Every finding on record at The Carlyle at Stonebridge Park

Based on interview and record review, the facility failed to ensure if hospice care is furnished in a LTC facility through an agreement with a hospice, the LTC facility must have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility that sets out the communication process, including how the communication with be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day and a provision that that LTC facility immediately notifies the hospice about the following: a significant change in the resident's physical, mental, social, or emotional status and clinical complications that suggest a need to alter the plan of care for 1 of 3 residents (Resident #1) reviewed for hospice services. The facility failed to notify Resident #1's hospice agency on 07/03/26-07/05/26 when the resident was showing signs of a possible UTI. This failure could place residents at risk for worsening of condition which could lead to serious harm.Findings included:Record review of Resident #1's Discharge MDS Assessment, dated 07/18/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 07/18/26 on hospice status. The MDS Assessment reflected Resident #1's active diagnoses included: cerebral atherosclerosis (narrowed arteries of the brain due to a build-up of plaque that causes cognitive decline and high risk of a stroke), heart disease, and respiratory failure. The MDS reflected Resident #1's BIMS score was not calculated. The MDS reflected Resident #1 was dependent on staff for most ADLs, and he had an indwelling catheter. Record review of Resident #1's Care Plan, revised 07/29/26, reflected that Resident #1 had a catheter. Interventions included: positioning the catheter bag and tubing below bladder level and away from entrance door, checking tubing for kinks each shift, monitoring, documenting for pain and discomfort due to catheter, monitoring, recording, and reporting to MD for s/sx of UTI. This document also reflected Resident #1 required hospice as evidenced by terminal illness of cerebral atherosclerosis. Interventions included: feeding resident as needed, assisting with ADLs and providing comfort measures, monitoring for decreased appetite, weight loss, skin breakdown, and n/v, monitoring for increased pain and discomfort, giving med/tx, and monitoring for relief, providing oral care daily, reporting decline in condition to hospice agency, and repositioning frequently.Record review of Resident #1's EHR reflected the resident had a BIMS score of 9, which indicated moderate cognitive impairment. Record review of Resident #1's progress notes reflected the following entries:07/02/26 at 11:38 a.m. - LVN B wrote: Resident complaint of pain where his suprapubic catheter is. Nurse assessed resident and asked him what his pain level was from 0-10. Resident state that the pain stopped. Nurse advised resident if the pain starts back up to let the nurse know. Will continue to monitor resident.07/02/26 at 2:48 p.m. - LVN B wrote: [LVN B] spoke with [MD] about [Resident #1] complaining of pain in the groin area. [MD] provided a new order to do a UA and C&S to make sure resident doesn't have a UTI. 07/02/26 3:03 p.m. - LVN B wrote: Urine needs to be collected from resident. Order is already input.07/02/26 at 9:20 p.m. - LVN C wrote: [Resident #1] c/o pain in the penile area, possibly r/t the indwelling catheter. [Hospice provider] was notified, and new order was received to administer Tylenol 325mg, two tablets by mouth every 4 hours as needed for pain. Medication will be administered as ordered, and [Resident #1] will continue to be monitored for pain relief and any changes in condition.07/03/26 1:48 a.m. - LVN A wrote: PRN Administration was: Effective. Follow-up Pain Scale was: 1.07/03/26 2:37 a.m. - LVN A wrote: urine specimen for UA C&S obtained and will be picked up in am.07/03/26 5:40 a.m. - LVN A wrote: follow [sic] cath bag changed and follow [sic, Foley] adjusted. Output 1600. Pt denies pain at this time.07/03/26 at 10:15 a.m. - LVN B wrote: PRN Administration was: Effective07/04/26 9:57 p.m. - LVN B wrote: Resident's catheter was emptied. Urine output was 1000ml. Resident has no complaints of pain or discomfort at this time.07/05/26 at 4:13 a.m. - LVN A wrote: Urine Culture > 100000 colony count [indication of a significant amount of bacteria present]. Sensitivity pending.07/05/26 at 8:43 a.m. - LVN B wrote: Resident requested pain medication.07/05/26 at 10:15 a.m. - LVN B wrote: Follow-up Pain Scale was: 0. PRN Administration was: Effective.07/05/26 at 1:58 p.m. - LVN B wrote: Nurse emptied resident's catheter. Urine output was 400ml. Resident is lying in bed with no complaints at this time.07/05/26 at 4:31 p.m. - LVN B wrote: Follow-up Pain Scale was: 2. PRN Administration was: Effective.07/06/26 at 11:54 a.m. - LVN D wrote: Seen by hospice nurse, 16FR foley [sic] inserted by the hospice and [Resident #1] tolerated well, new antibiotic order received for Augmentin (prescription combination antibiotic) 875mg bid for 7 days for UTI.Prior to the Progress Notes dated 07/06/26 at 11:54 a.m., there was no documentation reflecting that the nurses had notified Resident #1's hospice agency that he was having possible symptoms of a UTI.Record review of Resident #1's consolidated physician orders, dated 08/06/26, reflected in part the following:-Admit to hospice DX: [Hospice provider]. Order date: 06/26/26-DNR. Order date: 06/18/26-Foley catheter-change anchor and drainage bag as needed. Start date 06/18/26-Foley catheter-change anchor and drainage bag every night shift every 15 days. Start date 06/18/26-Foley catheter- Check for patency (tubing remains open, clear and functioning) and placement. Ensure that privacy bag is on at all times to maintain privacy. Current size 16FR/10 CC every shift. Start date: 06/18/26-Foley catheter care- every shift with soap and water or may use wipes as appropriate/ desired by [Resident #1]. Start date: 06/18/26-Tylenol (pain med) Oral Tablet 325 MG (Acetaminophen) **DAW** Give 325 mg by mouth every 4 hours asneeded for pain. Start date: 07/02/26- Amoxicillin-Pot Clavulanate (combination antibiotic) Tablet 875-125 MG. Give 1 tablet by mouth every 12 hours for bacterial infection-/ UTI for 7 Days. Start date: 07/06/26; End date: 07/13/26- Hydrocodone-Acetaminophen (narcotic pain med) Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain related to pain, unspecified. Start date: 07/15/26- Morphine Sulfate ER (narcotic pain med) Oral Tablet Extended Release 15 MG (Morphine Sulfate) Give 1 tablet by mouth one time a day for pain related to pain, unspecified. Start date: 07/16/26Record review of Resident #1's hospice contract, dated 06/13/25, reflected in part the following: This agreement for Nursing Facility and Inpatient Respite Services ( Agreement) is entered into and effected as of 6/13/26, by and between [Hospice provider], a Texas limited partnership and [Nursing facility] .Now, therefore, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows:.1.8 Hospice Services means those services and items that are (i) reasonable and necessary for the palliation and management of a Hospice Patient's terminal Illness and related conditions, and (ii) within the definition of Medicare-covered hospice services, all as specified in such Hospice Patient's Plan of Care. Such services include, but are not limited to, medical direction and management of the Hospice Patient, nursing, counseling (including spiritual, dietary and bereavement), social work, provision of medical supplies, durable medical equipment and drugs, all as necessary for the palliation of pain and symptoms associated with and necessary for the care of the Hospice Resident's terminal illness and related conditions.1.10 Interdisciplinary Team means a team of individuals employed (or contracted) and selected by [hospice provider] which includes a (i) Doctor of Medicine or osteopathy, (ii) registered nurse, (iii) social worker, (iv) pastoral and/or other counselor.2.1.3 Coordination, Supervision and Evaluation of Services. [Hospice provider] will coordinate, supervise and evaluate the delivery of services provided to a Hospice Patient hereunder in the following manner:2.1.3.1 [Hospice provider] will promote open and frequent communication, in person, by phone or FAX, or in writing between [hospice provider] and Facility staff concerning the Hospice Plan of Care and [Resident #1's] needs. [Hospice provider] staff, will attend Facility's patient care conferences when [Resident #1] will be discussed.2.1.4.1 In the provision of care to [Resident #1], the Facility shall be responsible for:2.1.4.1.1 Providing Services as contained in the Hospice Plan of Care2.1.4.1.2 Communicating to designated [hospice provider] personnel any changes in the [Resident #1's] condition, including [Resident #1's] reaction to treatment and recommendations for appropriate modifications to [Resident #1's] Hospice Plan of Care. In an interview on 08/06/26 at 10:30 a.m., Resident #1's family stated Resident #1 was currently admitted to an inpatient hospice facility after discharging from the nursing facility on 07/18/26. She stated that although Resident #1 admitted to the nursing facility on hospice and she understood that he was at the end of his life, she believed the facility's negligence caused a significant decline in the resident's health. Resident #1's family stated she believed due to inadequate training and insufficient staff, the facility failed to provide acceptable standards of care and treatment, including catheter care. She stated the facility's failure to monitor for signs of infection and notify the treating providers per Resident #1's care plan resulted in the resident ending up in the hospital on [DATE] diagnosed with a kidney infection and urosepsis. In an interview on 08/06/26 at 11:05 a.m., the MD stated Resident #1 was admitted to the nursing facility on hospice. The MD stated Resident #1 was at the nursing facility for a short period, and he only saw him once. The MD stated Resident #1 had a Foley catheter, and along with his other co-morbidities he was at high risk for UTIs. The MD stated the facility notified him that Resident #1 was experiencing pain, so he ordered a UA although it was not typical for hospice patients to have lab work completed. The MD stated hospice only treated symptoms to provide comfort. The MD stated that while the facility notified him of all changes in residents' conditions, the hospice team had priority for notification regarding hospice patients. In an interview on 08/06/26 at 1:10 p.m., the Hospice RN stated Resident #1 was her patient and she cared for him at the nursing facility once a week, on Mondays, and as needed. The Hospice RN stated hospice services were available 24 hours a day and a nurse could come out at any time. The hospice RN stated she provided catheter care for Resident #1 and the resident was being treated for pain. She stated hospice was in the process of figuring out a better pain regimen for Resident #1, but it was difficult because he could not specify where the pain was coming from. She stated the resident would sometimes point to the catheter tubing when asked where he was feeling pain, and she could not determine if the pain was internal. She stated Resident #1's catheter was changed once a month and as needed. The hospice RN stated the facility was expected to notify hospice first regarding any changes in Resident #1's condition. She stated the facility was typically good about doing so until they dropped the ball during the weekend of 07/03/26-07/05/26. The hospice RN stated Resident #1's pain did not remain managed, and hospice was not notified of the change. She stated she visited Resident #1 on 07/06/26 and her notes indicated that a new Foley catheter was inserted and the resident did not tolerate it well due to pain. She stated Resident #1 also had discharge that looked like an infection. The hospice RN stated Resident #1 received a new order for antibiotics and stronger pain medication. She stated Resident #1 informed her that he experienced pain and discomfort over the weekend. She stated if the facility had notified hospice over the weekend, she would have come to the facility sooner to treat the resident's symptoms and make him comfortable. The hospice RN stated Resident #1 responded well to the antibiotics initially, but the infection came back and treatment had to be changed on 07/15/26. She stated Resident #1 was discharged from the nursing facility on 07/18/26 after a change in condition. In an interview on 08/06/26 at 1:35 p.m., the ADON stated she worked at the facility for 3 years. The ADON stated she was familiar with Resident #1 but did not work with him directly. The ADON stated it was protocol for the facility to notify the hospice provider of any changes for residents receiving hospice services. She stated the expectation was for the nurses to also notify the facility's MD to ensure that he was in the loop. The ADON stated hospice services were available 24 hours a day and the nurses were aware that they could be called at any time. In an interview on 08/06/26 at 2:15 p.m., CNA E stated she worked at the facility for 1.5 years and provided cared for Resident #1. CNA E stated Resident #1 required extensive assistance and the aides were responsible for providing catheter care that included, emptying the resident's catheter bag and cleaning his perineal area. CNA E stated during catheter care the aides had to monitor for changes in urine or other signs of infection. She stated that she never observed any blood or pus in Resident #1's urine or catheter tubing. CNA E stated sometimes during perineal care, Resident #1 would complain of pain and state My penis is hurting. CNA E stated she would always report the resident's complaints to her charge nurse immediately. In an interview on 08/06/26 at 2:45 p.m., LVN B stated she worked at the facility for about a month, and she cared for Resident #1. LVN B stated Resident #1 complained of pain in his groin area on her first day working with him, and she contacted the facility's physician. who gave an order for a UA. She did not state that she notified the hospice provider. LVN B stated she worked with Resident #1 again the following weekend, on 07/04/26, and the resident did not complain of pain during her initial assessment. LVN B stated Resident #1 would complain about pain more when Resident #1's family was present. LVN B stated she was trained in notifying the physician of changes upon hire and knew to notify the hospice provider for residents receiving hospice care. LVN B stated her knowledge of this also came from her nursing experience. In an interview on 08/06/26 at 3:12 p.m., the Regional Director of Clinical Services stated it was the facility's policy to notify the physician of any changes in a resident's condition because, as Medical Director, he was responsible for managing all residents' care at the facility. He stated LVN B informed them that she attempted to notify the hospice provider regarding Resident #1's pain on 07/02/26, but there was no response, so she contacted the facility's MD and received an order for the UA. The Regional Director of Clinical Services confirmed that the attempt to notify hospice was not documented in Resident #1's clinical chart on this day. She stated the nurses were expected to document all communication. The Regional Director of Clinical Services stated the facility did not have a policy regarding notification to hospice providers, and they referred to their general policy on notifying a physician. The Regional Director of Clinical Services stated she spoke with the corporate managers to consider revising the policy to include hospice notification. She stated the facility also did not have training specific to hospice notification, but it was addressed during the nurses' skill checkoffs. In an interview on 08/06/26 at 3:30 p.m., the Interim DON stated she started as Interim DON at the facility on 07/08/26. She stated for residents on hospice, it was important to report any changes in their condition to the hospice provider, but she informed staff that it was best practice to notify both the attending physician and hospice provider. The Interim DON stated she was informed that Resident #1 admitted to facility as hospice patient with foley catheter and was being treated for a UTI. She stated hospice was also adjusting Resident #1's pain regimen to better manage his pain. The Interim DON stated the nurses were reporting Resident #1's complaint of pain to the facility's physician, and the hospice provider to her knowledge. In an interview on 08/06/26 at 4:12 p.m., LVN A stated she worked the overnight shift and cared for Resident #1. LVN A described Resident #1 as a hospice patient with a Foley catheter that caused him pain. She stated Resident #1 often complained of pain in his groin area and would pull at the catheter. LVN A stated hospice was the point of contact for notification of changes in the resident's condition. She stated the day shift nurses were responsible for notifying the hospice provider and as an overnight nurse she would leave a note if any changes needed to be reported from her shift. LVN A stated it was usually more convenient to notify the facility's MD of changes in condition because they could get new orders quicker; however, she was aware that hospice also had to be notified. LVN A stated it was reported that Resident #1 received an order for a UA after c/o pain and discomfort. LVN A stated she received the UA results during her overnight shift and documented a note to alert everyone. LVN A stated she did not notify hospice at that time. LVN A stated Resident #1 had good urine output and did not show any signs of an infection such as blood or pus in his urine. LVN A stated Resident #1 only complained about pain and the order for pain medication was effective after administration. In an interview on 08/06/26 at 4:45 p.m. with the Administrator and Interim DON, the Interim DON stated not notifying the hospice providers of changes in condition for residents receiving hospice services could place the residents at risk of not having continuum of care. The Administrator stated his expectation was for the nurses to notify the facility's MD first because that has always been their practice and allow the MD to advise them to notify hospice. Record review of the facility's policy titled Notification of Changes, revised 11/2025, reflected in part the following: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Definitions: Life-Threatening Conditions: Examples - Heart Attack or Stroke. Clinical Complications: Examples - Development of stage 2 pressure injury, recurrent episodes of delirium, recurrent UTIs or onset of depression. Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction) or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has not been used on that resident before).Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include:.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include:a. Life-threatening conditions, or b. Clinical complications.3. Circumstances that require a need to alter treatment. This may include:a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences.ii. Acute condition. iii. Exacerbation of a chronic condition.Further review of this document reflected that it did not address the facility's communication process with the hospice provider.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for medication administration. The facility failed to administer Resident #1's oxycodone 10mg at 9:00 PM on 07/13/26 according to physician's orders. This failure could place residents at risk for diminished quality of care. Findings included:Review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female resident admitted to the facility on [DATE]. The resident had a BIMS score of 14 which indicated the resident's cognition was intact. The resident's diagnoses included polyneuropathy (condition where many peripheral nerves all over the body malfunction at the same time), muscle wasting, pain, and age-related physical debility. The MDS also reflected the resident ambulated with a walker and was independent or required set up only for ADLs. The MDS further indicated the resident was on a pain medication regimen. Review of Resident #1's care plan revised on 09/15/25 [SP1.1]reflected she was on oxycodone and interventions included to administer medications as ordered by the physician. Review of Resident #1's monthly physician orders for July 2026 reflected the resident was taking oxycodone oral tablet 10mg by mouth four times a day for pain (start date 05/01/25). [SP2.1]Review of Resident #1's July 2026 MAR reflected the resident did not receive the oxycodone on 07/13/26 at 9:00 PMReview of the narcotic count sheet for Resident #1's oxycodone revealed it was given by LVN D at 2:00 AM. Observation and interview on 07/23/26 at 10:58 AM revealed Resident #1 was in her room sitting on her chair. The resident stated there was a day recently (07/13/26) where she was not given her oxycodone and was told they had run out and did not get the next dose until 3:00 AM. Resident #1 said that because she had neuropathy, and she had been in pain. Interview on 07/23/26 at 1:32 PM with LVN B revealed she worked with Resident #1 and stated the resident was on a scheduled pain medication regimen. LVN B stated she did not recall Resident #1 ever expressing to her that she was having pain or ever requesting PRN pain medication. LVN B stated the resident remained at her baseline and continued to walk around the facility with her walker. Interview on 07/23/26 at 1:47 PM with CNA C revealed she routinely worked with Resident #1 and she had not noticed the resident in any pain nor had the resident expressed being in pain the day she had worked with her. CNA C said Resident #1 continued to walk around the facility with her walker and was never in bed during the day.Interview on 07/23/26 at 3:24 PM with the ADON revealed she was not aware Resident #1 had not received her 9:00 PM dose of oxycodone on 07/13/26. The ADON said the resident should receive her medications, so they were not at risk for pain. Interview on 07/23/26 at 4:25 PM with the Interim DON revealed she was not aware Resident #1 had gone without her 9:00 PM dose of her oxycodone on 07/13/26. The Interim DON said if the nursing staff were waiting for the pharmacy to deliver medications and a certain medication was due; the nurses should reach out to the doctor to see if they can give a different medication. The Interim DON also said the nurses should continue to follow up with the pharmacy to check the status of the medication. The Interim DON further stated it was important for residents to have their medication to ensure they have coverage for pain. Interview on 07/23/26 at 5:17 PM with LVN A revealed she was told Resident #1 was out of her oxycodone for her 9:00 PM dose (07/13/26) so she called pharmacy and they told her the medication was in route and would arrive during their night run but was not given a specific time. LVN A said they looked in the e-kit to see if they had Resident #1's oxycodone dose and they did not and the doctor was not called to see if they could give the resident something else. LVN A said she left her shift at 10:00 PM (07/13/26) and the pharmacy night run had not arrived, so they let the oncoming nurse know (LVN D) about Resident #1's oxycodone. LVN further stated she saw Resident #1 walking around the facility, and she did not complain of pain or look to be in any distress. Attempts to contact LVN D on 07/23/26 at 5:25 PM were unsuccessful. Review of the facility's policy titled Medication Administration implemented on 10/01/25 reflected the following: PolicyMedications 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.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. LVN C failed to document on the EMAR when she administered hydrocodone (pain medication) to Resident #1 on 05/11/26 at 4:00 AM. This failure could place residents at risk for loss of prescribed medications, potential for not receiving their prescribed medications, and risk of drug diversion. Findings included: Review of Resident #1's None of the Above MDS Assessment, dated 05/06/26, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her MDS did not included any active diagnoses, information regarding her cognition nor medications. Review of Resident #1's admission Record, dated 05/12/26, reflected the following diagnoses: non-displaced intertrochanteric fracture of left femur (a hip fracture where the bone cracks below the hip joint but remains properly aligned). Review of Resident #1's Order Summary Report, dated 05/12/26, reflected the following:Hydrocodone-Acetaminophen Tablet 5-325 MG, Give 1 tablet by mouth every 6 hours as needed for Pain with an active order date of 05/07/26. Review of Resident #1's Licensed Medication Administration Record for May 2026 reflected the following: Hydrocodone- Acetaminophen Tablet 5-325 MG, Give 1 tablet by mouth every 6 hours as needed for Pain and showed she received only 2 doses on 05/11/26, one dose at 10:47 AM by LVN A and one dose at 6:30 PM by LVN B. There was no documentation of a dose given by LVN C at 4:00 AM. Review of Resident #1's Controlled Drug Receipt/Record/Disposition Form, dated 05/01/26, reflected the following: 05/11/26 at 4:00 AM LVN C signed that she administered Resident #1 her hydrocodone medication. Review of Resident #1's Progress Notes for May 2026 did not reflect any note about her receiving hydrocodone on 05/11/26 at 4 AM. Review of Resident #1's Care Plan, revised 05/11/26, reflected the following: Focus: [Resident #1] is on pain medication therapy.Hydrocodone 5-325mg [sic] PRN r/t hip pain.Interventions: Administer ANALGESIC [sic] medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [sic]. Observation and interview on 05/12/26 at 1:00 PM, Resident #1 was in her room watching television and appeared comfortable. Resident #1 said she was not in any pain, and the staff brought her pain medications to her timely. Resident #1 said she had no concerns about her pain medications. Resident #1 said she could not recall the exact times she got her pain medications but each time she requested one, they brought one to her. Interview on 05/12/26 at 1:31 PM, the ADON said all staff knew to document both on the narcotic count sheet and the resident's EMAR when they administered a narcotic medication. The ADON said the purpose of making sure staff documented on both the narcotic count sheet and the EMAR was to make sure that they can follow-up and see if the medication was effective or not and can also look to see what medications the resident received. The ADON said this information also helps the next nurse know when the last time the resident received the medication. The ADON looked at Resident #1's narcotic count sheet and saw that LVN C failed to document in Resident #1's EMAR that a medication was administered to her at 4 AM on 05/11/26. The ADON said LVN C would have been responsible for making sure the nurse documented the administration on the resident's EMAR. Interview on 05/12/26 at 2:07 PM, LVN C said she did give Resident #1 a hydrocodone on 05/11/26 at 4:00 AM because the resident was complaining of pain. LVN C said she recalled documenting on the narcotic count sheet that she administered the medication, but she was not certain whether she documented it in the resident's EMAR. LVN C said she knew she was supposed to document in the resident's EMAR when she administered a medication. LVN C said she knew since she was the person who administered that medication at that time that she was responsible for documenting the administration in the resident's EMAR. Interview on 05/12/26 at 2:10 PM, the DON said she had been auditing all the medication carts recently to make sure the narcotic count sheets were matching the information documented in each resident's EMARs. The DON said staff knew that when they administered a narcotic medication they were supposed to sign off on the narcotic count sheet and document in the resident's EMAR that the medication was administered. The DON said the purpose was to show that the medication was given at that time by that nurse. The DON said the nurse who administered the medication would be responsible for this documentation in the resident's EMAR. The DON said if the nurse did not document a medication administration in the resident's EMAR then it might not be true that it was administered. The DON said staff were recently trained on 05/01/26 and 05/08/26 regarding medication administration and should have been aware of the expectations to document in their EMAR when a narcotic was administered to them. Review of the facility's In-Service Training Report, dated 05/01/26, and titled Narcotic Count.When administering narcotics, you must sign the narcotic book and the EMAR; you must also go back and do follow up documentation reflected staff were trained, but LVN C was not listed. Review of the facility's In-Service Training Report, dated 05/08/26, and titled Medication Cart.You must sign the narcotic out on the EMAR and on the narcotic sheet at the same time reflected staff were trained but LVN C was not listed. Review of the facility's policy, revised 12/01/25, and titled Medication Administration reflected: .19. Sign MAR after administered.20. If medication is controlled substance, sign narcotic book.

Based on observation, interview and record review the facility failed to ensure the interdisciplinary team determined if a resident was able to self-administer medications for 3 of 33 residents (Resident #41, Resident #115 and Resident #118) reviewed for resident rights.1.The facility's interdisciplinary team failed to ensure Resident #41 was clinically appropriate to self-administer Fluticasone Propionate Nasal Spray, Azelastine HCL and Major Deep Sea Premium Saline Nasal Spray that were at the resident's bedside.2.The facility failed to ensure Resident #115, with nasal spray at her bedside, was clinically appropriate to self-administer medications that were at the resident's bedside.3. The facility failed to ensure Resident #118 was clinically appropriate to self-administer cough syrup that were at the resident's bedside. The failure had the potential to place residents at risk for unsafe drug administration.Findings included:1.Record review of Resident #41's quarterly MDS assessment, dated 11/14/25, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. The residents' diagnoses included chronic systolic heart failure (heart muscle weakens and cannot pump enough blood to meet the body's needs), hypothyroidism (thyroid gland does not make enough hormone into bloodstream), and chronic total occlusion of coronary artery (coronary arteries blockage). Resident #41's BIMS score was 10 which indicated moderate cognitive impairment.Record review of Resident #41's Care Plan, revised date 12/07/25, reflected no indication of Resident #41 able to self-administer any medications. Record review of Resident #41's clinical records reflected no assessment was completed to indicate if Resident #41 was able to self-administer any medication. Record review of Resident #41's order summary report reflected the following: Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 2 sprays in both nostrils two times a day for allergy -Start Date - 05/01/2025. Resident #41 had no physician orders for the use of Azelastine HCL (nasal spray) and Major Deep Sea Premium Saline (nasal spray). Observation and interview on 01/06/26 at 11:27 AM, revealed Resident #41 had a bottle of Fluticasone Propionate Nasal Spray, a bottle of Azelastine HCL (nasal spray), and another bottle of Major Deep Sea Premium Saline (nasal spray) at her bedside table. Resident #41 stated she had the bottles for a long time, and the staff were aware of it. She stated staff had not mentioned anything to her about keeping them in her room. Resident #41 stated she administered the nasal spray twice a day. She stated staff come by to ensure she administered them. Interview on 01/07/26 at 1:34 PM, LVN C revealed she was the nurse assigned to 700 Hall and had no residents in her hall that could self-administer any medications including nasal spray. She stated she was the nurse assigned to Resident #41. LVN C observed three bottles of nasal sprays at Resident #41's bedside table. She stated she was not aware Resident #41 had three bottles of nasal spray and indicted Resident #41 only had an order for the Fluticasone Propionate nasal spray. She stated she was not sure where the other two nasal sprays came from. LVN C stated residents were not supposed to keep medications or nasal spray at bedside. She stated residents needed to be assessed first to ensure they could self-administer any medication and needed to be care plan for it. LVN C stated the potential risk of keeping medications at the bedside would be the resident using the medication out of doctor's orders. Interview on 01/08/26 at 4:32 PM, ADON A revealed there were no residents in the facility who could self-administer any medications. She stated the residents needed to be assessed first, obtained a physician's order to self-administer, educate the residents, provide a lock box, and care plan. ADON A stated LVN C notified her about Resident #41 having bottles of nasal sprays at bedside. She stated Resident #41 had not been assessed or had a physician order for her to self-administer any nasal spray medication. She stated the potential risk would be resident over medicate themselves or someone else take the medication. 2.Record review of Resident #115's admission MDS, dated [DATE], reflected Resident #115 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #115's BIMS had not been completed. Resident #115's MDS was pending completion. Record review of Resident #115's undated Baseline Care Plan did not address Resident #115's need or use of medications at her bedside. Record review of Resident #115's clinical records reflected no assessment was completed to indicate if Resident #115 was able to self-administer medication. Record review of Resident #115's order summary report reflected the following: Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 2 sprays in both nostrils one time a day for nasal Congestion Start date:1/3/2026 8:00 AM.Record review of Resident #115's MAR reflected Resident #115 was administered Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 2 sprays in both nostrils one time a day for nasal Congestion Start date:1/3/2026 8:00 AM on 01/04/26, 01/05/26, 01/06/26, 01/07/26, and 01/08/26.Observation and interview on 01/06/26 at 10:57 AM, revealed Resident #115 had a bottle of Fluticasone Propionate Nasal Spray 50 mcg at her bedside. Resident #115 stated she had the medication since being admitted on [DATE] from the hospital. Resident #115 stated she kept the medication at her bedside because sometimes her nose got dry, and she used it as needed to keep her breathing comfortably. Resident #115 stated she was not sure if staff knew she had the nasal spray, but they never took them away from her. Interview on 01/06/26 at 11:20 AM, the Staffing Coordinator was observed exiting Resident #115's room. The Staffing Coordinator revealed she was fairly new to working the floor and was helping to answer the call light. The Staffing Coordinator stated she just changed Resident # 115; however, she did not see the nasal spray at the bedside table. The Staffing Coordinator stated she was not sure if there were any residents who could self-administer their own medications and medications should not be kept at residents' bedside. The Staffing Coordinator observed the nasal spray at Resident #115's bedside table and stated she would follow up with the Charge Nurse. The Staffing Coordinator stated all staff were responsible for removing any medications found in resident rooms. The Staffing Coordinator further stated not doing so placed residents at risk of misusing the medication. Interview on 01/06/26 at 12:19 PM, ADON B revealed there were no residents able to have medications at their bedside or self-administer medications due to risk of overdosing. ADON B stated she was notified by LVN F that Resident #115 had a nasal spray at her bedside. ADON B stated she was told by LVN F that she had attempted to remove the nasal spray previously and Resident #115 had refused to release the medication but today she was able to remove the nasal spray. ADON B stated she expected nursing staff to remove any medication found in resident rooms, contact the family to pick it up or store the medication on the nursing carts. ADON B further stated the physician should be called to notify them medication was found at the bedside and consult for a prescription to administer to the resident from the nursing cart. Interview on 01/06/26 at 1:45 PM LVN F stated she was previously informed that Resident #115 had the nasal spray at her bedside, however, did not want to release the medication and had been hiding the medication in her bed. LVN F stated she explained to Resident #115 that there needed to be a physician's order to have use of the medication while in the facility. LVN F stated Resident #115 was afraid that she would not have access to the medication as needed or had a stuffy nose. LVN F stated she educated Resident #115 that if she needed the medication, she would inform the nursing staff which could administer the nasal spray in a safe manner. LVN F stated she was able to remove the nasal spray and would contact the physician for an order. LVN F stated resident administering their own medications were at risk of not using the medication as prescribed, not talking it properly, and overdosing. LVN F stated nursing and medication aides were responsible for ensuring scheduled and prn medication were given at the right time for safety issues.Interview on 01/08/26 at 5:15 PM, the DON revealed she had no residents who could self-administer any medication or nasal spray. She stated residents were not allowed to keep medications at bedside unless a physician order had been obtained and the resident had been assessed to self-administer. She stated the potential risk of keeping medications at the bedside would be someone else could get the medication or the resident using the medication whenever.3. Record review of Resident #118's admission MDS, dated [DATE], reflected Resident #118 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #118's BIMS had not been completed. Resident #118's MDS was pending completion.Record review of Resident #118's undated Baseline Care Plan, did not address Resident #118's need or use of medications at her bedside.Record review of Resident #118's clinical records reflected no assessment was completed to indicate if Resident #118 was able to self-administer medication.Record review of Resident #118's order summary report did not reflect an order or use of cough syrup.Record review of Resident #118's MAR did not reflect an order or use of cough syrup.Observation and interview on 01/06/26 at 12:00 PM revealed Resident #118 had a medication cup full of dark liquid at his night stand. Resident #118 stated he was in a car accident, and he sometimes had a cough when he tried lying flat or tried to catch his breath. Resident #118 stated family members were just visiting and left the medication in the cup on his nightstand. Resident #118 stated he had not used the cough syrup.Observation and interview on 01/06/26 at 12:19 PM with ADON B revealed was not sure what medication was in the medication cup, she stated she was just in the room with Resident #118 and assisted with his bed bath. ADON B asked Resident #118 to identify what was in the cup and he stated it was cough syrup provided by his family members. ADON B explained to Resident #118 that she had to remove the medication and contact the physician to ensure he was able to have cough medication. ADON B removed the cough syrup in the medication cup and removed the medication bottles from the family bag at the night stand. ADON B stated that in order for residents to have medication at their bedside an assessment was required, ADON B stated no resident in the facility had been assessed to self-administer their own medications. According to ADON B all staff were responsible for removing any medication found in resident rooms. ADON B stated residents with access to medications in their room could be placed at risk of having negative interactions with other medications or double dosing.Interview on 10/08/25 at 4:00 PM, the DON revealed she did not have any residents in the facility who could self-administer their own medications. The DON stated if the resident wanted to keep medications at her bedside a physician order had to be obtained. She stated the potential risk of keeping medications at the bedside would place residents at risk of over medicating. The DON stated the expectation of all staff was to remove any medications found in resident rooms and inform the charge nurse immediately. The DON stated the charge nurse would be responsible for ensuring all medications were removed, contact the physician and educate family and residents to turn in medications to the nursing station and not directly to residents.Record review of facility Self-Administration of Medication policy, revised February 2021, reflected the following: Residents have the right to self-administer medications if the interdisciplinary team had determined that it is clinically appropriate and safe for the resident to do so. 1.As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

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, the comprehensive person-centered care plan, and the residents' choices for 1 of 44 residents (Resident #45) reviewed for quality of care. The facility failed to obtain physician orders for the use of an arm sling and leg brace for Resident #45. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions.Findings included: Record review of Resident #45's admission MDS assessment, dated 10/06/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses that included stroke (loss of blood flow to part of the brain), muscle weakness (loss of strength to move, felt as difficulty with tasks, balance issues, or trembling), abnormalities of gait and mobility. He had a BIMS score of 9, which indicated his cognition was. The moderately impaired. MDS reflected Resident #45 had functional limitation in range of motion, impairment on one side for upper and lower extremity. Resident #45 used a walker and wheelchair for mobility. Record review of Resident #45's care plan, undated, reflected Resident #45 had Activity of Daily Living self-care performance deficit related to right side weakness due to stroke. Goals included to maintain current level of function. Interventions included Resident #45 required assistance by 1 or 2 staff to dress. This may fluctuate with weakness, fatigue, and weight bearing status. SKIN INSPECTION: Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.Record review of Resident #45's undated care plan did not address his need, use for an arm sling, or leg brace. Record review of Resident #45's physician orders dated 01/08/26 did not reveal the use of an arm sling or leg brace. Observation and interview on 01/06/26 at 2:26 PM revealed Resident #45 with an arm sling and wrap on his right arm along with a leg brace on his right leg. Resident #45 expressed the use of the arm sling, and the leg brace was used due to him having a stroke and he required the use of the devices. According to Resident #45 he has utilized both devices for at least two years. Resident #45 stated he wore both devices daily, and he required assistance daily to administer the devices. Interview and observations on 01/08/26 at 2:23 with CNA J revealed Resident #45 with his right arm wrapped with an elastic wrap along with an arm sling. Resident #45 also wore a leg brace on his right leg. CNA J stated Resident #45 had utilized these devices for at least 3 months. CNA J stated, Resident #45 usually asked me for assistance daily to administer the devices. CNA J stated Resident #45 liked to be independent as much as possible with his activities of daily living skills and these devices helped him to do. CNA J stated Resident #45 had not had any injuries or skin condition from wearing either device. Interview on 01/08/26 at 2:00PM with ADON B revealed she had observed Resident #45 with the use of both an arm sling and leg brace. ADON B stated she thought Resident #45's orders were placed in the clinical record for use of the arm sling and the leg brace. ADON B stated it was the responsibility of the nurses to place orders for the use of Resident #45's devices. ADON B stated not addressing the use of Resident #45's devices placed him at risk of delayed monitoring or treatment of skin conditions, also improper fit and wearing of the devices. Interview on 01/08/26 at 2:23 PM with the DON revealed there should be orders in place if Resident #45 was wearing devices. The DON stated he should have been evaluated by the therapy department, and received orders from them, orders entered by her, ADON or his charge nurse. The DON stated she expected all staff to work together to ensure to have all the rights things in place so that Resident #45 could get the greatest benefit out of using the arm sling and leg brace. The DON stated not doing so placed Resident #45 at risk for skin conditions. Interview on 01/08/26 at 2:40 PM with Director of Rehabilitation revealed she knew Resident #45 utilized an arm sling and leg brace for his right-side extremities. The Director of Rehabilitation stated Resident #45 entered the facility with both devices. The Director of Rehabilitation Resident #45 was not currently on therapy services therefore, nursing staff would be responsible for placing orders with the physician. The Director of Rehabilitation stated not having an order and effectively monitoring Resident #45 with his devices placed him at risk of having skin conditions due to the continued use of devices. Record review of the facility's Activities of Daily Living dated June, reflected the following: A Nursing Restorative Care Program is written for the individual needs of the Patients must be maintained in accordance with the Restorative Nursing Program. Patients wearing a medical device (split, brace, immobilizer, or other) will have their skin inspected (under the device) every shift and include documentation in the Treatment Administration Record. Note: If a medical device is used for orthopedic purposes a physician's order will be obtained.

Based on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition 2 of 5 residents (Resident #42 and Resident #75) reviewed for foot care. The facility failed to provide Resident #42 and Resident #75 assistance with toenail care. Resident #42 and Resident #75 toenails were observed to be about half inch long on each foot.This failure could place the residents at risk for decreased feelings of self-worth and infection.Findings include: 1.Record review of Resident #42's Quarterly MDS assessment, dated 12/26/25, revealed Resident #42 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #42 had cognition intact with a BIMS score of 04 (indicating severe cognitive impairment). Resident #42 required partial/moderate assistance from staff with shower/bathes and set up / clean up with personal hygiene. Active diagnosis included Arthritis (joint pain and stiffness), need for assistance with personal care, limitation of activities due to disability. Review of Resident #42's care plan, undated, revealed it did not address Self Care Performance Deficit. Further review revealed she had Diabetes. Goal: Resident will have no complications related to diabetes. Interventions included to check all body for breaks in skin and treat promptly as ordered by doctor. Interview and Observation on 01/06/26 at 12:05 PM with Resident #42 revealed her laying in bed, Resident #42 uncovered her legs and feet and stated, I wished they would cut my toenails, they said they didn't have anyone to do it. Resident #42 stated she felt her toenails were a bit long, she had spoken with someone to have them cut but they had not returned to do so. Observation and Interview on 01/08/26 at 10:01 AM with CNA E revealed Resident #42 laying in bed resting, CNA E asked Resident #42 if she could observe her feet and responded that Resident #42's toenails were long and needed to be cut. CNA E stated Resident #42's shower days were Tuesday, Thursday, and Saturdays during the 2-10:00 PM shift. CNA E stated that CAN's providing the shower were responsible for ensuring the toenails were cut or trimmed. CNA E stated she would be willing to address Resident #42's toenails however needed to consult with the nurse first. CNA E stated CNA's were supposed to indicate any nailcare on the shower sheets so that the Charge Nurse could address the issue or identify if the resident had a diagnosis of Diabetes, if that was the case the Nurse would be responsible to ensure that nailcare was provided by trimming or cutting the toenails. Interview on 01/08/26 at 10:10 AM with LVN F revealed Resident #42 had a diagnosis of Diabetes, and she was responsible for trimming, cutting her toenails. According to LVN F, residents that were Diabetic were also placed on the list to be seen by the podiatrist on a monthly basis. LVN F stated she worked closely with CNAs on the floor, and it was usually brought to her attention when she needed to trim or cut resident nails or toenails. LVN F stated she worked closely with Resident #42 and her family to keep her toenails trimmed however she had not paid much attention to Resident #42's toenails lately. According to LVN F, not keeping resident toenails trimmed and cut placed residents at risk of having a hang nail, nails getting too long, or they could scratch themselves. Interview on 09/18/25 at 10:37 AM with CNA F revealed resident nail care was to be completed during shower days however she usually paid attention to resident nails daily and would clean or trim them if needed. CNA F stated it was the responsibility of the aides to complete nail care and grooming for residents on their halls, not doing so placed residents at risk of scratching, or cutting themselves or others. 2. Record review of Resident #75's Quarterly MDS assessment, dated 10/01/25, revealed Resident #75 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #75 had cognition intact with a BIMS score of 07 (indicating moderate cognitive impairment). Resident #75 required substantial/maximal assistance from staff with shower/bathes and with personal hygiene. Active diagnosis was high blood sugar.Review of Resident #75's care plan, undated, revealed Resident #75 had an Activities of Daily Living self-care performance deficit related to unsteady gait and balance with cognitive deficits. Goals included to maintain current level of function. Interventions included Avoid scrubbing and pat dry sensitive skin. Check nail length and rim and clean on bath day and as necessary. Report any changes to the nurse. Resident required staff assistance for bathing/showers. Further review revealed he had Diabetes. Goal: Resident will have no complications related to diabetes. Interventions included to check all body for breaks in skin and treat promptly as ordered by doctor. Interview and Observation on 01/06/26 at 3:05 PM of Resident #75 laying in bed, Resident #75 had his right foot exposed showing his toenails measuring about half inch long. When asked about his toenails Resident #75 stated I would like someone to trim my toenails. Resident #75 stated that he should get his toenails trimmed by a doctor but was not sure when the last time he had his toenails trimmed. Interview on 01/08/26 at 10:30 AM with CNA I revealed she worked with Resident #75 in the past however he was currently on 2-10:00 PM shift for showers on Monday, Wednesday, and Fridays. CNA I stated she noticed how long Resident #75's toenails were, stating they were too long. According to CNA I, CNAs were responsible for showers which included indicating on the shower sheet if nails needed to be addressed. CNA I stated nurses reviewed the shower sheets and rounded weekly on Sundays to trim resident toenails and podiatry came monthly. CNA I stated not keeping resident toenails trimmed placed residents at risk of resident toenails growing long, introducing fungus and bacteria if not cleaned and trimmed as needed. Interview on 01/08/26 at 4:00 PM with DON revealed she expected residents to have hand hygiene which included nail care. The DON stated it was the responsibility of the CNAs to complete nail care if residents were not diagnosed with Diabetes, otherwise the charge nurse would trim and clean resident nails, or resident would be referred to podiatry. According to the DON if during the shower nail care was needed CNAs were to mark it on the sheet and nurse will sign off and address any concerns. The DON stated when nursing staff did not provide nail care it placed residents at risk of nails accumulating dirt, curling under and grown into resident's skin.Review of the facility's policy dated June 2025 titled Activities of Daily Living policy reflected: Every effort must be made to assure that assignments of nurses and nurse aides to Patients are as consistent as possible. A Kardex (documentation system that enables nurses to reference key patient information) must be prepared from the electronic medical record to assist direct care staff in providing assistance to Patients in their activities of daily living.A Nursing Restorative Program is written for the individual needs of the Patients must be maintained.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 2 of 33 residents (Resident #39 and Resident #118) on one hall reviewed for storage of medications.1.The facility failed to ensure two pills (Zoloft and Memantine) were not left on the floor in Resident #39's room on 01/06/26. 2. The facility failed to ensure Resident #118 cough syrup was not left unattended at his bedside on 01/06/26. This failure could place residents at risk of consuming unsafe medications.Findings included: 1. Record review of Resident #39's annual MDS assessment, dated 12/02/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. The residents' diagnoses included anxiety disorder (involve more than occasional worry or fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hepatic encephalopathy (brain disorder caused by liver failure), and Non-Alzheimer's Dementia (brain condition that slowly damages your memory, thinking, learning and organizing skills). Resident #39's BIMS score was 10 which indicated moderate cognitive impairment. Record review of Resident #39's physician orders reflected the following orders: SERTRALINE TAB 25MG Give 1 tablet orally in the evening for depression Start date 05/02/25. MEMANTINE TAB HCL 5MG Give 1 tablet orally two times a day for Alzheimer's Start date 10/28/25. Record review of Resident #39's January 2026 MAR reflected SERTRALINE TAB 25MGGive 1 tablet orally in the evening for depression time 2000 (8:00 PM) and MEMANTINE TAB HCL 5MG Give 1 tablet orally two times a day for alzheimers (9:00 AM and 2100 (9:00PM) MAR indicated only Memantine was provided at 9:00AM on 01/06/26. Observation and interview on 01/06/2026 at 2:33 PM revealed to small pills located by Resident #39's closet door upon entrance to her room. Resident #39 stated she was provided with her medications, and she had taken them. She stated she could not recall who administered them to her. Resident #39 stated she did not know whose pills were on the floor, but she could assure the pills were not hers. Interview and observation on 01/06/26 at 2:41 PM with LVN D revealed he was the nurse assigned to Resident #39. Observed LVN D entered Resident #39's room and observed the pills on the floor and he picked them up. He identified the pills as Zoloft and Memantine tab. He stated he did not provide Resident #39 medications in the morning, he stated it was the DON. LVN D stated when he conducted his rounds, he did not notice the pills on the floor. LVN D stated the potential risk of leaving medications unattended would be someone else taking it. Interview on 01/07/26 at 2:52 PM with the DON revealed she administered medication on the 800 Hall on 01/06/26 and LVN D took over the medication chart at around 9:00 AM. She stated she provided Resident #39's medications and observed her take it. She stated LVN D informed her pills were found on the floor in Resident #39's room . She stated she did not administer those pills to the resident. The DON stated the expectation of when administering medications nurses should stay in the room and observe the resident take the medication. If a nurse drops a pill, they need to pick it up and put it in the biohazard. Potential risk of leaving medication unattended would be someone else picking it up and could cause harm. 2. Record review of Resident #118's admission MDS, dated [DATE], reflected Resident #118 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #118's BIMS had not been completed. Resident #118's MDS was pending completion. Record review of Resident #118's undated Baseline Care Plan, did not address Resident #118's need or use of medications at her bedside. Record review of Resident #118's clinical records reflected no assessment was completed to indicate if Resident #118 was able to self-administer medication. Record review of Resident #118's order summary report did not reflect an order or use of cough syrup. Record review of Resident #118's MAR did not reflect an order or use of cough syrup. Observation and interview on 01/06/26 at 12:00 PM revealed Resident #118 had a medication cup full of dark liquid at his night stand. Resident #118 stated he was in a car accident, and he sometimes had a cough when he tried lying flat or tried to catch his breath. Resident #118 stated family members were just visiting and left the medication in the cup on his night stand. Resident #118 stated he had not used the cough syrup. Observation and interview on 01/06/26 at 12:19 PM with ADON B revealed was not sure what medication was in the medication cup, she stated she was just in the room with Resident #118 and assisted with his bed bath. ADON B asked Resident #118 to identify what was in the cup and he stated it was cough syrup provided by his family members. ADON B explained to Resident #118 that she had to remove the medication and contact the physician to ensure he was able to have cough medication. ADON B removed the cough syrup in the medication cup and removed the medication bottles from the family bag at the night stand. ADON B stated that in order for residents to have medication at their bedside an assessment was required, ADON B stated no resident in the facility had been assessed to self-administer their own medications. According to ADON B all staff were responsible for removing any medication found in resident rooms. ADON B stated residents with access to medications in their room could be placed at risk of having negative interactions with other medications or double dosing. Interview on 10/08/25 at 4:00 PM, the DON revealed she did not have any residents in the facility who could self-administer their own medications. The DON stated if the resident wanted to keep medications at her bedside a physician order had to be obtained. She stated the potential risk of keeping medications at the bedside would place residents at risk of over medicating. The DON stated the expectation of all staff was to remove any medications found in resident rooms and inform the charge nurse immediately. The DON stated the charge nurse would be responsible for ensuring all medications were removed, contact the physician and educate family and residents to turn in medications to the nursing station and not directly to residents. Record review of facility Medication Labeling and Storage policy, revised February 2023, reflected the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on interview and record review, the facility failed to coordinate the assessment with the pre-admission screening and resident review (PASARR ) program for one (Resident #49) of five resident assessments reviewed for PASARR evaluations.The facility did not refer Resident #49 to the appropriate state-designated mental health authority for review when she received a new diagnosis of bipolar disorder. This failure could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASARR services.The findings were:Record review of Resident #49's quarterly MDS assessment, dated 12/17/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. The residents' diagnoses included anxiety disorder (involve more than occasional worry or fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychotic disorder (a collection of symptoms that affect the mind), schizophrenia (affects how people think, feel and behave), bipolar disorder (condition that causes extreme mood swings) and chronic diastolic heart failure (ventricle becomes stiffer than usual). Resident #49's BIMS score was 06 which indicated severe cognitive impairment. The MDS further revealed Resident #49 was currently taking antipsychotic medication.Record review of Resident #49's Care Plan revised date 12/06/25, reflected [Resident #49] uses psychotropic medications Zyprexa and Haldol r/t DX of Bipolar/Depression/anxiety. She is not eligible for PASRR Services d/t election of Hospice services. Goal: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions: Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Discuss with MD, family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy.Record review of Resident #49's PASARR Level 1 Screening, dated 04/23/25, reflected she did not have a mental illness. Review of Resident #49's listed diagnoses on 01/06/26 revealed she was diagnosed with schizoaffective disorder, unspecified on 11/21/25. Further review revealed she was diagnosed with schizoaffective disorder, bipolar type on 01/05/26. Interview on 01/08/26 at 9:37 AM, the MDS Coordinator revealed she was responsible for submitting PASARR's whether for newly admitted residents or related to updates for new diagnoses for residents. The MDS Coordinator stated if a resident was diagnosed with a new mental illness after they had a PASARR submitted already she was supposed to send a new PASARR level 1 or obtained a 1012 form; depending on if the resident had a primary diagnosis of dementia. MDS Coordinator stated she was informed Resident #49 did not require a new PAASSR level one because the resident was receiving hospice services and would not qualify. However, after completing her research she was wrong and needed to complete a new PASARR level 1. She stated no potential risk if a new PASARR level 1 was not submitted because the resident was already receiving psych services. Interview on 01/08/26 at 5:37 PM, the Administrator revealed MDS Coordinator was responsible for completing and updating the PASARR assessments and submitting them timely. The Administrator stated if a new diagnosis was given to a resident the MDS Coordinator should have followed up with the mental health authority. Potential risk for not submitting PASARR assessment would be the resident could miss services. Record review of facility's Resident Assessment - Coordination with PASARR Program policy, dated 12/1/25 reflected the following: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

Based on observations, interviews, and record review the facility failed to ensure necessary treatment and services to promote healing for 1 of 5 residents (Resident #10) reviewed for pressure ulcers. The facility failed to ensure Resident #10's Stage 3 pressure ulcer was covered with a dressing. This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents. Findings included:Record review of Resident #10's quarterly MDS assessment, dated 11/20/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. The residents' diagnosis was pressure ulcer of sacral region. Resident #10's BIMS score was 04 which indicated severe cognitive impairment. The MDS assessment Section M - Skin Conditions indicated Resident #10 was at risk of pressure ulcers and had an unhealed pressure ulcer. Record review of Resident' 10's care plan, revised date 01/04/26, reflected: Focus: The resident has a Stage III pressure ulcer to Sacrum. Goal: The resident's pressure ulcerwill show signs of healing and remain free from infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Treatment to pressure ulcer per physician's order. Focus: Wound Management. Goal: Wound will be free of signs or symptoms of infection. Wound will show signs of improvement. Interventions: Provide wound care per treatment order.Review of Resident #10's physician orders dated 01/04/26 revealed Wound Treatment - Collagen and Calcium Alginate w/ Silver as needed to sacrum if dressing becomes saturated, soiled, or dislodged -Start Date-01/05/26. Observation on 01/08/26 at 1:12 PM, Resident #10's wound care was provided by Treatment Nurse and Wound Care NP. Resident #10's brief was removed, resident had wound to her sacrum that is open to air, no dressing in place. Resident #10 had moderate amount of soft stool, no stool on or near the wound. After peri care was completed, the wound was cleansed with wound cleaner, and wound bed was debrided. Wound bed has pink healthy tissue. Interview on 01/08/26 at 1:35 PM, Treatment Nurse revealed there should have been a dressing in place when she removed the brief. She stated Resident #10 had a hospice CNA visit in morning of 01/08/26 and received a bed bath, and the dressing probably came off at that time. She stated as far as she knew the CNAs had not alerted anyone of the need to replace the dressing. Interview on 01/08/26 at 1:38 PM, Wound Care NP revealed the lack of dressing to the wound when the brief was removed was not too concerning since there was no stool in the wound itself. He stated that is why a PRN order was written, so staff would know how to replace the dressing if it came off between wound care treatments. Interview on 01/08/26 at 1:40 PM, Resident #10 revealed she felt like her wound was healing well, had no complaints of pain during or after wound care. Unknown of when dressing came off. Interview on 01/08/2026 at 2:52 PM by phone, Hospice CNA revealed he was the CNA who visited Resident #10 today (01/08/26) at around 10:30 AM. He stated he was covering for another Hospice CNA who was on leave. Hospice CNA stated he provided Resident #10 with a bed bath and basic day to day care. He stated when he provided Resident #10's bed bath he did not observe any dressing on the resident sacrum. Interview on 01/08/2026 at 2:47PM, CNA G revealed he was the CNA assigned to 700 Hall; however, CNA H was the CNA assigned to Resident #10. CNA G stated Resident #10 Hospice CNA never mentioned anything about the resident wound dressing. Attempted to interview CNA H who was assigned to Resident #10 on 01/08/2026 at 3:04 PM and then at 3:06 PM by phone; however, there was no answer. Interview on 01/08/26 at 3:16 PM, LVN C revealed she was the nurse assigned to Resident #10. She stated CNA H nor Hospice CNA report to her regarding Resident #10's wound dressing coming off. She stated if a wound dressing comes off it was expected for the CNAs to inform her, and she could redress it. She stated the risk of not having a dressing could lead to an infection.Interview on 01/08/26 at 4:24 PM, ADON A revealed if a wound dressing comes off it was expected for the CNAs or Hospice CNAs to notify the nurse, and the nurses were to apply a new dressing. She stated if a dressing comes off, they had PRN treatment orders to follow. She stated she was not aware of Resident #10 not having a wound dressing on. ADON A stated the potential risk if the dressing comes off would be infections.Interview on 01/08/26 at 5:17 PM, the DON revealed if a wound dressing comes off when completing care, the CNAs were to notify the nurse, and the nurses were to redress it. She stated the risk of not having a dressing could lead to an infection or possibility of wound deteriorating. Record review of facility Wound Care policy, received October 2010, reflected the following: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

Based on observation, interview, and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 2 of 5 residents (Resident #10 and Resident #104) records reviewed for treatment documentation.The facility failed to document wound care treatments on the Treatment Administration Record for Resident #10 and Resident #104 indicated by blanks on residents January 2026 TAR.These failures could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included:1.Record review of Resident #10's quarterly MDS assessment, dated 11/20/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. The residents' diagnoses included Alzheimer's Disease (brain condition that slowly damages your memory, thinking, learning and organizing skills), pressure ulcer of sacral region, and chronic obstructive pulmonary disease (a progressive lung condition causing airflow blockage and breathing difficulties), and anxiety disorder (involve more than occasional worry or fear). Resident #10's BIMS score was 04 which indicated severe cognitive impairment.Record review of Resident' 10's care plan, revised date 01/04/26, reflected: Focus: The resident has a Stage III pressure ulcer to Sacrum. Goal: The resident's pressure ulcerwill show signs of healing and remain free from infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Treatment to pressure ulcer per physician's order. Focus: Wound Management. Goal: Wound will be free of signs or symptoms of infection. Wound will show signs of improvement. Interventions: Provide wound care per treatment order.Record review of Resident #10's physician order dated 01/04/26 reflected Wound Treatment - Collagen and Calcium Alginate w/ Silver every day shift Cleanse wound toSacrum with Normal Saline or Skin Cleanser. Pat Dry. Apply Collagen to wound bed/tunneling, then Calcium Alginate w/ Silver to wound bed. Cover with Dry Dressing. Start Date 01/05/26. Record review of Resident #10's TAR for January 2025 reflected there was no documentation showing that wound care was provided on 01/05/26 and 01/06/26. Observation and interview on 01/06/2026 at 11:52 AM, Resident #10 was observed in her room lying down in bed. Resident #10 stated she was doing well. Resident #10 stated she admitted with a wound on her bottom, in which she was provided with wound care daily. She stated staff come in to turn her side to side. Observed pressure relieving devices on resident bed. 2.Record review of Resident #104's quarterly MDS assessment, dated 11/20/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. The residents' diagnoses included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities), generalized edema (swelling from excess fluid buildup), and hyperlipidemia (fats in blood). Resident #104's BIMS score was 09 which indicated moderate cognitive impairment. Record review of Resident' 104's care plan, revised date 12/22/25, reflected: Focus: [NAME] has current skin concerns: Right Medial foot r/t Surgical Wound by Podiatry. Goal: Areas will heal without complications over the next 90 days. Interventions: Perform treatments per order, if no improvement x2 weeks report to MD. Treatment as ordered.Record review of Resident #104's physician order, reflected Apply foam dressing to R foot lesion medial side. Start Date 12/20/25. Record review of Resident #104's TAR for January 2025 reflected there was no documentation showing that treatment was provided on 01/05/26.Interview on 01/06/2026 at 3:26 PM, Resident #104 was observed in her wheelchair in her room. Resident #104 stated she had no open wounds; however, she had something on her right foot that she was getting treatment for. Resident #104 stated she received treatment every other day. Interview on 01/08/26 at 12:41 PM, Treatment Nurse revealed she had been out on leave and returned to work on 01/07/25. She stated it was the responsibility of the nurses to provide wound care when she was on leave. She stated once wound care was completed nurses should document that wound care was provided. Treatment Nurse stated if the resident TAR had blanks it could be that treatment was not provided or the nurse forgot to document. Interview on 01/08/26 at 5:20 PM, the DON revealed if the Treatment Nurse was not available to provide wound care, it was the responsibility of the nurses to complete wound care. The DON stated ADON B provided wound care on the days that the Treatment Nurse was on leave. She stated the ADON completed the wound care/treatments but forgot to sign them off on the TAR. The DON stated if the TAR had blanks it would mean that the nurse forgot to document. She stated she expects for her nurses to document or sign the TAR once treatment was completed. The DON stated there was no potential risk as long as the treatment was provided. Interview on 01/08/26 at 5:29 PM, ADON B stated she completed wound on Resident #10 and Resident #104 on 01/05/26. She stated the Treatment Nurse was out on leave and she provided wound care to residents while she was gone. ADON B stated she could not recall if she documented in the residents TAR. She stated if the TAR was blank meant she failed to document the treatment as completed. She stated the potential risk of not documenting accordingly would be that staff not knowing if treatment was done based on documentation and lack of continuity of care. Record review of facility Wound Care policy, received October 2010, reflected the following: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation The following information should be recorded in the resident's medical record: .2. The date and time the wound care was given. 10. The signature and title of the person recording the data.

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 #8) reviewed for infection control.LNV C failed to put on appropriate PPE, a gown, before administering daily water flush via gastronomy tube to Resident #8, who was on enhanced barrier precautions.This failure could place residents at risk of cross contamination and the spread of infection.Findings included:Record review of Resident #8's significant change in status MDS assessment, dated 10/22/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had a diagnosis of gastrostomy status (surgical opening into the stomach for nutritional support). Resident #8's BIMS score was 07 which indicated severe cognitive impairment.Record review of Resident #8's care plan, revised date 12/06/2025, reflected: Focus: [Resident #8] has a tube feeding r/t poor appetite. The tube is flushed with water TID. Goal: The resident will be free of aspiration through the review date. Interventions: Provide care to G-Tube site as ordered and monitor for s/sx of infection.Record review of Resident #8's physician order dated 12/18/2025, reflected: Enhanced Barrier Precautions every shift Follow Facility Policy - **USE for patients with any of the following (when Contact Precautions do not otherwise apply): Wounds or indwelling medical devices, regardless of MDRO colonization.Observation on 01/08/26 at 8:41 AM revealed LVN C prepared to provide Resident #8's water flush. Resident #8's door had the following sign: Stop, Enhanced Barrier Precautions - Everyone Must - Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and gown for the following High Contact Resident Care Activities. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Observed a bin inside the resident room with gowns. LVN C performed hand hygiene and donned a pair of gloves. Without donning a gown, LVN C then provided Resident #8's 250 ml water flush via gastrostomy tube. Interview on 01/08/26 at 9:17 AM with LVN C revealed she was the nurse assigned to Resident #8. She stated residents who had catheters, g-tubes, IVs or infections were on enhanced barrier precautions. She stated Resident #8 was on enhanced barrier precautions because the resident had a g-tube. LVN C stated residents on enhanced barrier precautions staff should don gloves, and gown. She stated she did not don a gown because she only provided Resident #8 with his water flush. LVN C stated she did not have to don gown for that only gloves. She stated she had been in-service on infection control but could not recall the exact date. LVN C stated there was no potential risk for no donning gown. Interview on 01/08/26 at 9:22 AM with ADON A revealed residents with g-tube, colostomy, wounds, and IVs were on enhanced barrier precautions. She stated staff should don gown and gloves when providing care to the residents. ADON A stated nurses should don gown and gloves when flushing g-tube. She stated staff had been in-serviced on infection control recently but could not recall the date. ADON A stated the potential risk would be infection control. Interview on 01/08/26 at 5:13 PM with the DON revealed residents placed on enhance barrier precaution nurses were expected to don gown and gloves when providing direct care. She stated flushing a g-tube was considered direct care and nurses should don gown and gloves. The DON stated she could not recall when the last in-service was on infection control was completed. She stated there was always a potential risk for not donning appropriate PPE. Record review of facility In-service Training Report, dated 06/27/25, reflected all staff were in-serviced on the following topic: Infection Control - Proper hand hygiene; PPE - donning - putting on isolation gown; doffing - taking of isolation gown.Record review of the facility's Enhanced Barrier Precautions policy, dated March 2024, reflected the following: Policy: Enhanced Barrier Precautions (EBP) is an infection control intervention to reduce transmission of multidrug- resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities.2.EBP will be used when performing the following high contact resident care activities: Device care or use: central line, urinary catheter, feeding tube, tracheostomy.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for medication administration.The facility failed to acquire and administer Resident #1's physician ordered medications timely when she admitted to the facility on [DATE], which resulted in the resident missing one dose of the antibiotic, Daptomycin-Sodium Chloride Intravenous Solution 700-0.9 mg/100 ml, six doses of the central nervous system stimulant, Adderall 20 mg, and seven doses of Juven, a physician-ordered therapeutic nutrition powder for wound healing, after she admitted to the facility on [DATE] following knee revision surgery.This failure could place residents at risk of not receiving medications as prescribed, decreased therapeutic effects of the medications, risk for drug diversion, delay in medication administration and worsening of their medical conditions.Findings included:Record review of Resident #1's admission MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included infection reaction to internal right knee prosthesis. Resident #1 had a BIMS of 15 which indicated her cognition was intact. Record review of Resident #1's Face Sheet printed on 10/16/25 reflected she had additional diagnoses of depressive episodes and attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type.Record review of Resident #1's care plan initiated on 09/06/25 reflected she was on antibiotic therapy and the care plan interventions included administering antibiotic medications as ordered by the physician. The care plan further reflected the resident had an intravenous access device with care plan interventions which included administering intravenous fluids as prescribed. Record review of Resident #1's hospital discharge records dated 09/05/25 reflected the resident had an infected knee revision following a knee replacement with polymicrobial infection (infection caused by two or more different microorganisms) and a chronic open wound for about six months. The hospital discharge records reflected the resident had orders for the following medications: - 0.9% sodium chloride with daptomycin 700 mg into the vein daily;- Adderall oral tablet 20 mg, give 1 tablet by mouth two times a day for ADHD; and- Juven one packet by mouth two times a day.Record review of Resident #1's September 2025 MAR reflected the following:- the antibiotic daptomycin-sodium chloride was not administered on 09/06/25 and first dose was on 09/07/25;- the first dose of Adderall was administered on 09/09/25, which meant the resident missed six doses since she admitted to the facility on [DATE]; and- two administrations of the Juven packet missed on 09/06/25; two administrations of the Juven packet missed on 09/07/25; one administration of the Juven packet missed on 09/08/25; and two administrations of the Juven packet missed on 09/09/25. In total, Resident #1 was not administered a total of seven Juven packets between 09/06/25 and 09/09/25.Interview on 10/15/25 at 5:29 PM, Resident #1 revealed she was admitted to the facility on [DATE] from the hospital. She stated there appeared to be some confusion with her medications at the facility. The resident said she did not know why, but she did not get some of her medications for a few days. She stated she did not recall how many, but it included her antibiotic, wound healing powder, and medications for her ADHD. Resident #1 said all she was told was that they were trying to get the medications from the pharmacy. She recalled she got the first doses on Monday or Tuesday (09/08/25-09/09/25). Resident #1 further stated she did not recall having any unwanted side effects as a result. Interview on 10/16/25 at 1:21 PM, MA A revealed she worked with Resident #1 on 09/06/25 and 09/07/25 from 6:00 AM to 10:00 PM. MA A said it appeared the pharmacy did not deliver all Resident #1's medications. She stated some of those medications included the resident's Adderall and Juven. She stated she did not know why the medications did not get delivered. MA A stated she thought the previous DON and LVN B had attempted to contact the pharmacy during that time. Interview on 10/16/25 at 3:56 PM, LVN C, who was the nurse who admitted Resident #1, revealed he did not recall who Resident #1 was. He stated many residents come and go on the skilled hall. LVN C stated that if a resident was missing some medications from the pharmacy, they would contact the physician to see if they could substitute it for something else. LVN C further stated it was important for the residents to have all their medications to continue their care. Interview on 10/16/25 was attempted via telephone with LVN B; however, the attempts were unsuccessful.Interview on 10/16/25 at 5:05 PM, the ADON revealed she was not aware Resident #1 had gone without some of her medications when she was admitted . The ADON said she only recalled Resident #1's name but no other details surrounding her stay. She stated the charge nurses were supposed to enter the residents' medication from the hospital discharge paperwork when they admitted to the facility, and they were supposed to verify the medications with the physician. If medications were not available, they were supposed to go to their emergency kit to see if they had them there. If the medications were not in the emergency kit, they were supposed to call the pharmacy and ask for a STAT delivery or call the doctor to see if they could substitute for a different medication. The ADON also stated it was important for residents to have all their medications available to prevent an adverse event, and the Juven powder was important because it was used for wound healing. The previous DON was no longer employed at the facility and could not be interviewed during this investigation. Interview on 10/16/25 at 5:25 PM, the RDCS revealed she did not know how Resident #1's medications were not available for the missing dates. The RDCS stated the charge nurses were responsible for following up with the physician if they could not obtain a certain medication. She stated she was not able to get any information as to what occurred with Resident #1's missing medications. The RDCS further stated it was important to the residents to have their medications to follow the care regime and so there was no lapse in care. Record review of the facility's Medication Administration policy dated November 2017 reflected the following: PolicyMedications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician a in accordance with professional standards of practice, in a manner to prevent contamination of infection.1. Upon admission (including readmission) of each Patient/Resident, the physician's orders for the Patient/Resident must be reviewed and reconciled by the Charge Nurse and the Director of Nursing or his/her designee for accuracy in the Electronic Medical Record.

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive assessment of a resident for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's catheter/catheter balloon remained in place in the bladder. On 08/04/25, the resident had a change in condition, and the NP ordered bloodwork, a UA, and a catheter change. During the catheter change, Resident #1 began to bleed from the catheter site and a few hours later, labs from the bloodwork came back critical and was sent to the hospital. Resident #1 was diagnosed with acute kidney failure and trauma to the urethra due to the catheter balloon not being in the right location. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 4:55 PM. The IJ template was provided to the facility on [DATE] at 5:10 PM. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for an adverse outcome to resident care or services and may also include the potential for physical and psychosocial harm.Findings included: Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke (occurs when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts), quadriplegia (partial or complete paralysis of both the arms and legs that is usually due to injury or disease of the spinal cord in the region of the neck), and nontraumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain often caused by a ruptured brain aneurysm). Resident #1 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS further reflected Resident #1 had an indwelling catheter and had impairment on both sides of his upper and lower extremities. Record review of Resident #1's care plan revised on 07/18/25 reflected he had a Foley catheter (a thin flexible catheter used especially to drain urine from the bladder) related to a neurogenic bladder (when a person lacks bladder control due to brain, spinal, or nerve problems). The goal was that Resident #1 would remain free from catheter-related trauma and interventions included change the catheter as needed and monitor/record/report signs and symptoms of UTI (an infection of any part of the urinary system), pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, altered mental status, change in behavior, and change in eating patterns. Record review of Resident #1's monthly orders for August 2025 reflected the following: Foley Catheter: 18 Fr 10cc bulb [a type of Foley catheter where the French scale indicates the size of the catheter, and the 10 cc designation indicates the size of the balloon that holds the fluid] as needed for occlusion [blockage or closing of an opening, blood vessel, or hollow organ] or leakage as needed Record review of Resident #1's May 2025, June 2025, and July 2025 TAR (a document in healthcare that tracks the administration of treatments and medications to patients) reflected the resident's catheter had not been changed. Record review of Resident #1's progress note documented by the NP reflected the following: .08/04/25 Seen at request of staff d/t AMS [a disruption in how the brain works that causes a change in behavior]. Pt is acting paranoid, thinks his food is being contaminated. Says his penis is swollen and tender.1. Altered mental status, unspecified altered mental status type STAT CBC [a blood test that measures the amounts and sizes of your red blood cells, hemoglobin, white blood cells, and platelets], BMP [a blood test that measures eight different substances in the blood], UA [a blood test that analyzes urine].await results .2. Swollen PenisSwitch out catheterGentle pericare [hygiene practice involving cleansing of the genital and anal area]Monitor closely. Record review of Resident #1's progress noted dated 08/04/25 documented by RN A reflected the following: This nurse received a new order for CBC, BMP, and UA in [lab system] and to change the Foley catheter, immediately this nurse deflated the balloon, patient began to bleed. This nurse notified the [physician], ordered not to remove the catheter but inflate it and leave in place and monitor patient and call if bleeding continues. Informed the incoming nurse to follow up. Further review of Resident #1's progress notes dated 08/05/25 documented by LVN B reflected the following: Critical lab results received. MD on-call notified. New order received to send patient to the hospital for evaluation.911 called, patient transported to the ER at [hospital]. Patient in stable condition at the time of leaving the facility. Record review of Resident #1 lab results report dated 08/04/25 reflected the following: BMP Results Reference Range Potassium 6.4 mmol/L 3.5 - 5.1BUN 103 mg/dL 6 - 25Creatinine 6.01 mg/dL 0.70 - 1.30 Potassium - (high potassium levels occur when blood potassium is too high, often caused by kidney problems, certain medications, or severe illness) BUN - (Blood Urea Nitrogen test which measures a waste product in the blood to assess kidney function) Creatinine - (a waste product from normal muscle breakdown that healthy kidneys filter from the blood and excrete in urine and measures this waste product to assess kidney function) Record review of Resident #1's hospital records dated 08/05/25 reflected the following: Assessment and Plan(Principal) Hyperkalemia [high potassium]Acute kidney injury.Gross hematuria [visible blood in the urine, making it appear pink, red, or brown] Due to Foley trauma. Balloon was noted to be in urethra. Catheter was removed. NP reports significant bleeding after catheter removed. Foley was reinserted. Patient with continued gross hematuria. No urology is available at this facility. House supervisor asked to assist with transfer to a higher level of care for urology evaluation. Hospital Labs Potassium - 5.9BUN - 94Creatinine - 4.88 Interview on 08/20/25 at 1:46 PM with RN A revealed during her shift on 08/04/25, Resident #1 refused his medications and refused to eat. She stated this was not Resident #1's baseline. She stated the NP happened to be doing her rounds that day, so she asked the NP to assess the resident. RN A said the NP ordered blood work and a UA to be done via straight catheterization. RN A said the Treatment Nurse was in the room when she (RN A) was going to remove Resident #1's catheter. RN A stated when she deflated the resident's catheter balloon, fresh blood came out on the drape under the resident and appeared to be mixed with urine. At that time, RN A said she stopped, left the catheter in place, and called the physician. The physician gave orders to leave the catheter in place, reinflate the catheter balloon, and monitor for further bleeding. RN A stated when she re-inflated the catheter balloon she did not feel resistance and the bleeding stopped. During the procedure, she said she did not notice any redness or swelling to Resident #1's penis. RN A further stated it was the end of her shift, and Resident #1's bloodwork results had not come back during her shift. She stated Resident #1 did not have issues with his catheter prior to that day. RN A said she had been trained on the insertion and removal of Foley catheters, but she did not give a date of the training. Interview on 08/20/25 at 2:40 PM with the Treatment Nurse revealed RN A got orders to change out Resident #1's catheter on 08/04/25, and she went in to assist. The Treatment Nurse said RN A deflated the catheter balloon and pulled out 10 cc of fluid via syringe. She stated blood began to come out from around the catheter on to the drape under the resident. The Treatment Nurse said she told RN A not to pull the catheter out and to leave it in place because the blood could indicate possible urethral trauma. The Treatment Nurse said RN A immediately called the physician and the physician gave orders to leave the catheter in place and re-inflate the balloon. The Treatment Nurse said there did not appear to be any resistance when RN A reinflated the balloon, and Resident #1 did not appear to be in any distress. The Treatment Nurse stated Resident #1 had urine in his bag after the attempted catheter removal. The Treatment Nurse stated she did not recall the resident having any issues with his catheter prior to that day they tried to change it. Interview on 08/20/25 at 3:57 PM with LVN B revealed he worked the night shift of 08/04/25 and Resident #1 had not been eating. He stated Resident #1 reported feeling tired which was not Resident #1's normal baseline. LVN B said he was given report to monitor the resident but had not been told blood had come out during an attempted catheter change. During his shift, he stated Resident #1's bloodwork results came back with some critical labs. He stated the physician was consulted and gave orders for Resident #1 to be sent to the hospital for further evaluation. When Resident #1 was sent to the hospital, the resident's vitals were within normal range. Prior to 08/04/05, LVN B stated Resident #1 had not had any catheter-related issues. Interview on 08/21/25 at 2:27 PM with CNA C revealed she had worked with Resident #1 around the time he had been sent to the hospital (08/05/25), but did not recall which day. CNA C said she provided care to the resident and noticed his penis was swollen, and there was blood coming from his penis around the catheter line, which she reported to LVN D. She stated LVN D was already aware of the resident's condition, and LVN D was checking on the resident. CNA C stated Resident #1 complained about discomfort to this catheter, and the resident wanted to make sure someone was checking on him during her shift. Interview on 08/21/25 at 2:35 PM with CNA E revealed she worked with Resident #1 the day he was sent to the hospital on [DATE] during the morning shift (6:00 AM to 2:00 PM), and had given the resident a bed bath. CNA E said when she changed the resident, she noticed his penis was swollen and had some dried drainage around his penis. CNA E said Resident #1 did not express he was in pain or discomfort. CNA A said she reported the drainage to RN A, who went to assess Resident #1. She stated later she saw the NP go into the resident's room. Interview on 08/21/25 at 3:16 PM with LVN D revealed he worked with Resident #1 on 08/04/25 during the 2:00 PM to 10:00 PM shift. He stated RN A reported to him that the NP ordered a UA and for Resident #1's catheter to be changed. RN A told LVN D she and another nurse (Treatment Nurse) tried to change the resident's catheter but when they had deflated the balloon and before they pulled the catheter out, blood was noted to be coming out from around the catheter. LVN D said RN A told him she had contacted the physician and he had given the orders to leave the catheter in and monitor. LVN D said he went in to see Resident #1 after getting report and there was some blood around the tip of the resident's penis, the collection bag had some urine in it but he did not see any blood in the bag. LVN D stated he did not notice any swelling to the resident's penis and there was nothing out of the ordinary during the resident of shift and the resident continued to have urine output in the bag with no blood in it. LVN D further stated Resident #1 did not have any issues with his catheter in the past. Interview on 08/21/25 at 3:45 PM with Resident #1 revealed, during his bed bath on 08/04/25, one of the aides (CNA E) told him his penis was infected and looked like it had some kind of drainage/puss to the area. The resident said the NP went in to see him and told the nurse his catheter needed to be changed. The Treatment Nurse assisted RN A and during the process, he stated he felt some pain, and it appeared something went wrong because it bled. Resident #1 said, sometime later, he was sent to the hospital, and the staff there told him something had ruptured in his urethra when they tried to change the catheter. Interview on 08/21/25 at 12:45 PM with the DON revealed the weekend of Saturday 08/02/25 and Sunday 08/03/25 Resident #1 did not want to eat and refused his medications. She stated RN A called her on Monday, 08/04/25 because said she and the Treatment Nurse tried to change the resident's catheter. RN A told her when they deflated the balloon, blood came out. RN A also told her the physician was called, and he gave orders to monitor the resident. The DON said they had ordered bloodwork and when those results came in, some of labs were critical so the resident was sent to the hospital. The DON further stated the nursing staff reported to her that Resident #1 continued to have urine output that afternoon before he was sent to the hospital. The DON said RN A had been trained on catheter insertion and removal upon hire and the training was a part of the Infection Control section. Record review of RN A's new hire training dated 09/16/25 reflected she took the Infection Control Portion. There were no other details to the training. Interview on 08/21/25 at 4:07 PM with the NP revealed she assessed the resident on 08/04/25 after staff told her Resident #1 had been acting confused and paranoid. The NP said when she assessed the resident she noticed his penis was slightly swollen so she ordered blood work, (CBC and CMP), a UA and a catheter change in case he had developed an infection (UTI). The NP said the resident's vitals were stable at the time, there was no bleeding to catheter site at the time, and there was yellow urine in the catheter bag. The NP stated she was not certain how the catheter balloon had gotten in Resident #1's urethra unless the catheter was tugged causing it to go into the urethra. Interview on 08/21/25 at 10:40 AM with the Physician revealed he cared for Resident #1, and there had not been any issues with the resident's catheter other than a couple UTIs. The last time the Physician had seen Resident #1 was on 07/30/25 for medication adjustments, and there were no issues with the resident's catheter. The Physician said, according to Resident #1's progress notes, Resident #1 had been seen by the NP on 08/04/25. He stated the NP documented that Resident #1's catheter was to be switched out because his penis was swollen. The Physician read Resident #1's hospital records and they said if it was documented that his catheter balloon was inflated in the urethra then it probably was causing bleeding from the trauma it caused the urethra. If the balloon was indeed in the urethra, the Physician stated it would explain why his BUN and Creatinine labs were critical which would indicate the resident was in acute renal failure because it would block the urine from flowing causing it to go back up into the kidneys. The Physician continued to read Resident #1's hospital records and said it appeared once the catheter was replaced his labs (Potassium, BUN, and Creatinine) began to decrease. The Physician said if the catheter balloon was in the urethra it was possibly inflated wrong or it was tugged on which would cause trauma and bleeding. Record review of the facility's policy titled Indwelling Catheter-Male and Female (Insertion and Removal of) reviewed on 06/2006 reflected the following: PurposeTo provide continuous drainage of the urinary bladder; to prevent contact of urine with open areas on the body; to obtain accurate measurement of urinary output; to obtain a sterile specimen for diagnostic purposes; and to instill medication into the bladder. Insertion of Indwelling Catheter .Procedure - .advance catheter one to one and one-half inches beyond the point of free flow or urine. - Check size of balloon; draw up sterile water to his amount (if not using pre-filled syringe), attach the syringe to the balloon port of the catheter. - Do not force water into balloon. If resistance is encountered or the patient complains of pain, deflated balloon, advance farther into the bladder and inflated. - Tug gently on catheter until you feel resistance. Removal of Indwelling Catheter.Procedure- Attach syringe to balloon port of catheter and aspirate entire amount of sterile water in balloon.- Pinch catheter and withdraw gently and slowly. Record review of the facility's policy titled Catheter Care, Urinary revised on September 2014 reflected the following: .Complications1. Observe the resident for complications associated with urinary catheters.b. Check the urine for unusual appearance (i.e., color, blood, etc.)c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed. d. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. An Immediate Jeopardy was identified on 08/21/25. The Administrator, DON and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 08/21/25 at 4:55 PM. The IJ template was provided to the facility on [DATE] at 5:10 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/22/25 at 8:30 AM and reflected the following: Concern:F684J - Quality of Care F684 - The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person -entered care plan, and the residents' choices based upon the comprehensive assessment of a resident. On 08/04/25, a [AGE] year-old male resident, who had a diagnosis of quadriplegia and who had a urinary catheter, experienced a change in condition resulting in loss of appetite and tiredness. The facility notified the Nurse Practitioner about the change in condition, and orders were given perform a straight catheter to obtain a sample for a urinalysis and for blood work to be done. When the nurse deflated the catheter balloon to remove the urinary catheter, she noticed blood coming out around the catheter. The physician was immediately notified and instructed the nurse to re-inflate the balloon and monitor for further bleeding. A few hours after this the resident's lab results arrived and showed that the resident had critical labs. The physician gave orders for the resident to be sent to the hospital. At the hospital, the hospital discovered that the catheter balloon had been inflated in the urethra causing trauma and bleeding. The resident was transferred to a higher level of care for a urology consultation. The facility failed to properly insert a urinary catheter which resulted in the resident experiencing urethral trauma and bleeding. Immediate Actions Resident #1 is no longer in the building. The Medical Director was assigned this resident. 1 The Ombudsman was notified of the content of the immediate jeopardy via email on 08/21/2025. 2 On 08/21/2025 The RDCS in-serviced the DON and the Unit Managers with test for competency on: - Following physicians' orders - Effective Documentation - Recognizing Changes in Condition - Urethral Catheter Placement with competency of test and with skill assessment checked off by nurse leadership/designee 3 On 08/21/2025 The RDCS and DON completed a 100% audit of all residents who are on catheters , who have the potential to be affected. The results of the audit yielded that no other residents were affected and were at their normal baseline. The Foley catheters were all appropriately placed and draining appropriately. Staff Training and Education Mandatory Training: Starting 08/21/2025 All licensed and registered nursing staff will undergo mandatory training on proper urinary catheter insertion and re-insertion techniques, including recognizing complications and responding appropriately. Training will be conducted by the DON/Clinical Designee. Competency Assessment: Each licensed or registered nursing staff member will be required to demonstrate competency in catheter insertion and re-insertion through hands-on evaluations. Staff who fail to demonstrate competency will not be allowed to work or perform catheter-related procedures until retraining and reassessment are completed. 4 On 08/21/2025 initiation of all in-house licensed and registered nurses and were re-inserviced with a test to validate competency on: Following physicians' orders Effective Documentation Recognizing Changes in Condition Urethral Catheter Placement with competency of test and with skill assessment checked off by nurse leadership/designee Systematic Approach 1. On 08/21/2025 A QAPI meeting was held, in attendance were the Medical Director (via TEAMS), Executive Director, DON, and the Regional Director of Clinical Services. Policy and Procedures on Physician Notification, Documentation and Changes in Condition were reviewed and found to be sufficient and met state and federal requirements. QAPI discussed the components and the interventions of this plan of removal. 2. The facility will incorporate catheter-related procedures into its annual staff training program and QAPI initiatives to ensure ongoing compliance and resident safety. Monitoring 1 DON, UMs were educated on 08/21/25 in the daily process of: a. The DON and Unit manager(s) were educated by the RDCS on 08/21/25 and will use the Grand Rounds process and 24-hour Summary to identify any and all residents who were may have been admitted with or given orders to insert a urethral catheter to ensure appropriate placement and flow. This will occur daily for 2 weeks, weekly for 2 weeks and then monthly. On the weekends and holidays, the Nurse Supervisor/Designee will complete the audit/review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. ******Any staff who are not present to complete the in-service by 8/21/2025 will be required to complete the in-service at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. The education will be conducted and monitored by the DON/Designee. Quality Assurance: Results of all monitoring by DON and Unit Manager shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. The DON will be responsible for bringing the results of the monitoring to the QA committee. Completion Date: 08/21/2025 Monitoring the facility's Plan of Removal included the following: Observation on 08/20/25 at 9:45 AM revealed Resident #1 was no longer at the facility. Record review of the In-service Training Report dated 08/21/25 reflected 12 charge nurses were educated on Foley insertion, verify placement, documentation, physician orders, change of condition, complete transfer form. Further review of the training revealed each charge nurse was given a competency test and a skills assessment checked off by nursing management. Interviews on 08/22/25 from 11:26 AM to 3:29 PM from nurses from various shifts were the DON, ADON, Treatment Nurse, RN A, LVN B, LVN D, LVN F, LVN G, LVN H, LVN I, LVN J, RN K, RN L, and LVN M. All staff were able to identify the following: - What type of documentation is required with resident that have Foleys; (i.e. color, odor, urine output, urine retention, discomfort to area and size of catheter and balloon inflation)- How to insert a catheter using sterile technique in males and females. (insert until there is urine return and go farther if resistance is felt) - What to do if they feel resistance when inflating the catheter balloon. - How to remove a catheter (pull the same amount of fluid that was inserted in the balloon, and gently pull out)- What to do if the is blood noted upon removal (do not remove and call the physician for orders)Each charge nurse had a competency test and skill assessment as part of their in-service. Review of the audits dated 08/21/25 revealed there were 5 residents with catheters and there were no issues identified with the resident's catheters. Observation on 08/22/25 of catheter care for Residents #2, #3, and #4 from 10:15 AM to 11:06 AM revealed appropriate technique was used, clear urine was flowing in the output bags, and there were no issued noted. There were no residents that required catheter insertion or changing. The Regional Nurse Consultant and DON were notified on 08/22/25 at 3:45 PM, the Immediate Jeopardy was removed. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 2 of 5 residents (Resident #1 ad Resident #2) records reviewed for treatment documentation. 1. LVN A documented Resident #1 had received his g-tube feeding on 05/24/25 morning and evening, but the resident did not receive his feeding for approximately 11 hours. 2. The facility failed to document wound care treatments on the Treatment Administration Record for Resident #2 indicated by blanks on Resident #2's June 2025 TAR. These failures could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: Record review of Resident #1's admission Record dated 06/24/25 reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #1's admission MDS assessment dated [DATE] reflected his dementia (loss of memory), gastro-esophageal (stomach acid flows back up into the esophagus and causes heartburn), hypertension (high blood pressure), Parkinson's disease, and seizure disorder. Resident #1's BIMS score was not complete due to Resident is rarely/never understood. MDS Section K - Swallowing/Nutritional Status indicated the resident's nutritional approach was a feeding tube. Record review of Resident #1's care plan revised date 05/27/25 reflected: Focus: The resident requires tube feeding r/t Dysphagia. provide Isosource 1.5 70cc/hr X 22 hours. Goal: The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: Provide care to G-Tube site as ordered and monitor for s/sx of infection. RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Record review of Resident #1's Order Summary Report reflected Isosource 1.5 Cal Oral Liquid (Nutritional Supplements) Give 70 ml via G-Tube every shift for Nutrition. Order date: 04/22/2025. Record review of Resident #1's May 2025 MAR reflected Isosource 1.5 Cal Oral Liquid (Nutritional Supplements) Give 70 ml via G-Tube every shift for Nutrition. MAR indicated Resident #1 feeding was documented as given on 05/24/25 - day and evening. Observation on 06/24/25 at 9:50 AM revealed Resident #1 in the common area sitting in his wheelchair. He could not answer questions. Resident #1's was connected to his feeding pump and the feeding pump was running. Interview and observation on 06/24/25 at 12:56 PM, Resident #1's Family Member revealed on 05/24/25 Resident #1 was not provided with his g-tube feedings for about 11 hours. She stated she had a camera in the room and in the footage, it showed around 10:45 PM Resident #1 had a fall in his room and landed on the right side of his bed. She stated the feeding pump was on the left side of the resident's bed, and when the resident was on the floor, she got concerned that the resident might had pulled his g-tube. Resident #1's Family Member stated when she reviewed the camera footage, she noticed Resident #1 was not connected to his feeding pump. Resident #1's Family Member stated she continued to review camera footage, and it showed Resident #1 being disconnected from his g-tube at 11:25 AM. She stated she contacted the facility, and the nurse entered the room and connected Resident #1's feeding tube at 10:54PM on 05/24/25. Observed camera video footage stamp date 05/24/25 at 11:32 AM Resident #1's feeding pump being disconnected from resident by LVN A but left feeding pump on. At 11:50 AM, LVN A observed entering the Resident #1's room due to feeding pump beeping and LVN A turned the feeding pump off. At 12:43PM, Resident #1 was transported out the room by CNAs. G-tube feeding pump was left in the room. At 7:44 PM, Resident #1 returned back to room, CNA B and LVN A transferred Resident #1 back to bed and CNA B provided incontinent care. At 7:48 PM, Resident #1 in bed resting, resident feeding pump was on the left side of Resident #1's bed turned off. Between 10:35 PM - 10:44PM, Resident was observed slowly moving towards his right side of the bed, slide off the bed and landed on his knees. Resident #1's feeding pump was off. At 10:45 PM, LVN D entered the room with another staff, resident was transferred back in bed and was connected to his feeding pump at 10:54 PM. An attempt was made to contact LVN A by phone on 06/24/25 at 2:07 PM; however, there was no answer. An attempt was made to contact CNA B by phone on 06/24/25 at 2:19 PM; however, there was no answer. Interview on 06/24/25 at 5:05 PM, the DON revealed she received a call from Resident #1 Family Member around 11:30PM/midnight regarding Resident #1's g-tube not being attached. She stated she contacted the facility but by that time Resident #1 feeding pump was already running. She stated she contacted LVN A and LVN A stated she had forgot to attach Resident #1. She stated LVN A just kept saying oh my god, oh my god. She stated during the investigation, she also noticed LVN A documented that the feedings were provided to Resident #1 when he did not. She stated when she questioned LVN A about the documentation LVN A got mad and ended the call. She stated LVN A was suspended pending investigation and once investigation was concluded she was terminated. She stated her expectations were for all nurses to document as they go and document what was being completed. She stated it was the responsibility of all nurses to document accurately and it was the responsibility of the ADONs and herself to ensure it was being done correctly. She stated the potential risk of not documenting correctly would be not being able to get history of what happened with the resident. Interview on 06/24/25 at 5:20 PM, the Administrator revealed LVN A admitted to forgetting to connect Resident #1 to his feeding. He stated after concluding his investigation he substantiated the incident. He stated during the investigation it was also confirmed LVN A documented the feedings were provided when they were not. He stated they took disciplinary actions and terminated LVN A. 2. Record review of Resident #2's admission Record dated 06/24/25 reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected his diagnoses included heart failure, hypertension (high blood pressure), hypothyroidism (the thyroid gland doesn't make enough thyroid hormone), colostomy status (opening stoma in the abdominal wall). Resident #2's BIMS score was 11 indicating moderate cognitive impairment. Record review of Resident #2's care plan revised date 04/15/25 reflected: Focus: Pressure Ulcer Prevention. Goal: The resident will remain free of skin breakdown over the next through the next review date. Interventions: Therapy disciplines to screen, evaluate, and treat as indicated. Record review of Resident #2 revealed no records were recorded of Resident #2 receiving wound care treatment on right lateral leg on 06/02/25, 06/04/25, 06/06/25, 06/11/25, 06/13/25, 06/16/25, 06/18/25, 06/18/25 and on 06/23/25 as indicated by blanks on the Treatment administration record. Record Review of Resident #2 progress notes for June 2025 did not reflect alternative documentation of wound treatments of the right lateral leg. Record review of physician orders dated 05/02/25 revealed Wound Treatment - Xeroform every evening shift every Mon, Wed, Fri for Skin tear wound Cleanse wound to Right Lateral leg with Normal Saline or Skin Cleanser. Pat Dry. Apply Xeroform to wound. Cover with Island Dressing. Observation and interview on 06/24/25 at 11:40 AM revealed Resident #2 in her bed in her room. Resident #2 stated she got her wound care three times a week and before she was getting wound care daily. She denied missing wound treatment. Observation/skin assessment on 06/24/25 at 11:56 AM with LVN D revealed she explained the procedure to Resident #2, she washed hands, put on gloves and positioned the resident. Resident #2 trauma/injury right superior lateral leg dressing was observed dated 6/24/25 and the dressing was intact and clean. Interview on 06/24/25 at 12:45 PM with wound care nurse revealed she was the wound care nurse. She stated she was aware she was supposed to document on treatment administration record every time she performed wound care, but she was not aware that every time she documented it was not showing on the treatment administration record. She stated the risk of not documenting after the wound care was done would mean treatment not administered and would be hard to monitor if the wound was getting better or not because it would be hard to tell when the wound care was last provided. She stated the facility policy was to sign the treatment administration record after wound care was performed. She stated she could not recall in-service on documentation since she was newly hired. Interview on 06/24/25 at 03:32 PM with the DON revealed her expectations were that staff to document accurately on the resident's treatment administration record. The DON said wound care nurse should have documented on Resident #2's treatment administration record that she had performed wound care. She stated she was the one responsible of ensuring the wound care was done and documented on treatment administration record/Medication administration record. The DON stated she does random checks on big pressure ulcer wounds but not skin tears. She said the purpose of documenting accurately was to make sure orders were completed correctly. The DON said the risk of staff not documenting care accurately could lead to care not being provided and the wounds would deteriorate. She stated she could not recall training on documentation to the staff since she had not noticed there was an issue with documentation of wound care. Record review of facility Documentation of Medication Administration on eMAR/eTAR, dated February 2010 reflected the following: To ensure proper documentation of medication administration and treatments in the medical record.

Based on observations, interviews, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 residents (Resident #1) reviewed for enteral feeding. The facility failed to follow physician's orders of providing Resident #1 with his 22 hours of feeding intake on 05/24/25. The noncompliance was identified as PNC. The noncompliance began on 05/24/25 and ended on 05/25/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care. Findings included: Record review of Resident #1's admission Record dated 06/24/25 reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #1's admission MDS assessment dated [DATE] reflected his diagnoses included dementia (loss of memory), gastro-esophageal (stomach acid flows back up into the esophagus and causes heartburn), hypertension (high blood pressure), Parkinson's disease, and seizure disorder. Resident #1's BIMS score was not completed due to Resident was rarely/never understood. MDS Section K - Swallowing/Nutritional Status indicated the resident's nutritional approach was a feeding tube. Record review of Resident #1's care plan revised date 05/27/25 reflected: Focus: The resident requires tube feeding r/t Dysphagia. provide Isosource 1.5 70cc/hr X 22 hours. Goal: The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: Provide care to G-Tube site as ordered and monitor for s/sx of infection. RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Record review of Resident #1's Order Summary Report reflected Isosource 1.5 Cal Oral Liquid (Nutritional Supplements) Give 70 ml via G-Tube every shift for Nutrition. Order date: 04/22/2025. Record review of Resident #1's May 2025 MAR reflected Isosource 1.5 Cal Oral Liquid (Nutritional Supplements) Give 70 ml via G-Tube every shift for Nutrition. MAR indicated Resident #1 feeding was documented as given on 05/24/25 - day and evening. Record review of the facility's Provider Investigation Report, completed by the Administrator on 05/02/25, reflected the following: 05/24/2025 The facility initiated an investigation on 05/25/2025, after resident feeding tube was unhooked around 11:30am in order to lift him off the floor when he fell. The feeding tube was not hooked back up to his body until 11pm. Investigation Summary: Resident suffered a fall in his room. Fall did not result in any physical harm to resident. Resident feeding tube [was detached in under to lift him up off the ground]. This incident took place at approximately 11:30am. Nurse forgot to reattach the feeding to resident body once he was lifted up off of the floor. Feeding remains unattached until 11pm when resident's daughter brought it to the nurse's attention. Feeding was reattached at that time. All resident with feeding were checked to ensure it was attached to their bodies. Resident's skin assessed by Treatment Nurse. There are no skin break down, wounds on resident's body, or signs of dehydration. Resident weight checked and he was not experienced any weight lost. Physician ordered labs. Lab results shows that resident has not experience any changes from baseline. Assessment: Head to toe assessment and pain assessment completed. Resident did not have any changes of condition or any adverse effect. Provider Action: Staff in-service on Abuse/Neglect and G-Tube Attachment. Facility initially placed alleged perpetrator on suspension, pending investigation. Facility now moving forward terminating staff member, post investigation. Observation on 06/24/25 at 9:50 AM revealed Resident #1 in the common area sitting in his wheelchair. He could not answer questions. Resident #1's was connected to his feeding pump and the feeding pump was running. Interview and observation on 06/24/25 at 12:56 PM, Resident #1's Family Member revealed on 05/24/25 Resident #1 was not provided with his g-tube feedings for about 11 hours. She stated she had a camera in the room and in the footage, it showed around 10:45 PM Resident #1 had a fall in his room and landed on the right side of his bed. She stated the feeding pump was on the left side of the resident's bed, and when the resident was on the floor, she got concerned that the resident might had pulled his g-tube. Resident #1's Family Member stated when she reviewed the camera footage, she noticed Resident #1 was not connected to his feeding pump. Resident #1's Family Member stated she continued to review camera footage, and it showed Resident #1 being disconnected from his g-tube at 11:25 AM. She stated she contacted the facility, and the nurse entered the room and connected Resident #1's feeding tube at 10:54PM on 05/24/25. Observed camera video footage stamp date 05/24/25 at 11:32 AM Resident #1's feeding pump being disconnected from resident by LVN A but left feeding pump on. At 11:50 AM, LVN A observed entering the Resident #1's room due to feeding pump beeping and LVN A turned the feeding pump off. At 12:43PM, Resident #1 was transported out the room by CNAs. G-tube feeding pump was left in the room. At 7:44 PM, Resident #1 returned back to room, CNA B and LVN A transferred Resident #1 back to bed and CNA B provided incontinent care. At 7:48 PM, Resident #1 in bed resting, resident feeding pump was on the left side of Resident #1's bed turned off. Between 10:35 PM - 10:44PM, Resident was observed slowly moving towards his right side of the bed, slide off the bed and landed on his knees. Resident #1's feeding pump was off. At 10:45 PM, LVN D entered the room with another staff, resident was transferred back in bed and was connected to his feeding pump at 10:54 PM. An attempt was made to contact LVN A by phone on 06/24/25 at 2:07 PM; however, there was no answer. An attempt was made to contact CNA B by phone on 06/24/25 at 2:19 PM; however, there was no answer. Interview on 06/24/25 at 5:00 PM, Physician revealed he was made aware of Resident #1 not receiving his feeding. He stated he could not recall how many hours he was off his feeding, but the nurse forgot to connect the resident. He stated he ordered a bolus feeding and lab work. He stated he reviewed Resident #1 lab work, and everything was fine. He stated there was no risk to the resident. He stated his expectation were for nursing staff to follow the orders. Interview on 06/24/25 at 5:05 PM, the DON revealed she received a call from Resident #1's Family Member around 11:30PM/midnight regarding Resident #1's g-tube not being attached. She stated she contacted the facility but by that time Resident #1 feeding pump was already running. She stated she contacted LVN A and LVN A stated she had forgot to attach Resident #1. She stated LVN A just kept saying oh my god, oh my god. The DON stated the doctor was notified and the doctor ordered an extra bolus feeding, and lab work to ensure there was no dehydration. She stated Resident #1's lab work results were good. She stated the dietician was also informed and Resident #1's weight had been stable. The DON stated they had the nurse check on the other residents who were on g-tubes with no concerns noted. She stated all nursing staff were in-serviced on abuse and neglect and monitor feeding tubes to make sure that they are connected at all times according to the doctor orders. She stated LVN A was suspended pending investigation and once investigation was concluded she was terminated. She stated the potential risk of not following physician orders could be weight loss and dehydration. Interview on 06/24/25 at 5:20 PM, the Administrator revealed LVN A admitted to forgetting to connect Resident #1 to his feeding. He stated after concluding his investigation he substantiated the incident. He stated his expectations were for his nursing staff to complete rounds, follow physician orders and make sure residents with g-tubes are connected. He stated if a resident was on continues feedings, and the resident was taken to another place in the facility the feeding pump should go with the residents. He stated the potential risk of a resident not receiving his feedings would be skin breakdown and dehydration. Record review of facility Administration of Formula via Feeding Tube Gravity, Bolus, Pump policy, reviewed date March 2019, reflected the following: To administer nutrients to patients who are unable to eat normally without complications: to assure proper absorption of nutrients by proper administration, without side effects The facility took the following actions to correct the noncompliance: Record review of Resident #1' physician orders reflected Resident #1 had an order for Enteral Feed Order one time only for 1 Day give x 1 bolus feeding (237ml) now of isosource 1.5 cal dated 05/25/25. Record review of Resident #1's Weight reflected no weight loss. Record review of Resident #1's Un-witnessed Fall (Skin assessment, Pain assessment) and Medication Error Assessment completed on 05/24/25 and 05/25/25 documented no concerns. Record review of the facility's In Service Training, dated 05/25/25, provided by the DON, reflected all facility nursing staff were In-Serviced on Abuse and Neglect, Monitor feeding tubes to make sure that they are connected at all time according to the doctors orders, Make sure g-tube are connected. Record review of Resident #1's Lab Results Report completed on 05/28/25 reflected normal levels. Interviews on 06/24/25 from 2:46 PM to 4:00 PM with ADON C, LVN E, LVN F, LVN G, LVN H, RN I, RN J, LVN K, LVN L, ADON M who work the shift of 6:00AM - 2 PM, and 2PM - 10 PM. Facility staff were able to verify education was provided to them. Facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect and residents on g-tubes. Nursing staff stated they were inserviced on making sure residents on g-tube were connected to feeding pumps according to physician orders, if residents on continues feedings were taken out of the room the feeding pumps must go with them. Staff stated they completed rounds during shift change with the incoming staff. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff revealed they would report to the Abuse Coordinator, the Administrator, immediately if they witnessed any type of abuse or neglect. The noncompliance was identified as PNC. The noncompliance began on 05/24/25 and ended on 05/25/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment of a resident and consistent with the resident's needs and choices for activities of daily living including toileting for one (Resident #1) of four residents reviewed for ADL assistance. CNA A failed to provide Resident #1 with a bedpan for toileting and instead told the resident to use her brief on 12/04/24. This failure could place residents at risk of feeling uncomfortable, disrespected, have a decreased self-esteem and a diminished quality of life. Findings included: Record review of Resident #1's Nursing Home Comprehensive MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a principal diagnosis of a fracture of shaft of the left femur. The resident had a BIMS score that reflected the resident was cognitively intact. The MDS did not reflect the resident needed assistance with toileting. Record review of Resident #1's Progress Notes dated 11/29/24 reflected: Continent of bowel and bladder. Uses bedpan. Extensive assists x 1 person with ADLs, per LVN C. Interview on 01/21/25 at 1:50 PM with Resident #1 revealed she was told to use her brief when she used her call light to ask for assistance for toileting. Resident #1 stated she could not walk and required a bedpan. Resident #1 also stated CNA A came into her room to respond to her call light on 12/05/24. Resident #1 said she was told by CNA A to use her brief because she did not have time to assist her. Interview on 01/22/25 at 9:36 AM with LVN B revealed she had not personally heard any staff tell a resident to use their brief instead of assisting with toileting the resident. LVN B stated she was told by Resident #1 that CNAs told her to use her brief because the aide did not have time to get a bedpan and assist the resident. LVN B said Resident #1 did not give her a specific name of a CNA. LVN B stated she did not report the incident because Resident #1 did not give her a specific name of a CNA. LVN B stated this was not the correct protocol, and the aide should have assisted the resident by providing her with a bedpan. LVN said if a resident must use her brief as told by a CNA, this was a dignity issue and could lead to skin breakdown. LVN B revealed the last time she was in-serviced on ADLs was upon her hire. Interview on 01/21/25 at 3:33 PM with CNA A revealed she assisted Resident #1 with toileting by providing her with a bedpan. CNA A stated she would open the bathroom door and stand there while the resident used the bedpan to give her privacy. CNA A said she would not leave a resident on the bedpan for more than five minutes. CNA A revealed she had told a resident to use their brief because there was not enough staff to assist the residents. CNA A stated she did not think it was Resident #1 she told to use her brief, but she could not recall who the resident was. However, CNA A stated she knew it was a resident on the same hall as Resident #1. CNA A stated she thought she was helping the resident because it was giving them relief, that someone came to check on them. CNA A said she was last in-serviced on 01/19/25 on ADLs. Interview on 01/21/25 at 4:44 PM with the ADON revealed she was unaware a staff member had told any residents to use their briefs instead of assisting them with toileting or bringing them a bedpan. The ADON stated she expected her staff to assist a resident with toileting if the resident needed assistance. The ADON also said a nurse could assist as well as an aide. The ADON revealed if she heard this occur or if it was reported to her that a staff member told a resident to use their brief, she would conduct a one-on-one training with the staff. Interview on 01/21/25 at 4:54 PM with the DON revealed the only time a resident should wait for assistance to toilet was when staff were passing trays. The DON stated if a resident needs to be changed or assistance with toileting, the CNA or nurse should stop and change them at that time. The DON stated she was unaware a staff member had told a resident to use her brief because there was not enough staff to assist her with toileting. The DON said a resident using her brief could lead to skin break down. The DON also stated this would be a dignity issue for the resident. The DON revealed she would begin in-servicing her staff immediately on the topic. Record review of the facility's Resident Rights policy, dated November 2016, reflected: . (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. (2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition or payment source .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #15) reviewed for comprehensive care plans. The facility failed to ensure Resident #15's care plan addressed pain management and behaviors. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. Findings included: Record review of Resident #15's Face Sheet, dated 10/03/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #16's quarterly MDS assessment, dated 06/19/24, reflected her diagnoses included Type 2 diabetes mellitus with foot ulcer, anxiety disorder, depression, and schizophrenia. Resident #15's had BIMS score of 09, which indicates moderate cognitive impairment. The MDS further revealed Section J - Pain Management indicated resident received scheduled pain medication regimen. Record review of Resident #13's October 2024 physician order sheet, reflected: Morphine 15 mg immediate release tablet (1) TABLET Oral, As Needed Every Six Hours Starting 06/20/2023. For Pain. Gabapentin 300 mg capsule (1) Capsule Oral, Two Times Daily Starting 10/02/2024. For Chronic Pain Syndrome. Record review of Resident #15's care plan, undated, reflected: Problems: Enhanced Barrier Precautions implemented r/t: Pressure ulcer, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers. Goals: The spread of an MDRO will be reduced over the next 90 days. Interventions: Monitors for signs and symptoms of infections. Care plan does not address pain management or behaviors. Observation and interview on 10/01/24 at 11:40 AM with Resident #15 revealed he had concerns regarding his pain medications. Resident #15 stated he was not receiving his pain medication as scheduled. He also stated staff would not provide him with the pain medication when he requested it. Resident #15's toes had some redness around them and scabbing. Resident #15 stated he had some wounds on his toes, and he was receiving wound care. He stated he removed the scabs once the wounds healed. Resident #15 stated he liked to pick at his scabs and remove them which would caused the wounds to reopen. Record review of Resident #15's September and October 2024 MAR reflected the resident received his pain medications as ordered. Interview on 10/02/24 at 3:22 PM with LVN C revealed Resident #15 was on scheduled pain medications. She stated Resident #15 had a history of making allegations of not receiving his pain medications. She stated Resident #15 would ask for more or stronger pain medications. LVN C stated Resident #15 had wounds around his legs and feet, and he was being seen by the Wound Care Nurse. She stated Resident #15 had a behavior of picking at the scabs once the wounds healed. LVN C stated since it was a recurring problem for the resident to pick at his skin and allege he was not receiving his pain medication, and it should be care planned. LVN C reviewed Resident #15's care plan and stated pain management and behaviors were not care planned. She stated the ADON and MDS Coordinator were responsible for care plans. Interview on 10/03/24 at 3:11 PM with the MDS Coordinator revealed all nursing staff were responsible for updating care plans. She stated anything in the MDS assessments should be care planned. The MDS Coordinator stated pain management and behaviors should be cared planned. She stated the Wound Care Nurse was responsible for care planning skin/wound care concerns. She stated the potential risk of not care planning pain management and behaviors was that the resident might receive improper care. Interview on 10/03/24 at 3:16 PM with the Wound Care Nurse revealed Resident #15 was receiving wound care for the wounds on his feet, and the wounds healed. She stated due to trauma or the resident picking at the scabs, the wounds reopened. She stated Resident #15 had a history of picking at his scabs after the wounds healed. She stated the resident's wounds and behaviors should be care planned. The Wound Care Nurse reviewed Resident #15's care plan and stated the resident's wounds were not care planned. She stated she thought the wounds were care planned. The Wound Care Nurse stated there was no potential risk to the resident if his wounds were not care planned since the resident was receiving wound care. Interview on 10/03/24 at 3:36 PM with the ADON revealed the MDS Coordinators were responsible for care plans. She stated almost everything should be care planned to include pain management and behaviors. She stated she was not aware Resident #15's care plan was not updated to address pain management or behaviors regarding the resident's wounds. She stated it was her responsibility to ensure care plans were updated. She stated care plans were important because the care plans let all staff know how to care for the patient, goals, and address any issues they had. Record review of the facility's Care Plans - Comprehensive policy, dated September 2010, reflected the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure various foods stored in the pantry were sealed, dated, and labeled. This failure could place all residents at risk for food contamination and food borne illness. Findings included: Observation and interview with the Dietary Manager on 10/01/24 beginning at 9:20 AM of the dry pantry revealed an unsealed and unlabeled 10-pound cardboard box dated 11/30/24 containing enriched macaroni product sitting on the bottom shelf of the dry pantry in the kitchen. There was also a 10-pound box of linguine opened, unsealed, and undated. The Dietary Manager observed the boxes and stated she was unaware the two boxes of opened, unsealed, undated, and unlabeled noodles were in the dry panty. The Dietary Manager then said it was the Cook's responsibility to store food in sealed, dated, and labeled containers. The Dietary Manager revealed the facility policy reflected all opened items were supposed to be sealed, dated, and labeled. The Dietary Manager then said she would trash both opened boxes of noodles because there was a risk that the residents could get sick if they ate the noodles. Interview on 10/01/24 at 9:49 AM with [NAME] A revealed the policy reflected all items in the dry pantry should be in sealed containers, labeled, and dated. [NAME] A stated if food was found not in a sealed container, it should be thrown away. [NAME] A was also unaware who placed the items in the pantry. [NAME] A concluded by stating if the facility policy was not followed, then residents could get sick. Interview on 10/01/24 at 9:42 AM with [NAME] B revealed the facility policy reflected if something was opened, it should be wrapped up, dated, and placed in a sealed container. [NAME] B stated if the facility policy was not followed, the residents could become sick if they were to eat those items. [NAME] B concluded by stating the Dietary Manager was responsible for ensuring all items were placed in sealed containers and properly labeled and dated. Interview on 10/03/24 at 2:38 PM with the Administrator revealed opened packages should be sealed, labeled, and dated. The Administrator stated the Dietary Manager was responsible for ensuring foods were stored safely. The Administrator declined to answer the risk to the resident if food items were not sealed, labeled and undated. Record review of the facility's Food Storage policy, dated March 2009, reflected: .Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must [sic] legible and accurately labeled, including the date the package was opened.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 22 residents (Resident #20) reviewed for pest control. The facility failed to ensure Resident #20's room was free of ants, and the resident sustained ant bites on his arms, legs, and stomach on 08/06/24, which were treated with hydrocortisone cream. The noncompliance was identified as PNC. The noncompliance began on 08/06/24 and ended on 08/08/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of a decreased quality of life. Findings included: Record review of Resident #20, quarterly MDS dated [DATE] reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #20 had diagnoses which included non-traumatic brain disfunction, cancer, coronary artery disease, and renal insufficiency. Record review also reflected Resident #20 had a BIMS of 11, which meant a moderate cognitive impairment. Record review of Resident #20 nursing notes written by LVN D, dated08/06/24, indicated Patient reported that he has ant bites, head to toe assessment done, ant bites noted on his hands and legs, denies pain complains of itching on the bite areas, states that he saw amts [ants] in his room, ant noted in patients room on the carpet and across the wall, MD notified new order hydrocortisone cream, cream applied on the affected areas, RP notified, ADON and ED notified, patient moved to room [ROOM NUMBER], will continue monitoring. Record review of Resident #20 nursing notes written by LVN E, dated 08/07/24, indicated New orders received from Dr [NAME] for Benadryl cream to areas of ant bites BID x 5 days. Apply to areas on both hands and knees. Review of the facility's provider investigation report dated 08/13/24 revealed the following: Head to Toe Skin Assessment & Pain Assessment completed. Resident has what appears to be ant bite marks on his arm and back. Resident stated reported [sic] that he has some itching but that he was pain free. Resident's MPOA and Facility Medical Director were immediately notified. Resident immediately relocated to a different room that is free of ants. In-services on identifying insect bites on residents and reporting insect sightings to Maintenance Director via Pest Control Log. Maintenance Director inspected resident's room. There were sightings of ants near the area where resident usually eats in his room. Skin assessment from nurse confirmed that resident had been bitten by ants on his arms and legs. 100% of residents room were inspecting for ants. There were no sightings of ants in any of the residents' room. Skins assessment completed on 100% of residents. No bite mark found on any of the residents. None of the residents reported having any bite marks or itching when asked during the skin assessment. Pest Control treated resident's room on 8/7. Pest Control treated each room in the facility, all public areas, dining room, and outside of the facility. Resident's room inspected and cleaned by Housekeeping Director, ensuring it is free of food with open containers. Maintenance Director inspected resident's room after Pest Control treatment to ensure it is free of ants. Resident monitored for by nurse, reporting no pain and itching as stopped. Interview and observation on 10/01/24 at 2:57 PM with Resident #20 revealed he woke to find about 25 bites covering on his both arms, both legs, and his stomach. Resident #20 said that the bites itched, so he went to the nurses' station to report the bites. Resident #20 stated that he went back to his room and discovered that ants crawling on the baseboard, under his bed, on his bed, and in his trash can. The facility treated his room, and he has not seen ants in his room since then. Resident #20 observed to have no visible bite marks. Interview on 10/01/24 at 2:00 PM with LVN C revealed that she came to work on 08/06/24 and was instructed to go from room to room inspecting form ants. LVN C stated that Resident #20 had large quantities of prepackaged snacks in his room. LVN C said that she assessed Resident #20 and saw 3-4 bites on both arms and both legs. LVN C revealed that the resident complained of itching. LVN C stated that she had not seen ants in the resident's room since that day. LVN C also said that at each nurses' station, there was a book that nurses document anything they need maintenance to address such as ants or pests. LVN C concluded by stating that when pests are seen and documented, then maintenance would contact the pest control company. Interview on 10/01/24 at 4:01 PM with Maintenance Director revealed he was called after hours on 08/06/24 about ants. The Maintenance Director said that he entered and inspected Resident #20's room. The Maintenance Director revealed he saw ants near the resident's window. The Maintenance Director stated he moved Resident #20 to another room that night, and then he checked the residents' rooms next to Resident #20's room. The Maintenance Director stated he saw ants in one other room, so he moved that resident that night as well so that his room could be treated for ants as well. The Maintenance Director revealed he called the after-hours pest control person on call so that he could schedule them to come out the following morning. The Maintenance Director stated the pest control company arrived about 7:00 AM on 08/07/24 and both rooms were treated. The Maintenance Director gave the staff all clear to move the residents back into their room. The Maintenance revealed that the pest control company came back out to the facility a week later and retreated the whole hallway, the two room that had active ants, and outside the facility as well. The Maintenance Director stated that he followed up weekly for three weeks by inspecting Resident #20's room for food in the waste basket. The Maintenance Director also said that he has not seen any ants since that time nor has the pest control company. The Maintenance Director revealed that until this incident with ants in the residents' rooms, no one had reported ants. The Maintenance Director also stated that he walked the grounds daily to look for things like ant piles. The Maintenance Director stated that his process was to notify the pest control company if something is reported to him, or he observed pests during his daily rounds. The Maintenance Director said the pest control company will come out the same day or the following day to treat, depending on availability when he calls them for treatment. The Maintenance Director concluded by stating that the risk to the resident for not having an effective pest control program was that a resident could get bit by a pest to which they are allergic. Interview on 10/03/24 at 2:06 PM with the Administrator revealed the pest control company came monthly and came additionally as needed to address anything that was urgent during the month as well. Administrator also said that management did angel rounds Monday through Friday while the manager on duty walked the premises on Saturday and Sunday to ensure that there were no pests or insects. Administrator also stated that direct care staff check the residents' rooms daily during their shifts as well as housekeeping. Administrator stated that it was all the staff's responsibility to check rooms for pests and report it in the maintenance logbook or the pest control book if pests are seen. Administrator stated the pest control book was at the front desk. Administrator revealed that a resident can be injured by bites from ants. Administrator stated that when Resident #20 reported the bites, he was given a head-to-toe assessment and moved to a different room so that he was not at risk for further injury. Administrator reported that his room was treated by pest control the following day and continued to be assessed for pain. Administrator stated that he maintenance director walks the grounds daily and inspects rooms as well. Administrator concluded by stating that all staff were in-serviced on looking for insects and pests and reporting insects and pests. This was completed on 08/06/24. Record review of the facility's pest control logs for 07/04/23 through 07/26/24 reflect the facility was treated for ants and pests once per month. Record review of the facility's pest control logs reflected the facility was treated for ants on 08/07/24. Observation on 10/02/24 at 10:25 AM revealed the exterior of the building including the interior courtyard and the windowsills had no ants. The porches of the facility were also observed with no ants sighted. There were no ant hills seen in the grass around the facility outside as well. There also were no ants observed in the residents' rooms or in the public areas of the facility during the investigation throughout the week. Record review of the facility's undated Pest Control Policy reflected, .1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's In-service Training Report dated 08/06/24 provided by the Administrator revealed the following: Topic: If you notice any type of bug/insect infestation or you see suspected bug bites on a resident, you MUST complete the following: Complete skin assessment Move resident to a different room Complete incident report Notify maintenance and place in maintenance /pest control log Notify management, MD and RP Maintenance book-located @ each nurses' station Pest Control log-Located at Receptionist desk in front Action to be Taken Employees must follow state/company policies and procedures. Employees educated on reporting insects and pests.

Based on interview and record review, the facility failed to notify the resident, resident representative and send a copy to the Office of the State Long-Term Care Ombudsman, of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 (Resident #) of 3 residents reviewed for discharge. The facility failed to notify Resident #74, the resident representative, and the Ombudsman in writing of the transfer/discharge of the resident to the hospital, the reason for the transfer/discharge, and the right to appeal. This failure could put residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Review of Resident #74's facesheet printed on 10/03/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. The resident's admitting diagnoses included COVID-19, heart failure, asthma, Parkinsonism, embolism and thrombosis (A blood clot, or thrombus, forms in a blood vessel, usually in the legs) to lower extremity, anxiety and depressed mood, and pain. Review of Resident #74's progress notes dated 08/26/24 reflected the following: Resident was complaining of SOB and chest pain with his CPAP (a machine that uses air pressure to keep airways open while sleeping on) Refused breathing tx and inhaler. Notified NP. New order received - Nitroglycerin 0.4SL given X 2 but refused the 3rd dose. Called 911 .resident still complaining of SOB. Notified RP. Resident left the facility. Sending to [Hospital] .DON/RP/Administrator made aware of the transfer .Resident sent to hospital RP called to notify the resident has PNA. Will keep resident in the hospital today for monitoring Interview on 10/03/24 at 2:42 PM with the Social Worker revealed she was aware Resident #74 has been discharged to the hospital and she was not sure if any type of discharge paperwork had been sent with the resident. The Social Worker said it would have been the Administrator's responsibility to provide any type of discharge paperwork to the resident or the family. Interview on 10/03/24 at 4:28 PM with the Administrator revealed Resident #74 was transferred to the hospital and did not return to the facility. The Administrator said he was not aware he had to send anything in writing with the resident or to the responsible party regarding the reason for discharge or information for the ombudsman because they were anticipating Resident #74 to return to the facility. Review of the facility's Transfer or Discharge Notice policy revised November 2016 reflected the following: .2. The Patient/Resident's representative will be provided with the following information The reason for the transfer or discharge; .h. The effective date of the transfer or discharge; i. The location to which the Patient/Resident is being transferred or discharged ; j. A statement of the Patient/Resident's appeal rights, including the name, address, (mailing and e-mail), and telephone number of the entity which received such requests: and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. k. The name, address, and telephone number of the state long-term care ombudsman .n. The facility must send a copy of the notice to a representative of the Office of the State Long term Care Ombudsman 44140

Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders for one (Resident #1) of one resident reviewed for parenteral fluids. The facility failed to obtain physician orders to manage, provide care, and change Resident #1's CVC dressing at least every 7 days and as needed if the dressing or site appeared compromised (damp, loosened or visibly soiled). The facility failed to change Resident #1's CVC dressing at least every 7 days and ensure Resident #1's central line was maintained per professional standards and facility policy. On 10/04/23 Resident #1 was transferred to the ER and admitted for a medical emergency - Sepsis (the body's extreme response to an infection) and Septic Shock (a life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection). An Immediate Jeopardy (IJ) was identified on 10/18/23. The IJ template was provided to the facility on [DATE] at 1:51 PM. While the IJ was removed on 10/19/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not immediate due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice place residents at high risk or the likelihood of, serious injury, harm, impairment, or death by not having their needs met, or receiving treatment in a timely manner in accordance with professional standards of practice. Findings included: Record review of Resident #1's Face Sheet, printed on 10/12/23, revealed the resident was a [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: HTN (a condition in which the blood vessels have persistently raised pressure);T2DM (a chronic condition that affects the way the body processes glucose [blood sugar]) with hyperglycemia (high blood glucose [blood sugar]); DVT (when a blood clot forms in a deep vein); and CKD (kidneys have mild to moderate damage). Record review of Resident #1's undated Five-Day PPS Assessment, signed by RN J on 09/06/23, verifying assessment completion, revealed a reentry from an acute hospital on 08/16/23. Resident #1 readmission diagnoses included Severe sepsis with septic shock (septicemia). Other health conditions reflected in the Five-Day PPS Assessment were fever and vomiting. Resident #1 had a BIMS Summary Score of 15 which suggested intact cognition. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 had an urostomy (an opening in the abdominal wall that re-directs urine away from the bladder) and colostomy (an opening formed in the abdominal wall to bypass a damaged part of the colon). Resident #1 receive parenteral/IV feeding, TPN (via right subclavian CVC). Resident #1 returned to SNF on 10/16/23 from an acute hospital stay (10/04/23 - 10/16/23). A record review on 10/12/23 of hospital medical records (visit: 08/08/23 - 08/16/23) revealed Resident #1's CVC was placed on 08/10/2023 during hospitalization in August 2023 for admission diagnosis of severe sepsis when PICC line was the source of sepsis. Record review on 10/12/23 at 2:19 PM of Resident #1's October 2023 physician order sheet reflected: -Order date 08/25/23: Take vital signs. Frequency: By shift starting 08/25/2023 Record review of Resident #1's September [09/01/23 - 09/30/23] and October [10/01/23 - 10/31/23] TARs, print date 10/17/23 at 4:36 PM, reflected the following orders did not have assigned administration times in the Date Range Specified: - IV - Flush SASH Method by shift starting 07/11/2023 - COMPLETED - IV - Site Check by shift starting 07/11/23 - COMPLETED - IV - Tubing Change every 24-hours starting 07/11/23 - COMPLETED - PICC - Dressing Change one time weekly starting 07/11/23 - COMPLETED - IV - Dressing Change every one week starting 07/12/23 - COMPLETED CVC dressing changes were not documented as completed on the August 2023, September 2023, or October 2023 TARs following the resident's return from the hospital on 08/16/23. The TARs did not reflect CVC (placed 08/10/23) dressing changes at least every 7 days beginning 08/17/23, 08/24/23, 08/31/23, 09/07/23, 09/14/23, 09/21/23, or 09/28/23. The next CVC dressing changed would have been scheduled for 10/05/23. Review of Resident #1's progress notes reflected: - On 10/03/23 at 11:49 PM, RN D entered, Dressing on the IV site changed, patient tolerated well, IV line flushing well, patient alert and oriented, able to verbalize needs, TPN running well, V/S within normal saline. continue to monitor. Record review on 10/12/23 at 2:05 PM, Resident #1's care plan (Effective: 06/06/23; Created: 06/19/23), date range: 06/06/23 - Present, did not reflect interventions for the care of CVC that included routine inspection and dressing changes at least every 7 days and as needed. Record review on 10/13/23 at 2:07 PM of Resident #1's hospital medical records, admitted [DATE] (still IP, no D/C date), reflected Resident #1 arrived at theER on [DATE] at 6:51 PM. Record review of the ER Provider Note dated 10/04/23 at 7:02 PM reflected, per EMS, [Resident #1] with fever of 103 ( F), chills and diaphoresis (unusual sweating) . nausea and vomiting as well. Resident #1's vital signs revealed: BP: 100/55; HR: 127; Temp: 100.6 F; Resp: 15. The ER provider physical exam revealed Resident #1 with AMS, tachycardic (heart rate over 100 beats a minute), sleepy; drowsy, but followed commands. The ER provider assessment/plan indicated (Resident #1) with indwelling subclavian catheter for TPN, urostomy and colostomy, presented with AMS, high fever, and very likely sepsis. sepsis IVF (Resident #1) with consistent low blood pressure. A consultation with ICU provider agreed with plan to admit Resident #1 to the ICU for constant monitoring and treatment of severe sepsis. Review of Resident #1's blood labs collected in theER on [DATE] at 7:02 PM revealed: Glucose: 163 mg/dL [Range 70 - 100] (measures the level of glucose (blood sugar) in the blood) BUN: 38 mg/dL [Range: 8 - 23] (measures the amount of urea nitrogen, a waste product, in the blood) RBC: 3.49 per mcL [Range: 4.7 - 6.1] (measures how many red blood cells circulating in the blood) HGB: 10.0 g/dL [Range: 13.8 - 17.2] (measures the amount of hemoglobin [Hgb] in the blood) HCT: 31.8% [Range: 40.7 - 50.3] (blood test that measures how much blood is made up of red blood cells) Lymphocyte, absolute: 0.35 cells/uL [Range: 0.95 - 3.07] (measures the levels of lymphocytes in an entire sample of whole blood as an absolute number instead of as a percentage) Lactate: 3.1 mmol/L [Range: 0.5 - 2.2] (blood test that measures the level of lactic acid made in the body at a given point in time) Record review of Septic Shock. (2023), accessed on 10/23/23 at https://www.ncbi.nlm.nih.gov/books/NBK430939/ revealed the presence of two of the four early clinical signs (fever [100.4 F]; HR more than 90 bpm; respirations more than 20 bpm; and SBP less than 100 mmHg) and laboratory findings of hyperglycemia (glucose more than 120 mg/dL), Thrombocytopenia (low platelet count), increased BUN, and/or lactic acidosis (more than 2 mmol/L) suggest severe sepsis. Severe sepsis with hypotension development progress to septic shock. A review of a hospital provider assessment and physical exam dated 10/04/23 at 11:35 PM revealed Sepsis Reperfusion Exam (a focused exam withing 6 hours of severe sepsis or septic shock presentation) was performed. Labs were notable for glucose 163 mg/dL . BUN 38 mg/dL, lactate 3.1 mmol/L . Hgb 10.0 g/dL/Hct 31.8% . CXR suggestive of early pneumonia . Repeat lactate on 10/04/23 at 9:39 PM was 2.7 mmol/L. IVF bolus of 30 mL/kg and broad spectrum abx were given. Record review of Resident #1's hospital medical records, admitted [DATE] (still IP, no D/C date), reflected a final diagnosis on 10/05/23 at 1:58 AM of Sepsis and Septic shock. A review of a hospital provider clinical notes dated 10/06/23 at 2:14 PM reflected fever overnight, acetaminophen x 1 . fever trending down. Blood cultures (drawn on 10/04/23 at 7:20 PM) noted positive for Staphylococcus epidermidis (bacteria cause infections), suspected source is central line . Bilateral lung infiltrates likely due to pneumonia . Plan: Repeat blood culture tomorrow (10/07/23) if (Resident #1) remains unstable or blood cultures are repeatedly positive then remove the tunneled Internal Jugular (a CVC surgically inserted into a vein in the neck). A review of a hospital provider clinical notes dated 10/09/23 at 9:27 AM reflected, Repeat blood cultures still positive for Staphylococcus epidermidis, orders placed to remove CVC . A review of a hospital provider clinical notes dated 10/09/23 at 9:34 AM reflected, tunneled catheter removal (inserted in August 2023) . tip sent for culture. A review of a hospital provider clinical notes dated 10/11/23 at 6:30 PM reflected, . Staphylococcus epidermidis bacteremia, sepsis source is central line. Record review of Resident #1's hospital medical records, admitted [DATE] (still IP, no D/C date), reflected CVC tunneled placement was performed 10/13/23 at 9:48 AM - 10:05 AM. During a phone interview on 10/12/23 at 12:51 PM, a family member stated concerns about Resident #1's hospitalization (on 10/04/23) for sepsis. The family member stated that they did not feel staff responded as quickly as should when Resident #1 had a change in condition. The family member stated they did not have notes in front of them to discuss the recurring issues. During an observation and interview (at the hospital) on 10/13/23 beginning at 10:49 AM, Resident #1 appeared clean, groomed, and dressed in a hospital gown. Resident #1 was observed in a full upright sitting position in bed. Resident #1 received a standard TPN solution administered through a CVC line (bandage strips and a few stitches noted at entry site) that was covered by a transparent drsg dated 10/13/23) at the right upper chest. Resident #1 had a midline abdominal colostomy with drainable ostomy pouch that drained dark brown liquid stool by gravity to a drainage bag that hung on left bed frame; and a right lower abdominal urostomy with urostomy pouch that drained pale yellow urine by gravity to a drainage bag that hung on right bed frame. Resident #1 appeared comfortable. Resident #1 was Alert, attentive, and oriented to level of awareness of self, place, time, and situation. Resident #1 was calm and cooperative. Resident #1 was reasonably responsive with purposeful movements, appropriate gestures and answered questions directly, accurately, and with relevance. Resident #1 had fair recall of immediate and past events. Resident #1 said that he was in the hospital for sepsis and the [hospital doctor(s)] said the central line was the source. Resident #1 said that he knew the CVC dressing should be changed every 7 days and he tried to stay on top of the due date to remind the nurses. Resident #1 said that there were times the CVC dressing was not changed weekly or was changed after 7 days had passed. Resident #1 said the CVC line that was currently in place was inserted that morning (10/13/23). Resident #1 said he was usually awake and alert but started feeling sluggish and slept most of the day (10/03/23). Resident #1 said he asked the nurse [later identified as LVN A] to check his temperature because he felt feverish (on 10/04/23 could not state the time for sure, but said it was sometime around 4:00 PM). Resident #1 said it took the nurse a while (described a while as 20 - 30 minutes) to return and check temperature. Resident #1 said he was told his temperature was high. Resident #1 said that [LVN A] returned after 15-20 minutes and performed a COVID test. Resident #1 said that [DNP L] was in his room around the same time LVN A informed that the COVID test was negative. Resident #1 said he did not recall exactly what happened, only remembered he was sent to the hospital. During an interview on 10/13/23 at 2:42 PM, LVN A said that she worked the 6A - 2P shift. LVN A said she was familiar with Resident #1's care needs. LVN A stated Resident #1 required staff assistance with ADLs, had a urostomy and colostomy drainage bags . received TPN via a PICC (LVN A could not recall if the central catheter line was placed in Resident #1's arm [PICC] or chest [CVC]). LVN A defined a change in condition in a resident is when their normal status changed from being alert, ability to walk, have a decline or when vital signs are outside of [physician ordered] parameters or different from measurements compared to baseline. LVN A said a CVC or PICC line dressing should be changed every seven days. LVN A said that LVNs could change the dressing if they were IV certified. LVN A said that she was IV certified and changed Resident #1's sterile dressing before, but did not know the exact date. LVN A said she worked and was assigned to Resident #1 the day he was sent to the ER [DATE]). LVN A said the cause was a fever. A record review of an email received 10/16/23 at 11:50 AM, a family member wrote, .there are a few other things not mentioned during the initial contact (10/12/23 at 12:51 PM). After [Resident #1] first round of sepsis from the PICC line on [DATE] thru [DATE] (2023) . [Resident #1] did not receive TPN until Saturday morning, August 19 (2023). They [SNF] have told [family member] that the pharmacy was so far away and if they don't get the order in early enough . delay in delivery of the order. This was not the first time had to wait several days to receive TPN. Record review on 10/18/23 at 10:44 AM of Resident #1's October 2023 physician order sheet reflected hospital discharge orders (written 10/16/23), antibiotic therapy via the CVC, vital sign measurement every shift (BP/Pain/Pulse/Pulse Oximeter/Respiration/Temperature); monitor for s/sx of complications related to TPN administration including air embolism (occurs when air is admitted into the vascular system), hypervolemia (too much fluid volume in the body), hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), infections, and Pneumothorax (collection of air outside the lung but within the pleural cavity [fluid filled space that surrounds the lungs]) each shift, and CVC site check, management, and dressing change one time weekly. During record review and interview on 10/18/23 beginning at 1:35 PM, RN D said that she worked evening shifts, 2P - 10P and was familiar with Resident #1 and his care needs as the primary assigned nurse. RN D said that she recalled working on 10/04/23 and Resident #1 did not have a decline in ADLs or a change in condition. RN D defined a change in condition as anything about a resident that was different from a resident normal clinical status. RN D said that she was required to complete a Daily Skilled Assessment for Resident #1 to provide information that [Resident #1] needed daily skilled (nursing) interventions. Review of Resident #1's progress notes and a note entered by RN D on 10/03/23 at 11:49 PM revealed dressing on the IV site changed, patient tolerated well, IV line flushing well . RN D said that she did not recall the date on the old IV dressing because she did not change the dressing. RN D said that she asked LVN E (WCN) to change the IV dressing because she [RN D] was too busy. RN D said that the task to change the IV dressing did not pop up on the TAR, that she knew it needed to be changed PRN because the bottom edge of the dressing was pulled away from the skin. RN D made a hand gesture, touching her chest, to suggest the area of the IV dressing was pulled away from [Resident #1's chest]. RN D said that sterile dressings to IV/PICC/CVC sites should be changed every 7 days and was reflected on the TAR. RN D said that there should always be an order to perform care or administer medication to a resident. Review of a Daily Skilled Assessment completed by RN D on 10/03/23 at 11:56 PM indicated Resident #1 level of consciousness was Alert-Responds readily but may be confused and had new or increased confusion. RN D said that she did not recall working 2P - 10P and probably selected the wrong item when charting and did not mean to select new or increased confusion. Record review of Resident #1's Daily Skilled Nurse Assessments [Date range: 09/01/23 - 10/04/23], printed 10/18/23 at 2:31 PM, provided by the NFA to support documentation by nurses that Resident #1's CVC dressing was changed every 7 days revealed in the section Describe any other services, education or training provided: 09/05/23 at 3:09 PM, completed by LVN N, reflected the response Central line drsg patent, clean dry and intact. The Daily Skilled Nurse Assessment did not indicate the dressing was changed. 09/11/23 at 1:41 PM (6 days later), completed by LVN A, reflected the response Central line dressing changed using sterile procedure, resident tolerated the procedure no signs of infection noted. Remains intact and flushable. 09/19/23 at 1:57 AM (8 days later), completed by LVN I, reflected the response Central Line dressing change. The first and the last Daily Skilled Nurse Assessment provided with the Assessments listed above, were not dated, or signed by a nurse. The CVC (placed 08/10/23) dressing changes were expected to be changed at least every 7 days beginning 08/17/23 then, 08/24/23, 08/31/23, 09/07/23, 09/14/23, 09/21/23, and 09/28/23. The next CVC dressing change would be scheduled on 10/05/23. During Record review and interview with the RDCS and Sr. E.D. on 10/18/23 beginning at 3:42 PM, the Sr. E.D. indicated nurses documented IV/CVC dressing changes in Resident #1's Daily skilled Nurse Assessments. The RDCS stated the task to change an IV/CVC dressing did not have to reflect on the TAR and the nurse did not have to document in a progress note. Attempted phone interview with LVN E on 10/18/23 at 4:18 PM was unanswered. No return call received before exit conference on 10/19/23. During a telephone interview on 10/19/23 at 3:26 PM, the MD said that he was also the Medical Director. The MD said that he was familiar with Resident #1. The MD said that CVC central line care and maintenance was important to minimize the risk of infection. The MD said that orders were written to provide central line care and dressing changes every 7 days for every resident that has a central line in place. The MD said if a resident had a CVC/PICC line and there were no orders, it was the nurse staff/nurse manager responsibility to ensure orders were obtained and reflected in the chart. The MD said that nurses should closely monitor the CVC site, flush the line every day (or as ordered) to prevent clotting. The MD said that handling of the CVC should be minimal to reduce the risk of contamination. Record review of Maintenance and Removal of Central Venous Catheters (n.d.), accessed on 10/23/23 at https://www.cdc.gov/infectioncontrol/pdf/strive/CLABSI104-508.pdf revealed CVC dressing status should be assessed at least daily, transparent dressings changed every 7 days and whenever dressing becomes damp, loosened or soiled. Record Review of the facility policy and procedure titled Central Venous Catheter Care and Dressing Changes, revised March 2022, read in part: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines included: 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised. 2. Maintain sterile dressing for all central vascular access devices. 3. Change the dressing if it becomes damp, loosened or visibly soiled, at least every 7 days, and immediately if the dressing or site appear compromised. 5. Assess central venous access devices with each infusion and at least daily. Assessment guideline indicated to observe insertion site and surrounding area for complications. Documentation guidelines indicated to: 1. The following information should be recorded in the resident's medical record: a. Date and time dressing was changed. b. Location and objective description of insertion site. c. Any complication, interventions that were done. d. Condition of sutures (if present). e. Any questions, education given to resident, resident's statement regarding IV therapy and response to procedure. f. Signature and title of the person recording the data. Reporting guidelines indicated to report any signs and symptoms of complications to physician, supervisor and oncoming shift; intervene as necessary. The NFA was notified of an Immediate Jeopardy (IJ) on 10/18/23 at 1:18 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 10/19/23 at 12:05 PM and included: Impact Statement: On 10/18/2023, the facility was provided notification that the survey agency has determined that the conditions at the center constitute an Immediate Jeopardy to resident health. The facility failed to change Resident #1's central line dressing every 7 days as ordered. Immediate Action: Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to Parenteral/IV Fluids on 10/18/2023 at 1:51 pm. The facility failed to change Resident #1's central line dressing every 7 days as ordered. Residents that can be affected are those with central lines. Systematic Approach: 1. Assessment - Resident #1 with signs and symptoms of sepsis was transferred to the hospital on 10/4/23 per the order of the Nurse Practitioner and was admitted to the hospital for sepsis, septic shock, and pneumonia. -The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 10/18/2023 at 3:20 pm. -An emergency QAPI meeting was held on 10/16/2023. -All residents will have any central line dressings observed by Director of Nurses or Assistant Director of Nurses on 10/18/2023 to identify any current patients that are at imminent risk related to not having the dressing changed per physician orders. The observations were completed on 10/18/23 by 6:00 pm. After completion of observations, no other residents were found to be at imminent risk of central line dressing changes not having been completed. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director and RDCS All nursing staff were educated to notify the DON/Nurse Managers immediately upon any central line dressing changes that had not been completed per physician orders. This education was provided on 10/18/2023. This education was provided by the DON and RDCS. Staff will not be allowed to begin their shift until the education has been completed. Treatments that are physician ordered will reflect on the MAR/TAR. This will include all CVC/PICC line care including sterile dressing changes per physician orders. 2. In-Services All staff were in-serviced on CVC/PICC line care including sterile dressing changes per physician orders by the RDCS/Director of Nursing and/or Nurse Managers. All new staff will receive the education as part of the onboarding orientation process prior to being assigned tasks and providing care to residents. No licensed staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all licensed clinical staff will be completed by 10/18/2023. All staff were in-serviced by 8:00pm on 10/18/2023. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 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 signatures and verbalization of understanding by all licensed facility staff. The Executive Director, DON and ADON were in-serviced by the RDCS on sterile dressing changes per physician orders on 10/18/23 by 4:00 pm. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 3. Monitoring Starting 10/18/23 the Executive Director, Director of nursing and/or Nurse Managers will review all central line orders to ensure dressing changes are completed per the orders. Observations will be made to ensure dressings have been changed. The Regional Director of Clinical Services will review the documentation each week for compliance. On 10/19/23 the surveyor began monitoring for implementation of the facility's plan of removal by: During a phone interview on 10/19/23 at 3:26 PM, the medical director acknowledged notification of the Immediate Jeopardy. Record review of the QAPI meeting minutes dated 10/16/23 at 12:30 PM reflected the following members in attendance: NFA, RDCS, DON B, DON C, ADON, RVP, and the medical director was notified by phone. The special discussion items reflected CVC Dressing Change. The QAPI Plan for CVC Dressing Change reflected a systematic approach, education, monitoring, and QA beginning 10/16/23 and education will continue through the first 30 days. During an interview on 10/19/23 at 4:22 PM, DON C indicated her first day as the full-time DON at the SNF was 10/13/23. DON C said that she participated in a QAPI meeting on 10/16/23 and the topic of discussion was change of condition, physician notification, and IV/CVC management and care (included dressing change). DON C said that she and the ADON reviewed all residents for any change of condition on 10/18/23 to identify abnormal vital signs or change of condition. DON C said on 10/18/23, in collaboration with nurse managers, provided in-services and training to nursing staff (CNAs, MAs, and LVNs/RNs) that included education about what is considered a change in condition (All nursing staff), action to take (LVNs/RNs), and physician notification (LVNs/RNs), the earlier the better. DON C stated that the nurse should call the physician immediately after assessment and document in the medical record. DON C said the in-services and training was on-going. DON C said that central line care and maintenance training was scheduled for all nurses (10/20/23 or to be determined) and IV dressing change skills check off would be completed. DON C said that she expected nurses to notify the ADON/DON, MD, NP (if delegated when MD was unavailable), and RP as soon as possible after assessment of the resident. DON C said if a resident change of condition was not reported, or within a timely manner, could lead to serious outcome, medical complications, hospitalization , or death. During an interview on 10/19/23 at 4:35 PM, the NFA stated that she assumed the role of administrator in August 2023. The NFA stated the facility and nurse management were responsible for ensuring staff could access, were educated, and followed policies and procedures. The NFA was not able to speak to the process of physician notification and could not produce related policies. The NFA was not able to speak to the procedure, the necessary steps, per the facility policy, to comply with central line management. The NFA stated steps discussed in a QAPI meeting to develop a list of changes, concerns, criteria that required physician notification and that it should be comprehensive. The NFA stated there should always be a clear understanding by all staff what is considered an acceptable timeframe for physician notification. Record review of an undated in-service titled Sterile dressing changes per physician orders conducted by the RDCS was presented to the NFA, DON, and ADON. In-services conducted by the DON and ADON beginning 10/18/23 and on-going, on the topic of IV/PICC line must be changed weekly and PRN revealed a summary of training that CVC/PICC line care included sterile dressing changes per physician orders. The sign in sheet reflected the following staff participated in the in-service: LVN F, LVN N, RN D, LVN I, LVN O, LVN P, LVN Q, ADON, and RN R. Record review of the In-Service Training Sheet, dated 10/18/23 on the topic of IV/PICC line must be changed weekly and PRN revealed the following staff were notified by DON C via phone call: LVN S, LVN T, LVN U (left message), LVN V (left message), LVN W (left message), RN X, LVN A, LVN G, LVN Y, RN Z, LVN H (left message), LVN AA (left message), RN R, RN AB, LVN AC (left message), and LVN AD. Interviews conducted on 10/19/23 with nurses scheduled on the 6A - 2P shift (LVN G [at 1:09 PM], LVN F [at 1:00 PM], LVN N [at 1:51 PM], and LVN A [at 2:29 PM]); 2P - 10P shift (RN D [at 2:15 PM], LVN H [at 2:36 PM weekend double LVN], and LVN I [at 2:43 PM])indicated they participated in an in-service training about recognizing change in condition, physician notification, and monitoring and changing an IV/CVC dressing. Each nurse stated in their own words the procedure was to notify the physician about the resident's change in condition as soon as possible - after vital signs were measured and an assessment performed. Each nurse verbalized the steps of procedure to change a sterile IV/CVC dressing every 7 days and there should be an order that reflected on the TAR. On 10/18/23, an Immediate Jeopardy was identified. The NFA was notified and provided an IJ template on 10/18/23 at 1:51 PM. While the IJ was lowered on 10/19/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to provide or obtain timely laboratory services to meet the needs of three (Resident #49, Resident #126, and Resident #174) of 18 residents reviewed for ordered laboratory work. 1. The facility failed to check the laboratory system containing Resident #49's UA results from [DATE] to [DATE] and report the results to the physician. The resident did not receive the first dose of antibiotic until [DATE]. As a result, the resident's health deteriorated due to an unidentified and untreated infection. The resident was admitted to the hospital with [REDACTED]. Resident #49 died at the hospital on [DATE]. 2. The facility failed to check the laboratory system containing Resident #126's lab results from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions until [DATE]. 3. The facility failed to check the laboratory system containing Resident #174's laboratory results and report the results to the physician from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions until [DATE]. An Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: 1. Review of Resident #49's most recent MDS assessment dated [DATE] revealed she was a [AGE] year-old-female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #49's Care Plan effective [DATE] revealed she was diabetic and at risk for frequent infections and [MEDICAL CONDITION]. Interventions included giving medications per physician order, and monitoring labs and reporting abnormalities to the MD. Review of Resident #49's UA lab with an approval date of [DATE] revealed the urine was slightly cloudy, WBC (white blood cell count) was TNTC (too numerous to count) and she had moderate bacteria. Review of Resident #49's Urine Culture results with an approval date of [DATE] (Friday) at 1:49 PM revealed that on [DATE] the colony count was greater than 100,000 cfu/ml (colony forming units of bacteria per milliter of urine). Further review of the urine culture revealed the resident had escherichia coli bacteria in her urine. (Escherichia coli - E-coli are a type of bacteria commonly found in the gastrointestinal (GI) tract that can cause Urinary Tract Infection.) Review of Resident #49's (MONTH) 2019 Medication Notes revealed she was prescribed the antibiotic [MEDICATION NAME] 500 mg two times daily for urinary tract infection with a start date of [DATE] (Monday). Review of Resident #49's MAR for (MONTH) 2019 revealed she received the first dose of antibiotic ([MEDICATION NAME]) on [DATE]. Interview on [DATE] at 5:49 PM with LVN J revealed she was told Resident #49 did not seem like herself the morning of [DATE] (Tuesday). When she entered the resident's room, she was not responding as she normally would. Her hands were cold and she could not get a pulse when she applied the pulse oximeter to her finger and her blood pressure was low. The physician was immediately contacted and the resident was sent to the hospital. An interview on [DATE] at 5:39 PM with ADON H revealed she was working as a floor nurse the morning of [DATE] (Tuesday). She went in to give Resident #49 her medications around 8:15 AM to 8:30 AM. The resident opened her eyes and refused her medications. She had just been made aware that the resident had been started on an antibiotic the previous day for a UTI. ADON H stated she was not familiar with Resident #49's baseline as she was just filling in that morning. After attending her morning meeting later that morning, she was approached by LVN J who told her Resident #49 needed to be sent to the hospital due to low blood pressure, facial droop, and not being able to open her eyes. Review of Resident #49's MAR indicated [REDACTED]. The resident's blood pressure was ,[DATE] (Normal ,[DATE]) and her pulse was 111 (Normal ,[DATE]). Review of Resident #49's clinical record revealed there was no documentation regarding the resident's change in condition. Review of Resident #49's hospital records dated [DATE] (Tuesday) revealed when she was seen in the emergency room , the resident was completely disoriented and responded to pain only. The resident was diagnosed with [REDACTED]. Interview on [DATE] at 1:36 PM with the DON revealed the facility had recently changed their lab system on [DATE], and they now had access to them online. She stated all the nursing staff had been trained to access the online lab site. She said she would pull labs daily, Monday through Friday around 8:45 AM to 9:00 AM to review during the morning department head meeting. On Saturday and Sunday, the weekend supervisor was responsible for going to the online system and pulling the labs to review. In the computer the approval date on the labs meant they were ready to be reviewed and printed online. The DON said she pulled the labs on Monday [DATE] and saw Resident #49's UA culture lab and had it sent to the doctor for review, not realizing the date on the lab was dated [DATE] until it was brought to her attention by the surveyor. She assumed the labs had been pulled on the weekend by the weekend supervisor and thought Resident #49's UA culture was new. She stated she expected the nurses to follow the labs once they are ordered. Interview on [DATE] at 11:03 AM with LVN E revealed she had worked with Resident #49 Friday evening [DATE]. She said she had been trained how to access labs on the new computer system but was not aware she needed to have been following Resident #49's labs specifically. Interview on [DATE] at 2:21 PM with LVN F revealed she had been the interim weekend supervisor for the last three weeks. She said she was responsible for checking the online lab system during the weekend, but had forgotten to pull the labs last Saturday and Sunday ([DATE] and [DATE]) because she had been too busy. Interview on [DATE] at 2:12 PM with Physician G revealed he was the physician for Resident #49 and said he would have started Resident #49 on antibiotics immediately if he would have been made aware of the UA culture on Friday, [DATE]. He further stated the current lab system the facility had in place was not a good one and he would be talking to the DON about putting in a better system for checking labs more regularly. 2. Review of Resident #126's admission MDS assessment revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #126's [MEDICATION NAME] and pre-[MEDICATION NAME] (proteins) lab was collected on [DATE] (Friday) at 5:50 AM and was approved at 2:02 PM, on the same day. The results showed both the resident's [MEDICATION NAME] and pre-[MEDICATION NAME] were low, but were not critical. Review of Resident #126's nurses notes dated [DATE] (Monday) revealed, lab reviewed and sent to Physician G for review and new order entered for Prosource Plus (liquid protein) BID 30 ml and dietitian was alerted for assessment and review of resident's nutritional status with newly obtained orders. Interview and observation of Resident #126 on [DATE] at 7:42 PM revealed she was in bed watching television. She was alert and oriented and stated she was feeling good. There were no concerns noted at that time. 3. Review of Resident #174's admission MDS assessment reflected he was admitted to the facility [DATE] with a Foley catheter in place and a [DIAGNOSES REDACTED]. Review of Resident #174's UA lab collected on [DATE] and approved on [DATE] (Sunday) revealed his urine was clear and there were few bacteria. Review of Resident #174's urine culture with an approval date of [DATE] (Wednesday) revealed the resident had a colony count greater than 100,000 cfu/ml. Further review of the urine culture revealed the resident had proteus mirabilis bacteria in his urine. (Proteus mirabilis is a common pathogen responsible for complicated urinary tract infections that sometimes causes bacteremia.) Review of Resident #174's nurses noted dated [DATE] (Thursday) revealed lab results were sent to Physician G and the resident was put on an antibiotic for a UTI. Interview and observation on [DATE] at 7:49 PM of Resident #174 revealed he was in bed watching television. He was alert and oriented and stated he was feeling good and he did not have any concerns regarding his Foley catheter. The Foley bag was noted to be hanging on his bed and the urine appeared to be clear. Interview on [DATE] at 4:03 PM with the DON revealed both Resident #126 and #174 had labs over the weekend and only Resident #126 was approved after they had been pulled for the day on [DATE]. Post interview on [DATE] at 4:00 PM with Resident #49's family revealed she had died earlier that morning ([DATE]). Review of the facility's polices and procedures revealed they did not have a policy on the new lab system that had been started on [DATE]. Review of the facility's current policy titled Tests - Laboratory dated [DATE] reflected .Nursing staff is to review all laboratory reports and notify prescribing physician of any abnormal results. The policy did not indicate how often labs should be checked on the new system by the staff. An IJ was identified on [DATE]. On [DATE] at 4:08 PM the Administrator was notified of the IJ and a plan of removal was requested. Plan of removal dated [DATE] was accepted on [DATE] at 1:28 PM and revealed all nursing staff were in-serviced on Lab/Diagnostics Process - Ordering for a resident and how often the online lab system should be checked and how each orders should be processed. Plan of Removal dated [DATE] was accepted on [DATE] at 1:28 PM and revealed the following: 1. Labs/ Neglect/ Quality of Care: A. The facility charge nurse LVN E and LVN F the Weekend Supervisor failed to ensure that lab results were reviewed and acted upon on Saturday, [DATE] for Resident #49. This failure included review and reporting of a final Culture and Sensitivity for Resident #49 so that appropriate treatment could be initiated timely. In-service will be completed prior to them working their next shift with LVN E and LVN F on retrieving labs timely and physician notification. In-services including: Lab protocol and Lab order entry and retrieving results will be completed by [DATE]. Additionally same in service will be conduct upon hire and at minimum quarterly. B. The facility has begun to conduct in-services to licensed nursing staff on reporting and follow-up of lab results to the physician per the facility policy. The facility policy states that lab reports should be reviewed by Nursing Staff and that notification to the prescribing physician should occur for any abnormal results in a timely manner. If changes that warrant a new or change in medication or treatment exists, the patient and patient representative is to be notified. These in-services began on [DATE] and will be completed [DATE] and were conducted by the DON. Any licensed nurse who has not received these in-services will not be permitted to work until training has been completed. In-services including: Lab protocol and Lab order entry and retrieving results will be completed by [DATE]. Additionally same in service will be conduct upon hire and at minimum quarterly. Once labs are completed and approved they will be faxed to each nurse's station for nurse's to address accordingly. Nurse's should be checking fax machine every two hours. In addition to charge nurses receiving faxes at the nurses station, the nurse managers, DON, ADON H, ADON I, and LVN F will retrieve labs from lab portal to validate all labs have been addressed by floor nurses to include physician notification and following any new or additional orders seven days a week at 10:00 am and 4:00 PM. The Facility has initiated an internal lab audit to ensure that all ordered labs have been processed, results received and addressed. This audit was completed by the DON, ADON H, and ADON I. This audit was completed by [DATE]. Findings will be discussed with Primary care physician as well as the Medical Director . There were 2 other residents affected by the failure of checking labs on the weekend. Those residents are identified as Resident #174 and Resident #126. Resident #174 the urinalysis ordered on (MONTH) 19, 2019, prelim results were obtained the 20th. Final Culture and Sensitivity was obtained the 23rd at 10:09 am.[MEDICATION NAME] initial dosed (MONTH) 24th at 8:00 PM. Finding were found during laboratory audit and notified the physician, resident had no negative outcome. Resident #126 pre-[MEDICATION NAME] was ordered (MONTH) 18, 2019 lab was available at 2:02 PM the same day. On (MONTH) 21, 2019 doctor notified of labs results at 4:19 p.m. No negative outcome. C. The facility shall utilize the 24 hour report and lab binder to track and reconcile labs every morning. Any results not received will prompt a phone call to the laboratory by the charge nurse and or the nurse managers ADON H and ADON I. Any results not acted upon will prompt action to ensure the physician is aware so that appropriate treatment if necessary can occur. The patient and patient representative shall also be made aware of results and treatment recommendations. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the shift to shift rounding. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any outstanding tests/ labs, phone calls out to physicians and/or address any other needs that a patient may have. Morning stand-up will occur with ADON H and ADON I, DON and the Administrator and labs will be reviewed at this time to ensure all have been completed and reported. The Weekend Supervisor will review labs every Saturday and Sunday morning and evening to ensure that all results have been obtained, processed and reported to the physician. Monitoring of this will be accomplished through Unit Managers ADON H and ADON I and the Director of Nursing verifying that labs are completed and reported on each day utilizing the lab tracking log/binder daily. Any identified issues will be corrected and brought forth to the QAPI monthly for the next twelve months. Committee to ensure that the continued effectiveness of the standards are maintained. Interviews on [DATE] with 25 of 30 nurses between between 4 PM to 8 PM, that the facility employs, revealed they had been in-serviced that Labs/diagnostics would now be faxed to each nurses station, and how often to check the lab system online if they are following up with an ordered lab and notifying the attending physician of the lab results, and all with a post test. The monitoring interviews included nurses from all shifts, 6am - 2pm, 2pm - 10pm, and 10pm - 6am. There were no concerns regarding lab/diagnostic training and monitoring by the staff. Interview with the Administrator on [DATE] at 4:34 PM revealed the facility nurses were all in-serviced ([DATE] and [DATE]) with the exception of two, one PRN nurse and another that was on FMLA. They would not be allowed to return to work without being in-serviced. The Administrator was notified on [DATE] at 8:03 PM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for three (Resident #49, Resident #126, and Resident #174) of 18 residents reviewed for labs. 1. The facility failed to have a system in place to ensure nurses were trained and knew how often to check labs. The facility failed to check the laboratory system containing Resident #49's UA results from [DATE] to [DATE] and report the results to the physician. The resident did not receive the first dose of antibiotic until [DATE]. As a result, the resident's health deteriorated due to an unidentified and untreated infection. The resident was admitted to the hospital with [REDACTED]. Resident #49 died at the hospital on [DATE]. 2. The facility failed to check the laboratory system containing Resident #126's lab results from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions until [DATE]. 3. The facility failed to check the laboratory system containing Resident #174's laboratory results and report the results to the physician from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions until [DATE]. An Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: 1. Review of Resident #49's most recent MDS assessment dated [DATE] revealed she was a [AGE] year-old-female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #49's Care Plan effective [DATE] revealed she was diabetic and at risk for frequent infections and [MEDICAL CONDITION]. Interventions included giving medications per physician order, and monitoring labs and reporting abnormalities to the MD. Review of Resident #49's UA lab with an approval date of [DATE] revealed the urine was slightly cloudy, WBC (white blood cell count) was TNTC (too numerous to count) and she had moderate bacteria. Review of Resident #49's Urine Culture results with an approval date of [DATE] (Friday) at 1:49 PM revealed that on [DATE] the colony count was greater than 100,000 cfu/ml (colony forming units of bacteria per milliter of urine). Further review of the urine culture revealed the resident had escherichia coli bacteria in her urine. (Escherichia coli - E-coli are a type of bacteria commonly found in the gastrointestinal (GI) tract that can cause Urinary Tract Infection.) Review of Resident #49's (MONTH) 2019 Medication Notes revealed she was prescribed the antibiotic [MEDICATION NAME] 500 mg two times daily for urinary tract infection with a start date of [DATE] (Monday). Review of Resident #49's MAR for (MONTH) 2019 revealed she received the first dose of antibiotic ([MEDICATION NAME]) on [DATE]. Interview on [DATE] at 5:49 PM with LVN J revealed she was told Resident #49 did not seem like herself the morning of [DATE] (Tuesday). When she entered the resident's room, she was not responding as she normally would. Her hands were cold and she could not get a pulse when she applied the pulse oximeter to her finger and her blood pressure was low. The physician was immediately contacted and the resident was sent to the hospital. An interview on [DATE] at 5:39 PM with ADON H revealed she was working as a floor nurse the morning of [DATE] (Tuesday). She went in to give Resident #49 her medications around 8:15 AM to 8:30 AM. The resident opened her eyes and refused her medications. She had just been made aware that the resident had been started on an antibiotic the previous day for a UTI. ADON H stated she was not familiar with Resident #49's baseline as she was just filling in that morning. After attending her morning meeting later that morning, she was approached by LVN J who told her Resident #49 needed to be sent to the hospital due to low blood pressure, facial droop, and not being able to open her eyes. Review of Resident #49's MAR indicated [REDACTED]. The resident's blood pressure was ,[DATE] (Normal ,[DATE]) and her pulse was 111 (Normal ,[DATE]). Review of Resident #49's clinical record revealed there was no documentation regarding the resident's change in condition. Review of Resident #49's hospital records dated [DATE] (Tuesday) at 1:34 PM revealed when she was seen in the emergency room . The resident was completely disoriented and responded to pain only. The resident was diagnosed with [REDACTED]. Interview on [DATE] at 1:36 PM with the DON revealed the facility had recently changed their lab system on [DATE], and they now had access to them online. She stated all the nursing staff had been trained to access the online lab site. She said she would pull labs daily, Monday through Friday around 8:45 AM to 9:00 AM to review during the morning department head meeting. On Saturday and Sunday, the weekend supervisor was responsible for going to the online system and pulling the labs to review. In the computer the approval date on the labs meant they were ready to be reviewed and printed online. The DON said she pulled the labs on Monday [DATE] and saw Resident #49's UA culture lab and had it sent to the doctor for review, not realizing the date on the lab was dated [DATE] until it was brought to her attention by the surveyor. She assumed the labs had been pulled on the weekend by the weekend supervisor and thought Resident #49's UA culture was new. She stated she expected the nurses to check for results from labs once they were ordered. Interview on [DATE] at 11:03 AM with LVN E revealed she had worked with Resident #49 Friday evening [DATE]. She said she had been trained how to access labs on the new computer system but was not aware she needed to have been following Resident #49's labs specifically. Interview on [DATE] at 2:21 PM with LVN F revealed she had been the interim weekend supervisor for the last three weeks. She said she was responsible for checking the online lab system during the weekend, but had forgotten to pull the labs last Saturday and Sunday ([DATE] and [DATE]) because she had been too busy. Interview on [DATE] at 2:12 PM with Physician G revealed he was the physician for Resident #49 and said he would have started Resident #49 on antibiotics immediately if he would have been made aware of the UA culture on Friday, [DATE]. He further stated the current lab system the facility had in place was not a good one and he would be talking to the DON about putting in a better system for checking labs more regularly. 2. Review of Resident #126's admission MDS assessment revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #126's [MEDICATION NAME] and pre-[MEDICATION NAME] (proteins) lab was collected on [DATE] (Friday) at 5:50 AM and was approved at 2:02 PM, on the same day. The results showed both the resident's [MEDICATION NAME] and pre-[MEDICATION NAME] were low, but were not critical. Review of Resident #126's nurses notes dated [DATE] (Monday) revealed, lab reviewed and sent to Physician G for review and new order entered for Prosource Plus (liquid protein) BID 30 ml and dietitian was alerted for assessment and review of resident's nutritional status with newly obtained orders. Interview and observation of Resident #126 on [DATE] at 7:42 PM revealed she was in bed watching television. She was alert and oriented and stated she was feeling good. There were no concerns noted at that time. 3. Review of Resident #174's admission MDS assessment reflected he was admitted to the facility [DATE] with a Foley catheter in place and a [DIAGNOSES REDACTED]. Review of Resident #174's UA lab collected on [DATE] and approved on [DATE] (Sunday) revealed his urine was clear and there were few bacteria. Review of Resident #174's urine culture with an approval date of [DATE] (Wednesday) revealed the resident had a colony count greater than 100,000 cfu/ml. Further review of the urine culture revealed the resident had proteus mirabilis bacteria in his urine. (Proteus mirabilis is a common pathogen responsible for complicated urinary tract infections that sometimes causes bacteremia.) Review of Resident #174's nurses noted dated [DATE] (Thursday) revealed lab results were sent to Physician G and the resident was put on an antibiotic for a UTI. Interview and observation on [DATE] at 7:49 PM of Resident #174 revealed he was in bed watching television. He was alert and oriented and stated he was feeling good and he did not have any concerns regarding his Foley catheter. The Foley bag was noted to be hanging on his bed and the urine appeared to be clear. Interview on [DATE] at 4:03 PM with the DON revealed both Resident #126 and #174 had labs over the weekend and only Resident #126 was approved after they had been pulled for the day on [DATE]. Post-interview on [DATE] at 4:00 PM with Resident #49's family revealed she had died earlier that morning ([DATE]). Review of the facility's polices and procedures revealed they did not have a policy on the new lab system that had been started on [DATE]. Review of the facility's current policy titled Tests - Laboratory dated [DATE] reflected .Nursing staff is to review all laboratory reports and notify prescribing physician of any abnormal results. The policy did not indicate how often labs should be checked by the staff. The facility's current Abuse Protocol policy dated (MONTH) (YEAR) reflected: .1 Neglect is the failure of the facility, its employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, mental anguish, or emotional distress. An IJ was identified on [DATE]. On [DATE] at 4:08 PM the Administrator was notified of the IJ and a plan of removal was requested. Plan of removal dated [DATE] was accepted on [DATE] at 1:28 PM revealed all nursing staff were in-serviced on Lab/Diagnostics Process - Ordering for a resident and how often the online lab system should be checked and how each orders should be processed. Plan of Removal dated [DATE] was accepted on [DATE] at 1:28 PM and revealed the following: 1. Labs/ Neglect/ Quality of Care: A. The facility charge nurse LVN E and LVN F the Weekend Supervisor failed to ensure that lab results were reviewed and acted upon on Saturday, [DATE] for Resident #49. This failure included review and reporting of a final Culture and Sensitivity for Resident #49 so that appropriate treatment could be initiated timely. In-service will be completed prior to them working their next shift with LVN E and LVN F on retrieving labs timely and physician notification. In-services including: Lab protocol and Lab order entry and retrieving results will be completed by [DATE]. Additionally same in service will be conduct upon hire and at minimum quarterly. B. The facility has begun to conduct in-services to licensed nursing staff on reporting and follow-up of lab results to the physician per the facility policy. The facility policy states that lab reports should be reviewed by Nursing Staff and that notification to the prescribing physician should occur for any abnormal results in a timely manner. If changes that warrant a new or change in medication or treatment exists, the patient and patient representative is to be notified. These in-services began on [DATE] and will be completed [DATE] and were conducted by the DON. Any licensed nurse who has not received these in-services will not be permitted to work until training has been completed. In-services including: Lab protocol and Lab order entry and retrieving results will be completed by [DATE]. Additionally same in service will be conduct upon hire and at minimum quarterly. Once labs are completed and approved they will be faxed to each nurse's station for nurse's to address accordingly. Nurse's should be checking fax machine every two hours. In addition to charge nurses receiving faxes at the nurses station, the nurse managers, DON, ADON H, ADON I, and LVN F will retrieve labs from lab portal to validate all labs have been addressed by floor nurses to include physician notification and following any new or additional orders seven days a week at 10:00 am and 4:00 PM. The Facility has initiated an internal lab audit to ensure that all ordered labs have been processed, results received and addressed. This audit was completed by the DON, ADON H, and ADON I. This audit was completed by [DATE]. Findings will be discussed with Primary care physician as well as the Medical Director . There were 2 other residents affected by the failure of checking labs on the weekend. Those residents are identified as Resident #174 and Resident #126. Resident #174 the urinalysis ordered on (MONTH) 19, 2019, prelim results were obtained the 20th. Final Culture and Sensitivity was obtained the 23rd at 10:09 am.[MEDICATION NAME] initial dosed (MONTH) 24th at 8:00 PM. Finding were found during laboratory audit and notified the physician, resident had no negative outcome. Resident #126 pre-[MEDICATION NAME] was ordered (MONTH) 18, 2019 lab was available at 2:02 pm the same day. On (MONTH) 21, 2019 doctor notified of labs results at 4:19 p.m. No negative outcome. C. The facility shall utilize the 24 hour report and lab binder to track and reconcile labs every morning. Any results not received will prompt a phone call to the laboratory by the charge nurse and or the nurse managers ADON H and ADON I. Any results not acted upon will prompt action to ensure the physician is aware so that appropriate treatment if necessary can occur. The patient and patient representative shall also be made aware of results and treatment recommendations. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the shift to shift rounding. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any outstanding tests/ labs, phone calls out to physicians and/or address any other needs that a patient may have. Morning stand-up will occur with ADON H and ADON I, DON and the Administrator and labs will be reviewed at this time to ensure all have been completed and reported. The Weekend Supervisor will review labs every Saturday and Sunday morning and evening to ensure that all results have been obtained, processed and reported to the physician. Monitoring of this will be accomplished through Unit Managers ADON H and ADON I and the Director of Nursing verifying that labs are completed and reported on each day utilizing the lab tracking log/binder daily. Any identified issues will be corrected and brought forth to the QAPI monthly for the next twelve months. Committee to ensure that the continued effectiveness of the standards are maintained. Interviews on [DATE] with 25 of 30 nurses between between 4 PM to 8 PM, that the facility employs, revealed they had been in-serviced that Labs/diagnostics would now be faxed to each nurses station, and how often to check the lab system online if they are following up with an ordered lab and notifying the attending physician of the lab results, and all with a post test. The monitoring interviews included nurses from all shifts, 6am - 2pm, 2pm - 10pm, and 10pm - 6am. There were no concerns regarding lab/diagnostic training and monitoring by the staff. Interview with the Administrator on [DATE] at 4:34 PM revealed the facility nurses were all in-serviced ([DATE] and [DATE]) with the exception of two, one PRN nurse and another that was on FMLA. They would not be allowed to return to work without being in-serviced. The Administrator was notified on [DATE] at 8:03 PM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal.

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit abuse and neglect for three (Resident #49, Resident #126, and Resident #174) reviewed for neglect. 1. The facility failed to have a system in place to ensure nurses were trained and knew how often to check labs. The facility failed to check the laboratory system containing Resident #49's UA results from [DATE] to [DATE] and report the results to the physician. The resident did not receive the first dose of antibiotic until [DATE]. As a result, the resident's health deteriorated due to an unidentified and untreated infection. The resident was admitted to the hospital with [REDACTED]. Resident #49 died at the hospital on [DATE]. 2. The facility failed to check the laboratory system containing Resident #126's lab results from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions until [DATE]. 3. The facility failed to check the laboratory system containing Resident #174's laboratory results and report the results to the physician from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions until [DATE]. An Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: The facility's current Abuse Protocol policy dated (MONTH) (YEAR) reflected: .1 Neglect is the failure of the facility, its employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Review of the facility's current policy titled Tests - Laboratory dated [DATE] reflected .Nursing staff is to review all laboratory reports and notify prescribing physician of any abnormal results. The policy did not indicate how often labs should be checked by the staff. 1. Review of Resident #49's most recent MDS assessment dated [DATE] revealed she was a [AGE] year-old-female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #49's Care Plan effective [DATE] revealed she was diabetic and at risk for frequent infections and [MEDICAL CONDITION]. Interventions included giving medications per physician order, and monitoring labs and reporting abnormalities to the MD. Review of Resident #49's UA lab with an approval date of [DATE] revealed the urine was slightly cloudy, WBC (white blood cell count) was TNTC (too numerous to count) and she had moderate bacteria. Review of Resident #49's Urine Culture results with an approval date of [DATE] (Friday) at 1:49 PM revealed that on [DATE] the colony count was greater than 100,000 cfu/ml (colony forming units of bacteria per milliter of urine). Further review of the urine culture revealed the resident had escherichia coli bacteria in her urine. (Escherichia coli - E-coli are a type of bacteria commonly found in the gastrointestinal (GI) tract that can cause Urinary Tract Infection.) Review of Resident #49's (MONTH) 2019 Medication Notes revealed she was prescribed the antibiotic [MEDICATION NAME] 500 mg two times daily for urinary tract infection with a start date of [DATE] (Monday). Review of Resident #49's MAR for (MONTH) 2019 revealed she received the first dose of antibiotic ([MEDICATION NAME]) on [DATE]. Interview on [DATE] at 5:49 PM with LVN J revealed she was told Resident #49 did not seem like herself the morning of [DATE] (Tuesday). When she entered the resident's room, she was not responding as she normally would. Her hands were cold and she could not get a pulse when she applied the pulse oximeter to her finger and her blood pressure was low. The physician was immediately contacted and the resident was sent to the hospital. An interview on [DATE] at 5:39 PM with ADON H revealed she was working as a floor nurse the morning of [DATE] (Tuesday). She went in to give Resident #49 her medications around 8:15 AM to 8:30 AM. The resident opened her eyes and refused her medications. She had just been made aware that the resident had been started on an antibiotic the previous day for a UTI. ADON H stated she was not familiar with Resident #49's baseline as she was just filling in that morning. After attending her morning meeting later that morning, she was approached by LVN J who told her Resident #49 needed to be sent to the hospital due to low blood pressure, facial droop, and not being able to open her eyes. Review of Resident #49's MAR indicated [REDACTED]. The resident's blood pressure was ,[DATE] (Normal ,[DATE]) and her pulse was 111 (Normal ,[DATE]). Review of Resident #49's clinical record revealed there was no documentation regarding the resident's change in condition. Review of Resident #49's hospital records dated [DATE] (Tuesday) revealed when she was seen in the emergency room , the resident was completely disoriented and responded to pain only. The resident was diagnosed with [REDACTED]. Interview on [DATE] at 1:36 PM with the DON revealed the facility had recently changed their lab system on [DATE], and they now had access to them online. She stated all the nursing staff had been trained to access the online lab site. She said she would pull labs daily, Monday through Friday around 8:45 AM to 9:00 AM to review during the morning department head meeting. On Saturday and Sunday, the weekend supervisor was responsible for going to the online system and pulling the labs to review. In the computer the approval date on the labs meant they were ready to be reviewed and printed online. The DON said she pulled the labs on Monday [DATE] and saw Resident #49's UA culture lab and had it sent to the doctor for review, not realizing the date on the lab was dated [DATE] until it was brought to her attention by the surveyor. She assumed the labs had been pulled on the weekend by the weekend supervisor and thought Resident #49's UA culture was new. She stated she expected the nurses to follow the labs once they are ordered. Interview on [DATE] at 11:03 AM with LVN E revealed she had worked with Resident #49 Friday evening [DATE]. She said she had been trained how to access labs on the new computer system but was not aware she needed to have been following Resident #49's labs specifically. Interview on [DATE] at 2:21 PM with LVN F revealed she had been the interim weekend supervisor for the last three weeks. She said she was responsible for checking the online lab system during the weekend, but had forgotten to pull the labs last Saturday and Sunday ([DATE] and [DATE]) because she had been too busy. Interview on [DATE] at 2:12 PM with Physician G revealed he was the physician for Resident #49 and said he would have started Resident #49 on antibiotics immediately if he would have been made aware of the UA culture on Friday, [DATE]. He further stated the current lab system the facility had in place was not a good one and he would be talking to the DON about putting in a better system for checking labs more regularly. 2. Review of Resident #126's admission MDS assessment revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #126's [MEDICATION NAME] and pre-[MEDICATION NAME] (proteins) lab was collected on [DATE] (Friday) at 5:50 AM and was approved at 2:02 PM, on the same day. The results showed both the resident's [MEDICATION NAME] and pre-[MEDICATION NAME] were low, but were not critical. Review of Resident #126's nurses notes dated [DATE] (Monday) revealed, lab reviewed and sent to Physician G for review and new order entered for Prosource Plus (liquid protein) BID 30 ml and dietitian was alerted for assessment and review of resident's nutritional status with newly obtained orders. Interview and observation of Resident #126 on [DATE] at 7:42 PM revealed she was in bed watching television. She was alert and oriented and stated she was feeling good. There were no concerns noted at that time. 3. Review of Resident #174's admission MDS assessment reflected he was admitted to the facility [DATE] with a Foley catheter in place and a [DIAGNOSES REDACTED]. Review of Resident #174's UA lab collected on [DATE] and approved on [DATE] (Sunday) revealed his urine was clear and there were few bacteria. Review of Resident #174's urine culture with an approval date of [DATE] (Wednesday) revealed the resident had a colony count greater than 100,000 cfu/ml. Further review of the urine culture revealed the resident had proteus mirabilis bacteria in his urine. (Proteus mirabilis is a common pathogen responsible for complicated urinary tract infections that sometimes causes bacteremia.) Review of Resident #174's nurses noted dated [DATE] (Thursday) revealed lab results were sent to Physician G and the resident was put on an antibiotic for a UTI. Interview and observation on [DATE] at 7:49 PM of Resident #174 revealed he was in bed watching television. He was alert and oriented and stated he was feeling good and he did not have any concerns regarding his Foley catheter. The Foley bag was noted to be hanging on his bed and the urine appeared to be clear. Interview on [DATE] at 4:03 PM with the DON revealed both Resident #126 and #174 had labs over the weekend and only Resident #126 was approved after they had been pulled for the day on [DATE]. Post interview on [DATE] at 4:00 PM with Resident #49's family revealed she had died earlier that morning ([DATE]). Review of the facility's polices and procedures revealed they did not have a policy on the new lab system that had been started on [DATE]. An IJ was identified on [DATE]. On [DATE] at 4:08 PM the Administrator was notified of the IJ and a plan of removal was requested. Plan of removal dated [DATE] was accepted on [DATE] at 1:28 PM revealed all nursing staff were in-serviced on Lab/Diagnostics Process - Ordering for a resident and how often the online lab system should be checked and how each orders should be processed. Plan of Removal dated [DATE] was accepted on [DATE] at 1:28 PM and revealed the following: 1. Labs/ Neglect/ Quality of Care: A. The facility charge nurse LVN E and LVN F the Weekend Supervisor failed to ensure that lab results were reviewed and acted upon on Saturday, [DATE] for Resident #49. This failure included review and reporting of a final Culture and Sensitivity for Resident #49 so that appropriate treatment could be initiated timely. In-service will be completed prior to them working their next shift with LVN E and LVN F on retrieving labs timely and physician notification. In-services including: Lab protocol and Lab order entry and retrieving results will be completed by [DATE]. Additionally same in service will be conduct upon hire and at minimum quarterly. B. The facility has begun to conduct in-services to licensed nursing staff on reporting and follow-up of lab results to the physician per the facility policy. The facility policy states that lab reports should be reviewed by Nursing Staff and that notification to the prescribing physician should occur for any abnormal results in a timely manner. If changes that warrant a new or change in medication or treatment exists, the patient and patient representative is to be notified. These in-services began on [DATE] and will be completed [DATE] and were conducted by the DON. Any licensed nurse who has not received these in-services will not be permitted to work until training has been completed. In-services including: Lab protocol and Lab order entry and retrieving results will be completed by [DATE]. Additionally same in service will be conduct upon hire and at minimum quarterly. Once labs are completed and approved they will be faxed to each nurse's station for nurse's to address accordingly. Nurse's should be checking fax machine every two hours. In addition to charge nurses receiving faxes at the nurses station, the nurse managers, DON, ADON H, ADON I, and LVN F will retrieve labs from lab portal to validate all labs have been addressed by floor nurses to include physician notification and following any new or additional orders seven days a week at 10:00 am and 4:00 PM. The Facility has initiated an internal lab audit to ensure that all ordered labs have been processed, results received and addressed. This audit was completed by the DON, ADON H, and ADON I. This audit was completed by [DATE]. Findings will be discussed with Primary care physician as well as the Medical Director . There were 2 other residents affected by the failure of checking labs on the weekend. Those residents are identified as Resident #174 and Resident #126. Resident #174 the urinalysis ordered on (MONTH) 19, 2019, prelim results were obtained the 20th. Final Culture and Sensitivity was obtained the 23rd at 10:09 am.[MEDICATION NAME] initial dosed (MONTH) 24th at 8:00 PM. Finding were found during laboratory audit and notified the physician, resident had no negative outcome. Resident #126 pre-[MEDICATION NAME] was ordered (MONTH) 18, 2019 lab was available at 2:02 PM the same day. On (MONTH) 21, 2019 doctor notified of labs results at 4:19 p.m. No negative outcome. C. The facility shall utilize the 24 hour report and lab binder to track and reconcile labs every morning. Any results not received will prompt a phone call to the laboratory by the charge nurse and or the nurse managers ADON H and ADON I. Any results not acted upon will prompt action to ensure the physician is aware so that appropriate treatment if necessary can occur. The patient and patient representative shall also be made aware of results and treatment recommendations. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the shift to shift rounding. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any outstanding tests/ labs, phone calls out to physicians and/or address any other needs that a patient may have. Morning stand-up will occur with ADON H and ADON I, DON and the Administrator and labs will be reviewed at this time to ensure all have been completed and reported. The Weekend Supervisor will review labs every Saturday and Sunday morning and evening to ensure that all results have been obtained, processed and reported to the physician. Monitoring of this will be accomplished through Unit Managers ADON H and ADON I and the Director of Nursing verifying that labs are completed and reported on each day utilizing the lab tracking log/binder daily. Any identified issues will be corrected and brought forth to the QAPI monthly for the next twelve months. Committee to ensure that the continued effectiveness of the standards are maintained. Interviews on [DATE] with 25 of 30 nurses between between 4 PM to 8 PM, that the facility employs, revealed they had been in-serviced that Labs/diagnostics would now be faxed to each nurses station, and how often to check the lab system online if they are following up with an ordered lab and notifying the attending physician of the lab results, and all with a post test. The monitoring interviews included nurses from all shifts, 6am - 2pm, 2pm - 10pm, and 10pm - 6am. There were no concerns regarding lab/diagnostic training and monitoring by the staff. Interview with the Administrator on [DATE] at 4:34 PM revealed the facility nurses were all in-serviced ([DATE] and [DATE]) with the exception of two, one PRN nurse and another that was on FMLA. They would not be allowed to return to work without being in-serviced. The Administrator was notified on [DATE] at 8:03 PM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Residents #49, #126 and #174) of 18 residents reviewed for labs. 1. The facility failed to check the laboratory system containing Resident #49's UA results from [DATE] to [DATE] and report the results to the physician. The resident did not receive the first dose of antibiotic until [DATE]. As a result, the resident's health deteriorated due to an unidentified and untreated infection. The resident was admitted to the hospital with [REDACTED]. Resident #49 died at the hospital on [DATE]. 2. The facility failed to check the laboratory system containing Resident #126's lab results from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions until [DATE]. 3. The facility failed to check the laboratory system containing Resident #174's laboratory results and report the results to the physician from [DATE] to [DATE]. Due to the delay, the physician was not notified and did not order necessary interventions until [DATE]. An Immediate Jeopardy (IJ) identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: 1. Review of Resident #49's most recent MDS assessment dated [DATE] revealed she was a [AGE] year-old-female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #49's Care Plan effective [DATE] revealed she was diabetic and at risk for frequent infections and [MEDICAL CONDITION]. Interventions included giving medications per physician order, and monitoring labs and reporting abnormalities to the MD. Review of Resident #49's UA lab with an approval date of [DATE] revealed the urine was slightly cloudy, WBC (white blood cell count) was TNTC (too numerous to count) and she had moderate bacteria. Review of Resident #49's Urine Culture results with an approval date of [DATE] (Friday) at 1:49 PM revealed that on [DATE] the colony count was greater than 100,000 cfu/ml (colony forming units of bacteria per milliter of urine). Further review of the urine culture revealed the resident had escherichia coli bacteria in her urine. (Escherichia coli - E-coli are a type of bacteria commonly found in the gastrointestinal (GI) tract that can cause Urinary Tract Infection.) Review of Resident #49's (MONTH) 2019 Medication Notes revealed she was prescribed the antibiotic [MEDICATION NAME] 500 mg two times daily for urinary tract infection with a start date of [DATE] (Monday). Review of Resident #49's MAR for (MONTH) 2019 revealed she received the first dose of antibiotic ([MEDICATION NAME]) on [DATE]. Interview on [DATE] at 5:49 PM with LVN J revealed she was told Resident #49 did not seem like herself the morning of [DATE] (Tuesday). When she entered the resident's room, she was not responding as she normally would. Her hands were cold and she could not get a pulse when she applied the pulse oximeter to her finger and her blood pressure was low. The physician was immediately contacted and the resident was sent to the hospital. An interview on [DATE] at 5:39 PM with ADON H revealed she was working as a floor nurse the morning of [DATE] (Tuesday). She went in to give Resident #49 her medications around 8:15 AM to 8:30 AM. The resident opened her eyes and refused her medications. She had just been made aware that the resident had been started on an antibiotic the previous day for a UTI. ADON H stated she was not familiar with Resident #49's baseline as she was just filling in that morning. After attending her morning meeting later that morning, she was approached by LVN J who told her Resident #49 needed to be sent to the hospital due to low blood pressure, facial droop, and not being able to open her eyes. Review of Resident #49's MAR indicated [REDACTED]. The resident's blood pressure was ,[DATE] (Normal ,[DATE]) and her pulse was 111 (Normal ,[DATE]). Review of Resident #49's clinical record revealed there was no documentation regarding the resident's change in condition. Review of Resident #49's hospital records dated [DATE] (Tuesday) revealed when she was seen in the emergency room , the resident was completely disoriented and responded to pain only. The resident was diagnosed with [REDACTED]. Interview on [DATE] at 1:36 PM with the DON revealed the facility had recently changed their lab system on [DATE], and they now had access to them online. She stated all the nursing staff had been trained to access the online lab site. She said she would pull labs daily, Monday through Friday around 8:45 AM to 9:00 AM to review during the morning department head meeting. On Saturday and Sunday, the weekend supervisor was responsible for going to the online system and pulling the labs to review. In the computer the approval date on the labs meant they were ready to be reviewed and printed online. The DON said she pulled the labs on Monday [DATE] and saw Resident #49's UA culture lab and had it sent to the doctor for review, not realizing the date on the lab was dated [DATE] until it was brought to her attention by the surveyor. She assumed the labs had been pulled on the weekend by the weekend supervisor and thought Resident #49's UA culture was new. She stated she expected the nurses to follow the labs once they are ordered. Interview on [DATE] at 11:03 AM with LVN E revealed she had worked with Resident #49 Friday evening [DATE]. She said she had been trained how to access labs on the new computer system but was not aware she needed to have been following Resident #49's labs specifically. Interview on [DATE] at 2:21 PM with LVN F revealed she had been the interim weekend supervisor for the last three weeks. She said she was responsible for checking the online lab system during the weekend, but had forgotten to pull the labs last Saturday and Sunday ([DATE] and [DATE]) because she had been too busy. Interview on [DATE] at 2:12 PM with Physician G revealed he was the physician for Resident #49 and said he would have started Resident #49 on antibiotics immediately if he would have been made aware of the UA culture on Friday, [DATE]. He further stated the current lab system the facility had in place was not a good one and he would be talking to the DON about putting in a better system for checking labs more regularly. 2. Review of Resident #126's admission MDS assessment revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #126's [MEDICATION NAME] and pre-[MEDICATION NAME] (proteins) lab was collected on [DATE] (Friday) at 5:50 AM and was approved at 2:02 PM, on the same day. The results showed both the resident's [MEDICATION NAME] and pre-[MEDICATION NAME] were low, but were not critical. Review of Resident #126's nurses notes dated [DATE] (Monday) revealed, lab reviewed and sent to Physician G for review and new order entered for Prosource Plus (liquid protein) BID 30 ml and dietitian was alerted for assessment and review of resident's nutritional status with newly obtained orders. Interview and observation of Resident #126 on [DATE] at 7:42 PM revealed she was in bed watching television. She was alert and oriented and stated she was feeling good. There were no concerns noted at that time. 3. Review of Resident #174's admission MDS assessment reflected he was admitted to the facility [DATE] with a Foley catheter in place and a [DIAGNOSES REDACTED]. Review of Resident #174's UA lab collected on [DATE] and approved on [DATE] (Sunday) revealed his urine was clear and there were few bacteria. Review of Resident #174's urine culture with an approval date of [DATE] (Wednesday) revealed the resident had a colony count greater than 100,000 cfu/ml. Further review of the urine culture revealed the resident had proteus mirabilis bacteria in his urine. (Proteus mirabilis is a common pathogen responsible for complicated urinary tract infections that sometimes causes bacteremia.) Review of Resident #174's nurses noted dated [DATE] (Thursday) revealed lab results were sent to Physician G and the resident was put on an antibiotic for a UTI. Interview and observation on [DATE] at 7:49 PM of Resident #174 revealed he was in bed watching television. He was alert and oriented and stated he was feeling good and he did not have any concerns regarding his Foley catheter. The Foley bag was noted to be hanging on his bed and the urine appeared to be clear. Interview on [DATE] at 4:03 PM with the DON revealed both Resident #126 and #174 had labs over the weekend and only Resident #126 was approved after they had been pulled for the day on [DATE]. Post interview on [DATE] at 4:00 PM with Resident #49's family revealed she had died earlier that morning ([DATE]). Review of the facility's polices and procedures revealed they did not have a policy on the new lab system that had been started on [DATE]. Review of the facility's current policy titled Tests - Laboratory dated [DATE] reflected .Nursing staff is to review all laboratory reports and notify prescribing physician of any abnormal results. The policy did not indicate how often labs should be checked on the new system. An IJ was identified on [DATE]. On [DATE] at 4:08 PM the Administrator was notified of the IJ and a plan of removal was requested. Plan of removal dated [DATE] was accepted on [DATE] at 1:28 PM revealed all nursing staff were in-serviced on Lab/Diagnostics Process - Ordering for a resident and how often the online lab system should be checked and how each orders should be processed. Plan of Removal dated [DATE] was accepted on [DATE] at 1:28 PM and revealed the following: 1. Labs/ Neglect/ Quality of Care: A. The facility charge nurse LVN E and LVN F the Weekend Supervisor failed to ensure that lab results were reviewed and acted upon on Saturday, [DATE] for Resident #49. This failure included review and reporting of a final Culture and Sensitivity for Resident #49 so that appropriate treatment could be initiated timely. In-service will be completed prior to them working their next shift with LVN E and LVN F on retrieving labs timely and physician notification. In-services including: Lab protocol and Lab order entry and retrieving results will be completed by [DATE]. Additionally same in service will be conduct upon hire and at minimum quarterly. B. The facility has begun to conduct in-services to licensed nursing staff on reporting and follow-up of lab results to the physician per the facility policy. The facility policy states that lab reports should be reviewed by Nursing Staff and that notification to the prescribing physician should occur for any abnormal results in a timely manner. If changes that warrant a new or change in medication or treatment exists, the patient and patient representative is to be notified. These in-services began on [DATE] and will be completed [DATE] and were conducted by the DON. Any licensed nurse who has not received these in-services will not be permitted to work until training has been completed. In-services including: Lab protocol and Lab order entry and retrieving results will be completed by [DATE]. Additionally same in service will be conduct upon hire and at minimum quarterly. Once labs are completed and approved they will be faxed to each nurse's station for nurse's to address accordingly. Nurse's should be checking fax machine every two hours. In addition to charge nurses receiving faxes at the nurses station, the nurse managers, DON, ADON H, ADON I, and LVN F will retrieve labs from lab portal to validate all labs have been addressed by floor nurses to include physician notification and following any new or additional orders seven days a week at 10:00 am and 4:00 PM. The Facility has initiated an internal lab audit to ensure that all ordered labs have been processed, results received and addressed. This audit was completed by the DON, ADON H, and ADON I. This audit was completed by [DATE]. Findings will be discussed with Primary care physician as well as the Medical Director . There were 2 other residents affected by the failure of checking labs on the weekend. Those residents are identified as Resident #174 and Resident #126. Resident #174 the urinalysis ordered on (MONTH) 19, 2019, prelim results were obtained the 20th. Final Culture and Sensitivity was obtained the 23rd at 10:09 am.[MEDICATION NAME] initial dosed (MONTH) 24th at 8:00 PM. Finding were found during laboratory audit and notified the physician, resident had no negative outcome. Resident #126 pre-[MEDICATION NAME] was ordered (MONTH) 18, 2019 lab was available at 2:02 PM the same day. On (MONTH) 21, 2019 doctor notified of labs results at 4:19 p.m. No negative outcome. C. The facility shall utilize the 24 hour report and lab binder to track and reconcile labs every morning. Any results not received will prompt a phone call to the laboratory by the charge nurse and or the nurse managers ADON H and ADON I. Any results not acted upon will prompt action to ensure the physician is aware so that appropriate treatment if necessary can occur. The patient and patient representative shall also be made aware of results and treatment recommendations. It is the responsibility of the licensed nurse to access the 24 hour report upon arrival for the shift to shift rounding. The off going nurse will utilize the 24 hour report to report off to the oncoming nurse any outstanding tests/ labs, phone calls out to physicians and/or address any other needs that a patient may have. Morning stand-up will occur with ADON H and ADON I, DON and the Administrator and labs will be reviewed at this time to ensure all have been completed and reported. The Weekend Supervisor will review labs every Saturday and Sunday morning and evening to ensure that all results have been obtained, processed and reported to the physician. Monitoring of this will be accomplished through Unit Managers ADON H and ADON I and the Director of Nursing verifying that labs are completed and reported on each day utilizing the lab tracking log/binder daily. Any identified issues will be corrected and brought forth to the QAPI monthly for the next twelve months. Committee to ensure that the continued effectiveness of the standards are maintained. Interviews on [DATE] with 25 of 30 nurses between between 4 PM to 8 PM, that the facility employs, revealed they had been in-serviced that Labs/diagnostics would now be faxed to each nurses station, and how often to check the lab system online if they are following up with an ordered lab and notifying the attending physician of the lab results, and all with a post test. The monitoring interviews included nurses from all shifts, 6am - 2pm, 2pm - 10pm, and 10pm - 6am. There were no concerns regarding lab/diagnostic training and monitoring by the staff. Interview with the Administrator on [DATE] at 4:34 PM revealed the facility nurses were all in-serviced ([DATE] and [DATE]) with the exception of two, one PRN nurse and another that was on FMLA. They would not be allowed to return to work without being in-serviced. The Administrator was notified on [DATE] at 8:03 PM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal.

Based on interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (Resident #1) of six residents reviewed for accidents and supervision. The facility failed to provide a safe transfer to Resident #1 to prevent an accident. The resident was being assisted with a sliding board transfer from her bed to her wheelchair, when the sliding board slipped off the bed during the transfer. The resident fell on the floor and sustained a fracture to her right femur (lower portion of the thigh bone). The failure could have affected the other two residents, who used sliding boards for transfers, by placing them at risk for injuries, fractures, and fear. Findings included: Review of Resident #1's Face Sheet, dated 08/26/14, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's comprehensive assessment, dated 08/12/14, reflected the resident had unclear speech; she could usually understand others and sometimes be understood by others. Resident #1's vision was moderately impaired, and her cognition was moderately impaired. The comprehensive assessment further reflected she was an extensive assist and required two persons' assist with trasnfers. Resident #1 was 67 inches tall and weighed 215 pounds. Her [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Plan of Care, revealed the following: -07/15/14: RAP/Problem/Need, "Patientt at risk for injury from transfers/falls related to refusal for staff to use gait belt at times." Goal, "Dignity will be maintained. Resident will not experience falls or injuries from falls over the next 90 days." Approach "1) Encourage resident to allow assist to staff/gait belt, 2) pt (patient) education when refuses use of gait belt, 3) determine safest mode of transfer for patient, 4) revise transfer plan as needed." -07/25/13: RAP/Problem/Need, "Residents, ADL Functions: Transfers: Extensive assistance, Assist: 1-2 person." Approach "... 4) Extensive assistance with alL ADLs. 5) Ext (extensive) Assist with transfer." The care plan was last reviewed on 07/05/14. Review of an additional care plan, titled Transfer Care Plan, dated 07/15/14, revealed the resident could be transferred with assist times one to two using a sliding board from bed to wheelchair and wheelchair to bed. The resident could use the stand lift with two persons assist for transfers to the shower chair. On 08/27/14 the care plan was revised and reflected the resident was a Hoyer lift transfer with two persons assist. An interview with the DON on 09/24/14 at 9:30 AM revealed Resident #1 was a sliding board transfer with one to two persons assist. When asked if a resident was a one to two persons assist, how staff decided whether to transfer the resident by themselves or to get additional help, she replied it depended on how the resident felt that day. Review of Resident #1's Daily care Guide revealed on 05/18/14 a handwritten note reflected the resident would have bolsters to the air mattress; floor mats on both sides of the bed; and the bed in low position. On 07/15/14 another hand written note reflected the resident could transfer with a sliding board from the wheelchair to the bed and the bed to the wheelchair with one to two persons assist. The resident was to use the stand lift with two persons assist for transfers to the shower chair. An interview on 09/24/14 at 3:20 PM with CNA D revealed she had worked with Resident #1 prior to the incident. She stated the staff could transfer her with a sliding board or a stand lift. CNA D stated she was told not to transfer Resident #1 alone. She revealed she would not feel comfortable transferring Resident #1 with the sliding board by herself. She stated the resident was too heavy. She stated at times Resident #1 would refuse to wear the gait belt, but she would explain it was for safety and that would usually work. Review of Resident #1's Physical Therapy discharge summary, undated, revealed the resident received therapy services from 05/13/14 through 06/09/14. The "Discharge Status and Recommendations" indicated Resident #1 was totally dependent on staff for transfers without attempts to initiate. The resident transferred with the use of the Hoyer lift. An interview on 09/24/14 at 4:35 PM with PT E revealed when Resident #1 was receiving therapy services she was a Hoyer lift transfer. She stated Resident #1 was not safe with a sliding board and was too difficult for a sit to stand transfer. Further interview with the DON on 09/24/14 at 5:00 PM revealed the CNAs had always transferred Resident #1 using a sliding board. The DON stated the therapy department did not tell her the resident needed a Hoyer lift transfer when she was discharged from therapy. The DON revealed she had not witnessed any problems regarding Resident #1 being transferred with a sliding board. When asked how it was determined if the resident needed the assistance of one or two persons with transfers, the DON replied it depended on what the resident was able to do and how comfortable the CNA was. Review of Resident #1's Nurse's Notes, revealed on 08/23/14 the resident was confused with some disorganized thinking. The physician was notified and ordered a UA, CBC, and BMP. Review of the facility's Accident/Incident Report, dated 08/26/14, revealed on 08/24/14 at 12:05 PM, RN C was notified by the nurse aide Resident #1 was on the floor. Upon entering the room, RN C found Resident #1 sitting on the floor against the bed (left side) and her back was close to the wheelchair. The report reflected the CNA said she was transferring the resident from the bed to wheelchair when the mattress sunk in and the sliding board slid off the bed and the resident lost her balance. A head to toe assessment was conducted. Her vitals were as follows, Blood Pressure 144/78; Pulse 74; Temperature 97.8; and Oxygen 94%. Resident #1 was complaining about pain to the right thigh and the right knee. Resident #1 was assisted back to bed with caution by immobilizing in maximum the affected extremity. Resident #1 was administered Tylenol 650 MG. A stat x-ray of the right knee and right femur were ordered. The results indicated the resident had a fracture. Resident #1 was sent to the ER. The follow-up indicated the resident was to have a leg brace and would be evaluated for the most appropriate transfer when she returned to the facility. In an interview with RN C on 09/24/14 at 1:16 PM, she revealed on the day of the incident the CNA called her for help. She stated the CNA told her she was trying to transfer Resident #1 from her bed to her chair and the resident fell . RN C revealed most of the time Resident #1 was able to ues the sliding board. She stated when she entered the room Resident #1 was sitting on the floor and her back was to the wheelchair. She said the resident had her left side to the bed. RN C revealed she assessed Resident #1 and asked if she was in pain. Resident #1 pointed to her right lower extremity. She stated she called for help and also stated Resident #1 was heavy. RN C stated she immobilized the affected area and kept her leg straight. She said they put her in bed. RN C revealed she notified the physician and the resident's family. She stated the physician ordered x-rays. She said after the results came in, the physician sent the resident out to the hospital immediately. She stated there was no redness or bruising to right lower extremity. Review of Resident #1's x-ray results, dated 08/24/14, revealed an acute comminuted (splintered, broken into pieces) distal diametaphyseal fracture of the right femur. An orthopedic consultation was warranted. Observation and interview on 09/24/14 at 10:15 AM revealed Resident #1 was in a low bed. She was alert. The investigator asked Resident #1 if she recalled the incident. The resident was unable to recall the fall. The investigator asked Resident #1 if she had any pain. Resident #1 pointed to her left arm with had an IV in it. The investigator asked if she had any pain to her right leg and the resident said, "A little." The resident then began to complain her back was itching. The resident was able to speak and be understood, but was not oriented to the day and situation. Observation on 09/25/14 at 12:35 PM of Resident #1 revealed she was lying in bed. The investigator attempted to speak with the resident, but the resident was not coherent and could not answer any questions clearly. Review of the facility's Provider Investigation Report (PIR), dated 08/29/14, revealed Resident #1's functional ability was "extensive;" she was not independently ambulatory; she was interviewable and had the capacity to make informed decisions. The report reflected on 08/24/14, CNA A was transferring Resident #1 from the bed to the wheelchair. The resident had an assisted fall to the floor and sustained a fracture to her right femur. A head to toe assessment of the resident was completed at the time of the incident. Resident #1 complained of pain to her right thigh and knee area. No swelling was noted to the right upper leg. RN C immobilized the leg and the resident was assisted to bed. The reported reflected the family and the MD were notified. Resident #1 was administered Tylenol PRN for pain. The MD ordered x-rays. The x-ray results were received at approximately 2:40 PM which indicated an acute distal right femur fracture. The MD gave orders to send Resident #1 to the hospital for evaluation. The "Provider Action Take Post-Investigation" indicated staff was in-serviced on daily care guides, transfers, gait belts, and abuse/neglect. All transfer care plans were reviewed and updated if needed. Review of in-service records provided after the incident on Abuse and Neglect, 08/25/14, Daily care guides, transfers, gait belts, abuse and neglect, 08/26/14, and Transfer Boards, 08/27/14, revealed the investigator could not comfirm an adequate amount of 10:00 PM to 6:00 AM shift staff had received the aforementioned in-services. Several signatures were illegible. The PIR included an attached written statement completed by CNA A, dated 08/24/14. The statement reflected the CNA was transferring Resident #1 around 12:00 PM. The aide was assisting the resident from the bed to the wheelchair using the sliding board. The resident refused to wear the gait belt and claimed it made her feel like she was suffocating. During the transfer, the mattress sunk in and the sliding board slipped off the bed. The resident's legs gave out and the CNA assisted her to the floor. The resident's right knee landed on the floor. CNA A immediately notified the nurse. An interview with CNA A on 09/24/14 at 9:42 AM revealed she worked at the facility for almost four years. She stated the morning of the incident she got Resident #1 dressed. She stated the resident was a "good" transfer. CNA A revealed she used the sliding board to transfer the resident from her bed to her wheelchair. She stated she transferred Resident #1 with the sliding board because the resident could assist with the transfer. She stated in the middle of the transfer to the chair, the board fell to the floor. She stated it slid from the bed. CNA A revealed when Resident #1 fell to the ground, she attempted to catch her. She said the resident was on her knees and began to fall forward, but she (CNA A) pulled the resident back. She stated she laid her backwards on the floor and called for help. CNA A revealed LVN B and other CNAs came to the room. She stated the nurse assessed Resident #1. A gait belt was put on the resident when she was assisted off the floor. Resident #1 was put into her wheelchair and then into her bed. CNA A revealed the resident did not complain of pain. CNA A stated before she left that day, at 2:00 PM, the resident had complained of pain. She reported the pain to the nurse. CNA A revealed she had used the gait belt on the resident at the time of the transfer. She stated sometimes the resident did not want to wear the gait belt. She said she had used the sliding board with Resident #1 in the past and had no incidents. CNA A revealed when she used a gait belt on Resident #1, she would obtain additional help to transfer the resident. In another interview with CNA A on 09/25/14 at 12:50 PM, she revealed she had been trained on transfers prior to the incident. She stated Resident #1 was able to assist during the transfer. CNA A revealed sometimes Resident #1 did not allow the CNAs to stand in front of her while assisting with the sliding board transfer. She stated she was standing behind the resident when she was assisting and the resident fell forward. An interview with Resident #1's family member on 09/25/14 at 9:42 AM revealed the resident was unable to move herself prior to the fracture. He/She stated since Resident #1 sustained the fracture she had not been getting out of bed. The family member revealed the resident had periods of deep sleep and a period of being coherent and it was a total extreme. He/She stated he/she could not say it was due to the fracture. He/She revealed Resident #1 would get out of bed daily; she was not an extrovert; and did not lie down a lot. Resident #1's family member said the resident would occasionally go to the dining room and would go to the beauty shop once a week. He/She revealed the facility was waiting on a piece for Resident #1's wheelchair. The family member stated he/she did not understand how the sliding board transfer was done when Resident #1 weighed 200 pounds. The family member revealed Resident #1 was a large woman and "dead weight." The family member stated his/her biggest concern was Resident #1 needed two people when conducting a transfer using the sliding board. He/She revealed he/she felt Resident #1's personal situation slipped through the cracks. The family member stated he/she felt Resident #1's size and how many people should be there for a transfer was not evaluated. Interview with LVN B on 09/24/14 at 10:00 AM revealed she worked at the facility for two years. She stated how much assistance a resident required could be found in the ADL flow book. She stated Resident #1 was CNA A's regular resident. She revealed the resident was currently a Hoyer lift transfer and the sliding boards were no longer being used. LVN B stated Resident #1 was able to bear very little weight on her legs prior to the incident. She said with assistance she could pivot her feet. LVN B revealed the resident had always been a two person assist with transfers. She stated Resident #1 could have one person assistance with other ADLs, but with transfers she required two people. LVN B revealed "they" did not transfer Resident #1 with a sliding board. LVN B stated Resident #1 had a fracture to her right leg. She stated she could express her needs. LVN B revealed she did not work the day the incident happened and she was not the nurse involved with assessing the resident. An interview with the DON on 09/24/14 at 9:30 AM revealed Resident #1 sustained a fractured femur. She revealed Resident #1 would refuse to wear the gait belt at times. She stated the resident had Osteoporosis. She said when the resident fell she was lowered to the ground by the CNA but her knee hit the floor. Review of the facility's Transfers: Method, Equipment, and Preparation policy, dated July 2014, revealed, "General Principles...Use gait belt on all assisted transfers. Patient's shoulders or arms are not appropriate to pull, push or lift upon. Cup your hand under the gait belt for greater control...If balance is lost, break fall. Do not try to hold the Patient up...Always transfer Patient in much the same manner if possible. Daily repetition make practice perfect...Get help if necessary or in doubt." Review of the facility's Transfers policy, dated July 2014, revealed, "Transfers with Assistance...When transferring a Patient (even with minimal assistance) always place a belt around his waist. (Tight enough for you to get your fingers around it)...." Review of the facility's General Staff guidelines-Gait Belt Policy, dated July 2014, revealed, "Purpose: Gait/Transfer belts provide a safe method for transfer and ambulation of the Patient. The Gait/Transfer Belt allows the patient to use their strength and not rely on strength of the person assisting them. The employee then has something secure to hold on to, allowing for control of the gait/transfer activity. Policy: At all times while on duty, the nursing employees are required to have on their person a Gait/Transfer Belt, and to use Gait Transfer Belt for all Patient transfers and ambulation...." Further interview with the DON on 09/24/14 at 11:45 AM revealed when asked what staff should do when a resident refused to wear a gait belt, she replied if it was an alert and oriented resident, they would go over safety with them and most of the time that worked. She stated they would care plan the problem. The DON revealed the facility would also go over the issue with the resident's family. She stated it depended on the type of transfer, if the resident was a stand-by assist or not. The DON stated they may or may not "up" the amount of assistance. Another interview with the DON on 09/24/14 at 5:00 PM revealed the resident would get in her wheelchair every day prior to her fracture. She stated the resident would occasionally have her meals in the dining room. When asked how Resident #1's quality of life had changed since the fracture, the DON replied the resident used go to the hair salon once a week, but she was a "homebody." She stated the resident was in her wheelchair a few hours each day, but was in her bed a lot. When asked how it was determined if the resident needed the assistance of one or two persons with transfers, the DON replied it depended on what the resident was able to do and how comfortable the CNA was. Interview on 09/24/14 at 5:00 PM with the DON revealed two residents, Residents #2 and #3 used sliding boards to transfer prior to the incident.

Based on observation, interview and record review, the facility failed to ensure the well-being for one (Resident #3) of one resident reviewed with a [MEDICAL CONDITION]. The facility failed to ensure they thoroughly reviewed an Accident/Incident Report dated 10/31/10 involving Resident #3, who had a fractured right hip, which they both signed, so they were aware of the time parameters involved from the time the resident fell on [DATE] to when he was sent to the hospital on [DATE]. The facility failed to supervise and monitor RNs B and C when Resident #3 experienced a change in condition to ensure Resident #3 received appropriate care in a timely manner. Resident #3 was found on 10/31/10 at 8:00 a.m. with symptoms of a fractured right hip. RN B paged the physician, who returned the call at 1:00 p.m. (five hours later). The physician ordered a stat x-ray. RN B immediately called it in as a stat order. The x-ray company did not take the x-ray until 9:45 p.m. (over 8 1/2 hours after it was ordered). RN B received a verbal x-ray report that Resident #3 had a right [MEDICAL CONDITION] at 10:30 p.m., but did not notify the physician. RN B gave report to RN C including the x-ray report about the right [MEDICAL CONDITION] and not having received the final x-ray report. RN C also waited to receive the final x-ray report (at 1:45 a.m. on 11/01/10) and called the physician, who told her to notify the on-call physician. The resident was finally transferred to the hospital at 3:00 a.m. From 8:00 a.m. on 10/31/10 until 3:00 a.m. at 11/01/10 (19 hours), RNs B documented the resident's continued complaints of pain, up to a 6 - 7 on a scale of 1 - 10, and RN C also documented the resident's complaints of pain, but the RNs did not obtain orders for pain medication to administer to the resident. RN B did not notify her supervisor, the DON or the Administrator when: 1) the physician did not respond to the page for five hours, and 2) the x-ray company took over 8 1/2 hours to respond to a stat order for an x-ray. The ADM and the DON were not aware of these failures until surveyor inquiry on 01/13/11. These failures caused a delay in treatment for [REDACTED]. An Immediate Jeopardy (IJ) was identified on 01/13/11. While the IJ was removed on 01/14/11, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" because all staff had not been inserviced, and the facility was still monitoring implementation of the Plan of Removal. These failures could affect the facility's 86 residents, including Resident #3, placing them at risk for not receiving care in a timely manner. Findings included: Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] for Resident #3 revealed he had short and long term memory problems, and was moderately impaired in his cognitive skills for daily decision-making. Observation on 01/11/11 at 11:11 a.m. revealed Resident #3 was wheeling himself in the hall in a wheelchair. Observation on 01/13/11 at 7:50 a.m. revealed Resident #3 was wheeling himself in his room in a wheelchair. Review of an Accident/Incident Report dated 10/31/10 for Resident #3 revealed, "Entered ___ (Resident #3's room) on A.M. hall rounds and asked how ___ (Resident #3) was feeling & why he had not been out of bed for breakfast. Pt. stated 'my hip hurts too bad and I can't eat.' Pt. indicated (right) hip when asked to show this nurse where he hurts. Asked if he had hit area or fallen. States 'I fell in the bathroom last night. I lost my balance and landed on my back.' Pt. stated he got himself up, it occurred 'about 3:00 (a.m.) o'clock," and he 'didn't tell anybody.' Denies hitting his head in fall." The form reflected, "Post Incident Diagnoses: [REDACTED]." Under Treatment was, "Xray prelim (preliminary) result called at 10:20 p.m." The anatomy of the body on the form indicated there was a light brown Hematoma on the right posterior hip, a light brown Hematoma on the right side of the hip and a dark purple Hematoma on the left wrist. Under Charge Nurse Investigation was, "...(Right) hip is beginning to show new bruising (with) no other area of bruising to back, no indication of hitting head, so impact appears to be primarily to (right) hip and (left) wrist where pt has dark purple Hematoma. no wrist pain noted...(authored by RN B)...." The report was signed by the DON and the ADM on 11/01/10. Review of a physician's telephone order dated 10/31/10 at 1:00 p.m. for Resident #3 revealed, "May order xray of (right) hip r/o (rule out) Fx (fracture)." Review of a Stat Xray report for Resident #3 dated 10/31/10 revealed, "...Impression: 1) Comminuted intertrochanteric [MEDICAL CONDITION] femur...." Review of the Neurological Evaluation Flow Sheet, which was stapled to the Accident/Incident Report for Resident #3 revealed on 10/31/10 at 8:00 a.m. neuro checks were initiated due to the unwitnessed fall. Assessments for the neuro checks were on 10/31/10 at 8:00 a.m., 8:15 a.m., 8:30 a.m., 8:45 a.m., 9:00 a.m. 9:30 a.m., 10:00 a.m., 10:30 a.m., 11:00 a.m., 12:00 p.m., 1:00 p.m., 2:00 p.m. and 3:00 p.m. Under "Observations" for all of the times listed, the following was documented: "C/O (complains of) (right) hip pain, no n/v (nausea/vomiting)...(authored by RN B)." On 10/31/10 at 11:00 p.m., RN C documented on the Neurological Evaluation Flow Sheet for Resident #3, "pain (right) hip," under Observations. Review of the October 2010 consolidated physicians' orders for Resident #3 revealed no orders for any pain medication. Review of the October 2010 Pain Record for Resident #3 revealed on 10/31/10 during the 6:00 a.m. to 2:00 p.m. shift, RN B documented Resident #3's pain level at a 7 on a scale of 1 to 10. On the 2:00 p.m. to 10:00 p.m. shift, RN B documented the resident's pain level as a 6. Review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Nurse's Notes dated 10/31/10 at 8:00 a.m. for Resident #3 revealed, "Entered pt room on 8am hall round and noted resident lying in bed & none of breakfast eaten. Pt stated he wasn't able to eat. Upon assess (assessment) pt noted to have hematoma to (left) wrist but denied pain to wrist & noted to have (right) hip pain upon palpation & (right) hip bruising upon visual assess. Pt states (right) hip painful. Inquired if pt had hit hip on something, fallen or was otherwise aware of when pain began. Stated he had fallen in bathroom of his rm 'about 3 o'clock this morning'...Neuro (checks) & v/s (vital signs) WNLs (within normal limits). No external rotation noted to (right) extremity...____ (Medical Director) paged (with) assess results to be reported for further orders @ 9:30 a.m. No return call by 12:30 p.m. Pt kept in bed for safety. Pt exhibits no overt distress. ...____ (Medical Director) paged again. call returned @ 1:00 p.m. (with) new order given: 1) call & report to ____ (orthopedic physician), 2) may get mobile xray (right) hip. ____ (Orthopedic physician) notified. Stated to return call if hip Fx (fracture) identified...'____ (xray company)' called for mobile xray. Will send staff to perform xray this evening per call.... 9:45 p.m. '____ (xray company)' mobile tech arrived at facility and two xray views taken...Results pending.... 10:30 p.m. '____ (xray company)' tech called facility (with) 'preliminary' film results which show 'intertrochanteric fx of (right) femur'.... Report given to oncoming RN (RN C) of results as well as need to notify ____ (Medical Director) of results, ____ (Orthopedic physician) of results & family.... Final film pending...(all authored by RN B)...." Review of Nurse's Notes dated 11/01/10 at 12:15 a.m. for Resident #3 revealed, "Final xray result still not received called (x-ray company) in this regard.... 1:25 a.m. Final result still not here. (x-ray company) called again.... 1:45 a.m. Final result received, ____ (Orthopedic physician) called. Instructions given to call on call Dr. On call Dr. called @ 2:00 a.m. instructions given to transport pt to ____ (hospital).... 3:00 a.m. Pt picked up by ____ (transport company)...." This was authored by RN C. Review of the employee roster, provided by the ADM on 01/12/11 as the current employee roster, revealed RN B and RN C were still employed with the facility. Review of the x-ray company, initiated on 09/15/10 revealed, "...Services: ...3) Reports: The Radiologist will dictate a report to the attending physician for each examination. (x-ray company) will promptly phone an abbreviated verbal report to the facility, then transcribe the full written report...to the attending physician...." The DON was interviewed on 01/13/11 at 12:10 p.m. and asked what she expected her nurses to do if they suspected a fracture on a resident. The DON stated she would expect them to notify the physician. When asked how she would expect them to notify the physician, the DON stated they needed to call the physician on the telephone. She added after hours and on weekends, there was an on-call physician. When asked how long she would expect her nurses to wait for a return call, the DON stated 5-10 minutes. She added they could always call the Medical Director. The DON was given the Incident/Accident Report to review for Resident #3. She was asked if she had any issues with the report. She stated she was told he had gone directly to the hospital after the fracture. The DON was then given the Nurse's Notes, dated 10/31/10 and 11/01/10 authored by RN B and RN C, to review. The DON added she did contact the Xray company about why it took so long to get the xray for Resident completed. The DON was then informed of: 1) the neuro checks indicating Resident #3 complained of pain from 8:00 a.m. through 11:00 p.m. (according to the document), and no evidence was located he was administered pain medication; 2) no evidence he was provided pain medication from 11:00 p.m. to 3:00 a.m.; 3) the physician not responding to the nurse's call for five hours; and 4) the xray company taking over 8 1/2 hours to obtain an xray. While the DON was concerned about the amount of time it took for the x-ray company to respond to the stat order for an x-ray, she had no response to timeliness of care provided by RNs B and C. Interview on 01/13/11 at 2:07 p.m. with the ADM revealed she had not been aware of the failures with Resident #3 until the DON shared the information with her, just before this interview. The ADM stated she never looked at the timing of the neuro checks, she just made sure they were completed. She added she missed seeing how long it took the staff/physicians to get Resident #3 out of the facility. The ADM stated it was not anyone's fault other than her own. When asked what plan was in place to ensure this did not happen again, the ADM stated she would be personally reviewing the clinical record from front to back in the future. On 01/13/11, an IJ was identified. On 01/13/11 at 3:14 p.m., the ADM was informed an IJ had been identified in Administration. A Plan of Removal for the IJ was requested from the ADM. The facility provided inservices, which were conducted prior to the identification of the IJ, to the survey team on 01/14/11. The inservices included Falls with Fractures QA, on 11/08/10 (RN B attended), Fall Prevention on 11/08/10, Fall Management Program/Medication Administration/Pain Med with Scores on 11/09/10 (RN B attended), Notification of DON of all Changes/and Inability to Reach Attending Physician on 11/12/10 (RN B attended), Things to Notify the DON Immediately Regarding Resident Care on 12/21/10 (RN B attended). RN C, who was employed at least through 01/06/11 (and was called and asked to work on 01/07/11 and 01/08/11) did not attend any of the inservices. Review of the facility's Plan of Removal, which was accepted on 01/14/11 at 11:20 a.m., revealed RNs and LVNs were being inserviced on Notification of Physicians and Response Times, Pain Medication and Pain Management Post Incidents with Injury and Acceptable Parameters for STAT order results. The plan went onto reflect, "...2)...c. Physicians who continue to disregard the policy on timely return calls will be contacted by the Medical Director/Executive Director and may have privileges suspended/revoked...3) Medical Treatment a. Contracted Xray company has been called and notified via email by Regional Director of Operations of required response time for STAT orders...c. Non-compliance by contracted company will result in contract termination...5) a Quality of care concerns regarding post falls with injury will be referred to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward...." On 01/14/11 at 9:49 a.m., Regional Director A stated RN C was terminated on 01/06/11. She provided a Personnel Status Form for RN B and RN C. Both forms indicated the two RNs were terminated on 01/06/11. Telephone interview on 01/14/11 at 10:01 a.m. with RN B revealed she was no longer employed at the facility. She stated she did recall the incident with Resident #3 on 10/31/10. She stated she noticed something was just not right with Resident #3. She stated he was holding the area (right hip). She stated he told her he fell in the bathroom about 3:00 a.m. that night, but did not tell anyone. When asked if Resident #3 was having pain, RN B stated he was, and she instructed him to stay in bed. She said she did not see any obvious signs of fracture, and he was only complaining of pain to the right hip. RN B confirmed it was several hours before the Medical Director returned her call. She stated she was told to get a Stat Xray. She said the xray was ordered abut 7:00 p.m. and was completed before she left at 10:30 p.m. RN B stated when she learned the hip was fractured, she was shocked. When asked if she notified her supervisor of the physician not returning her call for five hours, RN B stated she did not. She added she felt the supervisors were already aware. When asked if she was interviewed or counseled by any member of management about the incident, RN B stated she was not. RN B was asked when she would administer pain medication to a resident. She stated she would administer medication typically for any pain level when it was about a 3 or 4 on a pain scale of 1 to 10. RN B was then informed of her documentation on the pain medication record, which reflected pain levels of 6 and 7 for Resident #3. When asked why Resident #3 was not medicated for the pain, RN B stated she thought she medicated him with [MEDICATION NAME], however she then added, she thought the [MEDICATION NAME] was ordered after he returned from the hospital. When asked about why the xray was delayed, RN B stated she notified the xray company, and they asked her if she needed the xray that day. RN B stated she told them she needed the xray "asap." When asked if the physician was notified of the preliminary xray report, RN B stated she was instructed to pass anything along to the next shift, if it was going to cause her to be on overtime. She said she did not notify the physician of the preliminary report, which was positive for a [MEDICAL CONDITION]. Telephone interview on 01/14/11 at 10:35 a.m. with RN C revealed she was PRN and her last shift worked was 01/06/11. When asked if she had been counseled or written up for work performance, RN C stated she had not. When asked about the incident with Resident #3, RN C stated she came on the 10:00 p.m. to 6:00 a.m. shift on the night in question (10/31/10 - 11/30/10). When asked if Resident #3 was experiencing pain, RN C stated he was sleeping when she came on and did not wake him. When asked about the neuro check at 11:00 p.m. on 10/31/10, which she had documented, which reflected he was having right hip pain, RN C stated the nurse (RN B), who had been on the shift just prior to hers, had told her that. RN C stated Resident #3 did have pain when they woke him up to be transported to the hospital on [DATE]. RN C stated she had the preliminary xray results but waited on the final result before notifying the physician. When asked if she was interviewed by any management staff about the incident, RN C stated she was called last night (01/13/11) and asked about the pain medication. RN C stated she believed she administered Tylenol before he left for the hospital, however it was not documented and not ordered. RN C stated the facility had standing orders for Tylenol. When asked about her termination from the facility, RN C stated she was not terminated. She stated she gave a two week notice, and then was PRN. She stated she was called on 01/07/11 and 01/08/11 and asked if she could work a shift in the facility. She denied being terminated. Interview on 01/14/11 at 12:08 p.m. with LVN D confirmed she contacted RN C by telephone on 01/07/11 and asked her to work in the facility due to needing nursing coverage. Interviews on 01/14/11 from 1:20 p.m. to 3:35 p.m. with five LVNs and one RN, revealed the plan of removal was being implemented. Nursing staff were able to state the plan of removal contents and were aware of the notification of physicians requirement. Review of a facility policy entitled, "Significant Change in Resident Status," dated February 2010, provided by the ADM revealed, "A significant change in Resident status is defined as deterioration or marked improvement in the health, mental, or psychosocial status in either life-threatening conditions, or in incidents of clinical complications. Scope and severity, examples of life-threatening conditions include, but are not limited to: ...Fractures... As a significant change in Resident condition occurs, the Charge Nurse will notify the physician, family...of the significant change immediately...." While the IJ was removed on 01/14/11, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" because all staff had not been inserviced, and the facility was still monitoring implementation of the Plan of Removal. Review of a staff list provided by the ADM on 01/12/11 revealed there were 14 RNs and 31 LVNs currently employed at the facility. The CMS-672 dated 01/11/11 provided by the ADM reflected the census was 86.

Based on observation, interview and record review, it was determined the facility failed to ensure services provided or arranged by the facility must meet professional standards of quality for one (Resident #3) of 15 sampled residents, but two (RN B and RN C) of 14 RNs currently employed in the facility. Resident #3 was found on 10/31/10 at 8:00 a.m. with symptoms of a fractured right hip. RN B notified the physician (Medical Director) by page, at 8:00 a.m. No return call from the Medical Director was received until 1:00 p.m. (five hours after the first page). RN B and RN C documented 14 times that Resident #3 was having pain in the right hip, however no pain medication was administered. Resident #3 was in the facility from 8:00 a.m. until 3:00 a.m. on 11/01/10 with documented pain and no pain medication was administered. RN B ordered an x-ray of the right hip at 1:00 p.m. The x-ray company did not take the x-ray until 9:45 p.m. (over 8 1/2 hours after it was ordered). RN B received the preliminary x-ray report of a fractured right hip at 10:30 p.m. via telephone call. RN B did not notify the physician. RN C came on at 10:00 p.m. and she did not notify the physician until 1:45 a.m. when the final report came in. Resident #3 was in the facility from 10:30 p.m. to 2:00 a.m. (3 1/2 hours) with a positive right [MEDICAL CONDITION] before transferred to a local hospital for treatment. RN B and RN C were still on the list of current employees. These failures caused a delay in treatment for [REDACTED]. This could have caused continued untreatable pain, [MEDICAL CONDITION] Embolism, or Respiratory Distress. These failures had the potential to affect all 86 residents who might experience a change in condition. Findings included: The Texas Board of Nursing documented in RULES AND REGULATIONS relating to NURSE EDUCATION, LICENSURE AND PRACTICE" in the Texas Administrative Code Title 22 Examining Boards, Part 11, Texas Board of Nursing, Chapter 211, General Provisions, effective July 2009, the following: TAC 217.12 Unprofessional Conduct The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licenses. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurses which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (1) Unsafe Practice -- actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to performl... nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11; (B) Carelessly or repeatedly failing to conform to generally accepted nursing standards in applicable practice settings; ...(4) Careless or repetitive conduct that may endanger a client's life, health, or safety. Actual injury to a client need not be established...." Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a re-entry MDS assessment dated [DATE] for Resident #3 revealed he had short and long-term memory problems, and was moderately impaired in his cognitive skills for daily decision-making. Observation on 01/11/11 at 11:11 a.m. revealed Resident #3 was wheeling himself in the hall in a wheelchair. Observation on 01/13/11 at 7:50 a.m. revealed Resident #3 was wheeling himself in his room in a wheelchair. Review of an Accident/Incident Report dated 10/31/10 for Resident #3 revealed, "Entered (Resident #3's room) on A.M. hall rounds and asked how (Resident #3) was feeling & whey he had not been out of bed for breakfast. Pt. stated 'my hip hurts too bad and I can't eat.' Pt. indicated (right) hip when asked to show this nurse where he hurts. Asked if he had hit area or fallen. States "I fell in the bathroom last night. 'I lost my balance and landed on my back. ' Pt. stated he got himself up, it occurred 'about 3:00 (am) o'clock" and he 'didn't tell anybody.' Denies hitting his head in fall." The form indicated , "Post Incident Diagnoses: [REDACTED]." Under Treatment was, "Xray prelim (preliminary) result called at 10:20 p.m." The anatomy of the body on the form indicated there was a light brown Hematoma to the right posterior hip, a light brown Hematoma to the right side of the hip and a dark purple Hematoma to the left wrist. Under Charge Nurse Investigation was, "...(Right) hip is beginning to show new bruising (with) no other area of bruising to back, no indication of hitting head, so impact appears to be primarily to (right) hip and (left) wrist where pt has dark purple Hematoma. no wrist pain noted...(authored by RN B)...." The report was signed by the DON and the ADM on 11/01/10. Review of a physician's telephone order dated 10/31/10 at 1:00 p.m. for Resident #3 revealed, "May order xray of (right) hip r/o (rule out) Fx (fracture)." Review of a Stat x-ray report for Resident #3 dated 10/31/10 revealed, "...Impression: 1) Comminuted intertrochanteric [MEDICAL CONDITION] femur...." Review of the Neurological Evaluation Flow Sheet for Resident #3 revealed on 10/31/10 at 8:00 a.m. neuro checks were initiated due to the unwitnessed fall. Assessments for the neuro checks were on 10/31/10 at 8:00 a.m., 8:15 a.m., 8:30 a.m., 8:45 a.m., 9:00 a.m. 9:30 a.m., 10:00 a.m., 10:30 a.m., 11:00 a.m., 12:00 p.m., 1:00 p.m., 2:00 p.m. and 3:00 p.m. Under "Observations" for all of the times listed previously revealed, "C/O (complained of) (right) hip pain, no n/v (nausea/vomiting)...(authored by RN B)." On 10/31/10 at 11:00 p.m., RN C documented, "pain (right) hip," under Observations. Review of the October 2010 consolidated physicians' orders for Resident #3 revealed no orders for any pain medication. Review of the October 2010 Pain Record for Resident #3 revealed on 10/31/10 during the 6:00 a.m. to 2:00 p.m. shift, RN B documented Resident #3's pain level at a 7. On the 2:00 p.m. to 10:00 p.m. shift, RN B documented the pain level as a 6. Review of the October 2010 MAR for Resident #3 revealed no pain medications were listed on the MAR. Review of Nurse's Notes dated 10/31/10 at 8:00 a.m. for Resident #3 revealed, "Entered pt room on 8am hall round and noted resident lying in bed & none of breakfast eaten. Pt stated he wasn't able to eat. Upon assess (assessment) pt noted to have hematoma to (left) wrist but denied pain to wrist & noted to have (right) hip pain upon palpation & (right) hip bruising upon visual assess. Pt states (right) hip painful. Inquired if pt had hit hip on something, fallen or was otherwise aware of when pain began. Stated he had fallen in bathroom of his rm 'about 3 o'clock this morning'...Neuro (checks) & v/s (vital signs) WNLs (within normal limits). No external rotation noted to (right) extremity...(Medical Director) paged (with) assess results to be reported for further orders @ 9:30 a.m. No return call by 12:30 p.m. Pt kept in bed for safety. Pt exhibits no overt distress. ...(Medical Director) paged again. call returned @ 1:00 p.m. (with) new order given: 1) call & report to (orthopedic physician), 2) may get mobile xray (right) hip. (Orthopedic physician) notified. Stated to return call if hip Fx (fracture) identified...'Stat xray' called for mobile xray. Will send staff to perform xray this evening per call...9:45 p.m. 'Stat xray' mobile tech arrived at facility and two xray views taken...Results pending....10:30 p.m. 'Stat xray' tech called facility (with) 'preliminary' film results which show 'intertrochanteric fx of (right) femur'...Report given to oncoming RN (RN C) of results as well as need to notify (Medical Director) of results, (Orthopedic physician) of results & family...Final film pending...(all authored by RN B)...." Review of Nurse's Notes dated 11/01/10 at 12:15 a.m. for Resident #3 revealed, "Final xray result still not received called (x-ray company) xray in this regard...1:25 a.m. Final result still not here. Stat Xray called again....1:45 a.m. Final result received, (Orthopedic physician) called. Instructions given to call on call Dr. On call Dr. called @ 2:00 a.m. instructions given to transport pt to (hospital)...3:00 a.m. Pt picked up by (transport company...." All this was authored by RN C. Review of the employee roster, provided by the ADM on 01/12/11 as the current employee roster, revealed RN B and RN C were still employed with the facility. Review of the Contract for the x-ray company, initiated on 09/15/10 revealed, "...Services:...3) Reports: The Radiologist will dictate a report to the attending physician for each examination. (x-ray company) will promptly phone an abbreviated verbal report to the facility, then transcribe the full written report...to the attending physician...." The DON was interviewed on 01/13/11 at 12:10 p.m. and asked what she expected her nurses to do if they suspected a fracture on a resident. The DON stated she would expect them to notify the physician. When asked how she would expect them to notify the physician, the DON stated they need to call the physician on the telephone. She added after hours and on weekends there was an on-call physician. When asked how long she would expect her nurses to wait for a return call, the DON stated 5-10 minutes. She added they could always call the Medical Director. The facility provided inservices to the survey team on 01/14/11. The inservices included Falls with Fractures QA, on 11/08/10 (RN B attended), Fall Prevention on 11/08/10, Fall Management Program/Medication Administration/Pain Med with Scores on 11/09/10 (RN B attended), Notification of DON of all Changes/and inability to reach attending physician on 11/12/10 (RN B attended), Things to notify the DON Immediately Regarding Resident Care on 12/21/10 (RN B attended). RN C, who was employed at least through 01/06/11 (and was called and asked to work on 01/07/11 and 01/08/11) did not attend any of the inservices. On 01/14/11 at 9:49 a.m. Regional Director A stated RN C was terminated on 01/06/11. She provided a Personnel Status Form for RN B and RN C. Both forms indicated the two RNs were terminated on 01/06/11. Telephone interview on 01/14/11 at 10:01 a.m. with RN B revealed she was no longer employed at the facility. She stated she did recall the incident with Resident #3 on 10/31/10. She stated she noticed something was just not right with Resident #3. She stated he was holding the area (right hip). She stated he told her he fell in the bathroom about 3:00 a.m. that night, but did not tell anyone. When asked if Resident #3 was having pain, RN B stated he was and that she instructed him to stay in bed. She stated she did not see any obvious signs of fracture, that he was only complaining of pain to the right hip. RN B confirmed it was several hours before the physician (Medical Director) returned her call. She stated she was told to get a Stat x-ray. She said the x-ray was ordered abut 7:00 p.m. and was completed before she left at 10:30 p.m. RN B stated when she learned the hip was fractured, she was shocked. When asked if she notified her supervisor of the physician not returning her call for 5 hours, RN B stated she did not. She added she felt the supervisors were already aware. When asked if she was interviewed or counseled by any member of management about the incident, RN B stated she was not. RN B was asked when she would administer pain medication to a resident. She stated she would administer medications typically for any pain level about a 3 or 4 on the pain scale. RN B was then informed of her documentation on the pain medication record reflecting pain levels of 6 and 7 after the fall. When asked why Resident #3 was not medicated for the pain, RN B stated she thought she did medicate him with [MEDICATION NAME], however she then added she thought the [MEDICATION NAME] was ordered after he returned from the hospital after the fracture. When asked about why the x-ray was delayed, RN B stated she notified the x-ray company and they asked her if she needed the x-ray that day. RN B stated she told them she needed the x-ray "asap (as soon as possible)." When asked if the physician was notified of the "preliminary" x-ray report, RN B stated she was instructed to pass anything along to the next shift, if it was going to cause her to be on overtime. She did not notify the physician of the preliminary positive fracture report. Telephone interview on 01/14/11 at 10:35 a.m. with RN C revealed she was PRN and her last shift worked was 01/06/11. When asked if she had been counseled or written up for work performance, RN C stated she had not. When asked about the incident with Resident #3, RN C stated she came on the 10:00 p.m. to 6:00 a.m. shift on the night in question. When asked if Resident #3 was experiencing pain, RN C stated he was sleeping when she came on and did not wake him. When asked about the neuro check at 11:00 p.m. authored by her, stating he was having right hip pain, RN C stated that was what she was told by the prior nurse assigned to him (RN B). RN C stated Resident #3 did have pain when they woke him up to be transported to the hospital. RN C stated she had the preliminary x-ray results but waited on the final result before notifying the physician. When asked if she was interviewed by any management staff about the incident, RN C stated she was called last night and asked about the pain medication. RN C stated she believed she administered Tylenol before he left for the hospital, however it was not documented and not ordered. RN C stated the facility had standing orders for Tylenol. When asked about her termination from the facility, RN C stated she was not terminated. She stated she gave a two week notice, and then was PRN. She stated she was called on 01/07/11 and 01/08/11 and asked if she could work a shift in the facility. She denied being terminated. Interview on 01/14/11 at 12:08 p.m. with LVN D confirmed she notified RN C by telephone on 01/07/11 and asked her to work in the facility due to needing coverage for a shift. Review of a policy entitled, "Significant Change in Resident Status," dated February 2010, provided by the ADM revealed, "A significant change in Resident status is defined as deterioration or marked improvement in the health, mental, or psychosocial status in either life-threatening conditions, or in incidents of clinical complications. Scope and severity, examples of life-threatening conditions include, but are not limited to:...Fractures...As a significant change in Resident condition occurs, the Charge Nurse will notify the physician, family...of the significant change immediately...." The Texas Administrative Code Rule 217.12 for nurses reflected: Unprofessional Conduct; The unprofessional conduct rules are intended to protect clients and the public form incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (1) Unsafe Practice--actions or conduct including, but not limited to: ... (B) Carelessly or repeatedly failing to conform to generally accepted nursing standards in applicable practice settings; ... (4) Careless or repetitive conduct that may endanger a client's life, health, or safety. Actual injury to a client need not be established. ... Source Note: The provisions of this ?217.12 adopted to be effective September 28, 2004, 29 TexReg 9192. Review of a staff list provided by the ADM on 01/12/11 revealed there were 14 RNs and 31 LVNs currently employed at the facility. The CMS-672 dated 01/11/11 provided by the ADM reflected the census was 86.