Every finding on record at The Courtyards at Pasadena

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility dietary staff failed to ensure temperatures were taken of grilled cheese before serving to residents during lunch meal service on 5/12/26.The facility dietary staff failed to properly sanitize the thermometer while temping each food. The facility dietary staff failed to use proper hand hygiene during lunch service on 5/12/26The facility dietary staff failed to properly wear hair nets during lunch service on 5/12/26. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food cross contamination.Findings Include: An observation and interview with Dietary [NAME] G of lunch food service on 5/12/26 at 11:04 am revealed temperatures of food were taken by [NAME] G. Dietary [NAME] G stated they had no sanitizing wipes to wipe the thermometer because they had not come in. Dietary [NAME] G proceeded to grab two connected paper towels, held them under her left arm against her clothing, and put them on the counter. Dietary [NAME] G started taking temperatures by wiping the thermometer on the paper towel she had on the counter and temping each food. Dietary [NAME] G continued to wipe the thermometer with the same paper towel and after she temped the Salsbury steak she dropped the paper towel on the floor and picked it up and put it back on the counter. Dietary [NAME] G then wiped the thermometer with the paper towel and proceeded to put the thermometer into the mixed vegetable and took the temperature. An observation of dietary staff serving trays during lunch service on 5/12/26 at 11:13 a.m. reflected Dietary [NAME] G serving food on the trays and the Dietary Manager assisting on the other side with the food trays. The Dietary Manager was observed with her hair net only covering her ponytail and the hair on the sides of her head and back of her head was exposed. At 11:23 a.m. Dietary [NAME] G took her gloves off after putting the fresh cooked bread rolls in a tray and then put new gloves on without washing her hands. Dietary [NAME] G proceeded to push a cart with the gloves she had on and went to the freezer, returned with the same gloves and proceeded to butter the tray of bread she had gotten out of the oven and put them in another container with the same set of gloves. Once Dietary [NAME] G was finished with putting the bread rolls away she took her gloves off and washed her hands. Dietary [NAME] G then put on some new gloves, got a loaf of bread out to make a grilled cheese, took the gloves off, and did not wash her hands. Dietary [NAME] G put on new gloves, rolled the cart she had gotten from the back and got serving spoons to put in the food trays. At 11:33 a.m. Dietary [NAME] G had discarded her gloves, put new gloves on without washing her hands and made 2 grilled cheese sandwiches. Once the grilled cheese sandwiches were done, Dietary [NAME] G put them to the side and never temped them. At 11:39 a.m. the Dietary Manager was observed washing her hands, she then went to where the serving trays were, picked up some trash on the counters, picked up the lid to the trashcan to throw the trash away and went back to the trays and touched them with her unwashed hands. An interview with Dietary [NAME] G on 05/12/2026 at 1:06 p.m. revealed she realized she had forgotten to wash her hands between glove changes during food service. Dietary [NAME] G stated glove changes should have been done as much as possible and when changing tasks. Dietary [NAME] G stated she was supposed to wash her hands after every glove change. Dietary [NAME] G stated it was not okay to use a paper towel instead of sanitizing wipes to clean the thermometer after each temp but reiterated the facility had not received their shipment of sanitizing wipes. Dietary [NAME] G stated using paper towels had not properly sanitized the thermometer and could have caused cross contamination of bacteria. Dietary [NAME] G stated she should not have held the paper towel under her arm against her clothing because it could cause cross contamination and illness for residents. Dietary [NAME] G stated the expectation for temperatures of food was all foods should have been temped. Dietary [NAME] G stated she had not temped the grilled cheese and should have. Dietary [NAME] G stated if food was not cooked to the right temperature it could have made residents sick and the only way to know if food was at the right temperature was to actually take the temperature of the food. An interview with the Dietary Manager on 05/12/2026 at 1:11 p.m. revealed the expectation for glove changes with kitchen staff was every time staff took gloves off, they needed to wash their hands with soap and water. The Dietary Manager stated her touching the trashcan lid and food trays was unsanitary and could have caused cross contamination. The Dietary Manager stated Dietary [NAME] G should not have used paper towels to wipe the thermometer between temps and she should have used the sanitizing wipes. The Dietary Manager stated the facility had a whole box of sanitizing wipes and they were stored in her office. The Dietary Manager stated she was unsure of the reason Dietary [NAME] G stated they had not had any wipes. The Dietary Manager stated the risk to the residents of not properly sanitizing the thermometer after every food temp was cross contamination. The Dietary Manager stated the risk of using a paper towel that was touching the cook's clothing to wipe the thermometer would have been bacteria from the cook's clothing could have gotten in the food. The Dietary Manager stated all foods made in the kitchen should have been temped and any alternatives items offered to the residents outside of the daily menu should have been temped as well to include the grilled cheeses. The Dietary Manager stated the risk of not temping all food was illness from undercooked food or food could have been too cold or too hot. The Dietary Manager stated hair nets should have covered the whole head and stated she fixed her net later. The Dietary Manager stated the risk to the residents of kitchen staff not wearing hair nets in the kitchen could have been hair in the food served to them. An interview with the Administrator on 05/14/2026 at 12:05 p.m. revealed all dietary staff should wear hair nets and it should have been covering all their hair not just portions. The Administrator stated the risk to the residents of staff not wearing hair nets correctly would have been hair falling in their food. The Administrator stated every time dietary staff changed their gloves, they should wash their hands between each glove change and the risk to the resident of improper hand hygiene in the kitchen was cross contamination. The Administrator stated all food served in the kitchen should have been temped before serving and the risk to the resident of not temping all food was the residents could have received food at an unsafe temp and food could not have been fully cooked. The Administrator stated dietary staff should not have used paper towels that touched any part of the cook's clothing to clean the thermometer, sanitizing wipes should have been used between each food temperature. The Administrator stated the risk to the resident of not appropriately sanitizing the thermometer was cross contamination. Review of the facility's Nutrition Policies and Procedures - Safe Food Temperatures revised 10/15/25 reflected .6. Hold hot foods at 135F or higher during meal service (on the tray line). Hold cold foods at 40F or lower during meal service (on the tray line). Review of the facility's Infection Prevention and Control Policies and Procedures - Hand Hygiene/Handwashing revised 9/2011 reflected .Hand hygiene/hand washing is done: before: .B. before eating or handling food.After:.H. after removal of medical/surgical or utility gloves. Review of the facility's Nutrition Policies and Procedures - Dress code revised 10/15/25 reflected .Dietary staff involved in food production adheres to the department dress code that includes: .6. Appropriate hair restraints (hair covers or nets, beard restraints) while involved in food production activities.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six of eight residents (Resident #100, Resident #37, Resident #20, Resident #34, Resident #5 and Resident #13) reviewed for infection control. 1. The facility failed to ensure LVN B performed hand hygiene after obtaining a FSBS for Resident #100 and Resident # 37 on 05/12/26 and failed to allow the glucometer the full 2 minutes of contact time to ensure adequate disinfection prior to using on Resident #37 on 05/12/26. 2. The facility failed to ensure RN A performed hand hygiene after sanitizing the glucometer, after glove removal after obtaining FSBS on Resident #20, and before retrieving Resident # 20's insulin pen on 05/12/26. 3. The facility failed to ensure CNA C and CNA D performed hand hygiene during incontinence care for Resident #34 on 05/13/26. 4. The facility failed to ensure CNA F and CNA E utilized Enhanced Barrier Precautions during incontinence and catheter care and failed to perform hand hygiene during incontinence care for Resident # 5 on 05/14/26. 5. The facility failed to ensure RN H wore appropriate PPE when performing supra-pubic catheter care for Resident #13 who was on Enhanced Barrier Precautions on 05/13/26. These failures could place residents at risk for infection and cross contamination. 1. Record review of Resident #100's, Face sheet, dated 05/14/26, reflected an [AGE] year-old female with an admission date of 11/09/24. Resident #100 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). Record review of Resident #37's, Face sheet, dated 05/14/26, reflected a [AGE] year-old female with an admission date of 05/02/26. Resident #37 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). During an observation on 05/12/26 at 11:18 a.m. LVN B was at the medication cart in front of Resident #100's room. LVN B put on gloves without performing hand hygiene, placed a glucometer, lancets, a few test strips and alcohol wipes on a tray and entered Resident #100's room to check her blood sugar. LVN B pricked the resident's finger and obtained a blood sugar reading of 168. LVN B returned to the medication cart, placed the tray containing the glucometer, used test strip and lancet on top of the medication cart. She removed her gloves and without performing hand hygiene opened the medication cart and retrieved the Resident's oral medication, Nateglinide (used to control blood sugar) 120 mg and popped one pill into a medication cup. LVN B re-entered the Resident's room and administered the medication. LVN B then left the room and without performing hand hygiene pushed the cart to Resident #37's room. LVN B then put on gloves, disposed of the used lancet and test strips and removed a germicidal wipe with a kill time of 2 minutes and wiped down the glucometer and the tray. LVN B then changed her gloves without performing hand hygiene she placed the glucometer on a tray, with some lancets, test strips and alcohol wipes and entered Resident #37's room without waiting the full 2 minutes to disinfect the glucometer. LVN B pricked the resident's finger and obtained a fingerstick blood sugar with a reading of 153. LVN B then returned to the medication cart, removed her gloves and without performing hand hygiene checked the computer and retrieved the resident's insulin pen and dialed in 4 units. LVN B put on new gloves without performing hand hygiene and entered the resident's room and administered the insulin. During an interview on 05/12/26 at 11:28 a.m. LVN B stated she was supposed to perform hand hygiene every time she changed her gloves and stated she realized she had failed to do that. She stated she knew she was supposed to disinfect the glucometer between each resident use, but stated she was not sure what the contact time was for the germicidal wipe she had used. LVN B retrieved the germicidal wipe and verified the contact time for disinfecting was 2 minutes. She stated she had not waited for the full amount of time needed to ensure the glucometer was properly disinfected. She stated the risk of these failures was the spread of infections and blood borne pathogens. 2. Record review of Resident #20's, Face sheet, dated 05/14/26, reflected a [AGE] year-old male with an admission date of 03/24/26. Resident #20 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). During an observation on 05/12/26 at 11:30 a.m. RN A was at the medication cart in front of Resident #20's room. RN A put on gloves and retrieved a germicidal wipe and sanitized the glucometer and placed it on a tray with test strips, lancets and alcohol wipes. RN A then removed her gloves and put on new gloves without performing hand hygiene and entered Resident #20's room to obtain a fingerstick blood sugar. The blood sugar reading was 112. RN A returned to the medication cart, removed her gloves and without performing hand hygiene she checked the computer for the resident's insulin orders. She stated the MD had also just ordered another medication to assist with blood sugar control and she would have to go to the medication room to retrieve the Liraglutide (used to improve blood sugar) pen. RN A returned to the medication cart, and without performing hand hygiene, pulled the resident's Humalog (lispro insulin) pen and attached needles to both the Humalog pen and the Liraglutide pen. She then dialed in 12 units on the Humalog pen and 0.6 mg on the Liraglutide pen. RN A then sanitized her hands, put on gloves and entered Resident #20's room and administered both injections. RN A returned to the medication cart, removed her gloves and performed hand hygiene. During an interview on 05/12/2026 at 11:40 a.m. with RN A she stated she should have performed hand hygiene after sanitizing the glucometer and immediately after she had obtained the fingerstick blood sugar and after she had returned to the medication cart. She stated she just forgot. She stated the risk was the spread of infections. 3. Record review of Resident #34's, Face sheet, dated 05/14/26, reflected a [AGE] year-old female with an admission date of 03/25/24. Resident #34 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy) and congestive heart failure (heart is too weak and stiff to pump). During an observation on 05/13/26 at 1:20 p.m. CNA C and CNA D entered Resident #34's room to provide incontinence care. Both staff performed hand hygiene and put on gloves and unfastened the residents' brief. CNA D raised up the resident's belly folds, wiped under her belly folds, and then wiped front to back changing the wipes with each wipe. Both staff then rolled resident onto her side. CNA C then wiped front to back, cleaning a small amount of bowel movement. CNA C then placed a clean brief under the resident without changing gloves or performing hand hygiene. CNA D then assisted with rolling resident back onto her back without first changing her gloves and performing hand hygiene. Both staff adjusted the brief, the sheets, repositioned her in bed all while still wearing dirty gloves. After completion of care both staff removed gloves and performed hand hygiene. During an interview on 05/13/26 at 1:35 p.m. CNAs D and C stated they were to do hand hygiene before care and after. After thinking for a bit, they both stated they should have done hand hygiene when they went from dirty to clean. CNA C stated this was her 2nd day and was training with CNA D. CNA D stated the facility did classroom training with them on incontinent care and stated she had gone to the training. She stated not doing hand hygiene properly could spread infection. 4. Record review of Resident #5's, Face sheet, dated 05/14/26, reflected an [AGE] year-old female with an admission date of 03/25/24. Resident #5 had a diagnosis which included fracture of the left femur (thigh bone) and congestive heart failure (heart is too weak and stiff to pump). During an observation on 05/14/26 at 10:00 a.m. revealed an Enhanced Barrier Precautions sign posted on Resident #5's door. CNA E and CNA F were observed entering Resident #5's room to provide catheter and incontinence care. Both staff washed their hands. CNA F opened Resident #5's top chest of drawers to retrieve gloves and wipes. Isolation gowns were observed in the drawer next to the gloves and wipes. CNA F retrieved gloves and put on 2 pairs of gloves, one on top of the other, and handed CNA E gloves. Neither staff put on a gown. Both staff repositioned the resident in the bed and then CNA F unfastened the resident's brief and provided peri care and catheter care, wiping down each groin and down the middle changing wipes with each stroke. CNA F then cleaned down the catheter tubing away from the resident's body. CNA F then removed the first pair of gloves and assisted to roll resident onto her side, revealing she had a small bowel movement. CNA E then wiped the resident's anal area from front to back, changed her gloves and put on clean gloves without performing hand hygiene and placed the clean brief under the resident and both staff rolled the resident back onto her back and fastened the brief. Both staff then removed their gloves but did not perform hand hygiene, and repositioned the resident, covered her up and attached the call light. Both staff then washed their hands in the resident's bathroom sink. During an interview on 05/14/26 at 10:10 a.m. CNA E and CNA F stated they knew Resident #5 was on enhanced barrier precautions, but stated they just forgot to put the gown on. They stated they were supposed to do hand hygiene before and after and then stated they should have used hand sanitizer between glove changes. They stated the risk of not performing hand hygiene correctly was the spread of infection. 5. Record review of Resident #13's admission MDS assessment dated [DATE] reflected Resident #13 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included hypertension (elevated blood pressure), Benign Prostatic Hyperplasia (a common, noncancerous enlargement of the prostate gland that affects many men over 50). Record review of Resident #13's Care Plan dated 03/26/26, reflected the following: Focus: [Resident #13] a requires an indwelling urinary catheter related to obstructive uropathy (blockage or obstruction in the urinary tract). Goal: Resident will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma During an observation on 05/13/26 at 10:31 a.m., There was signage on Resident #13 which indicated he was on Enhanced Barrier Precautions. RN H entered Resident#13's room to perform suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen directly into the bladder to drain urine) care. RN H washed her hands, and put on gloves but no gown. RN H uncovered Resident#13, exposed the SPC catheter exit site, and removed the old dressing. RN H changed her gloves but did not perform hand hygiene. She cleaned the catheter exit site with gauze soaked with normal saline, changed her gloves again, but did not perform hand hygiene, and applied a clean split gauze dressing on the site. RN H then covered Resident#13, disposed of the trash, removed her gloves, washed her hands, and exited the room. During an interview on 02/10/26 at 10:47 a.m., RN H stated she did not put the gown on, because she forgot. RN H stated that residents' Suprapubic catheter care was a form of high contact which required Resident #13 to be on Enhanced Barrier Precautions and required the use of a gown and gloves during care. She said the risk of not wearing appropriate PPE was increased risk of infection and possible cross contamination among the residents. During an Interview with the DON on 05/14/26 at 07:25 a.m., he stated any resident that required Enhanced Barrier Precautions had signage on the resident's door, and for any high contact activity which included transfer, peri care, and any medical device care, the staff had to wear gown and gloves. He stated he and the unit managers were responsible for training staff in infection control. The DON further stated training for Enhanced Barrier Precautions was done on hire, on monthly staff meeting, and as needed. The DON stated they used Enhanced Barrier precautions to prevent infection to high-risk residents. During a follow-up interview with the DON on 05/14/26 at 11:50 a.m. he stated the staff had been trained on the proper sanitizing of glucometers and when to perform hand hygiene during glucose monitoring. He stated the staff were to use the EPA approved Sani-wipes to clean the glucometers and ensure they were to wait the required contact time to ensure the glucometer was disinfected. He stated staff were to always perform hand hygiene after any procedure, before moving to the next procedure. He stated the risk of not following the proper procedures was cross contamination and potential for the spread of blood borne pathogens. He stated staff were to change their gloves and perform hand hygiene after they performed incontinence care and before applying the clean brief and always before going from dirty to clean. He stated by not following proper hand hygiene it placed residents at risk of urinary tract infections. He stated they had just completed staff training on infection control and enhanced barrier precautions on 04/30/26. He stated he and the unit managers will continue to train and make rounds to ensure the staff were following the correct procedures. Review of the facility policy titled Infection prevention and control policies and procedures, dated 03/15/2023 revealed Subject: Transmission-Based/standard Precautions, and enhanced barrier precaution .1. Enhanced Barrier Precautions (EBP) – Expand the use of PPE (Gown and gloves) during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. B. Enhanced-Based Precautions are implemented during the following high-contact resident care: . 7) Device care or use: Central line, urinary catheter, feeding tube. Record review of the facility's policy titled, Disinfection of Patient/Resident Care Equipment: Blood Glucose Meters, dated May 2023, reflected, .Blood glucose meters and point of care testing devices are at high risk of becoming contaminated with bloodborne pathogens.The facility uses a two-step cleaning and disinfecting procedure between every patient/resident use.Use an EPA disinfectant wipe.to remove any visible contaminants, soil or other debris.Use a second EPA wipe disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.Contact time is the total time needed for the disinfectant solution to remain wet on the surface to achieve disinfection of all the stated efficacy kill claims. The contact time requirements can be located on the product label. Record review of the facility's policy titled, Hand Hygiene/Hand Washing, dated September 2011, reflected, .Hand Hygiene/hand washing is done: .Before Patient/resident contact.After.contact with soiled or contaminated articles, such as articles that are contaminated with body fluids.After patient/resident contact.After removal of medical/surgical or utility gloves.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of six residents (Resident #37 and Resident #20) reviewed for pharmacy services. 1. The facility failed to ensure LVN B followed the manufacturer's instructions to prime the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in the required amount of Insulin to be administered to Resident #37 on 05/12/26. 2. The facility failed to ensure RN A followed the manufacturer's instructions to prime the Humalog pen (Insulin Lispro) (Hormone) and the Liraglutide (Hormone) prior to dialing in the required amount of Insulin and Glucagon-like peptide-1 hormone to be administered to Resident #20 and failed to ensure RN A held the pen to Resident #20's skin the required amount of time to ensure complete administration of the Humalog on 05/12/26. These failures placed residents at risk of not receiving the full dosage of medication. Findings included: 1. Record review of Resident #37's, Face sheet, dated 05/14/26 reflected a [AGE] year-old female with an admission date of 05/02/26. Resident #37 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). Record review of Resident #37's Physician's Order for May 2026, reflected, Insulin lispro insulin pen: 100 unit/ml; amt: 4 units; subcutaneous (under the skin) .Three times a Day before Meals. with a start date of 05/02/26. An observation on 05/12/26 at 11:22 a.m. revealed LVN B put on gloves and entered Resident #37's room to obtain a fingerstick blood sugar. The blood sugar reading was 153. LVN B returned to the medication cart and checked the computer to determine the amount of insulin was 4 units of Lispro insulin. LVN B retrieved the insulin pen from the medication cart and attached a needle and dialed in 4 units without priming (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the pen to ensure all air was expelled. LVN B put on gloves and entered Resident #37's room and administered the insulin to Resident #37. During an interview on 05/12/2026 at 11:28 a.m. with LVN B she stated she was not aware she had to prime the Insulin pen. She stated she had not read the manufacturer's instructions on administration but stated going forward she would prime the pen each time. 2. Record review of Resident #20's, Face sheet, dated 05/14/26 reflected a [AGE] year-old male with an admission date of 03/24/26. Resident #20 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy) Record review of Resident #20's Physician's Orders for May 2026, reflected, Insulin lispro insulin pen: 100 unit/ml; amt: 12 units; subcutaneous.before Meals. with a start date of 04/28/26. liraglutide pen injector; 0.6 mg/0.1 mL (18 mg/3 mL); amt: 0.6mg; subcutaneous.once a day, with a start date of 05/12/26. During an interview on 05/12/2026 at 10:16 a.m. Resident #20 stated he did not think the staff was injecting his insulin correctly because he could feel it running down his hip some of the time. He stated he had told the staff and the doctor. During an observation on 05/12/26 at 11:30 a.m. revealed RN A put on gloves and entered Resident #20's room to obtain a fingerstick blood sugar. The blood sugar reading was 112. RN A returned to the medication cart, reviewed the orders, and stated Resident #20 gets routine 12 units of Insulin Lispro and then additional sliding scale based on his blood sugar. She stated today he would only get his routine dosage of 12 units. She stated the MD had also just ordered another medication to assist with blood sugar control and she would have to go to the medication room to retrieve the Liraglutide pen. RN A returned to the medication cart, then pulled the resident's Humalog (lispro insulin) pen and attached needles to both the Humalog pen and the Liraglutide pen. She then dialed in 12 units on the Humalog pen and 0.6 mg on the Liraglutide pen without priming either pen. RN A then sanitized her hands, put on gloves and entered Resident #20's room. She injected the Humalog in the resident's right lower abdomen, pushed the dose administration button and immediately pulled the pen away from the skin revealing an undetermined amount of insulin running down the resident's abdomen. She then injected the liraglutide in the residents' left lower abdomen, holding the pen against the resident's skin for about 6 seconds. During an interview on 05/12/2026 at 11:40 a.m. with RN A she stated she was not aware she had to prime the insulin pens or the Liraglutide. She stated she did know she was supposed to hold the pen against the resident's skin for 6 seconds and stated she did not realize she had not done that with the Humalog and stated she did not see the insulin run out. She stated the risk was the resident was not getting the proper amount of insulin. She stated going forward she would prime the pens and make sure she was holding the pens against the skin the required amount of time. In an interview with the DON on 05/14/26 at 11:50 a.m. he stated the insulin pen was to be primed with 2 units before each injection to ensure the air was out of the pen and to determine it was working correctly. He stated failure to do so could result in the resident receiving too little medication which could result in ineffective treatments and uncontrolled blood sugars. He stated he had just started with the facility and was not sure what education the nursing staff had received but stated he had already began re-educating the nurses on the proper protocol for priming the insulin pens and the amount of time required to hold the pen against the skin to ensure proper medication administration. He stated in addition their pharmacy consult will do random checks and observation with the staff during their monthly review. Record review of the facility's reference material titled, Insulin Pen Quick Reference Guide, dated 2021, reflected, Humalog (lispro) U100 Kwikpen .Air shot before each use-2 units hold dose knob for 5 seconds.References: Manufacturer Full Prescribing information and/or instructions for use. Review of the manufacture instructions for Lispro obtained from https://www.lillyinsulinlispro.com/ searched on 02/28/26 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps. Review of the manufacturer's instructions for Liraglutide obtained from https// www.Saxenda(R) (liraglutide) injection 3mg on 05/16/26, reflected, . Attach a new needle.Prime (flow check) for a new pen. If it's the first use of a new pen, turn the selector to the flow-check symbol (two dots). Point the needle up and press/hold the dose button until the counter shows 0. Look for a drop at the needle tip. Repeat up to six times if needed; if no drop appears, change the needle and try again. Do not use the pen if a drop still doesn't appear. Set your prescribed dose. Turn the dose selector to the dose your clinician prescribed.Choose and a clean site.Wipe with an alcohol swab and let it air-dry. Rotate locations to give skin time to recover. Insert and inject. Hold the pen so you can see the dose counter. Insert the needle.Press and hold the dose button until the counter shows 0. Keep the needle under the skin for at least 6 seconds to help ensure the full dose is delivered.

Based on observation, 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 time frames to meet residents' medical, nursing, mental and psychosocial needs, for 1 (Resident #129) of 8 residents reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #129's oxygen therapy. This failure could affect residents by placing them at risk for not receiving necessary care and services. Record review of Resident #129's Quarterly MDS assessment, dated 04/23/26 reflected a [AGE] year-old female with an original admission date of 11/22/23 and readmission date of 05/08/26. Pertinent diagnoses included hypertension (elevated blood pressure), diabetes mellitus type 2 (high blood sugar), Non-Alzheimer's Dementia (a group of brain disorders causing cognitive, behavioral, and language decline, often affecting individuals under 65), and Non-Traumatic Brain Dysfunction (damage to the brain caused by internal factors rather than external physical force). Resident#129 had a BIMS of 12 indicating moderate cognitive impairment. Section O-C1 reflected resident did require oxygen while residing at the facility. Record review of Resident #129's care plan dated 04/09/26 did not reveal oxygen therapy as a care area and/or problem. Record review of Resident #129's Order Summary Report dated 06/30/25, reflected O2 (oxygen) at 4 liters per minute via nasal cannula. EQUIPMENT Oxygen: Change O2 tubing/nasal cannula/mask/humidification system weekly. Once A Day on Thursday. Observation of Resident #129 in her room on 05/12/26 at 10:12 a.m. revealed resident was asleep and had oxygen on via nasal cannula. The concentrator (a medical device that pulls in ambient air, filters out nitrogen, and delivers purified oxygen (typically 90%-95% pure)) was set at 4 liters per minute. The nasal cannula tubing was not dated, the solution bottle on the concentrator was dated 04/28/26. In an interview on 05/14/26 at 07:15 a.m. with the MDS Nurse stated he was responsible for the care plans, initiation and update. He stated the charge nurses too had the responsibility to update the care plans any time there was a new order or change in resident's condition. He stated the care plans updates were done quarterly during the IDT meeting. When asked how this missing care plan could potentially affect resident care, he stated staff would not know how to care for the resident. Interview on 05/14/26 at 07:20 a.m. ADON L stated she was going in the last three months through the residents' care plans and updating, and she did not get to Resident#129's care plan yet. She stated she would like for Resident#129's oxygen therapy to have been care planned as ordered and those were her expectations, so all the direct care staff for the resident would know how to handle the oxygen therapy care. Interview on 05/14/26 at 07:25 a.m. with DON stated the expectation was to complete an audit of the residents' care plans by the MDS nurse, and the charge nurses, to make sure they were up to date. He stated residents' oxygen therapy should be care planned according to the doctor's orders. The DON stated the risk to residents the staff would not know the oxygen therapy was on if not care planned. Review of facility policy titled Care plan process, person-centered care, dated 05/05/2023, revealed, The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centeredcare of the resident that meet professional standards of quality care.6. The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #86) of 8 residents reviewed for ADLs. The facility failed to ensure Resident #86 had her fingernails cleaned and trimmed on 05/12/26. These failures could place residents who were dependent on staff for ADL care at risk for infections, and a decreased quality of life.Record review of Resident #86's quarterly MDS assessment, dated 04/08/26, reflected a [AGE] year-old female with an admission date of 09/22/25, and readmission on [DATE]. Resident #86 had active diagnoses which included hypertension (elevated blood pressure), type 2 diabetes mellitus (elevated blood sugar), cerebral vascular accident (stroke) hemiplegia (partial paralysis on one side of the body), and heart failure. Resident#86 had a BIMS score of 14/15 indicating intact cognition. Further review revealed she required partial/moderate assistance for personal hygiene. Staff assessment listed her as moderately cognitively impaired. Record review of Resident #86's care plan revised on 04/22/26 reflected, ADLS function status/rehabilitation potential .[Resident #86] .partial/moderate assistance .Interventions .encourage and provide positive feedback for any effort . Observation and interview on 05/12/26 at 10:19 AM revealed Resident#86 was lying in bed quietly, she had long nails on both hands, they were approximately 0.4 cm in length extending from the tip of her fingers. The nails were discolored tan and the underside, and the nail beds had dark brown colored residue. Resident #86 stated she wanted her fingernails trimmed and cleaned. In an observation and interview on 05/12/26 at 1:54 PM, CNA I looked at Resident#86's fingernails and stated, they needed to be trimmed and cleaned. She stated that Nurses and CNAs were responsible for cleaning and trimming residents' fingernails. She stated that for residents with diabetes, Nurses were responsible for trimming fingernails as needed. CNA I stated the risks of long, dirty fingernails included increased risk of infection and decreased quality of life. In an interview on 05/14/26 at 07:20 AM. ADON L stated nail care on all the residents should be done during the shower days, and as needed. She stated CNAs were responsible unless the residents were diabetic, and then the nurses were responsible. She stated the risk would be potential for infection and skin integrity problems. During an interview on 05/14/26 at 07:25 AM, the DON stated CNAs were responsible for checking on residents and providing appropriate care and grooming every shift and as needed. He stated the nurses in charge for the Halls were also responsible for checking on residents to ensure their needs were met. The DON stated not providing appropriate care, and grooming placed residents at risk of infection, skin breakdown, and dignity issues. Record review of the facility's policy titled, Activities of daily living, optimal function with revise dated May 5, 2023, reflected, The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 (Resident #129) residents reviewed for respiratory care. The facility failed to ensure Resident #129's oxygen tubing was dated, and the humidifier bottle changed weekly per MD order on 05/12/26. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.Record review of Resident #129's Quarterly MDS assessment, dated 04/23/26 reflected a [AGE] year-old female with an original admission date of 11/22/23 and readmission date of 05/08/26. Pertinent diagnoses included hypertension (elevated blood pressure), diabetes mellitus type 2 (high blood sugar), Non-Alzheimer's Dementia (a group of brain disorders causing cognitive, behavioral, and language decline, often affecting individuals under 65), and Non-Traumatic Brain Dysfunction (damage to the brain caused by internal factors rather than external physical force). Resident#129 had a BIMS of 12 indicating moderate cognitive impairment. Section O-C1 reflected resident did require oxygen while residing at the facility. Record review of Resident #129's care plan dated 04/09/26 reflected the oxygen therapy for the Resident had not been care planned. Record review of Resident #129's Order Summary Report dated 06/30/25, reflected O2 (oxygen) at 4 liters per minute via nasal cannula. EQUIPMENT Oxygen: Change O2 tubing/nasal cannula/mask/humidification system weekly. Once A Day on Thursday. Observation of Resident #129 in her room on 05/12/26 at 10:12 a.m. revealed resident was asleep and had oxygen on via nasal cannula. The concentrator was set at 4 liters per minute. The nasal cannula tubing was not dated, the solution bottle (for an oxygen concentrator is a humidifier bottle (or bubbler) used to add moisture to the oxygen, preventing your nose and throat from drying out) on the concentrator was dated 04/28/26. In an observation and interview on 05/12/26 at 1:08 p.m. LVN K looked at Resident #129's oxygen tubing and stated it was not dated, and looked at the bottle solution on the concentrator, and stated she would change the bottle to a new one, because that one had a 04/28/26 date on it. LVN K stated it was the responsibility of the nurses to check the oxygen tubing every shift and make sure they were up to date, and it was the responsibility of the night shift nurses to change the tubing and the concentrator solution bottle weekly. She stated not changing the concentrator's tubing and solution bottle as ordered could cause development of infection, and the solution may not be effective and cause dry nose and throat for the resident. In an interview with the DON on 05/14/26 at 07:25 a.m. the DON stated, his expectations were for the nurses to change the oxygen therapy tubing weekly and as needed, label with the date, and for the solution bottle to be changed weekly and if it became emptied during the week period and also dated. He stated the risk to residents not getting oxygen therapy properly, could be drying of the nasal cavity, and a source of infection if it stayed longer than one week. Record review of facility policy titled Respiratory policies and procedures revised April 01, 2022 reflected Subject: Oxygen Therapy general policy.15. Label tubing and humidifier with date, time, and RC practitioner initials.

Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. -The facility failed to ensure that one of one deep fryer grease was clean. -The facility failed to ensure that the stove in the kitchen was kept clean. -The facility failed to ensure that the rail above the stove was free of grease. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination Kitchen observation and interview with the Dietary Manager on 03/17/25 at 8:45AM, revealed the following: The cooking area revealed the deep fryer had dark looking grease with brown floating substances on top of the grease. In the interview, the Dietary Manager said the grease was supposed to be changed weekly. She was not sure when it was changed last, sometimes last week. Observation of one of two stoves in the kitchen revealed baked on grease (a dark looking substance inside the oven). The Dietary Manager said the stove needed to be cleaned. Observation of the grill above the cooking stove revealed the grease trap rails above the stove had grease dripping along the rail. In an interview the Dietary Manager said the commercial cleaners did clean the grill and the rails . She said she would look to find out when it was last cleaned. She said she was responsible to check to ensure that all areas of the kitchen were clean, but all kitchen employees were responsible for cleaning behind them . She said cooking in an unclean environment may lead to cross contamination and food burn illness. During an interview with the facility's Dietitian on 03/19/25 at 12:05PM he said the Dietary Manager was new and had done a great job cleaning the kitchen. He said the Ddietary Manager was about 3 weeks old at the facility. He said he was at the facility once a week and as needed. He said he provide education and observe meal services from time to time. Record review of fFacility's policy on kitchen sanitation dated 2020 and revised 06/20/2023 revealed in part SUBJECT: SANITATION & FOOD SAFETY IN FOOD AND NUTRITION SERVICES POLICY: The Certified Dietary Manager (COM) will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. PROCEDURES: 1. Infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food borne illness. (Refer to Exhibit 2E, Major Food Borne Illnesses in section J of this manual).

51036 Based on observation, interview and record review, the facility failed to ensure that assessments accurately reflected resident's status for 3 (Resident #9, Resident #43 and Resident #380) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure that Resident #9's Admission MDS dated [DATE] accurately reflected her inability to hear normal conversation and her oral dental need. The facility failed to ensure that Resident #43's quarterly MDS dated [DATE] accurately reflected the resident had functional limitation in range of motion of upper and lower extremities. The facility failed to ensure that Resident #380's discharge MDS dated [DATE] accurately reflected the resident's fall that occurred on 2/8/25. These failures could place residents at risk of receiving inadequate care and services based on inaccurate assessments. Findings include: Resident #9 Record Review of Resident #9's face sheet dated 3/19/25, revealed [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified fracture of the T9-T10 vertebra (primary diagnoses) rib fracture left side , heart disease, Essential hypertension, hypothyroidism (a condition that occurs when the thyroid gland doesn't make enough thyroid hormone), pain and muscle weakness. Record review of Resident #9's admission MDS dated [DATE] revealed her BIMS score was coded as 14 out of 15 which indicated she was cognitively intact. On hearing, speech, and vision she was coded as adequate. On oral dental status she was coded as Z which indicated no problem with her oral cavity. Observation and interview on 03/17/25 at 10:50 AM revealed Resident was sitting in her chair between her bed and her roommate. Observation revealed she had her glasses on , and a dental cup was on her nightstand. During the interview, she stated several times that she could not hear and said to speak louder because she was hard of hearing. A writing pad was used during the interview. She said she had dentures, and her lower dentures were in the dental cup on her nightstand. She said she did not wear her dentures because the lower dentures didn't fit and needed adjustment. She said it was hard to eat certain food items if not soft enough. She said she had a cavity on one of her upper teeth . During an interview with the MDS Coordinator on 03/18/25 at 2:50PM he said he was not responsible for section L of the MDS. He said section L (oral dental section of the MDS) He said that section of the MDS was done by speech therapy and if a resident needed a dental examination, the Social Worker would add the resident's name to the list . During an interview with the Speech therapist on 03/18/25 at 3:40PM, she said she assessed residents recommended to her due to swallowing difficulty such as dysphasia , and those who hads strokes. She said she assessed for the ability to swallow. During an interview with the DON on 03/19/25 at 10:40 AM, she said the MDS (PPS) Ccoordinator was responsible for ensuring that all MDS assessments accurately reflected the resident's condition. Resident #43 Record Review of Resident #43's face sheet dated 3/19/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Stiffness of Right Hand, Stiffness of Left Hand, Cerebral Infarction (Stroke) and Hemiplegia (one sided weakness or paralysis) and Hemiparesis (weakness in one leg, arm, or side of the face) affecting Right Dominant Side. Record review of Resident's #43's quarterly MDS dated [DATE] revealed that BIMS could not be conducted. It was also revealed in section GG0115 completed by the MDS Coordinator/PPS Coordinator the resident did not have any limitations captured for the upper or lower extremities. Record review of Resident #43's doctor's progress note dated 10/17/2024 revealed that Resident #43 had a CVA (Stroke) with right sided deficits and severe cognitive deficits. Record review of Resident #43's Physical Therapy Evaluation & Plan of Treatment dated 5/16/24 revealed Resident #43 had bilateral (both) lower extremity contractures (condition that causes limited movement of a joint). Record review of Resident #43's Physical Therapy Treatment Encounter Note dated 6/20/24 revealed the resident had bilateral lower extremity contractures (condition that causes limited movement of a joint). Record review of Resident #43's care plan revealed Resident #43 had a history of CVA (Stroke) and right hemiparesis (weakness in one leg, arm, or side of the face), aphasia (inability to comprehend or communicate) and dysphagia (difficulty swallowing) with a start date of 1/1/24. Observation on 3/18/25 at 1:15 p.m., revealed Resident #43's legs were bent and drawn up towards his trunk. During an interview on 3/19/25 at 9:35 a.m., LVN L said that Resident #43 had weakness in his right arm and leg, and they were contracted. During an interview on 3/19/25 at 9:48 a.m., ADON A said that Resident #43 was contracted. ADON A said that Resident #43 had diagnosis of hemiplegia/hemiparesis of the right dominant side and stiffness of the left hand. During interview on 3/19/25 at 10:10 a.m., the MDS Coordinator/PPS Coordinator said that Resident #43 had weakness but was not contracted that limited his range of motion to be able to do things like dressing. Resident #380 Record Review of Resident #380's face sheet dated 3/19/25, revealed resident is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (Chronic Lung Condition causing Restricted Airflow), Unspecified Atrial Fibrillation (Irregular Heartbeat) and Type 2 Diabetes Mellitus. Record review of Resident #380's quarterly MDS dated [DATE] revealed a BIMS score of 9 that suggested moderate cognitive impairment. Record review of Resident #380's discharge MDS dated [DATE] revealed in section J1800 the resident had not had any falls since admission/entry or reentry or to the prior assessment. Record review revealed Resident #380 had MDS assessments completed on 2/7/25 and 3/6/25. Record review of Resident #380's Search Progress Notes for 2/8/25 revealed that LVN I documented on 2/8/25 at 07:30 a.m. Resident #380 was found on top of his fall mat on the floor lying on his left side. During an interview on 3/19/25 at 9:48 a.m., ADON A said that LVN I had documented regarding Resident #380's fall on 2/8/25 that he was having agitation and restlessness and had thrown items on the floor. ADON A said that per LVN I's documentation he was found on top of the fall mat. ADON A said she worked on 2/8/25 but was not working at the time of Resident #380's fall. During interview on 3/19/25 at 10:03 a.m., the MDS Coordinator/PPS Coordinator said that if the MDS was not correctly completed then the facility may not be adequately able to provide for the resident. During interview on 3/19/25 at 10:10 a.m., the MDS Coordinator/PPS Coordinator said he would have to review Resident #380's chart and if he missed a fall then he would correct the MDS. During interview on 3/19/25 at 10:15 a.m., the MDS Coordinator/PPS Coordinator said he made a mistake regarding the MDS for Resident #380 and had missed the fall. The PPS Coordinator said he updated the discharge MDS dated [DATE] to reflect the fall. Record review of Resident 380's corrected discharge MDS dated [DATE] completed by MDS Coordinator/PPS Coordinator revealed in section J1800 that resident had fallen since admission/entry or reentry or the prior assessment. The Surveyor attempted to contact LVN I on 3/19/25 at 2:05 p.m. but was unable to reach LVN I or leave a voicemail. During interview on 3/19/25 at 2:52 p.m., the DON said the PPS Coordinator is who completed the MDS. The DON said that when the MDS was ready to be transferred she would check to see if the MDS was completed. The DON said that the MDS Coordinator checked the MDS for accuracy. During interview on 3/19/25 at 2:56 p.m., the Administrator said that PPS Coordinator was the MDS Coordinator who managed the MDS' and agreed he would be the one to check for accuracy. Record review of facility's Nursing Policies and Procedures with subject MDS - Primary Assessment with email revision on 9/28/2023 revealed The facility will complete its state-specific version of the Minimum Data Set (MDS) based on the Primary Reason for Assessment within the required timeframes according to applicable low and regulations.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #73 and #119) of 6 residents and 3 of 4 staff (CNA I, CNA J, CNA K) reviewed for infection control. The facility failed to ensure that proper signage was in place for Resident #73 and Resident #119 who were on enhanced barrier precautions. The facility failed to ensure that CNA I, CNA J, and CNA K were knowledgeable and able to appropriately answer questions regarding enhanced barrier precautions. The facility failed to ensure that CNA I was wearing PPE while caring for Resident #73 who was on enhanced barrier precautions. The failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: Resident #73 Record Review of Resident 73's face sheet dated 3/19/25, revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (Kidney Failure) and dependence on renal (kidney) dialysis. Record review of Resident #73's quarterly MDS dated [DATE] revealed a BIMS score of 13 that suggested cognition was intact. Record review of Resident #73's care plan revealed that EBP during tube feeding/wound care or close contact with wound. PPE required: gloves, gowns, face protection of procedure has risk of splashes or sprays. with approach start date of 12/9/24. Record review of Resident #73's orders revealed active orders dated 3/19/25 related to g-tube (a tube inserted into the stomach for feeding, hydration and medications) site care since of 3/6/2025. Observation on 3/17/25 at 10:22 a.m. of Resident #73's door, room and hallway revealed there was no signage regarding enhanced barrier precautions. Observation on 3/18/25 at 2:15 p.m. of Resident #73's door and hallway revealed that there was no signage regarding enhanced barrier precautions. Observation on 3/18/25 at 3:25 p.m. of Resident #73's door and hallway revealed that there was no signage regarding enhanced barrier precautions. During an interview on 3/18/25 at 3:35 p.m., RN M said that Resident #73 should be on enhanced barrier precautions and that supplies of PPE were kept in the resident's top dresser drawer in their room. During an observation on 3/18/25 at 3:45 p.m., revealed RN M showed the gloves on top of the dresser in Resident #73's room but there were no gowns in the dresser or room that could be found by RN M. During an interview on 3/18/25 at 3:45 p.m., CNA I said that Resident #73 was not on precautions right now but had been before. CNA I denied wearing a gown while bathing or changing Resident #73. Resident #119 Record Review of Resident #119's face sheet dated 3/20/25, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Nontraumatic Intracerebral Hemorrhage (Brain Bleed), Dysphagia (Difficulty Swallowing) and Gastrostomy (Feeding tube inserted in Stomach) Status. Record review of Resident #119's comprehensive admission MDS dated [DATE] revealed a BIMS could not be completed. Record review of the MDS also revealed the resident has a feeding tube while a resident. Record Review of Resident #119's orders revealed an active order for enteral feeding tube site care since 1/10/25. Record review of Resident #119's care plan with problem start date of 1/20/25 revealed that EBP during tube feeding/wound care or close contact with Enteral feeding site. PPE required: gloves, gowns, face protection if procedure has risk of splashes or sprays. Observation on 3/17/25 at 10:59 a.m. of Resident #119's door, room and hallway revealed that there was no signage regarding enhanced barrier precautions. Observation on 3/18/25 at 2:15 p.m. of Resident #119's door and hallway revealed that there was no signage regarding enhanced barrier precautions. Observation on 3/18/25 at 3:26 p.m. of Resident #119's door and hallway revealed that there was no signage regarding enhanced barrier precautions. Interview on 3/18/25 at 3:35 p.m., RN K said that Resident #119 should be on enhanced barrier precautions. RN K said there should be a sign on the outside of the resident's door and if it was not there then it must have fallen. Interview on 3/18/25 at 3:42 p.m., CNA H said Resident #119 was on enhanced barrier precautions and she would wear a gown while changing the resident. Interview on 3/18/25 at 3:49 p.m., CNA J said she would know if a resident was on enhanced barrier precautions by the sign on the door. When asked what kind of residents would need to be on enhanced barrier precautions, CNA J said residents who wore briefs or were incontinent. Interview on 3/19/25 at 9:49 a.m., CNA J said she had given the wrong answer yesterday regarding what residents would need to be on enhanced barrier precautions and enhanced barrier precautions were for residents with g-tubes and a Foley catheter. CNA J said she would wear a gown and gloves and a mask depending on the situation for residents with enhanced barrier precautions. Interview on 3/19/25 at 9:44 a.m., CNA K said that enhanced barrier precautions were everyone who was bedbound, needed barrier cream and rolled every two hours. CNA K said she would know if a resident was on enhanced barrier precautions by the orange sign on the door and she would wear a gown if the resident was on enhanced barrier precautions. Interview on 3/20/25 at 2:52 p.m., the DON said she took note of residents with wounds, foley catheters (tube inserted into the bladder to drain urine), traches (a hole surgically made in the throat to assist with breathing) and feeding tubes which triggered the enhanced barrier precautions. The DON said that in their daily morning meetings they reviewed residents for enhanced barrier precautions. The DON said that when a resident triggered for enhanced barrier precautions then the orange sign was placed on the resident's door and PPE placed in the resident's room. The DON said that then the enhanced barrier precautions was added to the resident's care plan. The DON said that she checked to make sure that the enhanced barrier precautions have been added to the resident's care plan and that PPE was in the resident's rooms. The DON said there was PPE available in the large restroom on the garden side of the facility and PPE is kept in the resident's drawers or armoire on the presidential side of the facility. The DON said she kept track of residents who were on enhanced barrier/isolation precautions using an excel spreadsheet and that she checked and update the spreadsheet every 2-3 weeks. Record Review of facility's Infection Prevention and Control Policies and Procedures with subject Transmission Based/Standard precautions, and Enhanced Barrier Precautions revised 5/15/23 revealed that enhanced barrier precautions which includes the use of gowns and gloves will be implemented during high-contact resident care activities for residents who have wounds and/or indwelling medical devices. Record review also revealed that enhanced barrier precautions will be implemented during high-contact resident care activities that include dressing, bathing/showering, transferring, providing hygiene, changing linens, and changing briefs or assisting with toilet. Record review also revealed The facility will post clear signage on the door or wall outside of the room indicating the type of precautions.

Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 2 of 3 residents (CR #127 & CR #128) reviewed for discharge summary. The facility failed to complete a discharge summary for CR #127. The facility failed to complete a discharge summary for CR #128. These failures could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: CR #127 Record review of the face sheet for CR #127 revealed a 77- year- old male who admitted to the facility on [DATE] with diagnoses that included, malignant neoplasm of brain (brain cancer), dementia (a condition in which a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with activities of daily life), repeated falls, pain, and seizures. Record review of CR #127's EMR on [DATE] at 11:40 am revealed that CR #127 died at the facility on [DATE] and had no discharge summary. CR #128 Record review of the face sheet for CR #128 revealed [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included End -stage renal failure , hypertensive chronic kidney diseases (commonly known as high blood pressure, heart failure, anemia, (Low red blood count), hypothyroidism (a condition where (the thyroid gland does not produce enough thyroid hormone), and dysphasia (swallowing difficulty) and pain. Record review of CR #128's clinical records revealed he was admitted to the facility on [DATE] and was discharged from the facility on [DATE]. Records review of CR #128 revealed no evidence of discharge summary. Record review of CR #128's Discharge MDS dated [DATE] revealed CR #128 was discharge from the facility returned not anticipated. Interview on [DATE] at 11:56 am with PPS Coordinator (MDS) said there was not a discharge summary for CR #127 in his EMR. The PPS Coordinator said the SW was responsible for completing the discharge summary on all residents. Interview on [DATE] at 12:33pm with the SW who said they did not find a discharge summary for CR #127 in the EMR. The SW said that they did not complete a discharge summary for CR #127 because they did not know they were responsible for completing the discharge summary if a resident passed away. The SW said they thought the charge nurses were responsible for completing the discharge summary for any resident who had an unplanned discharge. The SW said they were only responsible for completing the discharge summary for residents with planned discharges . Interview with the DON on [DATE] at 1:00pm who saidrevealed per the facility policy and procedure, the SW was responsible for completing the discharge summary on all residents' which included both planned and unplanned discharges. Interview with the Administrator on [DATE] at 2:41 pm who saidrevealed they were the direct supervisor of the SW but that the Regional Consultant trained the SW on their job duties which included the completion of forms. In an interview with the facility SW on [DATE] at 3:00PM, sheShe said CR #128 requested to be sent to the hospital and CR #128 was on a special program. She said she did not do the discharge summary because the program that was responsible for CR #128 discharged CR #128 from the program. Attempted telephone interview with the Regional Consultant on [DATE] at 3:04pm and again on [DATE] at 11:48am but was unable to reach prior to facility exit. Follow up interview with SW who said they were trained by the Regional Consultant onand the facility's discharge summary process, but the training only included planned resident discharges. and planned discharges. The SW said they were never trained on completing the discharge summary for resident's who died , because usually when a resident passeds away, the charge nurse completeds the documentation and then discharged s the resident from the electronic medical record system. The SW said they did not know how to complete a discharge summary after a resident was discharged from the computer system, without reactivating the resident in the computer system. The SW said they never asked any questions regarding the discharge summaries for residents with unplanned discharges because it was never an issue until surveyor's began asking questions about the unplanned discharges for residents without discharge summaries . Record review of the facility's policy titled, Social Services Policies and Procedures .Subject: Discharge Summary, dated Complete Revision: [DATE], revealedread in part .A discharge summary is also completed when a resident is fully discharged from the facility (i.e., to another nursing facility, to the community or death).2. The Discharge Summary is completed when the patient or resident is permanently discharged for any reason and return to the facility is not anticipated.3. Each discipline is responsible to complete a section of the Discharge Summary-the Social Worker will initiate the DC Summary for all discharges. 39977

Based on interview, and record review, the facility failed to ensure a resident who displayed or diagnosis with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1(Resident #51) of 5 residents. The facility failed to follow up to ensure Resident #51 received a psychiatric consultation after an order was written on 09/19/2024 from the physician. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings Included: Record review of Resident #51's admission face sheet dated 05/08/2024 indicated an [AGE] year-old female. Resident #51 was admitted with a diagnose of the following: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder. Record review of Resident #51's physician orders dated 9/19/24 read in part consult Deer Oaks for psychological and psychiatric services, med management, may provide psychiatric services. DX: Depression, unspecified. Record review of Resident #51's admission assessment dated [DATE] reflected Resident #51 having a BIMS score of 11 which indicated she had moderate cognitive impairment. Resident #51's mood interview in Section D of the MDS assessment noted Resident #51's total severity score was 11 which could indicate moderate anxiety, depression, or conditions which required further assessments. Record review of Resident's #51's care plan revealed in part: Problem Start Date: 05/14/2024. Category: Behavioral Symptoms resident is having mood and behavior needs as evidence by periods of refusing ADL care, Therapy services, and medications including eye drops. Long Term Goal Target Date: 06/18/2025. Resident will have a reduction in unwanted mood or behaviors, for an increased quality of life by end of next 90-day review. Further review revealed, on 5/24/24 Resident #51's care plan was updated with interventions in place for promptly arrange for psychiatric services for Resident #51 after a displayed increased signs of anxiety and aggressive behaviors dated on 5/14/24. Record review of Resident #51 physician progress notes dated from 2/01/24 to 03/18/2025 revealed no documentation of any referral to psychiatric services. There was no documentation of any physician or nurse practitioner notification for psychiatric related services. Interview with the Director of Nursing on 3/18/25 at 1:00PM revealed She cannot explain why the order was not carried out or followed up on and she believed Resident's #51's responsible party declined services. Interview with the MDS nurse on 3/18/25 at 1:45PM revealed awareness of the care plan addressing Resident #51's goals and interventions was to be seen by psychological consult but did not know why she was not seen or followed up on. Interview with the facility Social Worker on 3/18/25 at 2:30PM revealed awareness of the order written for Resident #51. The facility had 2 social workers and she only did short term residents, and the other Social Worker did long term care. The Social Worker stated she was aware of the facility policy for psychological referrals but could not answer as to why Resident #51 was not seen. The facility currently use Deer Oaks company for psychological services, and she did not see Resident's #51's name on the list to be seen. It was believed Resident's #51's responsible party declined services but did not have any documentation for declining services. Social Worker stated due to Resident #51 not getting the psych services she could have a decline in her mental state which could lead to behavior problems. Interview with the long-term social worker on 3/18/25 at 4:15PM, she stated she was not aware of order written for Resident #51. Social worker stated due Resident #51 not receiving psychological services could put Resident #51 at risk for further mental health decline. Interview with Resident's #51's responsible party on 3/19/2025 at 11:35am revealed she was not aware of any orders for Resident#51's needing to see psych services. Record review of the facility's policy on psychological services dated 06/09/2023 revealed ? the following: SOCIAL SERVICES POLICIES AND PROCEDURES SUBJECT: ASSESSMENT AND ANALYSIS OF BEHAVIOR HEALTH NEEDS POLICY: Staff will utilize a knowledge and understanding of mental illness, trauma, substance abuse, disease process and cultural diversity to assess the potential needs of each resident. The staff will incorporate behavior management techniques and cultural knowledge to assist patients/residents in reaching and maintaining their highest practical physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and care plan. The assessment includes evaluation of emotional and mental wellbeing, and prevention and treatment of mental and substance abuse disorders. Social Services or designated staff will facilitate community referrals to meet the needs of the resident related to mood, behavior, mental illness, or cultural identity. PROCEDURES: 1. Evaluate for and identify potential issues related to mental illness, substance abuse, disease process, trauma, and cultural diversity to assist in completing a comprehensive assessment related to mood, behavior, quality of life and personal preferences. Social Services or designee will make referrals for further evaluation, treatment, or support in a timely manner. The assessment will be completed within 7 days of admission to the facility and periodically, as needs are identified. 2. Patients or residents not initially identified as having mental or psychosocial adjustment difficulty who are later diagnosed or identified have medical record documentation to justify why needs were not identified. An example of this documentation would include, Symptoms did not initially manifest, and family was unaware or not forthcoming about past needs. Once needs become evident evaluations/assessments will be completed to ensure needs are documented and a plan of care developed.

Based on interview and record review, the facility failed to provide or obtain laboratory services ordered by the physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law, including scope of practice laws, to meet the needs for 1 (Resident #380) of 6 residents reviewed for laboratory services. The facility failed to ensure that blood glucose checks that were ordered on 3/17/25 were performed on 3/18/25 and before breakfast on 3/19/25 for Resident #380. The failure could place residents at risk of not receiving timely diagnosis or treatment, and not receiving appropriate monitoring for health and well-being. Findings include: Record Review of Resident #380's face sheet dated 3/19/25, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation (Irregular Heartbeat) and Type 2 Diabetes Mellitus. Record review of Resident #380's quarterly MDS dated [DATE] revealed a BIMS score of 9 that suggested moderate cognitive impairment. Record review of Resident #380's orders revealed an order dated 3/17/2025 for AC bg check Three Times A Day Before Meals 08:00 AM, 12:00 PM, 04:00 PM. Record review of Resident #380's Recent Progress Notes revealed on 3/17/25 at 6:29 p.m. that ADON A documented resident request bg's be assessed due to blood sugars being elevated during hospital stay recently. MD/NP/PA made aware, new order for bg ac. endorsed accordingly. Record review of Resident #380's Search Vitals Results for documented blood sugars revealed no blood sugars were documented before 3/19/2025 at 10:03 a.m. During an interview on 3/17/25 at 9:45 a.m., Resident #380 said that the nurse was going to have to start checking his blood sugars. During an interview on 3/19/25 at 9:48 a.m., ADON A said the resident's blood sugar results should be on a flow sheet in the electronic medical record. ADON A checked Resident #380's electronic medical record but was unable to find any blood sugar results documented. ADON A said she entered the order for Resident #380's blood sugars on 3/17/24 and the blood sugar order went to the wrong flow sheet. ADON A said she updated the electronic medical record now so Resident #380's blood sugars would be on the correct flow sheet. ADON A called RN L and instructed her to check Resident #380's blood sugar now. During an interview on 3/19/25 at 9:57 a.m., ADON A said that RN L notified her via phone that Resident #380's blood sugar was 158. ADON A instructed RN L to notified Resident #380's doctor regarding the blood sugar reading. During an interview on 3/19/25 at 10:32 a.m., the DON said that when an order was entered it would go over to the flow sheet which would trigger the nurse to know regarding new orders. The DON said the order should go on the 24-hour report for nurses. During an interview on 3/19/25 at 10:33 a.m., ADON A said that she did not put the order for blood sugar checks for Resident #380 on the 24-hour report for nurses. ADON A said that Resident #380's doctor had instructed to continue to monitor his blood sugars after being notified regarding his blood sugar level this morning. During an interview on 3/19/25 at 12:58 p.m., RN K said that new orders should be documented in the resident's chart and added to the 24-hour report which was a word documented that was updated and printed out nightly. During an interview on 3/19/25 at 1:00 p.m., LVN H said that information regarding new orders were passed along from shift to shift by being documented in the progress notes and the 24 hour nurse report sheet. During an interview on 3/19/25 at 1:07 p.m., MD A said that Resident #380 did not have any adverse effects to not having his blood sugars checked. During an interview on 3/19/25 at 1:07 p.m., ADON A said that Resident #380's blood sugar was 127 and Resident #380's hospice had updated the blood sugar check order to be daily and to notify hospice if the blood sugar was over 250. During an interview on 3/19/25 at 2:18 p.m., RN L said she did not work on 3/17/25 or 3/18/25 so she was not aware that Resident #380 had orders for blood sugar checks. RN L said that when a new order was received then the nurse would enter a progress note and then write on the 24-hour report sheet to endorse to the next nurse. Record review of the facility's Nursing Policies and Procedures revised May 5, 2023, with subject of Blood Glucose Monitoring revealed The facility provides point of care blood glucose monitoring according to standards of practice and infection prevention and control principles. Record review of facility's Nursing Policies and Procedures revised May 5, 2023, with subject Physician Orders revealed that staff should Record order changes in Progress Notes and 24-Hour Report.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #1) out of 3 residents reviewed for infection control, in that: The facility failed to ensure CNA B contained the dirty wipes after cleaning Resident #1; CNA B threw the used wipes across Resident #1 to the trash can located at the opposite side of the bed whilre providing incontinent care to Resident #1. The facility failed to ensure that CNA C did not put clean gloves in her scrubs pocket during incontinent care for Resident #1. These failures could increase the spread of infection and place residents living in the facility at risk of exposure to infections. Findings include: Record review of face sheet revealed Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His diagnoses include need for assistance with personal care, hypertension, acute respiratory failure, overactive bladder, communication deficits, shortness of breath, muscle wasting, constipation, generalized anxiety disorder, cognitive communication deficit. Record review of MDS (minimum data set) dated 2/28/2024 revealed Resident #1 needed extensive assistance for ADL care and required one-person physical assistant. Record review of the care plan dated 3/10/2024 revealed Resident #1 had impaired functional mobility and required assistance with ADLs, with interventions included to assess the degree of functional impairment and assist resident with ADL's (Activity of Daily Living) based on the current level of mobility. On 04/08/2024 at 3:15pm in an observation, CNA B was providing incontinent care on Resident #1. CNA B was cleaning Resident #1 and she was throwing the wipes across the bed to the other side where the trash can was located, some of the wipes fell on the floor. CNA C was assisting CNA B during the incontinent care. CNA C removed gloves from her scrubs pocket and donned them during the incontinent care. On 04/08/2024 at 3:35pm in an interview with CNA B, she stated she had training on infection control during hiring with hands-on checkoffs, and she also had an in-service on infection control too. She stated the deficient practice could potentially spread microorganisms into the air and cause contamination. On 04/08/2024 at 3:39pm in an interview with CNA C, she stated she was trained on infection control when she was hired at the facility. CNA C verbalized the understanding that her pocket was not sanitized and thereby contaminated the clean gloves. On 04/08/2024 at 8:10pm in an interview with the DON, she said tomorrow (04/09/2024) would be an excellent day for training because they actually had skills checkoff tomorrow and they did check offs on everything that the CNAs did like peri care/incontinent care, hand washing, donning gloves, and all kind of infection control stuffs. She stated they did that training monthly or yearly depending on what was going on. She stated Everybody gets training tomorrow and skills checkoff, just in case they forgot all the rules and regulations about patient care. The DON stated the deficient practice placed residents at risk for cross contamination and infection. Record review of facility policy titled 'Infection Prevention and control policies and procedures' dated 02/17/2021 revealed in part, the infection prevention and control program consist of currently acceptable infection control standards practices and activities, and training provided to employees regarding hand hygiene, hand washing, universal standard and transmission based precautions, proper handling of linens, waste, equipment and supplies.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement . The facility failed to prevent the following. 1. A Plastic Container of American Cheese dated [DATE]. 2. A Plastic Container of Mozzarella Cheese had no label and was not dated. 3. A Plastic Container of Powdered Cheese had no label was not dated. 4. A Plastic Container Cream Mexicana Sour Cream with expiration date [DATE] 5. A Plastic Container of Hard-Boiled Eggs, no label dated [DATE]. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on [DATE] at 6:30 AM revealed that leftover foods were not discarded prior to the use by date. 1. A Plastic Container of American Cheese dated [DATE]. 2. A Plastic Container of Mozarella Cheese had no label and was not dated. 3. A Plastic Container of Powdered Cheese had no label was not dated. 4. A Plastic Container Cream Mexicana Sour Cream with expiration date [DATE] 5. A Plastic Container of Hard Boiled Eggs , no label dated [DATE]. Interview with the AM Cook on [DATE] at 6:35 AM he stated that the leftover food stored in the refrigerator should have been used or discarded prior to use by date. Record review of facility's policies and procedures for food and safe handling dated [DATE] read in part .8. Foods are labeled to. identify container contents and the date it was prepared. Food items are stored in disposable, tightly covered containers, or sealable plastic bags. Items will be stored for three (3) days. Expired and unlabeled items will be discarded.

F656/3790 Based on observation, interview, and record review, the facility failed to implement person-centered care plans for each resident's services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 55 residents (Resident #119) reviewed for the development and implementation of comprehensive care plans. The facility failed to ensure Resident #119's refusals of showers was reflected in his comprehensive care plan. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Record review of Resident #119's face sheet revealed a 77-year -old male admitted on [DATE] at 10:08 PM . His diagnoses included other specified sepsis (condition in which the body responds improperly to an infection. The infection-fighting processes turn on the body, causing the organs to work poorly) (Primary, Admission), other specified diseases of anus and rectum, encephalopathy (conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form), unspecified, urinary tract infection, site not specified, cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), unspecified, hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle weakness (generalized), dysphagia (medical term for difficulty swallowing), unspecified, other lack of coordination, cognitive communication deficit, need for assistance with personal care, and other speech and language deficits following unspecified cerebrovascular disease. Record review of Resident #119's quarterly MDS assessment which assesses a resident's capabilities to perform ADLs, dated 01/15/2024, revealed the resident had a BIMS score of 10 out of 15 indicating the resident was moderately cognitively impaired. He required partial/moderate assistance with personal hygiene. Showering/bathe of self was left blank. The resident was shown to be incontinent in both urinary and bowel. Record review of Resident #119's Care Plan dated 01/18/2024, read in part .Problem: Start Date: 01/21/2024 Category: ADLs Functional Status/Rehabilitation Potential Resident #119 requires assistance with all ADL's r/t: impaired cognition and Dx of CVA w/Rt hemiplegia. Goal: Long Term Goal Target Date: 04/21/2024- Resident #119 will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over next 90 days. Approach: Start Date: 01/21/2024 staff will assist during bath/shower to the extent necessary while allowing Resident #119 to participate as much as they are able. The resident's Care Plan did not include the residents frequent shower refusals. Record review of residential Shower Book dated 01/01/2024-01/31/2024 noted resident refused on 01/12, 01/19, 01/24, 01/31. The log showed 01/08, 01/22, 01/26, 01/29, were blank and the resident received a Bed bath on 01/17, and a Shower on 01/15. Record review of Point of Care History dated 01/01- 02/01/2024 noted Resident #119 received one bath on 01/15/2024. Interview on 01/31/2024 at 1:05 PM with LVN A. She said every other day residents got showers and it was either Monday, Wednesday, Friday, or Tuesday, Thursday, Saturday. She said Resident #119 refused to shower a lot. She said she needed to write a note about him refusing to take a shower today. She said she did not see a note for his refusal . Interview on 01/31/2024 at 1:08 PM with the Shower tech/CNA. She said residents got showers every other day. She said usually a nurse would document that the resident refused to take a shower. She said there was a shower book of hers where she logged when a resident refused a shower/bath. She said she did not like to write refuse because then the later shifts would not attempt to ask the residents if they wanted a shower. She said she just asked Resident #119, and he refused to take a shower and he refused often to take a shower. She said she can usually talk him into taking a shower about every 2 weeks. She said one shower a week was not enough. She said infections could develop if a resident did not take a shower enough. Interview and observation on 01/30/2024 at 1:57 PM with Resident #119. The resident was lying in bed watching TV, water on bedside table, and call light on right side of bed. He was dressed in a blue shirt. There was a smell of body odor on the resident. He said staff treated him well, but he said he had not had a bath since he had been here. He said he did not know how long he had been at the facility. He said he thought he got the treatment and services he needed minus the showers. Interview and observation on 01/31/2024 at 1:03 PM with Resident #119. He said he had refused to take a shower twice while at the facility. He said he did not know how often he was supposed to get a shower. The resident still had a smell of body odor about him. Interview on 02/01/2024 at 10:57 AM with Resident #119. He said he refused a shower yesterday. Interview on 02/01/2024 at 11:05 AM with the Shower tech/CNA. She said sometimes residents just did not want a shower with her, but they do with the CNA at nighttime. She said she told the nurse for that shift whenever the resident refused their shower. She said Resident #119's shower day was yesterday, and he refused. She said she thought refusing showers should be on his care plan. She said she did not like to write refuse in the log or kiosk so that others will try and get them showered. Interview on 02/01/2024 at 12:20 PM with LVN B said Resident #119 had not been at the facility long, but every time he was asked about a shower, he only accepted one shower. She said he had been here for less than a month. She said it was a problem that he was not getting showers. She said the facility notified the family. She said his refusals were referred to the ADON. She said if a resident refused to shower, then another nurse talked with him. She said refusal of showers should be in the Care Plan . Interview on 02/01/2024 at 12:25 PM with LVN A said she did not know how often Resident #119 refused his showers. She said the shower tech told her he refuses often. She said shower refusals should be in the resident's Care Plan if a resident refused often enough . Interview on 02/01/2024 at 12:20 PM with the MDS Coordinator. He said regarding showers and baths, there was a Care Plan for ADLs that included hygiene. He said once it was determined there was an issue with something, then a behavioral plan for resistance or refusal of care was added to the Care Plan. He said shower refusals were added to the Care Plan when there was a history of that behavior and when he became aware of it. He said when they become aware and that it is not a onetime incident, the behavior would be added to the resident's Care Plan. He said he is worked at the facility for [AGE] years and his role at the facility was MDS coordinator. He said he worked Monday-Friday, 8 AM-5 PM. He said he was familiar with Resident #119. He said he knew he was admitted in the beginning of January for a stroke, and he did his comprehensive care plan. He said he became aware of today that he was refusing his showers after this state surveyor had requested shower logs for the resident. He said he did not know how long the resident had refused showers. He said policy or procedure for shower refusals was once staff were notified, the Clinical Interdisciplinary team meet and look at the incident/behavior from care standpoint. They notified RPs, and PCP, and arranged for a Care Plan meeting with the resident and try to determine the cause of refusal and work at resolving the issue. He said he did not know why he was not told sooner. He said when he did the resident's initial MDS that shower refusal behavior was not present. He said he was last in-serviced on care plans last year, about Springtime. He said the DON was responsible for ensuring Care Plans were implemented. He said the risk to residents was there was potential for them not receiving adequate care, and hygiene there could be adverse effects of health and skin. He said the worst thing that can happen to the resident when proper protocols are not practiced was the resident could receive inadequate care, and there was potential for injury. He said he thought the failure occurred in this situation, for him due to a lack of communication. In an interview on 02/01/2024 at 12:29 PM with the DON, she said she worked at the facility since 12/18/23. She said she worked 7 AM- 4 PM, Monday - Friday. She said she was not familiar with Resident #119. She said she had not heard anything negative, no complaining, and his documents said he was alert, but when talking with him, you can see he needed help. She said she mostly read papers, and refusals of the residents. She read over orders, printed reports on refusals of medications and supplements. She said she made sure Care Plans were accurate regarding refusal of medications or supplements. She said she depended on her ADONs for help. She said she was responsible for reports and the follow up on the reports. She said policy for Care Plans was if the resident was new, they needed an initial Care Plan, and the MDS Coordinator entered the Care Plans. She said she got more involved when there was a fall, refusal of medications/supplements, and wounds. She said if someone had an episode, or psychological issues then she would add that to the Care Plan. She said if a resident's behavior was brought to her attention, then the facility would Care Plan for that. She said there were a lot of refusals, but they are not shown in the documentation. She said she had heard recently in the last couple of days about Resident #119 refusing showers. She said she and the MDS Coordinator talked about Resident #119, and by printing out the report they saw that the resident refused, and it needed to be on his Care Plan. She said they are going to try other people to shower him. She said she would change the process of the shower tech to tell her personally about residents who had shower refusals. She said the process was that the Shower Tech should notify the ADON when there was a refusal for showers. She said she was last in-serviced on Care Plans last month. She said the nurse management team was responsible for ensuring protocol was followed regarding including refusals to the resident's Care Plan. She said the risk to the resident if policy or protocol was not followed was the resident may not get the best care. She said the worst thing that can happen to the resident when proper protocols are not practiced was the resident could have skin breakdowns. She said she thought the failure occurred because there was a breakdown in communication. She said it should go from the Shower tech to the nurse, from the nurse to the ADON, and from the ADON to the clinical team.

Based on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 01-30-24 at 7:10 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and the door was wide open. In an interview on 01-30-23 at 7:20 am, with the AM Cook, he stated that the dumpster doors always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of facility's Nutrition Policies and Procedures on waste disposal dated 6/20/23 read in part.1. Waste will be disposed. of in a manner to prevent transmission of disease, nuisance or breeding place for insects and feeding places for rodents and other. mammals. Procedures.5. Always cover waste containers and close dumpster's door.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (CR #1) of 5 residents reviewed for quality of care. The facility failed to ensure CR #1, who was cognitively impaired and wearing a wander guard, received adequate supervision when the facility sent him to the doctor's office unsupervised. CR #1 left the doctor's office and was found outside of a building in the rain by a bystander. An immediate jeopardy (IJ) was identified on 1/26/24 at 9:40 a.m. While the IJ was removed on 1/27/24 at 3:30 p.m., 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 and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of elopement or injury. Findings include: Record review of CR #1's face sheet dated 12/2/23 revealed a [AGE] year-old male admitted on [DATE] and discharged on [DATE]. His diagnoses were: metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), need for assistance with personal care, difficulty in walking, lack of coordination, bacteremia (the presence of bacteria in your blood), diabetes, acute kidney failure, chronic kidney disease, hypertension (high blood pressure), and pain. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. He required assistance with ADLs. No wandering behaviors observed during the lookback period. Record review of CR #1's care plan last revised 11/30/23 revealed he required assistance with all ADLs related to: impaired cognition, impaired communication, impaired balance and weakness, start date 11/19/23. He had impaired communication as evidenced by reduced ability to be understood by others, reduced ability to understand others, and impaired daily decision-making ability, start date 11/19/23. Approach included to provide a quiet, non-hurried environment, free of background noises and distractions. CR #1 had impaired cognition which may increase as the disease progresses, start date 11/19/23. Approach included to offer reassurance when confusion increases. Record review of CR #1's Elopement Risk assessment dated [DATE] revealed the resident was not alert and oriented to person, place or time, he was confused, and he did not have safe decision-making capabilities. He was aware of his surroundings, he did not have a history of wandering, he had not attempted or expressed a desire to leave the health care center or expressed discontent, he had not attempted to leave home, he was easily redirected and did not have a diagnosis that required supervision. Record review of CR #1's nursing note dated 11/29/23 at 12:44 p.m. written by LVN A revealed CR#1 was exhibiting exit seeking behavior. The writer reached out to the MD to request wander guard monitoring order for resident safety. Call back pending. Record review of CR #1's nursing note dated 11/30/23 at 11:14 a.m. written by LVN A revealed a call was received back from the MD. A new order was received: May apply wander guard to resident. Record review of CR #1's MD orders dated 10/31/2023 - 1/27/24 revealed there was no order for wander guard listed. Record review of CR #1's nursing note dated 11/30/23 at 11:50 a.m. written by LVN A revealed he was picked up by the transportation company via wheelchair for a scheduled appointment. Resident dressed, alert, and in stable condition. Record review of the local police department report for CR #1 dated 11/30/23 at 3:54 p.m. revealed a citizen found; a male in a wheelchair sitting in the rain in front of a cancer center in (City). Male in the wheelchair exhibited signs of mental illness and identified himself as (CR #1). He could not remember which nursing facility he was living at. EMS was notified and transported CR #1 to local hospital. Record review of CR #1's Emergency Department Record dated 11/30/23 at 4:26 p.m. revealed, .Emergency Notes: Patient received from (name) EMS stating that he wanted to be checked out Patient was found wandering outside in the rain by someone driving and was then picked up and taken to (local police department). Once at the police department, they called EMS to have the resident taken to the ER Patient was asked if he knew where he lived and patient stated, I don't know. Noted to have wonder guard (sic) on right wrist, so this nurse started to call facilities to find out where the patient lived .no visible injuries . no complaints of pain or discomfort . confusion noted throughout conversations . Record review of CR #1's local hospital records dated 11/30/23 at 4:35 p.m. revealed patient was brought to ED for evaluation. EMS stated patient was brought from jail for medical check. Patient states he was with his friend helping him do work outside when he was brought to the hospital. Patient states his permanent home is in a rehabilitation hospital, but he does not know which one although he states he was there last night. Patient denies any current complaints . Re-evaluation/Progress #1 please note after patient arrived it was found out he is a resident of a nearby nursing home. They state patient went to doctors visit unsupervised and wandered out and then police found him and brought him to the hospital . primary impression: wandering. Record review of CR #1's nursing note dated 11/30/23 at 4:51 p.m. written by LVN A revealed the facility received a call from the transportation company to report her driver was on scene of appt to pick up resident and clinic staff stated resident refused to be seen by the MD and was no longer at their facility. The ADON was made aware. Record review of CR #1's nursing note dated 11/30/23 at 5:18 p.m. written by LVN B (previous ADON) revealed she received a call from the local hospital about resident currently being in ER . transportation arranged with transportation company. Record review of CR #1's nursing note dated 11/30/23 at 7:00 p.m. written by RN P revealed citizen returned from the local hospital at this time. No s/s of distress noted. Record review of CR #1's nursing note dated 11/30/23 at 7:05 p.m. written by RN P revealed CR #1's MD was notified of his return to the facility. During an interview on 1/25/24 at 10:11 a.m. with LVN A, she said CR #1's exit seeking behaviors were that he made comments about wanting to go home and was going toward the front of the building. She said he would roam the halls and ask where the doors were but said she did not remember him coming to the front or going out of the building. She said she called the MD, and he gave an order to place a wander guard. She said on the day of his appointment (11/30/23) CR #1 was alert and talking. She said she gave CR #1's paperwork to the driver which was their normal protocol. She said she did not believe any staff went with CR #1 because he was his own RP, alert, and oriented x 2-3 (oriented to person and place; oriented to person, place and time), and able to consent for care. She said the facility would send a staff if the resident was demented, nonverbal, and not able to verbalize their needs. She said they redirected him, and he was not exit seeking after placing the wander guard and he knew it was best for him to stay in the facility for his safety. She said his exit seeking was more of a temporary thing and based on his behavior that day, and she did not feel he was trying to leave the building. She said the transportation company went to CR #1's MD appt to pick him up but he was not there. The clinic told transportation he refused to be seen and they did not know where he went. She said she reported the information to the ADON and the ADON began to make phone calls. She said she did not do anything after that. She said it was facility's job to ensure the resident was safe and she would assume a staff member needed to go to the appointment to ensure he was where he should have been and not get lost. During an interview on 1/25/24 at 10:37 a.m. with LVN B (previous ADON), she said she was not aware CR #1 left the building or had an appointment. She said the nurses may have scheduled CR #1's appointment on a day she was not at the facility. She said she was not aware if anyone went with him, and it was not appropriate for him to go alone because he was confused and would not have answered questions. She said staff accompanied a resident if they did not have family, were not alert and oriented, and could not sign paperwork on their own. She said if she had known about his appointment, she would have sent staff because he had a wander guard. She said he wore a wander guard because it was reported he made comments about family and wanted to go outside and was ready to go home. She said he was never exit seeking or went to the door to try to leave. She said CR #1 had episodes of confusion and would make comments about family but did not have family. She said CR #1 could get in his wheelchair and roll around with no problems. She said the nurse (LVN A) informed her transportation called to see where he was because they could not find him. LVN B said she called the hospital, doctors office, transportation company, Administrator, and nurse management to locate the resident. She said the local hospital called the facility and notified them that he was there. When he returned to the facility, CR #1 told her his brother and sister picked him up and he did not know where they were taking him. She said after the incident occurred (on 11/30/23) the facility conducted in-services with them and said once a resident was out of the facility for 2 hours, call the doctor's office and check on them. She said the facility also hired a transportation driver to help take residents to their appointments. During an interview on 1/25/24 at 11:15 a.m. with the transportation company manager, he said (on 11/30/23) his driver picked CR #1 up from the nursing facility at 12:00 p.m. for a 12:45 p.m. appointment. He said Driver A dropped CR #1 off at the MD office, gave his paperwork and dispatch number to the office and asked them to call the number when he was ready. He said the office did not call about CR #1. He said it was unusual for residents to stay in the office after 5 p.m. so around 6 p.m. he instructed Driver B to go check on CR #1. He said the driver went to the office and it was closed. He said the driver did not see the patient or anyone else. He said the transportation company called the facility to notify them of the situation. During an interview on 1/25/24 at 11:22 a.m. with Driver B, he said he went to the office suite number to pick up CR #1, but he was not there. He said he and nurses at the office looked for him around the building but did not see him. During an interview on 1/25/24 at 11:32 a.m. with Driver A, he said the nursing facility told him to take CR #1 to his appointment but did not give any special instructions. He said it was raining a little bit that day. He said he handed the receptionist the resident's pamphlet and transportation number to call when he was ready, and left CR #1 in their care. He said CR #1 seemed slighty off but was still cognizant. He said the facility did not send anyone to accompany CR #1. During an interview on 1/25/24 at 11:52 a.m. with LVN A, she said she received an in-service after the incident on 11/30/23 that if a resident went out and was gone for 2 hours she should call and check on the resident. She said she was also in serviced on sending a staff out with the resident. During an interview on 1/25/24 at 1:15 p.m. with the Administrator, she said she did not know why a CNA did not accompany CR #1 to his appointment and she did not make the arrangement for his appointment that day. She said she did not feel CR #1 was appropriate for a wander guard because there was no consent for it. She said the facility did not report the incident because they decided he was his own RP, did not have a dementia diagnosis and decided to leave the appointment on his own. She said prior to the appointment he was not a wander guard resident. She said she was unsure if he had dementia or confusion. She said it may have been her fault that CR #1 ended up with a wander guard because there was an incident where he went out of the front door pushing a bedside tray. She said she did not know enough about CR #1 and did not know if he needed to be supervised at his appointment or not because the situation was fluid. She said the residents had autonomy and the facility had to allow them to make their own decisions. She said she expected the MD office to notify the facility or call the transportation company. She said the nursing facility was responsible for all resident who wore a wander guard or not. She said she was unsure if an incident was documented on it. She said the facility hired a van driver, but it was not because of the incident and the position was planned since October. Interview on 1/25/24 at 3:24 pm with LVN A, she said CR #1's MD gave the order for the wander guard, and she put it in the system. She said she did not remember who put the wander guard on the resident, but she knew it was placed because she saw it on him. Interview on 1/25/24 at 5:32 p.m. with CR #1's MD, he said he did not remember the circumstances around why CR #1 needed a wander guard. He said he remembered the wander guard came up but he personally did not write an order. He stated the facility may have written the order under his name. He said CR #1 could wander because he had some degree of confusion. He said the resident was very confused at the hospital but then became less confused at the facility. He said he was not aware of the details of CR #1 leaving his appointment. He said if a resident wore a wander guard, someone should go out with them. He said the EMS transportation and/or clinic bore some responsibility. Record review of LVN A's Performance Feedback dated 12/4/23 read in part, . this is an opportunity for improvement . Description: elopements, wander guard appropriateness, and appointments . Record review of the facility's Managing Dr's Appts in-service dated 12/4/23 conducted by RN T read in part, .if a resident requires to be accompanied for a Dr's appointment, please communicate with the scheduler to see if someone can go with the resident if not, the appointment should be re-scheduled. For the residents that go without being accompanied, if they are not back at the facility in at least 3 hours, call the Dr's office and find out if everything is okay (depending on the type of appointment). Residents who are cognitively impaired must always be accompanied. There were 25 signatures on the in-service. Record review of the facility's morning meetings notes dated 1/2/24 - 1/26/24 provided by the DON revealed residents with appointments for the day were listed on the notes. Record review of the facility's Resident Rights: Transportation policy dated 1/27/21 read in part, .the facility provides safe and efficient transportation as available, and in collaboration with community transportation providers to meet patient and resident needs . Procedures .9. Transportation is provided for medical appointments .B. Nursing staff or designee will provide handoff information to the receiving entity and may include but is not limited to continuity of care document, labs, consents, MARS, TARS, face sheet .17. The facility will encourage family to transport and participate in appointments and outings when the conditions for safety and infection precautions are possible .19. Transportation Aid will accompany as deemed necessary by facility leadership . On 1/26/24 at 9:40 a.m., the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was left with the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on 1/26/24 at 4:55 p.m.: PLAN OF REMOVAL F689 Name of facility: (name) Date: 1/26/24 Immediate action: CR #1 is no longer residing in the facility as of 12/1/23. Review of recent BIMS of current residents was completed by Director of Nursing/Designee on 1/25/24 to identify residents with BIMS of less than 8 and wearing a wander guard for exit seeking behaviors. 4 residents identified as having a BIMS less than 8 and wear a wander guard for exit seeking behaviors. Review of upcoming appointments was completed by Director of Nursing/Designee on 1/25/23 to identify upcoming appointments for residents with BIMS of 8 or less and wearing a wander guard for exit seeking behaviors. None identified. Review of recent BIMS of current residents completed by Director of Nursing/Designee on 1/26/24 to identify cognitively impaired residents, with a BIMS less than 8. Seventy-five(75) residents identified. Review of upcoming appointments was completed by Director of Nursing/Designee on 1/26/23 to identify upcoming appointments for cognitively impaired residents. 2 residents with BIMS less than 8 were identified to have appointments on 1/26/24. Both residents have someone scheduled to accompany them to these appointments. Reeducation provided to Director of Nursing and Administrator by the Clinical Consultant on 1/26/24 on need for family/Responsible Party or facility staff to accompany residents with a BIMS of less than 8 or residents wearing a wander guard for exit seeking behaviors. Re-education provided to licensed nurses and certified nursing assistants on need for residents with BIMS of less than 8 or residents wearing a wander guard for exit seeking behaviors to have a family member/Responsible Party or facility staff accompany them to outside appointments. This education was completed by 1/26/24 by the Director of Nursing. Any licensed nurse or certified nursing assistant not receiving this education by the target date will receive prior to their next scheduled shift. A review of the day's outside appointments will be completed in clinical morning meeting Monday - Friday by the Administrator to validate any resident with a BIMS of less than 8 and any resident wearing a wander guard for exit seeking behaviors has a family member/Responsible Party or facility staff member scheduled to accompany them. This will begin on 1/29/24 and continue Monday - Friday. The Nurse Managers will communicate to the licensed nurse verbally and by writing on the 24 hour report that a resident will have a family member/Responsible party or staff member accompany the resident on an appointment. Licensed Nurses will validate residents with a BIMS of less than 8 or residents wearing a wander guard have a family member/responsible party or facility staff accompaniment with them prior to the resident leaving for any outside appointment. Licensed Nurses will validate prior to the end of their shift any resident who has left for an appointment without an accompaniment has returned. If the resident has not returned, the licensed nurse will follow up with the office staff at the appointment for an update on the resident and this will be communicated to the next shift. Elopement Policy was reviewed on 1/26/24 by the Administrator and Director of Nursing and no changes were indicated. Ad Hoc QAPI was held on 1/26/24 to review the contents of this plan. The Medical Director was notified on 1/26/24 of the Immediate Jeopardy and the contents of this plan. MONITORING Record review of the facility's Quality Assessment and Assurance Meeting Minutes dated 1/26/24 signed by the Medical Director, Administrator, and DON revealed the IJ template was attached. Record review of the facility's BIMS score and appointments in-service dated 1/26/24 conducted by the Corporate RN revealed the objectives of the in-service were: -train the trainer -BIMS score - what does it mean? Why is it important? -Outgoing appointment - residents with a BIMS of 8 or below may need to be supervised* *dialysis appointments might be an exception. The in-service was signed by the Administrator and DON. Record review of the facility's Managing Dr's Appt. in-service dated 1/26/24 revealed all nursing staff were to ensure that residents with BIMS or less than 8 and wearing a wander guard exit seeking behaviors to have a facility staff accompany them to any outside appointments. There were 40 signatures on the in-service. Record review of Order Report by Category (Safety Devices) dated 1/26/24 revealed there were 5 residents who wore a wander guard and 4 of the 5 residents had a BIMS score less than 8. During an interview on 1/27/24 at 9:36 a.m. with the MDS nurse, he said he received in-services on 1/25/24 and 1/26/24 on all patients going out to an appointment who have a BIMS score of 8 or below would have family or staff go with them and remain. If no one was able to go, the appointment would be rescheduled. He said the nurse caring for the patient was provided with a current list of patients BIMS score. He said they reviewed the wander guard policy and any patient wearing a wander guard absolutely had to have someone accompany them to the appointment. During an interview on 1/27/24 at 9:46 a.m. with Transportation Aid, she said she was trained to ask the nurse for the resident's BIMS score. If it was 8 or lower, she would stay at the appointment with the resident. At dialysis, she would stay with them until they were called to the back by staff. She said she would ask the staff for estimated pick up times. She said she was provided with a list of residents who wore wander guards, and she would have to stay with them at the appointment. She said the majority of time, family would meet them at the appointment. She said if a resident was not at the appointment at pick up, she would ask the office where they were and would then call the facility. During an interview on 1/27/24 at 11:38 a.m. with LVN J, she said she was in-service on appointments. She said any resident with a wander guard needed an escort. She said they looked at the resident's score to see if it was safe for them to go alone. She said if it was unsafe staff would go out with the resident because it was too dangerous. During an interview on 1/27/24 at 12:01 p.m. with CNA T, she said if a resident had a BIMS score of 8 or less, they had to be accompanied to an appointment by a CNA for safety. She said if a resident had not returned, she would notify her nurse. She said residents with wander guards for elopement required supervision as well because they would wander. During an interview on 1/27/24 at 12:27 p.m. with CNA E, she was in-serviced on appointments. She said there was a list of residents that indicated if staff had to go with them or not. During an interview on 1/27/24 at 12:35 p.m. with RN K, she said residents with a BIMS lower than 8 or who had a wander guard would be discussed and need to have staff accompany them to an appointment. She said if a resident who went unaccompanied had not returned, she would call the office to see where they were. During an interview on 1/27/24 at 1:06 p.m. with the DON, she said residents with a BIMS of 8 or below or resident with a wander guard would be sent to an appointment with either staff or family. She said the nurses would check on the resident if they were able to go unsupervised and were not back from their appointment. During an interview on 1/27/24 at 2:45 p.m. with the Administrator, she said the Corporate RN trained her on appointments. She said if the resident had a low BIMS, someone would accompany them. If they had a wander guard, a family member would attend. She said during every morning meeting, resident appointments were discussed and if they were accompanied or not. She said if a resident had not returned, the nurse would be on alert and call the office. The facility was notified the IJ was removed on 1/27/24 at 3:30 p.m. however, 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 due to the facility continuing to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 2 out of 10 residents (#5, and #6), reviewed for care plans. 1. Resident #5's care plan was not updated to include contact isolation due to ESBL, having a UTI, or having a midline, and receiving antibiotics (Meropenem), after a significant change had occurred. 2. Resident #6's care plan did not include contact isolation due to candida auris. This deficient practice could place residents at risk of not receiving care and services that are needed to attain/maintain their highest practicable quality of life. 1. Record review of Resident #5's face sheet indicated she was a [AGE] year-old female, readmitted on [DATE], with diagnoses of Unspecified Dementia, without behavioral disturbance (mental disorder where person loses ability to think, remember, learn, and make decisions), psychotic disturbance (severe mental disorders causing abnormal thinking and perceptions), mood disturbance and anxiety (irregularities or distortions in a person's mood and feelings of severe panic), cerebral infarction (stroke), essential hypertension (high blood pressure not caused be another medical condition), Type 2 diabetes mellitus (body doesn't produce enough insulin resulting in high blood sugar) , and seizures. Record review of hospital records for Resident #5, dated 4/29/23, revealed the resident had a positive blood culture for ESBL, and a positive UA that indicated a UTI. The records stated the urine culture was pending on 4/29/23. According to the records, the Infectious Disease doctor was treating the resident for ESBL in the urine, with Meropenem for 1 week via IV. Record review of Resident #5's progress notes from when she arrived back at the facility on 5/2/23, to the most current progress note on 5/10/23, revealed the resident was on contact isolation due to ESBL of the urine. The progress note from 5/10/23 also stated, the resident .continues on IV antibiotics: Meropenem 1g Q8hr until 5/13/23 for DX: UTI/ESBL. Midline to LUE intact and patent, flushes well. No s/s of infiltration to site. Record review of Resident #5's most recent care plan printed on 5/11/23, with a revision date of 5/4/23, revealed no care plan documentation or interventions for contact isolation, ESBL, UTI, midline, or the antibiotic Meropenem. Observation on 5/11/23 at 9:54am and 2:48pm, revealed Resident #5's door had TBP for contact isolation on the outside of it. An isolation caddy hung on the outside of the door during both observations. In an interview with the DON on 5/11/23 at 4:00pm she revealed the resident was transferred to the hospital on 4/28/23 due to AMS and came back to the hospital on 5/2/23, with ESBL of the urine. The DON stated they (the facility) were behind on scanning the hospital records, so the chart was not updated, including the care plan. The DON went on to say, when a resident is transported back from the hospital, the transporter gives the medical packet to the nurse who is going to be receiving the resident. At that time, the nurse goes through the packet and enters all the orders into the computer. The DON said, then the ADON would get the packet of orders and go through them and compare them to the orders entered in the computer, to ensure they are correct. According to the DON, at that time the ADON would also call the MD and ask if he/she wanted to continue the orders the hospital ordered, or if he/she wanted to add anything. Per the DON, what should have happened in this instance, was whoever called the MD to confirm the orders, should have informed the MD that the resident was on Meropenem for ESBL and asked the MD if he/she wanted to put the resident on contact isolation. Then, the order should have been entered into the computer at that moment. The DON thought that someone received the order from the MD but did not put the order into the computer. 2. Record review of Resident #6's face sheet indicates he's a [AGE] year-old male, admitted on [DATE], with diagnoses of metabolic encephalopathy (a chemical imbalance in the blood that causes changes in the brain), unspecified paraplegic (form of paralysis that affects the lower body), hypertensive chronic kidney disease (long term high blood pressure that reduces blood flow to the kidneys causing failure), end stage renal disease (kidney failure), Type 2 diabetes mellitus (body doesn't make enough insulin resulting in high blood sugar), pressure ulcer of sacral region (sore near the tailbone), dysphagia (trouble swallowing), urinary tract infection (bladder infection). Record review of Resident #6's progress notes from 5/11/23 revealed no record of contact isolation or candida auris. Record review of Resident #6's physician orders on 5/11/23, revealed no orders for contact isolation due to candida auris. Record review of Resident #6's most recent care plan printed on 5/11/23, with a revision date of 5/11/23, revealed no care plan documentation or interventions for contact isolation or candida auris. Observation on 5/11/23 at 9:54am and 2:48pm, revealed Resident #6's door had TBP for contact isolation on the outside of it. An isolation caddy hung on the outside of the door during both observations. In an interview and record review with the DON on 5/11/23 at 3:45pm, she stated Resident #6 had been on contact isolation for candida auris since he was admitted on [DATE]. The DON was not sure why there was not any documentation of the isolation or candida auris. The DON found the first progress note that documented contact isolation due to candida auris, on 4/18/22. The contact isolation was documented until September 2022, and then documentation stopped. The DON stated Resident #6 had to be on contact isolation the whole time he was there as a resident, so the isolation would continue indefinitely. She also was not sure how staff knew originally to put the resident on isolation, since there was not an order, but thought the MD must have given someone a verbal order, and they failed to put it into the computer. The DON said she did not use agency nurses, so they all knew the residents and knew Resident #6 was on isolation. She also said most of her staff knew Resident #6 was on isolation because he had been at the facility for so long, all the staff knew him. Per the DON, she did not know why there was not a care plan for the isolation because she remembered creating it. She said there should have been a care plan on him and did not know what happened to it. The DON remembered making a special care plan since it was for candida auris, and the corporate office made a big deal about it. In an interview with the DON on 5/11/23 at 4:00pm she revealed everyone (herself, the nurses, the Administrator) were responsible for the care plan being updated and correct. However, ultimately the DON was responsible for ensuring the care plans were updated and correct. Per the DON, if care plans were not updated, the facility was not following the treatment plan and the resident was not receiving appropriate services. Record review of facility's policies and procedures for person centered care plan process, dated 10/19/17, revealed: Policy: .a summary of the resident's medications and dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility . Procedures: Following RAI Guidelines develop and implement a comprehensive person-centered care plan .to meet a resident's medical, nursing, and mental and psychosocial needs . The Interdisciplinary Team will review for effectiveness and revise the care plan after each assessment . Thru ongoing assessment, the facility will initiate care plans when the resident's clinical status or change of condition dictates the need .

Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 1 resident (resident #210) out of 7 residents reviewed for pressure ulcers. 1. Facility failed to assess or evaluate Resident #210's pressure ulcers on admission. 2. Facility failed to perform wound care for resident #210 from 09/15/2022 to 09/19/2022 while in the facility. These failures placed residents at risk for developing worsening of pressure injuries, severe pain, infections, and [CONDITION(S)]. Findings include: On 10/20/2022 at 1:58 p.m. review of face sheet revealed resident #210 was a [AGE] year-old female admitted to the facility on ,d+[DATE] 2022. Resident #210 was admitted with multiple wounds, her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), [CONDITION(S)], and cerebral infarction. - On 10/20/2022 at 2:08p.m., record review of Admission record revealed there was no wound assessment completed for resident #210's admission on 09/15/2022. - On 10/20/2022 at 2:08p.m., record review of order showed there was no order for wound care during resident #210's admission on 09/15/2022. - On 10/20/2022 at 2:08p.m., record review of wound management revealed no assessment was completed on resident #210's wound from the day of admission 09/15/2022 to 10/20/2022. - On 10/20/2022 at 2:08p.m., record review of wound care for Resident #210 revealed Doctor's weekly visit that reflected one wound assessment was completed on Resident #210 done on 10/04/2022. - On 10/20 2022 at 2:25p.m., record review of Resident 210's TARs (Treatment Administration Record) revealed the following: - Stage 4 Pressure ulcer to sacrum - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. - Stage 4 pressure ulcer to right hip - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. - DTI (deep tissue injury) - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. - Unstageable Pressure ulcer to left lateral ankle - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. - Unstageable Pressure ulcer to left lateral leg - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. - Unstageable Pressure ulcer to left lower buttock - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. - Unstageable Pressure ulcer to right elbow - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. On 10/21/2022 at 10:42 a.m. resident #210 was observed in bed, bed bound, non-verbal and ADL total dependent. Interview on 10/21/2022 at 11:58 am. Wound Care Nurse stated when resident #210 was admitted on [DATE], she was on vacation and she would not know why the wound was not assessed and cared for. Wound Care Nurse stated usually the facility would have someone take care of resident's wound whenever she was not in the building because residents' wounds could get worsen if their wounds were not taken care of. Wound Care Nurse stated that she did not know who was responsible for wound care on those days she was not on duty. Interview on 10/21/2022 at 09:32 am Wound Care Doctor stated he was unable to see Patient #210 because she might have been admitted on the days, he did not visit the facility. Wound Care Doctor stated that whenever there was admission with a wound, the wound care nurse would take a picture of the wound and send to him for orders and if he was made aware of the resident's situation, he would have given orders for the wound care. On 10/21/2022 at 1:02 p.m. record review of facility policy revealed: 1. Policy titled 'Wound Evaluations' dated 06/01/2022 reads, Evaluation of wounds will be performed on admission, weekly and on discovery. 2. Policy titled 'wound documentation' dated 06/01/2022 reads, on admission and/or discovery, the clinician initiates the wound documentation process.

Based on observation, interview and record review, 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, and metabolic abnormalities for one (Resident #103) of five residents reviewed for enteral nutrition. Facility failed to ensure the [MEDICATION(S)] (nutritional supplement) was not expired before administering it to Resident 103. This failure could place the resident at risk for feeding drug interactions, malnutrition, dehydration, and illness. Findings include: Review of Resident #103's face sheet revealed an [AGE] year-old male admitted on [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #103's Admission MDS dated [DATE] revealed he had a BIMS score of 9 out of 15 which indicated his cognition was moderately impaired. Resident #103 required extensive assistance of one to two staff assist with bed mobility and required extensive assistance of one to two staff assist for transfers, dressing and toilet use. Resident # 103 was incontinent of bladder and bowel. K0100. Swallowing Disorder. C. Coughing or choking during meals or when swallowing medications. K0510. Nutrition approach, While a Resident, B. Feeding tube. Review of Resident #103's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Enteral Administration history for Resident #103 revealed 4 bolus feedings administered on [DATE] & 1 bolus feedings administered [DATE] at 9:03 am. Observation and interview on [DATE] beginning at 11:18 a.m. revealed LVN A walked into Resident #103's room and stated she was going to prepare his tube feeding. The surveyor observed 8 containers of [MEDICATION(S)] (8 fluid ounces) sitting on top of a dresser in Resident # 103's room. LVN A removed 2 of the 8 containers of [MEDICATION(S)] and poured them into 2 different measuring cups. After preparing Resident # 103's tube feeding, the surveyor asked LVN A if she was ready to administer the tube feeding and LVN A stated yes. The surveyor stopped LVN A and asked her to look at the expiration dates on the [MEDICATION(S)] containers. When LVN A looked at the 8 [MEDICATION(S)] containers on top of Resident # 103's dresser she stated the dates on all of the containers had expired on [DATE] and she did not think to check the dates before preparing the tube feeding. LVN A stated she was not going to administer the expired [MEDICATION(S)] because the risk of doing so could cause the resident to have an upset stomach, nausea, or vomiting. Interview on [DATE] at 11:36 am ADON stated the [MEDICATION(S)] should not be expired and stated she did not have a response for it being expired in Resident # 103's room and on the shelf in the medication room to be used. ADON stated it was the responsibility of the nursing staff to review medication prior to administration, including but not limited to the expiration date. ADON stated ingestion of expired enteral nutrition could cause Resident # 103 to get infections, have allergic reactions, affect their vital signs and multiple other things could happen when giving expired enteral feedings. Interview on [DATE] at 3:36 pm CSD stated expired tube feeding formula should not be used because the risk would be less effective like with any medication. The CSD stated all nurses had to check the expiration dates before giving any medications. Record review of the NF policy on Medication Management Program revised on [DATE] read in part . The facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations.

Based on interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 1 of 5 residents (CR# 1) reviewed for quality of care. The facility failed to implement CR#1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure LVN A reported CR#1's critical lab level and medication change during the change of shift to the oncoming nurse for implementation resulting in the resident not receiving ordered medication .CR#1 was found unresponsive 16 hours later. The facility failed to ensure RN B immediately called 911 emergency services when CR#1 was found unresponsive and without a blood pressure reading but instead called the physician and non-emergency EMS resulting in a delay in emergency care and intervention for CR#1 whose [MEDICATION(S)] level increased from 165 (at the facility) to 179 (at the hospital) with altered mental status. An Immediate Jeopardy (IJ) situation was identified on 9/2/21. While the IJ was removed on 9/3/21, the facility remained out of compliance at a scope of isolated and severity of actual 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 delayed medical intervention, decline in health and death. Findings include: Record review of CR#1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and was transferred to the emergency roiagnom on [DATE] at 4:50am. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1's admission Minimum Data Set (MDS), dated [DATE], revealed CR#1 had a Brief Interview for Mental Status (BIMS) of 5, which indicated cognitive impairment. Record review of CR#1's nursing note written by RN B, dated 8/24/2021 at 12:00 AM, read, Admission labs: CBC, BMP ordered for next lab routine date 8/24/21 and then weekly on Mondays thereafter via online, requisitions printed and placed in lab book. Record Review of CR#1's nursing note written by RN B, dated 8/24/2021 at 10:13 AM, read in part, .Resident is AAOx3-4 with episodes of confusion and forgetfulness. Resident is able to make needs known to the staff, requires assistance x1 with ADLs . Record review of CR#1's nursing note, dated 8/24/21 at 3:14 PM read, The Doctor visited resident and gave orders for CBC, CMP and [MEDICATION(S)] level to be drawn every Thursday due to confusion. Requisition for ordered labs were completed and placed in the lab book. Record review of CR#1's lab report, dated 8/25/21 read, Critical Value, RRB (received-read back), LVN A on 8/25/2021 at 11:40 AM . which revealed CR#1's [MEDICATION(S)] level of 165. Record review of CR#1's nursing note written by RN B, dated 8/26/21 at 4:35 AM, read, Upon rounding citizen was hard to arouse, non-responsive to verbal or tactile stimulation. Would only open eyes for a second and wound not verbally respond to writer. Resp even and unlabored. Unable to obtain BP, Spo2 at 95% on RA. Temp 97.5. Call placed to the doctor and gave order to send citizen to ER ASAP. After reviewing labs, [MEDICATION(S)] level noted to be critically high at 165. Non-emergency 911 contacted at this time. EMS en route. Record review of CR#1's nursing note written by RN B, dated 8/26/21 at 4:50 AM, read in part, EMS in facility at this time to transport citizen to ER. Citizen stable upon departure but still non-responsive per baseline . Record review of CR#1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 received the 30 ml of [MEDICATION(S)] on 8/24/21 at 1:00 PM, 5:00 PM and 9:00 PM and on 8/25/21 at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. Record review of CR#1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the August 2021 mediation administration record revealed CR#1 did not receive the increased [MEDICATION(S)] order. CR#1 received 30 mL of [MEDICATION(S)]. Record review of the nursing 24-hour report, dated 8/25/21 for 6a-6p shift, indicated CR#1 was stable with no new orders checked. Record review of CR#1's Prescription Fax Order, dated 8/26/21 at 8:59 AM, revealed the order for [MEDICATION(S)] 40 mL four times daily was ordered on 8/26/21 and the order for 30 mL of [MEDICATION(S)] four times daily was discontinued on 8/25/21 at 11:48 AM due to a change in order. In an interview with LVN D on 8/31/21 at 9:50 AM, LVN D stated when new admissions are admitted the facility completes a head to toe assessment, check vitals and writes communication for new diets and orders. The MD is notified and a COVID test is completed and if they're positive, they notify the DON and Administrator. She stated when labs were drawn and were critical, the lab would call the facility and would also fax the results. LVN D stated the nurse would pull labs from the lab system and would notify the MD. If the labs were critical, they would call the MD to get any orders or see what the MD wanted to do. If labs were abnormal, sometimes the resident would be sent out to the hospital if the MD ordered to do so, it depended on what was going on with the resident. In an interview with CR#1's Responsible Party (RP) on 8/31/21 at 10:28 AM CR#1's RP stated CR#1 was in the hospital. She stated CR#1 was not given the proper medication, which he needed due to [CONDITION(S)] of the liver. She stated when she brought CR#1 to the facility, she went over his medication with a nurse and handed them the list of medications and dosages he received at home. CR#1's RP stated CR#1 had to have a blood transfusion at the hospital due to not getting his iron medication. She stated CR#1's liver was leaking blood and he would have a procedure in the hospital today (8/31/21) to drain the fluid from his stomach. In an interview on 8/31/21 at 2:50 PM with the Director of Nursing (DON), she stated when a critical lab was called in from the lab, the lab tech would speak to the nurse on duty for the specific resident. The DON stated if the nurse received a critical lab, they would contact the physician immediately to inform them of the critical lab. She stated if the physician made an order change, the nurse was to put the order in the system at that time and read the order back to the physician to ensure accuracy. The DON stated the nurse would also inform the family of the critical lab. She stated if the physician wanted to send the resident to the hospital, they would give an order to send the resident to the hospital. In an interview on 8/31/21 at 2:51 PM with LVN A, she stated at change of shift, the nurses were to give report to the oncoming nurse to discuss any changes with the residents, such as change in condition, new orders, medication changes or lab reports. LVN A stated she would relay any critical lab values to the oncoming nurse. LVN A stated for residents with critical labs, she would call the doctor and discuss the labs and document any changes in the order and would notify the family. She stated she would chart the conversation in her nursing notes. LVN A stated whenever a critical lab was reported from the lab, the lab would call the facility before the fax came through and the nurses would place it in folders for the doctor to review. LVN A stated she received a call for critical labs for CR#1, which stated his [MEDICATION(S)] level was 165. She stated she called the doctor and the doctor asked about the [MEDICATION(S)]. LVN A stated the current [MEDICATION(S)] order was for 30 ml. She stated the doctor increased the order to 40 ml, four times a day and to repeat his CBC/BMP on 8/26/21. LVN A stated while putting in the new order from the doctor, she got another call from lab which stated CR#1 had a critical HGB level. She stated the doctor informed her to continue to monitor the resident and changes would be made as needed. LVN A stated she administered the 40 ml of [MEDICATION(S)] to CR#1. LVN A stated at change of shift, she notified the nurse of CR#1's critical lab value. LVN A said she dropped the ball and forgot to document the changes in her notes regarding the critical lab value and her conversation with the doctor regarding CR#1. She stated when she was leaving for the day, CR#1 was responsive before she left the facility around 9 pm. In an interview on 8/31/21 at 3:32 PM with the doctor, she stated she received the call on 8/25/21 from LVN A informing her of CR#1's critical [MEDICATION(S)] level. The doctor stated she gave the order to change CR#1's [MEDICATION(S)] from 20g (30ml) every four hours to 40 grams (60ml) every six hours. The doctor stated she wanted CR#1's medication change to start the same day she gave the order. The doctor stated she wanted to try the increase in [MEDICATION(S)] and monitor the resident with the increase in medication. The doctor stated had she not wanted the order to increase the same day and monitor for any changes, she would have given the order to send the resident to the emergency room right away. The doctor stated increasing the [MEDICATION(S)] dose as ordered would have lowered the [MEDICATION(S)] level. In an interview on 8/31/21 at 6:33 PM with RN B, she stated CR#1 was alert and able to make his needs known. She stated CR#1 was able to take his medications and knew what medication he was taking. RN B stated when she went to assess him at 4:30 AM, he was unresponsive. She stated she tried to arouse him, he only opened his eye for a second and then closed his eyes again. She stated he was not able to verbalize anything, which was different from his baseline. RN B stated she attempted to get his vitals but couldn't get his blood pressure, due to her blood pressure cuff not working. She stated she did not remember if she attempted to get his heart rate, but he was breathing at 95% on room air. RN B stated she called the doctor and told her about her assessment and the change in the resident. She called the doctor first due to him having a pulse and his breathing was unlabored and due to her assessment. RN B stated once she received the order from the doctor to send CR#1 to the hospital, she called the Police department, non-emergency line. RN B stated she called non-emergency due to her assessing the resident and him opening his eyes, she knew he was still alive, but not responding normally. RN B stated it took EMS 15-20 minutes to arrive to facility. RN B stated when she saw CR#1's critical lab, he was already on his way to the hospital. RN B stated she was not aware his [MEDICATION(S)] level was high. She stated when she got report from LVN A, she did not let her know his labs were critical. She stated LVN A gave report for CR#1 and LVN A told her he had labs drawn but didn't mention his labs were critical. RN B stated on 8/26/21 during report, she informed LVN A she had to send CR#1 out to the hospital. RN B stated LVN A then told her the doctor increased CR#1's [MEDICATION(S)] order. RN B stated she was not aware of this change in the order and continued to give the normal 30 ml of [MEDICATION(S)]. RN B stated when she gave report to the oncoming nurse, she would give them a report sheet and would tell the nurse about any new changes for each resident, such as medication changes, change in condition, behaviors, labs and any family dynamics. RN B stated she would also document the changes in the residents nursing notes. In an interview on 8/31/21 at 7:10 PM with Hospital RN L, she stated CR#1 was stable. She stated CR#1 was still confused and remained on the telemetry unit. Hospital RN L stated the doctors were still monitoring his labs and his [MEDICATION(S)] levels. In an interview on 9/2/21 at 8:30 AM with Hospital RN M, she stated CR#1 admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated on 8/30/21 CR#1 had a paracentesis, which is a needle placed in the body cavity to remove fluid, to remove 1.7 L of fluid off his stomach. She stated his [MEDICATION(S)] level was still elevated ( from 165 to 179 u/dl) which was being monitored by the doctor. She stated she had no current discharge date for CR#1 and would continue monitoring him. In an interview on 9/2/21 at 11:35 AM with the Administrator, she stated an investigation began on 8/31/21 at 8 AM. She stated LVN A was suspended pending the investigation. She stated LVN A has not returned any of the phone calls regarding the investigation. In an interview on 9/2/21 at 12:23 PM with the DON stated she was made aware CR#1 was sent out at 4:30AM on 8/26/21 due to a change in condition, but at the time was not aware it was non-emergency EMS. The DON stated nursing should call 911 if a resident is nonresponsive to avoid a delay in medical treatment. The DON stated upon her investigation, she found that at 8am the lab called to inform LVN A of the critical lab. She stated LVN A called and informed the doctor of the critical lab and was directed to increase the [MEDICATION(S)]. She stated per LVN A, 40 ml of [MEDICATION(S)] was given to CR#1, but she forgot to put the order on CR#1's MAR. The DON stated she called the doctor and confirmed she did speak with LVN A but gave the order for 40 g of [MEDICATION(S)] to be increased on 8/25/21 and not the next day and also not 40 ml of [MEDICATION(S)]. In an interview on 9/3/21 at 11:47 AM with the Administrator, she stated she was not sure why LVN A didn't ask for assistance for getting orders in and writing orders timely. She stated nothing like this has happened before and she expected the licensed nurses to be able to communicate with each other and get orders from the medical doctor and placed in the system timely to ensure the resident were properly cared for in emergency situations. She stated she knows the IJ came about due to lack of communication and documentation. She stated the DON and ADON would continue to train all staff and new employees on the protocols of the facility. The Administrator stated training and in-servicing would continue regarding change in condition, shift change and giving report, critical labs and medication management. She stated management would continue doing audits and observations for a month. The Administrator stated she had not heard from LVN A, despite many attempts. Record review of information on [MEDICATION(S)] Levels retrieved from https://medlineplus.gov/lab-tests/[MEDICATION(S)]-levels/ on 09/13/2021 revealed This test measures the level of [MEDICATION(S)] in your blood. [MEDICATION(S)] is a waste product made by your body during the digestion of protein. Normally, [MEDICATION(S)] is processed in the liver, where it is changed into another waste product called urea. Urea is passed through the body in urine. Signs and symptoms of high [MEDICATION(S)] level include: confusion, excessive sleepiness, disorientation- the condition of being confused about time, place, and/or your surroundings, mood swings , hand tremors. If your body can't process or eliminate [MEDICATION(S)], it builds up in the bloodstream. High [MEDICATION(S)] levels in the blood can lead to serious health problems, including brain damage, coma, and even death. High [MEDICATION(S)] levels in the blood are most often caused by liver disease. Other causes include kidney failure and genetic disorders. Record review of the facility 24 Hour Report Policy dated 7/1/2016 read in part, The nursing staff will complete a 24-Hour Report on each unit/floor, each shift, 7 days per week. The 24-hour report will include, among other things, any status change, changes in resident conditions, appropriated notification and the verification of documentation of any changes .6. The licensed nurse will fill in the narrative section when a change in condition needs to be further documented . Record review of the facility Shift Change Communication Policy dated 7/23/2019 read in part, Shift change reports will occur during resident transfer of care from one provider to another to assure continuity of care .Exchange of information may include but is not limited to . 3c) Critical lab results, 3d) Recent addition, discontinuation or dosage change of medication . Record review of the facility Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication/Treatment: 2) Transcribe the order onto the MAR . as appropriate. Initial and date the entry on the MAR .6) Record order changed in Progress Notes and 24-Hour Report. The Administrator and the Director of Nursing were notified of Immediate Jeopardy (IJ) on 9/2/21 at 11:35 AM. The Administrator was provide the IJ template on 9/2/21 at 11:38 AM. The following Plan of Removal submitted by the facility was accepted after several revisions on 9/2/21 at 3:21pm. Identified resident is not currently in facility. Residents who reside in the facility and have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An audit of physician ordered laboratory tests for the past 30 days for current residents was completed on 9/2/21 by the Director of Nursing / designee to identify any medication changes as a result of abnormal or critical laboratory results and validate that the physician ordered medication change was implemented timely. If any concerns identified related to timely implementation of the medication change, the resident will be assessed, and the physician contacted for further direction. Licensed nurses will be re-educated by the Director of Nursing / designee on the following: Orders given by the physician as a result of the critical laboratory test results are to be documented at the time the order is received and implemented timely Shift to shift report is to be given to oncoming nurse for effective communication regarding resident care and treatment, such as changes of condition, new orders, incident/accidents, abnormal labs. When a resident is found to be unresponsive or in need of emergency services, nurses are to use critical judgement to intervene for an emergency transfer to an acute care facility for changes in condition that cannot be treated effectively in the facility, such as unresponsiveness, inability to obtain a blood pressure or pulse, injury requiring immediate attention. This re-education will be completed on 9/2/21. Any licensed nurse not receiving this training by this date will receive prior to next scheduled shift. This information will be presented to licensed agency staff and in new hire orientation. The Director of Nursing / designee will review laboratory test results in the Clinical Morning meeting Monday through Friday and the charge nurse will review on the weekends to validate that any physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing / designee will review the 24-hour report and will attend shift to shift report daily for 5 days or until compliance has been achieved to validate that communication is occurring related to the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The Director of Nursing / designee will review the 24-hour report and the Facility Activity report Monday through Friday and the charge nurse on weekends to validate that if a resident had a change of condition and needed emergency services intervention that it occurred timely. The medical director was notified of the Immediate Jeopardy on 9/2/21. An Ad Hoc Quality Assurance Performance Improvement meeting was held on 9/2/21 to discuss the contents of this plan. Policies were reviewed and used for training purposes. No revisions were necessary. Surveyor Verification of Plan of Removal was as follows: In an interview on 9/3/21 at 5:47 AM with RN B, she stated she was in-serviced this week about change in conditions, notifying the medical doctor with any changes and sending residents out to the ER via 911 immediately if they're not responsive. She stated they were to write down what the doctor told them for medications changes to ensure no medication errors and to ensure the order was changed timely. She stated during shift change, report would be given to the oncoming nurse and to discuss any changes which occurred with the resident during the shift. In an interview on 9/3/2021 at 5:52 AM with CNA A, stated she was in-serviced on if she notices a resident with a change in condition, she will notify the nurse immediately. In an interview on 9/3/21 at 5:53 AM with RN C, she stated she had an in-service last night (9/2/21) regarding resident change in conditions, looking for signs and symptoms of changes, critical lab values for residents and notifying the doctor of the labs as well as making medication changes accurately and timely after talking to the doctor. She stated the nurses were to document any changes and also write it on the 24-hour report. RN C stated nurses were to exchange report to the oncoming nurse. She stated if a resident had any medication changes, she would put the new order in immediately to be implemented. In an interview on 9/3/21 at 5:58 AM with LVN F, stated she was in-services yesterday (9/2/21) on critical labs, change in conditions, medication management and notifying doctor of any changes. She stated she was informed for any resident that is unresponsive, she will call 911 immediately. She stated after she does an assessment of the resident and they're still unresponsive, she will call 911 and the notify doctor, DON and family afterwards. She states she will give report to oncoming nurse and inform the nurse of any changes in condition, new orders or medication changes. Observation made on 9/3/21 at 6:17 AM of 6pm-6am nurse giving report to 6am-6pm nurse and going over 24-hour report and discussing each resident. In an interview on 9/3/21 at 6:19 AM with LVN H, she stated she was recently in-serviced this week (8/30/21) about critical labs, giving report, medication pass policy and procedures, changes in condition and notifying the doctor of any changes with the resident. She stated if a resident is unresponsive, she will check vitals, obtain blood pressure, pulse and oxygen level. She stated if she cannot arouse the resident, she will call 911 and have the resident sent out immediately and will contact the doctor, DON and family afterwards. She stated at shift change, nurses are to go over 24-hour report and discuss any changes in condition with the resident. In an interview on 9/3/21 at 10:28 AM with LVN G , she stated she was in-serviced on 8/31/21 on giving report to oncoming nurse, sending residents on via 911 if they are unresponsive, calling the doctor regarding critical labs and making any medication changes immediately. She stated she was also in-serviced on documentation being done timely. LVN G stated a policy with all the policies were left at the nursing station for nurses to review. Record review of the facility in-service sheets 8/30/21 revealed nurses from both shifts, including weekends and weekdays, were in-serviced on pulling labs throughout each shift, notifying the doctor or nurse practitioner of lab results first and documenting intervention and notifications, interventions to be documented on 24-hour report and charting each shift and entering progress notes of all communications. Record review of the facility in-service sheets 8/30/21 revealed nurses from both shifts, including weekends and weekdays, were in-serviced on changes in conditions, noticing what the change is, completing change in condition assessments, notifying doctor and DON/Administrator, make a progress note and carry out all interventions and new orders, notifying the responsible party, and documenting all interactions or interventions put in place. Record review of the facility in-service sheets 8/30/21 revealed nurses from both shifts, including weekends and weekdays, were in-serviced on obtaining physicians orders via telephone and verbally, physician communications and contacting 911 immediately for life-threatening events, laboratory testing policy and what to do with a critical lab. Record review of the facility in-service sheets 8/30/21 revealed nurses from both shifts, including weekends and weekdays, were in-serviced on utilizing 911 emergency services for life threatening events when unable to obtain vitals, unresponsive residents, no pulse, respirations or code blue, and possible critical labs. Record review of the facility in-service sheets dated 9/2/21 revealed the DON and ADON will monitor and audit shift change and 24-hour reports to ensure communication is provided per the facility policy. The Administrator and the Director of Nursing was informed the Immediate Jeopardy was removed on 9/3/21 at 11:40 AM. The facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 6 residents (CR #1) reviewed for quality of care in that: The facility failed to consult CR #1's physician when the resident was found on the floor and had a change of condition. Less than 30 minutes later, CR #1 had a change of condition and expired at the facility. An Immediate jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure placed residents at the facility at risk of not having their needs met following a change of condition which could lead to injury or death. Findings include: Intake # 5, 0 and 0 CR #1 Record review of the closed clinical records for CR #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. The review revealed CR #1 had the following Diagnoses: [REDACTED]. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE]. The review revealed that on [DATE], a portion of CR #1's skull had been removed to relieve swelling and pressure which resulted in CR #1 essentially having a portion of his head with only skin over the brain. Record review of the hospital records revealed CR #1 had been fitted with an orthotic splint with an orthotic resting schedule of 2 hours on, 2 hours off and a protective helmet to be worn while out of bed. The review also revealed the use of pillows and a wedge cushion for head protection. The review further revealed the resident was discharged from the hospital to the facility on [DATE]. The review of hospital records revealed a hand-written notation that discharge orders had been reviewed with the physician/Medical Director for the facility. Record review of nursing notes from the facility regarding CR# 1 dated [DATE] 1:30 PM revealed LVN A assessed CR#1 at that time. The note further revealed the resident was admitted with a helmet. LVN A noted CR #1's surgical incision on the left side of head, but did not mention [MEDICAL CONDITION] or craniectomy. Record review of CR #1's physician order's dated (MONTH) 2019 revealed orders for the following medications: [REDACTED]. The review revealed the resident also had orders for a regular pureed diet with thickened liquids and orders for PT, OT and ST evaluations. The review revealed no orders for any type of devices, helmet or protection for his head. Record review of the facility's fall risk assessment dated [DATE] completed by LVN A revealed CR #1 was deemed to be a moderate fall risk. Record review of physician progress notes [REDACTED].#1 revealed the Medical Director visited CR #1 and noted CR #1 had left middle cerebral artery stroke with hemorrhagic conversion, midline shift, herniation and [DIAGNOSES REDACTED] after a craniectomy on [DATE]. He was stabilized and sent to (skilled nursing facility) for rehab and medical management. Precautions to put in place were fall precautions, wound precautions and dietary management. There was no mention of head protection. A record review was conducted of CR#1's baseline care plans dated [DATE]. The review revealed care plans for several areas. Review of one care plan read, Problem .has needs related to [MEDICAL CONDITION] Goal .will remain free of injury over next 90 days Approach Encourage .to use environmental devices such as hand grips, hand rails, etc. Keep bed in lowest position. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Provide proper well maintained footwear. The review revealed no care plan specific to fall risk, [MEDICAL CONDITION] or post-surgery precautions. Record review of physical therapy notes dated [DATE] revealed CR #1 was to have an assistive device during transfers. Record review of physical therapy notes dated [DATE] for CR #1 revealed CR #1 was a fall risk and was to use the helmet when out of bed and a resting hand splint for proper positioning. Record review of nurse's notes dated [DATE] at 6:50 PM written by LVN A revealed the nurse was called to the resident's room by a CNA. .Resident was on his back angled slightly to the right with his head at the foot of the bed . The review further revealed CR #1 was conscious and was asked 4 times if he hit his head. The note indicated the resident stated no. The review also revealed CR #1 was transferred back to bed via mechanical lift with 3 staff. There was no documentation that the physician was consulted when he was found on the floor. Record review of a Neurological Evaluation Flow Sheet dated [DATE] at 6:50pm revealed LVN A conducted a neurological assessment. CR #1's vitals were documented as follows: Blood pressure- ,[DATE], pulse 120. Record review of a Neurological Evaluation Flow Sheet dated [DATE] at 7:05pm revealed LVN A conducted a neurological assessment. CR #1's vitals were documented as follows: Blood pressure- ,[DATE], pulse 70. Record review of nurses' notes dated [DATE] at 7:15 PM written by LVN A revealed CR #1 was attempting to sit up in bed, was becoming restless and agitated and was gasping for air. The resident stopped breathing and the nurse was unable to obtain a pulse. The review further revealed the side rails were lowered and the bed was lowered to the floor at which time CPR was initiated and 911 was called. Interview on [DATE] at 11:45 AM with the DON revealed she had been informed of the incident involving CR #1. She stated she was notified of the incident and was not at the facility but believed in retrospect she should have gone to the facility. She stated that she believed that more than likely, based on the resident's medical history, he expired as a result of a [MEDICAL CONDITION] embolism. Interview on [DATE] at 1:00 PM with LVN A, she said CR #1 seemed fine on the day of the incident. She stated CR #1 always slept a lot. She said he was usually calm and she did not recall any shaking moments indicative of [MEDICAL CONDITION] involuntary movements. She said around 6:50 PM, Resident #2 and an aide came to get her to go to CR#1's room. She stated her assessment revealed no bruising or blood on the resident whose left side of his head she described as concave and having stitches. She stated that she asked CR #1 if he hit his head, and he said no. She described assessing CR #1 and reported his vitals and neuros were normal and he was returned to bed via mechanical lift with the assistance of CNA B and CNA C. She stated that in her opinion she believed CR#1 maneuvered himself through the gap between the two upright bedrails on his left side and momentum carried him away. She described the resident a few minutes later, around 7:15pm after the fall as agitated and gasping for air. She said LVN D came in to assist them and lowered him to the floor and started CPR. She said they were unsuccessful in reviving CR #1 who was pronounced by EMTs who had arrived to assist. LVN A further stated she was suspended for a week without pay for failing to notify the physician after he fell . She further stated she realized now that she should have contacted the doctor as required. She stated she received orientation and training when she was hired but did not recall any specific training as to how to care for residents with brain injuries. An interview was conducted with Physical Therapist E on [DATE] at 1:05 PM. He stated he only saw the resident briefly only on one occasion. He further stated the resident could move his left side but not his right. He stated the head was exposed. He further stated that CR#1's left side was very strong. An interview was conducted on [DATE] at 1:10 PM with Physical Therapist G. Physical Therapist G stated that CR #1 could not communicate. She further stated that it required 2 persons to even sit him up for therapy and that it required a lot of strength on the part of staff to do so. She stated he could not move at all and it was very surprising about the fall. She reported he was seen on (MONTH) 6, 2019 at which time he appeared more alert and appeared to understand more commands. An interview was conducted on [DATE] at 1:12 PM with Physical Therapist I . She stated she was surprised to learn of the resident's fall. She stated he really could not move much and it required 2 therapists to move him up to a position for therapy. An interview was conducted on [DATE] at 1:15 PM with OTA F. She stated she remembered seeing CR #1. She reported it required 2 staff members to get him up to sit. One day he stated the words, poo poo and they determined that he required incontinent care and consequently, summoned an aide. She further stated she did not see how it was possible for him to fall from the bed. She was questioned as to whether there was a fall mat by his bed and she replied there was not. An interview was conducted with Speech Therapist G on [DATE] at 1:45 PM. She stated they conducted an evaluation of CR #1 and he could not do much swallowing. She stated that CR #1 had a helmet when he came in and when he was evaluated. She further stated he could nod yes but kept uttering non-sensically the word four, four, four repeatedly. She stated she does not know how accurate his yes, no responses were. She was questioned about seeing a fall mat in his room and she replied she did not. During an interview on [DATE] at 3:30 PM, Resident #2 who was aphasic but alert to self and surroundings, was asked simple yes and no questions. In summary, the resident presented information to the effect that he saw the resident on the floor then went in his wheelchair and got a nurse. The nurse followed him to the room. He did not think CR #1 was hurt by anyone, staff or residents, and he believed CR #1 had a fall. An interview on [DATE] at 11:10 AM with the DON revealed she received a text about 7:30 PM on [DATE] informing her of CR #1's fall and having coded. She further stated that LVN A was his assigned nurse and she was a new nurse and this was her first code. She stated that LVN A was suspended, came in for training during her suspension and was re-instated the following week. The DON stated the bed rails were never up as this would be a restraint. Interview with the facility's Administrator on [DATE] at 1:20 PM revealed she has a dedicated desk nurse to review orders from the hospital. She said the Medical Director did not order a helmet for CR #1. She further stated that CR #1's hospital orders did not include orders for either a helmet or a splint. A telephone interview was conducted with the Medical Director, CR#1's physician, on [DATE] at 1:35 PM. He stated that CR #1 had a craniectomy performed and was stabilized in the hospital. He stated he did not know how the resident could have fallen from bed but stranger things have happened. He stated that it does appear he could have slid out of bed. He further stated he saw him 2 days prior to the incident and he could not say the word no. The doctor stated CR #1 could have thrown a [MEDICAL CONDITION] embolism. He said there was so much pressure on the [DIAGNOSES REDACTED] that it affected bleeding. He reported he did not recall the resident having a helmet but added he thinks he might have come with one from the hospital. The physician described the bed as being knee high. He further stated CR #1 was a very sick guy. He was asked about the bed rails being up, he replied that he could not recall if they were up or not when he saw them but when he makes his rounds the rails were up on residents' beds. An interview was conducted on [DATE] at 4:00 PM with CNA B. She was asked about the height of CR #1's bed and she stated she herself is 5' 4 and the bed about the height of her knees. She stated she was making rounds and on the day of the incident had just gone into CR#1's room to see if he required incontinent care. She reported that 3 to 5 minutes later Resident #2 came and informed them to come with him. She followed Resident #2 to CR#1's room where she discovered him on the floor towards one side. She stated he was lying by the bed full length on his right side. She reported the bed rails were up. She said she placed him on a pillow and went to get help and the blood pressure cuff. After he was assessed it required 3 persons to assist him back to bed as he was too heavy. She reported being in the room the entire time of the incident. She stated he attempted to sit up and then laid back down. She stated that when he laid back down, his eyes rolled back into his head and he closed his eyes. She said attempts were made by staff to get a pulse in his wrist and throat resulted in only a faint pulse. They assisted him from the bed back to the floor with the nurse and initiated CPR. When the EMTs came, they took over. CNA B further stated she had worked with CR #1 and although not specifically assigned to him she recalled feeding him. She stated that she did not recall training on caring for a brain-injured resident but did work with another resident on another hall who had a similar [DIAGNOSES REDACTED]. She stated she never did see a helmet on CR #1 or in the room. In an interview on [DATE] at 11:50 AM with the facility's social worker, she stated that the MDS Nurse or the DON receive the clinicals from the sending institution/hospital to determine the prospective resident's skilled nursing needs. She stated she did not get to interact much with CR #1 as he was non-verbal. An interview was conducted on [DATE] at 12:00 noon with Social Worker B, the local hospital's social worker that was housed at the nursing home. He stated the facility had a contract with the hospital (that CR #1 discharged from) to provide skilled nursing care and therapies for patients upon discharge from the hospital. He stated that the facility evaluated prospective patients to determine if their needs can be met in this skilled nursing setting. An interview was conducted on [DATE] at 12:30 PM with the MDS nurse. The MDS nurse at that time was asked about CR#1's clinical condition. The MDS nurse stated that CR #1 required extensive assist. He stated he himself developed the baseline care plans. He stated he did not recall if CR#1 had any protective head gear. He said if he had noted an order for [REDACTED]. He stated he did not recall CR #1 having any extra pillows except for his head and no wedges. He stated he did not see the helmet and CR #1 was not using the hand rail. The MDS Nurse further added that needs of residents were discussed during the daily morning meetings. He stated attempts were made to interview CR #1 but he was not verbal. He also stated when he reviewed CR #1's clinicals before admission, he did not see any orders for splints or head gear. When asked about the use of the mechanical lift to return the resident to bed, he stated he felt a draw sheet would have been safer. The MDS Nurse stated CR #1 could have used a wedge between the side rail area and his upper torso and head to protect him. He added that he should have brought the issue up during morning meetings and care planned the intervention. He said he never observed CR#1 out of bed and his mobility in bed did not raise concerns about falls before the incident. Interview on [DATE] at 4:10 PM with CNA C revealed that she was one of the aides who assisted CR #1 back to bed with the mechanical lift when he was found on the floor. She reported she had not ever observed CR #1 out of bed. She stated she was trained on topics of abuse and neglect and patient care but did not recall any training specific to caring for residents with brain injuries. Interview with the Medical Records Director on [DATE] at 4:15 PM revealed she scanned all of the medical information that comes from the hospital. She stated the desk nurse placed the information in a basket. She said she uploaded the documentation the next day. She further stated she uploaded all of the information with the exception of medications and physician's orders [REDACTED]. An interview was conducted with LVN D on [DATE] at 4:20 PM. She stated on the day of the incident, she was on the computer at the desk when a resident came by (Resident #2) and attempted to inform them something was wrong. She said he did not speak so she went with him and LVN A to CR#1's room where CR #1 was discovered to be on the floor beside his bed. She said after he was returned to bed, he started to breathe like he was holding his breath and then exhaled. She said she checked his pulse, but he was not responding. She said they lowered him to the ground and 911 was called. She said when EMTs arrived, they took over CPR. She stated in response to questioning that CR #1 was supposed to be transferred by mechanical lift. She stated prior to his breathing difficulties, he began getting agitated. She stated she recalled CR #1 as being fairly young. She stated she did not recall any orders for a splint or a helmet. She stated the records from the hospital go to Medical Records Department where they were scanned into the computer. She stated she does not recall usually receiving orders for specialized head protection. She further stated she did not recall seeing CR #1 with a helmet on during his stay at the facility. She further stated that when a resident was admitted on the weekend, they were to be seen by therapy the following Monday. Surveyor asked if she thought CR #1 was capable of falling from the bed and she stated she has seen paralyzed people try to do so. She added she did not recall if the bed rails were up. She stated that she does not know what could have happened. An interview was conducted on [DATE] at 4:30 PM with the Administrator and DON. They stated that the facility has 2 marketing staff members that go to the location or hospital to discuss the prospective resident's discharge to their facility. The 2 marketing staff members were not nurses but they review the documentation/clinical records brought from the hospital to determine if they could meet the needs of the person. In the event further assessment was indicated, the company had clinical individuals on staff to go to the hospital for additional assessment. The Administrator stated they have a dedicated nurse at all times to review orders from the hospital, then the resident's physician signs off on which orders to maintain and which should be discontinued. In an interview on [DATE] at 9:00 AM with the Administrator she reported that she understood now that the facility could have done more with regard to coordination with the hospital for quality of care provided. Record review of Evidence-Based Nursing Review of Craniectomy Care from the website: https://www.ahajournals.org/doi/pdf/10.1161/strokeaha.114XXX 5 dated (MONTH) 2014 read in part, Patients with DC (Decompressive Craniectomy) are at high risk for fall from their underlying stroke pathology and are at higher risk for injury after fall because of the compromised skull bone. Single case reports indicate that fall after DC may have disastrous consequences. Although an inhospital fall may result in an adverse outcome including trauma and even death in any patient population, patients after DC are at a higher risk for adverse outcome after fall because of the compromised skull bone and exposed cerebrum. Centers with adverse events related to fall after craniectomy recommended including cognitive assessment in the postcraniectomy care and considering all patients after DC at high risk for fall and injury after fall regardless of neurological examination . Of paramount importance is protecting the exposed cranium from fall or pressure with proper positioning, head protection, and helmet. A significant concern for a patient after DC is pressure to the open cerebrum or injury from fall. Positioning the patient onto the craniectomy site may place pressure on the cerebrum and should be avoided. Positioning may be supported with towels, pillows, and positioning devices to prevent pressure onto the cerebrum . The Administrator and DON were notified of the Immediate Jeopardy (IJ) on [DATE] at 3:30pm due to the above-referenced failures. A Plan of Removal was requested at that time. After one revision, the final Plan of Removal was accepted on [DATE] at 2:25 PM. An interview was conducted on [DATE] at 4:30 PM with the Administrator stated she felt the issue did not constitute an IJ. An interview was conducted with the DON on [DATE] at 9:30 AM. She indicated she understood the care issues and the I.J, (Immediate Jeopardy). IMMEDIATE JEOPARDY PLAN OF REMOVAL dated (MONTH) 8, 2019 read, The resident identified no longer resides in the facility. Residents who are admitted or readmitted to the facility have the potential to be affected by the current deficient practice. An audit of current residents admitted in the past 60 days was completed by members of the nursing management on (MONTH) 8, 2019 to validate that any resident admitted /readmitted with special needs has interventions implemented and care plans and profiles are updated to reflect current status. The nurse management team identified residents with special care need during this audit and those identified were evaluated to validate that special needs were implemented. This was completed on (MONTH) 8, 2019 Licensed nurses will be re-educated by the nurse management team regarding the following: Prior to admission and upon admission/readmission the hospital information is to be reviewed as well as physician orders [REDACTED]. Prior to the development of the baseline care plan, special needs for the resident is communicated via the 24 hour report and shift to shift report and communicated to Certified Nursing Assistants. The profile is to be updated with special needs once the baseline care plan is implemented. Abuse, Neglect, Exploitation, Mistreatment Certified Nursing Assistants will be re-educated by the nurse management team regarding the following: If assigned a new admission or readmission the nurse should be communicating any special needs that are required if the profile has not been developed. If the nurse has not updated the Certified Nursing Assistant, the Certified Nursing Assistant should ask if there is any special care need for equipment, fall prevention including special care needs for closed head injuries prior to administering care or at the beginning of the shift. Abuse, Neglect, Exploitation, Mistreatment This reeducation will be completed by (MONTH) 9, 2019. Any Licensed Nurse or certified Nursing Assistant not receiving this re-education prior to this date will receive prior to the next scheduled shift. This information will be presented in New Hire orientation. The Director of Nursing was re-educated by the Nursing Consultant on (MONTH) 8, 2019 regarding the management of the day to day delivery of care and the validation of implementation of interventions for residents with special needs. The Nurse Assessment Coordinator was re-educated by the Director of Nursing on (MONTH) 8, 2019 regarding screening possible admissions for special care needs and communicating those needs to licensed nurses and Certified Nursing Assistants. The Administrator was re-educated by the Regional Vice President of Operations on (MONTH) 8, 2019 regarding the management of day to day delivery of care and the validation of implementation of interventions for residents with special needs. Starting (MONTH) 9, 2019, the Director of Nursing and members of nursing management will review the hospital records of admissions and re-admissions and the discharge summary to validate that any special care needs are identified, communicated and implemented. This will be a part of the initial admission/readmission review and will be once again reviewed as part of the clinical morning meeting process to validate that any special care needs were implemented and communicated. Starting (MONTH) 12, 2019, a report will be given to the Weekend Supervisor by the Director of Nursing that will contain any special care needs for any possible weekend admissions or readmissions and update regarding any admissions/readmissions during the previous week. The Director of Nursing and members of nursing management will observe shift to shift report for three consecutive weeks starting (MONTH) 8, 2019, to validate that special needs are communicated during the shift to shift report and the on-coming nurse communicates to the certified nursing assistant prior to baseline care plan being developed and the profile updated to reflect any special care needs for any admission/readmission. Any areas of concern will be addressed by nurse management at the time of discovery. Ad Hoc Quality Assurance Performance Improvement Committee was conducted on (MONTH) 8, 2019 to review the Plan of Removal The Medical Director was notified on (MONTH) 8, 2019. Following acceptance of the facility's Plan of Removal, a record review was conducted of the facility's in-services that had been initiated for direct care staff. Documentation of the following was reviewed: Documentation of in-services for direct care staff on the topic of abuse and neglect conducted [DATE] through [DATE] for all shifts, Documentation of in-services on the topics of review of admission/admission packet and shift to shift report for all direct care staff conducted [DATE] through [DATE] for direct care and administrative nursing staff, Documentation of in-service on the topic of facility management conducted on [DATE] for the Administrator by corporate executive, Documentation of in-service conducted [DATE] for the DON conducted by the Nurse Consultant for the corporation, Additionally, documentation was reviewed that indicated a meeting of the Quality Assurance and performance Committee had been conducted to review these issues. Additionally, throughout the day on [DATE], interviews were conducted with a sample of 6 direct care staff, (both licensed nurses and aides from all shifts) to verify the in-services had in fact been conducted and to validate their understanding of the information presented to them. Observations and record review of 2 additional sampled residents revealed physician orders [REDACTED]. The Administrator was notified that the IJ was lowered on [DATE] at 2:25pm. 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 interviews and record reviews, the facility failed to ensure residents had the right to be free from neglect for 1 of 6 residents (CR #1) reviewed for neglect in that: The facility failed to ensure CR #1, who was admitted to the facility post-craniectomy with part of his skull removed, had a baseline care plan to address his health status. They had no interventions in place to prevent injury to his brain. The facility failed to ensure CR #1 had fall interventions in place to prevent a head injury. CR #1 was found on the floor with his head at the foot of the bed. The resident was placed back in back with a mechanical lift and expired less than 30 minutes later. An Immediate jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure placed residents at the facility at risk of neglect leading to injury or death. Findings include: Intake # 5, 0 and 0 CR #1 Record review of the closed clinical records for CR #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. The review revealed CR #1 had the following Diagnoses: [REDACTED]. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE]. The review revealed that on [DATE], a portion of CR #1's skull had been removed to relieve swelling and pressure which resulted in CR #1 essentially having a portion of his head with only skin over the brain. Record review of the hospital records revealed CR #1 had been fitted with an orthotic splint with an orthotic resting schedule of 2 hours on, 2 hours off and a protective helmet to be worn while out of bed. The review also revealed the use of pillows and a wedge cushion for head protection. The review further revealed the resident was discharged from the hospital to the facility on [DATE]. The review of hospital records revealed a hand-written notation that discharge orders had been reviewed with the physician/Medical Director for the facility. Record review of nursing notes from the facility regarding CR# 1 dated [DATE] 1:30 PM revealed LVN A assessed CR#1 at that time. The note further revealed the resident was admitted with a helmet. LVN A noted CR #1's surgical incision on the left side of head, but did not mention [MEDICAL CONDITION] or craniectomy. Record review of CR #1's physician order's dated (MONTH) 2019 revealed orders for the following medications: [REDACTED]. The review revealed the resident also had orders for a regular pureed diet with thickened liquids and orders for PT, OT and ST evaluations. The review revealed no orders for any type of devices, helmet or protection for his head. Record review of the facility's fall risk assessment dated [DATE] completed by LVN A revealed CR #1 was deemed to be a moderate fall risk. Record review of physician progress notes [REDACTED].#1 revealed the Medical Director visited CR #1 and noted CR #1 had left middle cerebral artery stroke with hemorrhagic conversion, midline shift, herniation and [DIAGNOSES REDACTED] after a craniectomy on [DATE]. He was stabilized and sent to (skilled nursing facility) for rehab and medical management. Precautions to put in place were fall precautions, wound precautions and dietary management. There was no mention of head protection. A record review was conducted of CR#1's baseline care plans dated [DATE]. The review revealed care plans for several areas. Review of one care plan read, Problem .has needs related to [MEDICAL CONDITION] Goal .will remain free of injury over next 90 days Approach Encourage .to use environmental devices such as hand grips, hand rails, etc. Keep bed in lowest position. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Provide proper well maintained footwear. The review revealed no care plan specific to fall risk, [MEDICAL CONDITION] or post-surgery precautions. Record review of physical therapy notes dated [DATE] revealed CR #1 was to have an assistive device during transfers. Record review of physical therapy notes dated [DATE] for CR #1 revealed CR #1 was a fall risk and was to use the helmet when out of bed and a resting hand splint for proper positioning. Record review of nurse's notes dated [DATE] at 6:50 PM written by LVN A revealed the nurse was called to the resident's room by a CNA. .Resident was on his back angled slightly to the right with his head at the foot of the bed . The review further revealed CR #1 was conscious and was asked 4 times if he hit his head. The note indicated the resident stated no. The review also revealed CR #1 was transferred back to bed via mechanical lift with 3 staff. There was no documentation that the physician was consulted when he was found on the floor. Record review of a Neurological Evaluation Flow Sheet dated [DATE] at 6:50pm revealed LVN A conducted a neurological assessment. CR #1's vitals were documented as follows: Blood pressure- ,[DATE], pulse 120. Record review of a Neurological Evaluation Flow Sheet dated [DATE] at 7:05pm revealed LVN A conducted a neurological assessment. CR #1's vitals were documented as follows: Blood pressure- ,[DATE], pulse 70. Record review of nurses' notes dated [DATE] at 7:15 PM written by LVN A revealed CR #1 was attempting to sit up in bed, was becoming restless and agitated and was gasping for air. The resident stopped breathing and the nurse was unable to obtain a pulse. The review further revealed the side rails were lowered and the bed was lowered to the floor at which time CPR was initiated and 911 was called. Interview on [DATE] at 11:45 AM with the DON revealed she had been informed of the incident involving CR #1. She stated she was notified of the incident and was not at the facility but believed in retrospect she should have gone to the facility. She stated that she believed that more than likely, based on the resident's medical history, he expired as a result of a [MEDICAL CONDITION] embolism. Interview on [DATE] at 1:00 PM with LVN A, she said CR #1 seemed fine on the day of the incident. She stated CR #1 always slept a lot. She said he was usually calm and she did not recall any shaking moments indicative of [MEDICAL CONDITION] involuntary movements. She said around 6:50 PM, Resident #2 and an aide came to get her to go to CR#1's room. She stated her assessment revealed no bruising or blood on the resident whose left side of his head she described as concave and having stitches. She stated that she asked CR #1 if he hit his head, and he said no. She described assessing CR #1 and reported his vitals and neuros were normal and he was returned to bed via mechanical lift with the assistance of CNA B and CNA C. She stated that in her opinion she believed CR#1 maneuvered himself through the gap between the two upright bedrails on his left side and momentum carried him away. She described the resident a few minutes later, around 7:15pm after the fall as agitated and gasping for air. She said LVN D came in to assist them and lowered him to the floor and started CPR. She said they were unsuccessful in reviving CR #1 who was pronounced by EMTs who had arrived to assist. LVN A further stated she was suspended for a week without pay for failing to notify the physician after he fell . She further stated she realized now that she should have contacted the doctor as required. She stated she received orientation and training when she was hired but did not recall any specific training as to how to care for residents with brain injuries. An interview was conducted with Physical Therapist E on [DATE] at 1:05 PM. He stated he only saw the resident briefly only on one occasion. He further stated the resident could move his left side but not his right. He stated the head was exposed. He further stated that CR#1's left side was very strong. An interview was conducted on [DATE] at 1:10 PM with Physical Therapist G. Physical Therapist G stated that CR #1 could not communicate. She further stated that it required 2 persons to even sit him up for therapy and that it required a lot of strength on the part of staff to do so. She stated he could not move at all and it was very surprising about the fall. She reported he was seen on (MONTH) 6, 2019 at which time he appeared more alert and appeared to understand more commands. An interview was conducted on [DATE] at 1:12 PM with Physical Therapist I . She stated she was surprised to learn of the resident's fall. She stated he really could not move much and it required 2 therapists to move him up to a position for therapy. An interview was conducted on [DATE] at 1:15 PM with OTA F. She stated she remembered seeing CR #1. She reported it required 2 staff members to get him up to sit. One day he stated the words, poo poo and they determined that he required incontinent care and consequently, summoned an aide. She further stated she did not see how it was possible for him to fall from the bed. She was questioned as to whether there was a fall mat by his bed and she replied there was not. An interview was conducted with Speech Therapist G on [DATE] at 1:45 PM. She stated they conducted an evaluation of CR #1 and he could not do much swallowing. She stated that CR #1 had a helmet when he came in and when he was evaluated. She further stated he could nod yes but kept uttering non-sensically the word four, four, four repeatedly. She stated she does not know how accurate his yes, no responses were. She was questioned about seeing a fall mat in his room and she replied she did not. During an interview on [DATE] at 3:30 PM, Resident #2 who was aphasic but alert to self and surroundings, was asked simple yes and no questions. In summary, the resident presented information to the effect that he saw the resident on the floor then went in his wheelchair and got a nurse. The nurse followed him to the room. He did not think CR #1 was hurt by anyone, staff or residents, and he believed CR #1 had a fall. An interview on [DATE] at 11:10 AM with the DON revealed she received a text about 7:30 PM on [DATE] informing her of CR #1's fall and having coded. She further stated that LVN A was his assigned nurse and she was a new nurse and this was her first code. She stated that LVN A was suspended, came in for training during her suspension and was re-instated the following week. The DON stated the bed rails were never up as this would be a restraint. Interview with the facility's Administrator on [DATE] at 1:20 PM revealed she has a dedicated desk nurse to review orders from the hospital. She said the Medical Director did not order a helmet for CR #1. She further stated that CR #1's hospital orders did not include orders for either a helmet or a splint. A telephone interview was conducted with the Medical Director, CR#1's physician, on [DATE] at 1:35 PM. He stated that CR #1 had a craniectomy performed and was stabilized in the hospital. He stated he did not know how the resident could have fallen from bed but stranger things have happened. He stated that it does appear he could have slid out of bed. He further stated he saw him 2 days prior to the incident and he could not say the word no. The doctor stated CR #1 could have thrown a [MEDICAL CONDITION] embolism. He said there was so much pressure on the [DIAGNOSES REDACTED] that it affected bleeding. He reported he did not recall the resident having a helmet but added he thinks he might have come with one from the hospital. The physician described the bed as being knee high. He further stated CR #1 was a very sick guy. He was asked about the bed rails being up, he replied that he could not recall if they were up or not when he saw them but when he makes his rounds the rails were up on residents' beds. An interview was conducted on [DATE] at 4:00 PM with CNA B. She was asked about the height of CR #1's bed and she stated she herself is 5' 4 and the bed about the height of her knees. She stated she was making rounds and on the day of the incident had just gone into CR#1's room to see if he required incontinent care. She reported that 3 to 5 minutes later Resident #2 came and informed them to come with him. She followed Resident #2 to CR#1's room where she discovered him on the floor towards one side. She stated he was lying by the bed full length on his right side. She reported the bed rails were up. She said she placed him on a pillow and went to get help and the blood pressure cuff. After he was assessed it required 3 persons to assist him back to bed as he was too heavy. She reported being in the room the entire time of the incident. She stated he attempted to sit up and then laid back down. She stated that when he laid back down, his eyes rolled back into his head and he closed his eyes. She said attempts were made by staff to get a pulse in his wrist and throat resulted in only a faint pulse. They assisted him from the bed back to the floor with the nurse and initiated CPR. When the EMTs came, they took over. CNA B further stated she had worked with CR #1 and although not specifically assigned to him she recalled feeding him. She stated that she did not recall training on caring for a brain-injured resident but did work with another resident on another hall who had a similar [DIAGNOSES REDACTED]. She stated she never did see a helmet on CR #1 or in the room. In an interview on [DATE] at 11:50 AM with the facility's social worker, she stated that the MDS Nurse or the DON receive the clinicals from the sending institution/hospital to determine the prospective resident's skilled nursing needs. She stated she did not get to interact much with CR #1 as he was non-verbal. An interview was conducted on [DATE] at 12:00 noon with Social Worker B, the local hospital's social worker that was housed at the nursing home. He stated the facility had a contract with the hospital (that CR #1 discharged from) to provide skilled nursing care and therapies for patients upon discharge from the hospital. He stated that the facility evaluated prospective patients to determine if their needs can be met in this skilled nursing setting. An interview was conducted on [DATE] at 12:30 PM with the MDS nurse. The MDS nurse at that time was asked about CR#1's clinical condition. The MDS nurse stated that CR #1 required extensive assist. He stated he himself developed the baseline care plans. He stated he did not recall if CR#1 had any protective head gear. He said if he had noted an order for [REDACTED]. He stated he did not recall CR #1 having any extra pillows except for his head and no wedges. He stated he did not see the helmet and CR #1 was not using the hand rail. The MDS Nurse further added that needs of residents were discussed during the daily morning meetings. He stated attempts were made to interview CR #1 but he was not verbal. He also stated when he reviewed CR #1's clinicals before admission, he did not see any orders for splints or head gear. When asked about the use of the mechanical lift to return the resident to bed, he stated he felt a draw sheet would have been safer. The MDS Nurse stated CR #1 could have used a wedge between the side rail area and his upper torso and head to protect him. He added that he should have brought the issue up during morning meetings and care planned the intervention. He said he never observed CR#1 out of bed and his mobility in bed did not raise concerns about falls before the incident. Interview on [DATE] at 4:10 PM with CNA C revealed that she was one of the aides who assisted CR #1 back to bed with the mechanical lift when he was found on the floor. She reported she had not ever observed CR #1 out of bed. She stated she was trained on topics of abuse and neglect and patient care but did not recall any training specific to caring for residents with brain injuries. Interview with the Medical Records Director on [DATE] at 4:15 PM revealed she scanned all of the medical information that comes from the hospital. She stated the desk nurse placed the information in a basket. She said she uploaded the documentation the next day. She further stated she uploaded all of the information with the exception of medications and physician's orders [REDACTED]. An interview was conducted with LVN D on [DATE] at 4:20 PM. She stated on the day of the incident, she was on the computer at the desk when a resident came by (Resident #2) and attempted to inform them something was wrong. She said he did not speak so she went with him and LVN A to CR#1's room where CR #1 was discovered to be on the floor beside his bed. She said after he was returned to bed, he started to breathe like he was holding his breath and then exhaled. She said she checked his pulse, but he was not responding. She said they lowered him to the ground and 911 was called. She said when EMTs arrived, they took over CPR. She stated in response to questioning that CR #1 was supposed to be transferred by mechanical lift. She stated prior to his breathing difficulties, he began getting agitated. She stated she recalled CR #1 as being fairly young. She stated she did not recall any orders for a splint or a helmet. She stated the records from the hospital go to Medical Records Department where they were scanned into the computer. She stated she does not recall usually receiving orders for specialized head protection. She further stated she did not recall seeing CR #1 with a helmet on during his stay at the facility. She further stated that when a resident was admitted on the weekend, they were to be seen by therapy the following Monday. Surveyor asked if she thought CR #1 was capable of falling from the bed and she stated she has seen paralyzed people try to do so. She added she did not recall if the bed rails were up. She stated that she does not know what could have happened. An interview was conducted on [DATE] at 4:30 PM with the Administrator and DON. They stated that the facility has 2 marketing staff members that go to the location or hospital to discuss the prospective resident's discharge to their facility. The 2 marketing staff members were not nurses but they review the documentation/clinical records brought from the hospital to determine if they could meet the needs of the person. In the event further assessment was indicated, the company had clinical individuals on staff to go to the hospital for additional assessment. The Administrator stated they have a dedicated nurse at all times to review orders from the hospital, then the resident's physician signs off on which orders to maintain and which should be discontinued. In an interview on [DATE] at 9:00 AM with the Administrator she reported that she understood now that the facility could have done more with regard to coordination with the hospital for quality of care provided. Record review of Evidence-Based Nursing Review of Craniectomy Care from the website: https://www.ahajournals.org/doi/pdf/10.1161/strokeaha.114XXX 5 dated (MONTH) 2014 read in part, Patients with DC (Decompressive Craniectomy) are at high risk for fall from their underlying stroke pathology and are at higher risk for injury after fall because of the compromised skull bone. Single case reports indicate that fall after DC may have disastrous consequences. Although an inhospital fall may result in an adverse outcome including trauma and even death in any patient population, patients after DC are at a higher risk for adverse outcome after fall because of the compromised skull bone and exposed cerebrum. Centers with adverse events related to fall after craniectomy recommended including cognitive assessment in the postcraniectomy care and considering all patients after DC at high risk for fall and injury after fall regardless of neurological examination . Of paramount importance is protecting the exposed cranium from fall or pressure with proper positioning, head protection, and helmet. A significant concern for a patient after DC is pressure to the open cerebrum or injury from fall. Positioning the patient onto the craniectomy site may place pressure on the cerebrum and should be avoided. Positioning may be supported with towels, pillows, and positioning devices to prevent pressure onto the cerebrum . The Administrator and DON were notified of the Immediate Jeopardy (IJ) on [DATE] at 3:30pm due to the above-referenced failures. A Plan of Removal was requested at that time. After one revision, the final Plan of Removal was accepted on [DATE] at 2:25 PM. An interview was conducted on [DATE] at 4:30 PM with the Administrator stated she felt the issue did not constitute an IJ. An interview was conducted with the DON on [DATE] at 9:30 AM. She indicated she understood the care issues and the IJ, (Immediate Jeopardy). IMMEDIATE JEOPARDY PLAN OF REMOVAL dated (MONTH) 8, 2019 read, The resident identified no longer resides in the facility. Residents who are admitted or readmitted to the facility have the potential to be affected by the current deficient practice. An audit of current residents admitted in the past 60 days was completed by members of the nursing management on (MONTH) 8, 2019 to validate that any resident admitted /readmitted with special needs has interventions implemented and care plans and profiles are updated to reflect current status. The nurse management team identified residents with special care need during this audit and those identified were evaluated to validate that special needs were implemented. This was completed on (MONTH) 8, 2019 Licensed nurses will be re-educated by the nurse management team regarding the following: Prior to admission and upon admission/readmission the hospital information is to be reviewed as well as physician orders [REDACTED]. Prior to the development of the baseline care plan, special needs for the resident is communicated via the 24 hour report and shift to shift report and communicated to Certified Nursing Assistants. The profile is to be updated with special needs once the baseline care plan is implemented. Abuse, Neglect, Exploitation, Mistreatment Certified Nursing Assistants will be re-educated by the nurse management team regarding the following: If assigned a new admission or readmission the nurse should be communicating any special needs that are required if the profile has not been developed. If the nurse has not updated the Certified Nursing Assistant, the Certified Nursing Assistant should ask if there is any special care need for equipment, fall prevention including special care needs for closed head injuries prior to administering care or at the beginning of the shift. Abuse, Neglect, Exploitation, Mistreatment This reeducation will be completed by (MONTH) 9, 2019. Any Licensed Nurse or certified Nursing Assistant not receiving this re-education prior to this date will receive prior to the next scheduled shift. This information will be presented in New Hire orientation. The Director of Nursing was re-educated by the Nursing Consultant on (MONTH) 8, 2019 regarding the management of the day to day delivery of care and the validation of implementation of interventions for residents with special needs. The Nurse Assessment Coordinator was re-educated by the Director of Nursing on (MONTH) 8, 2019 regarding screening possible admissions for special care needs and communicating those needs to licensed nurses and Certified Nursing Assistants. The Administrator was re-educated by the Regional Vice President of Operations on (MONTH) 8, 2019 regarding the management of day to day delivery of care and the validation of implementation of interventions for residents with special needs. Starting (MONTH) 9, 2019, the Director of Nursing and members of nursing management will review the hospital records of admissions and re-admissions and the discharge summary to validate that any special care needs are identified, communicated and implemented. This will be a part of the initial admission/readmission review and will be once again reviewed as part of the clinical morning meeting process to validate that any special care needs were implemented and communicated. Starting (MONTH) 12, 2019, a report will be given to the Weekend Supervisor by the Director of Nursing that will contain any special care needs for any possible weekend admissions or readmissions and update regarding any admissions/readmissions during the previous week. The Director of Nursing and members of nursing management will observe shift to shift report for three consecutive weeks starting (MONTH) 8, 2019, to validate that special needs are communicated during the shift to shift report and the on-coming nurse communicates to the certified nursing assistant prior to baseline care plan being developed and the profile updated to reflect any special care needs for any admission/readmission. Any areas of concern will be addressed by nurse management at the time of discovery. Ad Hoc Quality Assurance Performance Improvement Committee was conducted on (MONTH) 8, 2019 to review the Plan of Removal The Medical Director was notified on (MONTH) 8, 2019. Following acceptance of the facility's Plan of Removal, a record review was conducted of the facility's in-services that had been initiated for direct care staff. Documentation of the following was reviewed: Documentation of in-services for direct care staff on the topic of abuse and neglect conducted [DATE] through [DATE] for all shifts, Documentation of in-services on the topics of review of admission/admission packet and shift to shift report for all direct care staff conducted [DATE] through [DATE] for direct care and administrative nursing staff, Documentation of in-service on the topic of facility management conducted on [DATE] for the Administrator by corporate executive, Documentation of in-service conducted [DATE] for the DON conducted by the Nurse Consultant for the corporation, Additionally, documentation was reviewed that indicated a meeting of the Quality Assurance and performance Committee had been conducted to review these issues. Additionally, throughout the day on [DATE], interviews were conducted with a sample of 6 direct care staff, (both licensed nurses and aides from all shifts) to verify the in-services had in fact been conducted and to validate their understanding of the information presented to them. Observations and record review of 2 additional sampled residents revealed physician orders [REDACTED]. The Administrator was notified that the IJ was lowered on [DATE] at 2:25pm. 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 interview and record review, the facility failed to develop and implement a baseline care plans for residents that include instructions needed to provide effective person-centered care for the residents that meet profesional standards of quality care for 1 of 6 residents reviewed (CR#1) for baseline care plans in that: CR #1's craniectomy and partial removal of the skull was not care-planned for the fragility of the area and head protection. CR #1's partial [MEDICAL CONDITION] and [MEDICAL CONDITION] with strength on one side was not addressed in care-planning to mitigate risk of falls. An Immediate jeopardy (IJ) was identified on 4/8/19. While the IJ was lowered on 4/9/19, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure placed residents at the facility at risk of not having their needs met and resulting in injury or death. Findings include: Record review of the closed clinical records for CR #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. The review revealed CR #1 had the following Diagnoses: [REDACTED]. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE] and discharged from the hospital to the facility on [DATE]. Record review of the hospital records revealed CR #1 had been fitted with an orthotic splint with an orthotic resting schedule of 2 hours on, 2 hours off and a protective helmet to be worn while out of bed. The review also revealed the use of pillows and a wedge cushion for head protection. The review revealed that a portion of CR #1's skull had been removed to relieve swelling and pressure which resulted in CR #1 essentially having a portion of his head with only skin over the brain. The review further revealed the resident was discharged from the hospital with [DIAGNOSES REDACTED]. The review of hospital records revealed a notation that discharge orders had been reviewed by the physician/Medical Director for the facility. Record review of nursing notes from the facility regarding CR# 1 dated 3/2/19 1:30 PM revealed LVN A assessed CR#1 at that time. The note further revealed the resident was admitted with a helmet and boots. Record review of CR #1's physician order's dated (MONTH) 2019 revealed orders for the following medications: [REDACTED]. The review revealed the resident also had orders for a regular pureed diet with thickened liquids and orders for PT, OT and ST evaluations. The review revealed no orders for devices, including durable medical equipment nor fall precautions. Record review of the facility's fall risk assessment dated [DATE] revealed CR #1 was deemed to be a moderate fall risk. A record review was conducted of CR#1's baseline care plans dated 3/7/19. The review revealed care plans for several areas. Review of one care plan read, Problem .has needs related to [MEDICAL CONDITION] Goal .will remain free of injury over next 90 days Approach Encourage .to use environmental devices such as hand grips, hand rails, etc. Keep bed in lowest position. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Provide proper well maintained footwear. The review revealed no care plan for falls, [MEDICAL CONDITION] or post-surgery precautions. Record review of physical therapy notes dated 3/7/19 revealed CR #1 was to have an assistive device during transfers. Record review of physical therapy notes dated 3/8/19 for CR #1 revealed CR #1 was a fall risk and was to use the helmet when out of bed and a resting hand splint for proper positioning An interview was conducted on 4/8/19 at 12:30 PM with the MDS nurse who stated he himself developed the baseline care plans. He stated CR#1 was an extensive assist but he could not recall if he had any protective head gear. He stated that in his profesional opinion, a physician would have wanted CR #1's head protected post-craniectomy and would have issued orders for protective devices. He stated he did not recall CR #1 having any extra pillows except for his head. He said CR #1 did not have wedges. He stated he did not see the helmet and CR #1 was not using the hand rail. The MDS Nurse further added that needs of residents are discussed during the daily morning meetings. The MDS Nurse further stated CR #1 could have used a wedge between the side rail area and his upper torso and head to protect him in addition to fall interventions. He added that he should have brought the issue up during morning meetings and care planned interventions. Record review of Evidence-Based Nursing Review of Craniectomy Care from the website: https://www.ahajournals.org/doi/pdf/10.1161/strokeaha.114XXX 5 dated (MONTH) 2014 read in part, Patients with DC (Decompressive Craniectomy) are at high risk for fall from their underlying stroke pathology and are at higher risk for injury after fall because of the compromised skull bone. Single case reports indicate that fall after DC may have disastrous consequences. Although an inhospital fall may result in an adverse outcome including trauma and even death in any patient population, patients after DC are at a higher risk for adverse outcome after fall because of the compromised skull bone and exposed cerebrum. Centers with adverse events related to fall after craniectomy recommended including cognitive assessment in the postcraniectomy care and considering all patients after DC at high risk for fall and injury after fall regardless of neurological examination . Of paramount importance is protecting the exposed cranium from fall or pressure with proper positioning, head protection, and helmet. A significant concern for a patient after DC is pressure to the open cerebrum or injury from fall. Positioning the patient onto the craniectomy site may place pressure on the cerebrum and should be avoided. Positioning may be supported with towels, pillows, and positioning devices to prevent pressure onto the cerebrum . The Administrator and DON were notified of the Immediate Jeopardy (IJ) on 4/8/19 at 3:30pm due to the above-referenced failures. A Plan of Removal was requested at that time. After one revision, the final Plan of Removal was accepted on 4/9/19 at 2:25 PM. An interview was conducted on 4/8/19 at 4:30 PM with the Administrator stated she felt the issue did not constitute an IJ. An interview was conducted with the DON on 4/9/19 at 9:30 AM. She indicated she understood the care issues and the I.J, (Immediate Jeopardy). IMMEDIATE JEOPARDY PLAN OF REMOVAL dated (MONTH) 8, 2019 read, The resident identified no longer resides in the facility. Residents who are admitted or readmitted to the facility have the potential to be affected by the current deficient practice. An audit of current residents admitted in the past 60 days was completed by members of the nursing management on (MONTH) 8, 2019 to validate that any resident admitted /readmitted with special needs has interventions implemented and care plans and profiles are updated to reflect current status. The nurse management team identified residents with special care need during this audit and those identified were evaluated to validate that special needs were implemented. This was completed on (MONTH) 8, 2019 Licensed nurses will be re-educated by the nurse management team regarding the following: Prior to admission and upon admission/readmission the hospital information is to be reviewed as well as physician orders [REDACTED]. Prior to the development of the baseline care plan, special needs for the resident is communicated via the 24 hour report and shift to shift report and communicated to Certified Nursing Assistants. The profile is to be updated with special needs once the baseline care plan is implemented. Abuse, Neglect, Exploitation, Mistreatment Certified Nursing Assistants will be re-educated by the nurse management team regarding the following: If assigned a new admission or readmission the nurse should be communicating any special needs that are required if the profile has not been developed. If the nurse has not updated the Certified Nursing Assistant, the Certified Nursing Assistant should ask if there is any special care need for equipment, fall prevention including special care needs for closed head injuries prior to administering care or at the beginning of the shift. Abuse, Neglect, Exploitation, Mistreatment This reeducation will be completed by (MONTH) 9, 2019. Any Licensed Nurse or certified Nursing Assistant not receiving this re-education prior to this date will receive prior to the next scheduled shift. This information will be presented in New Hire orientation. The Director of Nursing was re-educated by the Nursing Consultant on (MONTH) 8, 2019 regarding the management of the day to day delivery of care and the validation of implementation of interventions for residents with special needs. The Nurse Assessment Coordinator was re-educated by the Director of Nursing on (MONTH) 8, 2019 regarding screening possible admissions for special care needs and communicating those needs to licensed nurses and Certified Nursing Assistants. The Administrator was re-educated by the Regional Vice President of Operations on (MONTH) 8, 2019 regarding the management of day to day delivery of care and the validation of implementation of interventions for residents with special needs. Starting (MONTH) 9, 2019, the Director of Nursing and members of nursing management will review the hospital records of admissions and re-admissions and the discharge summary to validate that any special care needs are identified, communicated and implemented. This will be a part of the initial admission/readmission review and will be once again reviewed as part of the clinical morning meeting process to validate that any special care needs were implemented and communicated. Starting (MONTH) 12, 2019, a report will be given to the Weekend Supervisor by the Director of Nursing that will contain any special care needs for any possible weekend admissions or readmissions and update regarding any admissions/readmissions during the previous week. The Director of Nursing and members of nursing management will observe shift to shift report for three consecutive weeks starting (MONTH) 8, 2019, to validate that special needs are communicated during the shift to shift report and the on-coming nurse communicates to the certified nursing assistant prior to baseline care plan being developed and the profile updated to reflect any special care needs for any admission/readmission. Any areas of concern will be addressed by nurse management at the time of discovery. Ad Hoc Quality Assurance Performance Improvement Committee was conducted on (MONTH) 8, 2019 to review the Plan of Removal The Medical Director was notified on (MONTH) 8, 2019. Following acceptance of the facility's Plan of Removal, a record review was conducted of the facility's in-services that had been initiated for direct care staff. Documentation of the following was reviewed: Documentation of in-services for direct care staff on the topic of abuse and neglect conducted 4/8/19 through 4/9/19 for all shifts, Documentation of in-services on the topics of review of admission/admission packet and shift to shift report for all direct care staff conducted 4/8/19 through 4/9/19 for direct care and administrative nursing staff, Documentation of in-service on the topic of facility management conducted on 4/8/19 for the Administrator by corporate executive, Documentation of in-service conducted 4/8/19 for the DON conducted by the Nurse Consultant for the corporation, Additionally, documentation was reviewed that indicated a meeting of the Quality Assurance and performance Committee had been conducted to review these issues. Additionally, throughout the day on 4/9/19, interviews were conducted with a sample of 6 direct care staff, (both licensed nurses and aides from all shifts) to verify the in-services had in fact been conducted and to validate their understanding of the information presented to them. Observations and record review of 2 additional sampled residents revealed physician orders [REDACTED]. The Administrator was notified that the IJ was lowered on 4/9/19 at 2:25pm. 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 interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 residents (CR #1) reviewed for quality of care in that: The facility failed to ensure CR #1, who was admitted to the facility post-craniectomy with part of his skull removed, had a baseline care plan to address his health status. They had no interventions in place to prevent injury to his brain. The facility failed to ensure CR #1 had fall interventions in place to prevent a head injury. CR #1 was found on the floor with his head at the foot of the bed. The facility failed to ensure CR #1 was transferred in a manner to prevent injury and stabilize his head. After CR #1 was found on the floor, he was placed back in bed using a mechanical lift. The facility failed to consult CR #1's physician when the resident was found on the floor. Less than 30 minutes later, CR #1 had a change of condition and expired at the facility. An Immediate jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure placed residents at the facility at risk of not obtaining the highest practicable level of well-being resulting in injury or death. Findings include: Intake # 5, 0 and 0 CR #1 Record review of the closed clinical records for CR #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. The review revealed CR #1 had the following Diagnoses: [REDACTED]. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE]. The review revealed that on [DATE], a portion of CR #1's skull had been removed to relieve swelling and pressure which resulted in CR #1 essentially having a portion of his head with only skin over the brain. Record review of the hospital records revealed CR #1 had been fitted with an orthotic splint with an orthotic resting schedule of 2 hours on, 2 hours off and a protective helmet to be worn while out of bed. The review also revealed the use of pillows and a wedge cushion for head protection. The review further revealed the resident was discharged from the hospital to the facility on [DATE]. The review of hospital records revealed a hand-written notation that discharge orders had been reviewed with the physician/Medical Director for the facility. Record review of nursing notes from the facility regarding CR# 1 dated [DATE] 1:30 PM revealed LVN A assessed CR#1 at that time. The note further revealed the resident was admitted with a helmet. LVN A noted CR #1's surgical incision on the left side of head, but did not mention [MEDICAL CONDITION] or craniectomy. Record review of CR #1's physician order's dated (MONTH) 2019 revealed orders for the following medications: [REDACTED]. The review revealed the resident also had orders for a regular pureed diet with thickened liquids and orders for PT, OT and ST evaluations. The review revealed no orders for any type of devices, helmet or protection for his head. Record review of the facility's fall risk assessment dated [DATE] completed by LVN A revealed CR #1 was deemed to be a moderate fall risk. Record review of physician progress notes [REDACTED].#1 revealed the Medical Director visited CR #1 and noted CR #1 had left middle cerebral artery stroke with hemorrhagic conversion, midline shift, herniation and [DIAGNOSES REDACTED] after a craniectomy on [DATE]. He was stabilized and sent to (skilled nursing facility) for rehab and medical management. Precautions to put in place were fall precautions, wound precautions and dietary management. There was no mention of head protection. A record review was conducted of CR#1's baseline care plans dated [DATE]. The review revealed care plans for several areas. Review of one care plan read, Problem .has needs related to [MEDICAL CONDITION] Goal .will remain free of injury over next 90 days Approach Encourage .to use environmental devices such as hand grips, hand rails, etc. Keep bed in lowest position. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Provide proper well maintained footwear. The review revealed no care plan specific to fall risk, [MEDICAL CONDITION] or post-surgery precautions. Record review of physical therapy notes dated [DATE] revealed CR #1 was to have an assistive device during transfers. Record review of physical therapy notes dated [DATE] for CR #1 revealed CR #1 was a fall risk and was to use the helmet when out of bed and a resting hand splint for proper positioning. Record review of nurse's notes dated [DATE] at 6:50 PM written by LVN A revealed the nurse was called to the resident's room by a CNA. .Resident was on his back angled slightly to the right with his head at the foot of the bed . The review further revealed CR #1 was conscious and was asked 4 times if he hit his head. The note indicated the resident stated no. The review also revealed CR #1 was transferred back to bed via mechanical lift with 3 staff. There was no documentation that the physician was consulted when he was found on the floor. Record review of a Neurological Evaluation Flow Sheet dated [DATE] at 6:50pm revealed LVN A conducted a neurological assessment. CR #1's vitals were documented as follows: Blood pressure- ,[DATE], pulse 120. Record review of a Neurological Evaluation Flow Sheet dated [DATE] at 7:05pm revealed LVN A conducted a neurological assessment. CR #1's vitals were documented as follows: Blood pressure- ,[DATE], pulse 70. Record review of nurses' notes dated [DATE] at 7:15 PM written by LVN A revealed CR #1 was attempting to sit up in bed, was becoming restless and agitated and was gasping for air. The resident stopped breathing and the nurse was unable to obtain a pulse. The review further revealed the side rails were lowered and the bed was lowered to the floor at which time CPR was initiated and 911 was called. Interview on [DATE] at 11:45 AM with the DON revealed she had been informed of the incident involving CR #1. She stated she was notified of the incident and was not at the facility but believed in retrospect she should have gone to the facility. She stated that she believed that more than likely, based on the resident's medical history, he expired as a result of a [MEDICAL CONDITION] embolism. Interview on [DATE] at 1:00 PM with LVN A, she said CR #1 seemed fine on the day of the incident. She stated CR #1 always slept a lot. She said he was usually calm and she did not recall any shaking moments indicative of [MEDICAL CONDITION] involuntary movements. She said around 6:50 PM, Resident #2 and an aide came to get her to go to CR#1's room. She stated her assessment revealed no bruising or blood on the resident whose left side of his head she described as concave and having stitches. She stated that she asked CR #1 if he hit his head, and he said no. She described assessing CR #1 and reported his vitals and neuros were normal and he was returned to bed via mechanical lift with the assistance of CNA B and CNA C. She stated that in her opinion she believed CR#1 maneuvered himself through the gap between the two upright bedrails on his left side and momentum carried him away. She described the resident a few minutes later, around 7:15pm after the fall as agitated and gasping for air. She said LVN D came in to assist them and lowered him to the floor and started CPR. She said they were unsuccessful in reviving CR #1 who was pronounced by EMTs who had arrived to assist. LVN A further stated she was suspended for a week without pay for failing to notify the physician after he fell . She further stated she realized now that she should have contacted the doctor as required. She stated she received orientation and training when she was hired but did not recall any specific training as to how to care for residents with brain injuries. An interview was conducted with Physical Therapist E on [DATE] at 1:05 PM. He stated he only saw the resident briefly only on one occasion. He further stated the resident could move his left side but not his right. He stated the head was exposed. He further stated that CR#1's left side was very strong. An interview was conducted on [DATE] at 1:10 PM with Physical Therapist G. Physical Therapist G stated that CR #1 could not communicate. She further stated that it required 2 persons to even sit him up for therapy and that it required a lot of strength on the part of staff to do so. She stated he could not move at all and it was very surprising about the fall. She reported he was seen on (MONTH) 6, 2019 at which time he appeared more alert and appeared to understand more commands. An interview was conducted on [DATE] at 1:12 PM with Physical Therapist I . She stated she was surprised to learn of the resident's fall. She stated he really could not move much and it required 2 therapists to move him up to a position for therapy. An interview was conducted on [DATE] at 1:15 PM with OTA F. She stated she remembered seeing CR #1. She reported it required 2 staff members to get him up to sit. One day he stated the words, poo poo and they determined that he required incontinent care and consequently, summoned an aide. She further stated she did not see how it was possible for him to fall from the bed. She was questioned as to whether there was a fall mat by his bed and she replied there was not. An interview was conducted with Speech Therapist G on [DATE] at 1:45 PM. She stated they conducted an evaluation of CR #1 and he could not do much swallowing. She stated that CR #1 had a helmet when he came in and when he was evaluated. She further stated he could nod yes but kept uttering non-sensically the word four, four, four repeatedly. She stated she does not know how accurate his yes, no responses were. She was questioned about seeing a fall mat in his room and she replied she did not. During an interview on [DATE] at 3:30 PM, Resident #2 who was aphasic but alert to self and surroundings, was asked simple yes and no questions. In summary, the resident presented information to the effect that he saw the resident on the floor then went in his wheelchair and got a nurse. The nurse followed him to the room. He did not think CR #1 was hurt by anyone, staff or residents, and he believed CR #1 had a fall. An interview on [DATE] at 11:10 AM with the DON revealed she received a text about 7:30 PM on [DATE] informing her of CR #1's fall and having coded. She further stated that LVN A was his assigned nurse and she was a new nurse and this was her first code. She stated that LVN A was suspended, came in for training during her suspension and was re-instated the following week. The DON stated the bed rails were never up as this would be a restraint. Interview with the facility's Administrator on [DATE] at 1:20 PM revealed she has a dedicated desk nurse to review orders from the hospital. She said the Medical Director did not order a helmet for CR #1. She further stated that CR #1's hospital orders did not include orders for either a helmet or a splint. A telephone interview was conducted with the Medical Director, CR#1's physician, on [DATE] at 1:35 PM. He stated that CR #1 had a craniectomy performed and was stabilized in the hospital. He stated he did not know how the resident could have fallen from bed but stranger things have happened. He stated that it does appear he could have slid out of bed. He further stated he saw him 2 days prior to the incident and he could not say the word no. The doctor stated CR #1 could have thrown a [MEDICAL CONDITION] embolism. He said there was so much pressure on the [DIAGNOSES REDACTED] that it affected bleeding. He reported he did not recall the resident having a helmet but added he thinks he might have come with one from the hospital. The physician described the bed as being knee high. He further stated CR #1 was a very sick guy. He was asked about the bed rails being up, he replied that he could not recall if they were up or not when he saw them but when he makes his rounds the rails were up on residents' beds. An interview was conducted on [DATE] at 4:00 PM with CNA B. She was asked about the height of CR #1's bed and she stated she herself is 5' 4 and the bed about the height of her knees. She stated she was making rounds and on the day of the incident had just gone into CR#1's room to see if he required incontinent care. She reported that 3 to 5 minutes later Resident #2 came and informed them to come with him. She followed Resident #2 to CR#1's room where she discovered him on the floor towards one side. She stated he was lying by the bed full length on his right side. She reported the bed rails were up. She said she placed him on a pillow and went to get help and the blood pressure cuff. After he was assessed it required 3 persons to assist him back to bed as he was too heavy. She reported being in the room the entire time of the incident. She stated he attempted to sit up and then laid back down. She stated that when he laid back down, his eyes rolled back into his head and he closed his eyes. She said attempts were made by staff to get a pulse in his wrist and throat resulted in only a faint pulse. They assisted him from the bed back to the floor with the nurse and initiated CPR. When the EMTs came, they took over. CNA B further stated she had worked with CR #1 and although not specifically assigned to him she recalled feeding him. She stated that she did not recall training on caring for a brain-injured resident but did work with another resident on another hall who had a similar [DIAGNOSES REDACTED]. She stated she never did see a helmet on CR #1 or in the room. In an interview on [DATE] at 11:50 AM with the facility's social worker, she stated that the MDS Nurse or the DON receive the clinicals from the sending institution/hospital to determine the prospective resident's skilled nursing needs. She stated she did not get to interact much with CR #1 as he was non-verbal. An interview was conducted on [DATE] at 12:00 noon with Social Worker B, the local hospital's social worker that was housed at the nursing home. He stated the facility had a contract with the hospital (that CR #1 discharged from) to provide skilled nursing care and therapies for patients upon discharge from the hospital. He stated that the facility evaluated prospective patients to determine if their needs can be met in this skilled nursing setting. An interview was conducted on [DATE] at 12:30 PM with the MDS nurse. The MDS nurse at that time was asked about CR#1's clinical condition. The MDS nurse stated that CR #1 required extensive assist. He stated he himself developed the baseline care plans. He stated he did not recall if CR#1 had any protective head gear. He said if he had noted an order for [REDACTED]. He stated he did not recall CR #1 having any extra pillows except for his head and no wedges. He stated he did not see the helmet and CR #1 was not using the hand rail. The MDS Nurse further added that needs of residents were discussed during the daily morning meetings. He stated attempts were made to interview CR #1 but he was not verbal. He also stated when he reviewed CR #1's clinicals before admission, he did not see any orders for splints or head gear. When asked about the use of the mechanical lift to return the resident to bed, he stated he felt a draw sheet would have been safer. The MDS Nurse stated CR #1 could have used a wedge between the side rail area and his upper torso and head to protect him. He added that he should have brought the issue up during morning meetings and care planned the intervention. He said he never observed CR#1 out of bed and his mobility in bed did not raise concerns about falls before the incident. Interview on [DATE] at 4:10 PM with CNA C revealed that she was one of the aides who assisted CR #1 back to bed with the mechanical lift when he was found on the floor. She reported she had not ever observed CR #1 out of bed. She stated she was trained on topics of abuse and neglect and patient care but did not recall any training specific to caring for residents with brain injuries. Interview with the Medical Records Director on [DATE] at 4:15 PM revealed she scanned all of the medical information that comes from the hospital. She stated the desk nurse placed the information in a basket. She said she uploaded the documentation the next day. She further stated she uploaded all of the information with the exception of medications and physician's orders [REDACTED]. An interview was conducted with LVN D on [DATE] at 4:20 PM. She stated on the day of the incident, she was on the computer at the desk when a resident came by (Resident #2) and attempted to inform them something was wrong. She said he did not speak so she went with him and LVN A to CR#1's room where CR #1 was discovered to be on the floor beside his bed. She said after he was returned to bed, he started to breathe like he was holding his breath and then exhaled. She said she checked his pulse, but he was not responding. She said they lowered him to the ground and 911 was called. She said when EMTs arrived, they took over CPR. She stated in response to questioning that CR #1 was supposed to be transferred by mechanical lift. She stated prior to his breathing difficulties, he began getting agitated. She stated she recalled CR #1 as being fairly young. She stated she did not recall any orders for a splint or a helmet. She stated the records from the hospital go to Medical Records Department where they were scanned into the computer. She stated she does not recall usually receiving orders for specialized head protection. She further stated she did not recall seeing CR #1 with a helmet on during his stay at the facility. She further stated that when a resident was admitted on the weekend, they were to be seen by therapy the following Monday. Surveyor asked if she thought CR #1 was capable of falling from the bed and she stated she has seen paralyzed people try to do so. She added she did not recall if the bed rails were up. She stated that she does not know what could have happened. An interview was conducted on [DATE] at 4:30 PM with the Administrator and DON. They stated that the facility has 2 marketing staff members that go to the location or hospital to discuss the prospective resident's discharge to their facility. The 2 marketing staff members were not nurses but they review the documentation/clinical records brought from the hospital to determine if they could meet the needs of the person. In the event further assessment was indicated, the company had clinical individuals on staff to go to the hospital for additional assessment. The Administrator stated they have a dedicated nurse at all times to review orders from the hospital, then the resident's physician signs off on which orders to maintain and which should be discontinued. In an interview on [DATE] at 9:00 AM with the Administrator she reported that she understood now that the facility could have done more with regard to coordination with the hospital for quality of care provided. Record review of Evidence-Based Nursing Review of Craniectomy Care from the website: https://www.ahajournals.org/doi/pdf/10.1161/strokeaha.114XXX 5 dated (MONTH) 2014 read in part, Patients with DC (Decompressive Craniectomy) are at high risk for fall from their underlying stroke pathology and are at higher risk for injury after fall because of the compromised skull bone. Single case reports indicate that fall after DC may have disastrous consequences. Although an inhospital fall may result in an adverse outcome including trauma and even death in any patient population, patients after DC are at a higher risk for adverse outcome after fall because of the compromised skull bone and exposed cerebrum. Centers with adverse events related to fall after craniectomy recommended including cognitive assessment in the postcraniectomy care and considering all patients after DC at high risk for fall and injury after fall regardless of neurological examination . Of paramount importance is protecting the exposed cranium from fall or pressure with proper positioning, head protection, and helmet. A significant concern for a patient after DC is pressure to the open cerebrum or injury from fall. Positioning the patient onto the craniectomy site may place pressure on the cerebrum and should be avoided. Positioning may be supported with towels, pillows, and positioning devices to prevent pressure onto the cerebrum . The Administrator and DON were notified of the Immediate Jeopardy (IJ) on [DATE] at 3:30pm due to the above-referenced failures. A Plan of Removal was requested at that time. After one revision, the final Plan of Removal was accepted on [DATE] at 2:25 PM. An interview was conducted on [DATE] at 4:30 PM with the Administrator stated she felt the issue did not constitute an IJ. An interview was conducted with the DON on [DATE] at 9:30 AM. She indicated she understood the care issues and the I.J, (Immediate Jeopardy). IMMEDIATE JEOPARDY PLAN OF REMOVAL dated (MONTH) 8, 2019 read, The resident identified no longer resides in the facility. Residents who are admitted or readmitted to the facility have the potential to be affected by the current deficient practice. An audit of current residents admitted in the past 60 days was completed by members of the nursing management on (MONTH) 8, 2019 to validate that any resident admitted /readmitted with special needs has interventions implemented and care plans and profiles are updated to reflect current status. The nurse management team identified residents with special care need during this audit and those identified were evaluated to validate that special needs were implemented. This was completed on (MONTH) 8, 2019 Licensed nurses will be re-educated by the nurse management team regarding the following: Prior to admission and upon admission/readmission the hospital information is to be reviewed as well as physician orders [REDACTED]. Prior to the development of the baseline care plan, special needs for the resident is communicated via the 24 hour report and shift to shift report and communicated to Certified Nursing Assistants. The profile is to be updated with special needs once the baseline care plan is implemented. Abuse, Neglect, Exploitation, Mistreatment Certified Nursing Assistants will be re-educated by the nurse management team regarding the following: If assigned a new admission or readmission the nurse should be communicating any special needs that are required if the profile has not been developed. If the nurse has not updated the Certified Nursing Assistant, the Certified Nursing Assistant should ask if there is any special care need for equipment, fall prevention including special care needs for closed head injuries prior to administering care or at the beginning of the shift. Abuse, Neglect, Exploitation, Mistreatment This reeducation will be completed by (MONTH) 9, 2019. Any Licensed Nurse or certified Nursing Assistant not receiving this re-education prior to this date will receive prior to the next scheduled shift. This information will be presented in New Hire orientation. The Director of Nursing was re-educated by the Nursing Consultant on (MONTH) 8, 2019 regarding the management of the day to day delivery of care and the validation of implementation of interventions for residents with special needs. The Nurse Assessment Coordinator was re-educated by the Director of Nursing on (MONTH) 8, 2019 regarding screening possible admissions for special care needs and communicating those needs to licensed nurses and Certified Nursing Assistants. The Administrator was re-educated by the Regional Vice President of Operations on (MONTH) 8, 2019 regarding the management of day to day delivery of care and the validation of implementation of interventions for residents with special needs. Starting (MONTH) 9, 2019, the Director of Nursing and members of nursing management will review the hospital records of admissions and re-admissions and the discharge summary to validate that any special care needs are identified, communicated and implemented. This will be a part of the initial admission/readmission review and will be once again reviewed as part of the clinical morning meeting process to validate that any special care needs were implemented and communicated. Starting (MONTH) 12, 2019, a report will be given to the Weekend Supervisor by the Director of Nursing that will contain any special care needs for any possible weekend admissions or readmissions and update regarding any admissions/readmissions during the previous week. The Director of Nursing and members of nursing management will observe shift to shift report for three consecutive weeks starting (MONTH) 8, 2019, to validate that special needs are communicated during the shift to shift report and the on-coming nurse communicates to the certified nursing assistant prior to baseline care plan being developed and the profile updated to reflect any special care needs for any admission/readmission. Any areas of concern will be addressed by nurse management at the time of discovery. Ad Hoc Quality Assurance Performance Improvement Committee was conducted on (MONTH) 8, 2019 to review the Plan of Removal The Medical Director was notified on (MONTH) 8, 2019. Following acceptance of the facility's Plan of Removal, a record review was conducted of the facility's in-services that had been initiated for direct care staff. Documentation of the following was reviewed: Documentation of in-services for direct care staff on the topic of abuse and neglect conducted [DATE] through [DATE] for all shifts, Documentation of in-services on the topics of review of admission/admission packet and shift to shift report for all direct care staff conducted [DATE] through [DATE] for direct care and administrative nursing staff, Documentation of in-service on the topic of facility management conducted on [DATE] for the Administrator by corporate executive, Documentation of in-service conducted [DATE] for the DON conducted by the Nurse Consultant for the corporation, Additionally, documentation was reviewed that indicated a meeting of the Quality Assurance and performance Committee had been conducted to review these issues. Additionally, throughout the day on [DATE], interviews were conducted with a sample of 6 direct care staff, (both licensed nurses and aides from all shifts) to verify the in-services had in fact been conducted and to validate their understanding of the information presented to them. Observations and record review of 2 additional sampled residents revealed physician orders [REDACTED]. The Administrator was notified that the IJ was lowered on [DATE] at 2:25pm. 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 ensure that it was being administered in a manner that enabled it to utilize its resources effective and efficiently to attain or maintain the highest practicable, physical, mental and psychological well-being for 1 of 6 residents reviewed (CR #1) for administration. The Administrator failed to provide guidance to the DON based on best practice to ensure that nursing staff were aware of the specialized individual needs of CR #1. THe DON failed to ensure nursing staff were competent to care for CR #1, who was admitted to the facility post-craniectomy with part of his skull removed. The DON and Administrator failed to ensure there was an effective system in place to review residents' clinical needs upon admission and follow through with necessary implementations for specialized care. An Immediate jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure placed residents at the facility at risk of not obtaining the highest practicable level of well-being resulting in injury or death. Findings include: An interview on [DATE] at 11:10 AM with the DON revealed she received a text about 7:30 PM on [DATE] informing her of CR #1's fall and having coded. She further stated that LVN A was his assigned nurse and she was a new nurse and this was her first code. She stated that LVN A was suspended, came in for training during her suspension and was re-instated the following week. The DON stated the bed rails were never up as this would be a restraint. Interview with the facility's Administrator on [DATE] at 1:20 PM revealed she has a dedicated desk nurse to review orders from the hospital. She said the Medical Director did not order a helmet for CR #1. She further stated that CR #1's hospital orders did not include orders for either a helmet or a splint. An interview was conducted on [DATE] at 4:30 PM with the Administrator and DON. They stated that the facility has 2 marketing persons that go to the location or hospital to discuss the prospective resident's discharge to their facility. The 2 marketing persons are not nurses but they review the documentation/clinical records brought from the hospital to determine if they can meet the needs of the person. In the event futher assessment is indicated, the company has clinical individuals on staff to go to the hospital for additional assessment. The Administrator stated they have a dedicated nurse at all times to review orders from the hospital. Then their physician signs off on which orders to maintain and which should be discontinued. The Administrator stated she felt the issue did not constitute an IJ. In an interview on [DATE] at 9:00 AM with the Administrator she reported that she understood now what the facility should have done with regard to administration of the facility. She stated that in all cases of new admittals, the facility's physician must be informed of the orders in order that they can be reviewed and interventions for safety precautions can be provided She reported they understand that residents with special needs such as in the case of brain injuries must have specialized protective implementations and training must be conducted for all direct care staff in caring for all residents including those with traumatic brain injuries. Interview with the DON on [DATE] at 9:30 AM revealed that she understood what needs to be implemented in order to ensure residents in the future have their needs reviewed, coordinated and care-planned at the time of admission, particularly in the case of residents with special needs relative to brain injuries. She stated that the failure was not ensuring that CR #1 had his hospital orders signed off and approved by the physician and failing to review hospital documentation to determine if certain protective devices should have been ordered. CR #1 Record review of the closed clinical records for CR #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. The review revealed CR #1 had the following Diagnoses: [REDACTED]. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE]. The review revealed that on [DATE], a portion of CR #1's skull had been removed to relieve swelling and pressure which resulted in CR #1 essentially having a portion of his head with only skin over the brain. Record review of the hospital records revealed CR #1 had been fitted with an orthotic splint with an orthotic resting schedule of 2 hours on, 2 hours off and a protective helmet to be worn while out of bed. The review also revealed the use of pillows and a wedge cushion for head protection. The review further revealed the resident was discharged from the hospital to the facility on [DATE]. The review of hospital records revealed a hand-written notation that discharge orders had been reviewed with the physician/Medical Director for the facility. Record review of nursing notes from the facility regarding CR# 1 dated [DATE] 1:30 PM revealed LVN A assessed CR#1 at that time. The note further revealed the resident was admitted with a helmet. Record review of CR #1's physician order's dated (MONTH) (YEAR)9 revealed orders for the following medications: [REDACTED]. The review revealed the resident also had orders for a regular pureed diet with thickened liquids and orders for PT, OT and ST evaluations. The review revealed no orders for devices, including durable medical equipment nor fall precautions. Record review of the facility's fall risk assessment dated [DATE] completed by LVN A revealed CR #1 was deemed to be a moderate fall risk. Record review of physician progress notes [REDACTED].#1 revealed the Medical Director visited CR #1 and noted CR #1 had left middle cerebral artery stroke with hemorrhagic conversion, midline shift, herniation and [DIAGNOSES REDACTED] after a craniectomy on [DATE]. He was stabilized and sent to (skilled nursing facility) for rehab and medical management. Precautions to put in place were fall precautions, wound precautions and dietary management. There was no mention of head protection. A record review was conducted of CR#1's baseline care plans dated [DATE]. The review revealed care plans for several areas. Review of one care plan read, Problem .has needs related to [MEDICAL CONDITION] Goal .will remain free of injury over next 90 days Approach Encourage .to use environmental devices such as hand grips, hand rails, etc. Keep bed in lowest position. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Provide proper well maintained footwear. The review revealed no care plan specific to fall risk, [MEDICAL CONDITION] or post-surgery precautions. Record review of physical therapy notes dated [DATE] revealed CR #1 was to have an assistive device during transfers. Record review of physical therapy notes dated [DATE] for CR #1 revealed CR #1 was a fall risk and was to use the helmet when out of bed and a resting hand splint for proper positioning. Record review of nurse's notes dated [DATE] at 6:50 PM written by LVN A revealed the nurse was called to the resident's room by a CNA. .Resident was on his back angled slightly to the right with his head at the foot of the bed . The review further revealed CR #1 was conscious and was asked 4 times if he hit his head. The note indicated the resident stated no. The review also revealed CR #1 was transferred back to bed via mechanical lift with 3 staff. There was no documentation that the physician was consulted when he was found on the floor. Record review of a Neurological Evaluation Flow Sheet dated [DATE] at 6:50pm revealed LVN A conducted a neurological assessment. CR #1's vitals were documented as follows: Blood pressure- ,[DATE], pulse 120. Record review of a Neurological Evaluation Flow Sheet dated [DATE] at 7:05pm revealed LVN A conducted a neurological assessment. CR #1's vitals were documented as follows: Blood pressure- ,[DATE], pulse 70. Record review of nurses' notes dated [DATE] at 7:15 PM written by LVN A revealed CR #1 was attempting to sit up in bed, was becoming restless and agitated and was gasping for air. The resident stopped breathing and the nurse was unable to obtain a pulse. The review further revealed the side rails were lowered and the bed was lowered to the floor at which time CPR was initiated and 911 was called. Interview on [DATE] at 11:45 AM with the DON revealed she had been informed of the incident involving CR #1. She stated she was notified of the incident and was not at the facility but believed in retrospect she should have gone to the facility. She stated that she believed that more than likely, based on the resident's medical history, he expired as a result of a [MEDICAL CONDITION] embolism. Interview on [DATE] at 1:00 PM with LVN A, she said CR #1 seemed fine on the day of the incident. She stated CR #1 always slept a lot. She said he was usually calm and she did not recall any shaking moments indicative of [MEDICAL CONDITION] involuntary movements. She said around 6:50 PM, Resident #2 and an aide came to get her to go to CR#1's room. She stated her assessment revealed no bruising or blood on the resident whose left side of his head she described as concave and having stitches. She stated that she asked CR #1 if he hit his head, and he said no. She described assessing CR #1 and reported his vitals and neuros were normal and he was returned to bed via mechanical lift with the assistance of CNA B and CNA C. She stated that in her opinion she believed CR#1 maneuvered himself through the gap between the two upright bedrails on his left side and momentum carried him away. She described the resident a few minutes later, around 7:15pm after the fall as agitated and gasping for air. She said LVN D came in to assist them and lowered him to the floor and started CPR. She said they were unsuccessful in reviving CR #1 who was pronounced by EMTs who had arrived to assist. LVN A further stated she was suspended for a week without pay for failing to notify the physician after he fell . She further stated she realized now that she should have contacted the doctor as required. She stated she received orientation and training when she was hired but did not recall any specific training as to how to care for residents with brain injuries. An interview was conducted with Physical Therapist E on [DATE] at 1:05 PM. He stated he only saw the resident briefly only on one occasion. He further stated the resident could move his left side but not his right. He stated the head was exposed. He further stated that CR#1's left side was very strong. An interview was conducted on [DATE] at 1:10 PM with Physical Therapist G. Physical Therapist G stated that CR #1 could not communicate. She further stated that it required 2 persons to even sit him up for therapy and that it required a lot of strength on the part of staff to do so. She stated he could not move at all and it was very surprising about the fall. She reported he was seen on (MONTH) 6, 2019 at which time he appeared more alert and appeared to understand more commands. An interview was conducted on [DATE] at 1:12 PM with Physical Therapist I . She stated she was surprised to learn of the resident's fall. She stated he really could not move much and it required 2 therapists to move him up to a position for therapy. An interview was conducted on [DATE] at 1:15 PM with OTA F. She stated she remembered seeing CR #1. She reported it required 2 staff members to get him up to sit. One day he stated the words, poo poo and they determined that he required incontinent care and consequently, summoned an aide. She further stated she did not see how it was possible for him to fall from the bed. She was questioned as to whether there was a fall mat by his bed and she replied there was not. An interview was conducted with Speech Therapist G on [DATE] at 1:45 PM. She stated they conducted an evaluation of CR #1 and he could not do much swallowing. She stated that CR #1 had a helmet when he came in and when he was evaluated. She further stated he could nod yes but kept uttering non-sensically the word four, four, four repeatedly. She stated she does not know how accurate his yes, no responses were. She was questioned about seeing a fall mat in his room and she replied she did not. A telephone interview was conducted with the Medical Director, CR#1's physician, on [DATE] at 1:35 PM. He stated that CR #1 had a craniectomy performed and was stabilized in the hospital. He stated he did not know how the resident could have fallen from bed but stranger things have happened. He stated that it does appear he could have slid out of bed. He further stated he saw him 2 days prior to the incident and he could not say the word no. The doctor stated CR #1 could have thrown a [MEDICAL CONDITION] embolism. He said there was so much pressure on the [DIAGNOSES REDACTED] that it affected bleeding. He reported he did not recall the resident having a helmet but added he thinks he might have come with one from the hospital. The physician described the bed as being knee high. He further stated CR #1 was a very sick guy. He was asked about the bed rails being up, he replied that he could not recall if they were up or not when he saw them but when he makes his rounds the rails were up on residents' beds. An interview was conducted on [DATE] at 12:30 PM with the MDS nurse. The MDS nurse at that time was asked about CR#1's clinical condition. The MDS nurse stated that CR #1 required extensive assist. He stated he himself developed the baseline care plans. He stated he did not recall if CR#1 had any protective head gear. He said if he had noted an order for [REDACTED]. He stated he did not recall CR #1 having any extra pillows except for his head and no wedges. He stated he did not see the helmet and CR #1 was not using the hand rail. The MDS Nurse further added that needs of residents were discussed during the daily morning meetings. He stated attempts were made to interview CR #1 but he was not verbal. He also stated when he reviewed CR #1's clinicals before admission, he did not see any orders for splints or head gear. When asked about the use of the mechanical lift to return the resident to bed, he stated he felt a draw sheet would have been safer. The MDS Nurse stated CR #1 could have used a wedge between the side rail area and his upper torso and head to protect him. He added that he should have brought the issue up during morning meetings and care planned the intervention. He said he never observed CR#1 out of bed and his mobility in bed did not raise concerns about falls before the incident. An interview was conducted with LVN D on [DATE] at 4:20 PM. She stated on the day of the incident, she was on the computer at the desk when a resident came by (Resident #2) and attempted to inform them something was wrong. She said he did not speak so she went with him and LVN A to CR#1's room where CR #1 was discovered to be on the floor beside his bed. She said after he was returned to bed, he started to breathe like he was holding his breath and then exhaled. She said she checked his pulse, but he was not responding. She said they lowered him to the ground and 911 was called. She said when EMTs arrived, they took over CPR. She stated in response to questioning that CR #1 was supposed to be transferred by mechanical lift. She stated prior to his breathing difficulties, he began getting agitated. She stated she recalled CR #1 as being fairly young. She stated she did not recall any orders for a splint or a helmet. She stated the records from the hospital go to Medical Records Department where they were scanned into the computer. She stated she does not recall usually receiving orders for specialized head protection. She further stated she did not recall seeing CR #1 with a helmet on during his stay at the facility. She further stated that when a resident was admitted on the weekend, they were to be seen by therapy the following Monday. Surveyor asked if she thought CR #1 was capable of falling from the bed and she stated she has seen paralyzed people try to do so. She added she did not recall if the bed rails were up. She stated that she does not know what could have happened. The Administrator and DON were notified of the Immediate Jeopardy (IJ) on [DATE] at 3:30pm due to the above-referenced failures. A Plan of Removal was requested at that time. After one revision, the final Plan of Removal was accepted on [DATE] at 2:25 PM. IMMEDIATE JEOPARDY PLAN OF REMOVAL dated (MONTH) 8, 2019 read, The resident identified no longer resides in the facility. Residents who are admitted or readmitted to the facility have the potential to be affected by the current deficient practice. An audit of current residents admitted in the past 60 days was completed by members of the nursing management on (MONTH) 8, 2019 to validate that any resident admitted /readmitted with special needs has interventions implemented and care plans and profiles are updated to reflect current status. The nurse management team identified residents with special care need during this audit and those identified were evaluated to validate that special needs were implemented. This was completed on (MONTH) 8, 2019 Licensed nurses will be re-educated by the nurse management team regarding the following: Prior to admission and upon admission/readmission the hospital information is to be reviewed as well as physician orders [REDACTED]. Prior to the development of the baseline care plan, special needs for the resident is communicated via the 24 hour report and shift to shift report and communicated to Certified Nursing Assistants. The profile is to be updated with special needs once the baseline care plan is implemented. Abuse, Neglect, Exploitation, Mistreatment Certified Nursing Assistants will be re-educated by the nurse management team regarding the following: If assigned a new admission or readmission the nurse should be communicating any special needs that are required if the profile has not been developed. If the nurse has not updated the Certified Nursing Assistant, the Certified Nursing Assistant should ask if there is any special care need for equipment, fall prevention including special care needs for closed head injuries prior to administering care or at the beginning of the shift. Abuse, Neglect, Exploitation, Mistreatment This reeducation will be completed by (MONTH) 9, 2019. Any Licensed Nurse or certified Nursing Assistant not receiving this re-education prior to this date will receive prior to the next scheduled shift. This information will be presented in New Hire orientation. The Director of Nursing was re-educated by the Nursing Consultant on (MONTH) 8, 2019 regarding the management of the day to day delivery of care and the validation of implementation of interventions for residents with special needs. The Nurse Assessment Coordinator was re-educated by the Director of Nursing on (MONTH) 8, 2019 regarding screening possible admissions for special care needs and communicating those needs to licensed nurses and Certified Nursing Assistants. The Administrator was re-educated by the Regional Vice President of Operations on (MONTH) 8, 2019 regarding the management of day to day delivery of care and the validation of implementation of interventions for residents with special needs. Starting (MONTH) 9, 2019, the Director of Nursing and members of nursing management will review the hospital records of admissions and re-admissions and the discharge summary to validate that any special care needs are identified, communicated and implemented. This will be a part of the initial admission/readmission review and will be once again reviewed as part of the clinical morning meeting process to validate that any special care needs were implemented and communicated. Starting (MONTH) 12, 2019, a report will be given to the Weekend Supervisor by the Director of Nursing that will contain any special care needs for any possible weekend admissions or readmissions and update regarding any admissions/readmissions during the previous week. The Director of Nursing and members of nursing management will observe shift to shift report for three consecutive weeks starting (MONTH) 8, 2019, to validate that special needs are communicated during the shift to shift report and the on-coming nurse communicates to the certified nursing assistant prior to baseline care plan being developed and the profile updated to reflect any special care needs for any admission/readmission. Any areas of concern will be addressed by nurse management at the time of discovery. Ad Hoc Quality Assurance Performance Improvement Committee was conducted on (MONTH) 8, 2019 to review the Plan of Removal The Medical Director was notified on (MONTH) 8, 2019. Following acceptance of the facility's Plan of Removal, a record review was conducted of the facility's in-services that had been initiated for direct care staff. Documentation of the following was reviewed: Documentation of in-services for direct care staff on the topic of abuse and neglect conducted [DATE] through [DATE] for all shifts, Documentation of in-services on the topics of review of admission/admission packet and shift to shift report for all direct care staff conducted [DATE] through [DATE] for direct care and administrative nursing staff, Documentation of in-service on the topic of facility management conducted on [DATE] for the Administrator by corporate executive, Documentation of in-service conducted [DATE] for the DON conducted by the Nurse Consultant for the corporation, Additionally, documentation was reviewed that indicated a meeting of the Quality Assurance and performance Committee had been conducted to review these issues. Additionally, throughout the day on [DATE], interviews were conducted with a sample of 6 direct care staff, (both licensed nurses and aides from all shifts) to verify the in-services had in fact been conducted and to validate their understanding of the information presented to them. Observations and record review of 2 additional sampled residents revealed physician orders [REDACTED]. The Administrator was notified that the IJ was lowered on [DATE] at 2:25pm. 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 ensure that pain management was provided to residents who require such services which were consistent with professional standards of practice and the residents' goals and preferences for 1 (Resident #365) of 8 residents reviewed for pain management. -The facility failed to ensure Resident #365's pain was controlled to meet her goals and preferences and allow her receive effective rehabilitation. This failure affected one resident and had the potential to affect 36 other residents on a pain management program causing worsening of pain, ineffective or delay in rehabilitation, decrease in quality of life, and worsening of medical condition. Findings Include: Resident #365 Record review of the clinical record for Resident # 365 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a Pain assessment dated [DATE] for Resident #365 revealed she was not expressing pain. She had incisional pain that was described as aching. Resident #365 rated the pain at a level 4 out of 10. Pain comes and goes. Interventions included [MEDICATION NAME] which were effective. Record review of Resident #365's Baseline Care Plan dated 2/23/18 revealed a care plan for pain management that stated the following: Pain management: Monitor pain, Verbal/descriptor, Location- right lower extremity, Treatment- see physician orders. Record review of Resident # 365's physician's orders [REDACTED]. -[MEDICATION NAME] 300mg orally three times a day -OT/PT/ST Evaluation and Treatment -[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5/325mg 1 tablet every 6 hours as needed for pain. -Tylenol 325mg, two tablets by mouth every 6 hours as needed for pain. Record review of Resident #365's Medication Administration Record [REDACTED] -[MEDICATION NAME] 300mg, 1 tablet by mouth was administered three times daily from 2/22/18 to 3/1/18. - [MEDICATION NAME] 5-325mg, 1 tablet by mouth was administered on 2/26/18 at 8:52am, 2/26/18 at 6:37am, 2/27/18 at 8:12am, 2/27/18 at 7:53pm, 2/28/18 at 4:49am, 2/28/18 at 3:03pm, 2/28/18 at 11:55pm and 3/1/18 at 6:42am. Nurse's documented the medication administration was effective for all dates listed. - Tylenol 325mg, 2 tablets by mouth was administered on 2/27/18 at 12:00pm, 2/28/18 at 8:02am, and 3/1/18 at 11:20am. Nurse's documented the medication administration was effective for all dates listed. Record review of Resident #365's daily pain assessments revealed LVN J documented pain on 2/26/18 at a level 10 out of 10 during the day and LVN M docuemented pain at a level 9 out of 10 at night. LVN J documented pain on 2/27/18 at a level 0 out of 10 during the day and LVN M documented moderate pain at night. LVN G documented she had moderate pain on 2/28/18 during the day. Observation on 2/26/18 at 8:46am revealed Resident #365 lying in bed. She was grimacing in pain. Dressing observed to right hip was dry and intact. Interview on 2/26/18 at 8:46am Resident #365 revealed she was having hip pain at level of 9 out of 10. She revealed that she was unsure if she could go to therapy in that amount of pain. She revealed that an acceptable level of pain would be 2-3 for her to tolerate. On 2/26/18 at 8:48am LVN J was notified of Resident #365's pain. In an interview on this date and time, she revealed that she would go assess Resident #365. Interview on 2/26/18 at 10:15am LVN J revealed that Resident #365 told her that she was in pain and did not want to worry her regarding her pain. LVN J revealed that she medicated Resident #365 for pain. Interview on 2/27/18 at 11:50am Resident # 365 revealed that she was having continuous pain. She stated that she had notified her nurse of continuing right hip pain. She revealed that the pain affects her appetite and her participation in therapy. In an observation and interview on 3/1/18 at 10:58am, Resident #365 was observed moaning and grimacing in pain. She revealed that medications were not controlling her pain. She stated pain was at a level of 10 out of 10. She stated that it was hard for her to move in this type of pain. Interview on 3/1/18 at 11:01am LVN I revealed that she was not aware of Resident #365 continued pain. She revealed that she would go assess the resident and notify the physician. Interview on 3/1/18 at 11:45am LVN G revealed that she had not notified the physician of Resident #365's continued pain. She stated Resident #365 had reported the pain to her and she was medicated that morning for pain. LVN G stated that the resident should be assessed before and after medications and the physician should be notified if pain is not controlled and pain continues. Interview on 3/1/18 at 11:53 am with the DON revealed that pain should be assessed on admission, after an incident, at least every shift, and before and after pain medication administration. The goal is for residents to have an acceptable level of pain. If pain medications are not effective, the physician should be notified. Interview on 3/1/18 at 1:33pm PTA B revealed that Resident # 365 was having increased pain in therapy and stated that her medications were not working. He revealed that her pain caused decreased participation in therapy. He revealed that he would notify the nurse. Record review of Resident #365's progress notes dated 2/26/18 to 2/28/18 revealed the resident was complaining of pain daily. PRN [MEDICATION NAME] administered. There was no documentation that a physician was consulted or notified. Record review of Resident #365's progress notes dated 3/1/18 at 11:51am (after surveyor intervention), written by LVN I, revealed a progress note stating the following: Citizen's pain discussed with this nurse. Citizen states she has leg cramps at bedtime and break through pain due to [MEDICAL CONDITION]. Dr. B contacted and notified of citizen pain. New Order: [MEDICATION NAME] 1 tablet orally every 4 hours Orders transcribed, nurse notified. Record review of the facility's Pain Management Policy revised 7/1/2016 revealed the following: *The intent of this policy is to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. *Ongoing evaluations of residents for pain will be completed at least 3 times daily and documented as the fifth vital sign on the residents' MAR. This evaluation will include verbal responses of level of pain 0-10, verbal description of pain such as slight, moderate, or severe and non-verbal descriptors as noted above. *Based on evaluation, the IDT, resident physician and the resident and/or representative, will develop, implement, monitor and revise as necessary interventions to prevent or manage the resident's pain. Based on the CMS 672 dated 2/26/18 there were 37 residents on the pain management program.

Based on observation, interview and record review, the facility failed to ensure that one of nine residents (Resident # 1) was free from physical abuse. Licensed Vocational Nurse (LVN) D and CNA A held Resident #1's wrists while CNA B performed incontinent care causing bruises to her wrists. This failure affected one resident and placed 34 other residents who had behavioral healthcare needs at risk of being abused or harmed while forcing care on them. Findings include: Resident #1 Record review of Resident #1's clinical chart revealed that she was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score revealed a score of 99, for unable to complete interview due to impaired cognition. Record review of Resident #1's Care Plan dated 1/8/2016 revealed that she refused care and had difficult behaviors. Interventions for behaviors included: · Obtain order for labs to rule out infectious process which may contribute to behavior · Assess for physical needs that need meeting · Return at a later time once patient has calmed to offer care needed · Ascertain the reason for behavior, offer comfort measures. Notify MD and RP if behaviors affect care, health, and living environment. Treat per MD order. Observation and interview on 3/10/2016 at 11:35AM of Resident #1 sitting in her room in her wheelchair revealed resident was clean and groomed. Resident #1 was alert and oriented to person and place. Resident #1 was communicating with CNA C and requested her jacket because she was cold. Resident #1 stated she was going to the dining room. Resident #1 said she was held down by two CNAs and her nurse one evening. Resident #1 said They harmed me and held me down . Resident #1 also said that they manhandled me and hurt my arms. Interview with LVN D on 3/10/16 at 1:55PM revealed that Resident #1 needed incontinent care and had been refusing all day, on 6am-2pm shift and their shift, 2pm-10pm. He said that towards the end of the shift she was totally soiled with urine and stool all over her. He said that himself and two CNAs came in to change the resident. Resident # 1 still refused. He said that they distracted Resident #1 and began cleaning the resident. Resident #1 became combative and started to try to hit them. At that time LVN D and CNA A held her wrist down to keep her from hitting them. LVN D stated that the physician or responsible party (RP) was not notified prior to them holding her wrist down while providing incontinent care. LVN D stated that the policy stated that if a resident is being combative or refused care then care should be stopped. Interview with CNA A on 3/10/16 at 2:02pm revealed that she went to change Resident #1 and she refused as she had done all shift. CNA A notified the nurse, LVN D, who came to assist her with CNA B. CNA A said the resident was soiled with stool and urine all over her and her bed. CNA A said that they began to clean the resident without her consent and she became combative. CNA A said that she and LVN D held the residents wrists down while CNA B cleaned the resident. CNA A said that they were taught in in-service ' s and training that when a resident becomes combative or refuses treatment they should be left alone, report it, and try again later. CNA B could not be reached by phone and she was not at work on day of investigation. Interview on 3/10/2016 at 2:15pm with the Director of Nurses (DON) revealed that staff were supposed to stop treatment or care when a resident refused or becomes combative. They were supposed to try other interventions and come back later. She said that there was visual bruising noted to Resident # 1 ' s wrist on the following day on 2/25/2016. Incident occurred on 2/24/2016. Record Review of Resident #1 ' s incident/accident investigation worksheet dated 02/26/16 revealed bruises to Resident #1 ' s left and right wrist/hand area. Resident #1 stated that the bruises were inflicted by staff. Record Review revealed that staff was in-serviced on 2/26/2016 on abuse and dealing with combative residents. Review of progress note written on 2/25/2016 by the Physician Assistant(PA) revealed resident stated that she was beaten up and she had bruising to bilateral wrists. Review of Progress note written on 2/25/2016 by Assistant Director of Nursing (ADON) revealed that head to toe assessment was done and the following was identified: a small area of fading discoloration gray in color to the left radial side of hand: near her thumb without any [MEDICAL CONDITION] noted. Citizen ' s right inner wrist also has an area of discoloration similar in color without noted [MEDICAL CONDITION]. Record Review of facilities investigation summary date 2/26/2016 read in part, Resident #1 ' s responsible party and physician was notified of bruising after incident. Review of progress note written on 2/26/16 by ADON read the following: Citizens RP called and notified of findings for skin assessments as well as citizens statements mad to the PA. At that time citizens RP thanked writer for calling and stated . (Resident #1) has a long history of mental health issues, and she gets really combative and delusional when she has a urinary tract infection [MEDICAL CONDITION] . Review of physician's order [REDACTED]. Review of progress note written 2/28/16 by LVN E revealed urinalysis results of white blood cell count=50+. MD notified of results and new order [MEDICATION NAME] received. Review of facility abuse and neglect policy revised 2/24/15 revealed under Component III-Prevention: · Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as rough handling of residents. Review of facility behavior management policy revised 10/1/15 revealed under examples to address behaviors: · Use matter of fact approach. Do not argue, rush, reason, or force. The facility's CMS 672 dated 3/10/16 listed 35 residents with behavioral healthcare needs.

Based on observation, interview, and record review, the facility failed to provide an environment that was as free as possible from accident risk by not supervising the residents and ensuring the wanderguard system was effective in order to prevent the elopement of 2 of (CRs #2 and 3) of five residents reviewed for accidents and hazards in that: -CR #2 eloped from the facility on 01/23/15 and was found by the police. -Visitors found CR #3 in a neighboring parking lot across a busy street 01/27/15 at 9:30 p.m. These failure affected two residents and placed 29 residents reflected on the facility Wanderguard checklist at risk for elopement from the facility without timely staff response and thorough investigations. An immediate jeopardy (IJ) was identified on 3/18/15 at 3:45 p.m. While the IJ was removed on 3/24/15 at noon the facility remained out of compliance at a pattern level and a severity of no actual harm with the potential for more than minimum harm in order to allow additional time to monitor the plan of removal for its effectiveness. 3, 6 Findings included: CR #2 Record review of CR #2's records revealed she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She resided in the 300 hall. She was discharged from the facility on 1/30/15. Review of CR #2's Current Orders sheet dated 01/28/15 reflected CR #2 was identified on 08/08/14 as having wandering behaviors. Record review of CR #2's Care Plan, dated 09/22/14, reflected "CR #2 has been deemed at risk for Elopement and has went home which is only 1 ½ blocks away r/t (related to) Dementia." An Approach reflected "Place a wanderguard Bracelet on CR #2 and monitor for attempts to leave the facility. " Record review of CR #2's Patient/Resident Incident/Accident Investigation Worksheet dated 01/23/15 at 9:50 p.m. revealed "During shift change citizen was not observed in room. Unit and facility as well as outside grounds searched in entirety. Staff on 100 hall front door alarm had sounded but citizen was not within view upon response. Administrative staff notified and code white announced. Shortly after received call from Pasadena Police Department that citizen was located at the end of Beverly Street but would not cooperate for police escourt (sic) back to facility." The Findings and Analysis reflected "Citizen eloped from facility. Wanderguard was in place and alarm sounded at front door." In an interview on 02/06/15 at 4:45 p.m., the Administrator said CR #2 was found at a business near the facility. He said that the wanderguard had sounded an alarm at the front door. He said the alarm had sounded at the 100 hall nurses' station. He said the front door wanderguard would lock that door, but the other doors of the facility had doors that sounded an alarm, but did not lock. The Administrator was asked if he received statements from staff as part of the investigation. He said he thought the progress notes were sufficient. Observation at that time revealed the Administrator opened the side door on the hallway near the 100 hall wing nurses' station, a door without a wanderguard lock. An alarm sounded and the alarm stopped only after the Administrator typed a number into the keypad. Observation on 3/18/15 at 8:00 a.m. revealed 1 door (nearest rooms 344-351) of the 3 doors exiting from the 300 hall wing only had a 15 second delay alarm. This door did exited to a sidewalk. There was no wanderguard box near the door which would have caused the door to lock if a resident with a wanderguard bracelet approached the door. Observation on 3/18/15 at 8:10 a.m. revealed there were 4 doors exiting the 100 hall wing. The side door near the therapy room did not have a wanderguard lock. Two of the 3 doors exiting the resident rooms did not have the wanderguard locks (rooms 133-149 and rooms 110-129). Record review of CR #2's PNs dated 01/23/15 revealed a chronology of events, but did not reveal any inquiry to the staff to determine how the resident eloped, or who responded to the alarm. There was no list of staff who were in the building at the time. Review of the Wanderguard List presented by the facility revealed there were 29 residents at the facility with Wanderguards. Review of the Weekly Wanderguard Exit Checks sheet revealed no documentation the exits were checked on the week beginning on 01/20/15. Interview on 3/18/15 at 10:07 a.m., the Director of Nurses (DON) said there was some talk before the January elopement of discharging CR #2. She had had a UTI (October 2014) and had been anxious with some behaviors that made them concerned about elopement. After she was treated for [REDACTED]. Interview on 3/18/15 at 10:07 a.m., the Director of Nurses (DON) said CR #2 was discharged to a secure (locked) assisted living unit. CR #3 Review of CR #3's Resident Admission Record revealed she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She resided in the 300 hall. She was discharged to another facility, a secure (locked) nursing facility. Review of CR #3's Patient/Resident Incident/Accident Investigation Worksheet dated 01/27/13 at 11:30 p.m. revealed "Nurse notified by visiting family member that citizen is outside. Nurse and CNA (Certified Nurse Aide) exited facility and found resident in neighboring parking lot. Citizen is sitting in w/c (wheelchair) accompanied by family member's son. Resident brought back to facility ..." The worksheet reflected "Citizen is exit-seeking and a high elopement risk. Citizen has a wanderguard on the left ankle." The Worksheet did not reflect the identity of the family members who discovered the resident. In an interview on 02/06/15 at 4:28 p.m., Licensed Vocational Nurse (LVN) E stated, "I was working 2 - 10 (2:00 p.m. to 10:00 p.m.). Resident #3 normally moves around in the community. Last time I saw her was about 9 (9:00 p.m.). I sat to do charting. A family member said she saw a resident outside. I saw CR #3 in the parking lot with the other family member's son. So we brought her back." LVN E stated that another staff member was with him, but she no longer worked at the facility. LVN E stated that when he returned with the resident, entering through the nearest entrance, the alarm sounded. LVN E stated, "She probably went out another exit." Observation revealed LVN E point to a parking lot adjacent to the facility as the location where the resident was discovered. In an interview with the Director of Nursing (DON) on 02/06/15 at 4:08 p.m., she stated she initiated the investigation, and the Assistant Administrator completed it. She stated that CR #3 was found in the parking lot of a restaurant across the (busy) street. The DON stated she did not interview any staff besides LVN E. When asked why the elopement was not reported to DADS until three days later, the DON stated, "We were trying to gather info." Interview on 3/18/15 at 10:07 a.m., the Director of Nurses (DON) said CR #3 was discharged to a secure (locked) nursing facility. In an interview on 3/18/15 at 11:30 a.m., when asked why some of the doors had Wanderguard locks and some did not, the Administrator said he did not know why some did not have locks. He said he spoke to his supervisor about it after the elopements and had not yet been able to secure an estimate for the whole facility. He said the response was "positive". The Administrator and Director of Nurses (DON) were notified that an immediate jeopardy (IJ) was identified on 3/18/15 at 3:45 p.m. While the IJ was removed on 3/24/15 at noon the facility remained out of compliance at a pattern level and a severity of no actual harm with the potential for more than minimum harm in order to allow additional time to monitor the plan of removal for its effectiveness. The PoR included: 1. Re-education was provided to facility nursing staff on elopement policies and procedures on 1/23/15. This training included but was not limited to: paging procedures, search procedures, problem solving skills, (Police, Local Health Department) notifications, use of the Patient Identification Books to identify those at risk, assessing who may be at risk, documentation, physical assessment, care planning, and leadership skills during these processes. On 3/19/15, the facility staff including; nursing, activities, housekeeping, and the dietary staff, received education regarding diversional activities and identifying when residents are at risk, like sun-downing. Included in this training are redirecting skills as well as identifying residents who are exit seeking to prevent future incidents. 2. The facility will conduct elopement drills monthly to keep staff prepared for a possible elopement. 3. The facility reviewed their Patient Identification Books on 1/23/15 and again on 3/18/15 for completeness and accuracy so that they may be used by staff to identify those at risk and outside entities in the event of an elopement. These books contain the residents face sheet and picture and will be kept at the nursing stations and at the front desk so staff can identify residents " at risk " . 4. All twenty-eight (28) residents with Wanderguards were reassessed on 1/23/15 and again on 3/20/15 to ensure the need for continued use. On 3/18/15, out of twenty-eight (28) original residents identified, three (3) were taken off the " high risk " list. Care plans were reviewed for the residents at risk for elopement and all had an " At Risk for Elopement " careplan. No residents were discharged as a result of these assessments as the facility has a plan in place to keep the residents safe until the permanent solution is achieved as listed below. The facility called the Wanderguard Company on 3/18/15 to receive direction on installing the system on these four (4) alarmed doors that are not currently served by the Wanderguard system. The Wanderguard Company came to the facility on [DATE] and will be presenting a quote for work to the administrator. Facility employees have been assigned to sit at these four (4) alarmed doors, 24 hours a day as of 3/18/15, and will continue to have these doors monitored and secured 24 hours a day until the permanent correction of this alleged deficient practice occurs by placing appropriate Wanderguard system alarms to these four (4) alarmed doors. The employees sitting at these doors will not have other duties but to secure these doors to ensure the safety of the residents and prevent any future incidents. The surveyors confined that the Plan of Removal had been implemented sufficiently to remove the IJ by: Interviews with 18 staff members revealed they described how they would recognize residents who were about to elope. This included resident behaviors that could possibly precede an elopement as well as the presence of a wanderguard bracelet. They all described appropriate measures to prevent the elopement. They all knew where to find information about each resident ("the book"). These staff included: -7 staff, including CNAs, nursing staff, kitchen, housekeeping and laundry staff on 3/23/15 on the afternoon shift. -11 staff, mostly nurses and CNAs 3/24/15 on the day shift. Record review elopement drills revealed there were drills conducted: -On 1/29/15 (no time listed) with 34 staff participated; and a second drill with the same date (no time listed) with 17 staff participated. -On 2/12/15 at 3:00 p.m. with 30 staff participated. -On 2/14/15 (no time) with 25 staff participated. -On 2/16/15 at 4:45 p.m. with 9 staff participated. -On 3/16/15 at 3:22 p.m. with 20 staff participated. Record review of the residents listed on the wanderguard list dated 3/13/15 revealed they all had care plans addressing their risk for elopement. Observation and interview on 3/20/15 at 12:50 p.m. revealed Staff F near the front lobby desk. At 12:56 he was at the 300 hall wing therapy door. When asked who was covering for him when he was at the front lobby desk, he pointed to Staff G and said she was. Interview on 3/20/15 at 12:57 p.m., Staff G said "I'm actually watching those 2 doors." as she pointed to the only two doors of the 300 hall wing that were visible from her position. When asked if she had ever been asked to watch other doors, she answered no, Daily observations between the 3/21/15 and 3/24/15 (at different times each day) revealed the facility posted staff in view of the doors that were not equipped with wanderguard lock with one exception. The Administrator was informed on 3/24/15 at noon 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 minimum harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. The facility had 29 residents listed on the Wanderguard list dated 2/5/15.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to one (Resident #1) of 5 residents reviewed for quality of care in order to attain the highest practicable physical well being according to his plan of care in that: The facility did not use a required brace during one of three falls involving transfers. He first complained about pain after the fall without the brace. He was eventually sent to the hospital emergency room (ER) and required emergency back surgery. The failure affected one person and placed 120 residents at risk of staff failing to meet the needs of residents. 9 Findings included: Review of Resident #1's Hospital 1 Skilled Nursing Facility/Long Term Acute Care Transfer Form, dated 12/16/14, revealed a [DIAGNOSES REDACTED]. of bed activity ... " Record review of Resident #1's Face Sheet revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Admission Report Sheet, dated 12/23/14 at 4:05 p.m. revealed his admitting [DIAGNOSES REDACTED]. The report indicated that Resident #1 required special equipment: "...Staples remove/TLSO brace while sitting up up in bed and chair." The report reflected that the Assistant Director of Nursing (ADON) A was the nurse who received the report. The date of the original surgery was not on the facility's admission sheet. Record review of Resident #1's comprehensive Physician Order Report revealed no order for the back brace prior to 12/30/14. Record review of the Physician's Order dated 12/30/14 revealed "Res (resident) to wear back brace anytime he is sitting up or out of bed." Record review of Resident #1's comprehensive Physician Order Report revealed no order for the back brace prior to 12/30/14. Record review of Resident #1's Minimum Data Set (MDS) assessment, dated 12/30/14, reflected he had a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. Resident #1 rejected evaluation or care during 4 to 6 of the 7 days prior to assessment. He required extensive assistance of two or more persons for bed mobility and transfers; was not steady, only able to stand with staff assistance for balance during transitions and walking. The MDS did not reflect the resident had functional limitation of Range of Motion. The MDS reflected the resident was 68 inches tall and weighed 223 pounds. Record review of the Care Plans implemented since admission for Resident #1 revealed no care plan for the back brace. Record review of Resident #1's Resident Progress Note (PN) dated 12/23/14 (date of admission) revealed "Pain medication effective according to client. Family member at bedside upsetting client (resident). Family member is stating that client is not supposed to be sitting up without the back brace." In an interview with a family member of Resident #1 on 02/05/15 at 12:00 noon, the family member stated Resident #1 did not have a back brace in place when the facility staff "dropped him." The family member stated the resident fell or was dropped on three different occasions at the facility. Fall #1 Record review of Resident #1's PN dated 12/26/14 at 2:16 p.m. revealed "Brace applied while in upright position. Pt (patient) worked with PT (Physical Therapy) this shift. Notified by PT that citizen (resident) was lowered to the floor during transfer to the chair ..." The PN reflected the resident weighed 222 pounds. Record review of the clinical record revealed no care plan addressing falls prior to Fall #2, which occurred on 12/29/14. Record review of the facility Incident/Accident Investigation Worksheets revealed there was one report in December 2014, dated 12/29/14. Fall #2 Record review of Resident #1's Patient/Resident Incident/Accident Investigation Worksheet, dated 12/29/14, revealed "While transferring Resident #1 to wheelchair x2 assist, Citizen had to be lowered to ground because he stated his legs were givin (sic) out. Citizen assessed. Active ROM (range-of-motion) noted to all 4 extremities. Citizen assisted back to wheelchair x 3 assist .... " Record review of Resident #1's PN dated 12/29/14 at 8:00 a.m. (Reflected as a late entry created on 12/30/14 at 3:53 a.m.) revealed "SN (Staff Nurse) rec'd a phone call from citizen's family member asking what happened to citizen and was he ok. Citizen's family member stated he called her stated that he fell today out of his w/c (wheelchair). After placing family member on hold and checking on citizen SN was made aware per citizen that he fell out of his wheelchair when he was being transferred from his bed to his wheelchair with the assist x 3 today around 4 pm. .... The incident was not reported to anyone at the time it occurred therefore SN was unaware of the incident happening. When SN asked if citizen was ok, I preceded to do a full head to toe assessment, Citizen stated he was ok and only hit his buttocks on the floor and was in no pain to his buttocks nor back at this time. Assessments did not reveal any skin breakdown nor bruising at this time. Will continue to monitor. Citizen stated he did not hit his head during the fall. Citizen stated he did not have his back brace on nor a gait belt at the time of transfer. SN then reported back to citizen's family member who was still holding on the phone for the outcome of the fall. SN reported that citizen was okay and fall did not result in any injury at this time. SN apologized to family member and assured her that future precautions would be taken to prevent this type of injury from occurring again and that the incident would be reported to chg (charge) nurse. Citizen's family member thanked SN for her assessment and report. SN notified ADON and reported all that transpired from the fall, phone call from citizen's family member, and collaborated on ways to prevent future falls/injuries ie; posting a sign regarding placing a back brace on citizen whenever he's up OOB (out of bed), possibly using a Hoyer lift and gait belt to assist with all transfers OOB. An incident report was completed at this time. " The PN reflected the signature of Licensed Vocational Nurse (LVN) B. Record review of Resident #1's PN dated 12/29/14 at 4:15 p.m. (Reflected as a late entry created on 12/30/14 at 11:53 a.m.) revealed "While transferring citizen to wc x 2 assist, citizen had to be lowered to ground because he stated his legs were giving out. Citizen assessed; active ROM (Range of Motion) noted to all four extremities. Citizen assited (sic) back to wheelchair x 3 assist - no c/o (complaints of) pain at this time. " Record review of PNs revealed Resident #1 complained of back pain at 7:15 p.m. on 12/29/14. The entry reflected the name of LVN B. Review of the clinical record for Resident #1 revealed a care plan dated 12/30/14. The care plan reflected "___ (Resident #1) is at risk for falls related to: impaired balance and a history of falls." The 'Approach' section reflected: Anticipate needs, Assure lighting is adequate and areas are free of clutter, Encourage citizen to ask for assistance from staff, Encourage socialization and activity attendance-as tolerated, Ensure call light is in reach while in bed, and Therapy to eval (evaluate) and treat per orders. The care plan did not reflect guidelines regarding safe transfers. There was no care plan addressing the back brace. In an interview at Hospital #2 on 03/05/15 at 12:20 p.m., Resident #1 stated he had experienced three falls at the facility. He stated that on one occasion, the therapists were assisting him with a transfer when his knee gave out. He stated that the therapists helped him to the floor, but that his legs were 'twisted.' Resident #1 stated that the back brace was on him at the time. Resident #1 stated that a second fall occurred when facility staff were changing out his bed (refer to Resident Incident/Accident Investigation Worksheet dated 12/29/14). Resident #1 stated, "I was asleep. They woke me up to change the bed. I asked who they were. They didn't answer. I said 'I can't transfer by myself.' They didn't tell me to put on the brace. I was out of it. I didn't ask for the brace." They wanted to use the slide board. I told them I don't use the slide board. I felt not that coherent. They said 'barely start to slide on the board. My knees gave out right away. I went straight to my knees. No one to help me." Resident #1 stated that a third fall occurred when the staff were attempting to transfer him out of bed (did not remember the date). He stated that the back brace was on at that time. In an interview and observation on 03/06/15 at 11:33 a.m., ADON A was asked who was responsible for initiating a care plan for Resident #1. ADON A replied, "I do that, or the Care Plan Nurse (LVN C)." ADON A was asked if Resident #1's back brace should have been care-planned. ADON A acknowledged that the back brace should have been care-planned. ADON A searched the computer, but did not locate a care plan for the back brace. ADON A stated that the order for the back brace "wasn't put in until the 30th." She acknowledged the brace was reflected in a chart entry on 12/26/14. In an interview on 03/06/15 at 11:50 a.m., LVN C stated that she and Certified Nurse Aide (CNA) D were the staff the changed out the resident's bed. LVN C stated, "I went to assist. He said he was able to assist with 1. His legs gave out. We lowered him to the ground. We got another nurse to help. Three of us transferred him back to the wheelchair. While on the floor, checked ROM, injuries, pain. No injuries noted." The nurse was asked if the resident had any type of orthotic. LVN D replied, Not that I know of. " LVN D acknowledged no back brace was used. In an interview on 03/06/15 at 11:56 a.m., CNA D stated "We were changing out the bed. Resident #1 told us he can stand. He said his leg gave out. We set him up on the floor." CNA D stated the resident was lowered to a sitting position. CNA D was asked if the resident had a back brace on. CNA D stated the resident did not have a back brace on. Fall #3 Review of the January 2015 Incident/Accident reports revealed no documentation of a fall for Resident #1 that month. Review of the PN for Resident #1, dated 01/05/15 at 4:41 a.m., revealed "Obsereved (sic) no bumps or bruising on head skin is intact, he has bruising to bues (bilateral upper extremeties)." Record review of Resident #1's PN dated 01/07/15 at 3:08 p.m. reflected "Nurse Practitioner (NP) in facility, new order STAT (immediate) Sacrum/Coccyx/lumbar X-RAY dx (diagnosis) Pain. HX (history) fall. Citizen reports to staff and NP that pain has increased and is unbearable at times, citizen reports that legs are not working he has feelings I legs but cannot move them." Record review of Resident #1's PN dated 01/08/15 at 3:29 a.m. revealed there were no fractures seen on the radiology report. Record review of Resident #1's Nurse's Note (NN) dated 01/08/15 at 2:10 p.m. reflected "Nurse Practitioner notified me to order STAT MRI (Magnetic Resonance Imaging) and CT (Computerized Tomography) Scan due to client stating 'I feel like I'm paralyzed due to a fall when they tried to transfer me. I haven't felt like this till I fell here.' He also states he was in more pain and discomfort because of fall. Client had not told me he felt paralyzed he would tell me that his back was hurting from the spinal surgery ...But client did not physically fall he was lowered down to the ground due to client losing his balance upon transfer. There was three incidents in all but no physical fall to the ground. X rays were completed yesterday and reviewed. Client still states something is wrong. Staff Nurse contacted Hospital 1 to schedule MRI and CT Scan. Date was scheduled for 1/12 (2015) at 8 a.m. and transportation was set up ... " Review of the care plan entitled "ADL (Activities of Daily Living)/Functional Rehabilitation Potential" revealed a "Problem Start Date" of 01/10/15, two days after Fall #3. The care plan reflected "TRANSFER: Assist of 2." Record review of Resident #1's PN dated 01/08/15 at 2:39 p.m. reflected "Citizen complains of having no sensation to BLE (bilateral lower extremities) 3 days s/p (status [REDACTED].#1 was sent to the discharging hospital (Hospital 2) for an MRI (pending titanium in surgical sites). Record review of Resident #1's PN dated 01/08/15 reflected " Received new orders from NP for MRI and CAT (sic) Scan with out contrast to be done at Hospital 1 ...MRI and CAT (sic) scan of the lumbar spine scheduled for Monday 1/12/2015 @ 7am." Record review of Resident #1's PN dated 01/08/15 at 3:59 p.m. reflected the physician saw Resident #1. Record review of Resident #1's PN, dated 01/08/15 at 8:00 p.m. reflected an ambulance service transported the resident from the facility to the hospital. Record review of Resident #1's PN dated 01/09/15 at 2:20 a.m. reflected the resident returned to the facility from Hospital 2 after having a CT Scan performed. Record review of Resident #1's Hospital #2 Emergency Provider Report dated 01/08/15 revealed a CT scan was performed, with the impression reflected as "No evidence of acute osseus trauma." A MRI was not performed due to possible "hardware" in the resident's back. Record review of Resident #1's Hospital #1 Emergency Department (ED) Physician Documentation, dated 01/09/15, revealed Resident #1 arrived at the ED on that date at 11:55 a.m. The History of Present Illness reflected "The patient presents with pain that is chronic. The problem was sustained during a fall. The symptoms are located in the [MEDICATION NAME] area and lumbar area." The [DIAGNOSES REDACTED]. The Merck Manual Nineteenth Edition, page 3228, reflected Cauda Equina Syndrome was a spinal cord injury involving the lower tip of the spinal cord. The reference reflected possible effects of the injury were "Hyporeflexic or areflexic paresis of the lower extremities, usually pain and hyperesthesia in the distribution of nerve roots, and usually loss of bowel and bladder control. " Record review of Resident #1's Hospital #1 History and Physical (H&P) dated 01/09/15 at 10:16 p.m., reflected "CT without contrast of the [MEDICATION NAME] spine showed multiple instrumentations and extensive postsurgical changes. The quality of the exam is of course affected by the extensive artifact produced by the surgical hardware. There is no obvious spinal cord compression on the scan. The CT of the lumbar spine showed extensive surgical changes as well, however is unable to rule out any spinal compressions due to be artifact presented." The H&P reflected "We will not be able to evaluate the full extent of his spinal cord status using CTs only. We will schedule him for a CT myelogram of the [MEDICATION NAME] and lumbar spine early in the morning tomorrow. " Record Review of the Hospital #1 Discharge Summary (to a different nursing facility), dated 02/02/15, revealed Resident #1 was readmitted to Hospital 1 on 01/09/15. One admitting [DIAGNOSES REDACTED]." The Hospital Procedures Performed reflected "[MEDICATION NAME] laminectomy, T7-T8 transpedicular diskectomy, posterior fusion with instrumentation on January 10, 2015." Record Review of the Hospital #1 Discharge Summary (to a different facility), dated 02/02/15, in the section titled Brief Review of the Presenting History and Physical, the physician indicated, "The patient is a [AGE] year-old young gentleman who was recently admitted to the hospital and underwent a thoracolumbar lumbar fusion surgery with very good clinical stable outcome postoperatively. The patient had high level of neurological dysfunction prior to surgery and was discharged to a skilled nursing facility and was actually able to ambulate, which he was not prior to surgery. Unfortunately, by history the patient suffered a fall and became progressively weak and subsequently paraplegic. He was now (sic) transferred to our facility nor was I notified prior to his admission as the change in neurological status. When he arrived to the hospital, he was medically cleared and taken for urgent surgery. Imaging study suggested a fracture with cord compression at the top of his construct. " Review of the facility policy entitled Care Plan Process, dated September 2011, revealed "The Interdisciplinary Team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames." The Policy reflected, "Procedures: 1. Initiate an Interim Plan of Care and complete within twenty-four (24) hours of admission based on the physician's orders and nursing admission data. The Interim Plan of Care will direct the residents care until a comprehensive care plan is developed. 2. Initiate an Acute Plan of Care when the resident's clinical status dictates the need such as but not limited to falls and pressure sore development." The CMS 672 dated 02/05/15 reflected the census was 121.

Based on observation, interview, and record review, the facility failed to make reasonable accommodations of individual needs for one resident (Resident #1) of five residents reviewed for accommodation of needs in that they did not consistently use his orthotic back brace when transferring him. The facility did not use a required brace during one of three falls involving transfers. He first complained about pain after the fall without the brace. He was eventually sent to the hospital emergency room (ER) and required emergency back surgery. The failure affected one resident and placed 120 residents at risk of not having their individual needs met. 9 Findings include: Review of Resident #1's Hospital 1 Skilled Nursing Facility/Long Term Acute Care Transfer Form, dated 12/16/14, revealed a [DIAGNOSES REDACTED]. Record review of Resident #1's Face Sheet revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Admission Report Sheet, dated 12/23/14 at 4:05 p.m. revealed his admitting [DIAGNOSES REDACTED]. The report indicated that Resident #1 required special equipment: "...Staples remove/TLSO (Thoraco-Lumbar Sacral Orthosis) brace while sitting up up in bed and chair." The report reflected that the Assistant Director of Nursing (ADON) A was the nurse who received the report. The date of the original surgery was not on the facility's admission sheet. Record review of Resident #1's comprehensive Physician order [REDACTED]. Record review of Resident #1's physician's orders [REDACTED]." Record review of Resident #1's Minimum Data Set (MDS) assessment, dated 12/30/14, reflected he had a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. Resident #1 rejected evaluation or care during 4 to 6 of the 7 days prior to assessment. He required extensive assistance of two or more persons for bed mobility and transfers; was not steady, only able to stand with staff assistance for balance during transitions and walking. The MDS did not reflect the resident had functional limitation of Range of Motion. The MDS reflected the resident weighed 223 pounds. Record review of the Care Plans implemented since admission for Resident #1 revealed no careplan for the back brace. In an interview with a family member of Resident #1 on 02/05/15 at 12:00 noon, the family member stated Resident #1 did not have a back brace in place when the facility staff "dropped him." The family member stated the resident fell or was dropped on three different occasions at the facility. Record review of Resident #1's Resident Progress Note (PN) dated 12/23/14 (date of admission) revealed "Pain medication effective according to client. Family member at bedside upsetting client (resident). Family member is stating that client is not supposed to be sitting up without the back brace." Record review of Resident #1's PN dated 12/26/14 at 2:16 p.m. revealed "Brace applied while in upright position. Pt (patient) worked with PT (Physical Therapy) this shift. Notified by PT that citizen (resident) was lowered to the floor during transfer to the chair ..." The PN reflected the resident weighed 222 pounds. Record review of the facility Incident/Accident Investigation Worksheets revealed no reports for Resident #1 in January 2015. There was one report in December 2014, dated 12/29/14. Record review of Resident #1's Patient/Resident Incident/Accident Investigation Worksheet, dated 12/29/14, revealed "While transferring Resident #1 to wheelchair x2 assist, Citizen had to be lowered to ground because he stated his legs were givin (sic) out. Citizen assessed. Active ROM (range-of-motion) noted to all 4 extremities. Citizen assisted back to wheelchair x 3 assist .... " Record review of Resident #1's PN dated 12/29/14 at 8:00 a.m. (Reflected as a late entry created on 12/30/14 at 3:53 a.m.) revealed "SN (Staff Nurse) rec'd a phone call from citizen's family member asking what happened to citizen and was he ok. Citizen's family member stated he called her stated that he fell today out of his w/c (wheelchair). After placing family member on hold and checking on citizen SN was made aware per citizen that he fell out of his wheelchair when he was being transferred from his bed to his wheelchair with the assist x 3 today around 4 pm. .... The incident was not reported to anyone at the time it occurred therefore SN was unaware of the incident happening. When SN asked if citizen was ok, I preceded to do a full head to toe assessment, Citizen stated he was ok and only hit his buttocks on the floor and was in no pain to his buttocks nor back at this time. Assessments did not reveal any skin breakdown nor bruising at this time. Will continue to monitor. Citizen stated he did not hit his head during the fall. Citizen stated he did not have his back brace on nor a gait belt at the time of transfer. SN then reported back to citizen's family member who was still holding on the phone for the outcome of the fall. SN reported that citizen was okay and fall did not result in any injury at this time. SN apologized to family member and assured her that future precautions would be taken to prevent this type of injury from occurring again and that the incident would be reported to chg (charge) nurse. Citizen's family member thanked SN for her assessment and report. SN notified ADON and reported all that transpired from the fall, phone call from citizen's family member, and collaborated on ways to prevent future falls/injuries ie; posting a sign regarding placing a back brace on citizen whenever he's up OOB (out of bed), possibly using a Hoyer lift and gait belt to assist with all transfers OOB. An incident report was completed at this time. " The PN reflected the signature of Licensed Vocational Nurse (LVN) B. Record review of Resident #1's PN dated 12/29/14 at 4:15 p.m. (Reflected as a late entry created on 12/30/14 at 11:53 a.m.) revealed "While transferring citizen to wc x 2 assist, citizen had to be lowered to ground because he stated his legs were giving out. Citizen assessed; active ROM (Range of Motion) noted to all four extremities. Citizen assited (sic) back to wheelchair x 3 assist - no c/o (complaints of) pain at this time. " Record review of PNs revealed Resident #1 complained of back pain at 7:15 p.m. on 12/29/14. The entry reflected the name of LVN B. In an interview and observation on 03/06/15 at 11:33 a.m., ADON A was asked who was responsible for initiating a care plan for Resident #1. ADON A replied, "I do that, or the Care Plan Nurse (LVN C)." ADON A was asked if Resident #1's back brace should have been care-planned. ADON A acknowledged that the back brace should have been care-planned. ADON A searched the computer, but did not locate a care plan for the back brace. ADON A stated that the order for the back brace "wasn't put in until the 30th." She acknowledged the brace was reflected in a chart entry on 12/26/14. In an interview on 03/06/15 at 11:50 a.m., LVN C stated that she and Certified Nurse Aide (CNA) D were the staff the changed out the resident's bed. LVN C stated, "I went to assist. He said he was able to assist with 1. His legs gave out. We lowered him to the ground. We got another nurse to help. Three of us transferred him back to the wheelchair. While on the floor, checked ROM, injuries, pain. No injuries noted." The nurse was asked if the resident had any type of orthotic. LVN D replied, Not that I know of. " LVN D acknowledged no back brace was used. In an interview on 03/06/15 at 11:56 a.m., CNA D stated "We were changing out the bed. Resident #1 told us he can stand. He said his leg gave out. We set him up on the floor." CNA D stated the resident was lowered to a sitting position. CNA D was asked if the resident had a back brace on. CNA D stated the resident did not have a back brace on. In an interview with Resident #1 on 03/05/15 at 12:20 p.m., the resident stated he had experienced three falls at the facility. He stated that on one occasion, the therapists were assisting him with a transfer when his knee gave out. He stated that the therapists helped him to the floor, but that his legs were 'twisted.' Resident #1 stated that the back brace was on him at the time. Resident #1 stated that a second fall occurred when facility staff were changing out his bed (refer to Resident Incident/Accident Investigation Worksheet dated 12/29/14). Resident #1 stated, "I was asleep. They woke me up to change the bed. I asked who they were. They didn't answer. I said 'I can't transfer by myself.' They didn't tell me to put on the brace. I was out of it. I didn't ask for the brace." They wanted to use the slide board. I told them I don't use the slide board. I felt not that coherent. They said 'barely start to slide on the board. My knees gave out right away. I went straight to my knees. No one to help me." Resident #1 stated that a third fall occurred when the staff were attempting to transfer him out of bed. He stated that the back brace was on at that time. Record review of Resident #1's PN dated 01/07/15 at 3:08 p.m. reflected "Nurse Practitioner (NP) in facility, new order STAT (immediate) Sacrum/Coccyx/lumbar X-RAY dx (diagnosis) Pain. HX (history) fall. Citizen reports to staff and NP that pain has increased and is unbearable at times, citizen reports that legs are not working he has feelings I legs but cannot move them." Record review of Resident #1's PN dated 01/08/15 at 3:29 a.m. revealed there were no fractures seen on the radiology report. Record review of Resident #1's Nurse's Note (NN) dated 01/08/15 at 2:10 p.m. reflected "Nurse Practitioner notified me to order STAT MRI (Magnetic Resonance Imaging) and CT (Computerized Tomography) Scan due to client stating 'I feel like I'm paralyzed due to a fall when they tried to transfer me. I haven't felt like this till I fell here.' He also states he was in more pain and discomfort because of fall. Client had not told me he felt paralyzed he would tell me that his back was hurting from the spinal surgery ...But client did not physically fall he was lowered down to the ground due to client losing his balance upon transfer. There was three incidents in all but no physical fall to the ground. X rays were completed yesterday and reviewed. Client still states something is wrong. Staff Nurse contacted Hospital 1 to schedule MRI and CT Scan. Date was scheduled for 1/12 (2015) at 8 a.m. and transportation was set up ... " Record review of Resident #1's file revealed no other evidence of assessment, monitoring or contact with the physician regarding the third incident. Record review of Resident #1's PN dated 01/08/15 at 2:39 p.m. reflected "Citizen complains of having no sensation to BLE (bilateral lower extremities) 3 days s/p (status [REDACTED].#1 was sent to the discharging hospital (Hospital 2) for an MRI (pending titanium in surgical sites). Record review of Resident #1's PN dated 01/08/15 reflected " Received new orders from NP for MRI and CAT (sic) Scan with out contrast to be done at Hospital 1 ...MRI and CAT (sic) scan of the lumbar spine scheduled for Monday 1/12/2015 @ 7am." Record review of Resident #1's PN dated 01/08/15 at 3:59 p.m. reflected the physician saw Resident #1. Record review of Resident #1's PN, dated 01/08/15 at 8:00 p.m. reflected an ambulance service transported the resident from the facility to the hospital. Record review of Resident #1's PN dated 01/09/15 at 2:20 a.m. reflected the resident returned to the facility from Hospital 2 after having a CT Scan performed. Record review of Resident #1's Hospital 2 Emergency Provider Report dated 01/08/15 revealed a CT scan was performed, with the impression reflected as "No evidence of acute osseus trauma." A MRI was not performed due to possible "hardware" in the resident's back. Record review of Resident #1's Hospital 1 Emergency Department (ED) Physician Documentation, dated 01/09/15, revealed Resident #1 arrived at the ED on that date at 11:55 a.m. The History of Present Illness reflected "The patient presents with pain that is chronic. The problem was sustained during a fall. The symptoms are located in the [MEDICATION NAME] area and lumbar area." The [DIAGNOSES REDACTED]. The Merck Manual Nineteenth Edition, page 3228, reflected Cauda Equina Syndrome was a spinal cord injury involving the lower tip of the spinal cord. The reference reflected possible effects of the injury were "Hyporeflexic or areflexic paresis of the lower extremities, usually pain and hyperesthesia in the distribution of nerve roots, and usually loss of bowel and bladder control. " Record review of Resident #1's Hospital 1 History and Physical (H&P) dated 01/09/15 at 10:16 p.m., reflected "CT without contrast of the [MEDICATION NAME] spine showed multiple instrumentations and extensive postsurgical changes. The quality of the exam is of course affected by the extensive artifact produced by the surgical hardware. There is no obvious spinal cord compression on the scan. The CT of the lumbar spine showed extensive surgical changes as well, however is unable to rule out any spinal compressions due to be artifact presented." The H&P reflected "We will not be able to evaluate the full extent of his spinal cord status using CTs only. We will schedule him for a CT myelogram of the [MEDICATION NAME] and lumbar spine early in the morning tomorrow. " Record Review of the Hospital 1 Discharge Summary (to a different nursing facility), dated 02/02/15, revealed Resident #1 was readmitted to Hospital 1 on 01/09/15. One admitting [DIAGNOSES REDACTED]." The Hospital Procedures Performed reflected "[MEDICATION NAME] laminectomy, T7-T8 transpedicular diskectomy, posterior fusion with instrumentation on January 10, 2015." Record Review of the Hospital 1 Discharge Summary (to a different facility), dated 02/02/15, in the section titled Brief Review of the Presenting History and Physical, the physician indicated, "The patient is a [AGE] year-old young gentleman who was recently admitted to the hospital and underwent a thoracolumbar lumbar fusion surgery with very good clinical stable outcome postoperatively. The patient had high level of neurological dysfunction prior to surgery and was discharged to a skilled nursing facility and was actually able to ambulate, which he was not prior to surgery. Unfortunately, by history the patient suffered a fall and became progressively weak and subsequently paraplegic. He was now (sic) transferred to our facility nor was I notified prior to his admission as the change in neurological status. When he arrived to the hospital, he was medically cleared and taken for urgent surgery. Imaging study suggested a fracture with cord compression at the top of his construct. " The CMS 672 dated 02/05/15 reflected the census was 121.