Every finding on record at The Colonnades at Reflection Bay

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 3 of 6 medication carts (halls 100, 300, 600) reviewed for labeling and expired medications. The facility failed to label a Lantus vial and a mupirocin ointment tube with resident specific information in the medication cart located on the 300 hall.The facility failed to label a Nuedexta bottle with resident specific information in the medication cart located on the 600 hall.The facility failed to label Tetrahydrozoline HCL 0.05% with resident specific information in the medication cart located on the 100 hall. These failures had the potential to result in medication administration errors.An observation of the medication cart for hall 300 on 4/30/2026 at 10:00 a.m. revealed 2 medications not labeled with resident specific information. A vial of Lantus 100 units/ml insulin was not labeled located in a Lantus box. A tube of mupirocin ointment usp 2% was not labeled. In an interview on 4/30/20206 at 10:05 a.m., LVN A said the medication should be labeled with the resident's name/date of birth . She said she checked the medication before administration. An observation of the medication cart for hall 600 on 4/30/2026 at 10:45 a.m. revealed a bottle of Nuedexta 20mg/10mg not labeled with resident specific information. In an interview on 4/30/20206 at 10:50 a.m. with LVN D, she said the Nuedexta bottle should have been labeled with resident's name and date of birth . She said without it being labelled they could not know who it belonged. An observation of the medication cart for hall 100 on 4/30/2026 at 12:49 p.m. revealed a bottle of tetrahydrozoline HCL 0.05% eye drops not labeled with a resident specific information. In an interview on 4/30/20206 at 12:50 p.m. with MA T, she said the eye drops should be labeled with resident information. She said if it was not labeled, they could not be sure who it belonged to. In an interview on 4/30/2026 at 1:00 p.m. with the Unit Manager, she said medications should always be labeled with resident information or they could not administer it. The facility's policy titled Medication Administration revised on 12/1/2025, stated in the policy: Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. The facility's policy titled Pharmacy Services dated 12/1/2025, revealed in the policy: Pharmaceutical Services refers to: The process (including documentation, as applicable) of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals (e.g., povidone iodine, hydrogen peroxide); Compliance Guidelines: The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided care consistent with professional standard of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 1 of 31 resident (Resident #93) reviewed for respiratory care.The facility failed to ensure Resident #93, who had COPD and required oxygen via nasal cannula, had a functioning oxygen concentrator for approximately 5 hours. Resident #93 was found to have oxygen saturation level below her baseline and complaints of not getting enough air.This failure placed the resident at risk for hypoxia (critical condition where body tissues are deprived of sufficient oxygen), respiratory distress, and deterioration of health. Findings include:Record review of Resident #93 face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: chronic respiratory failure with hypoxia (long-term condition where the respiratory system cannot adequately oxygenate the blood, resulting in low oxygen levels), shortness of breath, hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (a progressive, incurable lung disease that obstructs airflow, causing severe breathing difficulties), acidosis (an excess acid buildup in blood or bodily fluids, occurring when the lungs or kidneys cannot maintain a healthy pH balance), and Generalized Anxiety Disorder (persistent, excessive, and uncontrollable worry about everyday matters).Record review of Resident #93's Quarterly MDS dated [DATE] revealed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Further review of the MDS revealed:a primary medical condition category of Debility, Cardiorespiratory Conditions (a combination of profound physical weakness and dysfunction in the heart or lungs)active diagnoses of respiratory failure and asthma, COPD, or chronic lung diseasea health condition of shortness of breath or difficulty breathing when lying flatspecial treatment that included oxygen therapyrespiratory therapy services provided for at least 15 minutes a day for 7 days within the last 7 daysRecord review of Resident #93's Care Plan revealed:A care area initiated on 5/8/2025 for a diagnosis of COPD. The resident received oxygen therapy related to ineffective gas exchange. Interventions included, in part, giving medications as ordered by MD; monitoring and documenting side effects and effectiveness; and monitoring for signs and symptoms of respiratory distress and reporting to MD PRN, including respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or total collapse of a lung), hemoptysis (coughing up blood or blood-tinged mucus from the respiratory tract), cough, and accessory muscle use (use of muscles other than the diaphragm and intercostals to assist breathing). Interventions also included providing O2 as ordered and providing reassurance to allay anxiety, including ensuring the resident had a method to call for assistance and staying with the resident during episodes of respiratory distress.A care area initiated on 6/1/2025 for COPD. The resident used supplemental O2 and exhibited SOB while lying flat. Interventions included, in part, giving aerosol or bronchodilators (medications that widen airways by relaxing bronchial muscles) as ordered; monitoring and documenting side effects and effectiveness; keeping the head of the bed elevated or placing the resident upright in a chair during episodes of difficulty breathing; and providing O2 as ordered.A care area initiated on 8/5/2025 for altered respiratory status and difficulty breathing. Interventions included, in part, administering medications/puffers as ordered; monitoring for effectiveness and side effects; monitoring and documenting changes in orientation, increased restlessness, anxiety, and air hunger (the distressing sensation of not getting enough air or inability to take a deep breath); and monitoring for signs and symptoms of respiratory distress and reporting to MD PRN, including increased respirations, decreased pulse oximetry, and increased heart rate.Record review of Resident #93's physician orders revealed:Oxygen: Obtain SpO2 (measures the percentage of oxygen-saturated hemoglobin in the blood) every shift, initiated on 5/1/2025.Oxygen: Oxygen was to be titrated to keep O2 at 90-92% for COPD; every shift, oxygen was to be titrated down due to high CO2 levels, with monitoring of saturation levels to maintain between 90-92%, initiated on 2/22/2026 and discontinued on 4/29/2026.Ipratropium Bromide Inhalation Solution 0.02% (Ipratropium Bromide) (a bronchodilator used to manage wheezing and breathing difficulties in COPD): 1 inhalation via nebulizer two times a day related to COPD, initiated on 3/18/2026.Oxygen: Oxygen was to be titrated at 3 lpm/nc to keep O2 above 90% for COPD; every shift, oxygen was to be titrated down due to high CO2 levels, with monitoring of saturation levels to keep above 90%, initiated on 4/29/2026.Record review of Resident #93's April 2026 MAR revealed:An order to obtain SpO2 every shift (day 6am-2pm, evening 2pm-10pm, and night 10pm-6am). From 4/1/2026 through 4/30/2026, SpO2 levels ranged from 96%-98%, with no readings below 96%.An order to titrate O2 to maintain levels at 90-92% for COPD; every shift, oxygen was to be titrated down due to high CO2 levels, with monitoring of saturation levels to maintain between 90-92%. From 4/1/2026 through 4/29/2026, the order was completed, and O2 saturation levels ranged from 96%-98%, with no complaints of SOB.An order to titrate O2 at 3 lpm/nc to keep O2 above 90% for COPD; every shift, oxygen was to be titrated down due to high CO2 levels, with monitoring of saturation levels to keep above 90%. From 4/29/2026 through 4/30/2026, the order was completed, and O2 saturation levels ranged from 97%-98%, with no complaints of SOB.An order for Ipratropium Bromide Inhalation Solution 0.02% (Ipratropium Bromide), 1 inhalation via nebulizer two times a day at 8am and 4pm. From 4/1/2026 through 4/30/2026, the treatment was administered, with findings of clear lung sounds and O2 saturation ranging from 96%-98%Record review of Resident #93's vitals log dated from 4/1/2026 through 4/30/2026 revealed that her O2 saturation levels ranged from 96%-98% while on O2 via nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen to individuals requiring respiratory support).Record review of Resident #93's progress note dated 3/16/2026 at 5:15pm by the RRT revealed, Patient assessed. Respiration regular and unlabored. Patient laying in bed with the head of the bed in a higher [NAME] (60-90 degree, upright, seated position primarily used to treat respiratory distress by maximizing chest expansion). HR 84, RR 17, O2 97% on 2lnc, breath sounds scattered crackles (abnormal popping or bubbling noises heard through a stethoscope during a physical exam) in all lobes of both lungs today. patient is short of breath when laying flat.Record review of Resident #93's progress note dated 3/23/2026 at 11:53am by the RRT revealed, Patient assessed. Patient laying in bed with the head of the bed in a higher [NAME]. Patient is short of breath when laying flat. HR 80, RR 16, O2 96% on 2lnc, breath sound is rhochi (low-pitched, rattling, or snoring-like lung sounds) in all lobes of both lungs today.Record review of Resident #93's follow-up note dated 4/8/2026 by the NP revealed, in part, .03/30/2026: Long-term resident seen in bed, stable and in no distress. Sitting up in bed. No edema (swelling caused by excess fluid trapped in the body's tissues) noted. Continues on oxygen for COPD. Voices chronic shortness of breath, not worse. Lungs with diminished sounds in lower lobes, clear to upper lobes. The History of Present Illness noted, in part, .XXX[AGE] year old female, is seen for SNF follow-up. She is lying in bed, stable and in no acute distress. She remains on oxygen at baseline. She is alert and oriented. Further review of the note revealed Review of Systems noting, in part, .GENERAL- stable, no distress, no fever, no chills, no malaise, no fatigue, no night sweats, no dizziness, on oxygen at baseline, alert and oriented. RESPIRATORY- chronic shortness of breath not worse, on oxygen for COPD, no cough, no wheezing, no chest pain with breathing. The follow up note physical examination revealed, in part, .GENERAL- lying in bed, stable, no acute distress, thin frail appearance, on oxygen at baseline, alert and oriented. RESPIRATORY- on oxygen, diminished lower lobes, clear to upper lobes, equal expansion, no respiratory distress. The NP further noted in the Assessment and Plan, in part, .CHRONIC RESPIRATORY FAILURE WITH HYPOXIA: Stable, no acute changes. Patient remains on baseline oxygen. Lungs with diminished sounds in lower lobes, clear to upper lobes. Alert and oriented. No respiratory distress noted. Continue current oxygen therapy. Monitor oxygen saturation.Record review of Resident #93's progress note dated 4/13/2026 at 11:44am by the RRT revealed, Patient assessed. Patient complained of cough. Patient laying in bed with the head of the bed in a higher [NAME]. Patient is short of breath when laying flat. Patient was educated on cough techniques. Patient perform return demonstrated satisfactorily. HR 77, RR17, O2 97% on 2lnc, breath sounds is scattered crackles in all lobes of both lungs today. patient will continue to benefit from breathing treatment at this time.Record review of Resident #93's progress note dated 4/20/2026 at 10:49am by the RRT revealed, Patient assessed. Patient laying in bed with the head of the bed in a higher [NAME]. Patient is short of breath when laying flat. HR 74, RR 16, O2 98% on 2lnc, breath sounds is scattered crackles in all lobes of both lungs today.Observation and interview on 4/28/2026 at 8:48am revealed Resident #93 was lying in bed with the head of the bed elevated and a nasal cannula placed in her nostrils, with tubing around her ears securing it in place. The tubing from the nasal cannula was attached to an oxygen concentrator located to the right of her bed. The oxygen concentrator had a humidifier attached with sterile water inside. The concentrator was making a humming noise; however, a red light was illuminated at the top of the machine next to a wrench symbol. The oxygen flow meter showed the floating ball at the bottom of the tube, indicating no flow rate. Resident #93 stated she felt okay and reported she could hear the O2 concentrator vibrating, so she believed it was on. The surveyor informed Resident #93 that the concentrator had a red light illuminated and was not showing a flow rate. Resident #93 stated she hoped it was working and denied any difficulty breathing at that time. She stated she used oxygen due to COPD and sometimes experienced SOB even while using O2. A nebulizer mask with tubing was observed on the nightstand, and Resident #93 stated she used the mask for breathing treatments. Resident #93 stated she would inform staff if she felt the oxygen was not working.Observation and interview on 4/28/2026 at 2:11pm revealed Resident #93 was lying in bed with the head of the bed elevated and a nasal cannula in place attached to the oxygen concentrator. She was observed fanning herself with a small piece of paper. Observation of the oxygen concentrator revealed a red light illuminated next to a wrench symbol, a humming noise from the machine, a flow rate reading below 0 lpm, and a loud beeping noise. Resident #93 stated she did not know where the beeping noise was coming from but reported it had been beeping for hours. She stated a staff member had entered the room earlier, heard the beeping, and told her they would get the nurse; however, no one had returned. Resident #93 stated, Oh, they don't care that it's beeping. She was unable to identify the staff member but stated it was a female. Resident #93 further stated, I don't feel like I'm getting enough air.Observation and interview on 4/28/2026 at 2:16pm revealed the surveyor approached the nurses station and requested Resident #93's nurse due to concerns regarding her oxygen concentrator. LVN B identified RN C as Resident #93's nurse. RN C was observed sitting at the nurses station typing on a computer. LVN B approached RN C and informed him the surveyor had questions regarding Resident #93's oxygen. RN C remained seated and continued typing until approximately 2:20pm, at which time he stood and stated he believed Resident #93's oxygen flow rate was set at 2 lpm. RN C was asked by the surveyor to assess the oxygen concentrator, as the setting could not be determined and the machine was beeping. RN C entered Resident #93's room with the surveyor and, upon observing the concentrator, stated Oh and adjusted the flow rate dial, after which the metal ball rose to 2 lpm on the flow meter. The oxygen concentrator continued to display a red light and emit a beeping alarm at that time. RN C stated he did not know the cause of the red light and alarm and reported he would need to consult with the respiratory therapist (RRT). The surveyor requested RN C obtain Resident #93's vital signs, as the resident was still fanning herself, although she stated she felt okay when asked by RN C. RN C left the room to retrieve a vital signs machine. While RN C was out of the room, the O2 concentrator light changed to green and the alarm ceased. Resident #93 stated she felt the oxygen was working and that she was starting to get some air. At approximately 2:26pm, RN C returned with the vital signs machine and applied a pulse oximeter to the resident's right index finger. The initial SpO2 reading was 92%. The pulse oximeter remained in place for approximately 1-2 minutes, during which readings fluctuated between 91%-93%. RN C also stated the concentrator light was now green, indicating it was functioning properly and delivering the set amount of oxygen.Observation and interview on 4/28/2026 at 3:08pm revealed Resident #93 was lying in bed, no longer fanning herself, with a nasal cannula in place. The oxygen concentrator displayed a green light, and the flow meter was set at 2 lpm. Resident #93 stated she had been fanning herself earlier because, I was trying to get some air. She reported she was now feeling okay and asked who the male staff member was that had entered the room earlier (RN C). The surveyor informed Resident #93 that RN C was her nurse from the morning and asked if she had seen him enter the room prior to adjusting the oxygen concentrator. Resident #93 responded, Maybe this morning.Interview on 4/28/2026 at 3:09pm revealed RN C stated he had entered Resident #93's room at approximately 7:20am and administered a breathing treatment. He stated the oxygen concentrator was functioning properly at that time and her O2 saturation was 98%. RN C was asked if he had returned to Resident #93's room later in the day, as an O2 saturation level had been documented at 2:00pm. RN C denied returning to the room prior to entering with the surveyor and stated the documented time reflected when he entered the information into the chart, not when the assessment occurred. RN C denied hearing any beeping from Resident #93's room and denied observing a red light on the O2 concentrator prior to the surveyor bringing it to his attention.Interview and record review on 4/28/2026 at 3:49pm revealed the Unit Manager stated the DON and ADON were both out sick. She stated she typically worked on the first floor and was not familiar with Resident #93, who resided on the second floor. The Unit Manager stated a resident with COPD should be monitored by assessing the O2 saturation levels and observing for symptoms of exacerbation, including SOB, abnormal breath sounds, or difficulty breathing. The Unit Manager was shown photographs taken by the surveyor on 4/28/2026 at 8:57am of Resident #93's oxygen concentrator, which showed a red light illuminated and no flow rate indicated on the flow meter. After reviewing the photographs, the Unit Manager stated the red light indicated the machine was not functioning properly. The Unit Manager stated if that occurred, the nurse should attempt to troubleshoot the machine and, if it remained nonfunctional, replace it with another unit. She further stated that if the machine displayed a red light or emitted a beeping alarm, staff should notify the nurse, and the nurse should immediately assess both the resident and the equipment. The Unit Manager stated that depending on the resident's baseline, a resident with COPD who required oxygen and went without it for approximately 5 hours could experience respiratory distress or respiratory failure. The Unit Manager was informed that Resident #93's baseline O2 saturation levels ranged from 97%-98% and that after the oxygen concentrator was adjusted by RN C, her O2 saturation levels ranged from 91%-93%. The Unit Manager stated she could not provide further clinical interpretation specific to Resident #93, as she was not familiar with the resident.Phone interview on 4/28/2026 at 7:20pm revealed CNA E stated she had worked the morning shift on 4/28/2026 with Resident #93. CNA E stated during her final rounds, toward the end of her shift, she heard a beeping noise coming from Resident #93's oxygen concentrator. CNA E stated she immediately reported the beeping to RN C. CNA E stated she was unsure what actions were taken after reporting the concern, as she continued with care for other residents. CNA E was unable to recall the exact time she reported the beeping but stated it was likely after 1:00pm. CNA E further stated she had entered Resident #93's room earlier that morning to empty her catheter bag and reported the oxygen concentrator appeared to be functioning at that time. She did not recall observing a red light on the concentrator during that encounter. CNA E was unable to recall the exact time of this observation but stated it occurred after 8:00am.Phone interview on 4/28/2026 at 8:09pm revealed MA A stated she had worked with Resident #93 on the morning of 4/28/2026. MA A stated she woke Resident #93 for her medications at approximately 7:00am, at which time the resident was observed to be without complaints. MA A recalled Resident #93 requested that the air conditioning be adjusted because she was cold. MA A stated she did not recall whether a red light was present on the oxygen concentrator but reported there was no beeping at that time. MA A stated she returned to Resident #93's room at approximately 11:50am to administer a medication shake and reported the resident continued to voice no concerns. She further stated she did not hear any beeping or observe a red light on the oxygen concentrator during that encounter. MA A stated Resident #93 was typically vocal and would use her call light if she felt unwell or was in distress. MA A reported Resident #93 consistently used O2 via nasal cannula and used it 24/7. MA A stated if she had observed the concentrator beeping or displaying a red light, she would have notified the nurse.Phone interview on 4/29/2026 at 7:09am revealed CNA D stated she had worked with Resident #93 on the morning of 4/28/2026. CNA D stated she did not recall hearing any beeping from Resident #93's room and believed the oxygen concentrator was functioning during her observations. However, CNA D stated she did not assess the concentrator light or verify the flow rate setting. CNA D was unable to recall the specific times she checked on Resident #93 but reported she observed the resident throughout her shift. CNA D denied Resident #93 voiced any concerns and denied observing any issues with the oxygen concentrator.Interview on 4/29/2026 at 9:20am revealed RT B stated she was not the usual respiratory therapist for the facility and was serving as a temporary replacement for the RRT. RT B stated the regular RRT might return to the facility later. RT B reviewed Resident #93's physician's orders for oxygen and stated she was unable to clarify the order or determine the appropriate oxygen settings for the resident. RT B stated physician orders typically included a specified oxygen flow rate and reported she was unsure what the appropriate setting should be. RT B stated she would attempt to obtain clarification regarding Resident #93's oxygen therapy requirements.Observation and interview on 4/29/2026 at 9:30am revealed RT B and the surveyor entered Resident #93's room and observed a new oxygen concentrator on the right side of the resident's bed. Resident #93 was observed smiling with a nasal cannula in place and stated she was feeling much better. She reported staff had brought in a new oxygen concentrator on 4/28/2026 shortly after the surveyor left the room. Resident #93 stated she knew something was wrong the previous day because she had been coughing frequently and reported she now felt she was getting enough air following replacement of the oxygen concentrator. RT B was present in the room, and at the surveyor's request, Resident #93's O2 saturation level was assessed and measured at 95%-96% with the nasal cannula in place and oxygen flow rate set at 3 lpm. RT B stated she would consult with the MD to clarify the physician's order regarding the appropriate oxygen flow rate setting.Phone interview on 4/29/2026 at 10:20am revealed the NP stated the facility had contacted her to clarify Resident #93's oxygen therapy order; however, she stated the existing order remained appropriate and did not require a specified oxygen flow rate. The NP stated the intent of the order was to maintain Resident #93's O2 saturation above 90%. She explained that for patients with COPD, baseline O2 saturation levels may be lower than those of individuals without COPD. She further clarified the order indicated a typical range of 90%-92% but did not require maintaining the resident strictly within that range, rather ensuring levels remained above 90%. The NP stated there was no concern with O2 saturation levels exceeding 92% and noted Resident #93's baseline of approximately 98% while on O2 via nasal cannula was appropriate. The NP stated there was no fixed flow rate for Resident #93 and explained that titrate meant adjusting the oxygen flow as needed to maintain O2 saturation above 90%. The surveyor informed the NP of observations indicating the oxygen concentrator had not been functioning for approximately 5 hours. The NP stated she was unable to comment on the situation, as she was not present and could not verify the duration the resident was without oxygen. The NP further stated concern for respiratory distress would arise if the resident was without oxygen for a prolonged period, such as multiple hours or days, but reiterated she could not determine the impact without direct assessment of the resident at that time.Phone interview attempted on 4/29/2026 at 2:29pm with the MD. There was no answer and a voicemail was left requesting a return phone call.Interview on 4/29/2026 at 5:09pm revealed the RRT stated that a red light on an oxygen concentrator indicated a malfunction and the machine should be removed from service for maintenance. The RRT stated that even if the machine resumed functioning after displaying a red maintenance light, it should still be replaced and evaluated to determine the cause of the malfunction. The RRT was informed of the surveyor's observations on 4/28/2026 indicating Resident #93's oxygen concentrator was not functioning for approximately 5 hours. The RRT stated t would not pose a risk to Resident #93 and reported the resident had been observed without O2 previously without issue. The RRT denied knowledge of whether Resident #93 had previously gone without O2 for a duration of 5 hours but maintained that would not place the resident at risk for complications or deterioration in respiratory status. The RRT stated the goal of therapy was to maintain the O2 saturation above 90% and reported concern would only arise if levels dropped below 90%. The RRT further stated that as long as the O2 saturation remained above 90%, it would be considered acceptable for Resident #93. The RRT stated the typical O2 setting for Resident #93 was approximately 3 lpm, with a range of 2-4 lpm depending on her needs. The RRT stated specific flow rate settings were not outlined in the physician order; however, licensed nursing staff should be aware of the appropriate O2 range the resident could tolerate via nasal cannula.Interview and observation on 5/1/2026 at 10:02am revealed Resident #93 was lying in bed with a nasal cannula in place and the oxygen concentrator set at 3 lpm. Resident #93 stated she had used O2 consistently for the past several years and did not go without it. She reported there was a time in the past when she did not require continuous oxygen; however, she stated that had been a long time ago. Resident #93 stated she was unsure what would occur if she did not have her oxygen but believed she would have difficulty breathing without it.Follow-up phone interview attempted with RN C on 5/1/2026 at 11:27am. Two calls were placed with no answer, and a voicemail was left requesting a return phone call. A text message was also sent to the number at this time requesting a return phone call.Follow-up interview on 5/1/2026 at 1:29pm revealed the surveyor asked the NP to clarify the risk posed to Resident #93 if she were without O2. The NP stated she would not respond to hypothetical questions regarding residents and reiterated she could not confirm whether Resident #93 had been without oxygen. The NP stated that without direct assessment, she was unable to determine the clinical impact or how the resident would have been affected.Follow-up interview on 5/1/2026 at 2:20pm revealed the Unit Manager stated nurses were expected to round on residents at a minimum of every 2 hours and continue rounding throughout the shift. The Unit Manager stated during rounds, staff should assess whether residents were stable, identify any changes in condition, and ensure equipment was present and functioning properly. The Unit Manager stated most equipment had alarms to alert staff if it was not functioning properly. She further stated the same expectations applied to CNA staff, and if any issues were identified, they should be reported to the nurse. The Unit Manager stated that if it was brought to the nurse's attention that equipment was not functioning, the nurse should immediately assess both the resident and the equipment. The Unit Manager stated she had not spoken with RN C on 4/28/2026 after being informed by the surveyor that the oxygen concentrator was not functioning and reported she was unsure who ultimately replaced Resident #93's oxygen concentrator.Record review of the facility oxygen administration policy implemented on 10/2025 revealed in part, .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1.The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen.Record review of the facility oxygen concentrator policy implemented on 11/1/2025 revealed in part, .An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting. 4. Use of the Concentrator: a. The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.).

Based on interview and record review, the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 31 residents (Resident #96) reviewed for resident rights. The facility failed to ensure Resident #96's right to be treated with respect and dignity on 4/15/26 when LVN U asked CNA Y to witness medication administration. A staff member poured medications in her mouth and LVN U asked her to open her mouth to ensure she swallowed them. Resident #96 had the ability to take medications independently. The failure could place residents at risk of emotional distress, embarrassment, and loss of dignity. Findings included:Record review of Resident #96's admission Record generated on 4/30/26 revealed she was admitted to the facility on [DATE] with diagnoses of pleural effusion (an abnormal, excess accumulation of fluid in the space between the lungs and chest cavity), interstitial pulmonary disease (a broad term for over 200 chronic, often progressive, lung conditions causing inflammation and scarring (fibrosis) of the lung tissue), bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs, including mania/hypomania, and severe lows, including depression), neuropathy (nerve damage causing pain, numbness, tingling, or weakness, primarily in the hands and feet due to damaged peripheral nerves), and anxiety disorder (mental health conditions involving excessive, persistent fear or worry that interferes with daily life). She was [AGE] years old. Record review of Resident #96's admission MDS assessment dated [DATE] revealed she had a BIMS of 15, indicating she had no cognitive impairment. The assessment determined she had no functional impairments of her upper extremities and required set-up or clean-up assistance with eating. Record review of Resident #96's care plan dated 4/10/26 revealed the resident was on pain medication therapy and was taking Hydrocodone and Pregabalin. Record review of Resident #96's Nurse Progress Note dated 4/15/26 at 9:50pm revealed, at approximately 07:30, patient requested PRN medications, patient was informed than an emergency situation was in progress and that medication would be administered when available. Patient initially verbalized understanding. During this time, while Iwas (sic) attending to another patient experiencing an emergency, patient became verbally aggressive, yelling from her room and making threatening statements including, 'I'm calling 911.' 'I'm a nurse, I know how to get this place shut down.'. I proceeded to administer medication to patient. Upon approach, patient became physically aggressive, grabbing my arm, bending my fingers to snatch the medication out of my hands, and striking my arm. patient also made accusatory statements, stating the nurse was stealing and taking her medication followed by yelling out [NAME] the nurse is withholding her medication. disengaged, administered medication, and ensured safety. Record review of Resident #96's care plan dated 4/17/26 revealed the resident had a behavior problem, including verbal and physical aggression and accusatory behavior related to bipolar disorder. Interventions included administering medications as ordered, anticipating and meeting the resident's needs and providing opportunities for positive interaction and attention. Record review of a provider investigation report dated 4/20/26 revealed on 4/16/26, Resident #96 reported an incident that occurred on 4/15/26 around 8:00pm. The investigation summary revealed, Patient stated that the charge nurse refused to give her pain medications when requested. The patient tried to grab the medication from the nurse and she pulled her hand away causing the medication and cup to fall to the floor. The patient stated that the nurse picked up the medication from the floor and left the room. [Resident #96] said that the nurse returned with the c.n.a. and the c.n.a. was instructed to pour the medication into her mouth and had her open her mouth to verify she had taken them. In an interview on 4/28/26 at 9:21am, Resident #96 said she recently encountered a nurse who was abusive toward her. She said one evening, she was upset that her medications were late and she was becoming vocal about it and speaking loudly. She said the situation could have been de-escalated quickly. She said instead, the nurse (name unknown) was upset with the resident, started filming the resident on her cell phone and told the resident that she could call 911. She said the medication cup spilled which caused her medications to fall to the floor. She said she felt that the nurse was taunting her. She said the nurse came back with a CNA (name unknown), and the CNA poured her medications into her mouth from a cup and asked the resident to open her mouth to show that she took them. She said taking medications like that made her feel like she was in prison. In an interview on 4/29/26 at 6:13pm, CNA Y said on the day that she worked with Resident #96, she answered the resident's call light when Resident #96 asked for her pain medications. She said she told the nurse (name unknown) when the nurse returned from a break. She said later, the nurse asked her to go in Resident #96's room as a witness to the nurse giving the resident her medications. When asked by the surveyor how the medications were administered, CNA Y said the nurse asked the resident to open her mouth, then the nurse poured the medications in the resident's mouth, and then said, Let me see. She said the resident opened her mouth to show that she took the medications. In an interview on 4/30/26 at 10:50am, MA T said Resident #96 reached for the medication cup and took her medications independently by mouth when MA T gave her medication. In an interview on 4/30/26 at 3:50pm, LVN U said she remembered caring for Resident #96. She said she checked on Resident #96 around 4:00pm. She said Resident #96's as-needed pain medications were due between 4:00pm and 6:00pm. She said Resident #96 asked for them around 8:00pm or 8:30pm. She said around 7:45pm, she was handling an emergency with another resident. She said Resident #96 began yelling around that time, stating that she needed her medication. She said around 8:00pm, Resident #96 was screaming bloody murder. She said a few minutes later, she walked into Resident #96's room to give her medication. She said she had a medicated cream and a cup of medications in her hand. She said Resident #96 was seated upright at the end of the bed. She said Resident #96 grabbed the nurse's shirt by the shoulder area, causing the cream to fall and hit the floor and caused the cup of medications to fall out of the cup and into the nurse's hand. She said when she bent over to pick up the cream, Resident #96 grabbed the nurse's hand, grabbed the pills and threw the pills into her (Resident #96's) mouth. She said she then backed away from the resident to the door, called for CNA Y, then gave her a beverage and asked her to open her mouth to make sure she swallowed her pills. She said she asked CNA Y to witness Resident #96 take her medications because, I didn't want her to say she didn't take them. In a follow-up interview on 4/30/26 at 6:09pm, CNA Y confirmed that when she witnessed Resident #96's medication administration, the nurse poured the medication in the resident's mouth, then asked the resident to open her mouth to show that she took the pills. In an interview on 5/1/26 at 1:20pm, the Administrator discussed the incident regarding Resident #96. She said she thought it was a concern that LVN U had a witness come into the room to watch medication administration. She said she thought it would be appropriate that LVN U checked to see if Resident #96 took her medication. She said she could see both sides. The Administrator said, I can see why the nurse asked to see that she took the meds, and I see why the resident would be upset. Record review of the facility's policy regarding Resident Rights dated 2/21/26 read, Employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness and dignity.

The facility failed to ensure a post-discharge plan of care was developed with the participation of the resident and ensure post-discharge medical and non-medical services were arranged for 1 of 4 residents (CR #1) reviewed for discharge process. The facility failed to review discharge instructions with CR #1 upon her discharge from the facility.The facility failed to provide CR #1 with a copy of the discharge summary at the time of discharge which caused delay in receiving her motorized wheelchair.The facility failed to provide CR #1 with a reconciled medication list upon discharge, resulting in CR #1 being discharged home without her medications, including prescribed pain medications. CR #1 did not receive her medications until the following morning after discharge. This failure placed residents at risk for unmanaged pain, interruption of essential medications, and decline in condition. Findings included:Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged home on [DATE]. Her diagnoses included: polyneuropathy (the simultaneous dysfunction of multiple peripheral nerves, causing symmetric numbness, tingling, and muscle weakness), Type II diabetes mellitus (a chronic metabolic condition where the body develops insulin resistance and inadequate insulin production, leading to high blood sugar), urinary tract infection (a bacterial infection affecting the bladder, urethra, or kidneys), and essential hypertension (is high blood pressuregreater than 130/80mmHg without a single known cause).Record review of CR #1's discharge MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating her cognition was intact. Further review of the discharge summary revealed:Resident received scheduled and PRN pain medication regimen within the last 5 days.Resident experienced occasional mild pain within the 5 days.Record review of CR #1's care plan initiated on [DATE] and cancelled on [DATE] revealed a focus area for having a raised bruise area to the right shin. Intervention included to monitor for pain, give med per order, monitor for relief.Record review of CR #1's discharge summary revealed CR #1 was discharged home on [DATE] at 6:56pm. Further review of the discharge summary revealed a section labeled Current Medications, with columns for Medication, Last Administered, Related Diagnoses, Start Date, and End Date. The Current Medications section contained no entries.Record review of CR #1's discharge instruction form, signed on [DATE] by RN B, revealed discharge information including a contact number for home health services, follow-up appointment details, and a section for patient Education/Teaching. The following items were indicated as completed:a. Medications called into pharmacyb. Medication education reviewed with patient/patient representativec. Take all medications as prescribedd. Go to physician appointments as schedulede. Share medication list with health care providersf. Contact physician before taking any additional medications not on the listg. Contact physician or pharmacist regarding medication storageh. Contact physician or pharmacist regarding disposal of expired or discontinued medicationsi. Bathe and moisturize skin at least three times weeklyj. Follow dietary recommendationsk. Prescriptions provided to patient/patient representative (see medication list for amount sent home)Further review of the discharge instruction form revealed a notation at the bottom stating, I acknowledge receipt of the current reconciled medications and agree to take the medications as prescribed by the physician. The discharge instructions set forth above have been explained to me. I understand all instructions and the importance of following them as specified. I absolve the nursing facility from all responsibility from any variance from these instructions. A box was checked indicating a handwritten signature was obtained from the patient, with instructions to see the miscellaneous tab of the resident's chart for a scanned copy. Further review of the form revealed no list of reconciled medications.Record review of CR #1's electronic record's miscellaneous tab on [DATE] revealed no scanned copy of signed discharge instruction form.Record review of CR #1's [DATE] MAR revealed medications she was currently taking at time of discharge on [DATE] included, in part:Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 40 unit subcutaneously at bedtime (8pm) related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS started on [DATE] and last administered [DATE].Lidocaine External Patch 4 % (Lidocaine) Apply to BOTH KNEE topically in the morning (8am) for BILATERAL (affecting two sides) KNEE PAIN started on [DATE] and last administered on [DATE].Biofreeze Cool The Pain External Gel 4 % (Menthol (Topical Analgesic) Apply to BOTH ANKLES topically three times (8am, 12pm, 8pm) a day for BILATERAL ANKLE PAIN started on [DATE] and last administered on [DATE] at 12:00pm.HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 61 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10, subcutaneously before meals (6:30am, 11:30am, 4:30pm) for Diabetes started on [DATE] and last administered on [DATE] at 4:30pm.AZO Cranberry Urinary Tract Oral Capsule 250-60 MG (Cranberry-Vitamin C) Give 1 capsule by mouth one time a day (8am) for UTI PREVENTION started on [DATE] and last administered on [DATE].Losartan Potassium Oral Tablet 50MG (Losartan Potassium) Give 50 mg by mouth one time a day (8AM) related to ESSENTIAL (PRIMARY) HYPERTENSION Hold for SBP less than 110, DBP less than60, and/or HR less than 60 started on [DATE] and last administered on [DATE] due to outside of parameters to administer on [DATE] and [DATE].Baclofen Oral Tablet 10 MG (Baclofen) Give 10 mg by mouth three times a day (8am, 12pm, 8pm) for Muscles Spams started on [DATE] and last administered on [DATE] at 8pm.Lyrica Oral Capsule 100 MG (Pregabalin) Give 1 capsule by mouth three times a day (8am, 12pm, 8pm) related to POLYNEUROPATHY, [Per MD orders do not change times on this medication] started on [DATE] and last administered at 8pm on [DATE].oxyCODONE HCl Oral Tablet 10MG (Oxycodone HCl) Give 1 tablet by mouth every 8 hours related to POLYNEUROPATHY, for 2 Weeks [[DATE] - [DATE] at 12AM, 8AM, and 4PM], last administered on [DATE] at 4pm with pain rating of 6/10.Phone interview on [DATE] at 10:50am revealed CR #1 stated she was discharged from the facility on [DATE] and had attempted to coordinate with the facility to obtain her discharge paperwork so a wheelchair could be delivered to her home. During the call, CR #1 included a [NAME] Specialist from the wheelchair company. The [NAME] Specialist confirmed difficulty coordinating with the facility to obtain discharge paperwork needed to process delivery of CR #1's wheelchair. The [NAME] Specialist stated residents were typically provided discharge documentation upon discharge, which would have allowed the company to proceed with delivery; however, CR #1 reported she did not receive any discharge paperwork from the facility. CR #1 further stated she did not receive any items from the facility at the time of discharge, including discharge paperwork or medications. She reported the facility arranged a ride share for approximately 7:00pm on [DATE], and when the ride arrived, the facility did not have her belongings or medications prepared but proceeded with discharging her. CR #1 stated she asked the nurse about her medications prior to leaving and was informed she could not take them home because they were narcotics.Interview on [DATE] at 3:45pm revealed the Discharge Planner stated she completed the top portion of the discharge instruction form, and the nurse was responsible for reviewing the form with the resident and obtaining the resident's signature prior to discharge. The Discharge Planner stated she was unaware of the process for handling the signed form after completion and indicated the nurse would need to be consulted for further information.Interview on [DATE] at 3:50pm revealed RN B stated she recalled CR #1 and her discharge. RN B stated the discharge instruction form was printed and reviewed with CR #1, and she reported CR #1 signed the form. RN B stated she placed the signed form in the box at the nurses station for medical records to scan into the resident's chart. RN B stated that if the form was not present in CR #1's record, medical records would need to be consulted. RN B further stated that residents were not provided a copy of the signed discharge instruction form at discharge; however, they were provided a discharge summary report, a medication order summary report, and their medications, along with a list of medications returned to them at discharge. RN B stated the items were provided to CR #1.Interview on [DATE] at 5:10pm revealed the Administrator stated she had consulted with Medical Records and confirmed CR #1's signed discharge instruction form was not present in the resident's chart. The Administrator stated that if the form had been received, it would have been scanned into the record. The Administrator further stated Medical Records staff were diligent in retrieving documents from the nurses station box and scanning them into the chart. She indicated the absence of the document suggested the form may not have been placed in the designated box at the nurses station and clarified medical records did not have the form.Interview on [DATE] at 5:29pm revealed the Unit Manager stated that when a resident was discharged home, the nurse was responsible for providing discharge instructions, a discharge summary, and the resident's medications. The Unit Manager stated that, in most cases, all remaining medications were provided to the resident at discharge, including narcotics. The Unit Manager stated that in some situations, depending on the quantity of narcotics remaining, the physician might limit the amount sent home; however, residents were not discharged without receiving any of their prescribed narcotic medications. The Unit Manager provided an example that if a resident had a 30-day supply remaining, the physician might elect to send only a 14-day supply home. The Unit Manager stated she was not familiar with CR #1 specifically but indicated there should have been a reconciled medication list that reflected the medications provided to the resident at discharge.Interview on [DATE] at 5:58pm revealed CR #1 stated she had been informed a few days prior to [DATE] that she would be discharged from the facility on that date. She reported staff were aware of her discharge, as nurses and CNA staff made comments on [DATE] regarding her leaving that day. CR #1 stated the Discharge Planner informed her on [DATE] that there were issues arranging transportation. She reported the Discharge Planner paid for a ride share out of pocket and scheduled pick-up for 7:00pm. CR #1 stated when the ride arrived, the facility had not prepared her belongings, medications, or discharge paperwork. CR #1 stated she contacted the Discharge Planner to report the situation and was instructed to proceed with the ride to avoid being charged. She reported that as she entered the ride, a nurse she believed to be RN B approached the vehicle and asked her to sign a paper. CR #1 stated she was told it was just something to sign due to her leaving and denied the document was explained as discharge paperwork. CR #1 further denied receiving discharge instructions or any documentation prior to leaving the facility. CR #1 stated she was discharged without medications and reported she went the remainder of the evening and the following morning without her prescribed medications, including pain medications. She stated the Discharge Planner delivered medications to her home on [DATE] at approximately noon and retrieved the facility wheelchair at that time. CR #1 stated the Discharge Planner left shortly after arrival due to parking concerns. CR #1 further stated that after reviewing the medications provided, she identified that Lyrica and AZO, medications she had brought from home, were not returned to her.Interview and record review on [DATE] at 9:00am revealed the Administrator stated she had additional information regarding the discharge of CR #1. The Administrator stated that at the time of discharge, CR #1's medications were not prepared, and the Discharge Planner delivered them to CR #1's home the following morning. The Administrator provided a copy of a text message log. Review of the log revealed a message from the Discharge Planner on [DATE] at 4:10pm stating, [CR #1] discharge today. Home Health. Back to Assisted Living. Ride Share pick up for 7pm. A subsequent message dated [DATE] at 9:22am stated, Nurse Manager not responding to my call or text. I'm driving from the north side trying to take [CR #1] her meds because they wasn't ready last night when her ride arrived and I'm heading to take them to her. An additional message stated, The building called me back just now, they are ready for me to pick them up. The Administrator stated a photograph was also taken of the medications provided to CR #1 by the Discharge Planner. Review of the photograph revealed multiple blister packs of medications and a bag containing a sheet of paper with CR #1's name written on it. The photograph did not clearly identify the specific medications or quantities provided. The Administrator stated the facility was unable to produce a reconciled list of medications provided to CR #1 at discharge. She reported a pharmacy sheet was available showing medications dispensed during the resident's stay and suggested it could be compared to the drug destruction log to infer which medications may have been returned. The Administrator acknowledged there should have been a documented list of medications provided to the resident; however, such documentation could not be located at the time.Record review of the drug destruction binder revealed no medications were destructed for CR #1 in [DATE].Interview and record review on [DATE] at 11:56am revealed the Discharge Planner stated the facility became aware on [DATE] that CR #1 would be discharged . The Discharge Planner stated CR #1 was informed and agreed to a discharge date of [DATE]. She reported that once a discharge date was established, the resident's name and discharge date were placed on a board in her office for staff awareness and discussed during the next morning meeting to ensure staff were prepared. The Discharge Planner stated she initiated discharge assessments and the discharge instruction form to begin documenting information related to the discharge. She reported that she typically selected a discharge time in advance and communicated it to staff to ensure all preparations were completed. The Discharge Planner stated that on [DATE], CR #1 expressed concern regarding transportation home, stating she did not have a way to leave the facility and could not afford to stay an additional day due to copay requirements. The Discharge Planner stated that at approximately 3:00pm, she obtained approval from the Administrator to arrange transportation through the facility van driver. She provided text messages showing she contacted the van driver on [DATE] at 3:07pm; however, no response was received. The Discharge Planner stated that due to concern about CR #1's ability to return home, she paid out of pocket for a ride share scheduled to arrive at 7:00pm. She reported sending a message to a group chat with nursing management staff on [DATE] at 4:19pm stating, [CR #1] pickup is for 7pm she cannot miss her ride. [RN D] can you make sure the nurse and CNA are aware? A response from RN D at 4:19pm stated, sure. Additional messages showed the Discharge Planner notified the group at 6:55pm that the ride had arrived. The Discharge Planner stated she was at home when the ride arrived and reported CR #1 called her stating the facility did not have her belongings, medications, or paperwork ready. The Discharge Planner stated she attempted to contact the facility and send messages to the management group but received no response. The Discharge Planner stated she learned the following morning that CR #1 had left the facility without her medications. She reported returning to the facility on [DATE] to retrieve the medications from nursing staff. She stated she had a nurse take a photograph of the medications, acknowledging she was not licensed to dispense medications but felt it was necessary to ensure CR #1 received them. The Discharge Planner stated she delivered the medications to CR #1's home at approximately 11:56am on [DATE]. She reported there was a list of medications with administration instructions included in the bag, and although she was not a nurse, she reviewed the instructions with the resident prior to leaving. The Discharge Planner stated she was unsure whether documentation existed regarding the medications delivered and could not confirm whether Lyrica or AZO were included. She reported the only documentation provided to CR #1 at that time was the medication list included in the bag.Interview on [DATE] at 12:45pm revealed RN D stated she was no longer employed at the facility and had ended her employment in [DATE]. RN D stated she did not recall CR #1 or any text messages related to CR #1's discharge. She further stated she did not believe she was working on [DATE], as she recalled being ill with COVID around that time. RN D was informed of text message documentation indicating she responded sure to a message from the Discharge Planner regarding ensuring CR #1 was prepared for discharge. RN D stated she did not recall the message and suggested the response may have been sent as a general acknowledgment. RN D stated nurse managers were not responsible for preparing residents for discharge and indicated that responsibility rested with the floor nurse and Med Aide. She stated staff were typically informed of planned discharges by the Discharge Planner. RN D further stated the group chat used for communication included management staff only and did not include direct care staff responsible for preparing residents for discharge.Interview on [DATE] at 1:00pm, the Administrator said according to their time tracking system RN D was working on [DATE] from 7am - 5pm and her last day of work was [DATE].Record review of the facility Transfer and Discharge policy implemented on [DATE] and date last reviewed/revised on [DATE] revealed in part, .b. A member of the interdisciplinary team will complete relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following. iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). c. Orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. d. Facility will assist with transportation arrangements to the new facility and any other arrangements as needed.

Based on interview and record review, the facility failed to accurately submit a PASRR Level 1 Screening screening when a resident admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for (1 Resident #9) of 4 residents reviewed for PASRR screenings. The facility did not correctly identify Resident #9 as having mental illness in their PASRR Level 1 Screening. This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and services in the appropriate setting. Findings included:Review of Resident #9's face sheet, dated 5/1/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: ileus (a condition in which the bowel does not work correctly), hemiplegia (complete paralysis) and hemiparesis (weakness) following cerebral infarction (a type of ischemic stroke), epilepsy (a brain condition that causes recurring seizures), dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), and schizophrenia (a serious mental health condition that affects how people thing, feel, and behave).Record review of the PASRR level 1 screening dated 3/27/26 revealed he was negative for mental illness, intellectual disability, and developmental disability.Record review of Resident #9's Comprehensive MDS, dated [DATE] revealed a BIMS score of 1 which indicated severe cognitive impairment. Resident #9 had an active diagnosis of schizophrenia and was taking an antipsychotic.Record review of Resident #9's physician's orders with a start date of 4/21/26 indicated he was prescribed Quetiapine Fumarate (atypical antipsychotic) oral tablet 50 mg, via g-tube two times a day.Record review of Resident #9's care plan dated 3/27/26 indicated he had a behavior problem, removing colostomy (an opening in the colon that lets stools pass from the body without going through the anus) bag and throwing it on the floor. Interventions included: anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, caregivers to provide opportunity for positive interaction/attention, stop and talk with him as passing by.During an interview and observation of Resident #9 on 4/28/26 at 8:20 a.m. revealed he was lying in bed wearing a hospital gown and watching tv. When questioned about the food Resident #9 repeated I'm alright or It's alright.During an interview with the MDS Coordinator on 5/1/26 at 10:55 a.m., she said she would upload the PASSR Level 1 in system within 72 hours. She said she did not check if the PASRR Level 1 was accurate; the Regional MDS Coordinator was responsible for checking the accuracy of the PASRRs. The MDS Coordinator said she was not sure if Resident #9 was referred to a psychiatrist. She said she was from a different state and the current state did things differently. She said she did not know the risk to the resident when an inaccurate PASRR was completed for the resident.Record review of the facility's policy titled Resident Assessment-Coordination with PASRR Program dated 12/20/25 revealed in part . This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .

Based on observation, interview and record review, the facility failed to ensure that residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 10 residents (Residents #33 and #28) reviewed for incontinent care. -Resident #1's Foley catheter bag was observed more than half full and was not emptied as needed during observation on 04/29/2026 at 11:22 a.m.- Resident #2's Foley catheter bag was observed more than half full and was not emptied as needed during observation on 04/30/2026 at 5:00 p.m. This failure could place residents with indwelling Foley catheter at risk of infection, sepsis, hospitalization and death. Findings included: Record review of Resident # 33's face sheet dated 03/02/2026 revealed, she was a [AGE] year-old female admitted on [DATE] with the following diagnoses: Sepsis (Life-threatening medical emergency caused by the body's response to infection that can lead to tissue damage, organ failure, and potential death), acute kidney failure, obstructive and reflux uropathy (blockage of urine flow, causing backflow that can lead to kidney damage and infection). Record review of Resident # 33's quarterly MDS dated [DATE] revealed she had a BIMS score of 13, indicating cognitively intact. Section H0300 urinary continence was coded; always incontinent. Record review of Resident # 33's comprehensive care plan dated 03/02/2026 revealed the following care areas:-The resident had an indwelling Foley catheter due to neurogenic bladder. Goal: The resident will be/remain free from Foley catheter related trauma. The resident will show no sign or symptoms of urinary infection. Interventions: Position Foley catheter bag and tubing below level of the bladder. Record review of Resident # 33's clinical care orders dated 3/19/2026 revealed, urinary Foley catheter care, check for patency (unobstruction) and empty Foley catheter bag every shift. Observation of Resident # 33's Foley catheter bag on 04/29/2026 at 11:22 a.m., revealed, the bag was 1600 cc out of 2000 ml full. In an interview with CNA A on 04/29/2026 at 12:35 p.m., she said she did check Resident # 33's Foley bag at the beginning of her shift, to record the output. She said usually she would empty the foley bag at the end of her shift or when it was full. CNA A said when she checked the foley bag at the beginning of her shift, it showed 200-300 cc. CNA A said failure to empty Resident # 33's Foley bag when it was due could lead to health deterioration. In an interview with LVN A on 04/29/2026 at 12:52 p.m., she said it was the responsibility of the CNAs to empty the Foley bag and report the readings to the nurse. She said Resident # 33 had a Foley catheter because of urinary retention. LVN A said she failed to check Resident # 33's Foley catheter to see if the previous shift had emptied the urine or documented the output. She said the fact that the Foley bag had 1600 cc at 11:22a.m., meant the night shift did not empty the bag. LVN A said if the bag was not emptied, there was a possibility of urine backing up into Resident # 33's bladder which could lead to UTI which might progress to sepsis, thereby causing infection into the blood stream. She said it could have resulted in a negative change in Resident # 33's health. In an interview on 04/29/2026 at 1:11 p.m., CNA B said it was the responsibility of the CNAs to empty the foley bag and then report the amount to the nurses who will document in PCC. She said, the norm was to check and empty the foley bag at least once during each shift. CNA B said, she emptied Resident # 33's foley bag on the night of 04/28/2026 breaking 04/29/2026 but did not remember if she told RN A the urine output amount. She said she was not authorized to document urine output in PCC (software used by the facility to document residents care). In a telephone interview on 04/29/2026 at 4:10 p.m., with RN A, she said it was the responsibility of the CNAs and the nurses to empty the Foley bag, but the responsibility of the nurses to document the output in PCC. RN A said, CNA B told her Resident # 33's output was 500 cc before 5:00 a.m. She said, from 4:00 a.m. to 11:22 a.m., she expected the output to have been 700 cc. She said if the Foley output was 1600 cc at 11:22 a.m., that meant the night shift did not empty the Foley bag. RN A said- Resident # 33 was on fluid restriction. She said if urine had backed up into the Resident # 33's bladder, and that could have resulted in UTI. In an interview with Resident # 33 on 04/29/2026 at 4:32 p.m., she said the Foley catheter was not emptied throughout the night. The facility staff work 8 hours shift-6a.m.-2 p.m., 2 p.m. to 10 p.m., and 10 p.m. to 6 a.m. She said she was depended on staff to help her because she cannot walk. In an interview with RN B on 04/29/2026 at 4:51 p.m., she said Resident # 33 had a Foley catheter due to urinary retention. She said it was the responsibility of the nurses and the CNAs to empty the foley bag. RN B said, I empty the Foley bag at the start of the shift while the CNAs were expected to complete the task at the end of the shift. She said at the end of the shift she recorded both readings. RN B said if there was 1600 cc of urine in Resident # 33's Foley bag, it meant the night shift did not empty the Foley bag. She said if Resident # 33 had a UTI, it might cause sepsis which could result to death. Resident # 28Record review of Resident # 28's face sheet dated 04/19/2026 revealed she was a [AGE] year-old female with the following diagnosis: neurogenic bladder (neurological damage which can result in symptoms such as overflow incontinence, urgency, and retention). Record review of Resident # 28's quarterly MDS dated [DATE] revealed she had a BIMS score of 13 indicating cognitive intactness. Section-H-bladder and bowel revealed she had an indwelling catheter (a flexible, close system tube inserted into the bladder to continuously drain into an external bag). Section I-15000 revealed she was paraplegic (paralysis affecting the lower part of the body). Record review of Resident # 28's care plan dated 4/19/2026 revealed the following areas:-Dependent on indwelling catheter for the management of neurogenic bladder. Goal: The resident will show no signs and symptoms of urinary infection. The resident will be/remain free from catheter related trauma. Intervention: Monitor for signs and symptoms of discomfort on urination and frequency. Monitor/document for pain/ discomfort due to catheter. Monitor/record/ report to MD for signs and symptoms of UTI: pain, blood-tinged urine, cloudiness, no output, foul smelling urine, fever, chills, altered mental status, changes in behavior and change in eating patterns.-Enhanced barrier precautions implemented related to urinary catheter. Goal: The spread of MDRO will be reduced. Intervention: Implement EBP. Monitor for signs and symptoms of infection, offer emotional support as needed related to infection risk of EBP. Record review of Resident # 28's clinical care order dated 01/05/2026 revealed: empty Foley every four hours. Record review of Resident # 28's MAR dated 4/19/2026 stated: Foley care, Foley bag to be emptied every four hours related to frequent urination. Observation of Resident # 28's foley catheter bag on 04/30/2026 at 5:00 p.m., revealed the bag was at 1500 cc out of 2000 cc full. Resident # 28 was not interviewed because she was asleep. In an interview with LVN B on 04/30/2026 at 5: 32 p.m., she said Resident # 28 was admitted with an indwelling foley catheter because she had an accident that resulted to spinal cord injury (damaged nerve with the spinal column which causes permanent paralysis). She said it was the responsibility of the nurses and CNAs to empty the foley bag. LVN B said the CNAs reported the output readings and she documented them in PCC. She said if 1500 cc of urine was observed at 05:00 p.m., in Resident # 28's foley bag, that was evident the 6 a.m.- 2 p.m. staff did not empty the foley bag at the end of their shift. In an interview with LVN C on 04/30/2026 at 06:08 p.m., she said CNA C did not report the output for Resident # 28 on 04/30/2026 at shift change to her. LVN C said it was the responsibility of the CNAs to empty the Foley bag and then report the output readings to the nurse. She said if there was 1500 cc output at 5:00 p.m., it meant the 6 am to 2 p.m. shift did not empty the Foley bag. LVN C said, Resident # 28 would be at risk for sepsis if she is not treated and could possibly lead to death. In an interview on 05/01/2026 at 07:20 a.m., the NM said Resident # 28 had an indwelling catheter due to urinary retention and obstructive uropathy (blockage of urine flow which causes urine to backup into the kidneys). The NM said- she expected the CNAs to empty the Foley bags and report the output to the nurses. She said if Resident # 33 and Resident # 28 had a foley bag of 1600 cc and 1500 cc respectively, they were susceptible to UTI which could lead to sepsis and if not treated could lead to unwanted hospitalization. She assumed the previous shifts did not empty the foley. In an interview on 5/01/2026 at 08:05 a.m., with the ADM, she said Resident # 33 and Resident # 28's foleys were not emptied by the previous shifts. She said that it could cause UTI and could result in sepsis. The ADM said she expected the staff to empty the foley bags every shift as stated in the residents' clinical orders. In an interview on 05/01/2026 at 12:31 p.m., with CNA C, she said she had emptied Resident # 28's Foley bag once during her shift. She said she did not report the readings to the nurse because she did not know she had to report the reading to the nurse. She acknowledged she was trained on Foley care and how to empty the Foley bag but did not recall what she was told to do after she emptied a Foley bag. On 05/01/2026 at 12:59 p.m., unsuccessful telephone call to LVN D who provided care to Resident # 28 on 04/30/2026 from 6a.m. to 2 p.m. The facility's policy titled Catheter Care revised on 12/01/2025, revealed: It is the policy of the facility to ensure that all residents with indwelling catheters receive appropriate catheter care. Catheter care will be performed every shift. Empty drainage bag routinely. Document care and report and concerns noted to the nurse on duty.

Based on observation, interviews and record reviews, the facility failed to ensure drugs and biologicals were secure and labeled for 7 (MC#1, MC#2, MC#3, MC#4, MC#5, MC#6, and MC#7) out of 14 medication carts.The facility failed to ensure medication carts were:1. Locked and secured when not in use.2. Drugs and biologicals were labeled. The failures could place residents at risk of drug diversion, use of expired medication and harm.Finding included:During an observation on [DATE] at 1:50 pm MC#1 was left unlocked, unsecure with drawers faced outward. The surveyor observed the key lock protruding outward with a red visible dot.During an interview on [DATE] at 2:10 pm, CMA A stated she was near the cart. CMA A stated the cart should have been locked when she stepped away. CMA A stated residents could get into the cart and take medications.During an observation on [DATE] between 5:30am to 6:10 am revealed:*MC#1 and MC#2 on the 1st floor were unlocked, and unsecure with drawers faced outward. Observed the key lock protruding outward with a red visible dot. The surveyor observed MA A not in view of the medication carts.*MC#3, MC#4, MC#5, MC#6, MC#7 on the 2nd floor were unlocked, and unsecured with drawers faced outward. Observed the key lock protruding outward with a red visible dot. Observed LVN C on the opposite side of the nursing station and not in view of the medication carts. *Observed MC#6 had the cart keys inside of a binder on top of the cart.*Observed the following biologicals on MC#2, MC#3, MC#4 and MC#5:*1-Insulin LSP Inje 100/ml was undated and not labeled with resident information*9 - Insulin LSP Inje 100/ml was undated* 1-Humlin inj 100/ml was undated* 4-Lantus solo inject 100 unit/ML was undated* 2-Heparin Sod inject 5000/ml was undatedDuring an interview and observation on [DATE] at 5:35 am LVN C stated the medication cart should be locked when not in use to protect residents from taking medication from the cart. LVN C stated the insulins were supposed to be dated when opened. LVN C stated that he did not administer insulin during his shift and did not touch the insulin. Observed LVN D checking insulins on the other medication carts on the 1st floor that were not left unlocked.During an interview on [DATE] at 6:04 am, LVN B stated the medication carts should not be left open. Observed the Executive Director on [DATE] at 6:10 am, locking the medication carts on the 2nd floor. During an interview on [DATE] at 6:25 am, LVN E stated insulin should be dated when opened. LVN E stated medication carts should be locked to prevent residents, staff, or visitors from taking medications. LVN E stated there were biological and routine medications on the cart that could harm the residents if they took the wrong medication. LVN E stated depending on the type of insulin it could stay on the cart for 28 days after being opened.During an interview on [DATE] at 6:40 am LVN D stated the medication carts should stay locked when not in use. LVN D stated insulin should be dated when opened. LVN D stated the insulin was good for 30 days depending on the type of insulin. During an interview on [DATE] at 2:18 pm, the ADON stated medication carts should be locked if nursing staff were not standing in front of the cart. The ADON stated locking the cart prevented residents from getting into the cart. During an interview on [DATE] at 1:45 pm, the Executive Director stated she started in-servicing staff and completed the POC on [DATE] for locking the medication cart and dating the opened insulin vials and insulin injectable pens. The Executive Director stated she had 14 medication carts and the carts were audited. The Executive Director stated the medication carts should be locked when nursing staff are not using them, and insulin should be labeled when opened.Record review of facility policy titled Medication Labeling and Storage, revised 02/2023 reflected, Medication Labeling .1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.5. Multi-dose vials that have been opened or accessed (e.g . needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vials .

Based on interviews and observations the facility failed to ensure the residents environment remained as free of accident hazards as possible for 2 (Rm#1 and Rm#2) of 6 bathrooms reviewed.The facility failed to ensure that sharps containers were not past the full line in 2 resident bathrooms. This failure could place residents at risk of being stuck by needles and cause infection.Finding included:During an observation on 11/20/25 at 9:30 am revealed RM#1 and RM#2 bathrooms sharps containers were observed above the full line.During an observation and interview on 11/20/25 at 10:05 am, the ADON and surveyor did a walk-through of RM#1 and RM#2. The ADON stated housekeeping and nursing staff were responsible for emptying out the sharp containers.During an interview on 11/20/25 at 11:10 am, LVN G stated the sharps container should be emptied once it got to the full line. LVN G stated the charge nurses had the key for the containers and sharps were disposed of in the red hazard bags.During an interview on 11/20/25 at 11:30 am, RN F stated when sharps containers were at full line then it was time to replace the container. RN F stated residents were endangered with getting their fingers stuck.During an interview on 11/20/25 at 11:10 am, LVN E stated the sharps containers should be eye balled daily and changed when the sharps were at the full line. LVN E stated the sharps container needed to be changed to prevent exposure to body fluids.During an interview on 11/20/25 at 1:15 pm, the Housekeeping Supervisor stated they did not have the key to the sharps containers and were not responsible for changing them.During an interview on 11/20/25 at 1:30pm, the Executive Director stated that she did not have a policy for emptying out the sharps containers. The Executive Director stated the sharps container should be emptied before it was full to help prevent staff and residents from hurting themselves and possibly caused infection. The Executive Director stated that infection control policy did not address sharps containers specifically, but nursing staff had been educated about the sharps container. The Executive Director stated very few residents had sharps containers in their bathrooms. The Administrator stated the LVNs were responsible for checking and changing those out.

Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 1 (MC#2) out of 14 medication carts. The facility failed to ensure the medication cart was free of expired insulin vial dated 09/07 on [DATE]. The failures could place residents at risk of poor insulin blood sugar control from expired insulin. Finding included:During an observation on [DATE] at 5:34 am on MC#2, the surveyor observed 1-Insulin LSP Inje 100/ml was dated 09/07.During an interview and observation on [DATE] at 5:35 am LVN C stated the insulins were supposed to be dated when opened. LVN C stated that he did not administer insulin during his shift and did not touch the insulin. During an interview on [DATE] at 6:25 am, LVN E stated depending on the type of insulin it could stay on the cart for 28 days after being opened. LVN E stated expired medication should be properly exposed of by giving it to the ADON. During an interview on [DATE] at 2:18 pm, the ADON stated expired medication should not be left on the medication cart. During an interview on [DATE] at 6:40 am, LVN D stated insulin should be dated when opened. LVN D stated the insulin was good for 30 days depending on the type of insulin. During an interview on [DATE] at 1:45 pm, the Executive Director stated she started in-servicing staff and completed the POC on [DATE] for locking the medication cart and dating the opened insulin vials and insulin injectable pens. The Executive Directoristrator stated she had 14 medication carts and the carts were audited.Record review of facility policy titled Medication Labeling and Storage, revised 02/2023 reflected, medication storage.3. If the facility has discounted, outdated.medications and biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying medications.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 4 resident reviewed for accidents and hazards. The facility failed to ensure Resident #2 did not leave the facility without supervision and/or staff knowledge on 06/06/2025 when she was found trying to cross the street and on 06/21/2025 when Resident #2 was found across the street at an apartment complex. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 06/05/2025 and ended on 07/06/2025. This failure could place residents at risk of unsafe elopements, injuries, hospitalization and/or death. Findings included: Review of Resident #2's face sheet reflected a [AGE] year-old-female admitted on initially admitted on [DATE] and discharged on 07/06/2025 with diagnoses of end stage renal disease (final stage of chronic kidney disease when the kidneys have deteriorated and no longer perform their functions), unspecified dementia (condition where a person experiences cognitive decline), unspecified convulsions (seizures where the specific cause cannot be determined), altered mental status (a change in a person's level of consciousness, alertness, and cognitive function), repeated falls, dependence on renal dialysis (medical necessity for a person to use a machine to filter their blood because their kidneys failed to do so), muscle weakness, and difficulty walking. Review of Resident #2 quarterly MDS dated [DATE] reflected Resident #2 had not exhibited wandering behavior. Resident #2 had a BIMS of 12. Review reflected Resident used a wheelchair or scooter and was able to independently ambulate. Review of Resident #2 care plan dated 05/01/2025 with revision date of 07/07/2025 reflected Resident #2 had an ADL self-care performance deficit related to confusion, dementia impaired balance, and limited mobility. Further review reflected Resident #2 had a potential risk for elopement as evidenced by history of attempt to leave facility unattended. Review reflected Resident #2 was found in the front parking lot on 06/06/2025 and attempted to leave premises, trying to cross the street with revision date of 07/07/2025 with interventions to assess for alternative placement frequent monitoring, and provide 1:1 sitter at bedside. Review reflected Resident #2 has impaired cognitive function, difficulty making decisions, short term memory loss with revision date of 07/07/2025 with interventions to cue reorient and supervise as needed. Review of Resident #2's elopement risk assessment dated [DATE] reflected Resident #2 was at risk and was cognitively impaired, able to ambulate and has intentionally or unintentionally attempted to leave the community. Review of both EMR # 1 and EMR #2 reflected there were no elopement assessments completed prior to 06/21/2025. Review of nursing progress notes dated 06/05/2025 written by LVN BB reflected Resident #2 was noticed by staff wheeling herself outside the facility trying to cross the road. Resident was approached by staff and brought back to the facility. [Resident #2] said she was trying to get to her family. Resident was brought back to her room and monitored continuously till end of shift. Oncoming nurse notified of [Resident #2's] elopement behavior. Review of Resident #2's nursing progress notes dated 06/06/2025 written by LVN BB reflected Resident #2 was found wandering outside the street trying to cross the road. She was brought back into the building and helped to her room. Review of Resident #2's nursing progress note dated 06/21/2025 at 12:34 PM written by LVN CC reflected Resident #2 was last seen at about 10:58 [am] when she refused to get her blood sugar checked, at about 11:18 [am], RN H came state someone saw a woman across the street with her head tied, message related to supervisor by the receptionist. The description looks like resident. RN H and other staff members also searched neighborhood, resident could not be seen at this time. [LVN CC] and another nurse crossed the street walked through the apartment complex resident was not seen. [LVN CC] notified 911, on call MD. DON aware. Review of Resident #2's nursing progress note by LVN CC dated 06/21/2025 at 1:40 PM, reflected head to toe assessment was done with no physical injury noted. Observation on 10/22/2025 at 8:30 AM reflected a four lane street in front of the facility with a sign posted the speed limit was 50 mph. During an interview on 10/22/2025 at 6:14 PM, LVN CC stated she worked on 06/21/2025 and was the nurse for Resident #2. She stated Resident #2 refused to go to dialysis and that she called and reported this to the doctor. LVN CC stated that Resident #2 was upstairs initially and LVN CC went to check on Resident #2 after her dialysis refusal and Resident #2 was not in her room. LVN CC stated that the receptionist stated sent someone upstairs to tell the nurse that Resident #2 was seen downstairs and that the receptionist was not used to Resident #2 being downstairs. LVN CC stated that she went downstairs and someone told her that someone was seen crossing the street. LVN CC stated she walked to the apartments across the street and asked around if anyone had seen the resident and after searching and not findings Resident #2 they returned to the facility. LVN CC stated she then returned to the facility and called the DON and that it had been at least 40 minutes. LVN CC stated she also called 911 and at this time other CNAs were still searching for Resident #2 and found her at the apartments across the street. LVN CC stated it was several CNAs that returned with Resident #2. LVN CC stated Resident #2 appeared the same and had no changes. LVN CC stated that the street in front of the facility was like a freeway and it was dangerous and could not believe Resident #2 went that far. LVN CC stated she did not recall the time of day and thought it was mid-morning or early afternoon. LVN CC stated she assessed Resident #2 for injuries and none were found. LVN CC stated she was not sure who told the receptionist Resident #2 had left the facility and that person had already left the facility. During an interview on 10/21/2025 at 5:42 PM, RN H stated it was reported by a family member of another resident that there was a man taking Resident #2 across the street. RN H stated she did not know the person who reported this to her and guessed it had to be the family member of a different resident. RN H stated she and another staff member went across the street to the apartment complex and Resident #2 was found at the complex. RN H stated prior to crossing the street she observed Resident #2 with an unknown male crossing the street (not on a cross walk) and they were walking towards the apartment complex with the unknown male pushing Resident #2 in a wheelchair. RN H stated she asked the unknown male after Resident #2 was found where he came from and he stated he was going inside the facility and became agitated and stated Resident #2 told him she lived in the apartments and he believed her. RN H stated when she went across the street to get Resident #2 it was the afternoon and it was not dark. RN H stated Resident #2 did not go outside prior to the elopement and mostly spent time in her room. RN H stated LVN CC completed a head to toe assessment. RN H stated Resident #2 had supervision because someone was with her and Resident #2 stated he was taking me to my apartment. RN H defined elopement as someone leaving home without any permission or anyone knowing about it or where that person was. RN H stated she considered this an elopement whether Resident #2 was with someone or not because Resident #2 left without any permission and she was not in her right mind. RN H stated she did not know how long Resident #2 was gone. During an interview on 10/21/2025 at 1:16 PM, RN AA stated that she has worked at the facility for 2 and a half years and used to work double weekend shift, but recently switched to 6:00 am - 2:00 pm. RN AA stated that she used to work with Resident #2 and that she was told that Resident #2 exited the facility and was found outside and she believed it was sometime before July 2025, but unsure exactly when. RN AA stated she worked the day Resident #2 eloped, but was not Resident #2's nurse that day. RN AA stated that Resident #2 was found by multiple staff at the apartments across the street. RN AA stated that all staff looked everywhere for Resident #2. RN AA stated the protocol for elopement was to assess the resident and take their vitals. RN AA stated that Resident mostly sat in her room, but was able to ambulate in her wheelchair. RN AA stated that the day of the elopement Resident #2 stated she was looking for her mom. RN AA stated that she was unsure how the resident got across the s treet and it was a very busy street in front of the facility. RN AA stated that staff reported the elopement to the DON and the ADM. RN AA stated prior to that incident, she was unsure if Resident #2 had any other elopements. During an interview on 10/21/2025 at 1:58 PM, FM stated that the facility notified him that Resident #2 would be discharged as she had walked off the property and she was transferred to a different facility that was secured. FM stated that Resident #2 was confused due to her dementia. During an interview on 10/21/2025 at 3:08 PM, the DON stated that she worked as the DON of the facility since March 2025. The DON stated she recalled working with Resident#2 and that she was a bit difficult. The DON stated Resident #2 often refused to take medication and go to dialysis. The DON stated Resident #2 was forgetful and had some memory loss. The DON stated she was contacted on 06/21/2025 by LVN CC that Resident #2 was outside. The DON stated when she arrived the facility Resident #2 was across the street at the apartments. The DON stated Resident #2 told the DON that she wanted to visit her family member. The DON stated she found Resident #2 before 1:00 PM and that it was sometime between 11:00 AM and 1:00 PM, but she was unsure exactly when it was. The DON stated Resident #2 had no injuries when she was found. The DON stated Resident #2 had no prior elopements and she was unsure why Resident #2's care plan had 06/06/2025 listed as an elopement. The DON stated Resident #2 would sit outside. The DON stated after 06/21/2025 Resident #2 was put on 1:1 supervision. The DON stated prior to the 06/21/2025 elopement there were no interventions in place. The DON stated the risk to an resident elopement was that with the traffic or people driving fast it was a hazard especially since Resident #2 cannot ambulate quickly in her wheelchair. The DON stated it was not figured out how Resident #2 left the facility and she had gone outside before but not to leave. The DON stated the building conducted a search when Resident #2 was reported missing and notified her and the ADM. The DON stated some staff walked around the building and some staff got into their vehicles and drove around. The DON stated Resident #2 had urinated and was sweaty, but had a bottle of water around her and was overall okay. The DON stated the temperature the day of the elopement was hot and stated it was in the 90's for sure. The DON stated she believed staff were in-serviced on elopement and reiterated the steps on what to do when an elopement happened. The DON stated after a resident was found, a head-to-toe assessment was done, notified the NP/MD and let the resident's family know they had been found. The DON stated the facility may then look for a more secured environment for the facility. The DON stated staff should document the elopement on an incident report and it was important so that follow up could have been done with the resident and ensure they were being monitored. The DON stated there were certain criteria that would mean an elopement was reportable to HHSC. The DON stated if the resident were confused, demented or wandered aimlessly and was exit seeking were all things that would make an elopement reportable to HHSC. The DON stated she considered this incident reportable, but did not think it was not reported and did not know why. During an interview on 10/21/2025 at 4:35 PM, Receptionist EE stated she was familiar with Resident #2 and Resident #2 used to attend some activities and she never saw her go sit outside. Receptionist EE stated Resident #2 tried to leave the building and Receptionist EE asked Resident #2 to go back upstairs, but she could not recall when this was. Receptionist EE stated she had not been informed of any residents who were unable to leave the building or that should not go outside unattended. Receptionist EE stated the road in front of the building was busy and she would not personally cross it and would suggest that residents not cross it and it was very dangerous. Receptionist EE stated that Resident #2 was in a wheelchair and moved at a slow pace. During an interview on 10/21/2025 at 5:01 PM, the ADM stated that Resident #2 had declined dialysis for the last few days. The ADM stated that Resident #2 came downstairs and sat outside. The ADM stated on 06/21/2025 she received a call from the facility that staff could not find Resident #2. The ADM stated she interviewed the nurse and RN H and it was reported to her that a different resident's family member reported that a resident was across the street and that the family member saw Resident #2 ask another family (not Resident #2's) to take her across the street and the unknown family member asked Resident #2 if she was allowed to go across the street to which Resident #2 replied yes. The ADM stated she did not know who either family member was, or what resident they were related to. The ADM stated Resident #2 was found across the street at an apartment complex with this unknown individual. The ADM stated by the time she arrived at the facility Resident #2 had been found and she started in-service with staff on elopement. The ADM stated Resident #2 was placed on 1:1 until she was discharged . The ADM stated once a resident went out they cannot keep them at the facility as they did not have an wander guard system. The ADM stated Resident #2 did not have any previous elopements. The ADM stated staff reported Resident #2 had refused medication and looked for her for lunch and that was when staff noticed they could not find her. The ADM stated it was about 10-20 minutes that Resident #2 could not be found. The ADM stated that Resident #2 told the unknown individual she wanted a burger and wanted to go to the restaurant across the street. The ADM stated Resident #2 was confused and refusal of dialysis caused increased confusion which was why she tried to go across the street and leave. The ADM defined elopement as when a resident left a building that was confused or had no intent as to where they were going and stated that Resident #2 had intention to go to the restaurant, but was not able to cross the street. The ADM stated she was unsure why Resident #2 had an elopement date of 06/06/2025 and 06/21/2025 was the only time she was aware Resident #2 had an elopement. The ADM stated Resident #2 was put on 1:1 supervision until a secured facility was found. The ADM stated elopements were reportable to HHSC if they met criteria but since the Resident had a family member with her it was not reportable because she had supervision. The ADM stated it would have been reported if there was a significant injury related to the elopement. The ADM stated it was not reported to HHSC because Resident #2 had someone with her. The ADM stated an investigation was done and that was how she found out a family member took her out and then an in-service was conducted. The ADM stated there were no statements because the unknown family members left. During a subsequent interview with the DON on 10/21/2025 at 5:15 PM, the DON stated that she found Resident #2 at the apartment complex and there were no other staff with the DON and Resident #2 was alone.During an interview on 10/22/2025 at 11:05 AM, ADM stated that there was no elopement reported to her on 06/05/2025 or 06/06/2025. The ADM stated had it been reported to her that Resident #2 tried to cross the street Resident #2 would have been put on 1:1 supervision and discharged much sooner. ADM stated she would have expected any elopement to be reported to her or the DON. The ADM stated an investigation would have been conducted with interview from Resident #2 to try and figure out what caused the elopement. The ADM stated during investigation normally she talked to the resident staff, find out the last time the resident was seen and put the resident on 1:1 and get with family to start the discharge process. The ADM stated there were no incident reports for 06/05/2025, 06/06/2025 or 06/21/2025 elopements. During an interview on 10/21/2025 at 2:52 PM, with MT I stated that she did not usually work weeks and recalled working with Resident #2 and stated that Resident #2 was confused. MT I stated that Resident #2 sometimes tried to elope. MT I stated he heard about when Resident #2 was found across the street at an apartment complex.During an interview on 10/21/2025 at 2:58 PM LVN FF stated she worked with Resident #2. LVN FF stated Resident #2 was confused quite a bit and she tried to leave the facility a couple of times. LVN FF stated she was not working when Resident #2 eloped from the facility and had only heard the staff looked for Resident #2 at she was not on the premises. LVN FF stated she knew someone brought Resident #2 inside the facility one time because she tried to go across the street. LVN FF stated the only interventions she recalled for Resident #2 was to keep an eye on her. LVN FF stated if a resident was missing the first thing to do was search everywhere and if the resident cannot be found to notify the DON and have all staff start to look for the resident. During an interview on 10/22/2025 at 12:42 PM MD G stated he recalled Resident #2 and she used to refuse dialysis. MD G stated that he did not recall her cognition level, but did believe she had a cognitive decline because she did not always understand the importance of going to dialysis. MD G stated if Resident #2 eloped from the facility and had been without dialysis there was a risk to develop uremia and cause confusion, but he was unsure if that is what Resident #2 experienced. Review of facility policy dated March 2012 titled Elopement Response Protocol reflected to Notify Department of Aging and Disability in accordance with guidelines for reportable incidents and based on elopement risk patient may be discharged . Head-to-toe nursing assessment must be completed upon return in addition the physician and responsible party must be notified and document. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 06/05/2025 and ended on 07/06/2025. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance:-Review of in-service dated 06/21/2025 titled elopements reflected in-service was completed with staff with no additional information included.-Review of in-service dated 06/27/2025 titled Elopement reflected in-service was completed with staff and reviewed the policy Elopement Response Protocol. -Review of Adhoc QAPI Plan dated 07/01/2025 reflected the ADM was notified on 06/21/2025 at 12:30 PM the facility that a resident was missing. Interview with charge nurse found resident refused medications an dialysis and was missing for approximately 20 minutes. Interview with weekend supervisor indicated patient asked another family member to take her across the street because she wanted to go get food. Family member took resident to the restaurant and then she wanted to go to the other side of the parking lot. RN H went across the street to get the resident and she was at the apartments. In-service on elopement was conducted and facility updated 100 % of elopement risk assessments. Review reflected there were no staff or witness statements included in the meeting notes. Review reflected inconsistencies among staff on Resident #2's 06/21/2025 elopement. Review reflected there was no investigation or information regarding a 06/05/2025 or 06/06/2025 elopement.-Review of Resident #2's monitoring sheet dated 06/21/2025 reflected Resident #2 was on 1:1 supervision -Review of Resident #2's monitoring sheets dated 06/28/2025 through 07/06/2025 reflected Resident #2 was on 1:1 supervision throughout each shift.-Review of facility elopement risk assessments dated 07/01/2025 reflected no residents were at risk for elopement.

Based on observation, interview and record reviews, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques and ensure that all licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one of eight (Resident #4) residents. The facility failed to ensure Resident #4 was not laid in a flat position while her feeding tube was actively flowing by CNA E on [DATE].The facility failed to ensure LVN D provided timely nursing care/interventions in response to Resident #4's possible aspiration on [DATE].An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 08:04 PM. While the IJ was removed on [DATE] at 2:20 PM, the facility remained out of compliance at a scope of isolate and severity level of actual harm because all staff had not been trained on safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions.These failures could place residents at risk for being provided care by staff who do not have the skills and competencies necessary for providing care and services. Findings included:Review of Resident #4's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included gastroesophageal reflux disease (a chronic condition where stomach acid flows back into the throat), gastrostomy status (an surgical external opening into the stomach for nutritional support), hemiplegia affecting right dominant side (paralysis to the right dominant side of the body), chronic obstructive pulmonary disease (chronic lung disease that limits airflow and causes ongoing respiratory symptoms), cerebral infarction (a blood clot that impairs blood flow through the artery in the brain), and dysphagia (difficulty swallowing). Review of Resident #4's significant change of status MDS, dated [DATE], reflected a BIMS score of 00 which indicated severe cognitive impairment.Review of Resident #4 care plan report, effective date [DATE], reflected Problems: [Resident #4] is at risk for impaired nutritional status and complications due to enteral [the delivery of nutrients directly into the stomach] feeding. with Interventions: Elevate HOB at least 30 degrees during and 1 hour after feeing. Monitor for s/s of Aspiration.Review of Resident #4's medication administration record, dated 02/2025, reflected Fibersource HN 0.05 gram-1.2 kcal/mL liquid for tube feed (65 cc/hr x 22) liquid enteral tube by shift starting [DATE] and signed off on [DATE] days by LVN A with 520.00 indicating the total milliliters Resident #4 was administered that shift. Review of Resident #4's treatment administration record, dated 02/2025, reflected G-tube - check for residual three times daily starting [DATE] with notes Check GT for residual. If more than 60 cc's hold feedings for 2 hours and recheck. Notify MD if residual remains above 60 cc's after holding for 2 hours. Also reflected was, G-tube - Elevate HOB () by shift starting [DATE]. Neither order reflected a signature on [DATE]. Review of Resident #4's nurses note, dated [DATE] at 11:23 PM, and written by LVN D reflected During routine rounds, the patient was observed with decreased respirations and a weak pulse. A reassessment was conducted, and vital signs were unobtainable. The patient was unresponsive with no signs of respiration or circulation. The attending hospice provider, Director of Nursing (DON), and family were notified of the patient's passing. The family was provided with emotional support and education on next steps per hospice protocol. The physician was notified, and the time of death was confirmed. Post-mortem care was provided according to hospice guidelines. The funeral home was contacted per the family's request. No signs of distress noted. Funeral home arrived around 2:30 pm and provided with required documentation.Observation of video footage without audio provided by Resident #4's FM D, dated [DATE], revealed the following with timestamps in military time as provided:12:20:40-12:20:49 - CNA E lowered the HOB to lay Resident #4 flat. The video stopped as CNA E was removing the top sheet from Resident #4. The feeding pump on the left side of the screen appeared to have the screen lit up, indicating it was on. 12:21:23 - Video resumed and Resident #4 was sitting with the head of her bed elevated approximately 45 degrees. CNA E then left the room. Resident #4 did not appear in any distress at that time.12:22:52-12:23:04 - CNA E returned to room, followed by LVN D. Resident #4 started at that time with a moderate amount of white fluid coming from her mouth and down the right side of her chin. LVN D was looking at Resident #4 then walked into the bathroom.12:23:18 - CNA was observed using a cloth to clean the white liquid off Resident #4's chin. LVN D was observed returning to the room as she was putting on gloves and the video stopped briefly.12:23:46-12:26:10 - The video resumed and LVN D was looking behind the nightstand next to the bed with an oral suction device in her hand. She appeared to locate the power cord to the suction machine and plugged it in. LVN D then appeared to be looking around the room and in drawers for something. LVN D appeared to not be able to find what she was looking for and left the room. CNA E remained in the room.12:30:44 - LVN D returned to the room with what appeared to be a suction catheter in her hand.12:30:47-12:30:55 - LVN D stood at the foot of Resident #4's bed waiting for CNA E to put on gloves and move out of the way. LVN D then set the suction catheter on the nightstand and entered the bathroom. 12:31:13 - LVN D exited the bathroom while putting on gloves. She then picks up the oral suction device (that was already in the room) and disconnected it from the suction tubing. She then appeared to be looking at the oral suction device and then touched the suction tubing near the suction machine/canister. The front panel for the feeding pump remained lit up indicating it was turned on. The video stopped.12:31:35 - The video resumed with LVN D standing at Resident #4's left side with oral suction device, connected to the suction tubing, in LVN D's right hand.12:32:16-12:32:32 - LVN D inserted oral suctioning device into Resident #4's mouth and moved it all around in her mouth then removed it from Resident #4's mouth.12:33:14-12:33:34 - LVN D put tip of oral suction device in water to clear the line. She then disconnected the oral suction device and connected the suction catheter. LVN D then placed the suction catheter in Resident #4's mouth. The video then stopped. 12:34:16 - The video resumed with LVN D laying the suction catheter on the nightstand. LVN D is then observed bending over and turning the dial on the oxygen concentrator that was delivering oxygen to Resident #4 through her nasal cannula.12:34:18-12:34:49 - LVN D is observed placing her hand on Resident #4's arm and shaking, then she moved her hand to Resident #4's chest. LVN D's hand then returned to Resident #4's arm to rub her arm forcefully. The feeding pump's screen remained on at this time.12:34:51-12:34:59 - LVN D placed her open left hand on Resident #4's left wrist, it appeared she was checking for a pulse. LVN D then removed her hand from Resident #4's wrist, took off gloves, and left the room. CNA E remained in room with Resident #4. 12:36:23-12:37:07 - LVN D appeared to attempt to get a response from Resident #4 by touching her arm. 12:37:07 - LVN D took her cell phone out of her pocket and called someone. 12:37:32 - LVN D left the room while talking on her cell phone. Feeding pump light remained on. 12:38:03-12:38:30 - LVN D returned to Resident #4's room and touched resident on the arm again to check for a response. She then turned to leave the room but stopped and turned around. She appeared to be talking to CNA E (no audio was provided with video) and lifted her right hand to point at the feeding pump. CNA E started touching the feeding pump, she then bent over to look at the pump closer and appeared to press something on the feeding pump. CNA E then stood back up and looked at LVN D and started talking while shaking her head left and right. LVN D then left the room, while CNA E continued to look at the feeding pump. 12:39:11 - CNA E left the room.12:43:50 - LVN D and CNA E were observed entering the room. LVN D walked directly to the oxygen concentrator and appeared to press something on the machine. LVN D then used her hand to hold Resident #4's wrist. She appeared to have been checking for a pulse. After releasing Resident #4's wrist, LVN D appeared to be talking to CNA E and pointed at feeding pump. LVN D then removed Resident #4's nasal cannula from her nose. She then walked around the bed to the feeding pump (the light on the screen of the feeding pump remained on) and appeared to be pressing something on the machine.12:44:47 - The light on the feeding pump screen turned off after LVN D was done touching it. She then disconnected Resident #4's PEG tube from feeding pump tubing. LVN D and CNA E then appeared to start post-mortem care (the care provided to a person after they die). 12:46:47 - LVN D left the room followed shortly after by CNA E.12:47:20 - CNA E entered the room and continued post-mortem care for Resident #4. 12:49:30 - Ex-DON entered Resident #4's room and entered the bathroom. She returned to the room shortly afterward. CNA E then exited the room. Ex-DON then approached Resident #4 and adjusted Resident #4's clothes, she then held Resident #4's wrist to possibly assess for a pulse. Ex-DON then appeared to touch the top of Resident #4's foot. 12:52:45 - CNA E returned to the room with linen. Ex-DON and CNA E continued providing post-mortem care to Resident #4, which included Ex-DON cleaning her eyes. 12:53:44 - LVN D returned to the room and appeared to have a conversation with Ex-DON. After the conversation, Ex-DON exits the room and LVN D and CNA E resume post-mortem care until the end of the video. --During a phone interview on [DATE] at 12:22 PM, FM D stated she was concerned about the care provided to Resident #4 on the day she died. She discussed the video from [DATE] that was submitted and stated she would attempt to resend with audio available. FM D stated she met with the ex-DON on [DATE] and showed her the video, but the ex-DON was no longer working at the facility, in fact, she quit that day. She stated the ex-DON told her several things in the video should have been done differently and was apologetic. She stated she could not remember the names of the staff members in the video that provided care to Resident #4. FM D stated Resident #4 was choking in the video and died shortly afterward. She stated she just wished staff would have moved faster to suction Resident #4 that day so that Resident #4 did not have to suffer before she died. During an interview on [DATE] at 09:19 AM, LVN D stated she was taking care of Resident #4 on the day she died. She stated that Resident #4 had been declining for an unknown amount of time. She stated the CNA (she could not remember who the CNA was that day) had provided care to Resident #4 and then reported to LVN D that Resident #4 needed to be suctioned. She stated the suction tubing in the room was not the correct one or was not functioning (she couldn't quite remember), so she had to leave the room to go get the correct materials to suction Resident #4. LVN D assessed Resident #4, she had some, but not a lot, clear secretions. LVN D denied Resident #4 showing any signs of distress or aspiration prior to her death. LVN D then stated, I don't remember the exact situation going on, I just remember caring for the patient. She then stated she just provided the general care for Resident #4 that day. LVN D stated, Honestly, I don't remember that far back, and I don't want to say something that isn't true.During an interview on [DATE] at 10:40 AM, the video without audio of Resident #4 was viewed with LVN D. She stated she had not seen the video before. She stated she still could not remember the name of the CNA working that day, even after seeing her on video. LVN D stated that the CNA should notify the nurse to turn off a feeding pump prior to providing care that required the head of the bed to be lowered. She stated that residents should not be laid flat if they are connected to a feeding pump and receiving formula through a PEG tube. She stated if they were laid flat while receiving a continuous feeding through a PEG tube, then the resident could aspirate (the stomach contents could go up the throat and into their airway). LVN D stated she was unaware that Resident #4's head of the bed was lowered to lay her flat by the CNA that day. She stated, It was not out of the ordinary for [Resident #4] to be suctioned. There was nothing alarming when I assessed her. LVN D was asked about the secretions coming from Resident #4's mouth in the video. She stated Resident #4 was drooling. She then stated, I don't remember her having a colored secretion, it was a clear secretion. LVN D stated after watching the video she had to go downstairs to obtain the materials needed to suction Resident #4. After viewing the video where she suctioned Resident #4, LVN D stated she didn't remember if the oral suctioning device was able to suction the secretions. She then stated, At this point, I feel uncomfortable with guessing what happened based on the video because I cannot hear what is being said. I feel like she was in her normal state. There was not a large amount of secretions. I was just doing my normal patient care for her. LVN D stated she remembered calling Ex-DON because she was in the building to let her know. She stated Ex-DON did not work at the facility anymore. When LVN D was asked about specifics of the video she kept repeating, I feel uncomfortable saying because I can't hear what is being said. She acknowledged checking for a radial pulse for Resident #4 while waiting for Ex-DON to enter the room during the video. LVN D remained resistant to answering questions during the interview. She was asked Should anything have been done differently? after watching the video. She responded, Honestly I couldn't hear what was going on, but I did my best to care for her as a patient.During an interview on [DATE] at 11:38 AM, the DON stated she started at the facility on [DATE]. She stated CNAs are required to notify the nurse to pause a feeding pump if they needed to provide care for the resident that required lowering the head of the bed to less than 30 degrees. She stated it was not within the CNA scope of practice to alter the feeding pump by pausing it, turning it on, and/or turning it off, even if the nurse is in the room and tells them to do it. The video of Resident #4, dated [DATE], was viewed with the DON. She stated the CNA in the video no longer worked in the facility and that she could not remember her name. The DON stated the feeding pump appeared to be on and running in the beginning of the video when CNA E entered the room. She stated the video showed CNA E laying Resident #4 completely flat and the pump appeared to still be running. She stated by laying Resident #4 in that position, it could cause aspiration, cause the formula to go back up into the esophagus[throat] and down into the lungs and aspirate The DON watched CNA E and LVN D (whom she identified by name) enter the room and liquid start coming from Resident #4's mouth and stated, looks like something is coming out of her mouth It looks like formula, white and opaque. The DON stated she would expect LVN D to move with a sense of urgency to turn off the feeding pump and set the resident all the way up. She stated the video showed it took LVN D almost 10 minutes to suction Resident #4 after she first showed signs of aspiration and even then, the pump continued to appear to be running. The DON watched the remainder of the video and stated, that was disheartening. She stated the staff did not appear to have a sense of urgency, the pump was not turned off until after the resident appeared without life, the resident was not properly assessed with vitals and lung sounds upon signs of aspiration, and post-mortem care was started prior to the RN pronouncing death in the video. She stated she thought the outcome of Resident #4 might have changed if CNA E had the nurse pause the feeding pump prior to lowering the head of the bed. The DON stated, If the nurse would have suctioned her and raised the head higher and stopped the feeding, it could have possibly changed the outcome. We don't know how much formula had already gone into the lungs. We could have done an x-ray to see if she needed some type of treatment. She stated the video never showed a RN pronouncement of death because that required a stethoscope to listen for lung and heart sounds and no stethoscope was witnessed in the video. She stated LVN D should have removed any medical treatments, including taking the nasal cannula off Resident #4, until after the death was pronounced by a RN. She stated she expected LVN D to assess Resident #4 and document what was witnessed, including the color and amount of fluids that came out of Resident #4's mouth, her assessment of lung sounds, interventions performed like: suctioning, what position Resident #4 was placed in and when the feeding pump was turned off, and also notification of proper personnel. After reviewing the nurses' note that documented the event, the DON stated, that's not how it went down. She didn't take a pulse ox, she didn't listen to the lungs. The note doesn't reflect the initial encounter with fluid coming from her mouth. She then stated she expected more from staff. The DON stated she would provide a staffing sheet for [DATE] and the employee files for the staff involved in the video.During an interview on [DATE] at 04:15 PM, the DON stated LVN D was scheduled to work 2pm-10pm that evening and would be working the remainder of her shift. During an observation on [DATE] at 04:17 PM, LVN D was witnessed standing at a medication cart on the 200-hall.During an interview on [DATE] at 04:40 PM, CNA R stated she had worked at the facility for about a week and had not received training on how to care for residents who were receiving enteral feedings. She stated if a resident had a feeding tube connected to a pump, then she could still lay the resident back flat and just needed to be aware of the feeding tube to not dislodge it. She didn't know if a resident could choke if they were laid flat. She stated she thought they could only choke if they were chewing on something. During an interview on [DATE] at 04:44 PM, CNA F stated she was trained by the ADON to press the pause button on feeding pumps prior to lowering the head of the bed to prevent the resident from aspirating and to restart the pump once the head of the bed was raised back up. During an interview on [DATE] at 04:46 PM, MT L stated a resident who received enteral nutrition through a feeding tube needed to have the pump paused prior to laying them down to provide peri-care. She stated she just paused the feeding pump and restarted it after providing care to the resident. She stated she did not have to notify the nurse to pause or restart the pump. During an interview on [DATE] at 04:57 PM, RN ZZ stated a resident who received enteral nutrition through a feeding tube needed to have the nurse stop and restart the pump before and after providing peri-care. She stated the nurse needed to be the one to stop and restart the pump because the nurse needed to assess the resident each time the pump is stopped and started. Attempted phone interview with MD G x 3 on [DATE] at 11:28 AM, 12:40 PM, and 05:43 PM without success.During an interview on [DATE] at 07:24 PM, the ADM stated the DON told her she had watched a video that was disheartening earlier that day but did not get any further details about the video. She stated she felt she had a good relationship with Resident #4's family. She stated she never discussed a video related to Resident #4 with Ex-DON. The ADM stated Ex-DON quit while the ADM was out of town. She stated prior to that she had discussed Ex-DON moving to the weekend nurse manager position in March. The video from [DATE] provided by FM D was viewed with the ADM. The ADM stated she did not know who the CNA in the video was. The ADM started shaking her head left and right. When asked why, she stated because she is lowering the head of the bed without having the nurse shut the pump off.Ok so she is spitting up.looks like formula to me. The ADM was able to identify LVN D and Ex-DON in the video. After the video, the ADM was asked what she observed wrong in the video and if protocol was followed. The ADM stated, Everything on it.the CNA lowered the head of the bed, the nurse did not turn off the pump.when she was throwing up she was not placed on her side while they were working to get the suction machine to work.the nurse did not do an assessment.she did not listen to lung sounds.I am in shock.No, protocol was not followed.I am so confused right now. The ADM stated she was not surprised to learn Resident #4 had died because she had been declining for some time. The ADM denied receiving the video in an email. She stated if she had seen the video before she would have fired the CNA, the LVN and reported it to regulatory services. The ADM stated the DON should have notified her about what was observed in the video and LVN D should have been removed from her shift immediately. The ADM stated she would notify the DON to escort LVN D out of the building immediately. Review of facility policy titled Nursing Policy & Procedure Enteral-Section 4, dated 06/2006 and last updated 03/2019, reflected Administration of Formula via Feeding Tube Gravity, Bolus, Pump.Procedures.Elevate head of bed at 30 to 45 degree angle or above during the feeding and for at least one hour after the feeding. Potential Complications of Tube Feedings.Responsibility.Licensed Nurse.Purpose.Prevention and possible solutions to complications in the tube fed Patient.Problem.Mechanical: Aspiration Pneumonia.Prevention/Possible Solution.Observe for signs and symptoms of aspiration (wheezes, rales, cough, apnea[temporary pause in breathing], hypotension[low blood pressure]).Elevate HOB 30 to 45 degrees during feeding and 30-60 minutes after feeding.Endotracheal[into the trachea/breathing tubes that connect mouth and nose to lungs] suctioning to stimulate cough when aspiration witnessed.This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The ADM was notified on [DATE] at 08:04 PM and a template was given.Observation on [DATE] at 08:21 PM, the ADM escorted LVN D out of the building.During an interview on [DATE] at 08:53 AM, the ADM identified CNA E as the CNA in the video. She stated the DON told her who the CNA was in the video. She stated CNA E was working last night and once she realized it, she sent CNA E home immediately. She stated she also suspended the DON because she did not remove LVN D and CNA E from providing care to the residents of the facility immediately after observing the video. The ADM provided the staffing sheet for [DATE].Review of facility Daily Sign in Sheet, dated Friday February 21, 2025, reflected LVN D and CNA E were assigned to Resident #4's room on that day. During an interview on [DATE] at 04:22 PM, MD G stated he was the primary physician for Resident #4. He stated he did not remember any specific information about Resident #4 though. He stated if a resident were receiving continuous feeding by a feeding pump through a PEG tube, then the head of the bed should be raised greater than 30 degrees to prevent aspiration. He stated a resident could aspirate at any time, but the chances of the resident aspirating if the head of the bed is lowered when they are receiving formula through a PEG tube greatly increases. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:26 PM: Immediate JeopardyPlan of Removal[DATE]F726 Competent Nursing Staff Immediate Action:Impact Statement:The facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques and ensure that all licensed nurses have the specific competencies and skill sets to care for residents necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility failed to ensure Resident #1 was not laid in a flat position while her feeding tube was actively flowing by CNA E.The facility failed to ensure LVN D provided timely nursing care/ interventions in response to Resident #4's possible aspiration on [DATE]. Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to failure to ensure that nurse aides are able to demonstrate competency in skills and techniques and ensure that all licensed nurses have the specific competencies and skill sets to care for residents necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.Systematic Approach:Immediate Action Resident #4 is no longer in facility. The Executive Director suspended LVN D, CNA E, and Director of Nursing as soon as Executive Director received notification from state surveyors at approximately 8:00pm on [DATE]. Depending on conclusion of ongoing investigation, if warranted and staff are to return, they will be provided with training prior to providing direct care to residents. The Executive Director initiated a formal investigation and initial report submitted to HHSC on [DATE]. The Executive Director notified the facility Medical Director of the Immediate Jeopardy on [DATE]. An emergency QAPI meeting was held on [DATE]. [DATE] The Regional Director of Regulatory Compliance, Regional Director of Clinical Services and Nurse Managers audited all current resident (a total of eight residents), with feeding tubes to ensure proper positioning during feedings (head of bed elevated to 30-45 degrees), medical orders reviewed to ensure Head Of Bed is elevated order is in place, and competency validation for current CNAs and licensed nurses. Competencies included safe positioning for nurses and CNAs, and oral suctioning for nurses. No additional residents were found to be at risk. Audits completed on [DATE]. Competencies to be completed on [DATE]. Executive Director, Regional Director of Regulatory Compliance, Nurse Managers will in-service all CNAs and Licensed Nurses in Safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions. Training for all newly hired staff will be completed prior to being assigned to the floor beginning [DATE]. Training for all PRN staff or staff who have not worked since 8/2025 will be completed prior to working beginning [DATE] and will continue until all PRN nursing staff have received training. Any PRN staff who has not worked in 60 days will be removed from the PRN program. Each employee will complete a post-test after their education to ensure staff are able to identify any residents at risk of aspiration. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. Education will be completed by [DATE]. Assessment [DATE] The Regional Director of Regulatory Compliance, Regional Director of Clinical Services and Nurse Managers audited all current residents with feeding tubes (a total of eight residents), to ensure proper positioning during feedings (head of bed elevated to 30-45 degrees), medical orders reviewed to ensure Head Of Bed is elevated, and competency validation for current CNAs and licensed nurses. Competencies included safe positioning for nurses and CNAs, and oral suctioning for nurses. No additional residents were found to be at risk. Audits completed on [DATE]. Competencies to be completed on [DATE] Who will be responsible: The Regional Director of Regulatory Compliance/ Unit Managers Who Will monitor: Executive Director/Regional Director of Clinical Services Completion Date [DATE] Monitoring Daily Audits: The Nurse Managers and/ or Designee will conduct two daily random observations of licensed nurses performing tube feedings for 30 days, ensuring proper positioning and suctioning technique as applicable. The Nurse Managers and/ or Designee will conduct two daily observations of CNAs providing care to a resident who receives tube feeding to ensure proper positioning, and ensuring CNAs are not turning off feeding pump, but instead communicating with nurse. Staff who fail to demonstrate competency will receive immediate retraining. Depending on conclusion of current investigation, if warranted and LVN D and CNA E are to return, they will be provided with training prior to providing direct care to residents After the 30 days, random observations will continue to be completed to include 10% of residents who receive enteral feedings per week for eight weeks. Staff who fail to demonstrate competency will receive immediate retraining. Nurse Managers and/or designee will audit new admissions with enteral feedings to ensure orders to maintain Head of Bed elevated are in place. Policy and Procedures Policy and procedures were reviewed by [NAME] President of Operations, Regional Director of Regulatory and Compliance, Regional Director of Clinical Services, Executive Director, and Director of Nursing. Policies include Administration of Formula Via Feeding Tube Gravity, Bolus, Pump. No policies needed any revisions. Monitoring of the POR on [DATE]-[DATE] included the following:Review of Resident #4's electronic health record reflected she was discharged from the facility on [DATE] at 01:45 PM to deceased .During interviews on [DATE] from 12:16 PM-06:30 PM and [DATE] from 09:10 AM - 01:30 PM, nine CNAs, six LVNs, and three RNs from different shifts all stated they were in-serviced before their shifts on safe positioning for residents receiving enteral feeding, aspiration precautions, and timely interventions, including competency training on suctioning for all licensed nurses. All were able to explain the correct positioning for residents receiving enteral feeding, who was allowed to start/stop/adjust/silence the feeding pump, signs and symptoms of aspiration, and what to do if they observe a resident aspirating. Review of LVN D's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct. Review of CNA E's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct.Review of the DON's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for unprofessional behavior.Review of facility-reported incident reflected, a formal complaint to regulatory authorities with intake number 1045259 was initiated and submitted on [DATE] at 10:23 PM.Review of the facility's AD HOC QAPI Plan, dated [DATE], reflected the medical director, the ADON, the ADM, and other facility and corporate staff were in attendance. Review of statement written by the ADM reflected: Medical Director.was notified of immediate jeopardy on [DATE] at approximately 9:00 PM. Review of electronic health records for eight of eight residents who received enteral nutrition revealed medical orders to ensure the head of the bed was elevated were in place.Observations on [DATE] between 11:50 AM and 4:45 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees. Observations on [DATE] between 09:30 AM and 01:00 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees.Review of facility au

Based on interviews, observations, and record reviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one of eight residents (Resident #4) reviewed for enteral nutrition. The facility failed to ensure Resident #4 was not laid in a flat position while her feeding tube was actively flowing by CNA E on [DATE].The facility failed to ensure LVN D provided timely nursing care/interventions in response to Resident #4's possible aspiration on [DATE].An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:39 AM. While the IJ was removed on [DATE] at 2:20 PM, the facility remained out of compliance at a scope of isolate and severity level of actual harm because all staff had not been trained on safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions.This failure could place residents at risk of tube malfunction, aspiration, and death.Findings include:Review of Resident #4's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included gastroesophageal reflux disease (a chronic condition where stomach acid flows back into the throat), gastrostomy status (an surgical external opening into the stomach for nutritional support), hemiplegia affecting right dominant side (paralysis to the right dominant side of the body), chronic obstructive pulmonary disease (chronic lung disease that limits airflow and causes ongoing respiratory symptoms), cerebral infarction (a blood clot that impairs blood flow through the artery in the brain), and dysphagia (difficulty swallowing). Review of Resident #4's significant change of status MDS, dated [DATE], reflected a BIMS score of 00 which indicated severe cognitive impairment. Review of Resident #4 care plan report, effective date [DATE], reflected Problems: [Resident #4] is at risk for impaired nutritional status and complications due to enteral [the delivery of nutrients directly into the stomach] feeding. with Interventions: Elevate HOB at least 30 degrees during and 1 hour after feeing. Monitor for s/s of Aspiration.Review of Resident #4's medication administration record, dated 02/2025, reflected Fibersource HN 0.05 gram-1.2 kcal/mL liquid for tube feed (65 cc/hr x 22) liquid enteral tube by shift starting [DATE] and signed off on [DATE] days by LVN A with 520.00 indicating the total milliliters Resident #4 was administered that shift. Review of Resident #4's treatment administration record, dated 02/2025, reflected G-tube - check for residual three times daily starting [DATE] with notes Check GT for residual. If more than 60 cc's hold feedings for 2 hours and recheck. Notify MD if residual remains above 60 cc's after holding for 2 hours. Also reflected was, G-tube - Elevate HOB () by shift starting [DATE]. Neither order reflected a signature on [DATE]. Review of Resident #4's nurses note, dated [DATE] at 11:23 PM, and written by LVN D reflected During routine rounds, the patient was observed with decreased respirations and a weak pulse. A reassessment was conducted, and vital signs were unobtainable. The patient was unresponsive with no signs of respiration or circulation. The attending hospice provider, Director of Nursing (DON), and family were notified of the patient's passing. The family was provided with emotional support and education on next steps per hospice protocol. The physician was notified, and the time of death was confirmed. Post-mortem care was provided according to hospice guidelines. The funeral home was contacted per the family's request. No signs of distress noted. Funeral home arrived around 2:30 pm and provided with required documentation.Observation of video footage without audio provided by Resident #4's FM D, dated [DATE], revealed the following with timestamps in military time as provided:12:20:40-12:20:49 - CNA E lowered the HOB to lay Resident #4 flat. The video stopped as CNA E was removing the top sheet from Resident #4. The feeding pump on the left side of the screen appeared to have the screen lit up, indicating it was on. 12:21:23 - Video resumed and Resident #4 was sitting with the head of her bed elevated approximately 45 degrees. CNA E then left the room. Resident #4 did not appear in any distress at that time.12:22:52-12:23:04 - CNA E returned to room, followed by LVN D. Resident #4 started at that time with a moderate amount of white fluid coming from her mouth and down the right side of her chin. LVN D was looking at Resident #4 then walked into the bathroom.12:23:18 - CNA was observed using a cloth to clean the white liquid off Resident #4's chin. LVN D was observed returning to the room as she was putting on gloves and the video stopped briefly.12:23:46-12:26:10 - The video resumed and LVN D was looking behind the nightstand next to the bed with an oral suction device in her hand. She appeared to locate the power cord to the suction machine and plugged it in. LVN D then appeared to be looking around the room and in drawers for something. LVN D appeared to not be able to find what she was looking for and left the room. CNA E remained in the room.12:30:44 - LVN D returned to the room with what appeared to be a suction catheter in her hand.12:30:47-12:30:55 - LVN D stood at the foot of Resident #4's bed waiting for CNA E to put on gloves and move out of the way. LVN D then set the suction catheter on the nightstand and entered the bathroom. 12:31:13 - LVN D exited the bathroom while putting on gloves. She then picks up the oral suction device (that was already in the room) and disconnected it from the suction tubing. She then appeared to be looking at the oral suction device and then touched the suction tubing near the suction machine/canister. The front panel for the feeding pump remained lit up indicating it was turned on. The video stopped.12:31:35 - The video resumed with LVN D standing at Resident #4's left side with oral suction device, connected to the suction tubing, in LVN D's right hand.12:32:16-12:32:32 - LVN D inserted oral suctioning device into Resident #4's mouth and moved it all around in her mouth then removed it from Resident #4's mouth.12:33:14-12:33:34 - LVN D put tip of oral suction device in water to clear the line. She then disconnected the oral suction device and connected the suction catheter. LVN D then placed the suction catheter in Resident #4's mouth. The video then stopped. 12:34:16 - The video resumed with LVN D laying the suction catheter on the nightstand. LVN D is then observed bending over and turning the dial on the oxygen concentrator that was delivering oxygen to Resident #4 through her nasal cannula.12:34:18-12:34:49 - LVN D is observed placing her hand on Resident #4's arm and shaking, then she moved her hand to Resident #4's chest. LVN D's hand then returned to Resident #4's arm to rub her arm forcefully. The feeding pump's screen remained on at this time.12:34:51-12:34:59 - LVN D placed her open left hand on Resident #4's left wrist, it appeared she was checking for a pulse. LVN D then removed her hand from Resident #4's wrist, took off gloves, and left the room. CNA E remained in room with Resident #4. 12:36:23-12:37:07 - LVN D appeared to attempt to get a response from Resident #4 by touching her arm. 12:37:07 - LVN D took her cell phone out of her pocket and called someone. 12:37:32 - LVN D left the room while talking on her cell phone. Feeding pump light remained on. 12:38:03-12:38:30 - LVN D returned to Resident #4's room and touched resident on the arm again to check for a response. She then turned to leave the room but stopped and turned around. She appeared to be talking to CNA E (no audio was provided with video) and lifted her right hand to point at the feeding pump. CNA E started touching the feeding pump, she then bent over to look at the pump closer and appeared to press something on the feeding pump. CNA E then stood back up and looked at LVN D and started talking while shaking her head left and right. LVN D then left the room, while CNA E continued to look at the feeding pump. 12:39:11 - CNA E left the room.12:43:50 - LVN D and CNA E were observed entering the room. LVN D walked directly to the oxygen concentrator and appeared to press something on the machine. LVN D then used her hand to hold Resident #4's wrist. She appeared to have been checking for a pulse. After releasing Resident #4's wrist, LVN D appeared to be talking to CNA E and pointed at feeding pump. LVN D then removed Resident #4's nasal cannula from her nose. She then walked around the bed to the feeding pump (the light on the screen of the feeding pump remained on) and appeared to be pressing something on the machine.12:44:47 - The light on the feeding pump screen turned off after LVN D was done touching it. She then disconnected Resident #4's PEG tube from feeding pump tubing. LVN D and CNA E then appeared to start post-mortem care (the care provided to a person after they die). 12:46:47 - LVN D left the room followed shortly after by CNA E.12:47:20 - CNA E entered the room and continued post-mortem care for Resident #4. 12:49:30 - Ex-DON entered Resident #4's room and entered the bathroom. She returned to the room shortly afterward. CNA E then exited the room. Ex-DON then approached Resident #4 and adjusted Resident #4's clothes, she then held Resident #4's wrist to possibly assess for a pulse. Ex-DON then appeared to touch the top of Resident #4's foot. 12:52:45 - CNA E returned to the room with linen. Ex-DON and CNA E continued providing post-mortem care to Resident #4, which included Ex-DON cleaning her eyes. 12:53:44 - LVN D returned to the room and appeared to have a conversation with Ex-DON. After the conversation, Ex-DON exits the room and LVN D and CNA E resume post-mortem care until the end of the video. During a phone interview on [DATE] at 12:22 PM, FM D stated she was concerned about the care provided to Resident #4 on the day she died. She discussed the video from [DATE] that was submitted and stated she would attempt to resend with audio available. FM D stated she met with the ex-DON on [DATE] and showed her the video, but the ex-DON was no longer working at the facility, in fact, she quit that day. She stated the ex-DON told her several things in the video should have been done differently and was apologetic. She stated she could not remember the names of the staff members in the video that provided care to Resident #4. FM D stated Resident #4 was choking in the video and died shortly afterward. She stated she just wished staff would have moved faster to suction Resident #4 that day so that Resident #4 did not have to suffer before she died. During an interview on [DATE] at 09:19 AM, LVN D stated she was taking care of Resident #4 on the day she died. She stated that Resident #4 had been declining for an unknown amount of time. She stated the CNA (she could not remember who the CNA was that day) had provided care to Resident #4 and then reported to LVN D that Resident #4 needed to be suctioned. She stated the suction tubing in the room was not the correct one or was not functioning (she couldn't quite remember), so she had to leave the room to go get the correct materials to suction Resident #4. LVN D assessed Resident #4, she had some, but not a lot, clear secretions. LVN D denied Resident #4 showing any signs of distress or aspiration prior to her death. LVN D then stated, I don't remember the exact situation going on, I just remember caring for the patient. She then stated she just provided the general care for Resident #4 that day. LVN D stated, Honestly, I don't remember that far back, and I don't want to say something that isn't true.During an interview on [DATE] at 10:40 AM, the video without audio of Resident #4 was viewed with LVN D. LVN D stated she had not seen the video previously. She stated she still could not remember the name of the CNA working that day, even after seeing her on video. LVN D stated that the CNA should notify the nurse to turn off a feeding pump prior to providing care that required the head of the bed to be lowered. She stated that residents should not be laid flat if they are connected to a feeding pump and receiving formula through a PEG tube. She stated if they were laid flat while receiving a continuous feeding through a PEG tube, then the resident could aspirate (the stomach contents could go up the throat and into their airway). LVN D stated she was unaware that Resident #4's head of the bed was lowered to lay her flat by the CNA that day. She stated, It was not out of the ordinary for [Resident #4] to be suctioned. There was nothing alarming when I assessed her. LVN D was asked about the secretions coming from Resident #4's mouth in the video. She stated Resident #4 was drooling. She then stated, I don't remember her having a colored secretion, it was a clear secretion. LVN D stated after watching the video she had to go downstairs to obtain the materials needed to suction Resident #4. After viewing the video where she suctioned Resident #4, LVN D stated she didn't remember if the oral suctioning device was able to suction the secretions. She then stated, At this point, I feel uncomfortable with guessing what happened based on the video because I cannot hear what is being said. I feel like she was in her normal state. There was not a large amount of secretions. I was just doing my normal patient care for her. LVN D stated she remembered calling Ex-DON because she was in the building to let her know. She stated Ex-DON did not work at the facility anymore. When LVN D was asked about specifics of the video she kept repeating, I feel uncomfortable saying because I can't hear what is being said. She acknowledged checking for a radial pulse for Resident #4 while waiting for Ex-DON to enter the room during the video. LVN D remained resistant to answering questions during the interview. She was asked Should anything have been done differently? after watching the video. She responded, Honestly I couldn't hear what was going on, but I did my best to care for her as a patient. During an interview on [DATE] at 11:38 AM, the DON stated she started at the facility on [DATE]. She stated CNAs are required to notify the nurse to pause a feeding pump if they needed to provide care for the resident that required lowering the head of the bed to less than 30 degrees. She stated it was not within the CNA scope of practice to alter the feeding pump by pausing it, turning it on, and/or turning it off, even if the nurse is in the room and tells them to do it. The video of Resident #4, dated [DATE], was viewed with the DON. She stated she had no knowledge of the incident or the video prior to the interview. She stated the CNA in the video no longer worked in the facility and that she could not remember her name. The DON stated the feeding pump appeared to be on and running in the beginning of the video when CNA E entered the room. She stated the video showed CNA E laying Resident #4 completely flat and the pump appeared to still be running. She stated by laying Resident #4 in that position, it could cause aspiration, cause the formula to go back up into the esophagus[throat] and down into the lungs and aspirate The DON watched CNA E and LVN D(whom she identified by name) enter the room and liquid start coming from Resident #4's mouth and stated, looks like something is coming out of her mouth It looks like formula, white and opaque. The DON stated she would expect LVN D to move with a sense of urgency to turn off the feeding pump and set the resident all the way up. She stated the video showed it took LVN D almost 10 minutes to suction Resident #4 after she first showed signs of aspiration and even then, the pump continued to appear to be running. The DON watched the remainder of the video and stated, that was disheartening. She stated the staff did not appear to have a sense of urgency, the pump was not turned off until after the resident appeared without life, the resident was not properly assessed with vitals and lung sounds upon signs of aspiration, and post-mortem care was started prior to the RN pronouncing death in the video. She stated she thought the outcome of Resident #4 might have changed if CNA E had the nurse pause the feeding pump prior to lowering the head of the bed. The DON stated, If the nurse would have suctioned her and raised the head higher and stopped the feeding, it could have possibly changed the outcome. We don't know how much formula had already gone into the lungs. We could have done an x-ray to see if she needed some type of treatment. She stated the video never showed a RN pronouncement of death because that required a stethoscope to listen for lung and heart sounds and no stethoscope was witnessed in the video. She stated LVN D should have removed any medical treatments, including taking the nasal cannula off Resident #4, until after the death was pronounced by a RN. She stated she expected LVN D to assess Resident #4 and document what was witnessed, including the color and amount of fluids that came out of Resident #4's mouth, her assessment of lung sounds, interventions performed like: suctioning, what position Resident #4 was placed in and when the feeding pump was turned off, and also notification of proper personnel. After reviewing the nurses' note that documented the event, the DON stated, that's not how it went down. She didn't take a pulse ox, she didn't listen to the lungs. The note doesn't reflect the initial encounter with fluid coming from her mouth. She then stated she expected more from staff. The DON stated she would provide a staffing sheet for [DATE] and the employee files for the staff involved in the video.During an interview on [DATE] at 04:15 PM, the DON stated LVN D was scheduled to work 2pm-10pm that evening and would be working the remainder of her shift. During an observation on [DATE] at 04:17 PM, LVN D was witnessed standing at a medication cart on the 200-hall. During an interview on [DATE] at 04:44 PM, CNA F stated she was trained by the ADON to press the pause button on feeding pumps prior to lowering the head of the bed to prevent the resident from aspirating and to restart the pump once the head of the bed was raised back up. Attempted phone interview with MD G x 3 on [DATE] at 11:28 AM, 12:40 PM, and 05:43 PM without success.During an interview on [DATE] at 07:24 PM, the ADM stated the DON told her she had watched a video that was disheartening earlier that day but did not get any further details about the video. She stated she felt she had a good relationship with Resident #4's family. She stated she never discussed a video related to Resident #4 with Ex-DON. The ADM stated Ex-DON quit while the ADM was out of town. She stated prior to that she had discussed Ex-DON moving to the weekend nurse manager position in March. The video from [DATE] provided by FM D was viewed with the ADM. The ADM stated she did not know who the CNA in the video was. The ADM started shaking her head left and right. When asked why, she stated because she is lowering the head of the bed without having the nurse shut the pump off.Ok so she is spitting up.looks like formula to me. The ADM was able to identify LVN D and Ex-DON in the video. After the video, the ADM was asked what she observed wrong in the video and if protocol was followed. The ADM stated, Everything on it.the CNA lowered the head of the bed, the nurse did not turn off the pump.when she was throwing up she was not placed on her side while they were working to get the suction machine to work.the nurse did not do an assessment.she did not listen to lung sounds.I am in shock.No, protocol was not followed.I am so confused right now. The ADM stated she was not surprised to learn Resident #4 had died because she had been declining for some time. The ADM denied receiving the video in an email. She stated if she had seen the video before she would have fired the CNA, the LVN and reported it to regulatory services. The ADM stated the DON should have notified her about what was observed in the video and LVN D should have been removed from her shift immediately. The ADM stated she would notify the DON to escort LVN D out of the building immediately. Review of facility policy titled Nursing Policy & Procedure Enteral-Section 4, dated 06/2006 and last updated 03/2019, reflected Administration of Formula via Feeding Tube Gravity, Bolus, Pump.Procedures.Elevate head of bed at 30 to 45 degree angle or above during the feeding and for at least one hour after the feeding. Potential Complications of Tube Feedings.Responsibility.Licensed Nurse.Purpose.Prevention and possible solutions to complications in the tube fed Patient.Problem.Mechanical: Aspiration Pneumonia.Prevention/Possible Solution.Observe for signs and symptoms of aspiration (wheezes, rales, cough, apnea[temporary pause in breathing], hypotension[low blood pressure]).Elevate HOB 30 to 45 degrees during feeding and 30-60 minutes after feeding.Endotracheal[into the trachea/breathing tubes that connect mouth and nose to lungs] suctioning to stimulate cough when aspiration witnessed.Observation on [DATE] at 08:21 PM, the ADM escorted LVN D out of the building.During an interview on [DATE] at 08:53 AM, the ADM identified CNA E as the CNA in the video. She stated the DON told her who the CNA was in the video. She stated CNA E was working last night and once she realized it, she sent CNA E home immediately. She stated she also suspended the DON because she did not remove LVN D and CNA E from providing care to the residents of the facility immediately after observing the video. The ADM provided the staffing sheet for [DATE].Review of facility Daily Sign in Sheet, dated Friday February 21, 2025, reflected LVN D and CNA E were assigned to Resident #4's room on that day.This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The ADM was notified on [DATE] at 10:39 AM and a template was given. During an interview on [DATE] at 04:22 PM, MD G stated he was the primary physician for Resident #4. He stated he did not remember any specific information about Resident #4 though. He stated if a resident were receiving continuous feeding by a feeding pump through a PEG tube, then the head of the bed should be raised greater than 30 degrees to prevent aspiration. He stated a resident could aspirate at any time, but the chances of the resident aspirating if the head of the bed is lowered when they are receiving formula through a PEG tube greatly increases. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:26 PM: Immediate JeopardyPlan of Removal[DATE]F693 Tube Feeding Management Immediate Action:Impact Statement:The facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. The facility failed to ensure Resident #4 was not laid in a flat position while her feeding tube was actively flowing by CNA E.The facility failed to ensure LVN D provided timely nursing care/ interventions in response to Resident #4's possible aspiration on [DATE]. Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to failure to ensure that ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.Systematic Approach:Immediate Action Resident #4 is no longer in facility. The Executive Director suspended LVN D, CNA E, and Director of Nursing as soon as Executive Director received notification from state surveyors at approximately 8:00pm on [DATE]. Depending on conclusion of ongoing investigation, if warranted and staff are to return, they will be provided with training prior to providing direct care to residents. The Executive Director initiated a formal investigation and initial report submitted to HHSC on [DATE]. The Executive Director notified the facility Medical Director of the Immediate Jeopardy on [DATE]. An emergency QAPI meeting was held on [DATE]. [DATE] The Regional Director of Regulatory Compliance, Regional Director of Clinical Services and Nurse Managers audited all current resident (a total of eight residents), with feeding tubes to ensure proper positioning during feedings (head of bed elevated to 30-45 degrees), medical orders reviewed to ensure Head Of Bed is elevated order is in place, and competency validation for current CNAs and licensed nurses. Competencies included safe positioning for nurses and CNAs, and oral suctioning for nurses. No additional residents were found to be at risk. Audits completed on [DATE]. Competencies to be completed on [DATE]. Executive Director, Regional Director of Regulatory Compliance, Nurse Managers will in-service all CNAs and Licensed Nurses in Safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions. Training for all newly hired staff will be completed prior to being assigned to the floor beginning [DATE]. Training for all PRN staff or staff who have not worked since 8/2025 will be completed prior to working beginning [DATE] and will continue until all PRN nursing staff have received training. Any PRN staff who has not worked in 60 days will be removed from the PRN program. Each employee will complete a post-test after their education to ensure staff are able to identify any residents at risk of aspiration. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. Education will be completed by [DATE]. Assessment [DATE] The Regional Director of Regulatory Compliance, Regional Director of Clinical Services and Nurse Managers audited all current residents with feeding tubes (a total of eight residents), to ensure proper positioning during feedings (head of bed elevated to 30-45 degrees), medical orders reviewed to ensure Head Of Bed is elevated, and competency validation for current CNAs and licensed nurses. Competencies included safe positioning for nurses and CNAs, and oral suctioning for nurses. No additional residents were found to be at risk. Audits completed on [DATE]. Competencies to be completed on [DATE]. Who will be responsible: The Regional Director of Regulatory Compliance/ Unit ManagersWho Will monitor: Executive Director/Regional Director of Clinical ServicesCompletion Date [DATE] Monitoring Daily Audits: The Nurse Managers and/ or Designee will conduct two daily random observations of licensed nurses performing tube feedings for 30 days, ensuring proper positioning and suctioning technique as applicable. The Nurse Managers and/ or Designee will conduct two daily observations of CNAs providing care to a resident who receives tube feeding to ensure proper positioning, and ensuring CNAs are not turning off feeding pump, but instead communicating with nurse. Staff who fail to demonstrate competency will receive immediate retraining. Depending on conclusion of current investigation, if warranted and LVN A and CNA B are to return, they will be provided with training prior to providing direct care to residents After the 30 days, random observations will continue to be completed to include 10% of residents who receive enteral feedings per week for eight weeks. Staff who fail to demonstrate competency will receive immediate retraining. Nurse Managers and/or designee will audit new admissions with enteral feedings to ensure orders to maintain Head of Bed elevated are in place. Policy and Procedures Policy and procedures were reviewed by [NAME] President of Operations, Regional Director of Regulatory and Compliance, Regional Director of Clinical Services, Executive Director, and Director of Nursing. Policies include Administration of Formula Via Feeding Tube Gravity, Bolus, Pump. No policies needed any revisions. Monitoring of the POR on [DATE]-[DATE] included the following:Review of Resident #4's electronic health record reflected she was discharged from the facility on [DATE] at 01:45 PM to deceased .During interviews on [DATE] from 12:16 PM-06:30 PM and [DATE] from 09:10 AM - 01:30 PM, nine CNAs, six LVNs, and three RNs from different shifts all stated they were in-serviced before their shifts on safe positioning for residents receiving enteral feeding, aspiration precautions, and timely interventions, including competency training on suctioning for all licensed nurses. All were able to explain the correct positioning for residents receiving enteral feeding, who was allowed to start/stop/adjust/silence the feeding pump, signs and symptoms of aspiration, and what to do if they observe a resident aspirating. Review of LVN D's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct. Review of CNA E's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct.Review of the DON's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for unprofessional behavior.Review of facility-reported incident reflected, a formal complaint to regulatory authorities with intake number 1045259 was initiated and submitted on [DATE] at 10:23 PM.Review of the facility's AD HOC QAPI Plan, dated [DATE], reflected the medical director, the ADON, the ADM, and other facility and corporate staff were in attendance. Review of statement written by the ADM reflected: Medical Director.was notified of immediate jeopardy on [DATE] at approximately 9:00 PM. Review of electronic health records for eight of eight residents who received enteral nutrition revealed medical orders to ensure the head of the bed was elevated were in place.Observations on [DATE] at 11:50 AM and 4:45 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees. Observations on [DATE] at 09:30 AM and 01:00 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees.Review of facility audit, dated [DATE], reflected orders for and observation of head of bed elevated for eight of eight residents that received enteral nutrition was completed by the RDRC.Review of facility audit, dated [DATE]-[DATE], reflected daily audits were conducted for observations of enteral feeding for of eight of eight residents that received enteral nutrition by either the ADM or the RDRC.Review of 20 post-tests and 20 skills check-off sheets, dated [DATE], reflected licensed nurses demonstrated proper skills and demonstrated knowledge on performing respiratory assessments, suctioning and respiratory care. Review of 107 post-tests, dated [DATE]-[DATE], reflected staff demonstrated knowledge of competency for enteral feeding. Review of in-service spread sheet reflected 98 of 103 staff had completed in-services as of [DATE]. During an interview on [DATE] at 1:30 PM, the ADM stated more than 90% of their staff had been in-serviced on safe positioning for residents receiving enteral feeding, aspiration precautions and timely intervention. She stated that no one would work until they were in-serviced. The ADM was notified the IJ was removed on [DATE] at 2:20 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.During an interview, after exit, on [DATE] at 05:04 PM, Ex-DON stated she previously worked at the facility, but quit on the last week in February 2025. She ac

Based on interview and record review the facility failed to ensure all alleged violations involving, abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury to the state survey agency for 1 of 4 residents (Resident #2) reviewed for abuse and neglect reporting. 1. The facility failed report to the SSA when Resident #2 eloped from the facility on 06/05/2025. 2. The facility failed report to the SSA when Resident #2 eloped on 06/21/2025 when she was found across the street at an apartment complex. This failure could place residents at risk of further abuse, physical harm, mental anguish, and/or unsafe elopements. Findings include: Review of Resident #2's face sheet reflected a [AGE] year-old-female admitted on initially admitted on [DATE] and discharged on 07/06/2025 with diagnoses of end stage renal disease (final stage of chronic kidney disease when the kidneys have deteriorated and no longer perform their functions), unspecified dementia (condition where a person experiences cognitive decline), unspecified convulsions (seizures where the specific cause cannot be determined), altered mental status (a change in a person's level of consciousness, alertness, and cognitive function), repeated falls, dependence on renal dialysis (medical necessity for a person to use a machine to filter their blood because their kidneys failed to do so), muscle weakness, and difficulty walking. Review of Resident #2 care plan dated 05/01/2025 with revision date of 07/07/2025 reflected Resident #2 had an ADL self-care performance deficit related to confusion, dementia impaired balance, and limited mobility. Further review reflected Resident #2 had a potential risk for elopement as evidenced by history of attempt to leave facility unattended. Review reflected Resident #2 was found in the front parking lot on 06/06/2025 and attempted to leave premises, trying to cross the street with revision date of 07/07/2025 with interventions to assess for alternative placement frequent monitoring, and provide 1:1 sitter at bedside. Review reflected Resident #2 has impaired cognitive function, difficulty making decisions, short term memory loss with revision date of 07/07/2025 with interventions to cue reorient and supervise as needed. Review of Resident #2 quarterly MDS dated [DATE] reflected Resident #2 had not exhibited wandering behavior. Resident #2 had a BIMS of 12. Review of Resident #2 elopement risk assessment dated [DATE] reflected Resident #2 was at risk and was cognitively impaired, able to ambulate and has intentionally or unintentionally attempted to leave the community. Review of both PCC (electronic health record) and MyUnity (electronic health record) reflected there were no elopement assessments completed prior to 06/21/2025. Review of nursing progress notes dated 06/05/2025 by LVN BB reflected Resident #2 was noticed by staff wheeling herself outside the facility trying to cross the road. Resident was approached by staff and brought back to the facility. [Resident #2] said she was trying to get to her family. Resident was brought back to her room and monitored continuously till end of shift. Oncoming nurse notified of [Resident #2's] elopement behavior. Review of nursing progress notes dated 06/06/2025 by LVN BB reflected Resident #2 was found wandering outside the street trying to cross the road. She was brought back into the building and helped to her room. Review of nursing progress note dated 06/21/2025 at 12:34 PM reflected Resident #2 was last seen at about 10:58 [am] when she refused to get her blood sugar checked, at about 11:18 [am], RN H came state someone saw a woman across the street with her head tied, message related to supervisor by the receptionist. The description looks like resident. RN H and other staff members also searched neighborhood, resident could not be seen at this time. [LVN CC] and another nurse crossed the street walked through the apartment complex resident was not seen. [LVN CC] notified 911, on call MD. DON aware. Review of nursing progress note by LVN CC dated 06/21/2025 at 1:40 PM, reflected head to toe assessment was done with no physical injury noted. During an interview on 10/21/2025 at 3:08 PM, the DON stated that she worked as the DON of the facility since March 2025. The DON stated she recalled working with Resident#1 and that she was a bit difficult. The DON stated that Resident #2 often refused to take medication and go to dialysis. The DON stated Resident #2 was forgetful and had some memory loss. The DON stated that she was contacted on 06/21/2025 by LVN CC that Resident #2 was outside. The DON stated that when she arrived the facility Resident #2 was across the street at the apartments. The DON stated Resident #2 told the DON that she wanted to visit her daughter. The DON stated that she found Resident #2 before 1:00 PM and that it was sometime between 11:00 AM and 1:00 PM, but she was unsure exactly when it was. The DON stated that Resident #2 had no injuries when she was found. The DON stated that Resident #2 had no prior elopements and she was unsure why Resident #2's care plan had 06/06/2025 listed as an elopement. The DON stated that Resident #2 would sit outside. The DON stated that after 06/21/2025 Resident #2 was put on 1:1 supervision. The DON stated that prior to the 06/21/2025 elopement there were no interventions in place. The DON stated that the risk to an resident elopement was that with the traffic or people driving fast it was a hazard especially since Resident #2 cannot ambulate quickly in her wheelchair. The DON stated that it was not figured out how Resident #2 left the facility and she had gone outside before but not to leave. The DON stated that the building conducted a search when Resident #2 was reported missing and notified her and the ADM. The DON stated that some staff walked around the building and some staff got into their vehicles and drove around. The DON stated that Resident #2 had urinated and was sweaty, but had a bottle of water around her and was overall okay. The DON stated that the temperature the day of the elopement was hot and stated it was in the 90's for sure. The DON stated that she believed staff were in-serviced on elopement and reiterated the steps on what to do when an elopement happened. The DON stated that after a resident was found, a head-to-toe assessment was done, notified the NP/MD and let the resident's family know they had been found. The DON stated the facility may then look for a more secured environment for the facility. The DON stated that staff should document the elopement on an incident report and it was important so that follow up could have been done with the resident and ensure they were being monitored. The DON stated that there were certain criteria that would mean an elopement was reportable to HHSC. The DON stated that if the resident were confused, demented or wandered aimlessly and was exit seeking were all things that would make an elopement reportable to HHSC. The DON stated she considered this incident reportable, but did not think it was not reported and did not know why. During an interview on 10/21/2025 at 5:01 PM, the ADM stated that Resident #2 had declined dialysis for the last few days. The ADM stated that Resident #2 came downstairs and sat outside. The ADM stated on 06/21/2025 she received a call from the facility that staff could not find Resident #2. The ADM stated she interviewed the nurse and RN H and it was reported to her that a different resident's family member reported that a resident was across the street and that the family member saw Resident #2 ask another family (not Resident #2's) to take her across the street and the unknown family member asked Resident #2 if she was allowed to go across the street to which Resident #2 replied yes. The ADM stated she did not know who either family member was, or what resident they were related to. The ADM stated that Resident #2 was found across the street at an apartment complex with this unknown individual. The ADM stated by the time she arrived at the facility Resident #2 had been found and she started in-service with staff on elopement. The ADM stated that Resident #2 was placed on 1:1 until she was discharged . The ADM stated that once a resident went out they cannot keep them at the facility as they did not have an wander guard system. The ADM stated that Resident #2 did not have any previous elopements. The ADM stated that staff reported Resident #2 had refused medication and looked for her for lunch and that was when staff noticed they could not find her. The ADM stated it was about 10-20 minutes that Resident #2 could not be found. The ADM stated that Resident #2 told the unknown individual she wanted a burger and wanted to go to the restaurant across the street The ADM stated that Resident #2 was confused and refusal of dialysis caused increased confusion which is why she tried to go across the street and leave. The ADM defined elopement as when a resident left a building that is confused or had no intent as to where they were going and stated that Resident #2 had intention to go to the restaurant, but was not able to cross the street. The ADM stated she was unsure why Resident #2 had an elopement date of 06/06/2025 for an elopement and that 06/21/2025 was the only time she was aware Resident #2 had an elopement. The ADM stated that Resident #2 was put on 1:1 supervision until a secured facility was found. The ADM stated elopements were reportable to HHSC if they met criteria but since the Resident had a family member with her it was not reportable because she had supervision. The ADM stated it would have been reported if there was a significant injury related to the elopement. The ADM stated it was not reported to HHSC because Resident #2 had someone with her. The ADM stated an investigation was done and that was how she found out a family member took her out and then an in-service was conducted. The ADM stated there were no statements because the unknown family members left. During a subsequent interview with the DON on 10/21/2025 at 5:15 PM, the DON stated that she found Resident #2 at the apartment complex and there were no other staff with the DON and Resident #2 was alone. During an interview on 10/21/2025 at 5:42 PM, RN H that it was reported by a family member of another resident stated there was a man taking Resident #2 across the street. RN H stated that she did not know the person who reported this to her and guessed it had to be the family member of a different resident. RN H stated that she and another staff went across the street to the apartment complex and Resident #2 was found at the complex. RN H stated prior to crossing the street she observed Resident #2 with a male crossing the street (not on a cross walk) and they were walking towards the apartment complex with the unknown male pushing Resident #2 in a wheelchair. RN H stated she asked the unknown male where he came from and that he stated he was going inside the facility and became agitated and stated Resident #2 told him she lived in the apartments and he believed her. RN N stated that when she went across the street to get Resident #2 it was the afternoon and it was not dark. RN H stated that Resident #2 did not go outside prior to the elopement and mostly spent time in her room. RN H stated that the LVN CC completed a head to toe assessment. RN H stated that Resident #2 had supervision because someone was with her and Resident #2 stated he was taking me to my apartment. RN H defined elopement as someone leaving home without any permission or anyone knowing about it or where that person was. RN H that she considered this an elopement whether Resident #2 was with someone or not because Resident #2 left without any permission and she was not in her right mind. RN H stated she did not know how long Resident #2 was gone. During an interview on 10/22/2025 at 11:05 AM, ADM stated that there was no elopement reported to her on 06/05/2025 or 06/06/2025. The ADM stated had it been reported to her that Resident #2 tried to cross the street Resident #2 would have been put on 1:1 supervision and discharged much sooner. ADM stated that she would have expected any elopement to be reported to her or the DON. The ADM stated an investigation would have been conducted with interview from Resident #2 to try and figure out what caused the elopement. The ADM stated during investigation normally she talked to the resident staff, find out the last time the resident was seen and put the resident on 1:1 and get with family to start the discharge process. The ADM stated there were no incident reports for 06/05/2025, 06/06/2025 or 06/21/2025 elopements, or witness statements. Review of TULIP from June 2025 through 10/22/2025 reflected no reports for elopements. Review of in-service dated 06/27/2025 titled Elopement reflected in-service was completed with staff and reviewed the policy Elopement Response Protocol. Review of Adhoc QAPI Plan dated 07/01/2025 reflected the ADM was notified on 06/21/2025 at 12:30 PM the facility that a resident was missing. Review reflected there were no staff or witness statements included in the meeting notes. Review reflected inconsistencies among staff on Resident #2's 06/21/2025 elopement. Review reflected there was no investigation or information regarding a 06/05/2025 or 06/06/2025 elopement. Review of facility policy dated March 2012 titled Elopement Response Protocol reflected to Notify Department of Aging and Disability in accordance with guidelines for reportable incidents and based on elopement risk patient may be discharged . Head-to-toe nursing assessment must be completed upon return in addition the physician and responsible party must be notified and document. Review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with revision date of September 2022 reflected if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review also reflected:2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that:The facility failed to care plan Resident #1's history of refusal of medication from 05/06/2025 until 06/16/25.This failure could place residents at risk of not receiving services and interventions for the residents' individual needs for person-centered care.Findings included:Review of Resident #1's face sheet dated 10/320/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage with loss of consciousness status unknown, sequela (bleeding on the brain's surface) where the patient lost consciousness, but the duration is unknown, and it's a sequela, meaning a condition resulting from a previous illness or injury), generalized idiopathic epilepsy and epileptic syndromes (a group of epilepsy syndromes characterized by seizures that originate in both hemispheres of the brain and affect the entire body), and other seizures (a type of seizure that is not a tonic-clonic (a type of generalized seizure that affects the entire brain) seizures).Review of Resident #1's quarterly MDS assessment, dated 07/31/25, reflected a BIMS score of 3, indicating severe cognitive impairment.Record review of Resident #1's care plan dated reflected the following focus areas:focus dated 08/01/25 potential for complications related to seizure disorder and anticonvulsant therapy (the use of medications to prevent or control seizures, also known as convulsions) with intervention dated 08/01/25 give medications per order and monitor labs-report focus dated 08/01/25 Resident #1 had a seizure disorder with intervention dated 08/01/25 give seizure medication as ordered by doctor. Further review revealed the residents medication refusals were not addressed. Review of Resident #1's orders reflected administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE]. Record review of Resident #1's eMAR for June 2025 reflected administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE]. LVN C entered eMAR Code #2 (resident refused) for the following dates: 06/03/25, 06/06/25, 06/09/25, 06/11/25, 06/12/25, 06/13/25, and 06/13/25.Review of Resident #1's orders reflected give 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for May 2025 reflected administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 05/13/25, 05/20/25, 05/21/25, 05/23/25, 05/26/25, 05/27/25, 05/28/25, 05/29/25, 05/30/25.Review of Resident #1's eMAR for June 2025 reflected administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) on 06/01/25 and MT B for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25 06/13/25, and 06/16/25. Review of Resident #1's orders reflected one 3 MG tablet Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected one 3 MG tablet Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused ) on 06/01/25. Review of Resident #1's orders reflected one 15 MG tablet of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for June 2025 one 15 MG tablet of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE]. MT A entered Code #2 (resident refused) on 06/01/25. Review of Resident #1's orders reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 5/13/25, 05/19/25, 05/20/25, 05/21/25, 05/23/25, 05/26/25, 05/27/25, 05/28/25, 05/29/25, and 05/30/25. Review of Resident #1's eMAR for June 2025 reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) on 06/01/25 and MT B for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/07/25, 06/08/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25, and 06/16/25.Review of Resident #1's orders reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 05/13/25, 05/20/25, 05/21/25, 05/23/25, and 05/26/25, 05/27/25, 05/28/25, 05/29/25, and 05/30/25. Review of Resident #1's eMAR for June 2025 reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) on 06/01/25 8:00 am and MT B for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/25/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25 and 06/16/25.Review of Resident #1's orders reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am for constipation start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates05/20/25, 05/21/25, 05/23/25, and 05/26/25, 05/27/25, 05/28/25, 05/29/25 and 05/30/25. Review of Resident #1's eMAR for June 2025 reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) for 8:00 am and 7:00 pm on 06/01/25 and MT B for 8:00 am on the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25 and 06/16/25.Review of Resident #1's orders reflected Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for seizure start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am for seizure start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) entered on 06/01/25 and MT B for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25 and 06/16/25.Review of Resident #1's orders reflected levetiraceta Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected levetiraceta Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am for seizures start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 05/13/25, 05/20/25, 05/21/25, and 05/23/25. Review of Resident #1's eMAR for June 2025 reflected levetiraceta Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) at 7:00 am and 7:00 pm on 06/01/25 and MT B at 7:00 am for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25, and 06/16/25.Review of Resident #1's orders reflected Tylenol 8-hour oral tablet extended release 650 MG (Acetaminophen) give one table by mouth every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for pain level start date 05/20/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected Tylenol 8-hour oral tablet extended release 650 MG (Acetaminophen) give one table by mouth every 8 hours at 7:00 am for pain level start date 05/20/25 and discharge date [DATE]. MA T entered eMAR Code #2 (resident refused) on 06/01/25 and MT B for the following dates: 06/02/25, 06/03/25, 06/05/25, 06/06/25 , 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25 and 06/16/25.Review of Resident #1's orders reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 05/21/25, 05/26/25, 05/27/25, 05/28/25, 05/29/25, and 05/30/25. Review of Resident #1's eMAR for June 2025 reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) at 7:00 am and 7:00 pm on 06/01/25 and MT B for 7:00 am on the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/24, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25, and 06/16/25.Interview on 10/20/25 at 8: 56 am with the ADON reflected if the number 2 was entered in a residents' eMAR it meant that the resident refused to take the medication. If a resident refused medication from the MT, the policy was for the MT to notify the nurse who would notify the RP and either the NP or MD. Interview on 10/20/25 at 9:22 pm with the NP via phone reflected Resident #1 refused to take his medications. She said he was very non-compliant about a lot of resident care; she gave the example of Resident #1 refusing to take his showers. She said Resident #1 would get angry with staff members and throw them out of his room. She said she cannot recall the number of times the facility called her and told her that Resident #1 refused to take his medications, but it was several times. Interview on 10/20/25 at 1:22 p.m., MT B reflected she had worked at the facility since 2011, worked with Resident #1 and Resident #1 did refuse to take his medications. She said when Resident #1 refused to take his medications, she would try 2 or 3 times to get him to take it and if he still refused, she would tell a nurse he refused. She said she was not sure if she had access to the care plans and it was the responsible of the nurse to document any medication refusals in resident progress notes. She said she discussed his medication refusals with the charge nurses but did not specifically remember who or when. Interview on 10/20/25 at 1:36 p.m., LVN C reflected she worked with Resident #1, and it was common knowledge he did not take his medication. She said she notified both the MD and the RP. She said she reported in staff morning meetings that Resident #1 did not take his medication. She said a care plan was the outline of the care a resident received when at the facility and a care plan included the expectations and goals that the facility had for residents. She said a possible negative effect of not care planning for resident medication refusals was that you would not know how to address the problem and the resident might not get medications the resident needs. Interview on 10/22/25 at 9:25 a.m., MT A via phone reflected she did not really remember Resident #1. She said it was the responsibility of a MT to notify the nurse if a resident refused medication. She said she would try three times to give a resident medication and after that, she would leave it up to the nurse to administer the medication to the resident.Interview on 10/22/25 at 3:40 p.m., the MDS Coordinator reflected a care plan encompassed what services were provided for a resident and was the A to Z, beginning to end, of resident information. He said he did the facility resident comprehensive care plans and sometimes he worked as a nurse on the floor. He said he relied on information received from the nurses who cared for the residents to add to a residents' care plan. He said if a resident refused medication, it should have been included in the resident's care plan. He said the possible negative effect of information not being included in a resident plan was that the information would not be disseminated to the front-line care givers and could affect residents care. Interview on 10/23/25 at 10:56 a.m., MT B reflected Resident #1 would say get out when she would try to give him his medications. She said she would go back two times and try to give him medications and some days he accepted it and some days he did not. She said every time he refused his medications she let someone know. She said she did not know the names of the nurses she told because there were quite a few nurses. Interview on 10/23/25 at 11:06 a.m., the MD reflected she was aware that Resident #1 refused his medications. Interview on 10/23/25 at 1:11 p.m., the ADON reflected a care plan was an individualized plan of care for that resident. She said a care plan started at resident admission and was added to as the facility learned about a resident. She said there was an opportunity to add to the care plan from the input from nurses and other people from the IDT Team (a patient, family members, and professionals from different fields to coordinate care). She said she knew that Resident #1 could be combative and resistant to care so maybe Resident #1 refused medications. She said it was important to identify which care a resident was resistant to and the approach to different refusals of care would be different. She said refusals to take medication should be care planned because staff could know about the refusals and follow the interventions and goals for that resident outlined in the residents' care plan. She said a possible negative effect of not care planning for medication refusals was lack of care for that resident and lack of interventions. Interview on 10/24/25 at 9:04 a.m., the Administrator reflected a care plan should tell you everything you need to know about how to are for the resident. She said it was necessary because you need to know what might or might not work for that resident. She said medication refusals should be care planned because it was a behavior and any behavior should be care planned and the facility needs to have interventions to address issues. She said medication refusals could be life threatening. She said everyone was responsible for a care plan. She said the MDS Coordinator was responsible because they did the charts. She said the nurse management team were responsible for making sure resident information was properly documented and the Administrator was ultimately responsible for making sure things were done. She said a possible negative effect of not documenting was that you are not going to fix the problem and in an extreme situation the resident could die. Interview on 10/24/25 at 11:44 a.m., the DON reflected it was her expectation that nurses document changes of condition and resident medication refusal was a change of condition. She said a care plan was an overall summary of how a resident should be cared for and how and what the staff would do to provide care for that resident. She said medication refusals should be care planned. She said the MDS Coordinator was responsible for the resident care plan, but nurses added to the resident care plan. She said that CNAs and MTs do not have any responsibility for care plans. A possible negative effect of not documenting medication refusals in a care plan would be that there would be no documentation that the resident did not get the therapeutic benefits of the medication. A refusal of medication in the care plan would trigger everyone to know that they needed to intervene in a different way when a resident refused to take the medication. She said that medication refusals could have been discussed in the facility morning meetings and resident care plans could be updated. Record review of facility policy Care Plan, Comprehensive Person-Centered dated March 2022 reflected a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for one (Resident #3) of six residents review for pharmacy services. The facility failed to administer the following medication to Resident #1: Nicotine Patch 05/01/25, 05/02/15, 05/05/25, 05/09/25, 05/15/25, 05/16/25, and 05/27/25 Folic Acid Tablet 05/01/25, 05/02/15, 05/05/25, 05/09/25, 05/15/25, 05/16/25, and 05/27/25 and 06/27/25 and 06/28/25 multiple vitamin tablet 5/01/25, 05/09/25, and 05/15/25 vitamin B1 05/01/25, 05/09/25, and 05/15/25 Docusate Sodium 05/01/25, 05/09/25, and 05/15/25 levetiracetam Solution 05/01/25, 05/09/25, and 05/15/25 Tylenol 05/01/25, 05/09/25, 05/13/25, and 05/15/25 Enteral Feed 05/01/25, 05/02/25, 05/14/25, 05/30/25, 06/06/25 and 06/12/25 This failure could place residents at risk of experiencing worsening of their condition, increased risk of falls, pain, and injury. Findings included:Review of Resident #1's face sheet dated 10/320/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage with loss of consciousness status unknown, sequela (bleeding on the brain's surface) where the patient lost consciousness, but the duration is unknown, and it's a sequela, meaning a condition resulting from a previous illness or injury), generalized idiopathic epilepsy and epileptic syndromes (a group of epilepsy syndromes characterized by seizures that originate in both hemispheres of the brain and affect the entire body), and other seizures (a type of seizure that is not a tonic-clonic (a type of generalized seizure that affects the entire brain) seizures).Review of Resident #1's quarterly MDS assessment, dated 07/31/25, reflected a BIMS score of 3, indicating severe cognitive impairment.Record review of Resident #1's care plan reflected focus dated 08/01/25 potential for complications related to seizure disorder and anticonvulsant therapy (the use of medications to prevent or control seizures, also known as convulsions) with intervention dated 08/01/25 give medications per order and monitor labs-report focus dated 08/01/25 Resident #1 had a seizure disorder with intervention dated 08/01/25 give seizure medication as ordered by doctor. Record review of Resident #1's order dated 02/11/25 reflected may give medication by mouth or via G-Tube (a feeding tube inserted through a surgical opening in the abdomen directly into the stomach to deliver nutrition, fluids, and medication). Record review of Resident #1's orders reflected Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day at 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE]. Record review of Resident #1's eMAR for May 2025 for administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day at 7:00 am for smoking sensation reflected blank spaces for the following dates: 05/01/25, 05/02/15, 05/05/25, 05/09/25, 05/15/25, 05/16/25, and 05/27/25. Review of Resident #1's orders reflected give Folic Acid Tablet (prevents and treats low levels of folate (vitamin B9) in your body) 1 MG via G-Tube one time a day for vitamin deficiency start date 06/27/25 discharge date [DATE]. Review of Resident #1's eMAR for May of 2025 for Folic Acid Tablet (prevents and treats low levels of folate (vitamin B9) in your body) 1 MG tablet one time a day at 7:00 am via G-Tube for vitamin deficiency start date 06/27/25 discharge date [DATE] blank spaces for the following dates: 05/01/25, 05/09/25, 05/15/25. Review of Resident #1's eMAR for June of 2025 for Folic Acid Tablet (prevents and treats low levels of folate (vitamin B9) in your body) 1 MG tablet one time a day at 7:00 am via G-Tube for vitamin deficiency start date 06/27/25 discharge date [DATE] blank spaces for 06/27/25 and 06/28/25. Review of Resident #1's orders reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] blank spaces for 05/01/25, 05/09/25, and 05/15/25.Review of Resident #1's orders reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for May 2025 reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] blank spaces for the following dates: 05/01/25, 05/09/25, and 05/15/25.Review of Resident #1's orders reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 8:00 pm for constipation start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 8:00 pm for constipation start date 05/01/25 and discharge date [DATE] blank spaces for the following dates and times 8:00 am 05/01/25, 8:00 am 05/09/25, and 8:00 am 05/15/25. Review of Resident #1's orders reflected levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE]. Review of Resident #1's orders reflected levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE] blank spaces for 7:00 am 05/01/25, 05/09/25, and 05/15/25,Review of Resident #1's orders reflected Tylenol 8-hour oral tablet extended release 650 MG (Acetaminophen) give one table by mouth every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for pain level start date 05/01/25 and discharge date [DATE].Review of Resident #1's orders reflected Tylenol 8-hour oral tablet extended release 650 MG (Acetaminophen) give one table by mouth every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for pain level start date 05/01/25 and discharge date [DATE] blank spaces for 7:00 am 05/01/25, 7:00 am 05/09/25, 11:00 pm 05/13/25, 7:00 am 05/15/25. Review of Resident #1's orders reflected enteral feed (the delivery of a special liquid nutrition formula directly into the digestive system through a tube to provide the nutrients and calories a person cannot get by eating or drinking) every shift lsosource 1.5 at 50 ml/hour (provides a continuous feeding rate with 75 calories per hour) via (by means of) feeding tube with auto flushes (enabled nurses to administer flush solution at regular intervals during continuous tube feeding, decreasing the risk of a clog and possibly sparing the patient the distress of tube replacement) at 30 ml every 4 hours. May remove for care and services start date 05/01/25 discharge date [DATE]. Review of Resident #1's eMAR for May of 2025 for enteral feed (the delivery of a special liquid nutrition formula directly into the digestive system through a tube to provide the nutrients and calories a person cannot get by eating or drinking) every shift Isosource ( a calorically dense complete nutrition formula ) 1.5 at 50 ml/hour (provides a continuous feeding rate with 75 calories per hour) via (by means of) feeding tube with autoflushes (enabled nurses to administer flush solution at regular intervals during continuous tube feeding, decreasing the risk of a clog and possibly sparing the patient the distress of tube replacement) at 30 ml every 4 hours. May remove for care and services start date 05/01/25 discharge date [DATE] reflected blank spaces for Day 05/01/25, Day and Night 05/02/25, Night 05/14/25, and Day 05/30/25.Review of Resident #1's eMAR for June of 2025 for enteral feed (the delivery of a special liquid nutrition formula directly into the digestive system through a tube to provide the nutrients and calories a person cannot get by eating or drinking) every shift Isosource ( a calorically dense complete nutrition formula ) 1.5 at 50 ml/hour (provides a continuous feeding rate with 75 calories per hour) via (by means of) feeding tube with autoflushes (enabled nurses to administer flush solution at regular intervals during continuous tube feeding, decreasing the risk of a clog and possibly sparing the patient the distress of tube replacement) at 30 ml every 4 hours. May remove for care and services start date 05/01/25 discharge date [DATE] reflected blank spaces for 06/06/25 night and 06/12/25 night.Interview on 10/20/25 at 12:14 pm with LVN J a Charge Nurse reflected if there was blank entry in the eMAR for a medication administration, the medication was not administered and it was a medication error and horrible resident quality of care and [NAME] tottered close to abuse and neglect. She said the charge nurses and DON were accountable to make sure medication was properly documented. Interview on 10/20/25 at 12:52 pm with LVN K reflected blanks in a residents' eMAR showed that the resident did not get a medication and it was bad because medication levels could be affected. She said it was not good quality of care and could risk residents' health all the way around for there to be blanks in the eMAR indicating no medication was administered. She said it was the responsibility of the charge nurse and the nurse administering the medication to make sure medication administration was documented. Interview on 10/20/25 at 1:36 pm with LVN C reflected if there were blank spaces in a resident eMAR, medication administration was not documented and therefore, medication administration did not take place. She said the negative effect of not documenting in the eMAR and therefore resident not receiving medication was that it did not attempting to resolve the problem the MD prescribed the medication to resolve. She said if the resident was not receiving the medication the disease process would probably worsen. It was not good quality of care not to document in the eMAR and the lack of medication administration could risk residents' health all the way around. She said documentation was the responsibility of the charge nurse and the nurse administering the medication. Interview on 10/23/25 at 10:27 am with LVN FF reflected if there were holes in the Emar, medication was not administered and it was a medication error. She said a possible negative effect of not documenting in the eMAR was that the resident did not get their medications or a resident could receive a double dose of medication and the resident would not receive the benefit of taking the medication. Interview on 10/23/25 at 1:11 pm with the ADON reflected it was important to document, and it was important to document communication in the eMAR from shift to shift. She said documentation was important to the resident for ongoing patient care. She said if you did not document that a resident received the medication the next shift will just assume he received the medication. Interview on 10/24/25 at 9:04 with the Administrator reflected the nurse management team were responsible to make sure that resident information was properly documented and the Administrator was ultimately responsible for making sure things were done. A possible negative effect of not documenting was that you were not going to fix the problem and a resident could die. She revealed that the holes in the resident eMAR were not proper documentation. She said if there was a blank the medication was not given. If it was not documented, it was not done. She said if residents did not get their medications, residents did not get the benefit of the medicationInterview on 10/24/25 at 11:44 am with the DON reflected if you did not document it stated you did not care for your resident and presented an overall statement of the care and treatment received. She said if it was not documented it was not done. She said it was the responsibility of the nurse managers to make sure staff were documenting properly. Record review of facility Medication Administration policy dated December 2012 reflected medications shall be administered in a safe and timely manner, and as prescribed, only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered;b. The dosage;c. The route of administration;d. The injection site (if applicable);e. Any complaints or symptoms for which the drug was administered;f. Any results achieved and when those results were observed; andg. The signature and title of the person administering the drug. Review of facility Refusal of Treatment policy dated May 2013 reflected Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care. The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician. Treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan. If the resident's refusal brings about a significant change, a reassessment will be made and such information will be incorporated into the resident's care plan. Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record.Documentation pertaining to a resident's refusal of treatment shall include at least the following:The date and time the staff tried to give a medication or treatment was attempted;The medication or treatment refused;The resident's response and reason(s) for refusal;The name of the person attempting to administer the treatment;That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment;The resident's condition and any adverse effects due to such refusal;The date and time the physician was notified as well as the physician's response;All other pertinent observations; andThe signature and title of the person recording the data.The Attending Physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal. For example, a resident's refusal to take a diuretic while experiencing acute congestive heart failure should be reported immediately, while a refusal to take a blood pressure medication while the blood pressure is well controlled can be reported within 24 hours.

Based on interviews and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of five residents reviewed for accurate clinical records, in that:The facility failed to document in Resident #1's EMR progress notes from 05/13/25 through 06/16/25 that the NP or MD and RP were notified of Resident #1's medication refusals.This failure put residents at risk for inaccurate medical records, decreased quality of care and decline in quality of life.Findings included:Review of Resident #1's orders reflected administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE] Record review of Resident #1's eMAR for June 2025 reflected administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by LVN C for 06/03/25, 06/06/25, 06/09/25, 06/11/25, 06/12/25, 06/13/25, and 06/13/25.Review of Resident #1's orders reflected give 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for May 2025 reflected administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused ) entered by MT B for 05/13/25, 05/20/25, 05/21/25, 05/23/25, 05/26/25 through 05/30/25.Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE] for dates 05/13/25, 05/20/25, 05/21/25, 05/23/25, 05/26/25 through 05/30/25. Review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE] for 06/01/25, 06/02/25 through 06/06/25, 06/09/25 through 06/13/25, and 06/16/25Review of Resident #1's orders reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 5/13/25, 05/19/25 through 05/21/25, 05/23/25, 05/26/25 through 05/30/25. Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] for 5/13/25, 05/19/25 through 05/21/25, 05/23/25, 05/26/25 through 05/30/25.Review of Resident #1's orders reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 05/13/25, 05/20/25, 05/21/25, 05/23/25, and 05/26/25 through 05/30/25.Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] for 5/13/25, 05/19/25 through 05/21/25, 05/23/25, 05/26/25 through 05/30/25.Review of Resident #1's orders reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 8:00 am 05/20/25, 8:00 am 05/21/25, 8:00 am 05/23/25, and 8:00 am 05/26/25 through 05/30/25. Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE] for 8:00 am 05/20/25, 8:00 am 05/21/25, 8:00 am 05/23/25, and 8:00 am 05/26/25 through 05/30/25. Review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE] for 8:00 am 06/02/25 through 06/06/25, 8:00 am 06/09/25 through 06/13/25 and 8:00 am 06/16/25.Review of Resident #1's orders reflected levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 7:00 am 05/13/25, 7:00 am 05/20/25, 7:00 am 05/21/25, and 7:00 am 05/23/25.Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE] for 7:00 am 05/13/25, 7:00 am 05/20/25, 7:00 am 05/21/25, and 7:00 am 05/23/25.Review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE] for 7:00 am and 7:00 pm 06/01/25 and MT B for 7:00 am 06/02/25 through 06/06/25, 7:00 am 06/09/25 through 06/13/25, and 7:00 am 06/16/25.Review of Resident #1 orders reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina) and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 7:00 am 05/21/25, 7:00 am 05/26/25 through 05/30/25.Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE] for 05/26/25 through 05/30/25.Review of Resident #1's orders reflected one 3 MG tablet Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected one 3 MG tablet Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused ) entered by MT A for 06/01/25. Record review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE] for 06/01/25.Review of Resident #1's orders reflected one 15 MG tablet of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for June 2025 one 15 MG tablet of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT A for 06/01/25.Record review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE] for 06/01/25.Review of Resident #1's orders reflected Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for seizure start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for seizure start date 05/01/25 and discharge date [DATE] eMAR Code #2 (resident refused) entered by MT A for 7:00 am 06/01/25 and MT B for 7:00 am 06/02/25 through 06/06/25, 7:00 am 06/09/25 through 06/13/25 and 7:00 am 06/16/25.Record review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for seizure start date 05/01/25 and discharge date [DATE] for 7:00 am 06/01/25 and MT B for 7:00 am 06/02/25 through 06/06/25, 7:00 am 06/09/25 through 06/13/25 and 7:00 am 06/16/25.Interview on 10/21/25 at 12:14 pm with LVN J reflected when a resident refused a medication you had to enter a progress note and input why the resident refused the medication and call the NP or MD and RP. Nurses were required to in the resident's progress notes what the NP or MD stated about the medication refusal. She said it was a problem if there was no documentation of the medication refusal in progress notes because there was no plan of action going forward or information if there was an adverse reaction. She said the nurse the communication was broken it was a gap in resident care. She said if you did not put a note in the progress notes, you probably did not notify the NP or MD. She said medication refusal could impede a resident's overall health status. Interview on 10/20/25 at 12:52 pm with LVN K reflected she worked with Resident #1 and administered him medication. If a resident refused medications the nurse was expected to notify the NP or MD and RP and document the refusal and the notifications in the residents EMR. The negative effect of not documenting that a resident did not receive medication and not attempting to resolve the problem was that the MD did not have an opportunity to address the problem. To not document when a resident refused medication was not good quality of care and could risk a resident's health. Documenting was the responsibility of the charge nurse and the nurse administering the medication. Interview on 10/20/25 at 1:36 pm with LVN C reflected it was common knowledge that Resident #1 refused his medication, and she notified the doctor and the RP and said, Lord I hope I did when asked if she documented the refusal and the notification in the progress notes. She said if Resident #1 did not have enough of his seizure medications, he could have had a seizure, and the doctor should have been notified and it should have been in the progress notes. She said if something was not documented, it was not done and if you did not document it did not take place. She said it was the responsibility of the charge nurse to make sure documentation was taken care.Interview on 10/23/25 at 1:11 pm with the ADON reflected if a resident refused mediation the refusal should be documented in the resident's progress notes and the notification to the MD and family of the refusal should be documented and the progress notes. She said it should be documented every time a resident refused medication. She said documenting was important to residents for the residents' ongoing patient care. Interview on 10/21/24 at 4:27 pm with the MD G reflected he knew that Resident #1 refused his medications, and it was his understanding that nursing staff would have to notify the RP. He said there was no notification that Resident #1's refusal of his seizure medication was that extensive. He said missing the doses could have caused a seizure, but they were monitoring his levels of seizure medications, and the labs did not indicate his levels were abnormal. Interview on 10/24/25 at 9:04 am with the Administer reflected the management and nursing team are responsible for making sure things are properly documented. Nurses should notify the MD, family when a resident refuses medication and this communication should be documented in the residents' progress notes. A possible negative effect of not documenting was that you were not going to fix the problem and a resident could die with the case of this, because Resident #1 refused his seizure medication, he could have had a seizure.Interview on 10/24/25 at 11:44 am with the DON reflected that it was her expectation that nurses documented in the progress notes for a change of condition and said a resident's refusal to take medication was a change of condition. She said medication refusal should be documented and notification of the refusal to the MD, family, and supervisor should be documented. She said that every time a resident refused medication it should be documented. She said the possible negative effect of not documenting medication refusals would be MDs would not be able to have the information to try a different route or different treatment. She said documentation was very important and was the verification of how you cared for the resident. She said if you did not document, it stated you did not care for your resident. She said you could not confirm that the MD or RP were contacted if it was not documented. She said if it was not documented it was not done. She said it was the responsibility of the nurse managers to make sure staff were documenting properly. The facility was unable to provide a policy on documentation.

Based on interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, for 1 of 4 residents (Resident #3) reviewed for quality of care. The facility failed to ensure Resident #3 had orders for tracheostomy care and that tracheostomy care was completed on 03/14/2025 and 03/15/2025. This failures could place residents at risk of inadequate care, respiratory distress and hospitalization. Findings include: Review of Resident #3 face sheet reflected a [AGE] year-old-male admitted on [DATE] at 7:00 PM and discharged on 03/15/2025 at 12:15 PM. Diagnoses included hypertensive heart disease (condition where prolonged high blood pressure damages the heart muscle), chronic kidney disease (condition where the kidneys gradually lose their ability to filter waste from the blood), malignant neoplasm of thyroid gland (cancer that develops in the thyroid gland). Review of admission MDS dated [DATE] reflected Resident #3 Section O titled Special Treatments, Procedures and Programs reflected tracheostomy care was not selected. Review of baseline care plan dated 03/15/2025 by ADON reflected Resident #3 was alert / cognitively intact. Review of care plan dated 03/15/2025 reflected Resident #3 was on enhanced barrier precautions with feeding tubes selected for the reason and tracheostomy was not selected. Review of admission/ re-admission charge nurse report form dated 03/14/2025 by RN ZZ reflected Resident #2 had a thyroidectomy, shortness of breath, neck swelling, and a peg tube. Review reflected Resident #3 was alert and oriented x3 (person, time, place, situation). There was no information that Resident #3 had a tracheostomy. Review of nursing admission assessment with admission date of 03/14/2025 reflected no tracheostomy was present for Resident #3. Review of Resident #3 hospital discharge instructions dated 03/14/2025 reflected Resident #3 required a portable trach suctioning, had a shiley (size 6) and a cuffless trach (reusable inner cannulas). Review reflected does patient have a tracheostomy?: Yes. Review of physician orders and treatments dated 03/15/2025 reflected there were no orders for tracheostomy care or suctioning. Review of the MAR/ TAR for Resident #3 dated 03/15/2025 reflected there were no treatments provided for tracheostomy care. Review of nursing progress notes dated 03/15/2025 by LVN O at 1:19 PM Resident #3's family member stated that Resident #3 complained of back pain and requested to be sent to the hospital. LVN O scheduled transportation with vital signs within normal limits. Interview was attempted with Resident #3 on 10/20/2025 at 3:14 PM , however, the number provided for Resident #3 was out of service. An email was sent at 3:17 PM on 10/20/2025 with no response. During an interview on 10/21/2025 at 10:51 AM, LVN O stated he has worked at the facility since December 2024. He stated that if residents were admitted with a tracheostomy, there was a suctioning machine set up in the residents room and the nurse had to make sure the resident had tracheostomy care per doctor's orders. LVN O stated this included PRN suctioning orders as well. LVN O stated it was hard to say often residents needed to be suctioned because secretions are different for every resident. LVN O stated that usually tracheostomy care was done in the morning between 4:00 am and 6:00 am. LVN O stated he worked overnight and he usually provided tracheostomy care in the morning which included to change the dressing of the tracheostomy. LVN O stated that if a resident was a new admission then orders were received from the hospital and then verified by the on-call doctor. LVN O stated that after admission the on-call provider would be notified that a resident admitted with a tracheostomy and the provider would give orders for care to be put into the system. LVN O stated he did not recall Resident #3 and whether or not the resident had a tracheostomy. During an interview on 10/22/2025 at 12:42 PM, MD G stated if a resident admitted to the facility with a tracheostomy then there is an order set for tracheostomy care that staff can put into the system and it was expected that they do so and verify orders with the provider. During an interview on 10/22/2022 at 3:24 PM, RN ZZ stated she did not recall Resident #3 or if he had a tracheostomy. RN ZZ stated that sometimes nurses will take report for other nurses and taking report did not always mean they completed the admission for the resident. RN ZZ stated there was a respiratory therapist that provide care a few times a week and that charge nurses also provided tracheostomy care. RN ZZ stated that usually tracheostomy care was done every shift and at least assessed. RN ZZ stated that if dressing was soiled it will get changed and it was also changed when tracheostomy care is provided. RN ZZ stated that there are also orders put into place as to when to provide tracheostomy care. RN ZZ stated for new admissions, the doctor usually put the orders for tracheostomy care. RN ZZ stated that there were also standing orders for tracheostomy care that the DON will put in. RN ZZ stated that usually suctioning was completed every four hours and as needed. During an interview and observation on 10/22/2025 at 3:48 PM, ADON stated she did not recall Resident #3 at all and that her name was on the assessment because she may have helped out the charge nurse. ADON reviewed Resident #3's discharge information and stated that based on the hospital discharge paperwork it looked like Resident #3 had a tracheostomy. ADON stated that charge nurses completed tracheostomy care and there was a respiratory therapist that came out a few times a week and would provide tracheostomy care as well and change out supplies and assess residents. ADON stated orders for tracheostomy care were provided by doctors and there were standing orders in place for resident who admitted with a tracheostomy that the nurse could put in. ADON stated there were also orders from discharge records from the hospital. ADON stated orders should be put in the same day the resident admitted to the facility. ADON stated it was important for orders to be put in so nurses know to provide tracheostomy care. ADON stated tracheostomy care was performed each shift and suctioning was provided according to how much secretion the resident had. ADON stated a potential risk for a resident not receiving tracheostomy care was risk of aspiration or shortness of breath. ADON stated usually she checked admission orders when she arrived the next morning, but she was not at the facility on weekends and the RN H would check the admissions on the weekends. An attempted telephone interview was conducted on 10/23/2025 at 11:39 AM and 1:03 PM with the DON a voicemail was left but the call was not returned. During an interview on 10/23/2025 at 12:02 PM, LVN Y stated that if a resident admitted with a tracheostomy the nurse was supposed to place all tracheostomy orders into the computer and that included the suctioning orders and tracheostomy care. LVN Y stated that tracheostomy care was provided each shift and suctioning was done as needed and when the care was performed. LVN Y stated that the doctor providers the orders and they are put into the system. LVN Y stated that there are existing orders that can be put in place for new admissions with tracheostomy. LVN Y stated that discharge orders were received and report is received form the hospital to ensure that information is received on whether or not the resident has a tracheostomy to ensure everything is put into place. During an interview on 10/23/2025 at 3:49 PM, the ADM stated there are standing orders that can be put into place for residents who admit with tracheostomies. The ADM stated there are batch orders that can be put in and reviewed with everything the residents needs for tracheostomy care. The ADM stated new admission orders are reviewed daily during the IDT which included significant changes and admissions. The ADM stated a resident should have had tracheostomy care the day of admission and the nurse should have verified those orders. The ADM stated if the hospital did not provide orders, staff can reach out to the hospital and once the orders were verified they can be put in. The ADM stated there was no time limit as to when orders could be verified with the doctor. The ADM stated a potential risk to a resident not having tracheostomy care orders could be respiratory distress or death. Review of in-services for February 2025 through October 2025 reflected there were no in-services conducted on tracheostomy care. Review of in-service dated 04/18/2025 titled admission Assessments was completed with nursing staff and reflected nurses are to complete admission assessment within 24 hours. Review of policy titled Tracheostomy Care with revision date of August 2013 reflected procedure included to check the physician order.

Based on interview, and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1 (CR#1) of 7 residents reviewed for pressure ulcers. -The facility failed to ensure CR #1 received the care and services to prevent a stage 2 pressure wound on her sacral from deteriorating to a Stage 4 measuring 7 (L) x 13 (W) x 3 (D). CR#1 was sent to a local hospital after family intervention and was diagnosed with fever and Sepsis. -The facility failed to immediately begin treatment after CR #1 was admitted on [DATE], a referral made by primary Physician on 3/14/2025 and the first visit by the wound care doctor/NP was on 3/26/2025. -The facility failed to implement new interventions when the sacral wound was not healing and required debridement for necrotic tissue. -The facility failed to ensure re-positioning was performed for CR #1, Resident #2, and Resident #3and did not have documentation on repositioning/turning frequency. An Immediate Jeopardy (IJ) was identified on 05/30/2025 at 1:28pm. While the IJ was removed on 6/4/2025 at 12:39pm., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of pain, worsening of wounds, infection, emotional distress, hospitalization, and death. Findings Included: Record review of CR #1's face sheet dated 5/28/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of partial intestinal obstruction (a blockage in the intestines that allows some but not all digested material to pass through), unspecified dementia(cognitive impairment), pressure ulcer of sacral region(injury to skin and underlying tissue due to prolonged pressure), stage 2, pressure-induced deep tissue damage of left heel, dysphagia (difficulty swallowing), hypothyroidism (a condition in which the thyroid gland does not produce produce enough thyriod hormone), and hyperlipidemia (condition in which there are high levels of lipids in the blood). Record review of CR #1's Discharge summary dated [DATE] from a local hospital revealed CR#1 was discharged on 3/13/2025 with an open abdominal wall wound due to the small bowel obstruction surgery, stage 2 sacral wound, unstageable right heel pressure wound, stage 2 left buttock and dementia. Record review of CR #1's admission MDS dated [DATE] revealed the following: *Section C0500- Brief Interview of Mental Status summary score was coded as 03-representing severe cognitive impairment. *Section GG- Functional Abilities: toileting, shower/bathe, oral hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer were coded as 01- Dependent on helper for all the effort. *Section H0400- Bowel Incontinence- was coded 3. Always incontinent *Section M0150- Risk of pressure ulcers were coded 1. Yes *Section M0210- Skin Condition Unhealed pressure ulcer was coded 1. For the number of unhealed ulcers (1) *Section M0300- C. Stage 3 number of ulcers was coded (1). Number of pressure ulcers that were present upon admission. *G. Unstageable - Deep tissue injury (1). Number of unstageable wounds *Section M1200- Check all that apply revealed: pressure reducing device for chair and bed, nutrition or hydration intervention, pressure ulcer, surgical wound, application of ointments and application of dressings to feet. Further review revealed Turning and re-positioning was not checked. Record review of CR #1's updated care plan dated 5/20/2025 revealed the following: *Focus: Wound management *Goal: CR#1 wound to show signs of improvement, will be free of signs of infection, management of pressure ulcer and prevention of future pressure ulcers. *Interventions: Administer antibiotic treatment as prescribed, encourage resident to elevate legs, if drainage present get order for culture, measure ulcer on regular intervals, monitor ulcer for signs of progression or declination and notify provider if no signs of improvement on current wound regiment. Further review of the care plan revealed the wound care focus did not have the location of the wound (s). Record review of CR #1's Care plan dated 4/14/2025 revealed: *Focus: Pressure ulcer prevention *Goal: CR#1 will remain free of skin breakdown *Interventions: Barrier cream, encourage floating heels, pressure redistribution mattress, turn/reposition q2 hours and PRN and use suspension devices, pillows, and/or wedges. Record review of CR #1's Braden scale for predicting pressure sore risk dated 3/13/2025 had a score of 9. This represented she was at high risk due to her being bedfast, limited mobility, poor nutrition, and constantly being moist. According to the score sheet, a total score of 12 or less represented high risk. Record review of CR #1's Wound Care progress note dated 3/14/25 written by Nurse A stated CR#1 was a new admission, skin assessment performed upon admission. Resident noted with surgical wound of the abdomen, wound to the sacrum, bilateral heel, also noted with G-tube and foley. Wound team will follow up with CR#1 on Wednesday/Friday during their next weekly visit. Record review of CR #1's Physician's progress notes for March 2025 written by Primary Physician or NP indicated: *3/14/25 the Primary physician wrote Chief Complaint: Evaluation and management of resident small bowel obstruction, stroke, lacunar infarct, glaucoma, and unstageable sacral wound. NPO and foley catheter noted. Referral to wound care. It was e-signed by primary physician on 3/18/2025 at 9:23pm *3/16/25 NP B wroteB wrote Chief complaint: Evaluation and management of resident small bowel obstruction, stroke, lacunar infarct, glaucoma, and unstageable sacral wound. Skin/breast: Abdominal wound covered with dressing, sacral wound. It was e-signed by NP B on 3/18/2025 at 9:56 p.m. *3/17/25 NP A wrote Chief complaint: Follow-up for small bowel obstruction, constipation, sacral wound reported, surgical site infection and CVA. Plan: Pain management, PT/OT, Vitamins, plan discussed with patient and nursing. It was e-signed by NP A on 3/22/2025 at 9:41pm. Record review of CR #1's weekly skin assessment dated [DATE] written by Nurse A revealed weekly evaluation completed by Wound doctor. Resident noted with post-surgical wound to the abdomen (13 w x 0.1 x not measurable, Stage 3 wound to sacrum was (0.5 X 1 X 0.2) noted to have no tunneling/normal skin (Zinc and turn and repositioning Q2 hours)and DTI to left heel (2 X2 X unmeasurable). Updated care plan notified family and physician. E-signed by WCN A on 3/19/2025 at 3:29pm Record review of Wound care doctors' initial assessment for CR#1 dated 3/26/25 were as follows: *Site #1-Post surgical wound abdomen full thickness (LxWxD) 13x 0.1x not measurable. *Site #2 - Stage 3 pressure wound sacrum measured 8x10x0.2 cm. Dressing treatment - Zinc ointment apply once daily and as needed for 16 days. Secondary dressing: Gauze Island w/bdr apply and as needed for 16 days. Turn side to side in bed every 1 -2 hours. Group 2- mattress; Reposition per facility protocol. *Site #3- Unstageable DTI of the left heel Record review of CR #1s weekly skin assessment written by Nurse A dated 3/26/2025, Weekly wound evaluation completed by wound doctor revealed CR#1 post-surgical wound to the abdomen (13 x 0.1 x not measurable depth, wound to sacrum (8 X 10 X 0.2) apply zinc cover with dry dressing. Low air mattress, offload bony prominences. Turn and reposition q2hours. Right foot abrasion (non-pressure) resolved. Left heel had the same measurements of 2X2X unmeasurable. Record review of CR #1's Weekly skin assessments written by Nurse A from 4/2/25 to 4/9/25 indicated: - dated 4/2/2024, Surgical abdominal wound was resolved. Stage 3 pressure injury sacrum wound 6x12x0.2 - Low air mattress, offload bony prominences. Turn and reposition q2hours, vitamin therapy wound supplement were nutritional interventions. Left heel had the same measurements of 2X2X unmeasurable. - dated 4/9/2024, Stage 3 pressure injury sacrum wound 6x14x0.2 - Low air mattress, offload bony prominences. Turn and reposition q2hours, vitamin therapy wound supplement were nutritional interventions, xeroform treatment. Left knee- scratch- resolved 4/9/2025. Record review of CR #1's Physician's progress notes dated 4/14/25 written by NP A revealed, Sacral wound reported- Decubitus ulcer of sacral wound care daily and PRN. Wound care following blisters to the wound was reported by wound care NP. It was e-signed by NP A on 4/15/2025 at 9:09 pm Record review of CR #1's Weekly skin assessments written by Nurse A from 4/16/25 to 4/23/25 indicated: *dated 4/16/25, Stage 3 pressure injury sacrum measured 6x15x not measurable treatment changed from xeroform to calcium alginate Santyl. Response to treatment: No change. Left heel had the same measurements of 2X2 X unmeasurable. *dated 4/23/25, Stage 3 pressure injury to sacrum changed to a Stage 4 on 4/23/2025 and measured 6x15x not measurable. Record review of CR #1's Wound care doctors' progress note dated 4/23/2025 revealed CR#1's sacrum wound was now a Stage 4 and measured at 6 x14 x unmeasurable (due to presence of nonviable tissue and necrosis (death of body tissue). Debridement performed on the sacral. Record review of CR #1's Wound care doctor's progress note dated 5/28/2025 revealed he did a debridement of CR#1's sacrum wound to decrease necrotic tissue. The wound measured at 5(L) x 14 (W) x 1 cm(D). Record review of CR#1's Medication administration log for March 1-31, 2025 3/14/2025 Jevity 1.2 cal 0.06 gram - 1.2 kcal/mL oral liquid order date 3/13/2025 discontinued 3/16/2025 Wound supplement (30cc) one time daily starting 3/14/2025 discontinued 3/16/2025. Multivitamin with minerals 1 tab oral one time daily Aspirin 81 mg tablet delayed release G-tube every one day starting 3/14/2025 Enoxaparin 40mg /0.4 mL subcutaneous syringe every one day starting 3/14/2025 Vitamin C 500 mg tablet oral two times daily start 3/15/2025 discontinued 3/16/2025 Lidocaine patch 4% topical patch every one day 3/16/2025 Jevity 1.2 cal 0.06 gram oral liquid (60ml/hr) starting 3/16/2025 Levothyroxine 88 mcg tablet every one day starting 3/14/2025 Melatonin 3 mg tablet Multi vitamin with minerals (1 tab) G-tube one time daily Vitamin C 500 mg tablet (1 tab) two times daily Liquid wound supplement (30 cc) one-time daily G-tube Doxycycline hyclate 100 mg tablet two times daily for seven days starting 3/19/2025 for local infection of skin (abdomen) 3/25/2025- Isosource HN 0.05 gram- 1.2 kcal/mL liquid tube feed (replaced Jevity) Record review of treatment administration log for March 2025, revealed the wound care doctor ordered Zinc Oxide one time daily starting on 3/27/2025. The order notes stated: Cleanse sacrum with normal saline or wound cleanser, pat dry, apply Zinc Oxide and cover with dry dressing. Further review revealed there were X's representing treatments were not done between March 1-27, 2025. Record review of CR#1's medication administration for April 1-30, 2025, revealed the following medications had no administration times nor a specified date range: -Multivitamin with minerals -Vitamin C 500 mg tablet two daily -Amoxicillin 875 mg g-tube every 12 hours Record review of CR#1's medication administration record for May 2025 revealed an order for wound supplement one time a day for wound, Give 30 cc -start date 5/3/2025 and discontinued 5/9/2025. -Protein supplement had X's from May 1-31st. This represented medication not given. Record review of POC (Plan of Care) bed mobility for CR#1 from 5/1/25-5/30/25 was documented as follows : -BED MOBILITY: SELF-PERFORMANCE - How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. -BED MOBILITY: SUPPORT PROVIDED - How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Further review revealed there was no documentation of assistance with bed mobility on 5/6/25, 5/9/25, 5/13/25, 5/17/25 nor 5/23/25-5/26/25. Observation of CR#1 on 5/28/2025 at 9:33 am revealed her to be asleep in supine position. There was a stench odor in her room. She was covered with a blanket. Observation of CR#1 on 5/28/2025 at 10:27am, observed to be in supine position FM and EMT inside of the room. An interview with CR#1's RP on 5/28/2025 at 3:20pm she stated before CR#1 was admitted to the facility, she resided at an assisted living facility but had been hospitalized due to a bowel obstruction. She said the hospital recommended she go to a rehabilitation for therapy. She said her family visited CR#1 almost daily. She said every time she visited, she had to ask staff about changing her briefs and/or giving her a bed bath. She said her room had a stench smell. She said she was not aware of the sacral wound was opened or infected until a few days ago . She said the wound care doctor and nurses provided care before 8am in the morning and she usually came much later in the day. She said this was why she did not know about the sacral wound. She stated they would come in and change her, yet they never said anything about her wound, it was covered. She denied staff informing her of the condition of CR#1's wounds. She stated that she had photos from the hospital a day before being admitted to the facility and the sacral wound was the size of a pea. She said the sacral wound she saw a couple of days ago had a large hole that she could put her fist inside of it. She said she was sickened by what she saw. She said she called 911 today (5/28) to get her emergency medical attention. She said CR#1 was lethargic and not herself on the previous day. An interview with attending physician for CR#1 at a local hospital on 5/28/2025 at 3:37pm, said CR#1 was admitted on [DATE] with a low-grade fever of 100.4 degrees Fahrenheit, had elevated WBC, a kidney infection and sepsis. He stated the Sepsis was likely coming from the wound in his clinical assessment. He stated that the sacrum wound had been measured at 7 (L) x 13 (W) x (3) depth upon admission. The hospital started CR#1 on IV fluids and two different antibiotics, vancomycin and Septra. He stated the wound was badly infected. The measurement taken at the hospital was larger than what the facility's wound care doctor documented on the same day . He stated that CR#1 had been admitted to the facility from their hospital. He stated that CR#1's wound was tunneling. He said it was not even opened when she left their hospital. He had reviewed her history. An interview with CR#1's primary doctor's NP on 5/29/2025 at 10:22am, she stated she had been in the building for about 1 year. She said some of her duties see all of the patients and provide medical care. She stated she visited the facility once a week. She stated upon initial assessment they look at the skin and if there are wounds the WC team follow the wounds. She said Wound care Doctor and nurses at the facility made up the wound care team. She stated CR#1 had wounds in her lower extremities but the sacral wound was not seen recently. She her abdomen wound had healed. She was not compliant with offloading and had a right to refuse. CR#1 was on an air mattress and was usually sitting up 45 degrees when she visited. She stated CR#1 did not like those heel boots. She said CR#1 had a poor prognosis. She said her nutritional status does not get great absorption with G-tube. She was not making any progress, so it was just about doing your best. She said she made the family aware of her poor prognosis and recommended hospice. She said she did not recall talking with CR#1's RP about the wound, just medically she was declining. She said repositioning was important for all patients especially if they were not ambulatory. She said CR#1 had an air mattress and it deflated in one area and inflated in another. It helped with moving but it was beneficial for someone to turn her. She said as a medical professional, some form of offloading and turning was necessary. She said she did not see her every day, so she had no way of knowing if she was being re-positioned and turned Q2 hours or not. She said she was not sure of her BIM score. She said CR#1 could nod or say no. She was not able to make two-or three-word sentences. She said the last visit with CR#1 was on 5/21/2025 when she saw herher, she was sitting up at 30-40 degrees, she noticed that her secretions had decreased. She would pocket secretions in her mouth. She said she did not have her boots on her heels. She allowed staff to put them on her. She encouraged her to wear the heel boots. She did not view the sacral ulcer that day. She did not see the dressing. Vitals were stable, no signs of infection to her. An interview on 5/29/2025 at 12:01pm with CNA A said she had been employed for 1 year on 6-2pm shift. She stated some of her duties were to feed residents, give showers, dental hygiene, getting residents dressed, change resident briefs, and drain catheters. She said she had not worked on CR#1's hall. She said CNAs did not assist with wound care. She said she had residents down her hall that had wounds. She said the wound care nurse and doctor are the only two that are in the room. She said in the past she had assisted with wound care by changing the briefs or helping to turn or re-position residents for treatment. She said they are supposed to turn residents every two hours. She said they were able to put in every time they provided care when they had electronic charting system 1. Now they have electronic charting system 2, and it only allowed them to check when they assisted with bed mobility. She said the nurses were able to enter care into electronic charting system 2, as2, as well. An interview with LVN A on 5/29/2025 at 12:09pm, she said she had been employed for 2 years as a charge nurse on 6a-2p. She said her duties were to make rounds, assessments, take blood sugars, vitals, insulin, g-tube feedings and sign off on CNA tasks were completed. She said she had to do wound care from time to time and TAO (triple antibiotic ointment) was used until there was a physician order. She said they had two fulltime wound care nurses so she rarely did wound care. She said she did not have CNA's help with wound care when she had to do it. She said the doctor, or his NP were the only people in the room. She stated she had not done wound care for CR#1. She said she documented any refusals for brief changes, re-positioning, and showers in the electronic charting system 2,.2, She said there had been some issues with CNA's giving showers on second shift and they had an in-service about it. She said she had to talk to several CNAs on her shift as well. She said she went behind them if they said there was a refusal. She said most residents will not deny care if you explain the importance. She said turning and re-positioning was vital to wounds healing. She said the electronic charting system 2 had turning and re-positioning on their task list. She said she would check off for the entire shift that they had been done. There was no way for nurses to document for example that it was done at 1pm, 3pm, or 5pm. She said keeping the residents clean and dry, showered, and re-positioning was important for wound healing or to prevent new wounds. An interview with CNA B on 5/29/2025 at 12:25pm, stated that she had been employed at the facility for about 4 years on both 6-2 and 2-10pm shifts. She stated CNAs did not assist with wound care. She said usually it was the nurse, doctor, or his NP. She denied observing CR#1's wound. She denied being asked to change CR#1's brief. She stated turning and re-positioning and keeping them dry was important for residents' wounds to heal especially on the sacral, but also on hip and heels. She said they did not document every time they turned because they keep up with it themselves and tell the nurse at the end of the shift that it had been done. The nurse would then check it off that it was done on their shift. She said some CNAs did not have access to the electronic charting system 2. There had been some log in issues. She was able to access the electronic charting system and stated she documented at the end of her shift. She said she turned all her patients to the left and then right every two hours. She said she kept up with it on her own. In an interview with the Wound care doctor on 5/29/2025 at 12:45pm, he said he had been coming to the facility about 6 months and saw about 25 patients a week. He stated his NP would also visit during the week. He said most of their visits were early mornings starting at about 6am. He said he saw CR#1 on yesterday (5/28/2025). He said he started visiting with CR#1 back in March 2025. She had wounds on her sacral, heels and the knee and surgical wounds were resolved. He said initially the sacral pressure wound was a stage 3 and it had deteriorated and became unstageable with necrotic tissue. He stated in the last two weeks, he had been debriding her slowly and it was improving. There was no necrotic tissue remaining on yesterday (5/28/2025). He said she did have a completely necrotic wound, one like hers was done gently and carefully. The remaining necrotic tissue was removed on yesterday. He said wounds are sometimes unavoidable due to co-mobility, nutrition, mental status, or infection of the wound. He said a combination of all of that determined whether they heal, stall or deteriorated. He denied the sacral wound was infected. He said his goal was to remove all of her necrotic tissue and that was done. He said she was not on any antibiotics because he had not identified any infection on her. He said he typically would round and order a wound culture before ordering antibiotics. He said her primary doctor could also order antibiotics/ labs if she had access or received the results of the wound culture before he does. He said he had not ordered a wound culture because she had no necrotic tissue left and no reason to order antibiotics. He said CR#1 was not able to follow directions. He said she did not have the capacity to turn herself nor remove the boots off her heels. He stated the wound care nurse made calls to inform FM of change in condition. He said CR#1 never refused care from him. He said she was not verbal. He said the nurse never notified him of any issues. He said when he visited her, she was often in the supine position, and this was not best for her sacral wound. He said she should not be in the supine position for more than 2 hours. He said turning and re-positioning was vital for wounds healing. He denied the sacral wound had an odor. He stated he ordered Daiken as it was a wound cleanser. It helps with odors, but that was not his reason for using it, just as a cleanser. He stated CR#1's wound had 0% necrotic tissue when he left her on 5/28/2028 around 6:45am. In an interview with wound care nurse A on 5/29/2025 at 1:56pm, she stated she had employed at the facility about here 1 year as WCN on day shift. She stated she worked on CR#1's hall and conducted wound assessments weekly for her. She stated CR#1 sacrum wound was difficult to heal since she was bedfast, and she required re-positioning every 2 hours. She said her right heel wound was resolved. She stated she had boots for her heels to prevent breakdown. She was admitted with the heel and sacrum wounds. She said she could not recall what the sacrum looked like when she was admitted . She could not recall the size. She said her documentation that the wound was a Stage 3 pressure injury wound and measured (0.5 X 1 X 0.2) noted to have no tunneling/normal skin (Zinc and turn and repositioning Q2 hours) when CR#1 was admitted on [DATE]. She said that was the measurements at the time. She said CR#1's measurements the next week was (8 X 10 X 0.2) came from the wound care doctor, who gave her the measurements and she documented that. She said he did the measuring. She said she cleaned and replaced CR#1's dressing daily. She said her treatment started when she was first admitted with maybe TAO but changed to alginate and calcium once the wound care doctor saw her for the initial visit. She said she was not sure why CR#1 was not seen by the wound care doctor until 3/26/2025. She said CR#1's doctor had made the referral a day or so after her admission. She said at some point, CR#1 was on IV antibiotics and this caused a lot of loose stool so she needed to be changed more often than 2 hours. She said this might be why the family said she had an odor. She said the residents sacral did have a slight odor. She said the WCD ordered Daikin which was also called sodium hypochlorite. He ordered it on yesterday (5/28/2025). She said the WCD would often start the Daikin if there was an odor. She said odor was a sign and symptom of infection. She stated she could not be sure if staff were turning and re-positioning her as needed. She stated turning and re-positioning was vital to helping heal wounds. She said CR#1 would say yes or no. But, never spoke using a full sentence. She said CR#1 never refused or said no to her. She said they do not use the assistance of CNA's while providing wound care. She said CR#1's wound was covered. She said loose stool could make a wounds worst on the sacral, especially since CR#1 had loose stools. She said she updated care plans with changes and called FM about changes as well. An interview with CR#1's primary physician on 5/29/2025 at 3:54pm she said she had been CR#1's physician for about two months. CR#1 was admitted with small bowel obstruction, dementia, stroke and not able to swallow. She had a feeding tube. She came to the facility for OT/PT, and with wounds. She stated as far as she knows the sacrum wound had improved and was smaller than when she was admitted . She said she did not measure the wound. She said the facility's WCN told her there was a wound and so she made the referral. She stated re-positioning would be important to be done every 1-2 hours for anyone bedfast or not mobile. She stated the resident had a poor prognosis, and the wounds were unavoidable because they were doing everything for her. She had an air mattress, g-tube feeding and was taking Vitamin C and a multi-vitamin. She did not recall if she had any protein or if she was on any antibiotics. She stated she did not know why the vitamins had not been given in April, she would have to check on that information. She said she recalled writing it as a tablet and then realized it had to be given via G-tube, but she made that change quickly because she was NPO. She said Daikin was used as a wound cleanser. She said odor was a sign and symptom of infection. She said she could not attest to the size or condition of the wound. She understood it was smaller than when she arrived. In an Interview with the DON on 5/29/2025 at 4:20pm, she stated she had been employed at the facility since March 2025. She said some of her duties were to make rounds, assessing charts, auditing charts, make sure orders are in, ensure staff are doing their jobs and the overall clinical management of the building. She stated she had not personally met CR#1. She stated she had not observed her wounds. She said they had a WC team that gave report at morning meetings if there were any issues. She said once a week they would discuss the wound report. The clinical team was made up of charge nurse, DON, ADON and wound care nurses. She said the WCN was required to perform weekly assessments. She said every Friday she printed the report to ensure weekly assessments are done. She stated she had not heard CR#1's wound was deteriorating. She said Daikin was used as a cleanser and could be used due to odors. She said odors were a sign and symptom of infection. She stated if a wound upon admission was a Stage 2 and now a stage 4 if would appear that it had gotten worst. She said some of the reasons some sacral wounds does not heal was due to not being turned and positioned, nutritional status, and not being adequately hydrated. She denied any complaints from CR #1's RP about her not being changed or re-positioned. She expected CNA's to change briefs at least every 2 hours, provide hygiene care and wound care nurses to assess, treat and let her know if there are any issues. In an interview on 6/3/2025 a confidential staff stated she had been employed at the facility for less than 1 year and worked the 2-10pm shift. She stated she worked on the Hall where CR#1 resided. She stated when CR#1 was admitted , she saw the spot on her sacral. She said CR#1 was incontinent of bowel and had a lot of diarrheas. She said the sacral was the size of a quarter, but it had healed and was not opened. She stated the last month or so, the wound was covered, and she had no idea how bad it had gotten. She said most of the time her boots were not on. She said she was not sure who took them off, but she was not capable of taking them off herself. She said they must keep up with every 2-hour turning and re-positioning themselves or put under bed mobility. She said she did not think it was made clear on where to put it because they had turning/re-positioning in the ecteronic charting system 1, but not in the electronic charting system 2, just bed mobility which was where she documented. She said she went down the hall and turned all Residents in the same direction and then 2 hours later to the opposite side. In an interview on 6/3/2025 at 3:45pm CNA D stated she had been employed at the facility for 1 month. She worked on the 6-2pm shift but working a double today on Hall 100. She stated her duties were to shower residents, hygiene, personal care and turn them every 2 hours. She stated she was aware CR#1 had a sacral wound, but it was always covered by a patch or dressing when she went in to change her. She stated CNAs did not assist with wound care. She said she heard recently that the wound was bad. She stated she never saw it. She said the doctor rounded with the wound care nurse. She stated CR #1 had a stench smell and received bed baths. She stated she always gave her bed baths and showers as scheduled. She said no one wanted to have an odor. She stated re-positioning was not in the electronic charting system 2, it was under bed mobility, and they have to put whether they assisted CR#1 or not. She denied CR#1 refused care. In an interview on 6/3/2025 at 3:45pm CNA D stated she had been employed at the facility for 1 month. She worked on the 6-2pm shift but working a double today on Hall 100. She stated her duties were to shower residents, hygiene, personal care and turn them every 2 hours. She stated she was aware CR#1 had a sacral woundwound, but it was always covered by a patch or dressing when she went in to change her. She stated CNAs did not assist with wound care. She said she heard recently that the wound was bad. She stated she never saw it. She said the doctor rounded with the wound care nurse. She stated CR #1 had a stench smell And received bed baths .baths. She stated she always gave her bed baths and showers as scheduled. She said no one would wanted to have an odor. She stated re-positioning was not in the electronic charting system 2, it was under bed mobilitymobility, and they have to put whether they assisted CR#1 or not. She denied CR#1 refused care. . 2. Observations of Resident #2's positioning while in bed revealed the following: 6/2/2025 at 11:47am- observed on to be on right side 6/2/2025 at 12:59pm- Observed on right side 6/2/2025 at 2:49pm- Observed to be on right side 3. Observation of Resident #3's positioning while in bed revealed the following: 6/2/2025 at 11:46 am - Observed to be on his back 6/2/2025 at 2:47pm- Observed on his ba

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 9 residents (CR#1, Resident #4 and Resident #5) reviewed for ADL's. -The 2:00 p.m.-10:00 p.m. shift failed to consistently provide showers for Resident #4 who was physically impaired, for at least 11 days causing body odor. She was scheduled to have showers on Tuesdays, Thursdays, and Saturdays. She filed a grievance concerning staff not showering her. - The facility failed to provide CR#1 bed baths on Monday, Wednesdays, Fridays on the 2:00-10:00pm shift. -The facility failed to provide Resident #5 with showers on Monday, Wednesdays, Fridays on the 6a-2pm shift causing him to formerly file two grievances with the facility concerning not getting showers. This failure could place ADL dependent residents at risk of experiencing embarrassment from odors, infection, and skin breakdown. Findings Included: Record review of shower schedule provided on 6/2/2025 revealed the following: *CR#1- was scheduled on Tuesdays, Thursdays, and Saturdays on the 2p-10pm shift *Resident #4- was scheduled to have a shower on Tuesdays, Thursdays, and Saturdays on the 2p-10pm shift *Resident #5- was on the schedule for showers on Mondays, Wednesdays, and Fridays on the 6a-2pm shift CR #1 Record review of CR #1's face sheet dated 5/28/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of partial intestinal obstruction (a blockage in the intestines that allows some but not all digested material to pass through), unspecified dementia(cognitive impairment), pressure ulcer of sacral region(injury to skin and underlying tissue due to prolonged pressure), stage 2, pressure-induced deep tissue damage of left heel, dysphagia (difficulty swallowing), hypothyroidism (a condition in which the thyroid gland does not produce produce enough thyriod hormone), and hyperlipidemia (condition in which there are high levels of lipids in the blood). Record review of Discharge summary dated [DATE] from a local hospital revealed CR#1 was discharged on 3/13/2025 with an open abdominal wall wound due to the small bowel obstruction surgery, stage 2 sacral wound, unstageable right heel pressure wound, stage 2 left buttock and dementia. Record review of admission MDS dated [DATE] revealed: *Section C0500- Brief Interview of Mental Status summary score was coded as 03-representing severe cognitive impairment. *Section GG- Functional Abilities: toileting, shower/bathe, oral hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer were coded as 01- Dependent on helper for all the effort. Record review of bathing Plan of Care (POC) in the electronic charting system #2 revealed the following: Bed baths for the last 30 days were documented as 5/12 and 5/14/2025. Resident #4 Record review of Resident #4's face sheet dated 5/29/2025 revealed she was a [AGE] year-old female that had been admitted to the facility on [DATE] with diagnoses of rash and other skin eruption. Record review of Resident #4's MDS dated [DATE] revealed: *Section C0500- Brief Interview of Mental Status was coded as 13. This indicted that she was cognitively intact. *Section GG- Functional Abilities revealed- Toileting hygiene, shower/bathe, upper body dressing and lower body dressing were all coded as (2) representing substantial/maximal assistance- helper does more than half the efforts. Record review of Resident #4's care plan dated 6/1/2025 revealed: *Focus: Resident #4 had an ADL self-care performance deficit r/t activity intolerance, limited mobility. There was no goal. The only Intervention was PT and OT evaluation and treatment as per MD. Record review of Plan of care (POC) for last 30 days revealed she was supposed to be showered 3 times a week on Tuesdays, Thursdays and Saturdays: -She did not have a shower between 5/10/2025 and 5/15/2025. -She did not have a shower between 5/15/2025 and 5/27/2025 -Between 5/28/2025-6/3/2025 she did not have a shower . Observation and interview on 5/28/2025 at 9:28am of Resident #4 revealed she had been a resident for 1 year. She stated she had physical therapy every day. She stated her main concern was she was not getting her showers as scheduled and sometimes she had an odor. She stated she asked (unknown)CNA on evening shift several times about her shower and she was told they would get help and come back. She said they would not return. She stated she spoke with a manager about it too. She stated she had not refused any showers. She said twice a small built CNA came in and she asked her to get help as she was heavy and required two people to transfer her from her bed to her wheelchair and then the shower chair. She had a fear of being dropped, but never told them no. Resident #5 Record review of Resident #5's face sheet dated 6/6/2025 revealed he was [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of acute systolic and diastolic heart failure (two distinct types of heart failure , both affecting the left ventricle), Type 2 diabetes mellitus,(a long-term condition in which the body has trouble controlling blood sugar) and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of Resident #5's care plan dated 5/1/2025 revealed he had an ADL self-care deficit, impaired balance, and limited mobility. Goal: Resident #5 would maintain current level of function in through review date 7/30/2025 Interventions: Resident #5 was totally dependent on staff for bathing/showers Record review of plan of care (POC) for the last 30 days showed Resident #5 had a shower on 5/28/2025, 6/2 and 6/4/2025 did not have showers on 5/5, 5/7, 5/9, 5/12, or 5/21/2025. Record review of grievance for last 3 months (March, April and May 2025) revealed residents filed the following grievances: *5/20/2025-Residnet #4 filed a grievance stating shestating she had not been showered in over 11 days. *5/6/2025- Resident #5 filed a grievance stating the 2-10 shift was not giving him his showers. Observation and Interview with Resident #5 on 5/29/2025 at 11:49am, he said he had been a resident for about 1 month. He stated the only concern he had was not getting his showers. He stated he was supposed to get a shower at least three times a week. He said Mondays, Wednesdays, and Fridays on the morning shift. He stated he asked staff about his showers, and they never came back or they would say it was not his day for a shower. He denied refusing showers. An interview on 5/29/2025 at 12:01pm with CNA A said she had been employed for 1 year on 6-2pm shift. She stated some of her duties were to feed residents, give showers, dental hygiene, getting residents dressed, change resident briefs, and drain catheters. She said they were able to enter showers into the electronic charting system #2. She denied not providing bed baths for CR#1, and showers for Residents #4 and Residents #5. She said she gave her the Residents showers as scheduled. She said if they were unable to shower the residents she had to report that to the charge nurse. She said nurses were told about any refusals. An interview with LVN A on 5/29/2025 at 12:09pm, she said she had been employed for 1 years as a charge nurse on 6a-2p. She said her duties were to make rounds, assessments, take blood sugars, vitals, insulin, g-tube feedings and sign off on CNA tasks were completed. She documented any refusals for brief changes, re-positioning or showers in the electronic charting system #2. She said there had been some issues with CNA's giving showers on second shift and they had an in-service about it. She said she had to talk to several CNAs on her shift as well. She said she went behind CNAs if they said there was a refusal. She said most residents will not deny care if you explain the importance An interview with CNA B on 5/29/2025 at 12:25pm, stated that she had been employed at the facility for about 4 years on both 6-2 and 2-10pm shifts. She stated her duties were to help residents with all of their care, such as hygiene, showers, brief changes, grooming and any other needs. She said some CNAs did not have access to the electronic charting system #2. There had been some log in issues for some of the staff. She was able to access the electronic charting system #2and stated that she documented at the end of her shift. She said if she did not get to a shower, she told the nurse because there is so much time in the day. In an observation and interview with LVN B on 5/29/2025 at 1:42pm, she said she had been employed at the facility for about 2 years. She stated she was the charge nurse on Hall where Residents #4 and 5 resided. She said the shower sheets are placed in a basket after the care givers provide showers. She stated she sometimes helped CNAs give shower and that was how she made sure they were done. She proceeded to show me the shower sheets. There was a stack of sheets in a basket located at the nursing station near Hall 100 dating back to March 2025. She stated she was not aware of who was responsible for inputting the shower sheets into the electronic charting system #2. She said her job was to make sure the care staff provided showers as scheduled and requested. She said sometimes staff told her residents refused showers and she had to ensure this was the case. She said most times, the residents will take a shower. She stated she could not recall Resident #4 refusing showers. She said it could be embarrassing for a resident not to get a shower. Hygiene is very important. In an interview with the Administrator on 5/29/2025 at 1:53pm, she stated she had been employed at the facility for 2 years. After she was shown the basket of shower sheet by LVN B from March 2025, she stated CR#1's RP never complained to her about not getting her bed baths, Resident #4 had refused showers and Resident #5 might have missed one shower and they did it the next day. She said it was her expectation that all residents received their showers as scheduled. She stated that the CNA s did not keep a binder with ADL documentation. In an Interview with the DON on 5/29/2025 at 4:20pm, she stated she had been employed at the facility since March 2025. She said some of her duties were to make rounds, assessing charts, auditing charts, make sure orders are in, ensure staff are doing their jobs and the overall clinical management of the building. She stated she was not told residents were not getting showers. She stated that it was her expectation that showers are given as scheduled. In an interview on 6/3/2025 a confidential staff. She stated she had been employed at the facility for less than 1 year and worked the 2-10pm shift. She stated that she worked on the Hall where CR#1, Resident #4 and Resident #5 resided. She stated she helped with showers and bed baths. She stated CR#1, Resident #4 or Resident #5 refused showers. She stated they recently had an in-services about showers not being provided. She stated there are always call-ins and this creates an issue for other staff. Record review of the facility's ADL policy 6/2011 read in part . 6. A CNA ADL Tracking Record (see form 7-4) must be maintained in accordance with the MDS coding guidelines and specific to the Patient's individual needs. The CNA ADL Tracking Record for each patient must be kept in a binder and documented daily on each shift. CNA ADL Tracking Records must be regularly monitored by the DON or designee to ensure that tasks are being performed as scheduled. At the end of the month, the completed CNA ADL Tracking Record for each Patient is filed in the Patient's medical record under the medication/treatment tab.

Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 3 residents (Resident#6) reviewed for incontinent care and for indwelling urinary catheters. -Resident #6 Foley catheter bag was lying in the bed near his left calf on 6/4/2025 and hanging to the floor on 6/6/2025. This failure could place residents at risk for accidental dislodgement of the catheter and trauma to the bladder and urethra Findings Included: Record review of Resident #6's face sheet dated 6/4/2025 revealed he was a 59 year59-year male that was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of rectois sigmoid junction, infection of continent stoma, chronic kidney disease, artificial opening of urinary tract. Record review of Resident #6's MDS dated [DATE] revealed: *Section GG- Functional Abilities - Toileting hygiene, shower/bathe, upper and lower body dressing were all coded as (1)- dependent *Section H- Bladder incontinence was coded as (9) - which was not rated, resident had a catheter, (indwelling, urinary ostomy or no urine output in 7 days. Bowel Incontience was coded as (9) not rated, resident had an ostomy or did not have a bowel movement. *Section C500- Brief Interview of mental status was coded as 15. This indicated Resident #6 was cognitively intact. Record review of Resident #6's care plan dated 5/10/2025 revealed: Focus: Resident required the use of an Ostomy Goal: Resident dignity will be maintainedmaintained, and the ostomy will remain functional over the next 90 days. Interventions: Document ostomy care in the clinical record, monitor site for swelling, pain, redness, provide otstomy care per MD orders and keep ostomy patent. In an observation and interview with Resident #6 on 6/4/2025 at 2:04pm, he stated he had not been in the facility long and would be leaving soon. He said he had colon cancer and had both an ostomy bag and foley catheter. His foley bag was observed near his knee lying on the bed. He stated the facility had not strapped the catheter down and it hurt when it hung from the bed. He said it was embarrassing to have it showing in his bed and most times tried to keep it covered. He said it would get heavy from so much urine and hurt his stomach. He stated he was going home soon on home health. In an interview with LVN E on 6/4/2025 at 2:15pm, she stated she had been employed for about 3 months and worked the 6a-2pm shift. She stated that the CNAs emptied foley and ostomy bags. She stated that Nurses check the site for swelling and infection and ensure the site is clean and document that the ostomy care and foley care was done. She said the best location would be down below his bladder, but he moved it. She stated the bag not being below the bladder could cause UTI's. She stated she had not educated the resident on the risk of the location of the bag. She said this could be embarrassing for a resident to have his bag lying in his bed. She said everyone should be treated with dignity and respect. Observation of Resident on 6/6/2025 at 1:51pm, revealed his foley bag was observed to be hanging on the floor. In an observation and interview with the DON on 6/6/2025 at 2:08pm, she stated theystated they were going to strap his foley bag to his thigh. She stated it should not have been on the floor. In a subsequent interview with the DON on 6/6/2025 at 3:20pm, she stated she had been employed for 3 months. She said some of her duties were to make rounds, assessing charts, auditing charts, make sure orders are in, ensure staff are doing their jobs and the overall clinical management of the building. She stated the foley catheter bag should be placed below the bladder. She stated the nurse had not previously talked to him about moving the bag into his bed or on the floor. She stated she had not personally talked to him about why he should not have the bag lying in his bed. She said she did today but had not documented it yet. She said her expectation was for CNAs to empty the foley and ostomy bags as ordered and as needed, ensure the bag is below the bladder and for the nurses to check the sites for swelling, pain and infection. She stated she had strapped the foley catheter bag to his thigh. She denied Resident #6 told her he was embarrassed. She admitted that she did not ask him how it made him feel. In an interview with the Administrator on 6/6/2025 at 3:31pm, she stated she was not clinical, but from her understanding the foley bag tubing should be placed below the bladder. She said urine had to flow and backup into the bladder and cause infection. She said she expected staff to drain the bags as ordered and as needed and for nurses to ensure the site was clean and for the bag to be secure in the proper location below the bladder. Record review of catheter care policy dated September 2014 state in part .The purpose of this procedure is to prevent catheter associated urinary tract infections. Maintaining Unobstructed urine Flow: 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Changing catheters: 2.Ensure that the catheter remains secured with a strap to reduce friction and movement at the insertion site (note: catheter tubing should be strapped to the resident's inner thigh.)

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 2 of 10 residents (CR #1 and Resident #440) reviewed for pharmaceutical services 1. The facility failed to ensure accurate administering of all drugs and biological to meet the needs of Resident #440, who was administered morphine more frequently than prescribed by the physician on [DATE] and who was administered with the incorrect dosage on [DATE]. 2. The facility failed to acquire, dispense, and timely administer all medications to meet the needs of CR#1, who missed 4 doses of Posaconazole (antifungal) 100mg delayed release tablet between [DATE] and [DATE]. An Immediate Jeopardy was identified on [DATE] at 1:28 PM, and on [DATE] at 9:27 AM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE]. due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for not receiving medications as ordered resulting in serious injury, decline in health, and death. Findings included: 1. Record review of Resident #440, who was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the prostate (growth in the prostate gland), urethral stricture (narrowing of the urethra), and stage 4 pressure ulcer to the sacral region (full thickness tissue loss that extended to the underlying muscle, tendon, or bone). Record review of Resident #440's Baseline Care Plan dated [DATE] revealed, the resident was alert & cognitively intact and on high-risk pain medications (narcotics). Record review of Resident #440's physician orders dated [DATE] revealed the resident was on morphine ER (extended release) 30 mg tablet, extended release every 12 hours. Record review of Resident #440's physician orders dated [DATE] revealed the resident was on morphine IR (immediate release) 15 mg tablet, every 6 hours as needed. . Record review of Resident #440's February 2025 medication administration record revealed morphine 30 mg tab ER, every 12 hours was administered as a scheduled order on [DATE] at 7: 00 AM and 7:00 PM. Record review of Resident #440's Controlled Drug Record revealed morphine 15 mg tab IR, every 6 hours as needed, was administered on [DATE] by the Med-Aides at 5:00 AM (1 tab), 8:00 AM (2 tabs), 11:30 AM (1 tab), 3:00 PM (1 tab), 11:00 PM (1 tab). [DATE] at 4:00 AM (2 tabs), and 8:00 PM (2 tabs) were administered. Review of Resident #440's progress note dated [DATE] revealed that while the NP was rounding, the residnet was alert x's 1 (person) and lethargic. She gave order to administer Narcan due to excessive sedation. Resident #440 was on continued monitoring by LVN K after Narcan administration. Record review of Resident #440's February 2025 indicated that the residnet was administered Narcan by LVN K on [DATE] at 4:00 PM. Record review of Resident #440's vital signs on [DATE] at 11:00AM indicated a Blood Pressure of ,d+[DATE]; Resipration-18; and oxygen saturation of 96% on room air, however, his pulse was not recorded. His oxygen saturations were record on [DATE] at 4:04 PM with an oxygen saturation of 97% on room air. Vital sign reading post narcan administration on [DATE] at 5:00 PM indicated a blood pressure of ,d+[DATE]; Respiration-18; oxygen saturation and pulse was not recorded. Observation and interview on [DATE] at 12: 58 PM with Resident #440 lying in bed. He was alert to person. He said he did get his pain meds earlier today and was without c/o pain. Resident #440 was less verbal than on [DATE] and [DATE]. He said he did not have an appetite but was very thirsty. The CNA was at bedside assisting the resident with his water intake. Telephone interview [DATE] at 3:57 PM with Med-Aide C, who said she administered Resident #440 Morphine IR 15 mg (2 tabs) instead of Morphine ER 30 mg 1tab after clarification with RN E on [DATE] at 8:00 AM and 11:30 AM. She said she was aware of the discrepancy between the medication administration record and the blister pack. However, she was given the ok to administer the Morphine IR 15 mg (2 tabs) instead of the scheduled Morphine ER 30 mg by RN E. She said the risk of administering too much morphine could cause decreased blood pressure, drowsiness, and/or death. Telephone interview on [DATE] at 7:16 PM with RN E, who said Resident #440 was administered Morphine for pain. She said the side effects of administering too much Morphine was sedation. RN E said the MD should be contacted if the resident shows signs of oversedation. She said Resident #440 was administered Narcan as ordered as an antidote for an overdose of opioids, after the NP was rounding and observed a decrease in his alertness and cognition. She said the risk of Morphine overdose was a resident could go in respiratory distress and may require rapid response/CPR. Interview on [DATE] at 7: 30 PM with the DON, who said Morphine was a pain medication. She said there was a discrepancy between the Morphine 30mg ER that was ordered and the Morphine 15mg IR that was administered. She said her expectation was that the staff would follow the MD's orders and clarify orders with the MD if they were incorrect or if the staff had questions or concerns regarding the orders. She said the risk of not following the orders and administering the correct Morphine dosage could cause the resident to go into respiratory distress. Interview at [DATE] at 11:18 AM with Dr D., who said she ordered Morphine IR 15mg Q 6 hours prn and scheduled Morphine 30mg ER q 12 hours. She said the difference in the 2 medications ordered was the onset, peak, and duration. She said just because the order was for morphine 30mg does not mean that the staff could give Morphine 15 mg, 2 tabs to equal 30mg because the difference was the morphine 15 mg IR tabs were PRN and Immediate release, and the Morphine 30 mg ER tabs were scheduled q 12 hrs and extended release. Dr. D said when she gives an order, the staff should follow the order or call for clarification if there are any concerns or questions. She said Resident # 440 should have been administered the Morphine ER, as ordered. She said the milligrams of the Morphine administered were the same, but the long-acting and short have different onset and duration of the medication. The NP was rounding, so she gave the Narcan, which was appropriate due to his drowsiness. She said the risk of not following the orders could lead to a bad outcome. Record review of pharmacy services policy, revise date ,d+[DATE], read in part .Policy Interpretation and Implementation: 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration . Record review of the medication administration policy, undated, read in part . 2. The 6 Rights of Mediation Administration. b. Right Drug. Verify prescription label to [DATE] times in different ways: i. Drug name ii. Drug strength. c. Right Dose. Verify the label to MAR, these MUST MATCH. e. Right Time. Confirm med-pass time window (1 hr. before to 1 hr. after administration time on MAR . On [DATE] at 1:18 PM, the administrator was informed that an Immediate Jeopardy situation was identified due to the above failures and a Plan of Removal was requested. Observation on [DATE] at 9:43AM of medication administration in-service was conducted by the DON to include the weekend supervisors with the initiation of the posttest. Interview on [DATE] at 11:17 AM with MA A, who works the ,d+[DATE] halls. She said the last in-service on medication administration and pharmaceutical services was on [DATE], and she had a competency post-test after the in-service. She said she would inform the nurse of a missed or unavailable medication. She said she would follow up with the nurse but would notify the DON and the doctor if it were still missing. MA A said the nurses have access to the E-Kit and can pull medication from it. If the medications were not in the E-Kit, the nurse would send a STAT order to the pharmacy. Interview on [DATE] at 11:26 AM with RN C, who said she was last in-service on medication administration and pharmaceutical services was [DATE]. She said she would check for missing/unavailable medication in the Pyxis and/or E-Kit. If it was not available in E-Kit, she said she would contact the pharmacy and MD regarding the missing medication. RN C said that she would fax the medication order to the pharmacy for new admission. She said the fax machine gives an ok confirmation that the pharmacy received the fax. She said the pharmacy delivers between ,d+[DATE] hrs after faxing the order. She said she would contact the doctor if the medication was unavailable after the ,d+[DATE] hours to see if there was a compatible medication or contact the pharmacy to get the medication STAT. She said she would also inform the weekend supervisor and/or DON that the medication was missing or unavailable. Interview on [DATE] at 11:38 AM with LVN B, who said her last in-service was on [DATE] with the DON on missing medication with a post-test at the end. She said the process was to 1st go to the E-Kit if the medications were missing. Contact the pharmacy for a STAT medication If the meds were not in the Pyxis or E-kit. She said she should contact the weekend supervisor and MD if not available and let them know that the medication was unavailable. Interview on [DATE] at 12:11 PM RN D, who said her last in-service was [DATE] with the DON on missing medication with post-test at the end. She said we initially would look in the pyxis for the missing medication. She said that if medications are not in Pyxis, the pharmacy delivery comes within ,d+[DATE] hours. She said for new residents, we fax the medication order to the pharmacy and receive an ok from fax machine, but we can also call to verify the orders were received. We get short slip for unavailable meds, but not for every medication. We let the DON know the medication was missing. We inform the MD to let them know that we need an order for another medication. We can also contact the pharmacy for the medication to be delivered Hot Shot (STAT). Record review on [DATE]-[DATE] of the pharmacy delivery sheets. Record review on [DATE] revealed and Immediate release and extended-release medication in-service was conducted by the regional nurse for the DON and Nurse managers. CR# 1 of undated facesheet revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Acute Myeloblastic Leukemia and Neutropenia (a condition characterized by an abnormally low number of neutrophils in the blood). CR#1 was immunocompromised due to the low neutrophil count. Review of CR#1's MD progress notes dated [DATE] revealed the resident was on neutropenic precautions (Important preventive steps you need to take while you have neutropenia). Review of CR#1's physician's orders revealed on [DATE] the resident was prescribed Posaconazole 100mg (3 tablets) one time daily, which is an antifungal. Review of CR#1's [DATE] medication administration record revealed Posaconazole was not administered as ordered on [DATE],[DATE], [DATE], and [DATE] because they were unavailable. Interview [DATE] at 10:11 AM with the RP, who said the staff did not administer CR#1's antifungal medications during his stay at the facility. She said his antifungal and antiviral medications were his most important meds due to his completion of chemotherapy and neutropenic status. The RP said on [DATE], she informed LVN J that she had his Posaconazole medications available in the resident's room. LVN J declined the medication and said his medications had to come from the facility's pharmacy. She said CR#1 was readmitted to the hospital on [DATE] because he had a fever at his MD appointment. Interview [DATE] at 3:19 PM with RN A, who said CR#1's physician's orders included Posaconazole 100mg tablet, delayed release (3 tablets). She said the medication was reconciled and faxed to the pharmacy on [DATE]. She said she gave report to the floor nurse after completing the initial admission process. She said CR#1's medication should have been administered to the resident as ordered by the physician. She said the resident who was immunocompromised and had a fever was an indication of infection. She said not receiving his antifungal medication for 3 days can lead to a serious illness and/or death. Interview on [DATE] at 3:51 PM with LVN C, she said most medications are usually delivered on the next pharmacy delivery if it is unavailable from the E-Kit (emergency medication kit). The next scheduled delivery was [DATE]. She said residents should have all medications administered as ordered within 24 hours. She said neutropenic residents were immunocompromised. LVN C said a fever (temperature >100.3) was an indication of infection. She said residents who were immunocompromised and had not received their antifungals for several days could cause the resident to be hospitalized and/or death. Interview [DATE] at 4:17 PM with the DON, who said the medication was not received until [DATE] at 11:00 PM. She said the staff did not administer the medication at that time because CR#1 was not in the facility until the early morning of [DATE]. The DON said the staff did not administer the medication when the resident returned to the facility, and she was uncertain why the medication administration did not occur upon arrival. She said the staff should have notified the physician that the medication had not been administered to CR#1 on [DATE], [DATE], [DATE], and [DATE]. The DON said that the nurses should have followed up with the pharmacy and/or doctor to see if the facility could have received a compatible antifungal until the medication arrived. She also said the facility could have accepted the medication offered by the RP and administered it to the resident. She said that based on his medical history and the resident being immunocompromised, fever was an indication of possible infection. She said not administering CR#1 prophylactic antifungal medication could place the resident at risk for his health being in danger. Telephone Interview on [DATE] 4:58 PM with Med-Aide A, who said she administered all medications that were available for CR#1. She said missing or non-available medications were reported to the nurse. She said she verbally reported to the nurse that CR #1 did not have his Posaconazole but does not remember the day. Interview on [DATE] at 5:23 PM with Med-Aide B, who said she informed the nurse on [DATE] that CR#1 was missing his Posaconazole. She said she does not remember the name of the nurse she reported to. Interview on [DATE] at 5:53 PM with MD, who said CR#1 was admitted to the facility with a neutropenic fever. She said the facility should have administered all medications, including Posaconazole, as ordered due to his neutropenia. She said the resident had an increased risk of infection because he did not receive his medication as ordered. Telephone Interview on [DATE] at 12:05 PM with the contracted pharmacist, Dr. X, who said he received the order for the Posaconazole on [DATE]. He said the medication was delivered on [DATE] at 11:22 PM. Telephone interview on [DATE] at 1:02 PM with LVN J, who said the admitting nurse (RN A) conducted the admit assessment and reconciled the orders. She denied getting report for CR#1 from the admitting nurse on [DATE]. She said the RP informed her on [DATE] that she had available meds for CR#1, but LVN J said the facility used their own pharmacy to administer medications. Interview [DATE] at 10:54 AM with the administrator, who said she was unaware that the Posaconazole was not administered until [DATE]. She said it was a specialty med, and the pharmacy could not get the medication sooner. The administrator said the process was for the nurse to notify the DON and the MD of the missing Posaconazole. The risk of CR #1 not having his Posaconazole could cause injury or harm if the resident required his medication because of a fungal infection. The administrator was informed of an Immedicate Jeopardy situation on [DATE] at 1:28 PM, and on [DATE] at 9:27 AM. A Plan of Removal was requested. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 11:16 AM. Immediate Action: An Emergency QAPI was held to review the findings of the citations and the community's present practices and processes. The DON and administrator will have a collaborative effort with respect to monitoring medications upon admission, and daily thereafter for established residents regarding missing or unavailable medications. There will be ongoing daily monitoring by DON or designee, to review medications for compliance. Upon notification of the deficient practice on [DATE], the following measures were put into place for nurses and medication aides as well as in-services to be completed by [DATE] (the DON/designee will teach the in-services) to ensure that the deficient practice will not recur: a 100% audit of all residents receiving both immediate release and extended-release medications will have MAR to Cart audits daily to ensure appropriate medications are being given. -Initiation of the Medication Availability Log, in which each Nurse/Med-Aide validates that they have all available medications for Administration each shift. This will be kept in the Narcotic Count Book and will be brought to the morning meetings for review and further evaluation by the Nurse Managers. After hours the Charge Nurses will notify the DON/Administrator of any deficits, the Weekend Supervisor will complete this on the weekends. -24- hour report will be reviewed 2x daily in clinical stand up for morning and afternoon shift to review communication with physician on medications not available, this will be done by the DON/Designee of Nurse Management. -A New order report will be printed every morning by the DON/Nurse Managers, this will be crossed referenced to validate physical availability of new medications in the community. -Pharmacy Delivery Sheets will be reviewed every morning by DON/Nurse Managers for medications that were delivered the previous evening. -The Clinical Smart Board, which is within our EMR, displays missed medications, will be reviewed twice daily, by the DON/Nurse managers, in clinical stand up for both morning and afternoon shift to review medications given, missed medications. -The DON/Nurse Management will communicate with pharmacy regarding medications not available and get estimated time of arrival or need to STAT medications. -The DON/Nurse Management will communicate with physician and/or medical director on medications missed or not available on patients that issues were identified. -The DON/Nurse Management will communicate all with physician and/or medical director on medication errors. _The DON/Nurse Management will notify the Administrator on all issues identified with pharmacy and medication delivery, availability and missed doses as well as medication errors. In addition to education on utilizing the Pyxis and Pharmacy Service in-services, a review of current policies and procedures were completed with the QAPI team determining that the current policy was sufficient and new protocols were put into place to achieve compliance. The Plan of removal was accepted on [DATE] at 11:16 AM and reflected the following: Record review of the 24-hour Report started on [DATE] and review twice daily. Record review on [DATE] of new medication order report. Record review of the clinical smart board review on [DATE] for both morning and evening shifts. Record review of missing medication log with administration signature and date noted on [DATE]. Record review on ,d+[DATE] and [DATE] of pharmacy communication log regarding medication not available and get estimated time on arrival or need for STAT. Record review on ,d+[DATE] and [DATE] of the Physician communication log regarding medication missed or medication not available. [DATE], no information noted on the pharmacy log. Record review of in-services that were conducted by the DON and administrator on [DATE] and [DATE] with topics to include: Pharmaceutical services (reviewing the 24-hour report for missing medications, how to review the smart board for missing medication and communicating with pharmacy regarding medications not available to get and estimated arrival or need to STAT medications), 6 Rights of Medication administration with competency validated by a posttest, Verifying prescription label to MAR, and Notification to physician of missing or unavailable medications. Record review revealed on [DATE], the facility completed an audit of all residents in the facility with orders for new admission medications and exiting residents' medication availability. Interview on [DATE] at 3:04 pm with LVN A. Who said she did attend the medication in-service was conducted by the DON. She said for new admits, she would verify the orders and place them in the system. She said the medication should be at the facility. She would look in the facility to ensure the medication was not in the Med room, on a med cart, or in the Pyxis. She said if she still was unable to locate the medication, she would contact the pharmacy to check if it had been ordered. If the medication was not ordered, she would fax the orders to the pharmacy and call and verify with the pharmacy that the order was received. She said staff should notify the DON, provider, and pharmacy if medications are missing. She said staff should always follow-up with DON, physician, and pharmacy if medications are missing. Interview on [DATE] at 3:45 PM with MA B, who said she did attend the medication in-service conducted by the DON. She said she documents the missing medications on the Missing Medication Log on her cart and reports the missing medications to the nurse and the DON. She said once the resident reaches the last blue line of the blister pack, she can scan and fax the sticker to pharmacy. She said the nurse would also follow up with the pharmacy. She said the difference between extended release and immediate release mediations was the duration it takes for the medication to last. MA B was able to provide the 6 medication administration rights, which included the right resident, dose, route, time, medication, and diagnosis. She said If the blister pack label was different from the MAR, she would inform the nurse so they could clarify with the doctor. Interview on [DATE] at 3:58 PM with MA C, who said she did attend the medication in-service conducted by the DON. She said she would notify the nurse of missing medications and document the missing medication on the new non-available medication log. She said depending on the type of medication it may be found in the Pyxis/E-kit. MA C said that for new residents, the staff should notify the nurses, who would check the pyxis to see if the medication was available. She said the nurse should contact the doctor to see if the MD wanted to use a substitute for the unavailable medication. She said that if medications are not available for the resident, I would also follow up with the pharmacy for STAT delivery. MA C provided the 6 medication administration rights to include the right name, dosage, resident, reason, route, and time. She said the difference between Immediate release and extended release was immediate release works immediately, while extended release was over time. She said she could not give the medication if the MAR and blister pack were different. She said she would report it to the DON if needed for medication clarification. Interview on [DATE] at 4:13 pm with MA H, who said if there were missing medications, we would notify the nurse. She would look in the Pyxis, and they would contact the DON. She said the 6 rights of medication administration were to verify the right resident on the MAR, the label, the dosage, route, and the right time. She said IR meds last for 6 hours and ER last for 12 hours. She said she would check the MAR, inform the nurse that a medication was missing, and document in the administrative notes. Interview on [DATE] at 4:31PM with LVN O, who said if medications were unavailable, she would notify the supervisor and the physician. She said if meds were missing, she would notify the supervisor, check with the pharmacy, and document on the EMR. She said the 6 rights were the right resident, medication, dose, route, time, documentation, and indication. She said the difference between ER and IR medications, was that immediate release meds are designed to start working immediately 4 to 6 hour and extended release last for 12 hours. LVN O said that for new residents, she would verify the medications with physician, enter them into the system, and fax to pharmacy with facesheet. She said if the resident does not get their medication, she would follow up with pharmacy, document, and fill out the medication reconciliation sheets. Interview on [DATE] at 4:38 pm with LVN Z, who said she would contact the DON, doctor or NP and document if a medication was unavailable or missing. She said with new residents, she would enter the medication into the EMR, verify the meds with doctor, and fax orders to the pharmacy and would call to confirm that the orders were received. She said to follow up on missing meds, she would call the pharmacy, call doctor and ask if there were any alternative meds. LVN Z said the 6 rights included the right resident, mediation, route, dose, time, documentation, and indication. She said Immediate release was based on the duration of the medications. Interview on [DATE] at 5:21 AM with LVN N, who said if medication was not available, he would check the Pyxis. He would notify the MD and the ADON/DON if the meds were still not there. He said that as soon as he got a new admission, he would contact the MD and verify medication orders. He would enter the orders into the system, print them, and fax the order to pharmacy. LVN N said the duration of ER medications was 12 hours, and the duration of IR was 4 to 6 hours. Interview on [DATE] at 5:27 AM with LVN T who said we check the med carts and pyxis for missing/unavailable medications. If we cannot get it STAT, we notify the doctor, pharmacy, and DON. LVN T said for new admits, after orders are verified with MD, we fax the medication order to the pharmacy. She said if it's a narcotic, she would get assistance for the DON with the ordering process; however, if the family had home meds, she would put the order in the system and make sure it matches the MD orders. She said the process for administering meds was to look at the label, verify the name, dose, and route, and compare it the MAR. LVN T said IR medication last from ,d+[DATE] hours, and ER meds can last up to 12 hours. Interview on [DATE] at 5:36 am with LVN S, who said that the staff calls the pharmacy, DON, and MD know that there are missing or unavailable meds. She said for the new admits, we verify orders from the doctor, put the orders in the system, and print and fax the order to the pharmacy. She said the rights for medication administration was the right resident, time, dose, route, reason, and the right medication. She said we should document all meds that are not available and place them on the medication log. LVN S said the difference between IR-immediately release, which lasts ,d+[DATE] hours and ER, which lasts for 12 hours. Observation on [DATE] at 7:50 AM of the med cart (100 and 300 hall) med pass performed by MA B without discrepancies. Missing Medication log noted on the med cart. No missing/unavailable meds were noted on the log. Interviews were conducted from [DATE] to [DATE] with staff from all shifts (6:00 AM.to 2:00 PM., 2:00 PM. to 10:00 PM., 10:00 PM. to 6:00 AM) The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 9:03 AM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of the resident, 1 resident (Resident #6) of 5 residents reviewed for wound care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan. -Resident #6 had a blackened area on her right great toe. -Facility staff did not assess the toe prior to surveyor intervention. -Facility staff did not report the toe issue to the physician prior to surveyor intervention. -Facility staff did not provide treatment to the toe prior to surveyor intervention. The deficient practice could place residents at risk for worsening of the wound and possible pain associated with the wound. Findings include: Record review revealed Resident #6 was an [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, hemiplegia (loss of use of one side), cerebral infarction (stroke), peripheral vascular disease, multiple contractures, and lack of coordination. Record review of the Quarterly MDS assessment dated [DATE] revealed Resident #6 exhibited severely impaired cognitive impairment. She required extensive assist from two persons for bed mobility. She exhibited limited range of motion of one upper extremety and both lower extremeties. Record review of the care plan (undated) revealed Resident #6 was at risk for skin breakdown. An Intervention read, in part, .Notify physician of the occurrence of new skin breakdown. Observation and interview on 12/6/23 at 4:51 p.m. of Resident #6' great toe on her right foot revealed an area of approximately 2 cm x 3 cm that was black. There was no dressing. RN A, Resident #6' Charge Nurse, was present in the room. When the Surveyor asked RN A about the toe, RN A said it was just left open to air. Record review of Resident #6' current Physician's Orders revealed no order regarding the toe. Review of the Nurses' Notes and Progress Notes for Resident #6 from 11/07/23 to 12/07/23 revealed no mention of the toe prior to the surveyor's observation. Observation and interview on 12/07/23 at 12:51 p.m. LVN C, the facility treatment nurse no one had informed her of Resident #6s right great toe. She said it was arterial. She said it was eschar. LVN C said Someone should have told me. I would have told (the physician). She said she would conduct a head-to-toe assessment and notify the doctor. In an interview on 12/07/23 at 2:20 p.m., RN A said when she observed the toe the previous day, she thought there was a treatment order. She said she did not check if there was an order. She said she thought it would be addressed by the wound care nurse. She said she did not mention the toe in her change of shift report. In an interview on 12/07/23 at 2:42 p.m. the DON said RN A should have conducted an assessment and contacted the physician when the wound was discovered. In an interview on 12/07/23 at 3:16 p.m. CNA B said she noticed Resident #6' toe was black on 'Monday [12/04/23] and Tuesday [12/05/23].' She said she did not tell anyone because she saw LVN C (the treatment nurse) going into the room. She said she thought the treatment nurse knew about it. I report wounds. That wasn't a wound. Her toe was black. In an interview on 12/07/23 at 3:23 p.m. CNA D said she reported the toe last week to the Charge Nurse. She said the Charge Nurse was from an Agency. In an interview on 12/07/23 at 4:05 p.m. LVN C said she assessed Resident #6's toe. She said it was 80% eschar and 20% granulation. She said she measured it at 4.5 x 3 x 'unable to measure.' She said she called the physician and received an order for Betadine. She said it was a recurring wound. She said the Charge Nurse the previous week was a facility nurse, not an agency nurse. She said that nurse was on leave this week. In an interview via telephone on 12/08/23 at 9:53 a.m. Physician E said Resident #6 did have circulation problems. She said she had been seeing Resident #6 since May of 2023, and the resident had not presented with foot issues. She said she was not told about the current right great toe issue the previous week. She said the staff should have informed her right away. She said the Nurse Practitioner would be at the facility on this day, and she would assess the resident in person on Monday (12/11/23). The facility Policy entitled Patient Care Management System 1 Skin (July 2022) read, in part, .4. Any newly identified wounds will be addressed by the Treatment Nurse or Charge Nurse to include assessment and documentation of the skin site and initiate appropriate clinical interventions .9. The Certified Nurse Aide will notify the Treatment Nurse or Charge Nurse of any newly identified skin issues .

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 1 (Resident #1) of 5 residents reviewed for abuse and neglect. CNA A yelled at Resident #1, slapped her left arm three times, and forcefully grabbed her arm, which caused a skin tear on her left arm on [DATE]. The noncompliance was identified as past noncompliance (PNC). The noncomplilance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of physical or emotional distress, and injury. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (a condition in which the blood vessels have persistently raised pressure), dementia with behavioral disturbance (impaired ability to remember, think or make decisions), Alzheimer's disease (a brain destroys memory and thinking skills) and atrial fabulation (an irregular and often very rapid heart rhythm) Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 03 out of 15 which indicated severely cognitive impairment. She required extensive assistance of 2 staff for bed mobility and toilet use. Record review of Resident #3's care plan printed [DATE] revealed she exhibits: verbal aggression, physical aggression, and resistance to care. Interventions were to recognize when resident is being manipulative, redirect behaviors when providing care, provide diversional activities, and provide 2-person assistance with ADL. Record review of the facility's provider investigation report dated [DATE] signed by the assistant executive director revealed the assistant executive director followed up on Resident #1's FM#1 concern about CNA A mistreating her Resident #1on 2 to p.m. shift on [DATE] when she was watching the camera in Resident #1's room. They reported to HHSC and Pearland police, and CNA A was suspended. They started the provider investigation right away. The assistant executive director and the corporate nurse spoke with the detective on [DATE], and the detective said he had seen the video and it was not good. They requested the video from the detective since the FM#1 had not sent them a copy. The detective sent a copy, and after they reviewed the video, which revealed CNA A did hit the resident arm multiple times and grabbed her left arm, which caused the resident to sustain a skin tear on her left arm. CNA A was terminated on [DATE]. Record review of Resident #1's nursing notes dated [DATE], written by LVN E, revealed the nurse came from downstairs and informed LVN E that Resident #1's family member was on the phone and said CNA A was mishandling the resident. LVN E went to the room immediately and observed two staff members in the room. LVN E ordered CNA A out of the room, and she asked MA B to stay and help her finish the care. She observed blood on Resident #1's left hand while the resident was fighting, hitting, and spitting. LVN E managed to cover the area with a dressing. The resident received incontinent care and was made comfortable in bed. No distress or discomfort was noted, and the resident was in a stable condition. Vital signs were stable, the bed was in the lowest position, the call light was within reach, and RP (responsible party) was notified. RP stated that she would send the video interaction to the administrators. Regional DON notified. I called the assistant administrator and left a message to return LVN E's call. The incoming nurse was informed to continue to monitor the resident for any changes in condition. The Doctor was notified. Record review of CNA A's personnel action form dated [DATE] revealed involuntary terminated due to policy violation and misconduct. It also revealed CNA A revived training on resident rights and abuse policy and reporting and he signed it on [DATE]. During an observation and interview on [DATE] at 10:20 a.m., Resident #1 was lying on her bed with her eyes closed, and she responded to her name but could not respond to questions or hold any conversation. During an observation on [DATE] at 5:10 p.m., the video revealed CNA A did not provide any privacy for Resident #1 because she was completely naked. It also showed CNA A yelled and hit the resident three times on her arm. CNA A grabbed her left arm forcefully when CNA A wanted to turn Resident #1, and she sustained a skin tear. During an interview on [DATE] at 11:03 p.m., the MDS coordinator said the facility was aware of Resident#1's behavior before she came to the facility, and her behavior was care planned upon admission on [DATE]. He said Resident #1 was hitting and scratching staff, but that does not make it right for staff to hit any resident, which meant CNA A did not follow the facility policy on abuse. He said the resident was seeing the PYSC to control her behaviors, and she was put on a mood stabilizer, anti-depressant, and trazodone. He stated the interdisciplinary team made angels round (check on resident and ask about their needs and assist the residents). The MDS coordinator said Resident #1 care plan was updated to two persons assist with ADL care after the incident. During an attempted interview on [DATE] at 11:18 a.m. CNA A did not answer the phone call. This Surveyor left a voicemail and provided the state cell number. During an interview on [DATE], MA B said she was working on the day of the incident, but she entered Resident#1's room when CNA A called her to assist with care, and it was after the incident. MA B said she was on the left side of the resident, and she noted blood on her arm. She went to the cart and took alcohol prep, and the two nurses came to the room and asked CNA A to leave the room. She said they provided care for the resident while she was hitting them. She said she was in service on abuse/neglect before and after the incident. She was also in-service on how to work with residents with Alzheimer's disease. MA B said staff should not hit, slap, or mistreat any resident, and when it happened, the staff failed to follow the facility policy. During an interview on [DATE] at 12:02 p.m., FM #1 said she called the facility and told the nurse about the male staff, and they intervened immediately. She said she would send the video later today ([DATE]). She also said the staff was not found guilty during the trial, but the facility had reported his license, and she was satisfied that he would not be able to work with older adults again. During an interview on [DATE] at 2:28 p.m., The administrator said he saw some part of the video CNA A was trying to change the resident, and he saw the staff slap the resident at least twice but could not remember the part of the body and he was in shock when he saw it. He said the staff did not follow the facility policy on abuse when he hit Resident #1. He said in-services were provided on abuse/neglect before and severally after the incident, and staff were also provided in-service on working with residents with Alzheimer's. The administrator said the management makes angel rounds, and the nurses and unit managers also make random rounds on residents, and they ask residents about how the staff was treating them and encourage the residents to report any concerns. During an interview on [DATE] at 2:44 p.m., the Regional Director of operation said the corporate nurse contacted him during the incident. He viewed the video, and it revealed CNA A was providing care for Resident #1 in her room, and she was naked. He said he saw the aide yelling at the resident to stop, and he hit the resident's hand about two to three times, and the resident was also yelling stop. He said he saw the skin tear but did not see when it happened. The Regional Director of Operation said the staff was in serviced on abuse/neglect and resident rights. He said they did skin sweeps and safe surveys with residents immediately. He also said they implemented a system for the unit manager and nurse to make random rounds and check for abuse. During an interview on [DATE] at 3:50 p.m., LVN E said she was Resident #1 nurse on the night of the incident. She said she became aware of the incident when a nurse told her Resident #1 family called and said CNA A was maltreating the resident because she saw it from the camera in the resident's room. She said she went into the resident's room and told CNA A to leave the room, and she completed the care with MA B. She said she tried to clean the skin tear on the left arm, but the resident was kicking, hitting, and spitting. She said she was able to apply skin dressing on the skin tear site. LVN E said she called the regional DON, and he told him what happened, and he said to send the CNA A home and continue to monitor. She called the assistant administrator, and she did not answer. Then she left a message, called the resident family, and spoke FM #2 and FM #1.Then she called the doctor, and the doctor said she said she would come and assess the resident. She said she had in service on abuse/neglect before the incident and had several in service on abuse after the incident. She said she made rounds randomly and asked the residents if any staff was maltreating them, and none had said anything about being abused. LVN E said the administrator was the facility's abuse coordinator, and she mentioned four types of abuse, and abuse is reported immediately. She said they had in service on reporting any incident immediately. She said the incident happened because CNA A did not follow the facility policy and training on abuse. She said the incident occurred late, around 10:00 p.m. Record review of the facility abuse protocol dated [DATE] read in part, . #1 the patient has the right to be free from abuse . #5 . the abuse coordinator will assure that all facility staff is in serviced on recognizing abuse, prevention and reporting upon employment and as necessary to maintain an abuse free environment . #7 . the following definitions are provided to assist our facility's staff members in recognizing incidents of patient abuse . #7a . abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . The facility took the following action to correct the non-compliance on between [DATE] and [DATE]: Record review of skin assessment for 8 residents that CNA A was taking care of on [DATE] dated [DATE] revealed Resident #1 had a skin tear on the upper left arm, and it measured 2.00cm x2.00cm. treatment intervention: xeroform and wound supplements: Multivitamin with minerals, and Vitamin C, while other residents did not have any new skin issues. Record review of the facility in service meeting revealed the following: abuse/neglect all employees on [DATE], abuse/neglect all employees on [DATE], resident rights [DATE], timely reporting all employees on [DATE], employee abuse investigation questionnaire on [DATE], abuse protocol all employees on [DATE]. These in-services were conducted by the Assistant executive director. During an interview on [DATE] at 10:42 a.m., Resident #2 said the staff had not yelled or hit him, and he felt safe in the facility. He said he was not afraid to report any incident and would report to the administrator or social worker if it did happen. During an interview on [DATE] at 10:44 a.m., Resident #3 said she felt safe in the facility and had no issues where the staff had yelled or hit her. Resident #3 said she would report to the nurse if the staff did anything she did not like, and she was not afraid to report any aide who would mistreat her. During an interview on [DATE] at 10:46 a.m., Resident #4 said he does not have any concerns with the care or treatment provided to him by the staff. He said none of the staff had abused or mistreated him. During an interview on [DATE] at 11:06 a.m., Resident #5 said she felt safe in the facility, none of the staff had yelled or mistreated her, and she would report if it happened. During an interview on [DATE], RN C said she did not work on the incident day, but other staff told her CNA A hit Resident #1's hand and jerked her around in bed, and she sustained a skin tear. She said she was in serviced on abuse/neglect, reporting, and working with residents with dementia. She said she knew the resident hit staff during care, and no staff should hit any resident for any reason. RN C said CNA A did not follow the facility policy because he hit Resident #1.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. The facility failed to appropriately implement written abuse policy which resulted in CNA A hitting and forcefully grabbing Resident #1 left arm which resulted in a skin tear during care. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This failure placed residents at risk of physical or emotional distress, and injury. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (a condition in which the blood vessels have persistently raised pressure), dementia with behavioral disturbance (impaired ability to remember, think or make decisions), Alzheimer's disease (a brain destroys memory and thinking skills) and atrial fabulation (an irregular and often very rapid heart rhythm) Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 03 out of 15 which indicated severely cognitive impairment. She required extensive assistance of 2 staff for bed mobility and toilet use. Record review of Resident #3's care plan printed [DATE] revealed she exhibits: verbal aggression, physical aggression, and resistance to care. Interventions were to recognize when resident is being manipulative, redirect behaviors when providing care, provide diversional activities, and provide 2-person assistance with ADL. Record review of the facility's provider investigation report dated [DATE] signed by the assistant executive director revealed the assistant executive director followed up on Resident #1's FM#1 concern about CNA A mistreating her Resident #1on 2 to p.m. shift on [DATE] when she was watching the camera in Resident #1's room. They reported to HHSC and Pearland police, and CNA A was suspended. They started the provider investigation right away. The assistant executive director and the corporate nurse spoke with the detective on [DATE], and the detective said he had seen the video and it was not good. They requested the video from the detective since the FM#1 had not sent them a copy. The detective sent a copy, and after they reviewed the video, which revealed CNA A did hit the resident arm multiple times and grabbed her left arm, which caused the resident to sustain a skin tear on her left arm. CNA A was terminated on [DATE]. Record review of Resident #1's nursing notes dated [DATE], written by LVN E, revealed the nurse came from downstairs and informed LVN E that Resident #1's family member was on the phone and said CNA A was mishandling the resident. LVN E went to the room immediately and observed two staff members in the room. LVN E ordered CNA A out of the room, and she asked MA B to stay and help her finish the care. She observed blood on Resident #1's left hand while the resident was fighting, hitting, and spitting. LVN E managed to cover the area with a dressing. The resident received incontinent care and was made comfortable in bed. No distress or discomfort was noted, and the resident was in a stable condition. Vital signs were stable, the bed was in the lowest position, the call light was within reach, and RP (responsible party) was notified. RP stated that she would send the video interaction to the administrators. Regional DON notified. I called the assistant administrator and left a message to return LVN E's call. The incoming nurse was informed to continue to monitor the resident for any changes in condition. The Doctor was notified. Record review of CNA A's personnel action form dated [DATE] revealed involuntary terminated due to policy violation and misconduct. It also revealed CNA A revived training on resident rights and abuse policy and reporting and he signed it on [DATE]. During an observation and interview on [DATE] at 10:20 a.m., Resident #1 was lying on her bed with her eyes closed, and she responded to her name but could not respond to questions or hold any conversation. During an observation on [DATE] at 5:10 p.m., the video revealed CNA A did not provide any privacy for Resident #1 because she was completely naked. It also showed CNA A yelled and hit the resident three times on her arm. CNA A grabbed her left arm forcefully when CNA A wanted to turn Resident #1, and she sustained a skin tear. During an interview on [DATE] at 11:03 p.m., the MDS coordinator said the facility was aware of Resident#1's behavior before she came to the facility, and her behavior was care planned upon admission on [DATE]. He said Resident #1 was hitting and scratching staff, but that does not make it right for staff to hit any resident, which meant CNA A did not follow the facility policy on abuse. He said the resident was seeing the PYSC to control her behaviors, and she was put on a mood stabilizer, anti-depressant, and trazodone. He stated the interdisciplinary team made angels round (check on resident and ask about their needs and assist the residents). The MDS coordinator said Resident #1 care plan was updated to two persons assist with ADL care after the incident. During an attempted interview on [DATE] at 11:18 a.m. CNA A did not answer the phone call. This Surveyor left a voicemail and provided the state cell number. During an interview on [DATE], MA B said she was working on the day of the incident, but she entered Resident#1's room when CNA A called her to assist with care, and it was after the incident. MA B said she was on the left side of the resident, and she noted blood on her arm. She went to the cart and took alcohol prep, and the two nurses came to the room and asked CNA A to leave the room. She said they provided care for the resident while she was hitting them. She said she was in service on abuse/neglect before and after the incident. She was also in-service on how to work with residents with Alzheimer's disease. MA B said staff should not hit, slap, or mistreat any resident, and when it happened, the staff failed to follow the facility policy. During an interview on [DATE] at 12:02 p.m., FM #1 ) said she called the facility and told the nurse about the male staff, and they intervened immediately. She said she would send the video later today ([DATE]). She also said the staff was not found guilty during the trial, but the facility had reported his license, and she was satisfied that he would not be able to work with older adults again. During an interview on [DATE] at 2:28 p.m., The administrator said he saw some part of the video CNA A was trying to change the resident, and he saw the staff slap the resident at least twice but could not remember the part of the body and he was in shock when he saw it. He said the staff did not follow the facility policy on abuse when he hit Resident #1. He said in-services were provided on abuse/neglect before and severally after the incident, and staff were also provided in-service on working with residents with Alzheimer's. The administrator said the management makes angel rounds, and the nurses and unit managers also make random rounds on residents, and they ask residents about how the staff was treating them and encourage the residents to report any concerns. During an interview on [DATE] at 2:44 p.m., the Regional Director of operation said the corporate nurse contacted him during the incident. He viewed the video, and it revealed CNA A was providing care for Resident #1 in her room, and she was naked. He said he saw the aide yelling at the resident to stop, and he hit the resident's hand about two to three times, and the resident was also yelling stop. He said he saw the skin tear but did not see when it happened. The Regional Director of Operation said the staff was in serviced on abuse/neglect and resident rights. He said they did skin sweeps and safe surveys with residents immediately. He also said they implemented a system for the unit manager and nurse to make random rounds and check for abuse. During an interview on [DATE] at 3:50 p.m., LVN E said she was Resident #1 nurse on the night of the incident. She said she became aware of the incident when a nurse told her Resident #1 family called and said CNA A was maltreating the resident because she saw it from the camera in the resident's room. She said she went into the resident's room and told CNA A to leave the room, and she completed the care with MA B. She said she tried to clean the skin tear on the left arm, but the resident was kicking, hitting, and spitting. She said she was able to apply skin dressing on the skin tear site. LVN E said she called the regional DON, and he told him what happened, and he said to send the CNA A home and continue to monitor. She called the assistant administrator, and she did not answer. Then she left a message, called the resident family, and spoke FM #2 and FM #1.Then she called the doctor, and the doctor said she said she would come and assess the resident. She said she had in service on abuse/neglect before the incident and had several in service on abuse after the incident. She said she made rounds randomly and asked the residents if any staff was maltreating them, and none had said anything about being abused. LVN E said the administrator was the facility's abuse coordinator, and she mentioned four types of abuse, and abuse is reported immediately. She said they had in service on reporting any incident immediately. She said the incident happened because CNA A did not follow the facility policy and training on abuse. She said the incident occurred late, around 10:00 p.m. Record review of the facility abuse protocol dated [DATE] read in part, . #1 the patient has the right to be free from abuse . #5 . the abuse coordinator will assure that all facility staff is in serviced on recognizing abuse, prevention and reporting upon employment and as necessary to maintain an abuse free environment . #7 . the following definitions are provided to assist our facility's staff members in recognizing incidents of patient abuse . #7a . abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . The facility took the following action to correct the non-compliance between [DATE] and [DATE]: Record review of skin assessment for 8 residents that CNA A was taking care of on [DATE] dated [DATE] revealed Resident #1 had a skin tear on the upper left arm, and it measured 2.00cm x2.00cm. treatment intervention: xeroform and wound supplements: Multivitamin with minerals, and Vitamin C, while other residents did not have any new skin issues. Record review of the facility in service meeting revealed the following: abuse/neglect all employees on [DATE], abuse/neglect all employees on [DATE], resident rights [DATE], timely reporting all employees on [DATE], employee abuse investigation questionnaire on [DATE], abuse protocol all employees on [DATE]. These in-services were conducted by the Assistant executive director. During an interview on [DATE] at 10:42 a.m., Resident #2 said the staff had not yelled or hit him, and he felt safe in the facility. He said he was not afraid to report any incident and would report to the administrator or social worker if it did happen. During an interview on [DATE] at 10:44 a.m., Resident #3 said she felt safe in the facility and had no issues where the staff had yelled or hit her. Resident #3 said she would report to the nurse if the staff did anything she did not like, and she was not afraid to report any aide who would mistreat her. During an interview on [DATE] at 10:46 a.m., Resident #4 said he does not have any concerns with the care or treatment provided to him by the staff. He said none of the staff had abused or mistreated him. During an interview on [DATE] at 11:06 a.m., Resident #5 said she felt safe in the facility, none of the staff had yelled or mistreated her, and she would report if it happened. During an interview on [DATE], RN C said she did not work on the incident day, but other staff told her CNA A hit Resident #1's hand and jerked her around in bed, and she sustained a skin tear. She said she was in serviced on abuse/neglect, reporting, and working with residents with dementia. She said she knew the resident hit staff during care, and no staff should hit any resident for any reason. RN C said CNA A did not follow the facility policy because he hit Resident #1.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (CR #1) reviewed for quality of care. The facility failed to check CR #1's vitals as ordered/scheduled for three times per day. The facility failed to promptly call 911 for CR #1 after he experienced shortness of breath and increased blood pressures. CR #1 coded before the transportation service arrived. The facility failed to complete an SBAR for CR #1 and failed to document accurate vitals after a change in his condition was identified. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for not receiving prompt medical attention. Findings include: CR #1 Record review of CR #1's face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE]. He had a recent discharge on [DATE] and readmitted post hospitalization on [DATE]. His [DIAGNOSES REDACTED]. He was listed as being full-code. Record review of CR #1's care plan dated [DATE] revealed he took [MEDICAL CONDITION] medications for depression and anxiety. The goal was he would not experience adverse side effects over the next 90 days. The interventions included monitoring/recording any displayed behavior or mood problems. Further review revealed panic/anxiety attacks and blood pressure abnormalities were not addressed in the care plan. Record review of CR #1's discharge MDS dated [DATE] revealed a BIMS score of ,[DATE] indicating he was cognitively intact. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's MAR dated [DATE] revealed the blood pressure medication carvedilol 12.5 mg tablet twice daily was ordered on [DATE]. There were no parameters to indicate when the medication should be withheld. It was scheduled for 9 am and 5 pm and administered per the order. There were no blood pressure results documented on the MAR. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's TAR dated ,[DATE] revealed his blood pressure, pain, pulse, pulse oximeter, respiration, and temperature on all three shifts were not recorded for any of the shifts on [DATE] or [DATE]. Record review of CR #1's nursing note dated [DATE] at 4:05 pm revealed he complained of shortness of breath and reported he had several panic attacks last week. CR #1 was given PRN medication. His o2 sat was 97%. No other vitals were documented. The note was signed by LVN A. Record review of CR #1's physician orders [REDACTED].>o [MEDICATION NAME] 90 mg prn was ordered on [DATE] o [MEDICATION NAME] .5 mg prn was ordered on [DATE] Record review of CR #1's MAR dated [DATE] revealed: - [MEDICATION NAME] .5 mg prn was administered at 4:10 pm - [MEDICATION NAME] 90 mg prn was to be administered if the systolic blood pressure was greater than 165. It was given at 4:44 pm due to the systolic blood pressure being at 199. Record review of CR #1's clinical record revealed there was no SBAR in his chart dated from [DATE] - [DATE]. Record review of nursing note dated [DATE] at 9:06 pm revealed CR #1 complained of shortness of breath and anxiety. His O2 saturation was 98% and other vitals were stable. His PRN was given and a message for the physician was left with no response back. His responsible parties were notified and already aware of the situation. His blood pressure was slightly elevated. Emergency transportation was called and provided an estimated time of arrival of 45 minutes to an hour. CR #1 was found unresponsive and CPR was initiated. EMT took over once they arrived. No other vitals were documented. No times were recorded in the note. The note was signed by LVN A. During a telephone interview on [DATE] at 11:50 am, CR #1's family member said on ,[DATE] at 4:10 pm she got a call from CR #1 saying he was having problems breathing. She said she thought it was due to him having withdrawals from [MEDICATION NAME] weeks prior. She said she told him to relax and try to calm down. She said CR #1 called back at 4:18 pm and she tried again to get him relax. She said at 4:23 pm she got a call from LVN A who said CR #1 was having trouble breathing. She said she missed a call from him at 5:21 pm and 5:24 pm . She said in between calls with CR #1, she was talking to LVN A. She said she asked LVN A what his vitals were and was told his blood pressure was high but could be due to him being excited. She said LVN A gave him [MEDICATION NAME] and wanted to wait for it to work. She said after several calls back and forth between CR #1 and LVN A, LVN A asked what they should do around 5:55 pm. She said she told LVN A they should listen to him because he knew his body and get an ambulance as he requested. She said LVN A said I'll call the ambulance that takes him to [MEDICAL TREATMENT]. By then the [MEDICATION NAME] should have kicked in. She said LVN A never gave her a timeframe for the ambulance. During a telephone interview on [DATE] at 8:04 am, LVN A said on [DATE] she worked 6 am to 10 pm. She said that day she did morning rounds and saw CR #1 around 6:15 am who was at his baseline. She said it was standard to take vitals once per shift, but if a resident received blood pressure medication their blood pressure was taken before administering the medication and documented on the MAR. She said she took CR #1's vitals on ,[DATE] and documented them on the MAR and was not sure why they were not populated on the document. She said later that evening CNA A informed her that CR #1 requested her. She said she went into CR #1's room and he said he felt like he was having an anxiety attack. She said she checked his vitals and they were stable but could not remember the exact vitals. The vitals she continued checking were blood pressure, pulse ox, and temperature. She said she wrote them down but could not say why none of the vitals from that day were documented anywhere. She said CR #1 informed her he had a had a PRN for anxiety and requested it. She said she gave him the PRN, left a message with the on-call physician due to his shortness of breath, and called his responsible party. LVN A said when she called his responsible party she said, I already know we're trying to calm him down. She said they were in agreement they would wait until the pill kicked in before trying other interventions. She said she checked on him 15 minutes after giving him the medication to see if the [MEDICATION NAME] was working and he was still complaining of being short of breath. She said sometime afterwards she went to check on him and His blood pressure went up a little bit - but it wasn't anything critical. She could not recall the actual reading, but said it was high enough she gave his PRN medication for high blood pressure. She said she tried to contact the DON, but she did not answer so she reached out to the ADON who instructed her to continue monitoring CR #1. She said she called all the proper entities and there was no one else to call when calls to the physician were unsuccessful. She could not recall when she called the physician, but she said it was at least twice. She said she visited him every 10 minutes and continued to take his vitals. She said, his main concern was his breathing but could not recall if he complained of any other symptoms. She said his pulse ox was between ,[DATE]% every time she checked it. She said she checked on him at an unknown time and CR #1 said the time before the pill worked in a couple of minutes, but it had not kicked in yet. She said another time she checked on him at an unknown time CR #1 said I don't know why the pill is not working. She said she suggested he be sent out to the hospital and called his responsible party to inform her of the plan. She said she checked his vitals again and everything was good. and called transportation. She said she could not remember what time she called transportation, but believe it took them 30 minutes to show up. She said she called the physician again at an unknown time and still did not get a response. She said she went to his room after seeing the transportation truck pull up and he was unresponsive. She said his eyes were open and she had the vital things on him but couldn't get anything. She said she called for help and asked CNA A to get LVN B. She said she and LVN B got him from the bed and put him down on the ground and initiated CPR. She said ,[DATE] minutes later EMT took over CPR and then transported him to the hospital. She said she could not remember times of any of the events. She could not say why his abnormal blood pressure was not addressed in her nursing notes. She said she called transportation instead of 911 because he was not in distress. She said she did not initiate a SBAR because he had complained of the anxiety before and she said she did not complete an incident report. She said she would have not done anything different and had not received any training since the incident. During a telephone interview on [DATE] at 8:50 am, CNA A said she got to the facility on [DATE] at 2:30 pm and did rounds. She said she didn't know much about the patient, but believed he was at his baseline that morning. She said CR #1 put on his call light ,[DATE] times at unknown times and requested the nurse. She said LVN A went into the room every time she was requested. She said he was having trouble breathing. She said the last thing she remembered she was sitting at the desk the nurse came and got me and said she needed my help, so I went to help her . Then she asked me to go get another nurse. During a telephone interview on [DATE] at 10:13 am, the physician said CR #1 was a new recent admission and he had saw him once. He described CR #1 as needing complex care. He said CR #1 periodically had shortness of breath and anxiety and was prescribed [MEDICATION NAME] prn. He said he was off on [DATE] and since the incident happened over the weekend the nurse should contact the on-call physician in the case of an emergency. He said on [DATE] when he arrived to work he was informed CR #1 had passed away. He said he was told by the facility that he began having shortness of breath and 911 was called. He said he was not aware of the time frame of the situation. He said, If somebody's short of breath you do whatever you can do, and if you can't confirm oxygenation, you have to make sure the physician's aware. He said if the physician was unable to be reached and the resident continued to experience shortness of breath, they should be sent out immediately via 911 During a telephone interview on [DATE] at 10:47 am, the DON said she had been in the position since [DATE] but had been working the floor ,[DATE]% of the time and had not been able to handle DON duties. She said she mostly worked the floor on the overnight shift 6 pm to 6 am. She said if a resident experienced a change in condition, an SBAR should be initiated, the physician should be contacted, and nursing interventions should be implemented in the meantime. She said if the physician could not be reached nurses should know to reach out to the Medical Director. She said she was not familiar with CR #1 or the incident on [DATE] and was unsure if she got a phone call from LVN A. She said on [DATE] at 8:13 pm, she got a text message from the ADON that said CR #1 was being sent out for high blood pressure and coded. She said in the event of a life-threatening situation and the physician could not be reached, the nurse should call 911. She said, you can't just wait on a phone call to save somebody's life and ABCs of nursing - airway is number one. She said if a resident was stable then non-emergent transportation was appropriate. She said she had not conducted any in-services following the incident with CR #1. During a telephone interview on [DATE] at 11:02 am, the ADON said, I remember the nurse calling and saying he was in pain. She said she contacted the provider and waiting for a response. She checked his vitals and his blood pressure was high. She called transportation and he coded before they arrived. She said at 5:40 pm she received a text message from LVN A that said Complaining of anxiety and hyperventilating. Gave PRN [MEDICATION NAME] and was waiting on a callback from the physician. LVN A talked to the responsibility party to try to get him to calm down but was unsuccessful. LVN A called the physician again. She told LVN A to document everything. She said she got a text message at 6:28 pm that said his blood pressure was ,[DATE] and LVN A asked if she could send CR #1 to the hospital. The ADON told her yes. She said at 8:36 pm she got a message saying 911 was there. She said she had not conducted any in-services following the incident with CR #1. She said if a resident was experiencing problems breathing 911 should be called. During a follow-up telephone interview on [DATE] at 9:58 pm, LVN A was asked why the ,[DATE] blood pressure was not documented anywhere she said, I honestly had it written down, but was not sure why she did not document it in the chart. She said she was a newer nurse which is why she was reaching out to the ADON during the incident. Record review of in-services dated after [DATE] revealed no trainings on change of condition, physician notification, or emergency/non-emergent transports. Record review of the facility's change in condition policy dated [DATE] revealed in part Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Further review revealed a significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the interact SBAR communication form. The Corporate Administrator was notified of Immediate Jeopardy (IJ) on [DATE] at 4:02 pm due to the above failures. A copy of the IJ template was provided and a Plan of removal was requested. The final plan of removal was accepted on [DATE] at 12:26 pm after several revisions were made. IJ plan of removal included: Immediate action: Systematic Approach: 1. Facility staff In-serviced staff by, Regional Director of Clinical Services on change of condition, completing and documenting vital signs timely, notifying physician. In-service began on [DATE] and will be completed by Monday [DATE]. Notification to Physicians, Change of Condition and identifying changes in conditions, Assessments, Emergency and/or Alternative Physician Care/Notification, Emergent/non-emergent notification and CPR Policies/procedures were reviewed by the Medical Director [DATE] no changes recommended. 2. Director of Nursing & Nurse Managers, RT immediately reviewed all patients that have respiratory illness and hypertension. Record audit as well as visual assessment completed on [DATE]. 3. Respiratory Therapist assessed all Patients [DATE] with [DIAGNOSES REDACTED]. 4. Notification to Physician: Policy related to Emergency Physician Care and Policy on notification a. QA committee meeting was held on [DATE] with Medical Director, Executive Director Interim DON, Regional Director of Clinical Services and Regional Director of Operations. Root Cause analysis was completed by Executive Director with the support/collaboration of Regional Director of Clinical Services, Interim Director of Nursing and Regional Director of Operations. Nursing staff was educated on timeliness of notification to the Physician related to Change of condition, assessing & recognizing change of condition and specified time related to return call from the Physician. In the event that a return call is not received within 15 minutes, a call is then placed to the Medical Director for directives. If Patient's condition continues to deteriorate with no return call within the established timeframe 911 is to be called in all emergency situations. Nursing staff were also in-serviced [DATE] on Facility policy related to what is considered an emergency that requires notification to the Physician. Facility staff were in-serviced [DATE] by Regional Director of Clinical Services using the Interact tool to guide them related to identifying emergent situations, assessing and notification to Physicians following established Care paths for emergency notification vs non-emergent notification utilizing the parameters established in the Interact policy endorsed by the Medical Director. b. The facility will document monitoring of change of status on the change of status log. This log will be reviewed daily in morning stand-up by the facility clinical team with additional review in Monthly QA meeting c. No facility staff will be allowed to return to active duty until such a time as the education described above is completed. d. Results of all monitoring shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. e. Changes identified by non-nursing staff will be communicated using the Interact Process. f. Completion Date: [DATE] Monitoring of Plan of Removal During an interview on [DATE] at 9:43 pm, LVN B said she worked from 6 am - 10 pm. She said if a resident was having a change in condition she must do an assessment. She said examples of emergency situations included respiratory distress or cardiac related. She said a non-emergency example could be abdominal pain. She said if the physician could not be reached after 15 minutes she was to contact the Medical Director in the case of a change in condition. She said vitals were to be documented every shift on the computer to include temperature, pulse, respirations, and blood pressure. She said blood pressure parameters were on the resident's medication order. During an interview on [DATE] at 9:54 pm, LVN D she said she worked from 6 am - 10 pm. She said in the case of a resident experiencing a change in condition the family and physician should be notified immediately and a SBAR should be completed. She said the Medical Director could be contacted if the physician was not able to be reached. She said an example of a non-emergency send out could be diarrhea and an emergency would be if the resident was unresponsive. She said blood pressure parameters were on the MAR. During an interview on [DATE] at 9:58 pm, LVN A said she worked from 6 am - 10 pm. She said she was trained if a resident was having a change in condition the physician and RP should be called and a SBAR should be completed. She said the Medical Director could be contacted if the physician could not be reached. She said she was given the parameter of 220 for blood pressure as an emergency. During an interview on [DATE] at 10:00 pm, LVN E said she worked weekends 6 am - 10 pm. She said an example of an emergency requiring a 911 call included [MEDICAL CONDITION]. She said if a resident had a change in condition she would assess, take vitals, call the physician, and complete a SBAR. She said if the physician was unreachable she would reach out to the Medical Director. She said a non-emergency transport was appropriate for residents whose conditions was stable. During an interview on [DATE] at 10:05 pm, RN B said she worked all three shifts. She said with a change in condition the steps would be to assess, notify the physician, and complete a SBAR. She said the Medical Director should be contacted if the physician was unable to be reached. She said vitals were checked on all residents every shift. She said the assessment would determine if the resident needed to be sent out via emergency or non-emergent transportation. During an interview on [DATE] at 10:15 pm, RN C said she worked from 10 pm - 6 am. She said if a resident had a change in condition she would complete an assessment and SBAR. She said she would notify the family, physician, and DON. She said an emergency prompting a call to 911 would include [MEDICAL CONDITION], breathing issues, or chest pain. She said blood pressure parameters were on the resident's medication order. During an interview on [DATE] at 10:20 pm, LVN F said he worked from 10 pm - 6 am. He said in the case of a change in condition he would check the vitals, notify the MD, and do a SBAR. He said an emergency would be if the resident's vitals were high or low. He said if the vitals were stable, he would call non-emergency transportation. He said if the physician was unreachable he would call the Medical Director. During an interview on [DATE] at 10:25 pm, LVN G said he worked from 10 pm - 6 am. He said he would assess the resident, take their vitals, and possibly call 911 if there was a change in condition. He said he would also complete a SBAR. He said he would call the physician if there was a change in condition and if they could not be reached he would call the Medical Director after 15 minutes. He said an assessment determined if the resident should be sent out via 911 or non-emergency transportation. Record review of the IJ binder dated [DATE] revealed in-services on change of condition, completing and documenting vital signs timely, notifying physician. Further review revealed the following policies were reviewed by the administrator and Medical Director: Notification to Physicians, Change of Condition and identifying changes in conditions, Assessments, Emergency and/or Alternative Physician Care/Notification, Emergent/non-emergent notification and CPR Policies/procedures. Assessments were documented for residents with respiratory concerns. The change of condition audit dated [DATE] revealed Resident #1, #2, and #3 had change in conditions. The log indicated the physicians were notified, the family was notified, and SBARs were complete. Record review of Resident #1, Resident #2, and Resident #3's clinical charts on [DATE] revealed SBARs were complete and proper entities were notified of their changes in condition. Assessments were completed, and blood pressure parameters were documented. The Administrator was notified that the IJ was removed on [DATE] at 10:51 am. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was an accident involving the resident resulting in injury for 1 of 3 residents (Resident #1) reviewed for notification of changes in that: - Resident #1's physician was not immediately notified when X-ray results identified a possible fracture requiring additional follow up to confirm or exclude the diagnosis. This failure affected one resident and placed her at risk of delayed evaluation and treatment. Intake #'s 5 and 7 Findings include: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Annual MDS assessment dated [DATE], revealed Resident #1's cognition was intact with no impairment with a BIMS score of 15 out of 15. Resident #1 had a functional limitation in range of motion and her upper and lower extremities were impaired on one side. She needed the extensive physical assistance of 1 person for transfers. Record review of Resident #1's care plan initiated on 9/21/17 revealed care plans to address risk for falls, increased risk for pain depressive moods and behaviors, incontinence of bowel and bladder, history of [MEDICAL CONDITION], and requires limited to extensive assistance with ADL functional mobility, actual fall on 2/11/19, [MEDICAL CONDITION] medication, left [MEDICAL CONDITION] and acute pain related to recent [MEDICAL CONDITION]. Further record review of Resident #1's care-plan initiated on 9/21/17 revealed to address the problem of risk for increased falls the goals date 4/30/19 read in part; Resident #1 will achieve an acceptable level of pain control within 1-2 hours of intervention. Resident will also receive non-pharmacological pain management interventions, with report of acceptable level of pain within 1-2 hours of intervention daily in the next 90 days. During an anonymous interview the person said they felt concerned because the facility delayed the patient receiving care for 22 hours post fall. The person said the patient received X-rays at 11:00 pm and was taken to the hospital the next day. Record review of the facility Accident/Incident Report dated 2/11/19 at 3:10 p.m. revealed that Resident #1 slipped/tripped and sustained a skin tear/laceration on the 2-10 shift. The incident was discovered/reported by CNA A. Record review of Resident #1's telephone physician orders dated 2/11/19 revealed Follow up accident and incident Notes; Alert MD of any complications or change in condition: Instructions: Therapeutic range: Physical monitors: Cognitive Patterns/Follow Up type/Musculoskeletal Changes/New or Additional Injury Noted. Telephone order read by RN A on 2/11/19 at 19:02 (7:02 p.m.). Record review of Resident #1's Clinical notes dated 2/11/19 revealed that at 7:45 p.m. Resident #1 complained of pain, notified Nurse Practitioner, new order received. X-ray hands and wrist and then whatever part of leg is specifically hurting. The note was electronically signed by RN A. Record review of Resident #1's Medication Administration Record [REDACTED]. Record review of Resident #1's pain assessment dated [DATE] at 11:26 pm revealed that Resident #1 was capable of communicating pain but did not communicate pain at that time. She had a [DIAGNOSES REDACTED].#1 was satisfied with pain control. Record review of the Nursing Home to Hospital Transfer form revealed that on 2/12/19 at 11:45 am, Resident #1 was transferred to the hospital. Under the comments section, it read, s/p fall with inconclusive fracture, primary reason for transfer-X-ray. Record review of the Radiology report dated 2/12/19 at 12:22 am results revealed conclusion: A subtle cortical step-off in left femoral neck with a linear [MEDICAL CONDITION] suspicious of a non-displaced femoral neck impaction fracture. Please correlate clinically and follow up is recommended to confirm or exclude this diagnosis. Record review of Resident #1's Clinical note dated 2/12/19 at 4:44 p.m. and signed by RN A revealed it read in part, Upon assessment resident lying on side position on the floor. Upon asking Resident #1 what happened, Resident #1 said that CNA A had completed shower and CNA A was assisting her to bed when her (Resident # 1's) good leg became weak and Resident # 1 fell to the floor. Resident #1 was assessed by RN A and then assisted to bed, head to toe assessment done, left side shoulder skin tear, left elbow scorch (sic) noted, left side of head redness noted. No new pain noted. NP (Nurse Practitioner), RP (Responsible Party), DON (Director of Nursing) notified. Bed placed in lowest position. During an interview on 2/15/19 at 3:10 pm CNA A she said, I took Resident #1 to the shower and she did good. While putting her in her wheelchair, her knees got weak and she fell forward and she hit her head on the dresser. I called the Nurse (RN A) and her and another staff helped get her off the floor and put her in bed. She was in pain after we got her in bed, her head and leg. She was hurting around 3:30 pm. She complained of pain about 10 minutes later. She was asking for an X-ray. She said RN A called, for the X-ray, but she did not know if they (X-ray) came that night or what. She said X-ray did not come during her shift. She said they gave her some Tylenol and she said it was not working. During an interview with the DON on 2/15/19 at 2:52 pm she said that CNA A reported the fall to RN A. She said Resident #1's vital signs and assessment were reported to the Nurse Practioner, Responsible Party, and Physician. She said first aide was provided to Resident #1. She said X-rays were taken but the results came back inconclusive. She said she was working on requesting Resident #1's documents/discharge paperwork from the hospital. During an interview on 2/15/19 at 3:18 pm RN A said that CNA A gave Resident #1 a shower and then transferred Resident #1 from shower chair to bed. During the transfer, Resident #1 fell . RN A said that Resident #1 did not complain of pain until 7:45 pm and she gave her [MEDICATION NAME]. She said she informed the Nurse Practitioner and called for X-Rays. She said they came to take the X-Ray before she left at 10:00 pm that same night. Observation and interview on 2/15/19 at 5:50 pm revealed Resident #1 was groomed and reclined in her bed. When asked about her fall, she began to cry, and said, They didn't do what they were supposed to do. I had to beg for an X-ray. They gave me my regular medicine. She said she had complained of pain earlier and knew something was wrong. She said the pain she was having was different from her regular pain. She said, I know in my heart they were wrong. During an interview on 2/15/19 at 6:39 pm the DON said Resident #1 returned back from the hospital with no records. She said the Nurse Practitioner was called with the X-ray results the night the results were obtained, but, the Nurse Practitioner did not answer and did not call back. She said the Nurse Practitioner came to the facility the next morning around 8:00 am, consulted with the Doctor and Resident #1 was transferred to the hospital. She said looking at the time line, she wished they would have called her (the DON) after not reaching the Nurse Practitioner. She said she would have told them to go ahead and send Resident #1 out and called the NP herself. She said they had no policy and procedure that directly applied to response and delay in sending a resident out. Record review of a document provided by the DON of the time line of the incident involving Resident #1 revealed the following: 2/11/19 Fall-3:10 pm, 7:45 pm Resident #1 complains of pain to left hip and X-rays were ordered. 2/12/19: 12:28 am-X-ray received to facility, X-ray result was inconclusive when reviewed by the NP (Nurse Practitioner) 9:00 am -NP reviewed X-ray again with the MD, 11:00 am -new order to transfer Resident #1 to local hospital for more in depth X-ray to confirm fracture. During an interview on 2/15/19 at 6:45 pm the Administrator said he would have gone ahead and sent Resident #1 to the hospital, it was pain. Record review of the facility policy and procedure entitled Pain Management, dated (MONTH) (YEAR) read in part, . 6). If a patient is assessed for unrelieved pain, the nurse must notify the attending physician to obtain an order for [REDACTED].>

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 for 1 of 3 residents (Resident #1) reviewed for quality of care in that: - The facility failed to seek timely medical treatment for [REDACTED]. Resident #1 had untreated pain and was not provided with medical care for a fracture. This failure affected one resident and placed her at risk of delayed evaluation and treatment. Intake #'s 5 and 7 Findings include: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Annual MDS assessment dated [DATE], revealed Resident #1's cognition was intact with no impairment with a BIMS score of 15 out of 15. Resident #1 had a functional limitation in range of motion and her upper and lower extremities were impaired on one side. She needed the extensive physical assistance of 1 person for transfers. Record review of Resident #1's care plan initiated on 9/21/17 revealed care plans to address risk for falls, increased risk for pain depressive moods and behaviors, incontinence of bowel and bladder, history of [MEDICAL CONDITION], and requires limited to extensive assistance with ADL functional mobility, actual fall on 2/11/19, [MEDICAL CONDITION] medication, left [MEDICAL CONDITION] and acute pain related to recent [MEDICAL CONDITION]. Further record review of Resident #1's care-plan initiated on 9/21/17 revealed to address the problem of risk for increased falls the goals date 4/30/19 read in part; Resident #1 will achieve an acceptable level of pain control within 1-2 hours of intervention. Resident will also receive non-pharmacological pain management interventions, with report of acceptable level of pain within 1-2 hours of intervention daily in the next 90 days. During an anonymous interview the person said they felt concerned because the facility delayed the patient receiving care for 22 hours post fall. The person said the patient received X-rays at 11:00 pm and was taken to the hospital the next day. Record review of the facility Accident/Incident Report dated 2/11/19 at 3:10 p.m. revealed that Resident #1 slipped/tripped and sustained a skin tear/laceration on the 2-10 shift. The incident was discovered/reported by CNA A. Record review of Resident #1's telephone physician orders dated 2/11/19 revealed Follow up accident and incident Notes; Alert MD of any complications or change in condition: Instructions: Therapeutic range: Physical monitors: Cognitive Patterns/Follow Up type/Musculoskeletal Changes/New or Additional Injury Noted. Telephone order read by RN A on 2/11/19 at 19:02 (7:02 p.m.). Record review of Resident #1's Clinical notes dated 2/11/19 revealed that at 7:45 p.m. Resident #1 complained of pain, notified Nurse Practitioner, new order received. X-ray hands and wrist and then whatever part of leg is specifically hurting. The note was electronically signed by RN A. Record review of Resident #1's Medication Administration Record [REDACTED]. Record review of Resident #1's pain assessment dated [DATE] at 11:26 pm revealed that Resident #1 was capable of communicating pain but did not communicate pain at that time. She had a [DIAGNOSES REDACTED].#1 was satisfied with pain control. Record review of the Nursing Home to Hospital Transfer form revealed that on 2/12/19 at 11:45 am, Resident #1 was transferred to the hospital. Under the comments section, it read, s/p fall with inconclusive fracture, primary reason for transfer-X-ray. Record review of the Radiology report dated 2/12/19 at 12:22 am results revealed conclusion: A subtle cortical step-off in left femoral neck with a linear [MEDICAL CONDITION] suspicious of a non-displaced femoral neck impaction fracture. Please correlate clinically and follow up is recommended to confirm or exclude this diagnosis. Record review of Resident #1's Clinical note dated 2/12/19 at 4:44 p.m. and signed by RN A revealed it read in part, Upon assessment resident lying on side position on the floor. Upon asking Resident #1 what happened, Resident #1 said that CNA A had completed shower and CNA A was assisting her to bed when her (Resident # 1's) good leg became weak and Resident # 1 fell to the floor. Resident #1 was assessed by RN A and then assisted to bed, head to toe assessment done, left side shoulder skin tear, left elbow scorch (sic) noted, left side of head redness noted. No new pain noted. NP (Nurse Practitioner), RP (Responsible Party), DON (Director of Nursing) notified. Bed placed in lowest position. During an interview on 2/15/19 at 3:10 pm CNA A she said, I took Resident #1 to the shower and she did good. While putting her in her wheelchair, her knees got weak and she fell forward and she hit her head on the dresser. I called the Nurse (RN A) and her and another staff helped get her off the floor and put her in bed. She was in pain after we got her in bed, her head and leg. She was hurting around 3:30 pm. She complained of pain about 10 minutes later. She was asking for an X-ray. She said RN A called, for the X-ray, but she did not know if they (X-ray) came that night or what. She said X-ray did not come during her shift. She said they gave her some Tylenol and she said it was not working. During an interview with the DON on 2/15/19 at 2:52 pm she said that CNA A reported the fall to RN A. She said Resident #1's vital signs and assessment were reported to the Nurse Practioner, Responsible Party, and Physician. She said first aide was provided to Resident #1. She said X-rays were taken but the results came back inconclusive. She said she was working on requesting Resident #1's documents/discharge paperwork from the hospital. During an interview on 2/15/19 at 3:18 pm RN A said that CNA A gave Resident #1 a shower and then transferred Resident #1 from shower chair to bed. During the transfer, Resident #1 fell . RN A said that Resident #1 did not complain of pain until 7:45 pm and she gave her [MEDICATION NAME]. She said she informed the Nurse Practitioner and called for X-Rays. She said they came to take the X-Ray before she left at 10:00 pm that same night. Observation and interview on 2/15/19 at 5:50 pm revealed Resident #1 was groomed and reclined in her bed. When asked about her fall, she began to cry, and said, They didn't do what they were supposed to do. I had to beg for an X-ray. They gave me my regular medicine. She said she had complained of pain earlier and knew something was wrong. She said the pain she was having was different from her regular pain. She said, I know in my heart they were wrong. During an interview on 2/15/19 at 6:39 pm the DON said Resident #1 returned back from the hospital with no records. She said the Nurse Practitioner was called with the X-ray results the night the results were obtained, but, the Nurse Practitioner did not answer and did not call back. She said the Nurse Practitioner came to the facility the next morning around 8:00 am, consulted with the Doctor and Resident #1 was transferred to the hospital. She said looking at the time line, she wished they would have called her (the DON) after not reaching the Nurse Practitioner. She said she would have told them to go ahead and send Resident #1 out and called the NP herself. She said they had no policy and procedure that directly applied to response and delay in sending a resident out. Record review of a document provided by the DON of the time line of the incident involving Resident #1 revealed the following: 2/11/19 Fall-3:10 pm, 7:45 pm Resident #1 complains of pain to left hip and X-rays were ordered. 2/12/19: 12:28 am-X-ray received to facility, X-ray result was inconclusive when reviewed by the NP (Nurse Practitioner) 9:00 am -NP reviewed X-ray again with the MD, 11:00 am -new order to transfer Resident #1 to local hospital for more in depth X-ray to confirm fracture. During an interview on 2/15/19 at 6:45 pm the Administrator said he would have gone ahead and sent Resident #1 to the hospital, it was pain. Record review of the facility policy and procedure entitled Pain Management, dated (MONTH) (YEAR) read in part, . 6). If a patient is assessed for unrelieved pain, the nurse must notify the attending physician to obtain an order for [REDACTED].>

Based on observation, interview and record review the facility failed to provide the necessary treatment and services to promote healing and prevent infection for 1 of 11 (CR#1) residents reviewed for wound care /treatments in that: CR#1 had multiple pressure ulcers was not provided daily wound care or assessments. CR#1's family initiated her transfer to the emergency roiagnom on [DATE]. She was diagnosed with [REDACTED]. This failure affected 1 closed record, CR#1, and placed one hospice resident with pressure sores at risk of infections, neglect, and decline in health status. Intake # 1 & 1 Findings included: Record review of CR#1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's Admission MDS assessment dated [DATE] revealed the resident had severely impaired cognition. She was dependent on staff for all ADLs. She had range of motion limitations of the upper extremity on one side and in both lower extremities. She was assessed as being at risk of developing pressure ulcers. She had one stage III (dimensions of 4 cm in length, 4 cm in width and 0.4 cm depth) and three unstageable - deep tissue injuries. Record review of CR#1's care plan dated [DATE] revealed a plan of care for a stage 3 sacral pressure ulcer with a goal that the size of the ulcer would decrease with evidence of healing over the next 30 days. Approaches included providing care according to the protocol for stage 3 pressure ulcers. Record review of CR#1's care plan dated [DATE] revealed plans of care for a stage 3 sacral pressure ulcer, deep tissue injury to left distal foot, and deep tissue injury to lateral heel. Approaches included, .treatment to pressure ulcer per physician order. Air mattress, and Foley catheter, notify physician of any signs and symptoms of infection to the site (example increase drainage , foul odor etc.) re-evaluate the site every 2 weeks for proper treatment , and weekly head to toe skin assessment. Record review of CR#1's care plan dated [DATE] revealed the resident required hospice as evidenced by terminal illness of [MEDICAL CONDITION] with [MEDICAL CONDITION]. The goal was that dignity would be maintained and the resident would be kept comfortable and pain free within one hour of intervention over the next 90 days. Approaches were to report decline in condition to hospice agency, turn and reposition every 2 hours, and oral care daily and as needed. Record review of CR#1's physician's orders [REDACTED].>Record review of CR#1's clinical notes report dated [DATE] revealed, . patient noted to be added to hospice care on [DATE] with new orders carried out, patient had current order for DNR (Do not resuscitate) but no active paper work signed at this time, will follow up with hospice social worker to ensure this process is complete and updated orders. Record review of CR#1's NP progress note dated [DATE] revealed, . skin physical exam- skin color, texture and turgor normal, left buttock skin tear -measuring , stage III sacrum , DTI left distal foot, unstageable to left medial foot. Assessment and plan - stage IV sacral ulcer -no improvement seen. Continue with daily wound care with calcium alginate and silver, continue to turn patient per facility protocol, aspiration precautions per facility protocol, sleep this morning no further labs for hospice patient. Record review of CR#1's hospice care collaboration meeting dated [DATE] revealed, . stage IV sacral pressure ulcer improving, and Stage IV to left foot improving. Record review of CR#1's undated hospice/facility order tracking sheet revealed the following documentation from hospice: [DATE]- unsure if hospice nurse assessed wounds [DATE]- diminished lung sounds x 5 lobes, shallow breathing, congested and oxygen now at 3 liters via nasal cannula. All dressing CDI, unsure if hospice nurse assessed wounds, left message for (family member) to return call. [DATE]- oxygen at 3.5 liters with diminishing lung sounds X 5 lobes, shallow breathing. Stage IV to sacrum with slight improvement, left foot wound deteriorating - 4 cm by 3 cm by 0.4 cm. Further record review of CR#1's undated hospice/facility order tracking sheet revealed the following documentation from the facility on [DATE]: oxygen saturation 88% on 2 liters of oxygen via nasal cannula, oxygen increased to 3 liters via nasal cannula, head of bed elevated, left foot wound deteriorating- increase in size and blister intact, facility nurse received new order from hospice nurse for wound care as needed due to patient's decline, (family member) at bed side and agrees with plan of care. Order in facility record: cleanse sacral wound and left foot wound and apply dry dressing as needed for palliative care. Record review of CR#1's TAR dated February 2017 revealed wound treatment starting date [DATE] - clean stage IV to sacral area with normal saline, pat dry, apply calcium alginate and cover with proactive dry dressing daily. Order was done [DATE], [DATE], and [DATE] and then discontinued on [DATE]. Clean unstageable wound to left foot and right lateral side with normal saline, pat dry and apply dry dressing three times weekly. Further review of TAR revealed the treatment was done once on [DATE] and then discontinued [DATE]. Record review of CR#1's TAR dated February 2017 revealed orders dated [DATE] to apply [MEDICATION NAME] to right hip [MEDICATION NAME] as needed. Further review of this TAR revealed cleanse sacral wound, apply dry dressing as needed for palliative care and cleanse left foot and apply dry dressing as needed for palliative care. Both treatments were ordered [DATE]. There were staff initials indicating treatments were done once on [DATE]. Record review of CR#1's TAR dated February 2017 revealed an order on [DATE] to cleanse sacral wound with normal saline, pat dry, apply alginate with silver and cover with dry dressing as needed. Cleanse right hip wound with normal saline, pat dry, apply alginate with silver and cover with dry dressing as needed. The TAR had no staff initials to indicate any treatment was done. Record review of CR#1's wound care specialist evaluation report dated [DATE] revealed: Stage 4 pressure wound of the left distal medial foot (deteriorated). Stage 3 sacral pressure wound (improved) Unstageable Deep Tissue Injury (DTI) of the left lateral heel (fluid filled) unavoidable, off load wound and reposition per facility protocol. Further review of CR#1's wound consult reports revealed services were signed off. Consultation and treatment were discontinued on [DATE] and wound care orders were taken over by hospice as of this date. Record review of CR#1's clinical notes dated [DATE] at 1:08 p.m., written by the Wound Care Nurse, revealed, . Upon wound treatment resident lying in bed eyes open, unable to respond verbally. Hospice Can (sic) present for treatment to assist. Sacral wound bed red with small amount of drainage, no odor at close range. Surrounding tissue normal. Wound to L(left) foot red with moderate bloody drainage, no odor. Foot wound deteriorated increasing in size. fluid (sic) filled blister has formed connecting to foot wound. blister (sic) intact. no (sic) sign of pain or discomfort upon touch. This nurse received new order from hospice nurse for wound care treatment as needed due to residents (sic) decline. End of Life wound treatment PRN (as needed) to prevent any unnecessary pain or discomfort. RP (responsible party) (family member) at bedside aware and agree with plan of care. physician (sic) made aware . Record review of CR#1's February 2017 Physician order [REDACTED]. The order did not specifiy how often staff were to assess the wound to determine if an as needed dressing change was needed. There was no documentation of a clarification order being obtained. Record review of CR#1's clinical notes dated [DATE] at 11:35 a.m. written by the Wound Care Nurse revealed, .UPon (sic) wound treatment resident lying in bed nonverbal, eyes open. resident (sic) has scrawny appearance, thin and frail. wound (sic) dressing dry and intact. upper (sic) back skin redden (sic). thin subcutaneous layer of fat noted. upper (sic) back at high risk for breakdown. made (sic) hospice nurse aware. Left message for (family member) to call facility. resident (sic) repositioned side lying. [DATE] at 9:41p.m. written by RN #1 revealed, .Resident's family was concerned about the wound. Up on (sic) (family member's) request cleaned the sacral wound and dressing done . [DATE] at 11:35 p.m. written by the Evening Supervisor revealed, .Family member at facility, concerned about patient's wounds that they have gotten worse compared to previous time. (family member) very upset and wanted to send patient to ER. Air mattress change was in progress. (Family member) was called earlier during the day wound nurse for update. (Family member) stated that his phone doesn't take private phone calls and that maybe that's why he is not getting vm (voicemails). Call placed to (hospice agency) for update and concerns about (family member's) request for her to be sent to ER, hospice nurse spoke with (family member) and offered to send nurse to reassess patient for better comfort step but (family member) wasn't ready for that. Facility wound nurse called to speak with (family member), this happened over speaker to reassure him that wounds were changed today but still upset. D.O.N was updated. At that point the (family member) seemed (sic) holding his head and yelling loud to (another family member) while in the room to an extent staff very was (sic) violent and called 911 and D.O.N was updated, at the same time, he had called 911 for hospital transfer. 911 ambulance crew arrived first and then police. Police stated felt like he was concerned about his (family member) but took report and (family member) was calm afterwards. 911 explained to him about hospital policy and how they would not take patient to any further (sic) hospital but the closest hospital. Record review of CR#1's hospital notes dated [DATE] revealed a [AGE] year old female with chief complaint of infected wound. Assessment revealed patient had two wounds to her back that were visibly infected and bruised. Patient's family member notes that he had informed nursing home staff of the wound that needed to be treated but states that he was repeatedly told that patient was at the end of life. Further review of CR#1's hospital record revealed Physical examination - sacral stage 4 decubitus ulcers with purulent discharge and foul odor, severely contracted left lower extremity and decubitus ulcer covered in bio dressing on left hip. Clinical impression and [DIAGNOSES REDACTED]. The plan was to admit CR#1 and initiate intravenous fluids and antibiotics. Observation on [DATE] at 10: 58 a.m., of CR#1 at the hospital revealed CR#1 was in her room in bed. She was alert, groomed, and made eye contacts but she was non-verbal. She had three intravenous antibiotics infusing and had a high protein formula infusing via her gastrostomy tube. Interview on [DATE] at 11:00 a.m., CR#1's family member said he was very disappointed in the way CR#1 was neglected by the facility. He recalled repeatedly asking staff to change the soiled dressing to her sacral wounds. The family member said the resident admitted to the facility for wound care but that the wounds got worse. The family member said CR#1 developed new wounds which were not properly cared for. The family member said he visited CR#1 daily after 7 p.m. and most times the wound dressing had not been changed for the day. He said he solicited for the charge nurse to do the dressing change since wound care/ nurse had gone for the day. Family member expressed this was an on-going issue. The family member said the dressings were not dated often and he started writing the date on the dressings to keep track of how often the dressings were changed. He said CR#1 had an Indwelling urinary catheter and her urine was almost red in color. He said he reported to the nurses but nothing was done. He said CR#1's urine collection bag was often not emptied. He said he complained of a lot of things especially poor care but was told the resident was at end of life and should be on hospice to get better care. The family member said CR#1 was admitted to hospice to help the facility coordinate care. He said CR#1 was not digesting the formula she received. He said he reported it to staff and it was not addressed. He recalled he lost it on [DATE] evening when he visited CR#1; he turned down the air conditioning in CR#1's room and then perceived a strong, foul odor that smelled like a dead rat. He said at that time he knew CR#1's wound was infected and the odor was coming from the wounds. When asked how he knew, he responded that CR#1 had experienced a wound infection in the past. He said he called the nurse to check the sacral wound. He said he noticed stool was on the bandage, and the wound area was blue and purple. He said he noticed CR#1 had a dressing to her right hip and when he removed it , CR#1's skin came off with the dressing. He said CR#1's nose was running and her urine in the urine collection bag was red. He said CR#1 had only been on hospice services for 2 weeks and all he was told was that the resident was at the end of life which was why the facility stopped providing care and treatment to the resident, leaving her to die of infection. He said if he could tell CR#1's wounds were infected, how come the nurses did not question the odor in her room. He expressed he was misinformed of the hospice services and never agreed to stop CR#1's wound care. He said the wounds got bigger; surrounding skin was dead and there was a heavy, foul drainage. Interview on [DATE] at 11: 15 a.m. Hospital RN Case Manager and Social Worker Case Manager said CR#1 arrived in a deplorable condition. They said CR#1's wounds were infected and the resident [MEDICAL CONDITION]. They said they were concerned as to how long the resident had been in that condition as the wounds were all over her and visibly infected. They said CR#1's skin on her upper back was reddened and had discoloration as well as bruises. They said the resident was currently admitted for aggressive antibiotic treatment and intravenous fluids. Interview on [DATE] at 12:40 p.m. Wound Care Nurse #1 said CR#1 admitted to the facility with wounds and was being seen by the wound specialist. She said the resident had a sacral stage IV pressure ulcer, DTI to left foot, and stage IV to the left foot. Her upper back and right hip were reddened over boney prominences but not open. A [MEDICATION NAME] dressing was used to protect the right hip area. Wound Care Nurse #1 said CR#1 started to decline and they talked to the family member about hospice due to couple of the resident's conditions. Wound Care Nurse #1 said the family member was called and messages were left for the family member, but he never called back. The resident was admitted to hospice for palliative care and the wound specialist stopped seeing her on [DATE] . She said the sacral wound started having extra drainage. She said hospice saw the wound on [DATE]. She said the sacral wound was red in the middle, had yellow slough which appeared somehow liquid. The surrounding skin to the sacral wound had dark purple discoloration. She said there was a slight odor to the sacral wound on Thursday, [DATE] which was different from the usual smell, and the drainage was small to moderate. She said she also re-started calcium alginate with silver. Wound Care Nurse #1 said in her absence, the charge nurse assumed responsibility of wound care on their respective halls. Interview on [DATE] at 1:20 p.m. DON when asked if he saw and assessed CR#1's wounds said he did not see the wounds but the facility had two wound care Nurses who were trained. He did not know why the resident's daily wound care treatments were discontinued and did not know who gave orders to discontinue the daily wound care. DON said wound care Nurse #1 received the order from hospice nurse. He explained the facility's expectation was coordinate patient care, he would expect facility staff to keep the resident physician in the facility updated of all changes in the treatment plan. He agreed the resident's daily wound care should not have been discontinued. Interview on [DATE] at 1:35 p.m. Hospice Nurse #3 said CR#1 was in her end of life process due to her disease process. She said hospice transferred her to comfort care since her wound will not heal. She said the wound care order was for as needed according the hospice policy which was to ensure CR#1's comfort. Hospice Nurse #3 said as needed meant when there is need to change the wound dressing, and as the resident tolerated. The idea was to reduce unnecessary pain from movement and discomfort from repositioning. Hospice Nurse #3 said being on hospice did not mean discontinuation of care like wound treatment. She expressed the resident's body was shutting down and would not benefit from medication or any other treatment. When asked who gave CR#1 the end of life diagnosis, Hospice Nurse #3 said she was unsure but the resident showed signs of it. When asked what signs CR#1 showed that were indicative of end of life, no response was given. When asked if the resident's vital signs consistently changed, she said no. Hospice Nurse #3 agreed that infections could cause deterioration and decline as well. Hospice Nurse #3 said she did not know that CR#1's wounds were infected. Interview on [DATE] at 2:00 p.m. Wound Care Nurse #1 said she received an order from Hospice Nurse #1 to discontinue CR#1's daily wound care on [DATE] . Interview on [DATE] at 4:50 p.m. RN#1 said CR#1's family member came into the facility around 9 p.m. on [DATE], called him into the resident's room, removed the dressing to her sacral wound and asked him to look at dressing. He said the dressing was not soiled, inside of the wound was yellowish, no drainage, or odor was noted. He said he changed the dressing as requested by CR#1's family member. He said he did not sign the TAR because there was not an option for him to sign for an as needed treatment on the TAR. He said the resident's family member called 911 to transfer CR#1 to the hospital because he said the resident's wounds were infected and smelled. He said facility staff called the police because CR#1's family member was yelling at (another family member) and staff were concerned that he may become violent toward the (other family member). Interview on [DATE] at 4:56 p.m., Evening Supervisor said he was in the facility on the night of [DATE] doing an admission. He said when he was called to CR#1's room, RN#1 was finishing up a dressing change to the sacral wound. He said CR#1's family member was upset about the wound and the resident's condition. CR#1's family member expressed concerns regarding wound care not being done, showed pictures of the wound with necrosis and decided to transfer the resident to the hospital against hospice orders. Interview on [DATE] at 11:23 a.m. Hospice Nurse #1 said she saw CR#1 twice during the admission process but was not part of her care team. Hospice Nurse #1 said she did not treat CR#1. She was asked about the order to change wound care to as needed. She said she did not give that order. Interview on [DATE] at 11:50 a.m., Hospice Nurse #2 said she was on call at the time CR#1 was admitted to hospice and helped during her admission. She said she took over CR#1's care last week. She denied giving the facility orders to discontinue the resident's daily wound care on [DATE]. Hospice Nurse #2 said she recalled an order given on [DATE] for wound care to DTI ( deep tissue injury) left heel. Hospice plan of care was requested multiple times throughout investigation. It was not provided prior to exit. Record review of facility residential hospice agreement dated [DATE] revealed, .hospice plan of care is a written document developed by the IDG (inter disciplinary group) at the time a patient is admitted to hospice that reflect the patients and family goal , includes intervention for problem identified throughout the assessment process and identified measurable outcomes. The plan of care is a comprehensive description of all the services and supplies necessary for the palliative and management of a patient's terminal illness and related conditions. The plan of care also provides a detailed statement of the scope and frequency of services to meet the patients and family's needs. The plan of care is approved by the attending physician. Hospice services include physician, nursing care and services by or under the supervision of a registered nurse. Palliative care mean those comfort measures used to optimize a patient's quality of life .In a hospice program, palliative care is provided to focus on reduction or abatement of symptoms associated with terminal illness such as pain . if a patient begins to die, no emergency services will be called , CPR will not be initiated . Hospice responsibility - shall develop a plan at the time of the admission and shall furnish a copy of such plan of care for such patient to the center at the time of patients admission into the hospice program the hospice plan will be updated from time to time based on assessed needs but no less frequently than every 15 days. A copy of all updated hospice plan will be furnished to the center. Hospice will consult with center, as reasonably necessary with respect to any modifications to the hospice plan of care . Center responsibility- center shall furnish to the individual who is both a patient of the center and a hospice patient all of those service which the center normally would have provided in the absence of the hospice programing accordance with the centers policies ,procedures and protocols, agreement with the patient and the patient's family and a required by Medicare and Medicaid regulations for long term care facilities and applicable federal, state and local laws. Record review of facility policy on patient care management skin dated [DATE] revealed a pressure injury plan of care must be completed upon identification of pressure ulcers and updated with any changes to interventions. Record review of the facility's policy and procedure for physician order [REDACTED]. responsibility of licensed nursing staff ( RN/LVN) -obtain order from physician - re-read order to MD to verify correctness, obtain [DIAGNOSES REDACTED]. Record review of the facility's policy and procedure for significant change in patients status dated [DATE] revealed, . a significant change in patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life threatening conditions or in incidents of clinical complications. Examples of life threatening conditions include but are not limited to cardiovascular or respiratory changes, fractures, semi-comatose state, choking, infections and dehydrations. Record review of the facility's policy and procedure for physician notification dated [DATE] revealed the types of conditions which raise frequency were listed as pressure sore and family concerns. It is the responsibility of the nursing staff to observe the change, make an assessment and notify the physician as indicated based on the assessment. The nurse will recognize the condition change, monitor the patient and continue to assess the condition and changes, notify the physician of any change in condition. Record review of facility's policy and procedure for abuse and neglect date dated [DATE] revealed, . Neglect is the failure of the facility , it's employees or service providers to provide good and services to a patients/resident that are necessary to avoid physical harm, pain, mental anguish and emotional distress. Facility DON on [DATE] reported there was one resident on hospice with a pressure sore.

Based on observation , interview, and record review the facility failed to implement policies and procedures that prohibit neglect of 6 of 26 residents (Residents #18, #12, #5, #6, #8 and #4) reviewed for neglect. --Resident #18 had a change in condition with a heart rate of 40 on 10/11/16 during night shift and was not provided any intervention. She was not administered as needed [MEDICATION NAME] on 4 occasions. Her physician was not consulted and she received no assessment or reassessment. --Resident # 12's physician ordered blood pressure medication ([MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours) had no parameters to guide its administration. --Resident #12 was receiving blood pressure medications outside of paramaters when heart rate was below 60 outside of physician ordered parameters. Staff were not monitoring significantly high blood pressure after morning medications to determine effectiveness of the intervention. Resident #12's physician was not consulted when heart rate was in the 50's on three occasions. --Resident #5 was not administered as needed [MEDICATION NAME] when his blood pressure was high on three occasions with no documentation of physician notification or assessment. --Resident #6 was administered a blood pressure medication outside of physician parameters and the physician was not consulted when her blood pressure readings were out of normal range. --Resident #8 received blood pressure medication outside of ordered heart rate parameter on two occasions. --Resident # 4's physician was not immediately consulted on three occasions when blood pressure medicatoins were held when they should have been administered. An immediate jeopardy (IJ) was identified on 11/17/16. While the IJ was removed on 11/19/16, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy . The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected 6 residents and placed an additional 102 residents at risk of blood pressure associated complications, stroke, internal bleeding, [MEDICAL CONDITIONS]/hypertension, harm, injury, hospitalization and possible death. Findings included: Resident #18 Record review of Resident #18's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #18 ' s quarterly assessment MDS dated [DATE] revealed the resident had moderately impaired cognition. She required total care for all ADLs. Record review of Resident # 18's care plan not dated the resident has a history of hypertension and currently takes anti-hypertensive medications , goal is the resident's blood pressure will stay within their normal limits , will not have signs and symptoms of hypo and hypertension over the next 90 days. Approaches include monitor blood pressure, increased [MEDICAL CONDITION], dizziness, headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #18's physician order [REDACTED]. [MEDICATION NAME] 10 mg tablet by mouth daily. Hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 100 mg tablet by mouth every eight hours. Hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 0.1 mg by mouth as needed every six hours for Systolic blood pressure greater than 170 or diastolic blood pressure greater than 100. Record review of Resident #18's MAR indicated [REDACTED]. Record review of Resident #18's MAR indicated [REDACTED] 52 on 11/03/16 at 12 AM 58 on 11/06/16 at 12 AM 57 on 11/9/16 at 12 AM 54 on 11/10/16 at 12 AM 59 on 11/11/16 at 12 AM 58 on 11/12/16 at 12 AM and 54 at 8 AM. 56 on 11/13/16 at 4:00 PM 55 on 11/15/16 at 12 AM Further review of above MAR indicated [REDACTED] 188 at 8 am on 11/09/16 198 at 8 am on 11/10/16 184 at 8 am on 11/12/16 and 189 at 4pm. Record review of Resident#18's nurse notes for November 2016 revealed no documentation that the resident's physician was notified of the elevated blood pressures and low heart rates. There was no documentation of the high blood pressure on 11/9/16, 11/10/16, or 11/12/16 being reassessed to determine if administration of scheduled medications was effective. Attempts were made on 11/19/16 to interview LVN#W who administered above medications out of parameter without success. Calls were not answered and not returned. Record review of Resident#18's nurse note dated 10/11/16 at 2:11 a.m , revealed, (Resident #18's) blood pressure at 12 am was 180 /68 with a pulse of 60. [MEDICATION NAME] was given per orders. At 1:30 am, resident had a large emesis and loose stool, CNA assigned to resident came to this nurse and went to her room. Vital signs were obtained. Oxygen saturation 94 at room air and pulse via pulse oximeter was 54. Blood pressure was obtained via manual cuff and was 120/58, Resident 318 was cleaned and bathed and bed linen changed, she is alert and verbal and watching television. At 5:43 a.m., blood pressure was 189/65 and heart rate was 40, [MEDICATION NAME] held, all information from this shift is in the doctor book. Interview on 11/19/16 at 6:35 a.m., LVN#Y When asked why she did not notify the resident physician of above incident, LVN#Y said she texted the Nurse practitioner a few times and there was no response. She monitored the resident who was stable. She passed on the information to the morning staff in report to follow up. She further said she checked on the resident and she was fine. Resident #12 Record review of Resident #12's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed he was assessed as scoring a 14 on his BIMS indicating he was cognitively intact. Record review of Resident #12's plan of care dated 3/9/16-present revealed a plan of care for hypertension with a goal of his blood pressure staying within their normal limits; will not have signs/symptoms of hyper/hypo tension . Interventions .monitor blood pressure .report abnormals to MD . Record review of Resident #12's November 2016 Physician order [REDACTED]. [MEDICATION NAME] ER 60 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 0.2 mg 1 tablet oral every 6 hours. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 6.25 mg 1 tablet oral two times daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 10 mg 1 tablet oral two times daily. Hold for SBP less than 110. [MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours. (No documentation of a parameter for when to give.) Record review of Resident #12's November 2016 Medication Administration Record [REDACTED] Resident #12 was given his ordered [MEDICATION NAME] ER 60 mg 1 tablet oral and [MEDICATION NAME] 6.25 mg 1 tablet by mouth on 11/5/16 at 8:00 am and [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/5/16 at 7:00 am and with a Pulse of 54 bpm (beats per minute). Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/2/16 at 1:00 am with a Pulse of 51 bpm; Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/5/16 at 1:00 p.m. with Systolic Blood Pressure (SBP) of 104. Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/6/16 at 1:00 am with Pulse of 53 bpm. Further review of Resident #12's November 2016 MAR indicated [REDACTED] 11/5/16, 7:00 p.m., BP 147/104 11/6/16, 8: 00 am, BP 162/104 11/8/16, 8:00 am, BP 189/106 11/9/16, 8:00, am, BP 168/93 11/10/16, 8:00 am, BP 176/92 11/12/16, 8:00 am, BP 147/102 11/15/16, 8:00 am, 180/98 and 11/16/16, 8:00 am, BP 166/94. Record review of Resident # 12's November 2016 Physician order [REDACTED]. Also record revealed the parameters for administering Blood Pressure medications to Resident #12 did not address abnormal Diastolic Blood Pressures. Record review of Resident #12's November 2016 nurse's notes did not show documentation that physician was consulted on the high and low BP's and the low pulse with medications being administered or held in some instances as shown above on 11/1/16 and 11/16/16. Resident # 5 Record review of Resident # 5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly assessment MDS dated [DATE] revealed BIMS score of 99 indicating the resident was unable to complete the interview, cognitive skill for daily decision making was modified independence. Resident had long and short term memory loss, required limited assistance with ADLs, and had limited range of motion on one side of upper extremity Record review of Resident # 5's undated care plan revealed the resident had a history of [REDACTED]. Approaches included monitor blood pressure, increased [MEDICAL CONDITION], dizziness, headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #5's Physician order [REDACTED]. [MEDICATION NAME] 10 mg oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 20 mg tablet oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 25 mg ( 3 tablets =75 mg) one time daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 50 mg tablet , oral twice daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 0.1 mg tablet oral as needed every eight hours for systolic blood pressure over 170. Hold for systolic blood pressure less than 110 and pulse less than 60. Order date was 8/10/16. Record review of Resident #5's MAR indicated [REDACTED] --[MEDICATION NAME] 10 mg oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. --[MEDICATION NAME] 20 mg tablet oral daily, [MEDICATION NAME] HCL 25 mg (3 tablets = 75 mg) one time daily, and [MEDICATION NAME] 50 mg tablet, oral twice daily. Record review of Resident #5's November 2016 MAR indicated [REDACTED]. Resident #5's systolic blood pressure was 171 on 11/08/16, 194 on 11/12/16 at 9 am, and 185 on 11/12/16 at 4pm. The as needed [MEDICATION NAME] was not administered on 11/8/16 or 11/12/16. Further record review of above MAR indicated [REDACTED]= 75 mg) one tiem daily, and [MEDICATION NAME] 50 mg tablet oral twice daily. Record review of Resident #5 ' s MAR indicated [REDACTED] Record review of Resident #5's November 2016 nurse's notes revealed no documentation that the resident's physician was notified of the elevated blood pressure on 11/08/16 and 11/12/16. Interview on 11/16/16 at 2:00 p.m., Unit Manager #2 said she was not aware of Resident #5's elevated blood pressure values. She said she expected licensed nurses to use their judgment when providing care to the resident. She said the resident should have been given the ordered as needed medication and her physician should have been consulted. She said there were no communications from the charge nurses for her to follow up with the resident's physician on those days. Interview on 11/16/16 at 2:08 p.m., RN #8 said she worked as a medication aide on 11/12/16 for the evening shift. She stated she gave the resident one as needed [MEDICATION NAME] medication and notified the charge nurse of the value. She said as the medication aide, she should notify the charge nurse since the charge nurses administer as needed medication after assessing of the resident. RN#8 said she did not document her intervention. Interview on 11/19/16 at 7:05 a.m., LVN #Q, who worked the morning shift on 11/12/16, said it was unusual for her not to notify a physician when a resident had a change in condition. She said she did not recall the incident on 11/12/16 when Resident #5 had a systolic blood pressure of 194. LVN #Q further said a blood pressure of 194 was high. She said she would check for any as needed medication, administer the medication, notify the resident's physician and continue to monitor the resident. Resident #6 Record review of Resident # 6's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly assessment MDS dated [DATE] revealed cognitive score of 2 indicating severely impaired cognition. Record review of Resident #6's undated care plan revealed she had a history of [REDACTED]. Approaches included monitor blood pressure, increased [MEDICAL CONDITION], dizziness , headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #6's Physician order [REDACTED]. [MEDICATION NAME] 12.5 mg by mouth every 12 hours, hold for systolic blood pressure less than 110 and pulse less than 60. Record review of Resident #6's MAR indicated [REDACTED]. Further review of above MAR indicated [REDACTED]. Resident's systolic blood pressure was 83 on 11/14/16 at 8 am. Record review of Resident #6's vital signs log for November 2016 revealed an average blood pressure baseline of 130 and heart rate of 65. Record review of Resident#6's nurse's notes revealed no documentation that the resident's physician was notified of the elevated blood pressure and heart rate on 11/9/16 and her low systolic blood pressure on 11/14/16. There were attempts made to contact MA #1, who administered Resident #6's medications, on 11/18 /16 and 11/19/16. The attempts were unsuccessful. Interview on 11/19/16 at 11:43 a.m., DON said all nurses were trained and licensed to provide care to residents who had hypertension. He further said the facility's pharmacist reviewed the resident's medications monthly with recommendations which staff implemented after consulting each resident's physician. The DON said the staff were evaluated on medication pass and were expected to follow the physician's orders [REDACTED]. He said he expected staff to have called the resident's physician when the residents' blood pressure and heart rate were either high or low than the general normal range. Resident #8 Record review of Resident #8's admission sheet revealed she was a [AGE] year old female. her admitted was 12/06/2011 with [DIAGNOSES REDACTED]. Record review of Resident #8's Annual MDS dated [DATE] revealed she was assessed as having a BIMS (brief interview for mental status) Score of 08 indicating moderately impaired cognitive skills for daily decision making. Record review of Resident #8's plan of care dated 3/22/16-present revealed there was no documentation of a plan of care for hypertension. Observation of Resident #8 on 11/14/16 at 8:50 p.m. revealed the resident was groomed and presented with no odors. She was sitting in the hall talking to her neighbor. Record review of Resident #8's November 2016 physician orders [REDACTED]. -[MEDICATION NAME] 50 mg 1 and 1/2 tablets (75 mg) every 12 hours -[MEDICATION NAME] 10 mg once daily by mouth -[MEDICATION NAME] HCL 25 mg 1 tablet every 8 hours by mouth Record review of Resident #8's Medication Administration Record [REDACTED]. Record review of Resident #8's MAR indicated [REDACTED]. Record review of Resident #8's MAR indicated [REDACTED]. Resident #4 Record review of Resident #4's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS of 11, indicating he was cognitively intact. Record review of Resident #4's plan of care dated 10/25/16-present revealed there was no documentation of a plan of care for hypertension. Record review of Resident #4's November 2016 Physician order [REDACTED]. [MEDICATION NAME] 20 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] ER 25 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 0.1 mg 1 tablet oral PRN every 6 hours for BP greater than 180/90. Record review of Resident #4's November 2016 Medication Administration Record [REDACTED] Blood Pressure medications - [MEDICATION NAME] 20 mg oral daily and [MEDICATION NAME] ER 25 mg oral daily were held as follows: 11/14/16, 8:00 am, BP 115/54 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50. Physician's parameters to hold medications were: Hold for Systolic Blood Pressure less than 110 and Pulse less than 60. The Physician was not notified that medications were held as shown above. Record review of Resident # 4's November 2016 Physician order [REDACTED].#4 did not address abnormal Diastolic Blood Pressures. Record review of Resident #4's November 2016 nurse's notes revealed no documentation of physician clarification to address the low diastolic blood pressure or notification of holding blood pressure medications outside of ordered physician parameters. During an interview on 11/18/16 at 1:18 p.m., LVN G said that she checked MD ' s orders; residents BP and Pulse before administering blood pressure medications and that if the BP and Pulse were within the MD ' s ordered parameters she would give the medication. She said that she would call the MD if the BP and Pulse were out of the MD ' s parameters. Asked why she held Resident #4 BP medications ([MEDICATION NAME] 20 mg oral daily and [MEDICATION NAME] ER 25 mg) on 11/14/16, 8:00 am, BP 115/54; 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50 when MD ' s parameter required her to administer medication, she said she used her nursing judgment. Asked whether she notified the MD of the Low DBP ' s and that she held the medications, she said that she did not call the MD because she was very busy and could not stay after her shift was over. Asked if she went back to document the incident she said no. When asked if the facility had Standard Orders she said most MD ' s only said - Hold for SBP less than 110 and Pulse less than 60. Record review of facility policy on abuse and neglect dated June 2013 revealed the facility will not condone patient abuse, neglect , mistreatment or misappropriation of patient property by anyone , including staff members , other patients, consultants , volunteers staff of other agencies serving the patients , family members legal guardians, sponsors, friends or other individuals. The abuse prevention coordinator will assume that all facility staff is in serviced on recognizing abuse, abuse prevention, and abuse reporting upon employment and as necessary to maintain an abuse environment . The executive director and his/her absence , the director of nursing will perform the duties of the abuse prevention coordinator . Record review of facility's in-service training report dated 4/6/16 for RNs, LVNs and Medication aides revealed topic medication administration and further read, you must follow proper medication administration protocol . 6 right of medication administration : right resident, right medication, right dose, right time, right route and right documentation. A resident also has a right to refuse medication , in case of this event the resident ' s family and physician must immediately be notified. Record review of the facility's policy on notification of physicians dated February 2010 revealed the types of conditions which arise frequently are listed, this is not inclusive; emesis, vital sings etc. It is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment the nurses will recognize the condition change, monitor the patient and continue to assess the condition and changes , notify the physician of any changes in condition. Record review of the facility's policy on significant change in patient status dated February 2010 revealed, .a significant change in patient status is defined as deterioration or marked improvement in the health , mental, 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 ; cardiovascular or respiratory changes, fractures, semi-comatose state, choking , infection and dehydration. As a significant change in patient condition occurs, the charge nurses will notify the physician , family or other appropriate person/agency of the significant change immediately. Documentation of significant change in condition requires updating of the plan of care and the minimum data set if unresolved in 14 days. The facility Administrator and DON were notified on 11/17/16 at 2:45 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted 11/ 18/16 . After several revisions, a plan was accepted on 11/18/16 at 1:35 p.m. Interview on 11/18/16 at 1:09 p.m , the Administrator said she was not aware of staff administering the blood pressure medications when the residents' blood pressure was out of ordered parameters. She said the surveyors brought this to her attention and after reviewing the residents data believed staff made poor judgments and failed to notify the residents physician of the changes, low heart rates and high blood pressures. She expressed she expected staff to be of best practice. Administrator said it was negligent tonot implement the physician order. Interview on 11/19/16 at 11:40 a.m., the DON said staff failed to follow the physician's orders [REDACTED]. He believed this was the cause of immediate jeopardy and the substandard quality of care identified in the facility. DON said the facility had systems in place which included having parameters in place for blood pressure medications, training staff and checking for proficiency in nursing skills. He further said he expected staff to notify the residents ' physicians whenever a physician's orders [REDACTED]. Immediate Jeopardy: Plan of Removal, 11/17/16. Systematic Approach 1. Accurate Dispensing of Antihypertensive Medications a. Licensed nursing staff and permitted CMA's was in-serviced by (Doctor A) Regional Director of Clinical Services 11/17/16 on the need for parameters for blood pressure medications, adhering to the parameters for blood pressure medications, physician notification per their instruction of blood pressure medication omission or parameter SBP >180 and DBP below 60 that poses a significant risk to the patient and is not addressed after administering ordered PRN medication and notification of heart rates above 100 and below 60. Licensed nurses or PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. The med aides were also in-serviced regarding reporting low and high BP SBP above 180 and below 60 readings as well as low/high heart rates( below 60 above 100) to the Charge nurses and UM. This standard protocol has been approved by all Physicians at Colonnades Started 11/17/2016 and ending 11/18/2016. b. The patients identified by the survey team as not having correct medication administration per parameters or physician orders [REDACTED]. Started and completed on 11/17/16. c. The facility conducted an audit on 11/16/16 and 11/17/16 on all patients with antihypertensive medication orders. Parameters related to high BP and Low BP (110/60 with pulse of 60 hold medication contact Physician) were added to all Patients with antihypertensive medications per Physicians orders. Started and completed on 11/17/2016 d. Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also audit daily utilizing tracking reports from the Electronic Medical Records system to evidence that antihypertensive medications were administered by staff and that there were no omissions of medications and that parameters were followed. This was started 11/17/16 and will continue indefinitely. e. As a systematic change, new antihypertensive medication orders will be monitored daily by the unit manager and the Director of Nursing during the morning meeting. This will be started on 11/18/16 and will continue indefinitely. The surveyors monitored the Plan of Removal on 11/18/16 and 11/19/16 during all three shifts including licensed, registered nurses and medication aides. Facility shift were 6 am to 2 pm, 2 pm to 10 pm, and 10 pm - 6 am. Monitoring was as follows: Facility protocols concerning management of resident with [DIAGNOSES REDACTED]. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on 11/18/16 and 11/19/16. In-services were conducted on all three shifts with over 80% of the nursing staff in attendance. 90% of the nursing staff covering three shifts were interviewed on 11/18/16 and 11/19/16, and all staff were able to express up to date knowledge on the facility's procedures for blood pressure medication administration, blood pressure parameters, use of as needed blood pressure medication, immediate notification of licensed nurse by medication aides during medication administrations, and physician notification for licensed nursing staff. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Record review of expanded sample residents with [DIAGNOSES REDACTED]. There were no identified elevated and low blood pressures or heart rates that required physician notification. Observations of residents with [DIAGNOSES REDACTED]. After monitoring the implementation of the plan, the IJ was removed . The Administrator and the DON were informed the IJ was removed on 11/19/16 at 11:35 a.m. While the IJ was removed on 11/19/16, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal

Based on observation , interview, and record review the facility failed to ensure 6 of 26 residents (Residents #18, #12, #5, #6, #8 and #4) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. --Resident #18 had a change in condition with a heart rate of 40 on 10/11/16 during night shift and was not provided any intervention. Resident #18 had heart rates below 60 on 9 occasions and elevated blood pressures of 188, 184, and 198. She was not administered as needed [MEDICATION NAME] on 4 occasions. Her physician was not consulted and she received no assessment or reassessment. --Resident # 12's physician ordered blood pressure medication ([MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours) had no parameters to guide its administration. --Resident #12 was receiving blood pressure medications outside of paramaters when heart rate was below 60 outside of physician ordered parameters. Staff were not monitoring significantly high blood pressure after morning medications to determine effectiveness of the intervention. Resident #12's physician was not consulted when heart rate was in the 50's on three occasions. --Resident #5 was not administered as needed [MEDICATION NAME] when his blood pressure was high on three occasions with no documentation of physician notification or assessment. --Resident #6 was administered a blood pressure medication outside of physician parameters and the physician was not consulted when her blood pressure readings were out of normal range. --Resident #8 received blood pressure medication outside of ordered heart rate parameter on two occasions. --Resident # 4's physician was not immediately consulted on three occasions when blood pressure medicatoins were held when they should have been administered. An immediate jeopardy (IJ) was identified on 11/17/16. While the IJ was removed on 11/19/16, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy . The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected 6 residents and placed an additional 102 residents at risk of blood pressure associated complications, stroke, internal bleeding, [MEDICAL CONDITIONS]/hypertension, harm, injury, hospitalization and possible death. Findings included: Resident #18 Record review of Resident #18's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #18 ' s quarterly assessment MDS dated [DATE] revealed the resident had moderately impaired cognition. She required total care for all ADLs. Record review of Resident # 18's care plan not dated the resident has a history of hypertension and currently takes anti-hypertensive medications , goal is the resident's blood pressure will stay within their normal limits , will not have signs and symptoms of hypo and hypertension over the next 90 days. Approaches include monitor blood pressure , increased [MEDICAL CONDITION], dizziness , headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #18's physician order [REDACTED]. [MEDICATION NAME] 10 mg tablet by mouth daily. Hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 100 mg tablet by mouth every eight hours. Hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 0.1 mg by mouth as needed every six hours for Systolic blood pressure greater than 170 or diastolic blood pressure greater than 100. Record review of Resident #18's MAR indicated [REDACTED]. Record review of Resident #18's MAR indicated [REDACTED] 52 on 11/03/16 at 12 AM 58 on 11/06/16 at 12 AM 57 on 11/9/16 at 12 AM 54 on 11/10/16 at 12 AM 59 on 11/11/16 at 12 AM 58 on 11/12/16 at 12 AM and 54 at 8 AM. 56 on 11/13/16 at 4:00 PM 55 on 11/15/16 at 12 AM Further review of above MAR indicated [REDACTED] 188 at 8 am on 11/09/16 198 at 8 am on 11/10/16 184 at 8 am on 11/12/16 and 189 at 4pm. Record review of Resident#18's nurse notes for November 2016 revealed no documentation that the resident's physician was notified of the elevated blood pressures and low heart rates. There was no documentation of the high blood pressure on 11/9/16, 11/10/16, or 11/12/16 being reassessed to determine if administration of scheduled medications was effective. Attempts were made on 11/19/16 to interview LVN#W who administered above medications out of parameter without success. Calls were not answered and not returned. Record review of Resident#18's nurse note dated 10/11/16 at 2:11 a.m , revealed, (Resident #18's) blood pressure at 12 am was 180 /68 with a pulse of 60. [MEDICATION NAME] was given per orders. At 1:30 am, resident had a large emesis and loose stool, CNA assigned to resident came to this nurse and went to her room. Vital signs were obtained. Oxygen saturation 94 at room air and pulse via pulse oximeter was 54. Blood pressure was obtained via manual cuff and was 120/58, Resident 318 was cleaned and bathed and bed linen changed , she is alert and verbal and watching television. At 5:43 a.m., blood pressure was 189/65 and heart rate was 40, [MEDICATION NAME] held, all information from this shift is in the doctor book. Interview on 11/19/16 at 6:35 a.m., LVN#Y When asked why she did not notify the resident physician of above incident, LVN#Y said she texted the Nurse practitioner a few times and there was no response. She monitored the resident who was stable. She passed on the information to the morning staff in report to follow up. She further said she checked on the resident and she was fine. Resident #12 Record review of Resident #12's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed he was assessed as scoring a 14 on his BIMS indicating he was cognitively intact. Record review of Resident #12's plan of care dated 3/9/16-present revealed a plan of care for hypertension with a goal of his blood pressure staying within their normal limits; will not have signs/symptoms of hyper/hypo tension . Interventions .monitor blood pressure .report abnormals to MD . Record review of Resident #12's November 2016 Physician order [REDACTED]. [MEDICATION NAME] ER 60 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 0.2 mg 1 tablet oral every 6 hours. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 6.25 mg 1 tablet oral two times daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 10 mg 1 tablet oral two times daily. Hold for SBP less than 110. [MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours. (No documentation of a parameter for when to give.) Record review of Resident #12's November 2016 Medication Administration Record [REDACTED] Resident #12 was given his ordered [MEDICATION NAME] ER 60 mg 1 tablet oral and [MEDICATION NAME] 6.25 mg 1 tablet by mouth on 11/5/16 at 8:00 am and [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/5/16 at 7:00 am and with a Pulse of 54 bpm (beats per minute). Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/2/16 at 1:00 am with a Pulse of 51 bpm; Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/5/16 at 1:00 p.m. with Systolic Blood Pressure (SBP) of 104. Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/6/16 at 1:00 am with Pulse of 53 bpm. Further review of Resident #12's November 2016 MAR indicated [REDACTED] 11/5/16, 7:00 p.m., BP 147/104 11/6/16, 8: 00 am, BP 162/104 11/8/16, 8:00 am, BP 189/106 11/9/16, 8:00, am, BP 168/93 11/10/16, 8:00 am, BP 176/92 11/12/16, 8:00 am, BP 147/102 11/15/16, 8:00 am, 180/98 and 11/16/16, 8:00 am, BP 166/94. Record review of Resident # 12's November 2016 Physician order [REDACTED]. Also record revealed the parameters for administering Blood Pressure medications to Resident #12 did not address abnormal Diastolic Blood Pressures. Record review of Resident #12's November 2016 nurse's notes did not show documentation that physician was consulted on the high and low BP's and the low pulse with medications being administered or held in some instances as shown above on 11/1/16 and 11/16/16. Resident # 5 Record review of Resident # 5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly assessment MDS dated [DATE] revealed BIMS score of 99 indicating the resident was unable to complete the interview, cognitive skill for daily decision making was modified independence. Resident had long and short term memory loss, required limited assistance with ADLs, and had limited range of motion on one side of upper extremity Record review of Resident # 5's undated care plan revealed the resident had a history of [REDACTED]. Approaches included monitor blood pressure, increased [MEDICAL CONDITION], dizziness, headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #5's Physician order [REDACTED]. [MEDICATION NAME] 10 mg oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 20 mg tablet oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 25 mg ( 3 tablets =75 mg) one time daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 50 mg tablet , oral twice daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 0.1 mg tablet oral as needed every eight hours for systolic blood pressure over 170. Hold for systolic blood pressure less than 110 and pulse less than 60. Order date was 8/10/16. Record review of Resident #5's MAR indicated [REDACTED] --[MEDICATION NAME] 10 mg oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. --[MEDICATION NAME] 20 mg tablet oral daily, [MEDICATION NAME] HCL 25 mg (3 tablets = 75 mg) one time daily, and [MEDICATION NAME] 50 mg tablet, oral twice daily. Record review of Resident #5's November 2016 MAR indicated [REDACTED]. Resident #5's systolic blood pressure was 171 on 11/08/16, 194 on 11/12/16 at 9 am, and 185 on 11/12/16 at 4pm. The as needed [MEDICATION NAME] was not administered on 11/8/16 or 11/12/16. Further record review of above MAR indicated [REDACTED]= 75 mg) one tiem daily, and [MEDICATION NAME] 50 mg tablet oral twice daily. Record review of Resident #5 ' s MAR indicated [REDACTED] Record review of Resident #5's November 2016 nurse's notes revealed no documentation that the resident's physician was notified of the elevated blood pressure on 11/08/16 and 11/12/16. Interview on 11/16/16 at 2:00 p.m., Unit Manager #2 said she was not aware of Resident #5's elevated blood pressure values. She said she expected licensed nurses to use their judgment when providing care to the resident. She said the resident should have been given the ordered as needed medication and her physician should have been consulted. She said there were no communications from the charge nurses for her to follow up with the resident's physician on those days. Interview on 11/16/16 at 2:08 p.m., RN #8 said she worked as a medication aide on 11/12/16 for the evening shift. She stated she gave the resident one as needed [MEDICATION NAME] medication and notified the charge nurse of the value. She said as the medication aide, she should notify the charge nurse since the charge nurses administer as needed medication after assessing of the resident. RN#8 said she did not document her intervention. Interview on 11/19/16 at 7:05 a.m., LVN #Q, who worked the morning shift on 11/12/16, said it was unusual for her not to notify a physician when a resident had a change in condition. She said she did not recall the incident on 11/12/16 when Resident #5 had a systolic blood pressure of 194. LVN #Q further said a blood pressure of 194 was high. She said she would check for any as needed medication, administer the medication, notify the resident's physician and continue to monitor the resident. Resident #6 Record review of Resident # 6's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly assessment MDS dated [DATE] revealed cognitive score of 2 indicating severely impaired cognition. Record review of Resident #6's undated care plan revealed she had a history of [REDACTED]. Approaches included monitor blood pressure, increased [MEDICAL CONDITION], dizziness , headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #6's Physician order [REDACTED]. [MEDICATION NAME] 12.5 mg by mouth every 12 hours, hold for systolic blood pressure less than 110 and pulse less than 60. Record review of Resident #6's MAR indicated [REDACTED]. Further review of above MAR indicated [REDACTED]. Resident's systolic blood pressure was 83 on 11/14/16 at 8 am. Record review of Resident #6's vital signs log for November 2016 revealed an average blood pressure baseline of 130 and heart rate of 65. Record review of Resident#6's nurse's notes revealed no documentation that the resident's physician was notified of the elevated blood pressure and heart rate on 11/9/16 and her low systolic blood pressure on 11/14/16. There were attempts made to contact MA #1, who administered Resident #6's medications, on 11/18 /16 and 11/19/16. The attempts were unsuccessful. Interview on 11/19/16 at 11:43 a.m , DON said all nurses were trained and licensed to provide care to residents who had hypertension. He further said the facility's pharmacist reviewed the resident's medications monthly with recommendations which staff implemented after consulting each resident's physician. The DON said the staff were evaluated on medication pass and were expected to follow the physician's orders [REDACTED]. He said he expected staff to have called the resident's physician when the residents' blood pressure and heart rate were either high or low than the general normal range. Resident #8 Record review of Resident #8's admission sheet revealed she was a [AGE] year old female. her admitted was 12/06/2011 with [DIAGNOSES REDACTED]. Record review of Resident #8's Annual MDS dated [DATE] revealed she was assessed as having a BIMS (brief interview for mental status) Score of 08 indicating moderately impaired cognitive skills for daily decision making. Record review of Resident #8's plan of care dated 3/22/16-present revealed there was no documentation of a plan of care for hypertension. Observation of Resident #8 on 11/14/16 at 8:50 p.m. revealed the resident was groomed and presented with no odors. She was sitting in the hall talking to her neighbor. Record review of Resident #8's November 2016 physician orders [REDACTED]. -[MEDICATION NAME] 50 mg 1 and 1/2 tablets (75 mg) every 12 hours -[MEDICATION NAME] 10 mg once daily by mouth -[MEDICATION NAME] HCL 25 mg 1 tablet every 8 hours by mouth Record review of Resident #8's Medication Administration Record [REDACTED]. Record review of Resident #8's MAR indicated [REDACTED]. Record review of Resident #8's MAR indicated [REDACTED]. Resident #4 Record review of Resident #4's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS of 11, indicating he was cognitively intact. Record review of Resident #4's plan of care dated 10/25/16-present revealed there was no documentation of a plan of care for hypertension. Record review of Resident #4's November 2016 Physician order [REDACTED]. [MEDICATION NAME] 20 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] ER 25 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 0.1 mg 1 tablet oral PRN every 6 hours for BP greater than 180/90. Record review of Resident #4's November 2016 Medication Administration Record [REDACTED] Blood Pressure medications - [MEDICATION NAME] 20 mg oral daily and [MEDICATION NAME] ER 25 mg oral daily were held as follows: 11/14/16, 8:00 am, BP 115/54 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50. Physician's parameters to hold medications were: Hold for Systolic Blood Pressure less than 110 and Pulse less than 60. The Physician was not notified that medications were held as shown above. Record review of Resident # 4's November 2016 Physician order [REDACTED].#4 did not address abnormal Diastolic Blood Pressures. Record review of Resident #4's November 2016 nurse's notes revealed no documentation of physician clarification to address the low diastolic blood pressure or notification of holding blood pressure medications outside of ordered physician parameters. During an interview on 11/18/16 at 1:18 p.m., LVN G said that she checked MD ' s orders; residents BP and Pulse before administering blood pressure medications and that if the BP and Pulse were within the MD ' s ordered parameters she would give the medication. She said that she would call the MD if the BP and Pulse were out of the MD ' s parameters. Asked why she held Resident #4 BP medications ([MEDICATION NAME] 20 mg oral daily and [MEDICATION NAME] ER 25 mg) on 11/14/16, 8:00 am, BP 115/54; 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50 when MD ' s parameter required her to administer medication, she said she used her nursing judgment. Asked whether she notified the MD of the Low DBP ' s and that she held the medications, she said that she did not call the MD because she was very busy and could not stay after her shift was over. Asked if she went back to document the incident she said no. When asked if the facility had Standard Orders she said most MD ' s only said - Hold for SBP less than 110 and Pulse less than 60. Record review of facility's in-service training report dated 4/6/16 for RNs, LVNs and Medication aides revealed topic medication administration and further read, you must follow proper medication administration protocol . 6 right of medication administration : right resident, right medication, right dose, right time, right route and right documentation. A resident also has a right to refuse medication , in case of this event the resident ' s family and physician must immediately be notified. Record review of the facility's policy on notification of physicians dated February 2010 revealed the types of conditions which arise frequently are listed, this is not inclusive; emesis, vital sings etc. It is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment the nurses will recognize the condition change, monitor the patient and continue to assess the condition and changes , notify the physician of any changes in condition. Record review of the facility's policy on significant change in patient status dated February 2010 revealed, .a significant change in patient status is defined as deterioration or marked improvement in the health , mental, 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 ; cardiovascular or respiratory changes, fractures, semi-comatose state, choking , infection and dehydration. As a significant change in patient condition occurs, the charge nurses will notify the physician , family or other appropriate person/agency of the significant change immediately. Documentation of significant change in condition requires updating of the plan of care and the minimum data set if unresolved in 14 days. The facility Administrator and DON were notified on 11/17/16 at 2:45 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted 11/ 18/16 . After several revisions, a plan was accepted on 11/18/16 at 1:35 p.m. Interview on 11/18/16 at 1:09 p.m , the Administrator said she was not aware of staff administering the blood pressure medications when the residents' blood pressure was out of ordered parameters. She said the surveyors brought this to her attention and after reviewing the residents data believed staff made poor judgments and failed to notify the residents physician of the changes, low heart rates and high blood pressures. She expressed she expected staff to be of best practice. Administrator said it was negligent tonot implement the physician order. Interview on 11/19/16 at 11:40 a.m., the DON said staff failed to follow the physician's orders [REDACTED]. He believed this was the cause of immediate jeopardy and the substandard quality of care identified in the facility. DON said the facility had systems in place which included having parameters in place for blood pressure medications, training staff and checking for proficiency in nursing skills. He further said he expected staff to notify the residents ' physicians whenever a physician's orders [REDACTED]. Immediate Jeopardy: Plan of Removal, 11/17/16. Systematic Approach 1. Accurate Dispensing of Antihypertensive Medications a. Licensed nursing staff and permitted CMA's was in-serviced by (Doctor A) Regional Director of Clinical Services 11/17/16 on the need for parameters for blood pressure medications, adhering to the parameters for blood pressure medications, physician notification per their instruction of blood pressure medication omission or parameter SBP >180 and DBP below 60 that poses a significant risk to the patient and is not addressed after administering ordered PRN medication and notification of heart rates above 100 and below 60. Licensed nurses or PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. The med aides were also in-serviced regarding reporting low and high BP SBP above 180 and below 60 readings as well as low/high heart rates( below 60 above 100) to the Charge nurses and UM. This standard protocol has been approved by all Physicians at Colonnades Started 11/17/2016 and ending 11/18/2016. b. The patients identified by the survey team as not having correct medication administration per parameters or physician orders [REDACTED]. Started and completed on 11/17/16. c. The facility conducted an audit on 11/16/16 and 11/17/16 on all patients with antihypertensive medication orders. Parameters related to high BP and Low BP (110/60 with pulse of 60 hold medication contact Physician) were added to all Patients with antihypertensive medications per Physicians orders. Started and completed on 11/17/2016 d. Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also audit daily utilizing tracking reports from the Electronic Medical Records system to evidence that antihypertensive medications were administered by staff and that there were no omissions of medications and that parameters were followed. This was started 11/17/16 and will continue indefinitely. e. As a systematic change, new antihypertensive medication orders will be monitored daily by the unit manager and the Director of Nursing during the morning meeting. This will be started on 11/18/16 and will continue indefinitely. The surveyors monitored the Plan of Removal on 11/18/16 and 11/19/16 during all three shifts including licensed, registered nurses and medication aides. Facility shift were 6 am to 2 pm, 2 pm to 10 pm, and 10 pm - 6 am. Monitoring was as follows: Facility protocols concerning management of resident with [DIAGNOSES REDACTED]. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on 11/18/16 and 11/19/16. In-services were conducted on all three shifts with over 80% of the nursing staff in attendance. 90% of the nursing staff covering three shifts were interviewed on 11/18/16 and 11/19/16, and all staff were able to express up to date knowledge on the facility's procedures for blood pressure medication administration, blood pressure parameters, use of as needed blood pressure medication, immediate notification of licensed nurse by medication aides during medication administrations, and physician notification for licensed nursing staff. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Record review of expanded sample residents with [DIAGNOSES REDACTED]. There were no identified elevated and low blood pressures or heart rates that required physician notification. Observations of residents with [DIAGNOSES REDACTED]. After monitoring the implementation of the plan, the IJ was removed . The Administrator and the DON were informed the IJ was removed on 11/19/16 at 11:35 a.m. While the IJ was removed on 11/19/16, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, adding both systolic and diastolic blood pressure parameters and following blood pressure medication parameters as ordered. Record review of a list provided by the facility revealed 108 residents identified to have the [DIAGNOSES REDACTED].

Based on observations, record review, and interviews, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical wellbeing of six (6) of 26 residents (Residents #4, #5, #6, #8, #12, and #18) who were reviewed for quality of care in that: --The Administrator failed to oversee and assist with the implementation of effective policies and procedures on identifying changes of condition and the consultation of physicians, and neglect. --The Administrator failed to supervise the DON on training and monitoring nursing staff to monitor and promptly consult physicians concerning change in conditions. --The DON failed to train nurses on notifying physicians of abnormal blood pressure values, heart rates, changes of condition, and verification of doctor orders to include all relevant information to effectively administer the prescribed medications. An Immediate Jeopardy (IJ) was identified on 11/17/16 at 2:45 p.m. While the IJ was removed on 11/19/16, the facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy at a scope identified at a pattern due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 6 residents and placed an additional 102 residents at risk of blood pressure associated complications, stroke, internal bleeding, [MEDICAL CONDITIONS], hypertension, harm, injury, hospitalization and possible death. Findings Included: Resident #4 Record review of Resident #4's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. --Resident # 4's physician was not immediately consulted on three occasions when blood pressure medicatoins were held when they should have been administered. Resident # 5 Record review of Resident # 5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. --Resident #5 was not administered as needed [MEDICATION NAME] when his blood pressure was high on three occasions with no documentation of physician notification or assessment. Resident #6 Record review of Resident # 6 ' s face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. --Resident #6 was administered a blood pressure medication outside of physician parameters and the physician was not consulted when her blood pressure readings were out of normal range. Resident #8 Record review of Resident #8's admission sheet revealed she was a [AGE] year old female. her admitted was 12/06/2011 with [DIAGNOSES REDACTED]. --Resident #8 received blood pressure medication outside of ordered heart rate parameter on two occasions. Resident #12 Record review of Resident #12's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. --Resident # 12's physician ordered blood pressure medication ([MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours) had no parameters to guide its administration. --Resident #12 was receiving blood pressure medications outside of paramaters when heart rate was below 60 outside of physician ordered parameters. Staff were not monitoring significantly high blood pressure after morning medications to determine effectiveness of the intervention. Resident #12's physician was not consulted when heart rate was in the 50's on three occasions. Resident #18 Record review of Resident #18's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. --Resident #18 had a change in condition with a heart rate of 40 on 10/11/16 during night shift and was not provided any intervention. Resident #18 had heart rates below 60 on 9 occasions and elevated blood pressures of 188, 184, and 198. She was not administered as needed [MEDICATION NAME] on 4 occasions. Her physician was not consulted and she received no assessment or reassessment. Attempts were made on 11/19/16 to interview LVN#W who administered above medications out of parameter without success. Calls were not answered and not returned. Interview on 11/19/16 at 11:43 a.m., DON said all nurses were trained and licensed to provide care to provide care to residents who had hypertension. He further said the facility's pharmacist reviewed the resident' s medications monthly with recommendations which staff implemented after consulting each resident's physician. DON said the staff were expected to follow the physician's orders [REDACTED]. He said he expected staffs to have called the resident ' s physician when the residents' blood pressure and heart rate were either high or low than the general normal range. The facility Administrator and DON were notified on 11/17/16 at 2:45 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted 11/ 18/16. After several revisions, a plan was accepted on 11/18/16 at 1:35 p.m. Interview on 11/18/16 at 11:40 a.m. with Administrator said that she considered the nurses not giving the blood pressure medications correctly as Neglect. She also said that they should have talked to the cognitively intact residents with high blood pressure to determine if they were receiving their medications. Interview on 11/18/16 at 1:09 p.m., the Administrator said she was not aware of staff administering the blood pressure medications when the residents ' blood pressure was out of ordered parameters. She said the surveyors brought this to her attention and after reviewing the residents data believed staff made poor judgments and failed to notify the residents physician of the changes, low heart rates and high blood pressures. She expressed she expect staff to be of best practice. Administrator said it was negligent not implement the physician order [REDACTED]. During an interview on 11/18/16 at 1:18 p.m., LVN G said that she checked MD ' s orders; residents BP and P before administering blood pressure medications and that if the BP and P were within the MD ' s ordered parameters she would give the medication. She said that she would call the MD if the BP and P were out of the MD ' s parameters. Asked why she held Resident #4 BP medications ([MEDICATION NAME] 20mg oral daily and [MEDICATION NAME] ER 25mg) on 11/14/16, 8:00 am, BP 115/54; 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50 when MD ' s parameter required her to administer medication, she said she used her nursing judgment. Asked whether she notified the MD of the Low DBP ' s and that she held the medications, she said that she did not call the MD because she was very busy and could not stay after her shift was over. Asked if she went back to document the incident she said no. When asked if the facility had Standard Orders she said most MD ' s only said - Hold for SBP less than 110 and P less than 60. Interview on 11/19/16 at 11:40 a.m., the DON said staff failed to follow the physician's order [REDACTED]. He believed this was the cause of immediate jeopardy and the substandard quality of care identified in the facility. DON said the facility had systems in place which included having parameters in place for blood pressure medications, training staff and checking for proficiency in nursing skills . He further said he expect staff to notify the residents ' physicians whenever a physician's order [REDACTED]. Record review of facility ' s in-service training report dated 4/6/16 for RNs, LVNs and Medication aides revealed topic medication administration and further read you must follow proper medication administration protocol . 6 right of medication administration : right resident, right medication, right dose, right time, right route and right documentation. A resident also has a right to refuse medication , in case of this event the resident ' s family and physician must immediately be notified . Record review of the facility's policy on notification of physicians dated February 2010 revealed the types of conditions which arise frequently are listed, this is not inclusive; emesis, vital sings etc. It is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment the nurses will recognize the condition change, monitor the patient and continue to assess the condition and changes , notify the physician of any changes in condition . Record review of the facility's policy on significant change in patient status dated February 2010 revealed a significant change in patient status is defined as deterioration or marked improvement in the health , mental, 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 ; cardiovascular or respiratory changes, fractures, semi-comatose state, choking , infection and dehydration. As a significant change in patient condition occurs, the charge nurses will notify the physician , family or other appropriate person/agency of the significant change immediately. Documentation of significant change in condition requires updating of the plan of care and the minimum data set if unresolved in 14 days. Record review of the list of residents receiving high blood pressure medications indicated 108 residents. Immediate Jeopardy: Plan of Removal, 11/17/16. Systematic Approach 1. Accurate Dispensing of Antihypertensive Medications a. Licensed nursing staff and permitted CMA ' s was in-serviced by (Doctor A)Regional Director of Clinical Services 11/17/16 on the need for parameters for blood pressure medications, adhering to the parameters for blood pressure medications, physician notification per their instruction of blood pressure medication omission or parameter SBP >180 and DBP below 60 that poses a significant risk to the patient and is not addressed after administering ordered PRN medication and notification of heart rates above 100 and below 60. Licensed nurses or PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. The med aides were also in-serviced regarding reporting low and high BP SBP above 180 and below 60 readings as well as low/high heart rates( below 60 above 100) to the Charge nurses and UM. This standard protocol has been approved by all Physicians at Colonnades Started 11/17/2016 and ending 11/18/2016. b. The patients identified by the survey team as not having correct medication administration per parameters or physician orders [REDACTED]. Started and completed on 11/17/16. c. The facility conducted an audit on 11/16/16 and 11/17/16 on all patients with antihypertensive medication orders. Parameters related to high BP and Low BP (110/60 with pulse of 60 hold medication contact Physician) were added to all Patients with antihypertensive medications per Physicians orders. Started and completed on 11/17/2016. d. Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also audit daily utilizing tracking reports from the Electronic Medical Records system to evidence that antihypertensive medications were administered by staff and that there were no omissions of medications and that parameters were followed. This was started 11/17/16 and will continue indefinitely. e. As a systematic change, new antihypertensive medication orders will be monitored daily by the unit manager and the Director of Nursing during the morning meeting. This will be started on 11/18/16 and will continue indefinitely. The surveyors monitored the Plan of Removal on 11/18/16 and 11/19/16 during all three shifts including licensed, registered nurses and medication aides. Facility shift were 6am to 2 pm, 2 pm to 10 pm, and 10 pm- 6 am. Monitoring was as follows: Facility protocols concerning management of resident with [DIAGNOSES REDACTED]. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on 11/18/16 and 11/19/16. In-services were conducted on all three shifts with over 80% of the nursing staff in attendance. 90% of the nursing staff covering three shifts were interviewed on 11/18/16 and 11/19/16, and all staff were able to express up to date knowledge on the facility's procedures for blood pressure medication administration, blood pressure parameters, use of as needed blood pressure medication, immediate notification of licensed nurse by medication aides during medication administrations, and physician notification for licensed nursing staff. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Record review of expanded sample residents with [DIAGNOSES REDACTED]. There were no identified elevated and low blood pressures or heart rates that required physician notification. Observations of residents with [DIAGNOSES REDACTED]. After monitoring the implementation of the plan, the IJ was removed . The Administrator and the DON were informed the IJ was removed on 11/19/16 at 11:35 a.m. While the IJ was removed on 11/19/16, the facility remained out of compliance at a severity of No Actual Harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, adding both systolic and diastolic blood pressure parameters and following blood pressure medication parameters as ordered. The facility CMS form 672 dated 11/16/16 revealed 129 residents, the facility provided a list of 108 residents identified to have the [DIAGNOSES REDACTED].

Based on record review and interview the facility failed to provide services in accordance with the written plan of care or physician's orders for six of 26 residents (Residents #18, #12, #5, #6, #8, and #4) who were reviewed for physician orders. --Resident #18 had heart rates below 60 on 9 occasions and elevated blood pressures of 188, 184, and 198. She was not administered as needed [MEDICATION NAME] on 4 occasions. --Resident # 12's physician ordered blood pressure medication ([MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours) had no parameters to guide its administration. A clarification order was not obtained. --Resident #12 was receiving blood pressure medications outside of paramaters when heart rate was below 60 outside of physician ordered parameters. Staff were not monitoring significantly high blood pressure after morning medications to determine effectiveness of the intervention. --Resident #5 was not administered as needed as ordered [MEDICATION NAME] when his blood pressure was high on three occasions with no documentation of physician notification or assessment. --Resident #6 was administered a blood pressure medication outside of physician parameters and the physician was not consulted when her blood pressure readings were out of normal range as per her plan of care. --Resident #8 received blood pressure medication outside of ordered heart rate parameter on two occasions. --Resident # 4's physician was not immediately consulted on three occasions when blood pressure medications were held when they should have been administered. There was no order to administer the medications outside of parameters. An immediate jeopardy (IJ) was identified on 11/17/16. While the IJ was removed on 11/19/16, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy . The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected 6 residents and placed an additional 102 residents at risk of blood pressure associated complications, stroke, internal bleeding, [MEDICAL CONDITIONS]/hypertension, harm, injury, hospitalization and possible death. Findings included: Resident #18 Record review of Resident #18's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #18 ' s quarterly assessment MDS dated [DATE] revealed the resident had moderately impaired cognition. She required total care for all ADLs. Record review of Resident # 18's care plan not dated the resident has a history of hypertension and currently takes anti-hypertensive medications , goal is the resident's blood pressure will stay within their normal limits , will not have signs and symptoms of hypo and hypertension over the next 90 days. Approaches include monitor blood pressure , increased [MEDICAL CONDITION], dizziness , headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #18's physician order dated 10/28/16 revealed the following: [MEDICATION NAME] 10 mg tablet by mouth daily. Hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 100 mg tablet by mouth every eight hours. Hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 0.1 mg by mouth as needed every six hours for Systolic blood pressure greater than 170 or diastolic blood pressure greater than 100. Record review of Resident #18's MAR indicated [REDACTED]. Record review of Resident #18's MAR indicated [REDACTED] 52 on 11/03/16 at 12 AM 58 on 11/06/16 at 12 AM 57 on 11/9/16 at 12 AM 54 on 11/10/16 at 12 AM 59 on 11/11/16 at 12 AM 58 on 11/12/16 at 12 AM and 54 at 8 AM. 56 on 11/13/16 at 4:00 PM 55 on 11/15/16 at 12 AM Further review of above MAR indicated [REDACTED] 188 at 8 am on 11/09/16 198 at 8 am on 11/10/16 184 at 8 am on 11/12/16 and 189 at 4pm. Record review of Resident#18's nurse notes for November 2016 revealed no documentation that the resident's physician was notified of the elevated blood pressures and low heart rates. There was no documentation of the high blood pressure on 11/9/16, 11/10/16, or 11/12/16 being reassessed to determine if administration of scheduled medications was effective. Attempts were made on 11/19/16 to interview LVN#W who administered above medications out of parameter without success. Calls were not answered and not returned. Record review of Resident#18's nurse note dated 10/11/16 at 2:11 a.m , revealed, (Resident #18's) blood pressure at 12 am was 180 /68 with a pulse of 60. [MEDICATION NAME] was given per orders. At 1:30 am, resident had a large emesis and loose stool, CNA assigned to resident came to this nurse and went to her room. Vital signs were obtained. Oxygen saturation 94 at room air and pulse via pulse oximeter was 54. Blood pressure was obtained via manual cuff and was 120/58, Resident 318 was cleaned and bathed and bed linen changed , she is alert and verbal and watching television. At 5; 43 a.m., blood pressure was 189/65 and heart rate was 40, [MEDICATION NAME] held, all information from this shift is in the doctor book. Interview on 11/19/16 at 6:35 a.m., LVN#Y When asked why she did not notify the resident physician of above incident, LVN#Y said she texted the Nurse practitioner a few times and there was no response. She monitored the resident who was stable. She passed on the information to the morning staff in report to follow up. She further said she checked on the resident and she was fine. Resident #12 Record review of Resident #12's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed he was assessed as scoring a 14 on his BIMS indicating he was cognitively intact. Record review of Resident #12's plan of care dated 3/9/16-present revealed a plan of care for hypertension with a goal of his blood pressure staying within their normal limits; will not have signs/symptoms of hyper/hypo tension . Interventions .monitor blood pressure .report abnormals to MD . Record review of Resident #12's November 2016 Physician Order revealed the following orders for blood pressure medications: [REDACTED] [MEDICATION NAME] ER 60 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 0.2 mg 1 tablet oral every 6 hours. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 6.25 mg 1 tablet oral two times daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 10 mg 1 tablet oral two times daily. Hold for SBP less than 110. [MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours. (No documentation of a parameter for when to give.) Record review of Resident #12's November 2016 Medication Administration Record [REDACTED] Resident #12 was given his ordered [MEDICATION NAME] ER 60 mg 1 tablet oral and [MEDICATION NAME] 6.25 mg 1 tablet by mouth on 11/5/16 at 8:00 am and [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/5/16 at 7:00 am and with a Pulse of 54 bpm (beats per minute). Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/2/16 at 1:00 am with a Pulse of 51 bpm; Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/5/16 at 1:00 p.m. with Systolic Blood Pressure (SBP) of 104. Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/6/16 at 1:00 am with Pulse of 53 bpm. Further review of Resident #12's November 2016 MAR indicated [REDACTED] 11/5/16, 7:00 p.m., BP 147/104 11/6/16, 8: 00 am, BP 162/104 11/8/16, 8:00 am, BP 189/106 11/9/16, 8:00, am, BP 168/93 11/10/16, 8:00 am, BP 176/92 11/12/16, 8:00 am, BP 147/102 11/15/16, 8:00 am, 180/98 and 11/16/16, 8:00 am, BP 166/94. Record review of Resident # 12's November 2016 Physician Order revealed physician ordered blood pressure medication ([MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours) had no parameters to guide its administration. Also record revealed the parameters for administering Blood Pressure medications to Resident #12 did not address abnormal Diastolic Blood Pressures. Record review of Resident #12's November 2016 nurse's notes did not show documentation that physician was consulted on the high and low BP's and the low pulse with medications being administered or held in some instances as shown above on 11/1/16 and 11/16/16. Resident # 5 Record review of Resident # 5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly assessment MDS dated [DATE] revealed BIMS score of 99 indicating the resident was unable to complete the interview, cognitive skill for daily decision making was modified independence. Resident had long and short term memory loss, required limited assistance with ADLs, and had limited range of motion on one side of upper extremity Record review of Resident # 5's undated care plan revealed the resident had a history of [REDACTED]. Approaches included monitor blood pressure, increased [MEDICAL CONDITION], dizziness, headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #5's Physician order dated 4/4/16 revealed the following: [MEDICATION NAME] 10 mg oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 20 mg tablet oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 25 mg ( 3 tablets =75 mg) one time daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 50 mg tablet , oral twice daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 0.1 mg tablet oral as needed every eight hours for systolic blood pressure over 170. Hold for systolic blood pressure less than 110 and pulse less than 60. Order date was 8/10/16. Record review of Resident #5's MAR indicated [REDACTED] --[MEDICATION NAME] 10 mg oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. --[MEDICATION NAME] 20 mg tablet oral daily, [MEDICATION NAME] HCL 25 mg (3 tablets = 75 mg) one time daily, and [MEDICATION NAME] 50 mg tablet, oral twice daily. Record review of Resident #5's November 2016 MAR indicated [REDACTED]. Resident #5's systolic blood pressure was 171 on 11/08/16, 194 on 11/12/16 at 9 am, and 185 on 11/12/16 at 4pm. The as needed [MEDICATION NAME] was not administered on 11/8/16 or 11/12/16. Further record review of above MAR indicated [REDACTED]= 75 mg) one tiem daily, and [MEDICATION NAME] 50 mg tablet oral twice daily. Record review of Resident #5 ' s MAR indicated [REDACTED] Record review of Resident #5's November 2016 nurse's notes revealed no documentation that the resident's physician was notified of the elevated blood pressure on 11/08/16 and 11/12/16. Interview on 11/16/16 at 2:00 p.m., Unit Manager #2 said she was not aware of Resident #5's elevated blood pressure values. She said she expected licensed nurses to use their judgment when providing care to the resident. She said the resident should have been given the ordered as needed medication and her physician should have been consulted. She said there were no communications from the charge nurses for her to follow up with the resident's physician on those days. Interview on 11/16/16 at 2:08 p.m., RN #8 said she worked as a medication aide on 11/12/16 for the evening shift. She stated she gave the resident one as needed [MEDICATION NAME] medication and notified the charge nurse of the value. She said as the medication aide, she should notify the charge nurse since the charge nurses administer as needed medication after assessing of the resident. RN#8 said she did not document her intervention. Interview on 11/19/16 at 7:05 a.m., LVN #Q, who worked the morning shift on 11/12/16, said it was unusual for her not to notify a physician when a resident had a change in condition. She said she did not recall the incident on 11/12/16 when Resident #5 had a systolic blood pressure of 194. LVN #Q further said a blood pressure of 194 was high. She said she would check for any as needed medication, administer the medication, notify the resident's physician and continue to monitor the resident. Resident #6 Record review of Resident # 6's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly assessment MDS dated [DATE] revealed cognitive score of 2 indicating severely impaired cognition. Record review of Resident #6's undated care plan revealed she had a history of [REDACTED]. Approaches included monitor blood pressure, increased [MEDICAL CONDITION], dizziness , headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #6's Physician order dated 3/29/16 revealed the following: [MEDICATION NAME] 12.5 mg by mouth every 12 hours, hold for systolic blood pressure less than 110 and pulse less than 60. Record review of Resident #6's MAR indicated [REDACTED]. Further review of above MAR indicated [REDACTED]. Resident's systolic blood pressure was 83 on 11/14 at 8 am. Record review of Resident #6's vital signs log for November 2016 revealed an average blood pressure baseline of 130 and heart rate of 65. Record review of Resident#6's nurse's notes revealed no documentation that the resident's physician was notified of the elevated blood pressure and heart rate on 11/9/16 and her low systolic blood pressure on 11/14/16. There were attempts made to contact MA #1, who administered Resident #6's medications, on 11/18 /16 and 11/19/16. The attempts were unsuccessful. Interview on 11/19/16 at 11:43 a.m , DON said all nurses were trained and licensed to provide care to residents who had hypertension. He further said the facility's pharmacist reviewed the resident's medications monthly with recommendations which staff implemented after consulting each resident's physician. The DON said the staff were evaluated on medication pass and were expected to follow the physician's orders. He said the staff were provided training upon hire and on an on-going basis. He said he expected staff to have called the resident's physician when the residents' blood pressure and heart rate were either high or low than the general normal range. Resident #8 Record review of Resident #8's admission sheet revealed she was a [AGE] year old female. her admitted was 12/06/2011 with [DIAGNOSES REDACTED]. Record review of Resident #8's Annual MDS dated [DATE] revealed she was assessed as having a BIMS (brief interview for mental status) Score of 08 indicating moderately impaired cognitive skills for daily decision making. Record review of Resident #8's plan of care dated 3/22/16-present revealed there was no documentation of a plan of care for hypertension. Observation of Resident #8 on 11/14/16 at 8:50 p.m. revealed the resident was groomed and presented with no odors. She was sitting in the hall talking to her neighbor. Record review of Resident #8's November 2016 physician orders revealed orders for: -[MEDICATION NAME] 50 mg 1 and 1/2 tablets (75 mg) every 12 hours -[MEDICATION NAME] 10 mg once daily by mouth -[MEDICATION NAME] HCL 25 mg 1 tablet every 8 hours by mouth Record review of Resident #8's Medication Administration Record [REDACTED]. Record review of Resident #8's MAR indicated [REDACTED]. Record review of Resident #8's MAR indicated [REDACTED]. Resident #4 Record review of Resident #4's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS of 11, indicating he was cognitively intact. Record review of Resident #4's plan of care dated 10/25/16-present revealed there was no documentation of a plan of care for hypertension. Record review of Resident #4's November 2016 Physician Order revealed the following orders for blood pressure medications: [REDACTED] [MEDICATION NAME] 20 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] ER 25 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 0.1 mg 1 tablet oral PRN every 6 hours for BP greater than 180/90. Record review of Resident #4's November 2016 Medication Administration Record [REDACTED] Blood Pressure medications - [MEDICATION NAME] 20 mg oral daily and [MEDICATION NAME] ER 25 mg oral daily were held as follows: 11/14/16, 8:00 am, BP 115/54 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50. Physician's parameters to hold medications were: Hold for Systolic Blood Pressure less than 110 and Pulse less than 60. The Physician was not notified that medications were held as shown above. Record review of Resident # 4's November 2016 Physician Order revealed the parameters for administering Blood Pressure medications to Resident #4 did not address abnormal Diastolic Blood Pressures. Record review of Resident #4's November 2016 nurse's notes revealed no documentation of physician clarification to address the low diastolic blood pressure or notification of holding blood pressure medications outside of ordered physician parameters. During an interview on 11/18/16 at 1:18 p.m., LVN G said that she checked MD ' s orders; residents BP and Pulse before administering blood pressure medications and that if the BP and Pulse were within the MD ' s ordered parameters she would give the medication. She said that she would call the MD if the BP and Pulse were out of the MD ' s parameters. Asked why she held Resident #4 BP medications ([MEDICATION NAME] 20 mg oral daily and [MEDICATION NAME] ER 25 mg) on 11/14/16, 8:00 am, BP 115/54; 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50 when MD ' s parameter required her to administer medication, she said she used her nursing judgment. Asked whether she notified the MD of the Low DBP ' s and that she held the medications, she said that she did not call the MD because she was very busy and could not stay after her shift was over. Asked if she went back to document the incident she said no. When asked if the facility had Standard Orders she said most MD ' s only said - Hold for SBP less than 110 and Pulse less than 60. Record review of facility's in-service training report dated 4/6/16 for RNs, LVNs and Medication aides revealed topic medication administration and further read, you must follow proper medication administration protocol . 6 right of medication administration : right resident, right medication, right dose, right time, right route and right documentation. A resident also has a right to refuse medication , in case of this event the resident ' s family and physician must immediately be notified. Record review of the facility's policy on notification of physicians dated February 2010 revealed the types of conditions which arise frequently are listed, this is not inclusive; emesis, vital sings etc. It is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment the nurses will recognize the condition change, monitor the patient and continue to assess the condition and changes , notify the physician of any changes in condition. Record review of the facility's policy on significant change in patient status dated February 2010 revealed, .a significant change in patient status is defined as deterioration or marked improvement in the health , mental, 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 ; cardiovascular or respiratory changes, fractures, semi-comatose state, choking , infection and dehydration. As a significant change in patient condition occurs, the charge nurses will notify the physician , family or other appropriate person/agency of the significant change immediately. Documentation of significant change in condition requires updating of the plan of care and the minimum data set if unresolved in 14 days. The facility Administrator and DON were notified on 11/17/16 at 2:45 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted 11/ 18/16 . After several revisions, a plan was accepted on 11/18/16 at 1:35 p.m. Interview on 11/18/16 at 1:09 p.m , the Administrator said she was not aware of staff administering the blood pressure medications when the residents' blood pressure was out of ordered parameters. She said the surveyors brought this to her attention and after reviewing the residents data believed staff made poor judgments and failed to notify the residents physician of the changes, low heart rates and high blood pressures. She expressed she expected staff to be of best practice. Administrator said it was negligent tonot implement the physician order. Interview on 11/19/16 at 11:40 a.m., the DON said staff failed to follow the physician's orders by administering blood pressure medications outside of ordered parameters . He believed this was the cause of immediate jeopardy and the substandard quality of care identified in the facility. DON said the facility had systems in place which included having parameters in place for blood pressure medications, training staff and checking for proficiency in nursing skills. He further said he expected staff to notify the residents ' physicians whenever a physician's order could not be implemented. Immediate Jeopardy: Plan of Removal, 11/17/16. Systematic Approach 1. Accurate Dispensing of Antihypertensive Medications a. Licensed nursing staff and permitted CMA's was in-serviced by (Doctor A) Regional Director of Clinical Services 11/17/16 on the need for parameters for blood pressure medications, adhering to the parameters for blood pressure medications, physician notification per their instruction of blood pressure medication omission or parameter SBP >180 and DBP below 60 that poses a significant risk to the patient and is not addressed after administering ordered PRN medication and notification of heart rates above 100 and below 60. Licensed nurses or PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. The med aides were also in-serviced regarding reporting low and high BP SBP above 180 and below 60 readings as well as low/high heart rates( below 60 above 100) to the Charge nurses and UM. This standard protocol has been approved by all Physicians at Colonnades Started 11/17/2016 and ending 11/18/2016. b. The patients identified by the survey team as not having correct medication administration per parameters or physician orders have been assessed with [REDACTED]. Started and completed on 11/17/16. c. The facility conducted an audit on 11/16/16 and 11/17/16 on all patients with antihypertensive medication orders. Parameters related to high BP and Low BP (110/60 with pulse of 60 hold medication contact Physician) were added to all Patients with antihypertensive medications per Physicians orders. Started and completed on 11/17/2016 d. Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also audit daily utilizing tracking reports from the Electronic Medical Records system to evidence that antihypertensive medications were administered by staff and that there were no omissions of medications and that parameters were followed. This was started 11/17/16 and will continue indefinitely. e. As a systematic change, new antihypertensive medication orders will be monitored daily by the unit manager and the Director of Nursing during the morning meeting. This will be started on 11/18/16 and will continue indefinitely. The surveyors monitored the Plan of Removal on 11/18/16 and 11/19/16 during all three shifts including licensed, registered nurses and medication aides. Facility shift were 6 am to 2 pm, 2 pm to 10 pm, and 10 pm - 6 am. Monitoring was as follows: Facility protocols concerning management of resident with [DIAGNOSES REDACTED]. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on 11/18/16 and 11/19/16. In-services were conducted on all three shifts with over 80% of the nursing staff in attendance. 90% of the nursing staff covering three shifts were interviewed on 11/18/16 and 11/19/16, and all staff were able to express up to date knowledge on the facility's procedures for blood pressure medication administration, blood pressure parameters, use of as needed blood pressure medication, immediate notification of licensed nurse by medication aides during medication administrations, and physician notification for licensed nursing staff. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Record review of expanded sample residents with [DIAGNOSES REDACTED]. There were no identified elevated and low blood pressures or heart rates that required physician notification. Observations of residents with [DIAGNOSES REDACTED]. After monitoring the implementation of the plan, the IJ was removed . The Administrator and the DON were informed the IJ was removed on 11/19/16 at 11:35 a.m. While the IJ was removed on 11/19/16, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, adding both systolic and diastolic blood pressure parameters and following blood pressure medication parameters as ordered. Record review of a list provided by the facility revealed 108 residents identified to have the [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to consult with the physician when a change of condition occurred for six of 26 residents (Residents #18, #12, #5, #6, #8 and #4) reviewed for physician consultation. The facility failed to consult with the physicians of Residents #18, #12, #5, #6, #8 and #4 when their blood pressures and rates were outside of ordered parameters and medication was administered or held outside of ordered parameters. An immediate jeopardy (IJ) was identified on 11/17/16. While the IJ was removed on 11/19/16, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy . The facility needed additional time to monitor and evaluate the effectiveness of their plan. This failure affected 6 residents and placed 102 other residents in the facility with hypertension at risk of not having their physicians consulted when they experienced a change in condition and required a possible change in their medical care. Findings included: Resident #18 Record review of Resident #18's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #18 ' s quarterly assessment MDS dated [DATE] revealed the resident had moderately impaired cognition. She required total care for all ADLs. Record review of Resident # 18's care plan not dated the resident has a history of hypertension and currently takes anti-hypertensive medications , goal is the resident's blood pressure will stay within their normal limits , will not have signs and symptoms of hypo and hypertension over the next 90 days. Approaches include monitor blood pressure , increased [MEDICAL CONDITION], dizziness , headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #18's physician order [REDACTED]. [MEDICATION NAME] 10 mg tablet by mouth daily. Hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 100 mg tablet by mouth every eight hours. Hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 0.1 mg by mouth as needed every six hours for Systolic blood pressure greater than 170 or diastolic blood pressure greater than 100. Record review of Resident #18's MAR indicated [REDACTED]. Record review of Resident #18's MAR indicated [REDACTED] 52 on 11/03/16 at 12 AM 58 on 11/06/16 at 12 AM 57 on 11/9/16 at 12 AM 54 on 11/10/16 at 12 AM 59 on 11/11/16 at 12 AM 58 on 11/12/16 at 12 AM and 54 at 8 AM. 56 on 11/13/16 at 4:00 PM 55 on 11/15/16 at 12 AM Further review of above MAR indicated [REDACTED] 188 at 8 am on 11/09/16 198 at 8 am on 11/10/16 184 at 8 am on 11/12/16 and 189 at 4pm. Record review of Resident#18's nurse notes for November 2016 revealed no documentation that the resident's physician was notified of the elevated blood pressures and low heart rates. There was no documentation of the high blood pressure on 11/9/16, 11/10/16, or 11/12/16 being reassessed to determine if administration of scheduled medications was effective. Attempts were made on 11/19/16 to interview LVN#W who administered above medications out of parameter without success. Calls were not answered and not returned. Record review of Resident#18's nurse note dated 10/11/16 at 2:11 a.m , revealed, (Resident #18's) blood pressure at 12 am was 180 /68 with a pulse of 60. [MEDICATION NAME] was given per orders. At 1:30 am, resident had a large emesis and loose stool, CNA assigned to resident came to this nurse and went to her room. Vital signs were obtained. Oxygen saturation 94 at room air and pulse via pulse oximeter was 54. Blood pressure was obtained via manual cuff and was 120/58, Resident 318 was cleaned and bathed and bed linen changed , she is alert and verbal and watching television. At 5; 43 a.m., blood pressure was 189/65 and heart rate was 40, [MEDICATION NAME] held, all information from this shift is in the doctor book. Interview on 11/19/16 at 6:35 a.m., LVN#Y When asked why she did not notify the resident physician of above incident, LVN#Y said she texted the Nurse practitioner a few times and there was no response. She monitored the resident who was stable. She passed on the information to the morning staff in report to follow up. She further said she checked on the resident and she was fine. Resident #12 Record review of Resident #12's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed he was assessed as scoring a 14 on his BIMS indicating he was cognitively intact. Record review of Resident #12's plan of care dated 3/9/16-present revealed a plan of care for hypertension with a goal of his blood pressure staying within their normal limits; will not have signs/symptoms of hyper/hypo tension . Interventions .monitor blood pressure .report abnormals to MD . Record review of Resident #12's November 2016 Physician order [REDACTED]. [MEDICATION NAME] ER 60 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 0.2 mg 1 tablet oral every 6 hours. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 6.25 mg 1 tablet oral two times daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 10 mg 1 tablet oral two times daily. Hold for SBP less than 110. [MEDICATION NAME] 0.1 mg 1 tablet oral as needed (PRN) every 6 hours. (No documentation of a parameter for when to give.) Record review of Resident #12's November 2016 Medication Administration Record [REDACTED] Resident #12 was given his ordered [MEDICATION NAME] ER 60 mg 1 tablet oral and [MEDICATION NAME] 6.25 mg 1 tablet by mouth on 11/5/16 at 8:00 am and [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/5/16 at 7:00 am and with a Pulse of 54 bpm (beats per minute). Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/2/16 at 1:00 am with a Pulse of 51 bpm; Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/5/16 at 1:00 p.m. with Systolic Blood Pressure (SBP) of 104. Resident #12 was given his ordered [MEDICATION NAME] 0.2 mg 1 tablet oral on 11/6/16 at 1:00 am with Pulse of 53 bpm. Further review of Resident #12's November 2016 MAR indicated [REDACTED] 11/5/16, 7:00 p.m., BP 147/104 11/6/16, 8: 00 am, BP 162/104 11/8/16, 8:00 am, BP 189/106 11/9/16, 8:00, am, BP 168/93 11/10/16, 8:00 am, BP 176/92 11/12/16, 8:00 am, BP 147/102 11/15/16, 8:00 am, 180/98 and 11/16/16, 8:00 am, BP 166/94. Record review of Resident # 12's November 2016 Physician order [REDACTED]. Also record revealed the parameters for administering Blood Pressure medications to Resident #12 did not address abnormal Diastolic Blood Pressures. Record review of Resident #12's November 2016 nurse's notes did not show documentation that physician was consulted on the high and low BP's and the low pulse with medications being administered or held in some instances as shown above on 11/1/16 and 11/16/16. Resident # 5 Record review of Resident # 5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly assessment MDS dated [DATE] revealed BIMS score of 99 indicating the resident was unable to complete the interview, cognitive skill for daily decision making was modified independence. Resident had long and short term memory loss, required limited assistance with ADLs, and had limited range of motion on one side of upper extremity Record review of Resident # 5's undated care plan revealed the resident had a history of [REDACTED]. Approaches included monitor blood pressure, increased [MEDICAL CONDITION], dizziness, headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #5's Physician order [REDACTED]. [MEDICATION NAME] 10 mg oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 20 mg tablet oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 25 mg ( 3 tablets =75 mg) one time daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] 50 mg tablet , oral twice daily, hold for systolic blood pressure less than 110 and pulse less than 60. [MEDICATION NAME] HCL 0.1 mg tablet oral as needed every eight hours for systolic blood pressure over 170. Hold for systolic blood pressure less than 110 and pulse less than 60. Order date was 8/10/16. Record review of Resident #5's MAR indicated [REDACTED] --[MEDICATION NAME] 10 mg oral daily, hold for systolic blood pressure less than 110 and pulse less than 60. --[MEDICATION NAME] 20 mg tablet oral daily, [MEDICATION NAME] HCL 25 mg (3 tablets = 75 mg) one time daily, and [MEDICATION NAME] 50 mg tablet, oral twice daily. Record review of Resident #5's November 2016 MAR indicated [REDACTED]. Resident #5's systolic blood pressure was 171 on 11/08/16, 194 on 11/12/16 at 9 am, and 185 on 11/12/16 at 4pm. The as needed [MEDICATION NAME] was not administered on 11/8/16 or 11/12/16. Further record review of above MAR indicated [REDACTED]= 75 mg) one tiem daily, and [MEDICATION NAME] 50 mg tablet oral twice daily. Record review of Resident #5 ' s MAR indicated [REDACTED] Record review of Resident #5's November 2016 nurse's notes revealed no documentation that the resident's physician was notified of the elevated blood pressure on 11/08/16 and 11/12/16. Interview on 11/16/16 at 2:00 p.m., Unit Manager #2 said she was not aware of Resident #5's elevated blood pressure values. She said she expected licensed nurses to use their judgment when providing care to the resident. She said the resident should have been given the ordered as needed medication and her physician should have been consulted. She said there were no communications from the charge nurses for her to follow up with the resident's physician on those days. Interview on 11/16/16 at 2:08 p.m., RN #8 said she worked as a medication aide on 11/12/16 for the evening shift. She stated she gave the resident one as needed [MEDICATION NAME] medication and notified the charge nurse of the value. She said as the medication aide, she should notify the charge nurse since the charge nurses administer as needed medication after assessing of the resident. RN#8 said she did not document her intervention. Interview on 11/19/16 at 7:05 a.m., LVN #Q, who worked the morning shift on 11/12/16, said it was unusual for her not to notify a physician when a resident had a change in condition. She said she did not recall the incident on 11/12/16 when Resident #5 had a systolic blood pressure of 194. LVN #Q further said a blood pressure of 194 was high. She said she would check for any as needed medication, administer the medication, notify the resident's physician and continue to monitor the resident. Resident #6 Record review of Resident # 6's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly assessment MDS dated [DATE] revealed cognitive score of 2 indicating severely impaired cognition. Record review of Resident #6's undated care plan revealed she had a history of [REDACTED]. Approaches included monitor blood pressure, increased [MEDICAL CONDITION], dizziness , headache, chest pain etc., report abnormal to the MD, encourage oral fluid intake within dietary limits, give medications per order -monitor labs -report abnormal to MD, diet as ordered, and encourage the resident to restrict sodium intake if not ordered by MD. Record review of Resident #6's Physician order [REDACTED]. [MEDICATION NAME] 12.5 mg by mouth every 12 hours, hold for systolic blood pressure less than 110 and pulse less than 60. Record review of Resident #6's MAR indicated [REDACTED]. Further review of above MAR indicated [REDACTED]. Resident's systolic blood pressure was 83 on 11/14/16 at 8 am. Record review of Resident #6's vital signs log for November 2016 revealed an average blood pressure baseline of 130 and heart rate of 65. Record review of Resident#6's nurse's notes revealed no documentation that the resident's physician was notified of the elevated blood pressure and heart rate on 11/9/16 and her low systolic blood pressure on 11/14/16. There were attempts made to contact MA #1, who administered Resident #6's medications, on 11/18 /16 and 11/19/16. The attempts were unsuccessful. Interview on 11/19/16 at 11:43 a.m., DON said all nurses were trained and licensed to provide care to residents who had hypertension. He further said the facility's pharmacist reviewed the resident's medications monthly with recommendations which staff implemented after consulting each resident's physician. The DON said the staff were evaluated on medication pass and were expected to follow the physician's orders [REDACTED]. He said he expected staff to have called the resident's physician when the residents' blood pressure and heart rate were either high or low than the general normal range. Resident #8 Record review of Resident #8's admission sheet revealed she was a [AGE] year old female. her admitted was 12/06/2011 with [DIAGNOSES REDACTED]. Record review of Resident #8's Annual MDS dated [DATE] revealed she was assessed as having a BIMS (brief interview for mental status) Score of 08 indicating moderately impaired cognitive skills for daily decision making. Record review of Resident #8's plan of care dated 3/22/16-present revealed there was no documentation of a plan of care for hypertension. Observation of Resident #8 on 11/14/16 at 8:50 p.m. revealed the resident was groomed and presented with no odors. She was sitting in the hall talking to her neighbor. Record review of Resident #8's November 2016 physician orders [REDACTED]. -[MEDICATION NAME] 50 mg 1 and 1/2 tablets (75 mg) every 12 hours -[MEDICATION NAME] 10 mg once daily by mouth -[MEDICATION NAME] HCL 25 mg 1 tablet every 8 hours by mouth Record review of Resident #8's Medication Administration Record [REDACTED]. Record review of Resident #8's MAR indicated [REDACTED]. Record review of Resident #8's MAR indicated [REDACTED]. Resident #4 Record review of Resident #4's Face Sheet revealed he was a [AGE] years old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS of 11, indicating he was cognitively intact. Record review of Resident #4's plan of care dated 10/25/16-present revealed there was no documentation of a plan of care for hypertension. Record review of Resident #4's November 2016 Physician order [REDACTED]. [MEDICATION NAME] 20 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] ER 25 mg 1 tablet oral daily. Hold for SBP less than 110 and Pulse less than 60. [MEDICATION NAME] 0.1 mg 1 tablet oral PRN every 6 hours for BP greater than 180/90. Record review of Resident #4's November 2016 Medication Administration Record [REDACTED] Blood Pressure medications - [MEDICATION NAME] 20 mg oral daily and [MEDICATION NAME] ER 25 mg oral daily were held as follows: 11/14/16, 8:00 am, BP 115/54 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50. Physician's parameters to hold medications were: Hold for Systolic Blood Pressure less than 110 and Pulse less than 60. The Physician was not notified that medications were held as shown above. Record review of Resident # 4's November 2016 Physician order [REDACTED].#4 did not address abnormal Diastolic Blood Pressures. Record review of Resident #4's November 2016 nurse's notes revealed no documentation of physician clarification to address the low diastolic blood pressure or notification of holding blood pressure medications outside of ordered physician parameters. During an interview on 11/18/16 at 1:18 p.m., LVN G said that she checked MD ' s orders; residents BP and Pulse before administering blood pressure medications and that if the BP and Pulse were within the MD ' s ordered parameters she would give the medication. She said that she would call the MD if the BP and Pulse were out of the MD ' s parameters. Asked why she held Resident #4 BP medications ([MEDICATION NAME] 20 mg oral daily and [MEDICATION NAME] ER 25 mg) on 11/14/16, 8:00 am, BP 115/54; 11/15/16, 8:00 am, BP 112/57 and 11/16/16, 8:00 am, BP 111/50 when MD ' s parameter required her to administer medication, she said she used her nursing judgment. Asked whether she notified the MD of the Low DBP ' s and that she held the medications, she said that she did not call the MD because she was very busy and could not stay after her shift was over. Asked if she went back to document the incident she said no. When asked if the facility had Standard Orders she said most MD ' s only said - Hold for SBP less than 110 and Pulse less than 60. Record review of facility's in-service training report dated 4/6/16 for RNs, LVNs and Medication aides revealed topic medication administration and further read, you must follow proper medication administration protocol . 6 right of medication administration : right resident, right medication, right dose, right time, right route and right documentation. A resident also has a right to refuse medication , in case of this event the resident ' s family and physician must immediately be notified. Record review of the facility's policy on notification of physicians dated February 2010 revealed the types of conditions which arise frequently are listed, this is not inclusive; emesis, vital sings etc. It is the responsibility of the nursing staff to observe the changes, make an assessment and notify the physician as indicated based on the assessment the nurses will recognize the condition change, monitor the patient and continue to assess the condition and changes , notify the physician of any changes in condition. Record review of the facility's policy on significant change in patient status dated February 2010 revealed, .a significant change in patient status is defined as deterioration or marked improvement in the health , mental, 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 ; cardiovascular or respiratory changes, fractures, semi-comatose state, choking , infection and dehydration. As a significant change in patient condition occurs, the charge nurses will notify the physician , family or other appropriate person/agency of the significant change immediately. Documentation of significant change in condition requires updating of the plan of care and the minimum data set if unresolved in 14 days. The facility Administrator and DON were notified on 11/17/16 at 2:45 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted 11/ 18/16 . After several revisions, a plan was accepted on 11/18/16 at 1:35 p.m. Interview on 11/18/16 at 1:09 p.m , the Administrator said she was not aware of staff administering the blood pressure medications when the residents' blood pressure was out of ordered parameters. She said the surveyors brought this to her attention and after reviewing the residents data believed staff made poor judgments and failed to notify the residents physician of the changes, low heart rates and high blood pressures. She expressed she expected staff to be of best practice. Administrator said it was negligent tonot implement the physician order. Interview on 11/19/16 at 11:40 a.m., the DON said staff failed to follow the physician's orders [REDACTED]. He believed this was the cause of immediate jeopardy and the substandard quality of care identified in the facility. DON said the facility had systems in place which included having parameters in place for blood pressure medications, training staff and checking for proficiency in nursing skills. He further said he expected staff to notify the residents ' physicians whenever a physician's orders [REDACTED]. Immediate Jeopardy: Plan of Removal, 11/17/16. Systematic Approach 1. Accurate Dispensing of Antihypertensive Medications a. Licensed nursing staff and permitted CMA's was in-serviced by (Doctor A) Regional Director of Clinical Services 11/17/16 on the need for parameters for blood pressure medications, adhering to the parameters for blood pressure medications, physician notification per their instruction of blood pressure medication omission or parameter SBP >180 and DBP below 60 that poses a significant risk to the patient and is not addressed after administering ordered PRN medication and notification of heart rates above 100 and below 60. Licensed nurses or PRN nurses who are unavailable for the in service will not be allowed to work until such in-services have been given. The med aides were also in-serviced regarding reporting low and high BP SBP above 180 and below 60 readings as well as low/high heart rates( below 60 above 100) to the Charge nurses and UM. This standard protocol has been approved by all Physicians at Colonnades Started 11/17/2016 and ending 11/18/2016. b. The patients identified by the survey team as not having correct medication administration per parameters or physician orders [REDACTED]. Started and completed on 11/17/16. c. The facility conducted an audit on 11/16/16 and 11/17/16 on all patients with antihypertensive medication orders. Parameters related to high BP and Low BP (110/60 with pulse of 60 hold medication contact Physician) were added to all Patients with antihypertensive medications per Physicians orders. Started and completed on 11/17/2016 d. Monitoring of appropriate assessment of patients will be completed daily through the Morning report as well as shift to shift report by Unit Managers, Director of Nursing or Designee. The facility will also audit daily utilizing tracking reports from the Electronic Medical Records system to evidence that antihypertensive medications were administered by staff and that there were no omissions of medications and that parameters were followed. This was started 11/17/16 and will continue indefinitely. e. As a systematic change, new antihypertensive medication orders will be monitored daily by the unit manager and the Director of Nursing during the morning meeting. This will be started on 11/18/16 and will continue indefinitely. The surveyors monitored the Plan of Removal on 11/18/16 and 11/19/16 during all three shifts including licensed, registered nurses and medication aides. Facility shift were 6 am to 2 pm, 2 pm to 10 pm, and 10 pm - 6 am. Monitoring was as follows: Facility protocols concerning management of resident with [DIAGNOSES REDACTED]. In-services on procedures concerning proper assessment and analysis of abnormal vital signs, changes of condition, and documentation, were conducted on 11/18/16 and 11/19/16. In-services were conducted on all three shifts with over 80% of the nursing staff in attendance. 90% of the nursing staff covering three shifts were interviewed on 11/18/16 and 11/19/16, and all staff were able to express up to date knowledge on the facility's procedures for blood pressure medication administration, blood pressure parameters, use of as needed blood pressure medication, immediate notification of licensed nurse by medication aides during medication administrations, and physician notification for licensed nursing staff. Interviews with nursing staff on all three shifts revealed no changes in condition had been identified since the immediate jeopardy was identified. Record review of expanded sample residents with [DIAGNOSES REDACTED]. There were no identified elevated and low blood pressures or heart rates that required physician notification. Observations of residents with [DIAGNOSES REDACTED]. After monitoring the implementation of the plan, the IJ was removed . The Administrator and the DON were informed the IJ was removed on 11/19/16 at 11:35 a.m. While the IJ was removed on 11/19/16, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan to ensure residents' physicians were promptly consulted following changes in condition, proper assessment, adding both systolic and diastolic blood pressure parameters and following blood pressure medication parameters as ordered. Record review of a list provided by the facility revealed 108 residents identified to have the [DIAGNOSES REDACTED].

Based on observation, interview and record review for 1 of 11 residents (#1) reviewed for abuse/neglect protocol failed to ensure that all alleged violations involving abuse are reported immediately to the administrator of the facility and to other officials in accordance with State law in that: --On 2/16/16 and 2/26/16 allegations were made of verbal abuse toward Resident #1. The allegations were not immediately investigated or reported to DADS until 02/29/2016 and 03/02/2016. --On 2/22/16 Corporate Office received a concern through their Compliance Line of Resident #1 potentially being verbally abused. No investigation was started by the Corporate Office until 2/24/16. An Immediate Jeopardy (IJ) was identified on 3/2/16 at 05:34 pm. While the IJ was lowered on 3/4/16 at 08:13 pm, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. This failure affected 1 resident and placed an additional 126 residents at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization . Intake # 4 Findings Include: Record review of complaint intake # 4 revealed an allegation that a visitor was in the facility on 2/21/16 when they observed a visitor in Resident #1's room and that person was overheard yelling at Resident #1. The alleged perpetrator was allegedly heard saying shut up several times and was loud. The intake alleged staff appeared fearful of the person yelling. Record review of Resident #1's admission sheet revealed she was a [AGE] year old who was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she was assessed as usually being understood and usually understanding. She was assessed as having moderately impaired cognitive skills for daily decision making-decisions poor; cues/supervision required. She had no behaviors. Record review of Resident #1's Nurse's Note dated 2/16/16 and timed 5:00 p.m. revealed, .Floor nurse reported that resident's Family Member E was in the room yelling at Resident #1. Upon going to the room to investigate further, the sitter was noted coming out of the room. IM (sic) going to call the police on his crazy (explicit word), in there talking to that lady like she is a child. When entered the room, the resident was in bed and Family Member E was sitting in a chair in front of the bed. No yelling noted or heard. No distress apparent from resident. Reported concerns to Executive Director (Abuse Coordinator). Record review of Resident #1's Nurse's Note, which appeared to be dated 2/26/16, changed to 2/16/16, then back to 2/26/16 with no time revealed, .While in hallway I heard a boom ( two lined out letters) and yelling coming from room Resident #1's room I walked in as family member, sitter and patient was walking out, Sitter mouthed to call police, I walked to the front to explain to the executive director what was going on, by then the son and sitter was walking to the the front to speak with the executive director nurse also heard son say to mother Family Member F is a (expletive), you cant (sic) come home anymore, I cant (sic) wait til you die (sic) Sitter stated Family Member E dont (sic) say that (sic) . Record review of Resident #1's Social Service Progress Note dated 2/28/16 revealed, .SW (Social Work) assistant came and informed SW that resident's sitter had some concerns with the way resident's son had been treating her. SW spoke with the sitter and the sitter stated that on Fri (Friday) Feb (February) 26th the resident's son came into resident's room and was screaming and shouting at the resident. Sitter stated that the son cursing at her and screaming about the facility taking her check. Sitter then said the son told the resident 'I can't wait for you to die' (sic) Sitter stated that the son then yanked the resident's wheelchair and pushed the bedside table over onto resident's foot. Sitter stated that the resident began to cry and was very upset. Sitter stated that she herself is afraid of the son. SW asked resident about that day and she said she really couldn't remember. That the only thing she remembers is some man standing over her. SW asked resident was she afraid of her son and resident stated'NO'. She stated that he yells and screams sometimes but she doesn't pay him any attention. SW informed the abuse coordinator/ED (sic) . The identification of who sitter and son were was not documented. Observation on 3/2/16 at 10:34 a.m. of Resident #1 revealed she was not in her room. Visitor A was seated in Resident #1's room. During an interview and observation on 3/2/16 at 10:34 a.m. with Visitor A she said Resident #1 was in therapy. She said the resident had been in the facility for approximately 6 months. She said she was the resident's sitter and she was in the building Monday through Friday from 8:00 a.m. till 1:00 p.m. She said Resident #1's son was abusive, but did not elaborate. Resident #1 was brought into the room by therapy. Resident #1 was groomed and without odor. She did not appear fearful. During an interview on 3/2/16 at 10:42 a.m. with Resident #1 she said she was, good, and that things were so far so good. She said she was getting everything she needed. She said no person had raised their voice when speaking to her. She said she was allowed to have visitors whenever she wanted. When asked if she felt safe she said, So far I do. During an interview on 3/2/16 at 12:05 p.m. with the Administrator he said Adult Protective Services had been called, not by him, due to family dynamics with Resident #1's family. He said Resident #1's daughter had Medical Power of Attorney. He said Resident #1had not been adjudicated incompetent. He said Family Member E had been trying to use Resident #1's Medicaid check to make improvements to Resident #1's house and was trying to get her back into her home. He said Family Member E had been banned from coming to visit the resident for right now. He said the sitter (Visitor A) was inconsistent with her story of what happened on 2/26/16. He said Visitor A had refused to give a written statement of the events on 02/26/16. He said the facility had called in a self report. As of the date of exit, one sheet of paper was provided and an in-service on abuse neglect dated 2/29/16. No self report number was provided by the Administrator for the incidents documented on 2/16/16 or 2/26/16 until 3/2/16. During an interview on 3/2/16 at 12:46 p.m. with the Administrator when asked about Resident #1's Nurse's Notes dated 2/16/16 and 2/26/16 he said no information was reported to him related to those incidents. He said he did not know about any of the information about Resident #1 until yesterday (3/1/16). Then he said the Social Worker had told him about it when it was reported to her (2/29/16). Record review of the State data base on 3/2/16 at 1:36 p.m. revealed there was no documentation of a self-report on the incident on 2/16/16 or 2/26/16. During an interview on 3/2/16 at 1:37 p.m. with the Social Worker she said the date on her note was an error. She said she had received the information on 2/29/16, not on 2/28/16. She said 2/28/16 was a Sunday and she was not at work. She said the Social Worker Assistant came to her and told her about the concern related to Resident #1. She said she interviewed the sitter and was told that on the previous Friday (2/26/16) Family Member E yelled and cursed at Resident #1 and knocked over an overbed table onto Resident #1's foot. She said the sitter did not know which foot but did not feel it was on purpose. She said the sitter would not provide a written statement. She said she was not aware of another incident on 2/16/16. She said LVN B/Unit Manager wrote the Nurse's Note dated 02/26/2016. During an interview on 3/2/16 at 1:40 p.m. with LVN B/Unit Manager she said she wrote the Nurse's Note dated 02/16/2016 concerning Resident #1. She said LVN C reported the incident to her on 2/16/16 but she did not witness the incident herself. She said she went to Resident #1's room and Family Member E was sitting at the foot of the bed. She said Resident #1 appeared to have been crying. She said Resident #1 indicated that she was ok by nodding in the affirmative. She said Family Member E stood up and told her they were just talking. She said Family Member E gets aggressive with staff, makes staff uncomfortable, makes inappropriate comments to staff, including her and used to make passes at her. She said Resident # 1 was left alone in her room with Family Member E. She said the sitter, Visitor A, left the room to see LVN C and was threatening to call the police. She said she went to the Administrator and reported the incident. She said the Administrator told her, It's his momma, he can talk to his momma any way he wants. She said the receptionist then came in and told the Administrator that Family Member E wanted to talk to him. She said Family Member E left the building after that. She said the Administrator took no action. She said she spoke to LVN C who said Family Member E was always loud, but this was different. She said LVN C told her Family Member E said, I can't wait till you die. She said Family E did not have any visiting restrictions with Resident #1. During an interview on 3/2/16 at 2:06 p.m. with the Administrator he said he had called in the 2/16/16 incident that day, 3/2/16. During additional interview with the Administrator on 3/2/16 at 2:10 p.m. he was asked about calling in the 2/26/16 incident. He said he had combined the 2/16/16 and 2/26/16 incidents into one self-report. He said he had one piece of paper for the incidents dated 03/01/2016. Record review of the .Investigation of Allegation (Resident #1) 3/1/16, provided by the Administrator, revealed, in it's entirety, .2/29/16 Allegation reported to Social Worker Assistant .Investigation of allegation of abuse of (Resident #1) revealed in talking to the siter (sic) that the son (Family Member E) was in the resident's room yelling and cursing at his mother. She also alleges that when he was taking her out of the room to come to talk to management about her money he hit the residents (sic) foot on the bed and wall.2/29/16 Resident was assessed by nurse and there were no areas of discoloration to BLE (Bilateral lower extremities). Social Worker went to talk to resident that the resident does not remember the incident. Called to son and informed him that he no (sic) to return to the facility until the investigation has been completed. Verbal acknowledgement given. There was no documentation to show an assessment in the clinical record, an incident report, interviews with residents or staff, or any action taken prior to 2/29/16 related to the allegations of potential verbal abuse of Resident #1. During an interview on 3/2/16 at 2:12 p.m. with RN C he said he was the Unit Manager for Resident #1's hall. He said he was not aware of any resident on his hall who had a visitation restriction including Resident #1. RN C he would have been informed if a resident on his hall had a visitation restricion. He said he would have been informed, it would have been documented in the 24 hour report, and it would have been brought up in the morning meeting. The interview continued on 3/2/16 at 2:30 p.m. with RN C. RN C said as a nurse if a family member were being verbally abusive he would go in the room, stay with the resident and call the police. He said he would notify the doctor, assess the resident, and notify the family. He said he would then complete an incident report. He said he would report an incident of abuse to the State if the Abuse Prevention Coordinator or Administrator did not act. He said Visitor A had not expressed any concerns to him regarding Resident #1. He had the 24 hour report with him. He said no one had reported any concerns of abuse to him regarding residents on his hall. Record review of the 24 hour report from 2/16/16 through 2/29/16 revealed no documentation related to any incidents concerning Resident #1 or measures taken to protect her. During a telephone interview on 3/2/16 at 2:57 p.m. with LVN C she said on 2/26/16 she was walking down the hall when she heard loud screaming/yelling. She said Resident #1's sitter, Visitor A, mouthed the words call the police to her. She said she went to the Administrator and reported the incident. She said she heard Family Member E call Family Member F a ho, and that he could not wait for her to die. She said she heard it but did not know if he was referring to Family Member F or Resident #1. She said Family Member E was not restricted from visiting Resident #1. She said after the incident Resident #1 was, .crying really hard. She said Resident #1 actually coded on me, about 30 minutes after the incident. She said Visitor A was with Resident #1 screaming the resident's name. She said RN C put the resident in bed while she and another nurse got the crash cart. She said the resident had low blood sugar, a systolic blood pressure in the 90's and diastolic blood pressure in the 50's, around 55-59. She said she was told to write on incident report. She said she did not remember who told her to write the incident report. LVN C said she failed to write the incident report. She said she reported the incident verbally to the Administrator and he did not say anything else to her about the incident. During an interview on 3/2/16 at 3:41 p.m. with the Social Worker she said incidents should be reported to the Administrator. She said when she told the Administrator on 2/29/16 about the incident, he told her he was going to have to tell Family Member E that he could not come to the building until the matter was resolved. She said she was not aware of the 02/16/2016 incident. She said the Administrator would inform staff if a resident has a visitation restricion. During an interview on 3/2/16 at 3:47 p.m. with the Area Director of Operations she said allegations of verbal abuse should be investigated and reported immediately to the State. She said staff members should report allegations of abuse to the Administrator. During an interview on 3/2/16 at 4:11 p.m. with Family Member E, who was in the building, he said the Administrator left him a voice message yesterday, 3/1/16, telling him he could not return. to the facility. He said he met with the Administrator on 03/02/2016 and was told that Visitor A had reported him as being loud. He said the Administrator did not provide any other details. He said he did talk loud. He said Resident #1 thought she should get her own check every month. He said he explained to Resident #1 that the facility would be receiving her check. He said he pays a sitter out of his own pocket to stay with Resident #1. He said the facility staff had not spokent to him prior to 03/01/2016. He said he had not had any arguments with Resident # 1. He said he had to call the police one time due to he found Resident #1 naked in bed and soaked with urine. He said a lady from Adult Protective Services called him and told him if he took his mother out of the nursing home, he would be arrested. He said he speaks loud and his voice travels He said he pays Visitor A $450 a week to come sit with Resident #1 from 8:00 a.m. to 1:00 p.m. 4 to 5 days a week. He said yesterday, 3/1/16 between 12:00 p.m. and 1:00 p.m. he received a voice mail saying he could not come visit. During an interview on 3/3/16 at 11:23 a.m. with the Administrator he said LVN B/Unit Manager wrote the nurse's note on 2/16/16. He said last Friday, 2/27/16, she had been given the day off to give her time to understand the seriousness of her performance issues. He said she was to be given a 30 day performance improvement plan on 03/02/2016. He said he had a meeting with the DON and ADON and LVN B/Unit Manager on 2/26/16 during which LVN B/Unit Manager became heated. He said he had not received any complaints from staff related to Family Member E being inappropriate with staff. He said Family Member E wanted Resident #1 to go home. He said that Family Member E hired two new sitters to replace Visitor A. During a telephone interview on 3/3/16 at 11:56 a.m. with LVN C she said she had been thinking and said there had been an additional incident related to Resident #1 on 2/15/16 or 2/16/16. She said she did not make a written statement at that time but that she had reported it to LVN B/Unit Manager. She said LVN B/Unit Manager told her she would write a report on it and report it to either the Social Worker or the Administrator. She said Visitor A reported to her that Family Member E was in Resident #1's room yelling at Resident #1 about Family Member F and going home. She said she did not hear Family Member E yell at Resident #1 on 02/16/2016. She said then she reported the incident to the Administrator. She said 2/16/16 and 2/26/16 were the only two incidents that she was aware of. During an interview on 3/3/16 at 12:29 with the sitter, Visitor A, she now said she had never reported anything to staff. She said the two nurses who had witnessed anything were gone. She now said she would not get involved. During an interview on 3/3/16 at 12:44 p.m. with RN C he said no staff member had reported an incident on 02/16/2016 or 02/26/2016 to him concerning Resident #1. He said he had not witnessed anyone yelling at Resident #1. During an interview on 3/3/16 at 2:00 p.m. with the Director of Clinical Operations he said the Regional Director of Clinical Services reviewed Resident #1's chart on 2/24/16. He said he asked the Regional Director of Clinical Services if he had seen the nurse's note dated 2/16/16 when he reviewed the chart and that he told him he did not. He said (name withheld) called the corporate office and they investigated. He said the Regional Director of Clinical Services did the investigation. He said corporate office received an anonymous call on 2/22/16 that Resident #1's family member was yelling at someone in Resident #1's room. He said they investigated and found it was Family Member E yelling at Visitor A. He said Resident #1 said she felt safe. He said Visitor A confirmed that it was her being yelled at and not Resident #1. He said they did their investigation on 2/24/16. During an interview on 3/3/16 at 3:32 p.m. with the DON said he held an all staff meeting on 02/29/2016 and all staff were inserviced on abuse and neglect. He said he was not able to recall the most recent in service on abuse and neglect prior to 02/29/2016. He said the incident on 02/26/2016 concerning Resident #1 was not reported to the Administrator. He said the facility staff have a lack of communication. He said he thinks the Corporate Office did not report the concern called in about abuse and neglect as it was a concern. During an interview on 3/3/16 at 3:53 p.m. with the Administrator he said he did not think the facility failed although an immediate jeopardy/substandard quality of care issue was identified by the surveyor. He said he was not aware of the incidents. He then said again he did not believe there was a failure. He did not respond when asked what the facility had done to protect Resident #1 during the investigation. He said he did not call Family Member E on 3/1/16 but that it was on 2/29/16. During an interview on 3/3/16 at 4:13 p.m. with the Social Worker she said corporate office did not involve her during their investigation on 2/24/16. She said she told the Regional Director of Clinical Services that she did not hear Resident #1's son yelling at Resident #1. During an interview on 3/3/16 at 4:20 p.m. with the Regional Director of Clinical Services he said a complaint was called in to corporate office on 2/24/16. He said he told the Administrator he was investigating an anonymous complaint to corporate. He said the Administrator told him he already knew which patient it was and named Resident #1. He said corporate usually comes out immediately. He said he and the Area Director of Operations had been notified. He said the Area Director of Operations may have told the Administrator the reason for the visit. He said after speaking with the Administrator he felt Resident #1 was not abused by her son. He said the Administrator informed him that Family Member E yelled at Visitor A not Resident #1. He said he did not interview Family Member E, Visitor A, or Resident #1. During an interview on 3/3/16 at 4:35 p.m. with the Area Director of Operations she said she was not there for the 2/24/16 investigation. She said that investigation was done by the Regional Director of Clinical Services. She said a verbal altercation between a family member and a sitter might be considered abuse. She said she interviewed Resident #1 on 03/02/2016. She said Resident #1 told her family member does not abuse her, yell at her and would never hurt her. She said the Social Worker called her on 2/29/16 and told her about the incident but no one seemed to know about the 2/16/16 incident. She said she told the Social Worker to begin the investigation and report it on the 29th. During an interview on 3/3/16 at 4:56 p.m. with the Director of Clinical Operations he said he felt the allegation of abuse toward Resident #1 which was called in on 02/22/2016 was a concern and not abuse. He said he disagreed that a concern of yelling is an allegation of abuse. He said the facility began an investigation into the concern within 48 hours. He said the word yelling was used, nor abuse, neglect, or mistreatment. He said a caller must use those words in order for it to be considered abuse/neglect. He said a concern is not an allegation. He said that he could provide something in writing from their legal council. Record review of the facility's Abuse Protocol dated June 2013 revealed, .1. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation of Patient property (collectively 'Patient Abuse') by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient, family members, legal guardians, sponsors, friends, or other individuals. .3. The Executive Director, and in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator. .7. Any person observing an incident of Patient Abuse or suspecting Patient Abuse must immediately report such incidents to the Charge Nurse. 9. The Abuse Prevention Coordinator will: a. Immediately (within 24 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance An IJ was identified on 3/2/16 at 5:34 p.m. and the Administrator, DON, and Area Director of Operations were notified at that time. A Plan of Removal (PoR) for the IJ was submitted on 3/2/16 and after revisions was accepted on 3/4/16 at 08:13 pm. The PoR included: .Immediate Jeopardy Plan of Removal March 2, 2016 . The following corrective items have been taken for (Resident #1): 1. The facility started an immediate and thorough investigation on 3/2/16 at 5:34 P.M. The resident was interviewed by (name), Area Director of Operations on 3/2/16 at 7:30 P.M. a. The resident does not have a roommate. b. (Social Worker) interviewed the sitter on 3/4/16 at 11:20 A.M (The sitter was previously interviewed and refused to write a statement). c. Alert and oriented residents were interviewed by Social Worker on 3/2/16 at 7:00 P.M. No further allegations were identified. d. Staff interviewed during the investigation were: .(listed names and job titles) . 2. Facility Staff involved in the investigation: .(listed names and job titles) . 3. To protect the resident, on 3/2/16 at 6:30 P.M. the facility placed an additional C.N.A. on the hall to increase monitoring where the resident resided. On 3/2/16 at 6:00 P.M. the residents son, (Family Member E) was again informed that he could not visit his mother secondary to an allegation of abuse, and any visit that did occur needed to be in a supervised area within the facility. The resident was adamant that her son never abused her. A psychosocial wellbeing assessment was completed by (Social Worker)-Social Worker 3/2/16 at 8:00 P.M. Dr. (doctor) A from the psych service is seeing (Resident #1) on 3/4/16 at 7:30 A.M 4. Attending physician was notified on 3/2/16 at 6:05 P.M. by (name) Area Director of Operations. 5. (name) Area Director of Operations interviewed (Resident #1) on 3/2/16 at 7:30 P.M. (Resident #1) denied the allegation that she was abused. 6. (Name and title) Area Director of Operations in-serviced the facility Executive Director (Administrator) on 3/2/16 at 6:05 P.M. on the facility abuse policy and a post test was be (sic) conducted. The in-service included the designation of the Executive Director as the Abuse Prevention Coordinator, the Abuse Coordinator is responsible for ensuring that all staff are in-serviced on recognizing abuse, abuse prevention and abuse reporting. 24 repot (sic) of abuse must be made to TDADS (Texas Department of Aging and Disability Services) and other appropriate authorities on incidents or allegations of abuse. 7. (name) R. N., (Registered Nurse) D.O.N. along with (Social Worker) the Social Worker and (ADON) , Regional Director of Clinical Services began inservice to all facility staff on the facility Abuse Policy on 3/2/16 at 6:05 P.M. The inservice consisted of the facility Abuse Coordinator, types of abuse, reporting of abuse, what to do if you suspect or witness any type of abuse. A subsequent post test to determine retention of this knowledge was administered. Any employee who is not inserviced will not be allowed to return to work until such a time as the inservice on Abuse, Mistreatment and Neglect is conducted and the post test is administered and passed. Employees will not be allowed to return to work until such a time as they can demonstrate competency in the Abuse Protocol by passing the post test. Inservices were completed on all shifts. Employees were advised that if they felt the abuse coordinator did not commence action on their concern that they were to reach out to their Regional Team or to call the Company Compliance hotline which goes directly to the Corporate Office. Monitoring: Record review of staff in-services revealed a staff in-service was conducted on 3/2/16 over the abuse prohibition policy and procedure. During an interview on 3/4/16 at 3:22 p.m. with the Administrator he said he had been in-serviced on abuse/neglect. He said the findings related to Resident #1 had been unsubstantiated. He said he had not informed Family Member E that he could return to the building. He said they planned to allow Family Member E to return to the facility and visit Resident #1 under supervision at first. Record review of documentation revealed the Administrator had been in-serviced on the facility's abuse protocol on 3/2/16. On 03/04/2016 7 CNAs said they had received in service on abuse and neglect. They responded that they would report abuse and neglect to the Abuse Coordinator/Administrator. They responded that if a resident was observed being abused they would protect the resident by removing the resident from the abusive situation. They responded that if action was not taken by the facility on abuse or neglect they would report it to the State. During an interview on 3/4/16 at 4:00 p.m. with RN E she said she was last in-serviced on abuse/neglect on 3/4/16. She said she would report abuse or neglect to the Administrator. She said she would protect the resident during the investigation. She said she would immediately report abuse to the Administrator and do an incident report. She said she would call the State if not action on abuse was taken. During an interview on 3/4/16 at 4:09 p.m. with the Data Entry Clerk she said she received the in-service on abuse/neglect on Monday. She said she would remove a resident to safety and then report to the Administrator. She gave examples of reportable incidents. She said she would write out a statement. She said if no action was taken she would call the State. During an interview on 3/4/16 at 4:40 p.m. with LVN I she said she was in-serviced on abuse/neglect on 3/4/16. She said a resident should be removed from an abusive situation. She said abuse should be reported immediately to the Administrator. She said she would report any type of verbal abuse or misappropriation as examples. She said she would complete an incident report and make a nurse's note. She said she would report to the State if no action was taken within the facility. During an interview on 3/4/16 at 4:45 p.m. with the Director of Clinical Operations he said all staff not yet in-serviced will be required to have the in-service and pass a test prior to working. During an interview on 3/4/16 at 5:41 p.m. with the DON said staff would have to have abuse/neglect training prior to returning back to work in the facility. During an interview on 3/4/16 at 7:00 p.m. with the Administrator when asked what he would do if someone brought a concern to him of abuse or neglect he said make sure the resident is safe and start a preliminary investigation. He said he would report it and do a thorough investigation. When asked for examples of what he would report he said a fracture of unknown origin and any type of abuse allegations. He said as part of the monitoring he interviewed many residents. He said abuse must be reported immediately to the State. Record review of facility training records documented an in-service on abuse/neglect on 3/2/16 with a post-test completed by participants. Record review of documentation provided by the facility revealed documentation of a psychosocial well-being assessment being completed for Resident #1 on 3/2/16. Record review of the Mental & Behavioral Health Visit Note dated 3/4/16 revealed an assessment of Resident #1 had been completed for .crisis intervention after altercation w/ (with) family member. Record review of the facility's evidence to support their plan revealed documentation of interviews with staff and residents with no concerns. The Administrator, DON, and Area Director of Operations were informed on 3/4/16 at 8:13 p.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. CMS Form 802 detailed that 15 residents resided on the 500 hallway.

Based on observation, interview and record review for 1 of 11 residents (#1) reviewed for abuse/neglect protocol failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents in that: --On 2/16/16 and 2/26/16 allegations were made of verbal abuse toward Resident #1 that were not immediately investigated. --On 2/22/16 Corporate Office received a concern through their Compliance Line of Resident #1 potentially being verbally abused. An Immediate Jeopardy (IJ) was identified on 3/2/16 at 05:34 pm. While the IJ was lowered on 3/4/16 at 08:13 pm, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. This failure affected 1 resident and placed an additional 126 residents at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization . Intake # 4 Findings Include: Record review of the facility's Abuse Protocol dated June 2013 revealed, .1. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation of Patient property (collectively 'Patient Abuse') by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient, family members, legal guardians, sponsors, friends, or other individuals. .3. The Executive Director, and in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator. .7. Any person observing an incident of Patient Abuse or suspecting Patient Abuse must immediately report such incidents to the Charge Nurse. 9. The Abuse Prevention Coordinator will: a. Immediately (within 24 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance Record review of complaint intake # 4 revealed an allegation that a visitor was in the facility on 2/21/16 when they observed a visitor in Resident #1's room and that person was overheard yelling at Resident #1. The alleged perpetrator was allegedly heard saying shut up several times and was loud. The intake alleged staff appeared fearful of the person yelling. Record review of Resident #1's admission sheet revealed she was a [AGE] year old who was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she was assessed as usually being understood and usually understanding. She was assessed as having moderately impaired cognitive skills for daily decision making-decisions poor; cues/supervision required. She had no behaviors. Record review of Resident #1's Nurse's Note dated 2/16/16 and timed 5:00 p.m. revealed, .Floor nurse reported that resident's Family Member E was in the room yelling at Resident #1. Upon going to the room to investigate further, the sitter was noted coming out of the room. IM (sic) going to call the police on his crazy (explicit word), in there talking to that lady like she is a child. When entered the room, the resident was in bed and Family Member E was sitting in a chair in front of the bed. No yelling noted or heard. No distress apparent from resident. Reported concerns to Executive Director (Abuse Coordinator). Record review of Resident #1's Nurse's Note, which appeared to be dated 2/26/16, changed to 2/16/16, then back to 2/26/16 with no time revealed, .While in hallway I heard a boom ( two lined out letters) and yelling coming from room Resident #1's room I walked in as family member, sitter and patient was walking out, Sitter mouthed to call police, I walked to the front to explain to the executive director what was going on, by then the son and sitter was walking to the the front to speak with the executive director nurse also heard son say to mother Family Member F is a (expletive), you cant (sic) come home anymore, I cant (sic) wait til you die (sic) Sitter stated Family Member E dont (sic) say that (sic) . Record review of Resident #1's Social Service Progress Note dated 2/28/16 revealed, .SW (Social Work) assistant came and informed SW that resident's sitter had some concerns with the way resident's family member had been treating her. SW spoke with the sitter and the sitter stated that on Fri [DATE]th the resident's family member came into resident's room and was screaming and shouting at the resident. Sitter stated that the family member cursing at her and screaming about the facility taking her check. Sitter then said the family member told the resident 'I can't wait for you to die' (sic) Sitter stated that the family member then yanked the resident's wheelchair and pushed the bedside table over onto resident's foot. Sitter stated that the resident began to cry and was very upset. Sitter stated that she herself is afraid of the family member. SW asked resident about that day and she said she really couldn't remember. That the only thing she remembers is some man standing over her. SW asked resident was she afraid of her family member and resident stated'NO'. She stated that he yells and screams sometimes but she doesn't pay him any attention. SW informed the abuse coordinator/ED (sic) . The identification of who sitter and family member were was not documented. Observation on 3/2/16 at 10:34 a.m. of Resident #1 revealed she was not in her room. Visitor A was seated in Resident #1's room. During an interview and observation on 3/2/16 at 10:34 a.m. with Visitor A she said Resident #1 was in therapy. She said the resident had been in the facility for approximately 6 months. She said she was the resident's sitter and she was in the building Monday through Friday from 8:00 a.m. till 1:00 p.m. She said Resident #1's family member was abusive, but did not elaborate. Resident #1 was brought into the room by therapy. Resident #1 was groomed and without odor. She did not appear fearful. During an interview on 3/2/16 at 10:42 a.m. with Resident #1 she said she was, good, and that things were so far so good. She said she was getting everything she needed. She said no person had raised their voice when speaking to her. She said she was allowed to have visitors whenever she wanted. When asked if she felt safe she said, So far I do. During an interview on 3/2/16 at 12:05 p.m. with the Administrator he said Adult Protective Services had been called, due to family dynamics with Resident #1's family. He said Resident #1's daughter had Medical Power of Attorney. He said Resident #1 had not been adjudicated incompetent. He said Family Member E had been trying to use Resident #1's Medicaid check to make improvements to Resident #1's house and was trying to get her back into her home. He said Family Member E had been banned from coming to visit the resident for right now. He said the sitter (Visitor A) was inconsistent with her story of what happened on 2/26/16. He said Visitor A had refused to give a written statement of the events on 02/26/16. He said the facility had called in a self report. As of the date of exit, one sheet of paper was provided and an in-service on abuse neglect dated 2/29/16. No self report number was provided by the Administrator for the incidents documented on 2/16/16 or 2/26/16 until 3/2/16. During an interview on 3/2/16 at 12:46 p.m. with the Administrator when asked about Resident #1's Nurse's Notes dated 2/16/16 and 2/26/16 he said no information was reported to him related to those incidents. He said he did not know about any of the information about Resident #1 until yesterday (3/1/16). Then he said the Social Worker had told him about it when it was reported to her (2/29/16). Record review of the State data base on 3/2/16 at 1:36 p.m. revealed there was no documentation of a self-report on the incident on 2/16/16 or 2/26/16. During an interview on 3/2/16 at 1:37 p.m. with the Social Worker she said the date on her note was an error. She said she had received the information on 2/29/16, not on 2/28/16. She said 2/28/16 was a Sunday and she was not at work. She said the Social Worker Assistant came to her and told her about the concern related to Resident #1. She said she interviewed the sitter and was told that on the previous Friday (2/26/16) Family Member E yelled and cursed at Resident #1 and knocked over an overbed table onto Resident #1's foot. She said the sitter did not know which foot but did not feel it was on purpose. She said the sitter would not provide a written statement. She said she was not aware of another incident on 2/16/16. She said LVN B/Unit Manager wrote the Nurse's Note dated 02/26/2016. During an interview on 3/2/16 at 1:40 p.m. with LVN B/Unit Manager she said she wrote the Nurse's Note dated 02/16/2016 concerning Resident #1. She said LVN C reported the incident to her on 2/16/16 but she did not witness the incident herself. She said LVN C went to Resident #1's room and Family Member E was sitting at the foot of the bed. She said Resident #1 appeared to have been crying. She said Resident #1 indicated that she was ok by nodding in the affirmative. She said Family Member E stood up and told her they were just talking. She said Family Member E gets aggressive with staff, makes staff uncomfortable, makes inappropriate comments to staff, including her and used to make passes at her. She said Resident # 1 was left alone in her room with Family Member E. She said the sitter, Visitor A, left the room to see LVN C and was threatening to call the police. She said she went to the Administrator and reported the incident. She said the Administrator told her Family Member E can speak to his mother as he wishes. She said the receptionist then came in and told the Administrator that Family Member E wanted to talk to him. She said Family Member E left the building after that. She said the Administrator took no action. She said she spoke to LVN C who said Family Member E was always loud but this time it was different. She said LVN C told her Family Member E had said I can not wait till you die. She said Family Member E did not have any visiting restrictions with Resident #1. During an interview on 3/2/16 at 2:06 p.m. with the Administrator he said he had called in the 2/16/16 incident that day, 3/2/16. He said he had combined the 2/16/16 and 2/26/16 incidents into one self-report. He said he had one piece of paper for the incidents dated 03/01/2016. Record review of the .Investigation of Allegation (Resident #1) 3/1/16, provided by the Administrator, revealed, .2/29/16 Allegation reported to Social Worker Assistant .Investigation of allegation of abuse of (Resident #1) revealed in talking to the siter (sic) that the son (Family Member E) was in the resident's room yelling and cursing at his mother. She also alleges that when he was taking her out of the room to come to talk to management about her money he hit the residents (sic) foot on the bed and wall.2/29/16 Resident was assessed by nurse and there were no areas of discoloration to BLE (Bilateral lower extremities). Social Worker went to talk to resident that the resident does not remember the incident. Called to family member and informed him that he no (sic) to return to the facility until the investigation has been completed. Verbal acknowledgement given. There was no documentation to show an assessment in the clinical record, an incident report, interviews with residents or staff, or any action taken prior to 2/29/16 related to the allegations of potential verbal abuse of Resident #1. During an interview on 3/2/16 at 2:12 p.m. with RN C he said he was the Unit Manager for Resident #1's hall. He said he was not aware of any resident on his hall who had a visitation restriction including Resident #1. He said he would have been informed, it would have been documented in the 24 hour report, and it would have been brought up in the morning meeting. The interview continued on 3/2/16 at 2:30 p.m. with RN C. RN C said if a family member were being verbally abusive he would go in the room, stay with the resident and call the police. He said he would notify the doctor, assess the resident, and notify the family. He said he would then complete an incident report. He said he would report an incident of abuse to the State if the Abuse Prevention Coordinator or Administrator did not act. He said Visitor A had not expressed any concerns to him regarding Resident #1. He had the 24 hour report with him. He said no one had reported any concerns of abuse to him regarding residents on his hall. Record review of the 24 hour report from 2/16/16 through 2/29/16 revealed no documentation related to any incidents concerning Resident #1 or measures taken to protect her. During a telephone interview on 3/2/16 at 2:57 p.m. with LVN C she said on 2/26/16 she was walking down the hall when she heard loud screaming/yelling. She said Resident #1's sitter, Visitor A, mouthed the words call the police to her. LVN C said she reported the incident to the Administrator. She said she heard Family Member E call Family Member F a ho, and that he could not wait for her to die. LVN C said she heard it but did not know if he was referring to Family Member F or Resident #1. She said Family Member E was not restricted from visiting Resident #1. She said after the incident Resident #1 was crying. She said Resident # coded on me about 30 minutes after the incident. She said Visitor A was with Resident #1 screaming the resident's name. She said RN C put the resident in bed while she and another nurse got the crash cart. She said the resident had low blood sugar, a systolic blood pressure in the 90's and diastolic blood pressure in the 50's, around 55-59. She said she did not remember who told her to write the incident report. LVN C said she failed to write the incident report. She said she reported the incident verbally to the Administrator and he did not say anything else to her about the incident. During an interview on 3/2/16 at 3:41 p.m. with the Social Worker she said incidents should be reported to the Administrator. She said when she told the Administrator on 2/29/16 about the incident, he told her he was going to have to tell Family Member E that he could not come to the building until the matter was resolved. She said she was not aware of the 02/16/2016 incident. She said the Administrator would inform staff if a resident has a visitation restriction. During an interview on 3/2/16 at 3:47 p.m. with the Area Director of Operations she said allegations of verbal abuse should be investigated and reported immediately to the State. She said staff members should report allegations of abuse to the Administrator. During an interview on 3/2/16 at 4:11 p.m. with Family Member E, who was in the building, he said the Administrator left him a voice message yesterday, 3/1/16, telling him he could not return. to the facility. He said he met with the Administrator on 03/02/2016 and was told that Visitor A had reported him as being loud. He said the Administrator did not provide other details. He said he did talk loud. He said Resident #1 thought she should get her own check every month. He said he explained to Resident #1 that the facility would be receiving her check. He said he pays a sitter out of his own pocket to stay with Resident #1. He said the facility staff had not spoken to him prior to 03/01/2016. He said he had not had any arguments with Resident # 1. He said he had to call the police one time due to he found Resident #1 naked in bed and soaked with urine. He said he speaks loud and his voice travels. He said yesterday, 3/1/16 between 12:00 p.m. and 1:00 p.m. he received a voice mail saying he could not come visit. During an interview on 3/3/16 at 11:23 a.m. with the Administrator he said LVN B/Unit Manager wrote the nurse's note on 2/16/16. He said last Friday, 2/27/16, she had been given the day off to give her time to understand the seriousness of her performance issues. He said she was to be given a 30 day performance improvement plan on 03/02/2016. He said he had a meeting with the DON and ADON and LVN B/Unit Manager on 2/26/16 during which LVN B/Unit Manager became heated. He said he had not received any complaints from staff related to Family Member E being inappropriate with staff. He said Family Member E wanted Resident #1 to go home. He said that Family Member E hired two new sitters to replace Visitor A. During a telephone interview on 3/3/16 at 11:56 a.m. with LVN C she said she had been thinking and said there had been an additional incident related to Resident #1 on 2/15/16 or 2/16/16. She said she did not make a written statement at that time but that she had reported it to LVN B/Unit Manager. She said LVN B/Unit Manager told her she would write a report on it and report it to either the Social Worker or the Administrator. She said Visitor A reported to her that Family Member E was in Resident #1's room yelling at Resident #1 about Family Member F and going home. She said she did not hear Family Member E yell at Resident #1 on 02/16/2016. She said on 2/26/16, RN C stopped her and she told him about the 2/26/16 incident. She said 2/16/16 and 2/26/16 were the only two incidents that she was aware of. During an interview on 3/3/16 at 12:29 with the sitter, Visitor A, she now said she had never reported anything to staff. She said the two nurses who had witnessed anything were gone. She now said she would not get involved. During an interview on 3/3/16 at 12:44 p.m. with RN C he said no staff member had reported an incident to him concerning Resident #1. He said he had not witnessed anyone yelling at Resident #1. During an interview on 3/3/16 at 2:00 p.m. with the Director of Clinical Operations he said the Regional Director of Clinical Services reviewed Resident #1's chart on 2/24/16. He said he asked the Regional Director of Clinical Services if he had seen the nurse's note dated 2/16/16 when he reviewed the chart and that he told him he did not. He said (name withheld) called the corporate office and they investigated. He said the Regional Director of Clinical Services did the investigation. He said corporate office received an anonymous call on 2/22/16 that Resident #1's family member was yelling at someone in room Resident #1's room. He said they investigated and found it was Family Member E yelling at Visitor A. He said Resident #1 said she felt safe. He said Visitor A confirmed that it was her being yelled at and not Resident #1. He said they did their investigation on 2/24/16, (two days after receiving the concern). During an interview on 3/3/16 at 3:32 p.m. with the DON said he held an all staff meeting on 02/29/2016 and all staff were inserviced on abuse and neglect. He said he was not able to recall the most recent in service on abuse and neglect prior to 02/29/2016. He said the incident on 02/26/2016 concerning Resident #1 was not reported to the Administrator. He said the facility staff have a lack of communication. He said he thinks the Corporate Office did not report the concern called in about abuse and neglect. During an interview on 3/3/16 at 3:53 p.m. with the Administrator he said he did not think the facility failed although an immediate jeopardy/substandard quality of care issue was identified by the surveyor. He said he was not aware of the incidents. He then said again he did not believe there was a failure. He did not respond when asked what the facility had done to protect Resident #1 during the investigation. He then said he did not call Family Member E on 3/1/16 but that it was on 2/29/16. During an interview on 3/3/16 at 4:13 p.m. with the Social Worker she said corporate office did not involve her during their investigation on 2/24/16. She said she told the Regional Director of Clinical Services that she did not hear Resident #1's son yelling at Resident #1. During an interview on 3/3/16 at 4:20 p.m. with the Regional Director of Clinical Services he said a complaint was called in to corporate office on 2/24/16. He said he told the Administrator he was investigating an anonymous complaint. He said the Administrator told him he already knew which patient it was and named Resident #1. He said corporate usually comes out immediately. He said he and the Area Director of Operations had been notified. He said the Area Director of Operations may have told the Administrator the reason for the visit. He said after speaking with the Administrator he felt Resident #1 was not abused by her family member. He said the Administrator informed him that Family Member E yelled at Visitor A not Resident #1. He said he did not interview Family Member E, Visitor A, or Resident #1. During an interview on 3/3/16 at 4:35 p.m. with the Area Director of Operations she said she was not there for the 2/24/16 investigation. She said that investigation was done by the Regional Director of Clinical Services. She said a verbal altercation between a family member and a sitter might be considered abuse. She said she interviewed Resident #1 during the evening on 03/02/2016 and that Resident #1 told her the family member does not abuse her, yell at her and would never hurt her. She said the Social Worker called her on 2/29/16 and told her about the incident but no one seemed to know about the 2/16/16 incident. She said she told the Social Worker to begin the investigation and report it on the 29th. During an interview on 3/3/16 at 4:56 p.m. with the Director of Clinical Operations he said he felt the allegation of abuse toward Resident #1 which was called in on 02/22/2016 was a concern and not abuse. He said he disagreed that a concern of yelling is an allegation of abuse. He said the facility began an investigation into the concern within 48 hours. He said the word yelling was used, not abuse, neglect, or mistreatment. He said a caller must use those words in order for it to be considered abuse/neglect. He said a concern is not an allegation. He said that he could provide something in writing from legal council. A Plan of Removal (PoR) for the IJ was submitted on 3/2/16 and after revisions was accepted on 3/4/16 at 08:13 pm. The PoR included: .Immediate Jeopardy Plan of Removal March 2, 2016 . The following corrective items have been taken for (Resident #1): 1. The facility started an immediate and thorough investigation on 3/2/16 at 5:34 P.M. The resident was interviewed by (name), Area Director of Operations on 3/2/16 at 7:30 P.M. a. The resident does not have a roommate. b. (Social Worker) interviewed the sitter on 3/4/16 at 11:20 A.M (The sitter was previously interviewed and refused to write a statement). c. Alert and oriented residents were interviewed by Social Worker on 3/2/16 at 7:00 P.M. No further allegations were identified. d. Staff interviewed during the investigation were: .(listed names and job titles) . 2. Facility Staff involved in the investigation: .(listed names and job titles) . 3. To protect the resident, on 3/2/16 at 6:30 P.M. the facility placed an additional C.N.A. on the hall to increase monitoring where the resident resided. On 3/2/16 at 6:00 P.M. the residents son, (Family Member E) was again informed that he could not visit his mother secondary to an allegation of abuse, and any visit that did occur needed to be in a supervised area within the facility. The resident was adamant that her son never abused her. A psychosocial wellbeing assessment was completed by (Social Worker)-Social Worker 3/2/16 at 8:00 P.M. Dr. (doctor) A from the psych service is seeing (Resident #1) on 3/4/16 at 7:30 A.M 4. Attending physician was notified on 3/2/16 at 6:05 P.M. by (name) Area Director of Operations. 5. (name) Area Director of Operations interviewed (Resident #1) on 3/2/16 at 7:30 P.M. (Resident #1) denied the allegation that she was abused. 6. (Name and title) Area Director of Operations in-serviced the facility Executive Director (Administrator) on 3/2/16 at 6:05 P.M. on the facility abuse policy and a post test was be (sic) conducted. The in-service included the designation of the Executive Director as the Abuse Prevention Coordinator, the Abuse Coordinator is responsible for ensuring that all staff are in-serviced on recognizing abuse, abuse prevention and abuse reporting. 24 repot (sic) of abuse must be made to TDADS (Texas Department of Aging and Disability Services) and other appropriate authorities on incidents or allegations of abuse. 7. (name) R. N., (Registered Nurse) D.O.N. along with (Social Worker) the Social Worker and (ADON) , Regional Director of Clinical Services began inservice to all facility staff on the facility Abuse Policy on 3/2/16 at 6:05 P.M. The inservice consisted of the facility Abuse Coordinator, types of abuse, reporting of abuse, what to do if you suspect or witness any type of abuse. A subsequent post test to determine retention of this knowledge was administered. Any employee who is not inserviced will not be allowed to return to work until such a time as the inservice on Abuse, Mistreatment and Neglect is conducted and the post test is administered and passed. Employees will not be allowed to return to work until such a time as they can demonstrate competency in the Abuse Protocol by passing the post test. Inservices were completed on all shifts. Employees were advised that if they felt the abuse coordinator did not commence action on their concern that they were to reach out to their Regional Team or to call the Company Compliance hotline which goes directly to the Corporate Office. Monitoring: Record review of staff in-services revealed a staff in-service was conducted on 3/2/16 over the abuse prohibition policy and procedure. During an interview on 3/4/16 at 3:22 p.m. with the Administrator he said he had been in-serviced on abuse/neglect. He said the findings related to Resident #1 had been unsubstantiated. He said he had not informed Family Member E that he could return to the building. He said they planned to allow Family Member E to return to the facility and visit Resident #1 under supervision at first. Record review of documentation revealed the Administrator had been in-serviced on the facility's abuse protocol on 3/2/16. On 03/04/2016 7 CNAs said they had received in service on abuse and neglect. They responded that they would report abuse and neglect to the Abuse Coordinator/Administrator. They responded that if a resident was observed being abused they would protect the resident by removing the resident from the abusive situation. They responded that if action was not taken by the facility on abuse or neglect they would report the abuse to the State. During an interview on 3/4/16 at 4:00 p.m. with RN E she said she was last in-serviced on abuse/neglect on 3/4/16. She said she would report abuse or neglect to the Administrator. She said she would protect the resident during the investigation. She said she would immediately report abuse to the Administrator and do an incident report. She said she would call the State if not action on abuse was taken. During an interview on 3/4/16 at 4:09 p.m. with the Data Entry Clerk she said she received the in-service on abuse/neglect on Monday. She said she would remove a resident to safety and then report to the Administrator. She gave examples of reportable incidents. She said she would write out a statement. She said if no action was taken she would call the State. During an interview on 3/4/16 at 4:40 p.m. with LVN I she said she was in-serviced on abuse/neglect on 3/4/16. She said a resident should be removed from an abusive situation. She said abuse should be reported immediately to the Administrator. She said she would report any type of verbal abuse or misappropriation as examples. She said she would complete an incident report and make a nurse's note. She said she would report to the State if no action was taken within the facility. During an interview on 3/4/16 at 4:45 p.m. with the Director of Clinical Operations he said all staff not yet in-serviced will be required to have the in-service and pass a test prior to working. During an interview on 3/4/16 at 5:41 p.m. with the DON said staff would have to have abuse/neglect training prior to returning back to work in the facility. During an interview on 3/4/16 at 7:00 p.m. with the Administrator when asked what he would do if someone brought a concern to him of abuse or neglect he said make sure the resident is safe and start a preliminary investigation. He said he would report it and do a thorough investigation. When asked for examples of what he would report he said a fracture of unknown origin and any type of abuse allegations. He said as part of the monitoring he interviewed many residents. He said abuse must be reported immediately to the State. Record review of facility training records documented an in-service on abuse/neglect on 3/2/16 with a post-test completed by participants. Record review of documentation provided by the facility revealed documentation of a psychosocial well-being assessment being completed for Resident #1 on 3/2/16. Record review of the Mental & Behavioral Health Visit Note dated 3/4/16 revealed an assessment of Resident #1 had been completed for .crisis intervention after altercation w/ (with) family member. Record review of the facility's evidence to support their plan revealed documentation of interviews with staff and residents with no concerns. The Administrator, DON, and Area Director of Operations were informed on 3/4/16 at 8:13 p.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. The resident room roster revealed a census of 127.

Based on observations, interviews and record reviews the facility failed to implement their written policy and procedures that prohibit mistreatment and neglect and abuse for 4 of 20 residents (Residents #4 )reviewed for incident and accidents and care. This was evidenced by: Resident #4 had 13 falls from January 2015 to May 2015 without effective interventions or supervision to prevent the falls. Resident #4 was sent to the hospital on [DATE] after a fall where he sustained an injury to his right eye and fractured ribs. This failure affected one residents and placed 130 residents at risk for abuse, neglect, injury and a decline in their health condition. # 7 Findings Include: Resident #4 Record review of Resident #4 ' s face sheet revealed the [AGE] year old Resident was admitted to the facility on [DATE] with a re-admitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4 ' s admission care plan dated 8/28/14 revealed the following: · A problem of Resident had increased risk for falls related to a potential medication side effects, cognitive deficits, history of falls, complex medical conditions, sensory loss and impaired mobility. The goal was to minimize the risks for falls through an effective fall prevention program through-out the duration of residents stay. Approaches included: 1) Perform fall risk assessment per facility policy, 2) Assess periodically for factors that may contribute to falls. 3) Encourage and remind patient to verbalize the need for assistance. 4) Keep call light within reach in room. Provide prompt assistance. 5) Assure lighting is adequate and areas free from clutter. 6) Provide assistance with activities of daily living (ADLs) functional mobility needs. 7) Falling star program. 8) Assess for dosage reduction of medications that increases risks for falls. 9) Rehab intervention as needed to minimize falls. 10) Provide adaptive/protective equipment as necessary. · There was a problem of Resident #4 exhibited memory loss and difficulty with decision making skills. This was related to delayed thought process, difficulty in word finding and impaired recall. The goal was attempt to delay further decline in patient ' s cognitive function through inter-disciplinary interventions in the next 90 days. The approaches included, 1) Periodically assess resident ' s cognitive function. 2) Provide re-orientation to time, place or name as needed. 3) Administer medications to enhance cognitive function as ordered. 4) Invite and escort to sensory stimulating activities as needed. 5) Assess for the need for rehab intervention as needed. 6) Encourage responsible party and family to visit as needed. 7) Monitor moods and behaviors .8) Keep routine as simple as possible for patient to follow. 9) Provide same caregiver if possible .10) Provide activities that correspond to resident ' s cognitive ability. 11) Speech therapy for cognitive re-training as ordered. · Resident #4 required limited-extensive assistance with ADL functional mobility, personal hygiene, toileting and eating related to physical and cognitive impairments due to cognitive loss, increased fall risk .fatigues easily. The goal was to anticipate and meet needs to minimize further decline in ADL function. Approaches included, 1) Encourage resident to verbalize needs. Anticipate as warranted. 2) Assess for need for rehab or restorative nursing .6) Observe fall precautions at all times. Reinforce safety strategies . Other information written under goals revealed, Oct ' 14- PT/OT, >mult/Falls, Dec ' 14-Rehab. There were review dates of 10/07/14, 12/09/14 and 03/10/15, however there were no revisions to goals or approaches. Record review of Resident #4 ' s Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 which indicated severe cognitive impairment. There were problems with sleep disturbance, depression, feeling tired/little energy and trouble concentrating. Resident #4 was assessed to have behaviors not directed toward others, rejection of care and wandering. His functional status was assessed as follows: bed mobility, transfers, walking in corridor and toileting- limited assistance of one person. (Limited assistance was described as resident was highly involved in activity and staff provide guiding of limbs or other non-weight bearing activities.) He was not steady but was able to stabilize without assistance. He used a walker and a wheelchair for mobility. He was frequently incontinent of bladder and occasionally incontinent of bowel. Since admission to the facility he had two or more falls without major injury. He had received a diuretic (fluid pill). He was receiving occupational therapy since 12/18/14. Physical therapy was marked as NOT ASSESSED . Record review of Resident #4 ' s quarterly MDS assessment dated [DATE] revealed a BIMS of 3 which indicated severe cognitive impairment. There were problems with sleep disturbance, depression, feeling tired/little energy, poor appetite, trouble concentrating, and fidgety/ restless/slow. Resident #4 was assessed to have behaviors not directed toward others, rejection of care and wandering. His functional status was assessed as follows: bed mobility, walking in room and corridor required limited assistance of one person. He required extensive assistance (staff provided weight-bearing support) of one person for transfers and toileting. He was not steady and required staff assistance to stabilize. He used a wheelchair for mobility. He was frequently incontinent of bladder and occasionally incontinent of bowel. He had two or more falls without major injury since admission to the facility. He had received a diuretic (fluid pill). Occupational and Physical therapy was marked as NOT ASSESSED . Record Rreview of Resident #4's Incident Packet revealed on 1/24/15 at 10:00am Resident #4 had an unwitnessed fall in his room that resulted in a raised area to his right forehead. The Resident was unable to recall when the incident occurred . The Charge Nurse Investigation-Interventions after the Accident/Incident: 1. Resident reported falling early in the morning. 2. Medication review. The DON/Nurse Manager Follow-Up/Change in Care Plan: Medication Review. The Fall Risk assessment dated [DATE] was assessed as 24. (a score of 10 or higher indicates the Resident is a high risk for falls. Screening Referral dated 1/26/15 revealed please screen due to: decreased safety, difficulty walking, difficulty transferring, recent fall, memory problems and fall risk score 10 or higher. Record review of Resident #4 ' s care plan dated 1/24/15 revealed the following:Resident at Risk for falls as evidenced by, cognitive impairment with a goal of dignity will be maintained. Resident will not experience falls or injuries from falls over the next 90 days. Approaches included: 1) Encourage resident to ask for assistance of staff. 2) Ensure call light is in reach, answer promptly. 3) Therapy to evaluate and treat per orders. 4) Anticipate needs, provide prompt assistance. 5) Assure lighting is adequate and areas are free of clutter. 6) Encourage socialization and activity attendance- as tolerated. 7) Falling star program. The following was handwritten on the care plan: 2/1/15-resident sustained [REDACTED]. room. Approaches (no dates when added) - 8) Medication review, 9) Monitor by rounding, 10) Treatment to skin tear, 11) Psych Eval /Med Review. Transfer Care Plan 1/26/15 revealed patient has the potential risk for injury due to unsafe independent transfers as identified by the nursing/rehab assessment. Goal: Patient will be free from injury. Patient will have safe transfers. Approaches: 1) Assess patient for appropriate transfer. 2) Educate patient/ responsible party on proper lift/transfer. 3) instructions, MUST circle one .3c) was circled, it read Patient to be transferred with assist of one and use of gait belt or stand aid .6) Encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's Incident packet revealed on 2/1/15 (No time documented, only 10-6 shift)- Accident/Incident Report read in part, Resident #4 had an unwitnessed fall in his room, pre accident medical status, alert X1 .Account of Occurrence: Resident found on the floor in his room at 1:00am. He was confused and had a skin tear to his left wrist .B. Charge Nurse Investigation-Interventions .Resident assisted back to bed, skin tear was treated, neuro checks in progress. C. DON/ Nurse Manager Follow-up/Change in Care Plan: Resident on hourly rounds. Record review of Resident #4 ' s Fall Risk assessment dated [DATE] revealed a score of 21. Resident #4 ' s Intervention Checklist (no date) revealed the following areas were checked yes: Fall Identifiers in place. Leaf on door/Red Band on mobility device. Therapy consult, discipline not circled. Psychiatric Consult (Two choices, Counseling and Psychiatrist, neither one was circled). Medication review by pharmacist. Restorative Program (instructions were to circle PT, OT or ST, none were circled.) Non-skid Shoes, Well-fitting Shoes. Low Bed. Bed Bar for Transfer Assistance. Bowel /Bladder Program. Labs as appropriate. UA C&S as appropriate. Pharmacist Medication Review. Resident #4 ' s Screening Referral dated 2/1/15 revealed the area for the Resident name and room number on the form were blank, no disciplinary was circled. The following boxes were checked, Recent Fall, Memory Problems. Record review of Resident #4 ' s Transfer Care Plan dated 2/1/15 revealed the following: it contained the same problem, goal and interventions as the previous Transfer Care Plan dated 01/26/15 except none of the interventions for #3 were circled as instructed to do so. Record review of Resident #4's Incident Packet revealed on 02/04/15 at 3:35pm the Resident had an unwitnessed fall in his room. Resident #4 was found on the floor beside his bed lying on his left side. There was no apparent injury noted. Resident #4 denied pain and hitting his head but could not remember what happened .Interventions after Accident/Incident was Pt. teaching in need to use call light done. DON/Nurse Manager Follow-Up/Change in Care Plan: Psych Eval/Medication Review. Resident #4 ' s Intervention Checklist (no date) revealed the following areas were checked yes: Fall Identifiers in place. Leaf on door/Red Band on mobility device. Psychiatric Consult (Two choices, Counseling and Psychiatrist, neither one was circled). Medication review by pharmacist. Non-skid Shoes, Well-fitting Shoes. Place Patient in open areas for maximum observation. Record review of Resident #4 ' s Screening Referral revealed he was being referred due to decreased safety, Increasing weakness, recent fall, memory problems and a fall risk score of 10 or higher. Record review of Resident #4 ' s Fall Risk assessment dated [DATE] had a score of 24. Record review of Resident #4 ' s care plan dated 2/4/15 revealed the following: Resident had increased risk for falls. The goal and approaches were the same as the previous care plan dated 01/24/15. The following approach was handwritten on the care plan: 8) Psych Eval/Medication Review. (no date to when approach was added). Record Review of Resident #4 ' s Transfer Care Plan dated 2/4/15 revealed, The problem was listed as patient has the potential risk for injury due to unsafe independent transfers as identified by the nursing/rehab assessment. Goal: Patient will be free from injury. Patient will have safe transfers. Approaches: 1) Assess patient for appropriate transfer. 2) Educate patient/ responsible party on proper lift/transfer. 3) instructions, MUST circle one .3b) was circled, it read Patient transfers independently, with stand by supervision .6) Encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's Incident Packet revealed on 03/16/15 at 8:45am the Resident had an unwitnessed fall in his bathroom. He was observed lying on his left side on the floor in his bathroom. He had an old skin tear to his right knee scab dislodged . Additional Account of Event- Resident failed to use assistive device of fall from assistance. Charge Nurse Intervention-Interventions after accident/incident was to remind resident to use assistive device and reorient to call light. DON follow-up was medication review by Pharmacist. Record review of Resident #4 ' s Intervention Checklist (no date) had the following areas checked yes: Fall Identifiers in place. Leaf on door/Red Band on mobility device. Psychiatric Consult (Two choices, Counseling and Psychiatrist, neither one was circled). Medication review by pharmacist. Record review of Resident #4 ' s Screening Referral revealed referral was due to recent fall. No more information was filled out on the form. Record review of Resident #4 ' s care plan dated 03/16/15 revealed the Resident was high risk for falls. It had the same goal and approaches as the previous care plans dated 1/24/15 and 2/4/15. Record review of Resident #4 ' s Transfer Care Plan dated 3/16/15 revealed, The problem was listed as patient has the potential risk for injury due to unsafe independent transfers as identified by the nursing/rehab assessment. Goal: Patient will be free from injury. Patient will have safe transfers. Approaches: 1) Assess patient for appropriate transfer. 2) Educate patient/ responsible party on proper lift/transfer. 3) instructions, MUST circle one .3b) was circled, it read Patient transfers independently, with stand by supervision .6) Encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's Incident Packet revealed on 3/20/15 at 10:30am the Resident had an unwitnessed fall in his bathroom. At 10:30am staff heard a loud noise in Resident #4 ' s room. He was found on the floor lying on his left side. Pointed to occipital region of head on right side. Intervention after accident/incident was to assist and supervise with bathroom. DON follow-up/ Change in care plan was to cont. to offer and assist with bathroom. Incident Statement was blank and was not signed. Review of Transfer Care Plan 3/20/15 revealed the Resident had a potential risk for injury due to unsafe, independent transfers. The goal and approaches were the same as previous care plan dated 3/16/15 except 3c was circled. It read Patient to be transferred with assist of one and use of gait belt or stand aid .6) Encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's Incident Packet revealed on 03/26/15 at 10:30am the Resident was standing in front of his room without his assistive device, lost his balance and fell into a sitting position. He was observed to be jerking and unbalanced. He received an abrasion to his right 4th finger. Additional account of the Event read, Resident does not comprehend the need for assistance and use of assistive devices due to dementia .Interventions after accident/incident was to monitor frequently, offered assistance. Call bell in reach, wheelchair locked within reach. DON follow-up was to get an UA C&S-lab work. Record review of Resident #4 ' s intervention checklist (no date) revealed the following areas checked yes, Fall identifiers in place, leaf on door, Therapy Consult (discipline not circled), medication review by pharmacist, non-skid shoes, well-fitting shoes, bed in low position, labs as appropriate and UA C&S as appropriate. Record review of Resident #4 ' s Nurses noted dated 3/26/15 at 4:00pm revealed continue to walk around room without assistive device. Record review of Resident #4 ' s Screening referral dated 3/26/15 revealed, discipline to screen not checked. The following reason for the screen had an X in the box decreased safety, difficulty walking, difficulty transferring, increasing weakness, recent fall and memory problems. Record review of Resident #4's Incident Packet revealed on 03/31/15 at 7:25pm revealed the family requested Nurse to the room as Resident #4 was lying on the floor in his room. There was no documentation in the areas for additional account of event and charge nurse investigation/Interventions after incident. DON follow-up was to collect urine for UA C&S. There was a screening referral (3/31/15) for PT to screen resident due to recent fall. Post fall investigation revealed Resident #4 was trying to sit in another chair. Intervention checklist had to interventions, therapy consult, PT checked and UA C&S as appropriate dated 4/1/15. Care Plan dated 3/31/15 same as other care plans with no reason marked for risk of falls. Same approaches except 8) Urine for UA C&S was handwritten in. Record review of Resident #4's Transfer Care plan dated 3/31/15 was not filled out under approaches 3). Instructions were to circle the appropriate approach (MUST circle one). Record review of Resident #4 ' s care plan dated 4/2/15 revealed Resident at risk for falls due to physical impairment and unsteady gait. Same goal as the care plan dated 1/24/15. The approaches were the same as the care plan dated 1/24/15 except under 7) the word star was lined through and the word leaf was added after program at the end and there was a new approach added as 8) Resident on antibiotic for Urinary Tract Infection [MEDICAL CONDITION]. The following was handwritten under problems: 4/15/15 fall near door to room and 4/8/15 actual fall. No other revisions or approaches were added or review dates documented. Record review of Resident #4's Incident Packet revealed on 4/2/15 at 4:00pm the resident was found sitting in the bed by the aid with blood on his left elbow. Resident #4 said he slipped and hit his elbow on the sink in the bathroom. Intervention after the incident was informed resident to use call light for assistance. DON follow-up was Resident on treatment for [REDACTED]. Fall Risk assessment dated [DATE] had a score of 11.Intervention checklist included fall identifiers in place. Leaf on door/Red band on mobility device. It was written in, On treatment for [REDACTED]. Screening referral form was blank and not signed. Transfer care plan was blank except the last approach was circled, it read encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's care plan dated 04/02/15 read in part, Resident at high risk for falls as evidenced by.physical impairment and unsteady gait. Goals and approaches were the saqme as previous care plans except an approach was written in as follows, 8) Resident on Antibiotics for UTI. Record review of Resident #4's Incident Packet revealed on 4/6/15 at 2:45pm Resident #4 was found in his bathroom on his knees looking into the commode. There was a small cut over the bridge of his nose and a skin tear on his right knee. The only intervention after the accident and DON follow-up was sent to the ER for eval. Screening form was blank and not signed. Fall risk score was 13. Intervention checklist had box by NA checked for all interventions. It was written in sent to ER for eval. Screening form was blank and not signed. Transfer care plan blank, #3 not circled. Record review of the care plan dated 4/6/15 revealed resident at risk for falls due to cognitive impairment (the only area checked). The goal was the same as the care plans dated 1/24/15 and 4/2/15. The only approach added was 8) Sent out for eval. No other revisions were noted to care plan and no other review dates were listed. 4/8/15 at 8:30pm-Resident was found lying on the floor in his room. He said he felt weak and had to lay down. No injuries noted. Intervention after accident/incident was resident was assessed by nurse. DON follow-up was educate resident to lay in bed when he was tired. Intervention list had N/A checked for all interventions. Written in to educate resident to lay in bed when tired. Fall risk-18. Transfer care plan 4/8/15 only had #6 circled. Care plan (no date) problem risk for falls as evidenced by unsteady gait. Goal same as previous and interventions same except handwritten in 8) educate resident when he is tired to lay in bed. Record review of Resident #4 ' s care plan dated 4/10/15 revealed Resident at risk for falls as evidenced by an unsteady gait. The goal was the same as the previous care plans dated 1/24/15, 4/2/15 and 4/6/15. The only other revision was an approach as 8) Urinalysis (UA) with culture and sensitivity (C&S) and a note (unable to determine date) not drawn .sent to ER for evaluation. 4/13/15 at 11:20pm-Resident was found kneeling in the bathroom with face down on toilet seat. Bleeding on his right eye, skin tear to fore head. 911 called. Intervention was assisted back to bed Cleaned right eye and forehead and sent to ER for evaluation. DON follow-up sent to ER for eval. Screen dated 4/10/15 for referral to PT/OT for decreased safety, diff walking, increasing weakness, and recent fall and memory problems. Care Plan dated 4/10/15 revealed risk for falls unsteady gait, dignity maintained no falls/injuries next 90 days, same interventions except 8) UA C&S. Interventions fall identifiers in place was checked N/A, Therapy consult for PT/OT dated 4/13/15 and UA C&S 4/13/15. Transfer with 3b circled. Record revie of FAcility sign-in sheet dated 04/13/15 revealed that there were 2 nurses and 1 CNA working the 10-6 shift on Resident #4's hall. The two nurses each had three halls and the CNA had one hall (800 hall) and part of another hall (700 hall). Record review of Resident #4 ' s care plan dated 4/14/15 revealed Resident at risk for falls. None of the areas falls were related to were checked. The goal was the same as the previous care plans dated 1/24/15, 4/2/15, 4 /6/15 and 4/10/15. There was an approach handwritten as 8) sent to ER for eval (no date) and 4/21/15 9) low bed and 4/23/15 10) bed alarm. There was a review date handwritten as 4/13/15. Record review of Resident #4 ' s hospital History & Physical dated 04/14/15 read in part . resident had a fall in nursing home and hit right eye on unknown object, unknown level of consciousness .family and patient denies complaints of nocturia (urge to urinate at night) .periorbital ecchymosis and [MEDICAL CONDITION] at the right .no [MEDICAL CONDITION] .Assessment/Plan-1. Fall .2. Injury of globe of eye with high intraocular pressures on the right, [MEDICATION NAME] (used for treatment of [REDACTED]. 3) Rib fracture, conservative therapy, incentive spirometry .4. [DIAGNOSES REDACTED], concerning give recurrent falls .7) Dementia . Record review of Resident#4's Chest/Abdomen/Pelvis CT scan dated 041/14/15 revealed acute fractures of the right posterior lateral eighth and ninth ribs with small righ pleual effusion. Record review of Resident #4's hospital discharge summary dated 04/17/15 read in part.discharge Diagnosis: [REDACTED]. Record review of Resident #4 ' s Ophthalmology Progress note dated 04/17/15 read in part .had a mechanical fall from standing, on [MEDICATION NAME], with partial thickness sclera laceration and retrobulbar hemorrhage and hyphemia (bleeding in the eye). His intraocular pressure was initially 40 and improved to 26 with medication .External exam revealed pro[DIAGNOSES REDACTED] (bulging of the eye), periorbital [MEDICAL CONDITION] with ecchymosis. Record review of Resident #4 ' s Transfer care plan dated 4/17/15 revealed the following: it was the same as the Transfer Care Plan dated 03/20/15. 5/1/15 at 10:40pm-Resident #4 was found sitting on the floor in his bathroom near the toilet seat. There was a small amount of blood on his left elbow from an old skin tear. The Resident was confused. Fall risk score was 23. Record review of Resident #4 ' s Nurse ' s note dated 5/1/15 at 11:40pm and 5/2/15 on 2p-10p shift read .Resident on every 15 minute checks. Observation and interview on 04/27/15 at 9:00am revealed Resident #4 was in bed. He was calm in manner. There was a bruise located around his right eye that was bluish-purple in color. In an interview at this time he did remember falling and said that a kid hit him in the eye and that was why he was brought to the facility. He also said that he did not need help with walking or going to the bathroom, he could do it himself. There was a wheelchair and a walker in his room; neither had a red band indicating that he was high risk for falls. Interview on 05/01/15 at 2:07pm with LVN L revealed that a Resident would have a leaf on their door and a red band on their assistive device if they were high risk for falls. Observation on 05/01/15 at 2:38pm revealed Resident #4 in bed with his eyes closed. There was a walker by his bed and a wheelchair located to the right of the foot of his bed. Neither assistive device had a red band on them to indicate he was high risk for falls. Observation and interview on 05/04/15 at 5:30am revealed Resident #4 in bed with his eyes closed. His wheelchair in room noted to have a red band on it to indicate he was a high risk for falls. CNA K was in his room by his bed. In an interview at this time she said she was with Resident #4 on the night shift because he was on 1:1 monitoring due to he had another fall Friday night (05/01/15). CNA K said that he had attempted to get up during the night and she assisted him. Interview on 05/04/15 at 5:35am revealed RN E said that he would check on Resident #4 every two hours. RN E said that Resident #4 would get up and wander at times. He also said that he had another fall on 05/01/15 and was now on 1:1 monitoring. He said that there was not enough staff at night to check on the residents as needed. Interview on 05/04/15 at 7:56am with PT A revealed Resident #4 was on case load since he was readmitted back to the facility after a fall. She said that Resident #4 did not have gait, balance or weakness issue but rather a safety awareness issue. She said that the safety issues were due to cognitive deficits and his dementia. PT A said that therapy had screened Resident #4 before but he was not appropriate. PT A then said the only reason he was back on therapy now was because he went to the hospital and came back newly diagnosed . When asked if Resident #4 was on Part A or Part for therapy she said she though Part A. Observation on 05/04/15 at 9:00am revealed CNA ZZ was caring for Resident #4. Resident #4 was wet. Further observation revealed CNA ZZ transferred Resident #4 from his wheelchair to his bed by lifting him under both shoulders and placing him on the bed. Resident #4 was unsteady when transferred. Observation and interview on 05/04/15 at 11:38am revealed Resident #4 sitting in his wheelchair. CNA ZZ was assisting him with getting ready for lunch. CNA ZZ said he just came back from therapy and he was tired. She also said that he was on frequent monitoring and she had to fill out a sheet every 15 minutes. Resident #4 ' s family member entered the room. When asked, Resident #4 said he would like to go back to bed. CNA ZZ transferred Resident #4 from his wheelchair to his bed without a gait belt by lifting him under his arms. Both shoulders moved in an upward motion when she transferred him. It took three attempts to get Resident #4 to stand for the transfer. Resident #4 was shaky and unsteady and would fall back into the wheel chair due to not being able to stand. After the second attempt to transfer Resident #4 the family member tried to assist in the transfer however CNA ZZ waived him off with her right hand stating that the Resident could do it and they did not need help. On the third attempt the Resident stood but was unsteady and when CNA ZZ turned him to sit him on the bed he fell on to the bed landing in a sitting position and CNA ZZ was pulled forward toward him. Interview on 05/04/15 at 11:45am revealed CNA ZZ said that she would usually transfer with the belt if they had one. When asked what kind of belt she said if they have jeans and a belt on she would use their belt. She said that she would usually transfer residents by lifting under their arms. She said she had a gait belt it was in her purse but she did not need to use one with Resident #4 because he could stand. When asked even though he was unsteady and it took multiple attempts to transfer him she said she did not need to use a gait belt with him. Interview on 05/04/15 at 2:16pm with RA B revealed all staff members were issued a gait belt and they were to be used when transferring a resident. She said you never life residents under the arms to transfer them. Regarding Resident #4 she said that sometimes he is steady and sometimes he is not. Interview on 05/04/15 at 11:50am with Resident #4 ' s family member revealed that the facility had not put the low bed or alarm in place until after he was admitted back to the facility from the hospital and this was at the family ' s request. He said the family and the DON, Social Worker (SW) and Administrator had a meeting prior to Resident #4 returning from the hospital. They did not want to put him in a low bed or give him a bed alarm because he could still walk. The family did say that one time before the facility had put a mat in Resident #4 ' s room that would alarm when he stepped on it. He said it was located between the Resident ' s bed and his bathroom; however, you could not open the bathroom door with the mat in place. He said that it was taken out of his room. Another family member was visiting Resident #4 (day and time not specified) and asked a Nurse (name not given) for assistance with the Resident. The Nurse informed the family member she was going on break and would assist him then. There was no offer to have another staff member assist the Resident and 55 minutes later the Nurse had not retuned and was observed outside smoking. The family member was unable to find another staff member because they all take breaks at the same time and there is not enough staff to meet the resident ' s needs. During a meeting on 05/04/15 at 12:45pm with the Administrator, DON, Medical Director, Senior Director of Nursing and Senior Director of Operations revealed the following: When discussed Resident #4 and the interventions put in place the facility Administration staff felt like they had done everything they could for him. The Senior Director of Nursing said the staff discussed Resident #4 in the 24 hour report. He then presented a 24 hour report form that the only information it contained was Resident #4 was a high fall risk. There were no interventions. He then said there was a form titled Daily Care Guide that the staff used for Resident #4. He presented this document and it had Resident #4 ' s name and he was at risk for falls. The column to the right of the form titled Interventions was blank. When asked about the column for interventions and why it was blank he did not respond. The Senior Director of Operations then presented a packet for Resident #4 that was completed after a fall (date not specified). She turned to a page titled Interventions and said that they marked an intervention that bed was in low position. When asked if that was the same as a low bed she said no. She then picked up another packet and turned to the form titled Interventions and it was blank, there were no interventions marked. She then said the form was just for new interventions. The manner in which Resident #4 was transferred was discussed. The Administrator and DON did not respond regarding whether this was an appropriate transfer, however the Senior Director of Operations said, Oh, that ha

Based on observation, interview and record review the facility failed to ensure one of 23 residents reviewed for supervision and transfer using an assistive device (Resident # 4) received adequate supervision to prevent a fall with injury. Resident #4 had 13 falls from January 2015 to May 2015 without effective interventions or supervision to prevent the falls. Resident #4 was sent to the hospital on [DATE] after a fall where he sustained an injury to his right eye and fractured ribs . CNA ZZ transferred Resident #4 from the wheelchair to the bed without a gait belt lifting him under the arms. This failure affected one resident and placed 120 residents at risk of injury from lack of proper and adequate supervision. # 7 Findings Include: Resident #4 Record review of Resident #4 ' s face sheet revealed the [AGE] year old Resident was admitted to the facility on [DATE] with a re-admitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4 ' s admission care plan dated 8/28/14 revealed the following: · A problem of Resident had increased risk for falls related to a potential medication side effects, cognitive deficits, history of falls, complex medical conditions, sensory loss and impaired mobility. The goal was to minimize the risks for falls through an effective fall prevention program through-out the duration of residents stay. Approaches included: 1) Perform fall risk assessment per facility policy, 2) Assess periodically for factors that may contribute to falls. 3) Encourage and remind patient to verbalize the need for assistance. 4) Keep call light within reach in room. Provide prompt assistance. 5) Assure lighting is adequate and areas free from clutter. 6) Provide assistance with activities of daily living (ADLs) functional mobility needs. 7) Falling star program. 8) Assess for dosage reduction of medications that increases risks for falls. 9) Rehab intervention as needed to minimize falls. 10) Provide adaptive/protective equipment as necessary. · · There was a problem of Resident #4 exhibited memory loss and difficulty with decision making skills. This was related to delayed thought process, difficulty in word finding and impaired recall. The goal was attempt to delay further decline in patient ' s cognitive function through inter-disciplinary interventions in the next 90 days. The approaches included, 1) Periodically assess resident ' s cognitive function. 2) Provide re-orientation to time, place or name as needed. 3) Administer medications to enhance cognitive function as ordered. 4) Invite and escort to sensory stimulating activities as needed. 5) Assess for the need for rehab intervention as needed. 6) Encourage responsible party and family to visit as needed. 7) Monitor moods and behaviors .8) Keep routine as simple as possible for patient to follow. 9) Provide same caregiver if possible .10) Provide activities that correspond to resident ' s cognitive ability. 11) Speech therapy for cognitive re-training as ordered. · · Resident #4 required limited-extensive assistance with ADL functional mobility, personal hygiene, toileting and eating related to physical and cognitive impairments due to cognitive loss, increased fall risk .fatigues easily. The goal was to anticipate and meet needs to minimize further decline in ADL function. Approaches included, 1) Encourage resident to verbalize needs. Anticipate as warranted. 2) Assess for need for rehab or restorative nursing .6) Observe fall precautions at all times. Reinforce safety strategies . Other information written under goals revealed, Oct ' 14- PT/OT, >mult/Falls, Dec ' 14-Rehab. There were review dates of 10/07/14, 12/09/14 and 03/10/15, however there were no revisions to goals or approaches. Record review of Resident #4 ' s Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 which indicated severe cognitive impairment. There were problems with sleep disturbance, depression, feeling tired/little energy and trouble concentrating. Resident #4 was assessed to have behaviors not directed toward others, rejection of care and wandering. His functional status was assessed as follows: bed mobility, transfers, walking in corridor and toileting- limited assistance of one person. (Limited assistance was described as resident was highly involved in activity and staff provide guiding of limbs or other non-weight bearing activities.) He was not steady but was able to stabilize without assistance. He used a walker and a wheelchair for mobility. He was frequently incontinent of bladder and occasionally incontinent of bowel. Since admission to the facility he had two or more falls without major injury. He had received a diuretic (fluid pill). He was receiving occupational therapy since 12/18/14. Physical therapy was marked as NOT ASSESSED . Record review of Resident #4 ' s quarterly MDS assessment dated [DATE] revealed a BIMS of 3 which indicated severe cognitive impairment. There were problems with sleep disturbance, depression, feeling tired/little energy, poor appetite, trouble concentrating, and fidgety/ restless/slow. Resident #4 was assessed to have behaviors not directed toward others, rejection of care and wandering. His functional status was assessed as follows: bed mobility, walking in room and corridor required limited assistance of one person. He required extensive assistance (staff provided weight-bearing support) of one person for transfers and toileting. He was not steady and required staff assistance to stabilize. He used a wheelchair for mobility. He was frequently incontinent of bladder and occasionally incontinent of bowel. He had two or more falls without major injury since admission to the facility. He had received a diuretic (fluid pill). Occupational and Physical therapy was marked as NOT ASSESSED . Record Review of Resident #4's Incident Packet revealed on 1/24/15 at 10:00am Resident #4 had an unwitnessed fall in his room that resulted in a raised area to his right forehead. The Resident was unable to recall when the incident occurred . The Charge Nurse Investigation-Interventions after the Accident/Incident: 1. Resident reported falling early in the morning. 2. Medication review. The DON/Nurse Manager Follow-Up/Change in Care Plan: Medication Review. The Fall Risk assessment dated [DATE] was assessed as 24. (A score of 10 or higher indicates the Resident is a high risk for falls. Screening Referral dated 1/26/15 revealed please screen due to: decreased safety, difficulty walking, difficulty transferring, recent fall, memory problems and fall risk score 10 or higher. Record review of Resident #4 ' s care plan dated 1/24/15 revealed the following: Resident at Risk for falls as evidenced by, cognitive impairment with a goal of dignity will be maintained. Resident will not experience falls or injuries from falls over the next 90 days. Approaches included: 1) Encourage resident to ask for assistance of staff. 2) Ensure call light is in reach, answer promptly. 3) Therapy to evaluate and treat per orders. 4) Anticipate needs, provide prompt assistance. 5) Assure lighting is adequate and areas are free of clutter. 6) Encourage socialization and activity attendance- as tolerated. 7) Falling star program. The following was handwritten on the care plan: 2/1/15-resident sustained [REDACTED]. room. Approaches (no dates when added) - 8) Medication review, 9) Monitor by rounding, 10) Treatment to skin tear, 11) Psych Eval /Med Review. Transfer Care Plan 1/26/15 revealed patient has the potential risk for injury due to unsafe independent transfers as identified by the nursing/rehab assessment. Goal: Patient will be free from injury. Patient will have safe transfers. Approaches: 1) Assess patient for appropriate transfer. 2) Educate patient/ responsible party on proper lift/transfer. 3) instructions, MUST circle one .3c) was circled, it read Patient to be transferred with assist of one and use of gait belt or stand aid .6) Encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's Incident packet revealed on 2/1/15 (No time documented, only 10-6 shift)- Accident/Incident Report read in part, Resident #4 had an unwitnessed fall in his room, pre accident medical status, alert X1 .Account of Occurrence: Resident found on the floor in his room at 1:00am. He was confused and had a skin tear to his left wrist .B. Charge Nurse Investigation-Interventions .Resident assisted back to bed, skin tear was treated, neuro checks in progress. C. DON/ Nurse Manager Follow-up/Change in Care Plan: Resident on hourly rounds. Record review of Resident #4 ' s Fall Risk assessment dated [DATE] revealed a score of 21. Resident #4 ' s Intervention Checklist (no date) revealed the following areas were checked yes: Fall Identifiers in place. Leaf on door/Red Band on mobility device. Therapy consult, discipline not circled. Psychiatric Consult (Two choices, Counseling and Psychiatrist, neither one was circled). Medication review by pharmacist. Restorative Program (instructions were to circle PT, OT or ST, none were circled.) Non-skid Shoes, Well-fitting Shoes. Low Bed. Bed Bar for Transfer Assistance. Bowel /Bladder Program. Labs as appropriate. UA C&S as appropriate. Pharmacist Medication Review. Resident #4 ' s Screening Referral dated 2/1/15 revealed the area for the Resident name and room number on the form were blank, no disciplinary was circled. The following boxes were checked, Recent Fall, Memory Problems. Record review of Resident #4 ' s Transfer Care Plan dated 2/1/15 revealed the following: it contained the same problem, goal and interventions as the previous Transfer Care Plan dated 01/26/15 except none of the interventions for #3 were circled as instructed to do so. Record review of Resident #4's Incident Packet revealed on 02/04/15 at 3:35pm the Resident had an unwitnessed fall in his room. Resident #4 was found on the floor beside his bed lying on his left side. There was no apparent injury noted. Resident #4 denied pain and hitting his head but could not remember what happened .Interventions after Accident/Incident was Pt. teaching in need to use call light done. DON/Nurse Manager Follow-Up/Change in Care Plan: Psych Eval/Medication Review. Resident #4 ' s Intervention Checklist (no date) revealed the following areas were checked yes: Fall Identifiers in place. Leaf on door/Red Band on mobility device. Psychiatric Consult (Two choices, Counseling and Psychiatrist, neither one was circled). Medication review by pharmacist. Non-skid Shoes, Well-fitting Shoes. Place Patient in open areas for maximum observation. Record review of Resident #4 ' s Screening Referral revealed he was being referred due to decreased safety, Increasing weakness, recent fall, memory problems and a fall risk score of 10 or higher. Record review of Resident #4 ' s Fall Risk assessment dated [DATE] had a score of 24. Record review of Resident #4 ' s care plan dated 2/4/15 revealed the following: Resident had increased risk for falls. The goal and approaches were the same as the previous care plan dated 01/24/15. The following approach was handwritten on the care plan: 8) Psych Eval/Medication Review. (no date to when approach was added). Record Review of Resident #4 ' s Transfer Care Plan dated 2/4/15 revealed, The problem was listed as patient has the potential risk for injury due to unsafe independent transfers as identified by the nursing/rehab assessment. Goal: Patient will be free from injury. Patient will have safe transfers. Approaches: 1) Assess patient for appropriate transfer. 2) Educate patient/ responsible party on proper lift/transfer. 3) instructions, MUST circle one .3b) was circled, it read Patient transfers independently, with stand by supervision .6) Encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's Incident Packet revealed on 03/16/15 at 8:45am the Resident had an unwitnessed fall in his bathroom. He was observed lying on his left side on the floor in his bathroom. He had an old skin tear to his right knee scab dislodged . Additional Account of Event- Resident failed to use assistive device of fall from assistance. Charge Nurse Intervention-Interventions after accident/incident was to remind resident to use assistive device and reorient to call light. DON follow-up was medication review by Pharmacist. Record review of Resident #4 ' s Intervention Checklist (no date) had the following areas checked yes: Fall Identifiers in place. Leaf on door/Red Band on mobility device. Psychiatric Consult (Two choices, Counseling and Psychiatrist, neither one was circled). Medication review by pharmacist. Record review of Resident #4 ' s Screening Referral revealed referral was due to recent fall. No more information was filled out on the form. Record review of Resident #4 ' s care plan dated 03/16/15 revealed the Resident was high risk for falls. It had the same goal and approaches as the previous care plans dated 1/24/15 and 2/4/15. Record review of Resident #4 ' s Transfer Care Plan dated 3/16/15 revealed, The problem was listed as patient has the potential risk for injury due to unsafe independent transfers as identified by the nursing/rehab assessment. Goal: Patient will be free from injury. Patient will have safe transfers. Approaches: 1) Assess patient for appropriate transfer. 2) Educate patient/ responsible party on proper lift/transfer. 3) instructions, MUST circle one .3b) was circled, it read Patient transfers independently, with stand by supervision .6) Encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's Incident Packet revealed on 3/20/15 at 10:30am the Resident had an unwitnessed fall in his bathroom. At 10:30am staff heard a loud noise in Resident #4 ' s room. He was found on the floor lying on his left side. Pointed to occipital region of head on right side. Intervention after accident/incident was to assist and supervise with bathroom. DON follow-up/ Change in care plan was to cont. to offer and assist with bathroom. Incident Statement was blank and was not signed. Review of Transfer Care Plan 3/20/15 revealed the Resident had a potential risk for injury due to unsafe, independent transfers. The goal and approaches were the same as previous care plan dated 3/16/15 except 3c was circled. It read Patient to be transferred with assist of one and use of gait belt or stand aid .6) Encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's Incident Packet revealed on 03/26/15 at 10:30am the Resident was standing in front of his room without his assistive device, lost his balance and fell into a sitting position. He was observed to be jerking and unbalanced. He received an abrasion to his right 4th finger. Additional account of the Event read, Resident does not comprehend the need for assistance and use of assistive devices due to dementia .Interventions after accident/incident was to monitor frequently, offered assistance. Call bell in reach, wheelchair locked within reach. DON follow-up was to get an UA C&S-lab work. Record review of Resident #4 ' s intervention checklist (no date) revealed the following areas checked yes, Fall identifiers in place, leaf on door, Therapy Consult (discipline not circled), medication review by pharmacist, non-skid shoes, well-fitting shoes, bed in low position, labs as appropriate and UA C&S as appropriate. Record review of Resident #4 ' s Nurses noted dated 3/26/15 at 4:00pm revealed continue to walk around room without assistive device. Record review of Resident #4 ' s Screening referral dated 3/26/15 revealed, discipline to screen not checked. The following reason for the screen had an X in the box decreased safety, difficulty walking, difficulty transferring, increasing weakness, recent fall and memory problems. Record review of Resident #4's Incident Packet revealed on 03/31/15 at 7:25pm revealed the family requested Nurse to the room as Resident #4 was lying on the floor in his room. There was no documentation in the areas for additional account of event and charge nurse investigation/Interventions after incident. DON follow-up was to collect urine for UA C&S. There was a screening referral (3/31/15) for PT to screen resident due to recent fall. Post fall investigation revealed Resident #4 was trying to sit in another chair. Intervention checklist had to interventions, therapy consult, PT checked and UA C&S as appropriate dated 4/1/15. Care Plan dated 3/31/15 same as other care plans with no reason marked for risk of falls. Same approaches except 8) Urine for UA C&S was handwritten in. Record review of Resident #4's Transfer Care plan dated 3/31/15 was not filled out under approaches 3). Instructions were to circle the appropriate approach (MUST circle one). Record review of Resident #4 ' s care plan dated 4/2/15 revealed Resident at risk for falls due to physical impairment and unsteady gait. Same goal as the care plan dated 1/24/15. The approaches were the same as the care plan dated 1/24/15 except under 7) the word star was lined through and the word leaf was added after program at the end and there was a new approach added as 8) Resident on antibiotic for Urinary Tract Infection (UTI). The following was handwritten under problems: 4/15/15 fall near door to room and 4/8/15 actual fall. No other revisions or approaches were added or review dates documented. Record review of Resident #4's Incident Packet revealed on 4/2/15 at 4:00pm the resident was found sitting in the bed by the aid with blood on his left elbow. Resident #4 said he slipped and hit his elbow on the sink in the bathroom. Intervention after the incident was informed resident to use call light for assistance. DON follow-up was Resident on treatment for [REDACTED]. Fall Risk assessment dated [DATE] had a score of 11.Intervention checklist included fall identifiers in place. Leaf on door/Red band on mobility device. It was written in, On treatment for [REDACTED]. Screening referral form was blank and not signed. Transfer care plan was blank except the last approach was circled, it read encourage patient to request needed assistance in all transfers, keep call light in reach. Record review of Resident #4's care plan dated 04/02/15 read in part, Resident at high risk for falls as evidenced by.physical impairment and unsteady gait. Goals and approaches were the same as previous care plans except an approach was written in as follows, 8) Resident on Antibiotics for UTI. Record review of Resident #4's Incident Packet revealed on 4/6/15 at 2:45pm Resident #4 was found in his bathroom on his knees looking into the commode. There was a small cut over the bridge of his nose and a skin tear on his right knee. The only intervention after the accident and DON follow-up was sent to the ER for eval. Screening form was blank and not signed. Fall risk score was 13. Intervention checklist had box by NA checked for all interventions. It was written in sent to ER for eval. Screening form was blank and not signed. Transfer care plan blank, #3 not circled. Record review of the care plan dated 4/6/15 revealed resident at risk for falls due to cognitive impairment (the only area checked). The goal was the same as the care plans dated 1/24/15 and 4/2/15. The only approach added was 8) Sent out for eval. No other revisions were noted to care plan and no other review dates were listed. 4/8/15 at 8:30pm-Resident was found lying on the floor in his room. He said he felt weak and had to lie down. No injuries noted. Intervention after accident/incident was resident was assessed by nurse. DON follow-up was to educate resident to lie in bed when he was tired. Intervention list had N/A checked for all interventions. Written in to educate resident to lie in bed when tired. Fall risk-18. Transfer care plan 4/8/15 only had #6 circled. Care plan (no date) problem risk for falls as evidenced by unsteady gait. Goal same as previous and interventions same except handwritten in 8) educate resident when he is tired to lie in bed. Record review of Resident #4 ' s care plan dated 4/10/15 revealed Resident at risk for falls as evidenced by an unsteady gait. The goal was the same as the previous care plans dated 1/24/15, 4/2/15 and 4/6/15. The only other revision was an approach as 8) Urinalysis (UA) with culture and sensitivity (C&S) and a note (unable to determine date) not drawn .sent to ER for evaluation. 4/13/15 at 11:20pm-Resident was found kneeling in the bathroom with face down on toilet seat. Bleeding on his right eye, skin tear to fore head. 911 called. Intervention was assisted back to bed Cleaned right eye and forehead and sent to ER for evaluation. DON follow-up sent to ER for eval. Screen dated 4/10/15 for referral to PT/OT for decreased safety, diff walking, increasing weakness, and recent fall and memory problems. Care Plan dated 4/10/15 revealed risk for falls unsteady gait, dignity maintained no falls/injuries next 90 days, same interventions except 8) UA C&S. Interventions fall identifiers in place was checked N/A, Therapy consult for PT/OT dated 4/13/15 and UA C&S 4/13/15. Transfer with 3b circled. Record review of Facility sign-in sheet dated 04/13/15 revealed that there were 2 nurses and 1 CNA working the 10-6 shift on Resident #4's hall. The two nurses each had three halls and the CNA had one hall (800 hall) and part of another hall (700 hall). Record review of Resident #4 ' s care plan dated 4/14/15 revealed Resident at risk for falls. None of the areas that were related falls were checked. The goal was the same as the previous care plans dated 1/24/15, 4/2/15, 4 /6/15 and 4/10/15. There was an approach handwritten as 8) sent to ER for eval (no date) and 4/21/15 9) low bed and 4/23/15 10) bed alarm. There was a review date handwritten as 4/13/15. Record review of Resident #4 ' s hospital History & Physical dated 04/14/15 read in part . resident had a fall in nursing home and hit right eye on unknown object, unknown level of consciousness .family and patient denies complaints of nocturia (urge to urinate at night) .periorbital ecchymosis and edema at the right .no edema .Assessment/Plan-1. Fall .2. Injury of globe of eye with high intraocular pressures on the right, Diamox (used for treatment of [REDACTED]. 3) Rib fracture, conservative therapy, incentive spirometry .4. [DIAGNOSES REDACTED], concerning give recurrent falls .7) Dementia. Record review of Resident#4's Chest/Abdomen/Pelvis CT scan dated 041/14/15 revealed acute fractures of the right posterior lateral eighth and ninth ribs with small right pleural effusion. Record review of Resident #4's hospital discharge summary dated 04/17/15 read in part.discharge Diagnosis: [REDACTED]. Record review of Resident #4 ' s Ophthalmology Progress note dated 04/17/15 read in part .had a mechanical fall from standing, on Coumadin, with partial thickness sclera laceration and retrobulbar hemorrhage and hyphemia (bleeding in the eye). His intraocular pressure was initially 40 and improved to 26 with medication .External exam revealed pro[DIAGNOSES REDACTED] (bulging of the eye), periorbital edema with ecchymosis. Record review of Resident #4 ' s Transfer care plan dated 4/17/15 revealed the following: it was the same as the Transfer Care Plan dated 03/20/15. 5/1/15 at 10:40pm-Resident #4 was found sitting on the floor in his bathroom near the toilet seat. There was a small amount of blood on his left elbow from an old skin tear. The Resident was confused. Fall risk score was 23. Record review of Resident #4 ' s Nurse ' s note dated 5/1/15 at 11:40pm and 5/2/15 on 2p-10p shift read .Resident on every 15 minute checks. Observation and interview on 04/27/15 at 9:00am revealed Resident #4 was in bed. He was calm in manner. There was a bruise located around his right eye that was bluish-purple in color. In an interview at this time he did remember falling and said that a kid hit him in the eye and that was why he was brought to the facility. He also said that he did not need help with walking or going to the bathroom, he could do it himself. There was a wheelchair and a walker in his room; neither had a red band indicating that he was high risk for falls. Interview on 05/01/15 at 2:07pm with LVN L revealed that a Resident would have a leaf on their door and a red band on their assistive device if they were high risk for falls. Observation on 05/01/15 at 2:38pm revealed Resident #4 in bed with his eyes closed. There was a walker by his bed and a wheelchair located to the right of the foot of his bed. Neither assistive device had a red band on them to indicate he was high risk for falls. Observation and interview on 05/04/15 at 5:30am revealed Resident #4 in bed with his eyes closed. His wheelchair in room noted to have a red band on it to indicate he was a high risk for falls. CNA K was in his room by his bed. In an interview at this time she said she was with Resident #4 on the night shift because he was on 1:1 monitoring due to he had another fall Friday night (05/01/15). CNA K said that he had attempted to get up during the night and she assisted him. Interview on 05/04/15 at 5:35am revealed RN E said that he would check on Resident #4 every two hours. RN E said that Resident #4 would get up and wander at times. He also said that he had another fall on 05/01/15 and was now on 1:1 monitoring. He said that there was not enough staff at night to check on the residents as needed. Interview on 05/04/15 at 7:56am with PT A revealed Resident #4 was on case load since he was readmitted back to the facility after a fall. She said that Resident #4 did not have gait, balance or weakness issue but rather a safety awareness issue. She said that the safety issues were due to cognitive deficits and his dementia. PT A said that therapy had screened Resident #4 before but he was not appropriate. PT A then said the only reason he was back on therapy now was because he went to the hospital and came back newly diagnosed . When asked if Resident #4 was on Part A or Part for therapy she said she though Part A. Observation on 05/04/15 at 9:00am revealed CNA ZZ was caring for Resident #4. Resident #4 was wet. Further observation revealed CNA ZZ transferred Resident #4 from his wheelchair to his bed by lifting him under both shoulders and placing him on the bed. Resident #4 was unsteady when transferred. Observation and interview on 05/04/15 at 11:38am revealed Resident #4 sitting in his wheelchair. CNA ZZ was assisting him with getting ready for lunch. CNA ZZ said he just came back from therapy and he was tired. She also said that he was on frequent monitoring and she had to fill out a sheet every 15 minutes. Resident #4 ' s family member entered the room. When asked, Resident #4 said he would like to go back to bed. CNA ZZ transferred Resident #4 from his wheelchair to his bed without a gait belt by lifting him under his arms. Both shoulders moved in an upward motion when she transferred him. It took three attempts to get Resident #4 to stand for the transfer. Resident #4 was shaky and unsteady and would fall back into the wheel chair due to not being able to stand. After the second attempt to transfer Resident #4 the family member tried to assist in the transfer however CNA ZZ waived him off with her right hand stating that the Resident could do it and they did not need help. On the third attempt the Resident stood but was unsteady and when CNA ZZ turned him to sit him on the bed he fell on to the bed landing in a sitting position and CNA ZZ was pulled forward toward him. Interview on 05/04/15 at 11:45am revealed CNA ZZ said that she would usually transfer with the belt if they had one. When asked what kind of belt she said if they have jeans and a belt on she would use their belt. She said that she would usually transfer residents by lifting under their arms. She said she had a gait belt it was in her purse but she did not need to use one with Resident #4 because he could stand. When asked even though he was unsteady and it took multiple attempts to transfer him she said she did not need to use a gait belt with him. Interview on 05/04/15 at 2:16pm with RA B revealed all staff members were issued a gait belt and they were to be used when transferring a resident. She said you never life residents under the arms to transfer them. Regarding Resident #4 she said that sometimes he is steady and sometimes he is not. Interview on 05/04/15 at 11:50am with Resident #4 ' s family member revealed that the facility had not put the low bed or alarm in place until after he was admitted back to the facility from the hospital and this was at the family ' s request. He said the family and the DON, Social Worker (SW) and Administrator had a meeting prior to Resident #4 returning from the hospital. They did not want to put him in a low bed or give him a bed alarm because he could still walk. The family did say that one time before the facility had put a mat in Resident #4 ' s room that would alarm when he stepped on it. He said it was located between the Resident ' s bed and his bathroom; however, you could not open the bathroom door with the mat in place. He said that it was taken out of his room. Another family member was visiting Resident #4 (day and time not specified) and asked a Nurse (name not given) for assistance with the Resident. The Nurse informed the family member she was going on break and would assist him then. There was no offer to have another staff member assist the Resident and 55 minutes later the Nurse had not retuned and was observed outside smoking. The family member was unable to find another staff member because they all take breaks at the same time and there is not enough staff to meet the resident ' s needs. During a meeting on 05/04/15 at 12:45pm with the Administrator, DON, Medical Director, Senior Director of Nursing and Senior Director of Operations revealed the following: When discussed Resident #4 and the interventions put in place the facility Administration staff felt like they had done everything they could for him. The Senior Director of Nursing said the staff discussed Resident #4 in the 24 hour report. He then presented a 24 hour report form that the only information it contained was Resident #4 was a high fall risk. There were no interventions. He then said there was a form titled Daily Care Guide that the staff used for Resident #4. He presented this document and it had Resident #4 ' s name and he was at risk for falls. The column to the right of the form titled Interventions was blank. When asked about the column for interventions and why it was blank he did not respond. The Senior Director of Operations then presented a packet for Resident #4 that was completed after a fall (date not specified). She turned to a page titled Interventions and said that they marked an intervention that bed was in low position. When asked if that was the same as a low bed she said no. She then picked up another packet and turned to the form titled Interventions and it was blank, there were no interventions marked. She then said the form was just for new interventions. The manner in which Resident #4 was transferred was discussed. The Administrator and DON did not respond regarding whether this was an

Based on interview and record review the facility failed to implement their policy on neglect for 2 of 6 residents (CR #1 and CR #2) reviewed for neglect, as evidenced by: -Facility failed to notify the MD of CR #1 that he had episodes of ,[DATE] bowel movements per shift and appropriate medical interventions were not initiated. -CR #1 was medicated with blood pressure medications on 3 occasions while his blood pressure had fallen below the parameters ordered by the MD. CR #1 was admitted to the hospital on [DATE] with low blood pressure. -CR #1 had an unwitnessed fall on [DATE] at 4:20 a.m. and facility staff did not provide neurological assessments. CR#1 was sent to the hospital via 911 upon arrival to [MEDICAL TREATMENT] clinic on [DATE] due to non-responsiveness and died at the hospital on [DATE] where he was diagnosed with [REDACTED]. -CR #2 was not assessed by facility staff when she experienced episodes of right sided facial drop and right arm contraction/pain on [DATE]. Staff failed to initiate and update the care plan of CR #2. -CR#2 had an unwitnessed fall on [DATE] which resulted on acute left knee fracture. Facility staff did not provide neurological assessments for CR #2 after her fall. This failure affected 2 CR and could place 139 current residents at risk of harm and not having their medical needs met. Findings included: Intake # 2 and 2 CR #1 Closed record review of the facility face sheet revealed CR #1 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of the admission MDS dated [DATE] revealed CR#1 required extensive assistance of one person for bed mobility, transfers, dressing and toilet use. He was always incontinent of bowel. Record review of CR #1's skilled daily nurses notes revealed in part: -[DATE] at 3 a.m. "CR #1 had 3 soft bowel movements". -[DATE] 10 to 6 shift "Had loose stool once. [MEDICATION NAME] given as ordered" . -[DATE] at 2 a.m. "CR #1 complaint of pain, had diarrhea X 2, foul odor. PRN [MEDICATION NAME] given" -[DATE] at 5 a.m. "Diarrhea X 2. pepto Bismol given" -[DATE] at 6:30 a.m. "CR #1 complaints of diarrhea, will medicate with pepto Bismol" -[DATE] at 6 :00 a.m. "Diarrhea X 5. Initial dose of [MEDICATION NAME]. Patient states "I have never been like this before". -[DATE] at 2:00 a.m. "still with loose stools X 1" -[DATE] at 4:20 a.m. "CR #1 found on floor on right side of bed sitting on his left side. Patient stating "call the ambulance. I called and he doesn't answer". CR #1 noted to have been awake all shift and talking in his room all night and putting his call light on multiple times for assistance. MD notified via answering service. CR #1 noted to have 4 - 5 loose stools this shift. Pulse 98 and blood pressure of ,[DATE]". Further review revealed no documentation of a neurological assessment for CR #1 due to an unwitnessed fall and no assessment of CR #1 before he was sent out to [MEDICAL TREATMENT] on [DATE] at approximate. 9:00 a.m. Record review of CR #1's laboratory stool culture reading dated [DATE] revealed positive for [MEDICAL CONDITION]. Record review of CR #1's Physician's telephone orders revealed the following orders: -[DATE] - [MEDICATION NAME] 2 mg X 1 now, then [MEDICATION NAME] 2 mg every 6 hours for 1 day. -[DATE] - send stool for [MEDICAL CONDITION]. -[DATE] - Pepto Bismol 30 ml every 6 hours as needed for diarrhea. -[DATE] - Start [MEDICATION NAME] 500 mg by mouth every 8 hours for 10 days for [DIAGNOSES REDACTED]icile. -[DATE] - STAT urinalysis with culture and sensitivity, blood cultures X 2, New onset confusion. Record review of CR #1's MD progress notes dated [DATE] revealed in part: History - New onset confusion duration is constant. Further record review revealed in part: Review of systems: Gastrointestinal: No abdominal pain, nausea, vomiting or change in bowel habits. Record review of CR #1 physician orders for [DATE] revealed the following order: - [MEDICATION NAME] 50 mg tablet, take half tablet by mouth twice a day. Take blood pressure, hold for systolic blood pressure (the blood pressure when the heart is contracting) less than 110. Record review of CR #1's [DATE] MAR indicated [REDACTED] [DATE] at 9:00 a.m.; the systolic blood pressure was documented as 106. [DATE] at 9:00 p.m.; the systolic blood pressure was documented as 98. [DATE] at 9:00 p.m; the systolic blood pressure was documented as 100. Record review of the facility accident/incident report dated [DATE] at 4:10 a.m. for CR #1 revealed in part: Nature of accident/incident: falls, bed, unwitnessed. Patient contributing factors: confused. Vitals: Blood pressure ,[DATE], Pulse: 98. Person in charge - account of occurrence: CR #1 found on floor on right side of bed sitting on his left side. Patient stating "call the ambulance. I called and he doesn't answer" CR #1 stated "I was reaching to my phone that I dropped on the floor". Charge nurse investigation - Interventions after accident/incident: CR #1 noted to have been awake all night during shift. Per C.N.A's CR #1 has been awake, talking in his room and putting call light on for assistance. He is on [MEDICATION NAME] for C.Difficile and has had 4 - 5 loose stools this shift. CR #1 does go to [MEDICAL TREATMENT] at 9:00 a.m. this morning. Record review of the facility "[MEDICAL TREATMENT] communication record" for CR #1 dated [DATE] revealed in part: Pre-[MEDICAL TREATMENT] information (Nursing facility Nurse) Please note any changes or information: none. In an interview on [DATE] at 11:18 a.m. the DON stated if a resident had increased episodes of vomiting or diarrhea, they would tell the doctor and see if he wanted to order labs. DON stated he was aware that CR #1 had episodes of loose stools, but he was not sure if MD was made aware of CR #1 having up to 5 loose stools on at least 2 shifts. He further stated that all changes in condition require MD and family notification and documentation of assessments is written on nurses notes including family notifications. The DON said CR #1 should have had a care plan to indicate his [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The DON stated neurological checks are conducted per neurological record facility policy and neurological checks were done only if residents hit their heads or at the discretion of the nurses. The DON stated, as he reviewed the facility policy for unwitnessed falls, all unwitnessed falls require neurological assessments. DON further stated CR #1 did not have neurological assessments completed, "I did not find them". Observation at that time revealed the DON reviewing CR #1's chart and then stating "I don't see his care plan". In an interview on [DATE] at 12:10 p.m. with NP B revealed he was aware of CR #1 having loose stools. NP B further stated "CR #1 had an order for [REDACTED].#1 was having ,[DATE] bowel movements per shift. He stated "I believe 4 to 5 is a lot of stools per shift, you need to make sure you replace the fluids lost. The facility can always call the on call MD". In an interview on [DATE] at 12:30 p.m. with LVN A, Surveyor asked her how the facility was managing CR #1's fluid loss to prevent dehydration. LVN A responded "he was a [MEDICAL TREATMENT] patient". In continued interview LVN A stated CR #1 went to [MEDICAL TREATMENT] on [DATE] and never came back to facility again. She stated was the unit manager for the station where CR #1 lived and she did not remember getting any reports from the night shift that CR #1 had ,[DATE] bowel movements at one night. She stated on [DATE] she worked on the night shift and CR #1 had a fall, 5 episodes of loose stools and his blood pressure was recorded as ,[DATE]. She stated she left message with the doctors answering service and reported the information to the day shift nurse. She further stated she did not start a neurological assessments on CR #1. In continued interview, LVN A was asked if she witnessed the fall of CR #1 and she stated "No". In a phone interview on [DATE] at 12:47 p.m. with the [MEDICAL TREATMENT] Center, RN C stated that on [DATE] she sent CR #1 to the hospital via 911 as soon as he arrived to the [MEDICAL TREATMENT] Center. She further stated that she received CR #1 unresponsive to any voice commands "he would usually joke with you, he looked different, slumped down to his chair". RN C further stated that she asked the transportation person " why did you bring him like that? " and transportation person replied "I am just a transportation person". In continued interview, RN C stated she immediately brought CR #1 to the back of the center and gave him oxygen right away and 911 was called. RN C further stated when EMT arrived, CR #1's blood pressure was ,[DATE] and his pulse was 102. In an interview on [DATE] at 1:15 p.m. with LVN D revealed that she was the nurse that sent CR #1 to [MEDICAL TREATMENT] on [DATE]. LVN D stated that she was aware that CR #1 had a fall but does not remember that he had an episode of low blood pressure. She further stated that she did not remember doing any neurological assessment on CR #1 due to the unwitnessed fall. She further stated that information about the fall, low blood pressure episode or 5 loose bowel movements on the night shift was not reported to [MEDICAL TREATMENT] Center. In an interview on [DATE] at 2:10 p.m. with the Administrator revealed that she was the abuse coordinator and that she was involved in training facility staff on abuse and neglect and monitoring the residents for signs and symptoms of abuse and neglect. In a phone interview on [DATE] at 8:15 a.m. with RP of CR #1 revealed that CR #1 "had severe diarrhea for at least 2 to 3 weeks before he was sent to the hospital". RP stated that he visited CR #1 every day at the facility and that CR #1 would tell him that he was having at least 15 to 20 bowel movements per day. He further stated he would tell the facility staff and "they kept telling me is diarrhea". In continued interview he stated during the times he visited CR #1 at the facility, he never saw anyone offering any fluids to him. "I would just see his constant diarrhea, one bowel movement after another". RP stated that CR #1 would tell him that he was extremely miserable with the diarrhea and kept asking for help "but they kept telling me is diarrhea". RP further stated CR #1 was afraid of dying and kept begging him for help "I did not know what else to do". In continued interview, RP stated when the facility notified him on [DATE] that CR #1 had a fall, they told him that CR#1 was already very disoriented when he fell down from his bed. PR further stated CR #1 was diagnosed at the hospital with extreme dehydration and low blood pressure and died at the hospital on [DATE]. CR #2 Closed record review of the facility face sheet revealed CR #2 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed CR#2 was cognitively impaired, required extensive assistance of one persons for bed mobility, transfer, locomotion and was always incontinent of bowel and bladder. Record review of CR #2's MD progress notes dated [DATE] revealed in part: History: -Chief Complaint: Asked by family members and staff to see patient regarding right-sided facial droop, right arm contraction and right arm pain. Caregiver stated that patient has new onset of right-sided facial droop and right contractor and has noticed that patient grimaces when touched on right arm. Caregiver states that she feels patient may have had a fall. No reports of fall received...Review of systems: Musculoskeletal: Right hand contraction noted, right arm pain. -Physical exam: General: Patient with right sided facial droop, right sided weakness, non-verbal on exam today. Right hand contraction and right side facial droop. -Diagnosis, assessment and plan: Will have CT of the brain without contrast to evaluate for TIA/[MEDICAL CONDITION] secondary to new onset right-sided weakness. Record review of CR #2's care plan revealed no information of CR #2's new onset right sided facial droop and right arm contraction or pain to right arm. Record review of CR #2's skilled daily nurses notes revealed that on [DATE] there were no nurses notes or assessments by facility staff when she experienced episodes of right sided facial drop and right arm contraction/pain on [DATE]. Further record review of nurse's note dated [DATE] at 4 p.m. revealed in part: "CR #2 stable, no distress, no adverse reaction noted to antibiotics". Nurse's note dated [DATE] at 4:30 a.m. that read in part: "while doing rounds CR #2 was noted on the floor besides her bed. CR #2 has a skin tear to her right leg, below the knee. CR #2 picked up off the floor and put back in the bed. MD ordered [MEDICATION NAME] and x-ray to right leg. CR #2 did not have other injuries. Further record review revealed no neurological assessments for CR #2 after her fall. Nurse's notes dated [DATE] at 4:34 p.m. revealed in part: "CR #2 complaining of left knee pain. Assessed and noted swelling to left knee. Tylenol given at 4:50p.m. Placed call to MD with new orders for x-ray to left knee. Results received. New orders to send CR #2 to hospital for [DIAGNOSES REDACTED]. Record review of the facility accident/incident report dated [DATE] at 4:30 a.m. for CR #2 revealed in part: Nature of accident/incident: checked on falls, unwitnessed. Person in charge - account of occurrence: "CR # 2 was noted on the floor in her room by her bed. Skin tear noted to the right knee". Record review of CR #2's x-ray results dated [DATE] at 9:16 p.m. revealed in part: Severity: Critical, Examination: left knee. History Left knee pain. Impression: [MEDICAL CONDITION] leg. Observation on [DATE] at 11:18 a.m. revealed the DON revealed flipping through CR #2's file looking for nursing assessments, care plan or nurses notes. At that time, he stated, It is not here". In continued interview at that time, the DON stated that neurological checks are conducted per neurological record facility policy and neurological checks were done only if residents hit their heads or at the discretion of the nurses. Further interview as surveyor showed the DON facility's policy and procedure for unwitnessed falls, DON stated "I see, all unwitnessed falls require neurological assessments" . DON further stated CR #1 did not have neurological assessments completed, "I did not find them". In an interview on [DATE] at 12:05 p.m. the DON asked LVN E why did CR #2 have a CT Scan test, and LVN E responded "I think it was a neurological issue". Record review of the facility policy and procedure dated February 2010 for "significant change in patient status" reads in part: ... "A significant change is patient status is defined as deterioration or marked improvement in the health, mental or psychosocial status in either life-threatening conditions". Record review of the facility policy and procedure dated February 2012 for "patient care management system 12" reads in part: ... " 8.- A situation, Background, Assessment and progress note must be completed upon a Patient's change in condition and prior to contacting the attending physician. The SBAR (Communication Form can replace a nurse's note and is filed in the Patient's medical record under the "Nurse's notes" tab. 9.- Documentation of a significant change in condition must have an update of the plan of care. Record review of the facility policy and procedure dated [DATE] for "Reportable incident protocol" revealed in part:.. "Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness". According to the facility 672 form, there were 139 residents at the facility.

Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental or psycho-social wellbeing according to the plan of care and comprehensive assessment for 2 of 6 residents (CR #1 and CR#2) reviewed for care and services, as evidenced by: -Staff failed to initiate and update the care plan of CR #1 when he had a change of condition and was diagnosed with [REDACTED]. -Facility failed to notify the MD of CR #1 that he had episodes of ,[DATE] bowel movements per shift and appropriate medical interventions were not initiated. -CR #1 was administered blood pressure medication outside of the parameters of the physician's orders on 3 days in [DATE]. CR #1 had an unwitnessed fall on [DATE] at 4:20 a.m. and facility staff did not provide neurological assessments. CR#1 was sent to the hospital via 911 upon arrival to [MEDICAL TREATMENT] clinic on [DATE] due to non-responsiveness and died at the hospital on [DATE] where he was diagnosed with [REDACTED]. -CR #2 was not assessed by facility staff when she experienced episodes of right sided facial drop and right arm contraction/pain on [DATE]. Staff failed to initiate and update the care plan of CR #2. -CR#2 had an unwitnessed fall on [DATE] which resulted in an acute left knee fracture. Facility staff did not provide neurological assessments for CR #2 after her fall. This failure affected 2 CR and could place 139 current residents at risk of a decline in their physical and/or mental well-being. Findings included: Intake # 2 and 2 CR #1 Closed record review of the facility face sheet revealed CR #1 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of the admission MDS dated [DATE] revealed CR#1 required extensive assistance of one person for bed mobility, transfers, dressing and toilet use. He was always incontinent of bowel. Record review of CR #1's skilled daily nurses notes revealed in part: -[DATE] at 3 a.m. "CR #1 had 3 soft bowel movements". -[DATE] 10 to 6 shift "Had loose stool once. [MEDICATION NAME] given as ordered" . -[DATE] at 2 a.m. "CR #1 complaint of pain, had diarrhea X 2, foul odor. PRN [MEDICATION NAME] given" -[DATE] at 5 a.m. "Diarrhea X 2. pepto Bismol given" -[DATE] at 6:30 a.m. "CR #1 complaints of diarrhea, will medicate with pepto Bismol" -[DATE] at 6 :00 a.m. "Diarrhea X 5. Initial dose of [MEDICATION NAME]. Patient states "I have never been like this before". -[DATE] at 2:00 a.m. "still with loose stools X 1" -[DATE] at 4:20 a.m. "CR #1 found on floor on right side of bed sitting on his left side. Patient stating "call the ambulance. I called and he doesn't answer". CR #1 noted to have been awake all shift and talking in his room all night and putting his call light on multiple times for assistance. MD notified via answering service. CR #1 noted to have 4 - 5 loose stools this shift. Pulse 98 and blood pressure of ,[DATE]". Further review revealed no documentation of a neurological assessment for CR #1 due to an unwitnessed fall and no assessment of CR #1 before he was sent out to [MEDICAL TREATMENT] on [DATE] at approximate. 9:00 a.m. Record review of CR #1's laboratory stool culture reading dated [DATE] revealed positive for [MEDICAL CONDITION]. Record review of CR #1's Physician's telephone orders revealed the following orders: -[DATE] - [MEDICATION NAME] 2 mg X 1 now, then [MEDICATION NAME] 2 mg every 6 hours for 1 day. -[DATE] - send stool for [MEDICAL CONDITION]. -[DATE] - Pepto Bismol 30 ml every 6 hours as needed for diarrhea. -[DATE] - Start [MEDICATION NAME] 500 mg by mouth every 8 hours for 10 days for [DIAGNOSES REDACTED]icile. -[DATE] - STAT urinalysis with culture and sensitivity, blood cultures X 2, New onset confusion. Record review of CR #1's MD progress notes dated [DATE] revealed in part: History - New onset confusion duration is constant. Further record review revealed in part: Review of systems: Gastrointestinal: No abdominal pain, nausea, vomiting or change in bowel habits. Record review of CR #1 physician orders for [DATE] revealed the following order: - [MEDICATION NAME] 50 mg tablet, take half tablet by mouth twice a day. Take blood pressure, hold for systolic blood pressure (the blood pressure when the heart is contracting) less than 110. Record review of CR #1's [DATE] MAR indicated [REDACTED] [DATE] at 9:00 a.m.; the systolic blood pressure was documented as 106. [DATE] at 9:00 p.m.; the systolic blood pressure was documented as 98. [DATE] at 9:00 p.m; the systolic blood pressure was documented as 100. Record review of the facility accident/incident report dated [DATE] at 4:10 a.m. for CR #1 revealed in part: Nature of accident/incident: falls, bed, unwitnessed. Patient contributing factors: confused. Vitals: Blood pressure ,[DATE], Pulse: 98. Person in charge - account of occurrence: CR #1 found on floor on right side of bed sitting on his left side. Patient stating "call the ambulance. I called and he doesn't answer" CR #1 stated "I was reaching to my phone that I dropped on the floor". Charge nurse investigation - Interventions after accident/incident: CR #1 noted to have been awake all night during shift. Per C.N.A's CR #1 has been awake, talking in his room and putting call light on for assistance. He is on [MEDICATION NAME] for C.Difficile and has had 4 - 5 loose stools this shift. CR #1 does go to [MEDICAL TREATMENT] at 9:00 a.m. this morning. Record review of the facility "[MEDICAL TREATMENT] communication record" for CR #1 dated [DATE] revealed in part: Pre-[MEDICAL TREATMENT] information (Nursing facility Nurse) Please note any changes or information: none. In an interview on [DATE] at 11:18 a.m. the DON stated if a resident had increased episodes of vomiting or diarrhea, they would tell the doctor and see if he wanted to order labs. DON stated he was aware that CR #1 had episodes of loose stools, but he was not sure if MD was made aware of CR #1 having up to 5 loose stools on at least 2 shifts. He further stated that all changes in condition require MD and family notification and documentation of assessments is written on nurses notes including family notifications. The DON said CR #1 should have had a care plan to indicate his [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The DON stated neurological checks are conducted per neurological record facility policy and neurological checks were done only if residents hit their heads or at the discretion of the nurses. The DON stated, as he reviewed the facility policy for unwitnessed falls, all unwitnessed falls require neurological assessments. DON further stated CR #1 did not have neurological assessments completed, "I did not find them". Observation at that time revealed the DON reviewing CR #1's chart and then stating "I don't see his care plan". In an interview on [DATE] at 12:10 p.m. with NP B revealed he was aware of CR #1 having loose stools. NP B further stated "CR #1 had an order for [REDACTED].#1 was having ,[DATE] bowel movements per shift. He stated "I believe 4 to 5 is a lot of stools per shift, you need to make sure you replace the fluids lost. The facility can always call the on call MD". In an interview on [DATE] at 12:30 p.m. with LVN A, Surveyor asked her how the facility was managing CR #1's fluid loss to prevent dehydration. LVN A responded "he was a [MEDICAL TREATMENT] patient". In continued interview LVN A stated CR #1 went to [MEDICAL TREATMENT] on [DATE] and never came back to facility again. She stated was the unit manager for the station where CR #1 lived and she did not remember getting any reports from the night shift that CR #1 had ,[DATE] bowel movements at one night. She stated on [DATE] she worked on the night shift and CR #1 had a fall, 5 episodes of loose stools and his blood pressure was recorded as ,[DATE]. She stated she left message with the doctors answering service and reported the information to the day shift nurse. She further stated she did not start a neurological assessments on CR #1. In continued interview, LVN A was asked if she witnessed the fall of CR #1 and she stated "No". In a phone interview on [DATE] at 12:47 p.m. with the [MEDICAL TREATMENT] Center, RN C stated that on [DATE] she sent CR #1 to the hospital via 911 as soon as he arrived to the [MEDICAL TREATMENT] Center. She further stated that she received CR #1 unresponsive to any voice commands "he would usually joke with you, he looked different, slumped down to his chair". RN C further stated that she asked the transportation person " why did you bring him like that? " and transportation person replied "I am just a transportation person". In continued interview, RN C stated she immediately brought CR #1 to the back of the center and gave him oxygen right away and 911 was called. RN C further stated when EMT arrived, CR #1's blood pressure was ,[DATE] and his pulse was 102. In an interview on [DATE] at 1:15 p.m. with LVN D revealed that she was the nurse that sent CR #1 to [MEDICAL TREATMENT] on [DATE]. LVN D stated that she was aware that CR #1 had a fall but does not remember that he had an episode of low blood pressure. She further stated that she did not remember doing any neurological assessment on CR #1 due to the unwitnessed fall. She further stated that information about the fall, low blood pressure episode or 5 loose bowel movements on the night shift was not reported to [MEDICAL TREATMENT] Center. In a phone interview on [DATE] at 8:15 a.m. with RP of CR #1 revealed that CR #1 "had severe diarrhea for at least 2 to 3 weeks before he was sent to the hospital". RP stated that he visited CR #1 every day at the facility and that CR #1 would tell him that he was having at least 15 to 20 bowel movements per day. He further stated he would tell the facility staff and "they kept telling me is diarrhea". In continued interview he stated during the times he visited CR #1 at the facility, he never saw anyone offering any fluids to him. "I would just see his constant diarrhea, one bowel movement after another". RP stated that CR #1 would tell him that he was extremely miserable with the diarrhea and kept asking for help "but they kept telling me is diarrhea". RP further stated CR #1 was afraid of dying and kept begging him for help "I did not know what else to do". In continued interview, RP stated when the facility notified him on [DATE] that CR #1 had a fall, they told him that CR#1 was already very disoriented when he fell down from his bed. PR further stated CR #1 was diagnosed at the hospital with extreme dehydration and low blood pressure and died at the hospital on [DATE]. CR #2 Closed record review of the facility face sheet revealed CR #2 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed CR#2 was cognitively impaired, required extensive assistance of one persons for bed mobility, transfer, locomotion, dressing, eating, and toilet use and was always incontinent of bowel and bladder. Record review of CR #2's MD progress notes dated [DATE] revealed in part: History: -Chief Complaint: Asked by family members and staff to see patient regarding right-sided facial droop, right arm contraction and right arm pain. Caregiver stated patient has new onset of right-sided facial droop and right contractor and has noticed that patient grimaces when touched by right arm. Caregiver states that she feels patient may have had a fall. No reports of fall received. Review of systems: Musculoskeletal: Right hand contraction noted, right arm pain. -Physical exam: General: Patient with right sided facial droop, right sided weakness, non-verbal on exam today. Right hand contraction and right side facial droop. -Diagnosis, assessment and plan: Will have CT of the brain without contrast to evaluate for TIA/[MEDICAL CONDITION] secondary to new onset right-sided weakness. Record review of CR #2's care plan revealed no information of CR #2's new onset right sided facial droop and right arm contraction or pain to right arm. Record review of CR #2's skilled daily nurses notes revealed that on [DATE] there were no nurses notes or assessments by facility staff when she experienced episodes of right sided facial drop and right arm contraction/pain on [DATE]. Further record review of nurse's note dated [DATE] at 4 p.m. revealed in part: "CR #2 stable, no distress, no adverse reaction noted to antibiotics". Nurse's note dated [DATE] at 4:30 a.m. that read in part: "while doing rounds CR #2 was noted on the floor besides her bed. CR #2 has a skin tear to her right leg, below the knee. CR #2 picked up off the floor and put back in the bed. MD ordered [MEDICATION NAME] and x-ray to right leg. CR #2 did not have other injuries". Further record review revealed no neurological assessments for CR #2 after her fall. Nurse's notes dated [DATE] at 4:34 p.m. revealed in part: "CR #2 complaining of left knee pain. Assessed and noted swelling to left knee. Tylenol given at 4:50 p.m. Placed call to MD with new orders for x-ray to left knee. Results received. New orders to send CR #2 to hospital for [DIAGNOSES REDACTED]. Record review of the facility accident/incident report dated [DATE] at 4:30 a.m. for CR #2 revealed in part: Nature of accident/incident: checked on falls, unwitnessed. Person in charge - account of occurrence: "CR # 2 was noted on the floor in her room by her bed. Skin tear noted to the right knee". Record review of CR #2's x-ray results dated [DATE] at 9:16 p.m. revealed in part: Severity: Critical, Examination: left knee. History Left knee pain. Impression: The acute distal femoral diametaphyseal fracture with posterior displacement. Record review of CR #2 physician orders for [DATE] revealed orders in part: Tylenol extra strength 500 mg tablet, take one tab by mouth every 4 hours as needed for pain/temperature. Record review of CR #2's MAR for [DATE] revealed that Tylenol extra strength 500 mg tablet was given only once on [DATE] and once during the ,[DATE] shift and once on [DATE] during the ,[DATE] shift and ,[DATE] shift. In an interview on [DATE] at 11:18 a.m. with the DON revealed the facility policy and procedure for any changes in condition is to update care plan, update MD and family on current condition of residents. The DON was asked the reason CR #2 was having the CT scan and the DON stated because the staff reported that something was going on with her and CR #2 was not herself. At that time, the DON was observed flipping through the chart, looking for initial assessments/nursing notes or an updated care plan, CR #2 and stated "is not there". The DON stated neurological checks are conducted per neurological record facility policy and that neurological checks were done only if residents hit their heads or at the discretion of the nurses. The DON was shown the facility's policy and procedure for unwitnessed falls and stated "I see, all unwitnessed falls require neurological assessments". DON further stated CR #2 did not have a neurological assessment completed, "I did not find them". In an interview on [DATE] at 12:05 p.m. the DON was observed asking LVN E "why CR #2 was having the CT Scan?" and LVN E responded "I think it was a neurological issue". Record review of the facility policy and procedure dated February 2010 for "significant change in patient status" reads in part: ... "A significant change is patient status is defined as deterioration or marked improvement in the health, mental. Or psychosocial status in either life-threatening conditions". Record review of the facility policy and procedure dated February 2012 for "patient care management system 12" reads in part: ... "8.- A situation, Background, Assessment and progress note must be completed upon a Patient's change in condition and prior to contacting the attending physician. The SBAR Communication Form can replace a nurse's note and is filed in the Patient's medical record under the "Nurse's notes" tab. 9.- Documentation of a significant change in condition must have an update of the plan of care. Record review of the facility policy and procedure dated [DATE] for "Medications" revealed no information on medication administration. According to the facility 672 form there were 139 residents at the facility.

Based on observation, record review and interviews, the facility failed to implement their policies to prohibit mistreatment, abuse or neglect for 1 of 8 residents reviewed for neglect, as evidenced by: Resident #1 was admitted to the facility with [MEDICAL CONDITION] of both eyes. The facility neglected to follow up her treatment resulting in the resident being sent to the hospital on [DATE] where she was diagnosed with [REDACTED]. The doctors were discussing the likelihood of removing the left eye. These failures affected 1 resident and placed an additional 156 residents at risk of neglect by not being provided appropriate care to address their medical conditions. Findings included: Intake # 2 Record review of Resident #1's clinical records revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the admission assessment dated [DATE] revealed Resident #1 was infected [MEDICAL CONDITION] and she was placed on contact isolation upon admission. Record review of the initial facility assessment of Resident #1, dated 1/8/2014, and the initial MDS, dated [DATE], did not note any abnormality in the appearance of the eyes. Record review of the admission MDS dated [DATE] revealed Resident #1 was severely impaired for cognition and was dependent on staff for all ADL. The skin section was marked 1 for stage 1 pressure sores. The vision section was marked 0, which meant her vision was adequate and she could see fine details, including regular print in newspapers/books. Record review of the care plan, dated 1/14/14, for the [MEDICAL CONDITION] revealed resident was to be treated with [MEDICATION NAME] (antibiotic medication) for 7 days. Record review of the physician's progress note, dated 1/21/2014, revealed that "Patient did not respond to the 7 day course of [MEDICATION NAME]- will consult ophthalmology to evaluate and treat. " Record review of the physician's progress note dated 2/21/2014 revealed the order for an ophthalmology consult was not carried out and the physician wrote, "[MEDICAL CONDITION], unspecified. Not improved with several courses of ophthalmic antibiotics, consult for ophthalmology pending." Record review of the physician's progress note further revealed that on 3/18/2014 when the ophthalmologist finally came to the facility, he refused to see and treat Resident #1 because the patient was as follows: "Pt (patient) in isolation. " Observation of Resident #1 at a local hospital on [DATE] at 10:40 am revealed she was on contact isolation and both eyes were covered with white gauze materials. Resident #1 had a [MEDICAL CONDITION], a G (gastrostomy) tube and a stage 2 ulcer at the back of her head. The sacral wound was not observed because the nurses at the hospital said it was not convenient for the patient to be turned around at the time of the observation . An interview with resident #1 was attempted at that time, however, due to the residents cognition level, she was not interviewable. Interview with Resident #1's family member on 4/15/14/ at 11:00 am, at the hospital, revealed 4 staff members, including the DON and LVN A, at the facility told her that Resident #1 had been seen by an ophthalmologist as ordered by the physician on 3/18/14. She stated that Resident #1 had [MEDICAL CONDITION] upon admission to the facility but the eyes were not swollen. In an interview with the hospital Doctor on 4/15/14 at 11:15 am, he stated that Resident #1 should have seen an ophthalmologist earlier than she did because both eyes, especially the left one, was now bad. He further stated, Doctors were also discussing the likelihood of removing the left eye. In an interview with RN A on 4/15/14 at 1:45 pm she stated that she knew Resident #1 from when she was admitted into the facility in January 2014. According to her, Resident #1's eyes were red, especially the left eye, but not swollen and that she was being treated with some eye drops. She further stated Resident #1's eyes were swollen by the time she was taken to the ER (emergency room ) on 04/12/14. In an interview with LVN B on 4/15/14 at 2:30 pm she admitted telling Resident #1's family member that Resident #1 had been seen by an ophthalmologist on 3/18/14. She stated she was aware that an ophthalmologist was in the facility on 3/18/14 and that Resident #1 was on the list of the Residents to be seen. She further stated she would be surprised to hear that Resident #1 was not seen by the ophthalmologist. In an interview with Executive Director on 4/16/14 at 1:20 pm. she stated she was aware nurses had made attempts to bring an ophthalmologist to see Resident #1 but they were not successful. When asked if there were any documents to evidence such attempts, she stated that there were none. She also stated the DON was out on medical leave. Record review of Resident #1's file revealed no further attempts were made to obtain ophthalmology services for Resident #1 until 4/12/2014 when the resident was taken to the ER for swollen eyes. Record review of Resident #1's hospital history and physical record dated 04/15/14 revealed the following about the residents eyes: "Both eyes protrude to a significant degree and the patient is not noted to close her eyelids fully. The left conjunctiva was injected (redness) and [MEDICAL CONDITION], the left cornea appears abraded and there appears to be a collection of purulent material in the anterior chamber of the left eye. The right eye conjunctiva are slightly injected. Patient is able to move eyes up and down to some degree, but extra ocular movements are limited. Eyes tend to gaze in upward direction. " Further review of the hospital record revealed Resident #1 was diagnosed with [REDACTED]. Record review of the facility Abuse Protocol, dated 3/2012, read in part: "...6 a. Abuse is defined as the ...deprivation by an individual , including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being...." The facility's form 672 revealed the census was 157 residents.

Based on observation, record review and interviews, the facility failed to follow their written policies to prohibit mistreatment, abuse or neglect for 1 of 8 residents reviewed for neglect, as evidenced by: Resident #1 was admitted to the facility with [MEDICAL CONDITION] of both eyes. The facility neglected to follow up her treatment resulting in the resident being sent to the hospital on [DATE] where she was diagnosed with [REDACTED]. The doctors were discussing the likelihood of removing the left eye. These failures affected 1 resident and placed an additional 156 residents at risk of neglect by not being provided appropriate care to address their medical conditions. Findings included: Intake # 2 Record review of the facility Abuse Protocol, dated 3/2012, read in part: "...6 a. Abuse is defined as the ...deprivation by an individual , including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being...." Record review of Resident #1's clinical records revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the admission assessment dated [DATE] revealed Resident #1 was infected [MEDICAL CONDITION] and she was placed on contact isolation upon admission. Record review of the initial facility assessment of Resident #1, dated 1/8/2014, and the initial MDS, dated [DATE], did not note any abnormality in the appearance of the eyes. Record review of the admission MDS dated [DATE] revealed Resident #1 was severely impaired for cognition and was dependent on staff for all ADL. The skin section was marked 1 for stage 1 pressure sores. The vision section was marked 0, which meant her vision was adequate and she could see fine details, including regular print in newspapers/books. Record review of the care plan, dated 1/14/14, for the [MEDICAL CONDITION] revealed resident was to be treated with [MEDICATION NAME] (antibiotic medication) for 7 days. Record review of the physician's progress note, dated 1/21/2014, revealed that "Patient did not respond to the 7 day course of [MEDICATION NAME]- will consult ophthalmology to evaluate and treat. " Record review of the physician's progress note dated 2/21/2014 revealed the order for an ophthalmology consult was not carried out and the physician wrote, "[MEDICAL CONDITION], unspecified. Not improved with several courses of ophthalmic antibiotics, consult for ophthalmology pending." Record review of the physician's progress note further revealed that on 3/18/2014 when the ophthalmologist finally came to the facility, he refused to see and treat Resident #1 because the patient was as follows: "Pt (patient) in isolation. " Observation of Resident #1 at a local hospital on [DATE] at 10:40 am revealed she was on contact isolation and both eyes were covered with white gauze materials. Resident #1 had a [MEDICAL CONDITION], a G (gastrostomy) tube and a stage 2 ulcer at the back of her head. The sacral wound was not observed because the nurses at the hospital said it was not convenient for the patient to be turned around at the time of the observation . An interview with resident #1 was attempted at that time, however, due to the residents cognition level, she was not interviewable. Interview with Resident #1's family member on 4/15/14/ at 11:00 am, at the hospital, revealed 4 staff members, including the DON and LVN A, at the facility told her that Resident #1 had been seen by an ophthalmologist as ordered by the physician on 3/18/14. She stated that Resident #1 had [MEDICAL CONDITION] upon admission to the facility but the eyes were not swollen. In an interview with the hospital Doctor on 4/15/14 at 11:15 am, he stated that Resident #1 should have seen an ophthalmologist earlier than she did because both eyes, especially the left one, was now bad. He further stated, Doctors were also discussing the likelihood of removing the left eye. In an interview with RN A on 4/15/14 at 1:45 pm she stated that she knew Resident #1 from when she was admitted into the facility in January 2014. According to her, Resident #1's eyes were red, especially the left eye, but not swollen and that she was being treated with some eye drops. She further stated Resident #1's eyes were swollen by the time she was taken to the ER (emergency room ) on 04/12/14. In an interview with LVN B on 4/15/14 at 2:30 pm she admitted telling Resident #1's family member that Resident #1 had been seen by an ophthalmologist on 3/18/14. She stated she was aware that an ophthalmologist was in the facility on 3/18/14 and that Resident #1 was on the list of the Residents to be seen. She further stated she would be surprised to hear that Resident #1 was not seen by the ophthalmologist. In an interview with Executive Director on 4/16/14 at 1:20 pm. she stated she was aware nurses had made attempts to bring an ophthalmologist to see Resident #1 but they were not successful. When asked if there were any documents to evidence such attempts, she stated that there were none. She also stated the DON was out on medical leave. Record review of Resident #1's file revealed no further attempts were made to obtain ophthalmology services for Resident #1 until 4/12/2014 when the resident was taken to the ER for swollen eyes. Record review of Resident #1's hospital history and physical record dated 04/15/14 revealed the following about the residents eyes: "Both eyes protrude to a significant degree and the patient is not noted to close her eyelids fully. The left conjunctiva was injected (redness) and [MEDICAL CONDITION], the left cornea appears abraded and there appears to be a collection of purulent material in the anterior chamber of the left eye. The right eye conjunctiva are slightly injected. Patient is able to move eyes up and down to some degree, but extra ocular movements are limited. Eyes tend to gaze in upward direction. " Further review of the hospital record revealed Resident #1 was diagnosed with [REDACTED]. Record review of the facility Abuse Protocol, dated 3/2012, read in part: "...6 a. Abuse is defined as the ...deprivation by an individual , including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being...." The facility's form 672 revealed the census was 157 residents.