2016 at 10:34 p.m. .Foley catheter draining cloudy yellow urine . Further record review revealed no information that the MD was notified of changes in color of urine. Continued record review of CR#1's Clinical Notes Report revealed the following: -8/11/2016 at 7:05 p.m. CR #1 returned from [MEDICAL TREATMENT] with decreased level of consciousness and lethargy. He is not responding to verbal or physical stimuli. Blood pressure 123/63, pulse [MEDICAL CONDITION] (fast heart rate) at 122, respirations 22 to 26 and temperature 103.2 axillary. Unable to squeeze hands. RP at bedside and very concerned and wants CR #1 to go to the hospital to be evaluated. Called MD and she advised CR #1 possible having [MEDICAL CONDITION] and needs to go to the ER for evaluation . (sepsis is a life-threatening condition in which the body is fighting a severe infection that has spread via the bloodstream) Record review of CR#1's Emergency Department notes dated 8/11/2016 at 8:06 p.m. revealed in part: .Altered Mental Status noticed by his (family member) today around 5:30 p.m. when he went to visit him. CR #1 had his scheduled [MEDICAL TREATMENT] today and usually returns to his room around 5:00 p.m. CR#1 was shivering and had a fever, not able to talk. Altered Mental Status. Associated symptoms include a fever. Not able to speak, looks at you and then closes his eyes. Had [MEDICAL TREATMENT] today and when family visited him he was altered and unable to speak, appears to try to talk. The severity of altered mental status is severe. -Clinical Impression: Altered mental status, Urinary tract infection, Lymphocytosis (elevated type of a white blood cell),[MEDICAL CONDITION]. -Plan: hospitalization for [MEDICATION NAME] (intravenously or by injection) antibiotics and further care. -Urinalysis with microscopic in part: Cloudy amber urine Bacteria: Many Leukocytes (white blood cells): Large. Reference Range: (Negative) Further record review of Urine Specimen Information in part: -Results: > 100,000 col/mL Lactose fermenting gram negative rods -Complete blood cell count in part: White blood cells 23.9 Reference Range: (4.0 - 10.0 K/uL) . Record review of CR#1's Infectious diseases consult note dated 8/12/2016 revealed the following: . Assessment: Leukocytosis, urinary tract infection and altered mental status. Plan:[MEDICAL CONDITION]/[MEDICAL CONDITION], leukocytosis, [DIAGNOSES REDACTED] (gram-negative, lactose-fermenting bacterium) urinary tract infection. At this point continue [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic), symptoms appear to be consistent with Gram Negative [MEDICAL CONDITION]. Would recommend changing foley. -History and Present illness in part: admitted from nursing home with fever, chills and altered mental status. Urine cultures revealed Lactose fermenting gram negative rods. Altered mental status with urosepsis on antibiotics In an interview on 9/8/2016 at 4:05 p.m. with the ADON, he stated that charge nurses are in charge of monitoring pericare to all residents with foley catheter tubes and that nurses also monitor the insertion site and the output of urine. He further said that CR #1 had his urine cloudy yellow but did not have any sediments. He then said that cloudy urine was not an indication of any problem unless it had sediments in it. Continued interview at that time, he said that he worked with CR #1 during the night shift on 8/9/2016 and 8/10/2016 and that he did not think there were any problems with CR#1's urine and then said It would alert me a bunch of sediments, dark color or any type of color change of urine from the original. If I see anything like that, I would call the MD to get orders for urinalysis. In an interview on 9/8/2016 at 4:25 p.m. with the DON, he stated that the nursing staff would monitor the residents with urinary catheters every shift and would look to see changes in the urine like sediments. He then said that blood in urine could be an indication of infection or trauma and continued saying CR #1 was a [MEDICAL TREATMENT] resident and he might have experienced changes in his urine or cloudiness . Further interview at that time, when asked about the different dates and different changes of CR #1's urine, the DON said different people might look at the presentation and might had different assessments. That might be a word issue. While ADON was using cloudy to describe the urine color, the other nurse was using reddish in color. It is just a different assessment terms that different nurses used to describe CR #1's urine color. Record review of the facility policy and procedure on Catheter care dated 6/14/2006 revealed in part; Purpose: To prevent infection and to reduce irritation. Documentation: Color, amount, consistency and odor of urine, notification of the physician of any condition change . The CMS 672 dated 09/08/16 indicated 5 residents had indwelling or external catheters.