Every finding on record at The Harrison at Heritage

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to provide treatment to Resident #1's right elbow according to physician's orders. This failure placed residents of risk for not receiving appropriate care and treatment and a decreased quality of life.Findings included: Review of Resident #1's Admissions MDS Assessment, dated 04/14/26, reflected that she was admitted to the facility on [DATE]. Her MDS Assessment did not indicate her diagnoses, her cognitive abilities, or anything regarding her care. Review of Resident #1's face sheet, dated 04/27/26, reflected that she had diagnoses of repeated falls and rhabdomyolysis (a condition characterized by the rapid breakdown of skeletal muscle, leading to the release of muscle breakdown products into the bloodstream, which can be harmful to the kidneys and may result in acute kidney injury). Review of Resident #1's Order Summary Report, dated 04/27/26, reflected an order for the following: Wound Treatment- Dry Dressing everyday shiftCleanse wound to ___R elbow___ with Normal Saline or Skin Cleanser. Pat Dry. Cover with Dry Dressing with a start date of 04/16/26 Review of Resident #1's Wound Care Treatment Administration Record for April 2026 reflected she did not receive care on 04/18/26, 04/19/26, or 04/25/26 for the following treatment: Wound Treatment- Dry Dressing every day shift Cleanse [sic] wound to ___R elbow___ with Normal Saline or Skin Cleanser. Pat Dry. Cover with Dry Dressing Review of Resident #1's Care Plan, initiated on 04/16/26, reflected the following: Focus: [Resident #1] has current skin concerns:[R elbow] [sic] Open Lesions-Other [sic] than Stasis/venous Area.Interventions: Perform treatments per order, if no improvement x2 weeks report to MD. Treatment as ordered. Observation and interview on 04/27/26 at 2:50 PM, Resident #1 was observed lying in bed with a long sleeved shirt on. Resident #1 said she was not sure what her treatment orders were for her elbows. Resident #1 said she was not sure if the treatment order was supposed to be for every day or every other day. Resident #1 said the WCN completed her treatments during the week but she did not get any treatments during the weekends. Interview on 04/28/26 at 8:50 AM, the WCN said she was at the facility during the week (Monday through Friday) and completed all resident's treatments. The WCN said on the weekends when she was not there, the charge nurses were responsible for completing their own treatments. The WCN said the facility also had a weekend supervisor and she was not sure if the weekend supervisor assisted in completing resident's treatments or not on the weekends. The WCN said there was a meeting on Fridays to communicate with the weekend staff to be aware of treatments completed over the weekends. The WCN said she did not have any other communication with the weekend staff regarding residents' treatments. The WCN said sometimes when she came in to work on Mondays to complete a resident's treatment, she would notice a dressing was missing on a few residents. The WCN said she was not sure what happened to the dressing and did not address it with the staff from the weekend or previous shifts. The WCN said normally if a dressing was missing or fell off during care the nurse would reapply the dressing and provide treatment. The WCN said when anyone completed a resident's treatment it was documented in the wound care treatment administration record. The WCN said all staff had access to the treatment cart to be able to complete a resident's treatment on the weekends. The WCN said all weekend nurses knew it was their responsibility to complete their assigned residents' treatments on the weekends. Interview on the phone on 04/28/26 at 10:46 AM, LVN A said he cared for Resident #1 this past Saturday (04/25/26) from 6:00 AM to 10:00 PM. LVN A said he did not provide any treatment for her elbow and the only interaction he recalled with her was when he provided her the requested pain medicine. LVN A said he worked double shifts on the weekends and sometimes the weekend supervisor completed residents' treatments on the weekends and sometimes he was responsible for them. LVN A said who was responsible for the residents' treatments on the weekends was dependent upon what the staff decided. LVN A said sometimes there was a conversation amongst the nurses about who was completing the treatments but not always. LVN A said he would normally look in the residents charts to see what treatments were due and if they were already completed he knew he did not need to do them, but if they were not completed yet then he would complete them himself. LVN A said he was not aware Resident #1 had treatment orders for her elbow that were due on Saturday (04/25/26). LVN A said since he was her assigned nurse he would have been responsible for completing her treatment. Attempted interview on the phone on 04/28/26 at 11:15 AM with RN B was unsuccessful as she did not answer or call back prior to exit; a message was left for a call back. RN B cared for Resident #1 on 04/19/26. Interview on the phone on 04/28/26 at 1:21 PM, the Previous DON said she recently left the faciity on Monday and no longer worked at the facility. The Previous DON said she was never made aware wound care was not completed on the weekends. The Previous DON said there was always enough staff on the weekends to ensure wound care was completed as ordered. The Previous DON said the nurses were responsible for completing their assigned residents' wound care unless there was an additional nurse who would then be delegated to completing wound care which would be shown on the schedule. The Previous DON said it should have been clear to the nurses that they would need to do their own wound care when a designated nurse was not scheduled to do the wound care over the weekend. Interview on 04/28/26 at 1:46 PM, the ADON said usually she would try to look at the resident's treatment administration records but had not done that recently. The ADON said she generally reviewed them to make sure residents were receiving their treatments as ordered. The ADON said the facility had an assigned Weekend Supervisor who managed the staff on the weekends. The ADON said she was never made aware residents treatments were not completed on the weekends. The ADON said the nurses were responsible for completing their assigned residents treatments on the weekends. The ADON said staff should document in the treatment administration record when they completed a residents' treatment. Interview on 04/28/26 at 2:14 PM, the Administrator said the charge nurses were responsible for completing wound care on the weekends. The Administrator said she had a sheet of paper that was provided to weekend staff that included instructions to complete their assigned residents' wound care. The Administrator said all staff on the weekends had access to the treatment cart to complete wound care for residents. The Administrator said staff also had access to each residents' wound care administration record to review which treatment orders were due. The Administrator said the purpose of completing wound care as ordered was to make sure wounds did not get worse. The Administrator said if residents did not receive ordered wound care the wound could deteriorate or worsen. The Administrator said she expected the weekend staff to complete the residents' ordered wound care treatments. The Administrator said all nurses were trained to complete an ordered residents' wound care treatments. Interview on 04/28/26 at 3:13 PM, the Weekend Supervisor said she had only been in the position for 3 weeks. The Weekend Supervisor said normally the charge nurses on the weekends were responsible for completing their assigned residents' wound care treatments. The Weekend Supervisor said she had not noticed or had been informed wound care treatments were not completed. The Weekend Supervisor said she did not check the residents' wound care treatment administration records to ensure wound care treatments were being completed. Review of the facility's Wound Treatment Management policy, dated 12/01/25, reflected the following: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. Treatments will be documented on the Treatment Administration Record or in the electronic health record.

Based on observations, interviews, and record reviews, the facility failed to ensure each bed had ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 2 of 21 residents (Resident #16 and #82) reviewed for privacy curtains. The facility failed to ensure Residents #16 and #82 were ensured full visual privacy by not having ceiling suspended curtains that extend around the bed. These failures could place residents at risk of lowered self-esteem. Findings included:1. Record review of Resident #16's annual MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included morbid obesity, chronic respiratory failure (ineffective breathing), heart failure, depression, and anxiety. His BIMs score was 11, which indicated he had moderate cognitive impairment. His Functional Ability assessment indicated he required staff assistance with most of his ADLs. His Bowel and Bladder assessment reflected he was always incontinent of bowel and bladder. Record review of Resident #16's care plan, dated 11/06/25, reflected he did not participate in facility activities, had a self-care deficit, was a high fall risk with actual falls, had bowel incontinence, and was at risk of pressure ulcers.Observation and interview on 12/02/25 at 10:17 AM of Resident #16's of room revealed his privacy curtain only covered part of his bed, leaving more than half of his bed unprotected. It appears at least one more section of the curtain would need to be added. The resident's bed is positioned with the foot towards the door, and the side facing the room. Resident #16 stated staff pull the curtain to cover the end of his bed from the doorway when they come in to perform incontinence care, but the rest of the bed is not covered. He stated it makes him nervous that someone will be able to see him when he is being changed. Resident #16 stated the curtains had been that way since he was admitted . 2. Record review of Resident #82's admission MDS, dated [DATE], reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included emphysema, stroke, kidney failure, and diabetes. His BIMS score was 9, indicating moderate cognitive impairment. His Functional Ability assessment indicated he required staff assistance with all his ADLs. His bowel and bladder assessment indicated he was always incontinent of bowel and bladder. Record review of Resident #82's care plan, dated 11/23/25, indicated he had a self-care deficit, was cognitively impaired, was incontinent related to immobility, and required dialysis for his kidney failure. Observation and interview on 12/02/25 at 10:33 AM Resident #82's privacy curtain did not provide full privacy. The resident had a curtain that separated his bed from his roommate, leaving the foot of his bed exposed. Interview attempted with the resident was not successful, the resident would not stay aware or answer questions. Interview on 12/03/25 at 9:53 AM CNA-A stated they pull the curtain between Resident #82's bed and his roommate, and keep the door closed to provide privacy when providing care. With Resident #16 she stated the curtain covered the end and part of the side of the bed, and they also kept the door closed for privacy when providing care. She stated she had not thought of notifying anyone about the curtains. Interview on 12/03/25 at 10:00 AM Housekeeper-B stated she was unaware of any room needing additional privacy curtains. She stated she would have to let her supervisor know when curtains needed to be addressed. Interview on 12/04/25 at 11:00 AM the Maintenance Director stated he was unaware of any curtains that needed to be added. He stated staff submit a work order when they need something addressed, and he did not think anyone had done so for the curtains.Interview on 12/04/25 at 11:20 AM the DON stated the privacy curtains should provide full coverage to ensure full privacy. She stated the nursing staff were responsible for notifying housekeeping if a curtain needed to be changed out, and maintenance if a curtain needed to be hung. She stated someone should have let her or the ADON know about any room not having full privacy coverage. She stated it was important to provide privacy for each resident for their dignity, as well as to establish their area of the room. The DON stated there was not a policy specific to privacy curtains. She did provide a policy on Safe Homelike Environment.Review of the facility's policy Safe and Homelike Environment, dated 10/01/25 reflected: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #132) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #132 was not prescribed a psychotropic drug for anxiety longer than 14 days PRN. Resident #132 was ordered PRN Alprazolam (a benzodiazepine medication used primarily to treat anxiety disorders and severe agitation) on 11/26/25 without a stop date. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. Findings included: Record review of Resident #132's MDS Assessment (the type of assessment was not listed), dated 12/01/25, reflected he was an [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #132 had a BIMS score of 14, indicating no cognitive impairment. Resident #132's active diagnoses included non-alzheimer's dementia (encompasses a variety of conditions that cause cognitive decline and memory loss beyond what is considered a normal part of aging) and anxiety disorder (a group of mental health conditions that cause fear, dread, and other symptoms that are out of proportion to the situation). Record review of Resident #132's Order Summary Report, dated 12/03/25 reflected the following: Alprazolam Oral Tablet 0.25 MG, Give 1 tablet by mouth every 12 hours as needed for anxiety related to Anxiety Disorder, Unspecified with a start date of 11/26/25. Record review of Resident #132's Care Plan, initiated 12/03/25, did not reflect his use of the anti-anxiety medication. Record review of Resident #132's November 2025 MAR reflected he did not receive any tablets of his ordered PRN Alprazolam medication. Record review of Resident #132's December 2025 MAR reflected he did not receive any tablets of his ordered PRN Alprazolam medication.Observation and interview on 12/02/25 at 10:33 AM, with Resident #132 revealed he did not have any concerns regarding his medications and did not feel anxious or need any medication to help him with his anxiety.Interview on 12/04/25 at 10:21 AM, RN H revealed she cared for Resident #132. RN H said he had an order for PRN Alprazolam but had not received any that she was aware of. RN H said Alprazolam was considered a psychotropic medication and was used to address a resident's anxiety. RN H said it should have a 14-day stop date associated with the order. RN H said when she looked in the system she did not see that the medication had a 14-day stop date. RN H said it would have been the responsibility of the admitting nurse to make sure that they checked with the doctor to add that to the order. RN H said Resident #132 came to the facility with the order in place from the hospital.Interview on 12/04/25 at 3:36 PM, the DON revealed all PRN psychotropic medications must have a 14-day stop date included with the order. The DON said this ensures the facility has the ability to reassess and reevaluate to make sure the medication was appropriate for residents. The DON said when the nurse received an order for a PRN psychotropics the nurse should ask the doctor or NP for the 14-day stop date and include it in the order. The DON said normally she and the ADON would check the orders to make sure the 14-day stop date was included in the order after it was put in the system. The DON said if this stop date was not included in the resident's order then the resident could have medication that was unnecessary for them.Record review of the facility's policy, dated 10/01/25, and titled Use of Psychotropic Medications reflected: 15. Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 44 residents (Resident #17) reviewed for care plans.The facility failed to ensure Resident #17's care plan addressed the use of a back brace and bilateral foot protectors. This failure could place residents at risk of not receiving the care required to meet their individual needsFindings included:Record review of Resident #17's admission MDS assessment, dated 11/17/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #17 had diagnoses of unspecified fracture of third thoracic vertebra (dislocations of the thoracic and lumbar spine are caused by very high-energy trauma), subsequent encounter for fracture with routine healing, muscle weakness (loss of strength to move, felt as difficulty with tasks, balance issues, or trembling), and other fractures. He had a BIMS score of 15, which indicated his cognition was intact. The MDS reflected Resident #17 had functional limitation in range of motion, impairment on both sides, upper and lower extremity. Record review of Resident #17's care plan, dated 12/02/25, reflected Focus: The resident is risk for falls r/t Gait/balance problems, Paralysis. Goal: The resident will not experience falls or injuries from falls through the review date. The resident will not sustain serious injury through the review date. Interventions: Anticipate and meet the residents' needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Care plan did not address the use of back brace or bilateral foot brace. Observation and interview on 12/02/25 at 1:33 PM, revealed Resident #17 was observed in his wheelchair. The resident was wearing his back brace. Resident #17 stated he had a motor accident and had several surgeries. Resident #17 stated he had to wear his back brace when he was out of the bed and could take it off when in bed. Resident #17 stated he put the brace on with staff assistance. He stated his foot braces were to be worn while in bed. Observed the foot braces in the resident's room. He stated he put them on by himself or staff helped him. Resident #17 stated he must wear the back brace for a total of 3 months.Interview on 12/04/25 at 9:52 AM, RN D revealed she was the nurse assigned to Resident #17. She stated Resident #17 admitted to the facility with the back brace and foot protectors. She stated Resident #17's back brace should be worn when out of bed and be removed when in bed. She stated the foot protectors should be worn only when in bed. RN D stated she was not sure if the back brace or foot protectors should be care planned but believed that it should. She stated she was not sure who was responsible for care plans.Interview on 12/04/25 at 11:09 AM, the MDS Coordinator revealed Resident #17's back brace and foot protectors should be care planned. He stated nurses and each department had access to resident's care plans. He stated it was the responsibility of the IDT and nursing staff to ensure residents' care plans were reviewed and updated quarterly. He stated he was not aware Resident #17 was not care planned for the use of the back brace or foot protectors. MDS Coordinator stated the back brace and foot protectors should be care planned because it was an intervention that the facility was providing for the resident. MDS Coordinator stated there was no potential risk if it was not care planned because the service was provided to the residents. Interview on 12/04/25 at 1:11 PM, the Unit Manager revealed Resident #17 admitted to the facility with the back brace and foot protectors. She stated the MDS Coordinators were responsible for care plans. Unit Manager stated she was not sure if the back brace or foot protectors should be care planned. Interview on 12/04/25 at 2:55PM, the DON revealed Resident #17 admitted to the facility with the back brace and foot protectors. She stated the MDS Coordinators were responsible for care plans. She stated she was not aware Resident #17's back brace and foot protectors were not care planned. She stated it should be care plan so that the care team are aware of what was implemented and to continue care. The DON stated she and nurse management followed up to ensure care plans were updated. She stated the potential risk would be lack of care, and ensuring the residents had what they needed. Record review of the facility's Comprehensive Care Plans policy, dated 10/01/25, reflected the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standard of quality. 1.The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated.

Based on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident status for 1 of 44 residents (Resident #88) reviewed for assessment accuracy.The facility failed to ensure Residents #88's MDS assessments were accurately coded for dialysis treatment. This failure could place residents at risk of not receiving the appropriate care and services to maintain the highest level of well-being.Finding included: Record review of Resident #88's admission MDS assessment, dated 10/27/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #88 had diagnoses of end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and fluids from the blood effectively), and hypertension (high blood pressure). She had a BIMS score of 15, which indicated her cognition was intact. The MDS did not reflected Resident #88 was receiving dialysis.Record review of Resident #88's care plan, dated 10/23/25, reflected Focus: The resident needs dialysis. Goal: The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Interventions: Check and change dressing daily at access site. Document. Do not draw blood or take B/P in arm with graft. Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis. Monitor labs and report to doctor as needed. Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Observation and interview on 12/02/25 at 1:30 PM revealed Resident #88 in her bed laying down. Resident #88 stated she went for dialysis on Mondays, Wednesdays, and Fridays. She stated the facility provided her with a form to take to dialysis. Resident #88 further revealed her site was dry, clean, and without complications.Interview on 12/04/25 at 11:09 AM, the MDS Coordinator revealed he was the MDS coordinator assigned to the skilled residents, which Resident #88 was one of them. He stated dialysis treatment should be coded in the resident's MDS. MDS Coordinator reviewed Resident #88 admission, and 5-day admission MDS and stated dialysis was not coded. He stated he missed it, and it would require him to complete a modification. He stated it was his responsibility to complete Resident #88's MDS assessment. He stated the Regional MDS completed spot checks, but not all the time. He stated it had not been brought up to his attention. He stated there was no potential risk to the resident, but more of a tracking method for CMS. Interview on 12/04/25 at 2:58 PM, the DON revealed the MDS Coordinators were responsible for completing the residents MDS assessment. She stated the expectations for MDS assessment were for the assessment to be completed accurately and on time. She stated the MDS Coordinator informed her that he missed a code for Resident #88's dialysis treatment in the MDS assessment. The DON stated the potential risk for the assessment not being completed accurately would be, not everything that needed to be capture was captured. Record review of the facility's Resident Assessment - RAI policy, dated 10/01/25, reflected the following: This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS.Policy Explanation and Compliance Guidelines:1. The current version of the RAI (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instructions found in the RAI Manual. 2. The assessment will include at least the following: o. Special Treatments and procedures.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 44 residents (Resident #17) reviewed for quality of care. The facility failed to obtain physician orders for the use of a back brace and bilateral foot protectors for Resident #17. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions. Findings included: Record review of Resident #17's admission MDS assessment, dated 11/17/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #17 had a diagnosis of unspecified fracture of third thoracic vertebra (dislocations of the thoracic and lumbar spine are caused by very high-energy trauma), subsequent encounter for fracture with routine healing, muscle weakness (loss of strength to move, felt as difficulty with tasks, balance issues, or trembling), and other fractures. He had a BIMS score of 15, which indicated his cognition was intact. The MDS reflected Resident #17 had functional limitation in range of motion, impairment on both sides upper and lower extremity. Record review of Resident #17's care plan, dated 12/02/25, reflected Focus: The resident is risk for falls r/t Gait/balance problems, Paralysis. Goal: The resident will not experience falls or injuries from falls through the review date. The resident will not sustain serious injury through the review date. Interventions: Anticipate and meet the residents' needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Care plan did not address the use of back brace or bilateral foot brace. Observation and interview on 12/02/25 at 1:33 PM, revealed Resident #17 was observed in his wheelchair. The resident was wearing his back brace. Resident #17 stated he had a motor accident and had several surgeries. Resident #17 stated he had to wear his back brace when he was out of bed and could take it off when in bed. Resident #17 stated he put the brace on with staff assistance. He stated his foot braces were to be worn while in bed. Observed the foot braces in the resident's room. He stated he put them on by himself or staff helped him. Resident #17 stated he must wear the back brace for a total of 3 months. Record review of Resident #17's November and December 2025 physician orders reflected there were no orders for the use of a back brace or bilateral foot braces. Interview on 12/04/25 at 9:48 AM, CNA F revealed she was the CNA assigned to Resident #17. She stated Resident #17 had a brace that should be worn while up out of bed, and foot protection braces must be worn while in bed to keep his feet straight and out of angle. She stated Resident #17 admitted with both back brace and foot protection braces. She stated staff help him put them on and Resident #17 adjust for his comfort. CNA F stated she was not sure of any physician orders. Interview on 12/04/25 at 9:52 AM, RN D revealed she was the nurse assigned to Resident #17. She stated Resident #17 admitted to the facility with the back brace and foot protectors. She stated Resident #17's back brace should be worn when out of bed and be removed when in bed. She stated the foot protectors should be worn only when in bed. RN D stated Resident #17 should have physician orders for both back brace and foot protectors. RN D reviewed Resident #17's physician orders and stated she did not see any physician orders. She stated she knows Resident #17 had orders, but she could not locate them. RN D stated nurses should ensure orders were in the system, however, the admitting nurse was responsible for putting in orders in the system. She stated Resident #17 was alert and oriented and knew when to put the brace on and when to remove them. She stated the potential risk would be not putting the back brace, foot protectors appropriately or staff forget to put them on. Interview on 12/04/25 at 1:11 PM, the Unit Manager revealed Resident #17 should have physician orders for the back brace and foot protectors. She stated Resident #17 did not have any orders until she put them in that day (12/04/25). Unit Manager stated the admitting nurse was responsible for putting orders in the system. She stated Resident #17 was alert and oriented and could voice when he wanted them on or off. Unit Manager stated the potential risk of not having physician orders would be staff not knowing Resident #17 must have braces on and could cause more damage due to his injuries. Interview on 12/04/25 at 2:55PM, the DON revealed Resident #17 admitted to the facility with the back brace and foot protectors. She stated physician orders should have been obtained so that they could monitor when Resident #17 had the brace and foot protectors on. The DON stated it was the responsibility of the admitting charge nurse and the nurse management to ensure all physician orders were obtained and put in the system. She stated she was not aware Resident #17 did not have orders for his back brace or foot protectors. The DON stated the potential risk of not having physician orders would be someone coming along and not knowing what was in place for Resident #17. Record review of the facility's admission Orders dated 10/01/25, reflected the following: A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and /or verbal orders for the resident immediate care and needs. Policy Explanation and Compliance Guidelines: 1.The written and/or verbal orders should include at a minimum: c. Treatment orders if indicated d. Routine care orders 2.The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. 3.The orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan.

Based on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 3 residents (Resident #102) reviewed for tube feedings.The facility failed to ensure Resident #102's tube feeding was administered per physician orders at a rate of 55 ml per hour continuously on 12/02/25 and 12/03/25. This failure could affect residents receiving enteral nutrition/hydration and place them at risk of overfeeding.Findings included:Record review of Resident #102's Quarterly MDS assessment, dated 09/05/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], the BIMS section was blank due to Resident #102 having short- and long-term memory problems and due to his cognitive skills for daily decision being severely impaired. Resident #102 was dependent on staff with eating and utilized a feeding tube. Resident #102's diagnoses included Aphasia (communication disorder), Stroke (blood supply to the brain is interrupted, due to a blocked blood vessel or bleeding in the brain), Hemiplegia (partial or total paralysis) or hemiparesis (weaknesses on one side of the body). Record review of Resident #102's care plan revealed Resident #102 required tube feedings related to Dysphagia (difficulty swallowing). Goal: Resident #102 would maintain adequate nutritional and hydration status as evidenced by weight stable, no signs or symptoms of malnutrition, or dehydration. Resident #102's insertion site would be free of infection. Interventions included the Registered Dietician to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. Speech therapy and treatment as ordered. Resident #102 was dependent with tube feeding and water flushes. See physician orders for current feeding orders. Record review of Resident #102's December 2025 Medication Administration Record reflected: Enteral Feed Order every shift Nutren 1.5 at 55 ml/hour via feeding tube. Up at (blank) to run continuously until total volume of ml administered. May remove for care and services. Start Date 11/29/25.G-Tube-Dual Pump Flush 45 cubic centimeters per hour, water every shift.G-Tube -Dual Pump Water Bag Change every night shift Nutren 2.0 0.08 gram-2kcal/ml at 55ml/hour x 22hours. Start Date 2/27/25.Observation and interview on 12/02/25 at 12:07 PM with Resident #102 revealed he was in his room sitting in a recliner chair visiting with family. The Family Member stated Resident #102 was nonverbal in communication and appeared sleepy and very drowsy. When the Family Member was asked about Resident #102's feeding, it was stated that Resident #102 had gone through some formula changes and had a flow rate of 55 ml/hour, but had recently observed an increase to 60 ml/hour. The Feeding Tube machine was observed to read a flow rate of 60 ml/hour continuously. Observation of the formula bag revealed Resident #102, Nutren 1.5, 60 ml/hour, 12/02/25, 11:00 AM. Observation and interview on 12/03/25 at 12:27 PM with LVN C revealed the Feeding Tube machine off. The formula bag revealed Resident #102, Nutren 1.5, 60 cc, 12/03/25, 6:52 AM. LVN C stated he administered Resident #102's formula that morning at a rate of 60 ml/hour with continuous feeding. LVN C reviewed Resident #102's orders for his tube feeding and revealed the flow rate should have been 55 ml/hour. According to LVN C, having an increase in flow rate placed Resident #102 at risk of fluid overload. LVN C stated Resident #102's order was updated and should have been at 60ml per [timeframe] , however, he could not recall when the order was increased. LVN stated nurses were responsible for ensuring orders were entered correctly and were responsible for following physician orders. LVN C stated the Unit Managers were responsible for reviewing all orders to ensure they were entered correctly. Interview on 12/03/25 at 1:08 PM with LVN C revealed he contacted the physician to confirm the order, and the physician stated Resident #102 was to remain at a flowrate of 60ml per [timeframe] continuous with intermittent 2 hour down time. LVN C stated not following physician orders, updating orders, or entering the updated orders, placed Resident #102 at risk of losing nutrients and weight. LVN C advised that nurses were responsible for updating the new orders provided by physicians in a timely manner.Interview on 12/04/25 at 1:10 PM with Unit Manger revealed nurses were responsible for entering and updating physician orders as they were given. The Unit Manager stated she was responsible for reviewing all orders to ensure they were properly entered. However, for the past couple of months, it had only been her that was responsible for Unit Manager tasks, and she fell behind. The Unit Manager stated although Resident #102's order had not been updated, he was receiving 60 ml/hour. The Unit Manager stated nursing staff should clarify the new order with the physician, notify family or the responsible party that the order changed, and document the consent or refusal for the new order. The Unit Manager further stated not having the updated order in the system placed Resident #102 at risk of being overfed, and not having nutrients administered appropriately.Interview on 12/04/25 at 2:51 PM with the DON revealed she was notified Resident #102 was receiving 60 ml per [timeframe] via his feeding machine, however, the orders read for him to receive 55ml per [timeframe]. According to the DON, if the orders for his flow rate revealed 55ml per [timeframe], nurses were responsible for following physician orders. The DON stated not following physician orders placed Resident #102 at risk for compromised nutrients and calories, risk for weight loss and malnutrition. The DON stated nursing management was responsible for ensuring the correct rate was administered.Record review facility policy dated 10/01/25 titled Care and Treatment of Feeding Tubes revealed: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders. Periodic evaluation of the amount of feeding being administered for consistency with the practitioner's orders.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #82 and #88) reviewed for dialysis.1.The facility failed to ensure Resident #82 and Resident #88 had a physician order to complete dialysis treatment. This failure could place residents at risk of inadequate monitoring after returning to facility.Findings included:Resident #82Record review of Resident #82's admission MDS assessment, dated 11/25/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #82 had diagnoses of end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and fluids from the blood effectively) and chronic obstructive pulmonary disease (COPD). He had a BIMS score of 09, which indicated his cognition was moderately impaired. The MDS reflected Resident #82 received dialysis.Record review of Resident #82's care plan, dated 12/02/25, reflected Focus: The resident needs dialysis r/t renal failure. Goal: The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Interventions: Do not draw blood or take B/P in arm with graft. Monitor vital signs. Notify MD of significant abnormalities. Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds.Record review of Resident #82's EHR reflected communication forms regarding Resident #82's pre- and post-dialysis vital signs monitoring were filled out by the nurse on duty.Record review of Resident #82's November and December 2025 physician's order reflected there were no orders for completing dialysis or to obtain and document vital signs prior to Resident #82 leaving for dialysis and upon return from dialysis.Observation on 12/02/25 at 10:33 AM, revealed Resident #82 in bed. An attempt was made to interview Resident #82, but the resident did not stay awake for the interview. The resident was in no apparent distress.Resident #88Record review of Resident #88's admission MDS assessment, dated 10/27/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #88 had diagnoses of end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and fluids from the blood effectively) and hypertension (high blood pressure). She had a BIMS score of 15, which indicated her cognition was intact. The MDS did not reflect Resident #88 was receiving dialysis.Record review of Resident #88's care plan, dated 10/23/25, reflected Focus: The resident needs dialysis. Goal: The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Interventions: Check and change dressing daily at access site. Document. Do not draw blood or take B/P in arm with graft. Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis. Monitor labs and report to doctor as needed. Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock.Record review of Resident #88's EHR reflected communication forms regarding Resident #88's pre- and post-dialysis vital signs monitoring were filled out by the nurse on duty.Interview and observation on 12/02/25 at 1:30 PM, Resident #88 revealed she went for dialysis on Mondays, Wednesdays, and Fridays. She stated the facility provided her with a form. Resident #88 further revealed her site was dry, clean and without complications.Record review of Resident #88's October, November, and December 2025 physician's order reflected there were no orders for completing dialysis on Monday, Wednesday, or Fridays or to obtain and document vital signs prior to Resident #88 leaving for dialysis and upon return from dialysis.Interview on 12/03/2025 at 2:29 PM, LVN C revealed he was the nurse assigned to Resident #88 today (12/03/25) and it was his first time working with her. He stated Resident #88's nurse was usually RN D. LVN C stated Resident #88 was a dialysis patient and resident leaves for her chair time at around 4:30AM on Mondays, Wednesdays and Fridays. LVN C stated Resident #88 should have an order for dialysis. LVN C reviewed Resident #88's physician orders and stated resident did not have any orders pertaining to dialysis. He said the admitting nurse was responsible for obtaining and putting in physician orders into the system. LVN C said the potential risk of not having physician orders would be resident not going to dialysis. Interview on 12/03/25 at 2:39 PM, RN D revealed she had been the nurse assigned to Resident #88 except for today (12/03/25). She stated Resident #88 was a dialysis patient and goes out 3 times week Mondays, Wednesdays and Fridays. RN D stated Resident #88 should have physician orders for dialysis. RN D reviewed Resident #88's physician orders, MAR and TAR and stated resident did not have any orders for dialysis. She stated the admitting nurse was responsible for obtaining orders; however, it was the responsibility of everyone to ensure all physician orders are put in the system. RN D stated the potential risk would be another staff working with the resident and not knowing if resident was a dialysis patient and could miss an appointment. Interview on 12/04/25 at 10:06 AM, LVN E revealed she was the nurse assigned to Resident #82. She stated Resident #82 was a dialysis patient. She stated prior to yesterday (12/03/25), Resident #82 did not have any physician orders for dialysis. She stated she was not aware Resident #82 did not have any physician orders. She stated the admitting nurse was responsible for putting the orders in the system and the unit managers and nurses would review them shift by shift. LVN E stated the potential risk would be the patient going to the incorrect site location, time.Interview on 12/04/25 at 1:04 PM, Unit Manager revealed she was the unit manager for all halls. She stated the admitting charge nurse was responsible for putting in orders in the system. She stated Resident #82 and Resident #88 were the only two dialysis patients. She stated she was not aware Resident #82 and Resident #88 did not have physician orders for dialysis until yesterday (12/03/25) when she completed the audit. She stated physician orders were needed for dialysis and to monitor the site and complete pre and post vitals. The Unit Manager stated she attempts to complete audits once a week; however, Resident #82 and Resident #88 were missed during the audit. She stated potential risk would be new staff not knowing residents require dialysis. Interview on 12/04/25 at 2:58 PM, the DON revealed Resident #82 and Resident #88 were the only two residents who were on dialysis. She stated she was not aware either of the residents did not have any physician orders pertaining to dialysis treatment and to monitor the shunt. The DON stated the expectation for new admits, was the charge nurse should follow up within 24 hours with nurse management to ensure all orders are in. She stated the potential risk of not having physician orders would be lack of continuous care and appointments being missed.Record review of facility Hemodialysis policy, dated 10/01/2025, reflected the following: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis. 13. The facility will ensure that the physician's orders for dialysis include: a. The type of access for dialysis (e.g graft, arteriovenous shunt, external dialysis catheter) and location; b. The dialysis schedule; c. the nephrologist name and phone number; d. the dialysis facility name and phone number; e. Transportation arrangements to and from the dialysis facility. f. Any medication administration or withholding of specific mediation prior to dialysis treatments; g. Any fluid restriction if ordered by the physician.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #8) reviewed for pharmacy services. The facility failed to ensure Resident #8 received her morning medications when LVN G prepared the medications and set them down on the hall railing to assist another resident. LVN G did not return to retrieve the medications off the hall and administer them to Resident #8. These failures could place residents at risk for medication error, drug diversion, and delay in medication administration. Findings included: Record review of Resident# 8's Entry MDS assessment, dated 08/23/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE], a BIMS of 07 indicated[PH1] severe cognitive with impairment. Resident #8's diagnoses included hypertension (high blood pressure) and Thyroid Disorder (condition that affect the thyroid gland that produces hormones that regulate metabolism and other bodily functions). The resident was dependent on facility staff to assist with toileting, bathing, and personal hygiene. Resident #8 required assistance with eating and oral hygiene. Record review of Resident #8's care plan revealed Resident #8 has hypothyroidism related to use/side effects of medication. Goal: Resident #8 will be free from signs and symptoms of hypothyroidism. Interventions included: Give thyroid replacement therapy as ordered, monitor side effects. Monitor /document/report any signs and symptoms of hyperthyroidism due to medication; obtain lab work as ordered. Stress the importance of taking the medication every day. Record review of Resident #8's MAR reflected at 5:00 AM on 12/03/25, LVN C provided Resident #8 with Liothyronine Sodium Oral tablet 5 MCG and Levothyroxine Sodium Oral Tablet 25 MCG. Record review of Resident #8's physician's orders dated 12/04/25 reflected an order for Levothyroxine Sodium oral tablet 25 mcg. Give 1 tablet by mouth in the morning for hypothyroidism. Start date 09/28/25. Also, Liothyronine Sodium oral tablet 5 mcg. Give 1 tablet by mouth in the morning for hyperthyroidism. Start date 08/17/25. Observation on 12/03/25 at 12:47 PM, on 600 Hall in the handrail revealed a clear medication cup with 606B written in black, a pink pill and a white pill. Observation and interview on 12/03/25 at 12:50 PM, with LVN C revealed medication cup labeled 606B, pink pill and white pill. LVN C stated he would review Resident #8's MAR and orders to see what medications had been administered. LVN C observed the nurse medication cart to reveal Resident #8's morning medication was Levothyroxine Tab 25 MCG, give 1 tablet by mouth every morning and Liothyronine Tab 5 MCG, Give 1 tablet by mouth in the morning. LVN C stated the early morning medications were administered by the overnight nursing staff prior to the end of their shift of 10:00 PM - 6:00 AM. LVN C stated he was not informed any residents had missed dose of medications. LVN C stated he had not previously seen the medication in the handrail. LVN C stated he needed to notify the physician of the missed doses. LVN C stated nurses were responsible for administering medications. LVN C stated when he administered medications he stood by the resident to ensure there was no choking, and medication had been administered properly. LVN C stated having found medication on the hall placed residents at risk of missed doses of medication, residents finding the medication and administering medication that does not belong to them. Interview on 12/04/2025 at 1:07 PM, the Unit Manager revealed she was notified about the medication found on the hall. The Unit Manager stated 5am medications were administered by the 10:00 PM - 6:00 AM nursing staff. The Unit Manager stated all nurses administering medications were to verify the dose and utilize the 5 rights of medication administration. The Unit Manager stated nurses should match the resident name, drug, dose, route, and right time of administration and ensure to stand and observe residents taking the medication. The Unit Manager stated not following the medication administration protocol, it placed residents at risk of having allergic reactions to medications that did not belong to them if they were to find and take medications that did not belong to them. Interview on 12/04/2025 at 2:51 PM, the DON revealed she was notified about medications found on the hallway. According to the DON when she spoke with the overnight nurse LVN G stated he was going to administer medication to Resident #8 when he saw another resident attempting to get out of bed and his attention was redirected to assist. According to the DON, not following the proper protocol placed Resident #8 a risk of not getting the medication she needed and others at risk of taking medication that did not belong to them. Interview on 12/04/25 at 3:15 PM, LVN G revealed he popped Resident #8's medication at the cart and was headed to Resident #8 when he observed another resident attempted to get out of bed, LVN G stated he sat the medication down to assist and prevent a fall. LVN G stated he forgot to return to the medication to administer. LVN G stated that he should have returned the medication to the cart and then assisted the resident back to bed. LVN G stated he failed to return to the handrail to retrieve the medication and administer. LVN G stated this incident placed Resident #8 at risk of not receiving her morning medication and placed other residents at risk of finding the medication and taking it themselves, administering medication that did not belong to them. Record review of facility policy dated 10/01/25 titled Medication Administration Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure that the six rights of medication administration are followed: Right resident, drug, dosage, route, time, documentation. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Observe resident consumption of medication. Sign MAR after administered. Correct any discrepancies and report to nurse manager.

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Residents #1) reviewed for abuse and neglect. The facility failed to report an incident where Resident #1 was found with a call light around his neck on 08/26/25. This failure could place residents at risk of neglect, injury, and lack of timely reporting of incidents. Findings included:Record review of the facility's current Abuse Prohibition Protocol policy, dated 08/25, revealed the following: .5. The Abuse Prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment. 7. i. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.10. The Abuse Prevention Coordinator will:a. Immediately (within 2 hours) report to the State agency and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The State agency and other appropriate authorities as required under applicable regulations and regulatory guidance. Record review of Resident #1's MDS Five Day assessment, dated 07/28/25, reflected the resident was an [AGE] year-old male, admitted to the facility on [DATE]. The resident's diagnoses included anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), cerebral infarction unspecified, (occurs when there is a disrupted blood flow to the brain), and hemiplegia following cerebral infarction affecting left nondominant side). This MDS reflected Resident #1 had moderate cognitive impairment with a BIMS score of 10. The MDS Section D0150 Resident Mood Interview further reflected Resident # 1 did not exhibit symptoms of feeling down, depressed, or hopeless and had no symptoms of having little interest or pleasure in doing things. Record review of Resident #1's hospital records, dated 07/17/25, reflected no suicidal ideations while Resident #1 was in the hospital previous to admission to the facility. Record review of Resident #1's care plan, dated 07/22/25, reflected the resident used psychotropic medication related to depression. Interventions included the resident would remain free of psychotropic related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Further review of Resident #1's care plan initiated on 10/09/25 did not reflect any history of having suicidal ideations/behaviors. Record review of Resident #1's clinical record did not reflect any suicidal ideations. Record review of Resident #1's progress notes dated 08/26/25 at 9:00 AM by LVN A reflected: Resident observed in bed. Patient alert and oriented x 2. Patient exhibited signs of agitation. Attempted to provide care to the resident. Resident refused care and proceeded to pull off the call light off the wall and wrap the cord around his neck. Patient then shouted out loud pull the cord I am better off dead than alive. Give me a bottle of sleeping pills. Resident become outrate [sic], unable to redirect. Notified MD, NP, and DON. New order received to send patient to . Hospital for psych evaluation. Family notified. Record review of Resident #1's progress notes, dated 08/26/25 at 9:02 AM, by DON reflected: Responded to the patient's room after being called by the nurse. The nurse reported that the patient had been attempting to wrap a cord around his neck. At the time of arrival, the nurse was holding the call light cord and was explaining to the patient that he could not use it in that manner. Upon speaking with the patient he expressed that he was upset about being placed in a nursing home. He shared that his daughter had told him he should just kill himself. He continued to ask for the cord, at which point I removed any objects from the room that could pose a risk of self-harm. The nurse manager and I remained in the room and performed a head to toe assessment to ensure that the patient had not caused himself any physical harm. I then assigned a staff member to stay in the room with the patient at all times, instructing them not to leave under any circumstances, as one-on-one monitoring was now required. Resident stated that he knows we love him just is sad because of his family. Resident assisted up to chair, resident barely has clothes, so staff went to laundry to get sweatpants for patient to wear. Resident in good spirits awaiting transportation. Record review of Resident #1's Head to Toe assessment, dated 08/26/25, completed by DON reflected: No markings around neck. No new skin concerns. Skin with no new areas.Record review of Resident #1's Change in Condition, dated 08/26/25 at 10:11 AM, by LVN A reflected: .Altered Mental Status on 08/26/25. This condition, symptom or sign has occurred before: No. Resident alert and oriented, knows what he is talking about. Appears distressed and agitated. Stated that he is better off dead than alive. Resident need psych eval. Mental status changes-Suicidal thoughts. Record review of a Situation Background Appearance Review and Notify Report for Resident #1, dated 08/26/25 by LVN A, reflected: The condition, symptom, or sign has occurred before: No. Altered level of consciousness. Danger to self or others. Sent to .Hospital. Interview on 10/09/25 at 11:54 AM, LVN A revealed he was Resident #1's 6:00 AM - 2:00 PM nurse. LVN A revealed that he went into Resident #1's room and found him with his call light cord out of the wall and had wrapped it around his neck. LVN A stated he took the cord from around Resident #1's neck and notified the DON, who came to Resident #1's room immediately. LVN A revealed the cord was not tight around the resident's neck and said there was no redness or injuries noted to his neck. LVN A stated that he notified the doctor and received an order to send Resident #1 out to the hospital for a psychiatric evaluation. LVN A said Resident #1 was kept on one-on-one supervision until the resident was picked up by the ambulance that same day. LVN A revealed the DON and Clinical Unit Manager cleared Resident #1's room of all sharp items and cords to prevent Resident #1 from harming himself while they were waiting for an emergency transport for Resident #1. LVN A also stated Resident #1 had not expressed any intent or suicidal ideations prior to this event. LVN A stated Resident #1 went to the dining room for all his meals and had not isolated himself prior to this incident. Interview on 10/09/25 at 12:06 PM, CNA B revealed she was Resident #1's 6:00 AM - 2:00 PM CNA. CNA B stated the resident had never expressed suicidal ideations prior to the incident. CNA B said that after the incident, Resident #1 said his daughter had dropped him off and left him at the facility therefore he felt like he wanted to die. CNA B revealed that Resident #1 was kept on one-on-one supervision until he was picked up by emergency transport and transported to the hospital. Interview on 10/09/25 at 4:22 PM, the Clinical Unit Manager revealed she and the DON responded to LVN A when he notified them about Resident #1 and the call light around his neck. The Clinical Unit Manager stated that Resident #1 was distraught at the time and stated that no one wanted him and that he was not going to get better. The Clinical Unit Manager said that she and the DON removed all items out of Resident #1's room that could be used to harm himself. The Clinical Unit Manager also stated she and the DON placed Resident #1 on one-on-one supervision until emergency transport arrived to take him to the hospital for a psychiatric evaluation. The Clinical Unit Manager said Resident #1 did not have suicidal ideations or mentioned that he felt like hurting himself prior to the incident. The Clinical Unit Manager revealed the Administrator was responsible for reporting incidents to the State. The Clinical Unit Manager also said that if the Administrator was not available to report to the State, the DON could report to the State when needed. Interview on 10/09/25 at 4:38 PM, the DON revealed that she was notified by LVN A that Resident #1 was stating that he was going to kill himself. The DON stated that she responded and went to Resident #1's room immediately. The DON said that Resident #1 was told by his daughter that he was useless during a visit. The DON said that she talked to Resident #1 calmly and took the things out of his room that could be a harm to him such as cords. The DON said the facility received an order to send Resident #1 out for a psychiatric evaluation. The DON stated the Administrator was responsible for reporting unusual events and she (DON) would be responsible if the Administrator was out of the building. The DON stated Resident #1 was picked up by emergency transportation later that day. However, Resident # 1 was placed on one-one-one until emergency transport arrived and the resident did not return from the hospital. Interview on 10/09/25 at 5:28 PM, the Administrator revealed that she was immediately notified of Resident #1's incident. The Administrator stated, Resident #1 did not appear depressed prior to this incident, and he had not expressed suicidal ideations. The Administrator stated that Resident #1 was placed on one-on-one supervision after the incident and then sent out for a psychiatric evaluation and did not return from the hospital. The Administrator also revealed that a head-to-toe assessment had been completed, and no redness or red marks were found on the resident's neck. The Administrator also stated that after the resident was found, they developed a new assessment which would have the resident placed on one-on-one supervision, would be referred to psychiatric serviced, and sent out for psychiatric evaluation. The Administrator stated they in-serviced immediately on this new policy after Resident #1 was found in his room. The Administrator stated she reviewed the regulations with her upper management, and felt this incident was not reportable.

Based on interview and record review the facility failed to ensure all alleged violations involving neglect, which included injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse and neglect.The facility failed to implement their policy on reporting an incident involving Resident #1 when he was found with a call light cord around his neck on 08/26/25. This failure could place residents at risk of and contribute to neglect. Findings included: Record review of Resident #1's MDS Five Day assessment, dated 07/28/25, reflected the resident was an [AGE] year-old male, admitted to the facility on [DATE]. The resident's diagnoses included anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), cerebral infarction unspecified, (occurs when there is a disrupted blood flow to the brain), and hemiplegia following cerebral infarction affecting left nondominant side). This MDS reflected Resident #1 had moderate cognitive impairment with a BIMS score of 10. The MDS Section D0150 Resident Mood Interview further reflected Resident # 1 did not exhibit symptoms of feeling down, depressed, or hopeless and had no symptoms of having little interest or pleasure in doing things. Record review of Resident #1's hospital records, dated 07/17/25, reflected no suicidal ideations while Resident #1 was in the hospital previous to admission to the facility. Record review of Resident #1's care plan, dated 07/22/25, reflected the resident used psychotropic medication related to depression. Interventions included the resident would remain free of psychotropic related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Further review of Resident #1's care plan initiated on 10/09/25 did not reflect any history of having suicidal ideations/behaviors. Record review of Resident #1's clinical record did not reflect any suicidal ideations. Record review of Resident #1's progress notes dated 08/26/25 at 9:00 AM by LVN A reflected: Resident observed in bed. Patient alert and oriented x 2. Patient exhibited signs of agitation. Attempted to provide care to the resident. Resident refused care and proceeded to pull off the call light off the wall and wrap the cord around his neck. Patient then shouted out loud pull the cord I am better off dead than alive. Give me a bottle of sleeping pills. Resident become outrate [sic], unable to redirect. Notified MD, NP, and DON. New order received to send patient to . Hospital for psych evaluation. Family notified. Record review of Resident #1's progress notes, dated 08/26/25 at 9:02 AM, by DON reflected: Responded to the patient's room after being called by the nurse. The nurse reported that the patient had been attempting to wrap a cord around his neck. At the time of arrival, the nurse was holding the call light cord and was explaining to the patient that he could not use it in that manner. Upon speaking with the patient he expressed that he was upset about being placed in a nursing home. He shared that his daughter had told him he should just kill himself. He continued to ask for the cord, at which point I removed any objects from the room that could pose a risk of self-harm. The nurse manager and I remained in the room and performed a head to toe assessment to ensure that the patient had not caused himself any physical harm. I then assigned a staff member to stay in the room with the patient at all times, instructing them not to leave under any circumstances, as one-on-one monitoring was now required. Resident stated that he knows we love him just is sad because of his family. Resident assisted up to chair, resident barely has clothes, so staff went to laundry to get sweatpants for patient to wear. Resident in good spirits awaiting transportation. Record review of Resident #1's Head to Toe assessment, dated 08/26/25, completed by DON reflected: No markings around neck. No new skin concerns. Skin with no new areas. Record review of Resident #1's Change in Condition, dated 08/26/25 at 10:11 AM, by LVN A reflected: .Altered Mental Status on 08/26/25. This condition, symptom or sign has occurred before: No. Resident alert and oriented, knows what he is talking about. Appears distressed and agitated. Stated that he is better off dead than alive. Resident need psych eval. Mental status changes-Suicidal thoughts. Record review of a Situation Background Appearance Review and Notify Report for Resident #1, dated 08/26/25 by LVN A, reflected: The condition, symptom, or sign has occurred before: No. Altered level of consciousness. Danger to self or others. Sent to .Hospital. Interview on 10/09/25 at 11:54 AM, LVN A revealed he was Resident #1's 6:00 AM - 2:00 PM nurse. LVN A revealed that he went into Resident #1's room and found him with his call light cord out of the wall and had wrapped it around his neck. LVN A stated he took the cord from around Resident #1's neck and notified the DON, who came to Resident #1's room immediately. LVN A revealed the cord was not tight around the resident's neck and said there was no redness or injuries noted to his neck. LVN A stated that he notified the doctor and received an order to send Resident #1 out to the hospital for a psychiatric evaluation. LVN A said Resident #1 was kept on one-on-one supervision until the resident was picked up by the ambulance that same day. LVN A revealed the DON and Clinical Unit Manager cleared Resident #1's room of all sharp items and cords to prevent Resident #1 from harming himself while they were waiting for an emergency transport for Resident #1. LVN A also stated Resident #1 had not expressed any intent or suicidal ideations prior to this event. LVN A stated Resident #1 went to the dining room for all his meals and had not isolated himself prior to this incident. Interview on 10/09/25 at 12:06 PM, CNA B revealed she was Resident #1's 6:00 AM - 2:00 PM CNA. CNA B stated the resident had never expressed suicidal ideations prior to the incident. CNA B said that after the incident, Resident #1 said his daughter had dropped him off and left him at the facility therefore he felt like he wanted to die. CNA B revealed that Resident #1 was kept on one-on-one supervision until he was picked up by emergency transport and transported to the hospital. Interview on 10/09/25 at 4:22 PM, the Clinical Unit Manager revealed she and the DON responded to LVN A when he notified them about Resident #1 and the call light around his neck. The Clinical Unit Manager stated that Resident #1 was distraught at the time and stated that no one wanted him and that he was not going to get better. The Clinical Unit Manager said that she and the DON removed all items out of Resident #1's room that could be used to harm himself. The Clinical Unit Manager also stated she and the DON placed Resident #1 on one-on-one supervision until emergency transport arrived to take him to the hospital for a psychiatric evaluation. The Clinical Unit Manager said Resident #1 did not have suicidal ideations or mentioned that he felt like hurting himself prior to the incident. The Clinical Unit Manager revealed the Administrator was responsible for reporting incidents to the State. The Clinical Unit Manager also said that if the Administrator was not available to report to the State, the DON could report to the State when needed. Interview on 10/09/25 at 4:38 PM with the DON revealed that she was notified by LVN A that Resident #1 was stating that he was going to kill himself. The DON stated that she responded and went to Resident #1's room immediately. The DON said that Resident #1 was told by his daughter that he was useless during a visit. The DON said that she talked to Resident #1 calmly and took the things out of his room that could be a harm to him such as cords. The DON said the facility received an order to send Resident #1 out for a psychiatric evaluation. The DON stated the Administrator was responsible for reporting unusual events and she (DON) would be responsible if the Administrator was out of the building. The DON stated Resident #1 was picked up by emergency transportation later that day. However, Resident # 1 was placed on one-one-one until emergency transport arrived and the resident did not return from the hospital. Interview on 10/09/25 at 5:28 PM, with the Administrator revealed that she was immediately notified of Resident #1's incident. The Administrator stated , Resident #1 did not appear depressed prior to this incident, and he had not expressed suicidal ideations. The Administrator stated that Resident #1 was placed on one-on-one supervision after the incident and then sent out for a psychiatric evaluation and did not return from the hospital. The Administrator also revealed that a head-to-toe assessment had been completed, and no redness or red marks were found on the resident's neck. The Administrator also stated that after the resident was found, they developed a new assessment which would have the resident placed on one-on-one supervision, would be referred to psychiatric serviced, and sent out for psychiatric evaluation. The Administrator stated they in-serviced immediately on this new policy after Resident #1 was found in his room. The Administrator stated she reviewed the regulations with her upper management, and felt this incident was not reportable. Record review of the facility's current Abuse Prohibition Protocol policy, dated 08/25, revealed the following: .5. The Abuse Prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment. 7. i. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment which promotes maintenance of enhancement of his or her quality of life and recognizing each resident individually for 1 of 7 residents (Resident #21) reviewed for resident rights. LVN D failed to treat Resident #2 with dignity and respect when she raised her voice and scolded the resident. The noncompliance was identified as past noncompliance. The noncompliance began on 01/28/25 and ended on 01/28/25. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk for diminished quality of life, loss of dignity and self-worth. Finding included: Record review of Resident #2's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility 04/12/22. Her diagnoses included cancer, Alzheimer's disease, stroke, non-Alzheimer's dementia, seizure disorder, anxiety, depression, bipolar disorder, and schizophrenia. The resident had a BIMS of 3 which indicated her cognition was severely impaired. The MDS also reflected Resident #2 required partial to substantial assistance with ADL's and was dependent with transfers. Record review of Resident #2's care plan printed on 03/06/25 reflected she required extensive assistance with bed mobility, toileting, bathing, and transfers. Interventions included to assist with ADL's as needed. Record review of the facility's Provider Investigation Report dated 02/04/25 reflected the following: The resident's family member sent a video to the Director of Nursing (DON) showing the alleged perpetrator answering the call light of this resident. While in the resident's room, the nurse raises her voice and appears to scold the resident for kicking of her covers and being restless in bed. The nurse states in a stern voice, 'I've already helped you .now why are you doing this .you've got to stop this.' The resident has a BIMS of a 3, has restless leg syndrome and unaware of her continuous actions/or behaviors. The nurse was interviewed and denied any 'wrong-doing' but also was defensive when questioned of the interactions. The nurse had been suspended pending investigation, and later termed on 01/31/25 for misconduct. The resident and family member were provided emotional support The employee was terminated. In-services continue on abuse/neglect and positive customer service. Satisfaction rounds continue with no issue noted Record review of Resident #2's video footage revealed LVN D entered the resident's room and with a raised voice said [Resident #2] stop playing with this call light. What do you want? I been here three times and you had your eyes closed. The resident was heard saying something but was not understood. LVN D continued to say, What do you want? Look for yourself. You got both of your covers on you already. Why do you keep on playing like this? What do you want? What else do you want? I fixed them up already. This is my third time you're not listening Observation and interview of Resident #2 on 03/05/25 at 11:17 AM revealed she was in bed watching TV with her headphones on. The resident stated the staff were treating her well but wanted a new roommate because the roommate would yell out at times. Resident #2 was asked about the incident where she was scolded by LVN D but she did not recall the incident. The resident reiterated all the staff were nice to her and she liked the facility. Interview on 03/07/25 at 9:33 AM with Resident #2's family revealed they had gone to visit the resident and the resident said they were mean and she did not like it there. The family said they had a camera in the room so that prompted them to look at it when she saw a staff member (LVN D) had been very ugly to the resident. The family further stated after the incident, Resident #2 did not say anything more and continued to say she loved the facility and got great care. Interview on 03/05/25 at 3:20 PM with RN E revealed Resident #2 was alert and oriented and able to make her needs known. RN E said the resident required total assistance with care and had never complained to her that she had been mistreated. Interview on 03/05/25 at 3:31 PM with CNA B revealed she worked with Resident #2 and said the resident was alert and oriented but had some moments of confusion. CNA B said Resident #2 there were time the resident would pull her call light repeatedly and then say she did not recall why she had pulled the call light or realized she had turned the light on. CNA B further stated Resident #2 had never mentioned she had been mistreated by staff. Interview on 03/06/25 at 9:50 AM with the Social Worker revealed she made daily rounds on Resident #2 and said the resident was alert and oriented but was forgetful at times. The Social Worker said the resident had never mentioned she had been mistreated by any staff member. Interview on 03/06/25 at 2:06 PM with the DON revealed Resident #2's family shared a video with her where it showed LVN D had been disrespectful to Resident #2. LVN D had entered the room and appeared to raise her voice at the resident and reprimand her for pushing the call light. The DON stated there were times Resident #2 would press her call light repeatedly but did not have any behaviors. The DON said once she saw the video, LVN D was sent home and during the investigation it was decided the LVN would be terminated for her actions. She further stated all staff were re-in-serviced on abuse/neglect and customer service. Interview on 03/06/25 at 2:54 PM with the Administrator revealed Resident #2's family had sent a video to the DON where it appeared LVN D had reprimanded the resident for pressing the call light. Once they were made aware of the incident, LVN D was sent home pending the investigation and later terminated. The Administrator said she spoke with Resident #2 after the incident and she did not appear to recall the incident. The Administrator further stated all staff had been re-in-serviced on abuse/neglect and customer service. Satisfaction rounds were made with other residents and there were no concerns noted and the family and the resident was offered support. Attempts to contact LVN D on 03/05/25 and 03/06/25 were unsuccessful. Record review of the facility's policy titled Abuse Protocol dated April 2019 reflected the following: 1. The Patient has the right to be free from Abuse, neglect, mistreatment of resident property, and exploitation .k. Mistreatment means inappropriate treatment or exploitation of a Patient Interview on 03/05/25 from 11:17 AM to 1:23 PM with 14 alert and oriented residents revealed they did not have any concerns with abuse/neglect or mistreatment from the staff. Record review of Resident #2's Psychosocial Well-being assessment dated [DATE] conducted by the Social Worker revealed the resident was in no distress or concerns noted. Record review of the facility's in-services titled Abuse/Neglect and Customer Service and Sensitivity Training dated 01/28/25 reflected 50 staff members participated in the in-service. Interview on 03/05/25 at 1:23 PM to 03/06/25 at 2:54 PM with staff from differnt shifts to include LVN A, CNA B, CNA C, LVN D, RN E, LVN F, CNA G, RN H RN I, CNA J, CNA K, LVN L, CNA M, LVN N, LVN O, RN P, and the Social Worker revealed they were all able to name the different types of abuse, reporting suspected abuse to the Administrator and providing the residents with good customer service. Record review of LVN D's personnel file revealed she had been terminated after the incident.

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 of 4 residents (Resident #1) observed for infection control. LVN A, CNA B and CNA C failed to wear a gown while providing care for Resident #1, who was on enhanced barrier precautions. This failure could lead to the resident being exposed to infections from other residents. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 0, and her diagnoses included dysphagia (swallowing difficulties), and the MDS reflected she had a feeding tube for nutrition. Record review of Resident #1's care plan dated 03/04/25 reflected: Focus: [Resident #1] Enhanced Barrier Precautions implemented rule out feeding tube. Goal: [Resident #1] The spread of an MDRO( is a germ that is resistant to many antibiotic) will be reduced over the next 90 days. Interventions: Implement enhanced barrier precaution: Offer emotional support as needed related to infection risk and use of EBP(Enhanced barrier precautions). Observation on 03/05/25 at 11:45AM on Resident #1's room revealed posting on the outside notifying staff and visitors the resident was on EBP, and it was required to wear a gown and gloves with all direct care of the resident. Observation on 03/05/25 at 11:50 AM revealed LVN A conducting a skin assessment for Resident #1. LVN A washed her hands, put on gloves, and performed the skin assessment. The gloves were the only PPE that LVN A wore while touching the resident to perform the skin assessment. Resident #1 was observed to have a gastronomy tube with a dressing dated 03/05/25. Observation on 03/06/25 at 10:04 AM revealed LVN A, CNA B and CNA C provideing Resident #1 with incontinence care. They washed their hands and gathered all the supplies they needed to provide the care. LVN A, who had only donned gloves as PPE, shut off the feeding pump and flushed the resident's the gastronomy tube. CNAs B and C washed their hands and put on gloves. The gloves were the only PPE they wore while providing Resident #1 with incontinence care. Interview on 03/06/25 at 11:50 AM with CNA B revealed she knew she was supposed to wear PPE when caring for residents on isolation. She stated Resident #1 was not on isolation. She stated she saw the sign but since she was not familiar with enhanced barrier precautions, she had no idea that she was supposed to wear a gown and gloves while providing Resident #1 with incontinence care. She stated she had not been putting on gloves and a gown while providing care for residents with g-tubes, Foley catheters, or who had wounds. She revealed she did not know the risk of not wearing the PPE, and she could not remember training on enhanced barrier precautions. Interview on 03/06/25 at 11:50 AM with CNA C revealed she knew she was supposed to wear PPE when caring for residents with an EBP sign on their doors. She stated she could not recall seeing one at Resident #1's room. She stated she knew she was only supposed to put on gloves and a gown when caring for residents with catheters. She stated she had done training on enhanced barrier precautions, but it was only for residents with Foley catheters to prevent contamination. She stated the risk of not wearing a gown and gloves was that it could lead to contamination. Interview on 03/06/25 at 12:25 PM with LVN A revealed she just forgot to wear her PPE. She stated she was aware she was supposed to wear gloves and a gown while coming into contact with Resident#1. She stated Resident #1 had signage by the door and a bin for PPE. She stated she knew all residents with g-tubes, Foley catheters, and chronic wounds were on enhanced barrier precautions. She stated failure to use enhanced barrier precautions was that it could put Resident #1 at risk of cross-contamination. She stated she had done training on enhanced barrier precautions. Interview on 03/06/25 at 1:38 PM with the DON revealed all residents on EBP required the staff to wear a gown and gloves when having direct contact with the resident such as turning, incontinence care, and providing medications via gastric tube. The DON stated the EBP were in place to protect the resident from exposure to infectious agents that might be on the provider's clothing, et cetera. The resident was on EBP precautions because the resident had gastric tube, that easily allowed the introduction of infections into the body. She stated she had done training on enhanced barrier precautions, and she was not sure whether the staff were in attendance since some were new to the facility. Record review of the facility's training records for EBP, dated 02/06/25, reflected LVN A, CNA B, and CNA C were not in attendance. Record review of the facility's Enhanced Barrier Precautions policy, dated March 2024, reflected: Enhanced Barrier Precautions is an infection control intervention to reduce transmission of multi-drug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. .EBP is indicated for residents with any of the following: .Infections or colonization with a CDC -targeted MDRO when contact precautions do not apply otherwise or, .Chronic wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous statis ulcers) and /or indwelling medical devices(devices fully embedded in the body,i.e. central lines, urinary catheters, feeding tubes, tracheostomy tubes) even if the resident is not known to be infected or colonized with a CDC Targeted MDRO)

Based on interview and record review, the facility failed to notify the resident or the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one of three residents (Resident #1) reviewed for discharge notices. The facility failed to notify Resident #1 in writing of his transfer/discharge to the hospital for altered mental status, the reason for the transfer, and the right to appeal and they failed to send a copy of the notice to the Ombudsman as soon as practicable. This failure could place residents at risk of being transferred or discharged , and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #1's face sheet, dated 01/23/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE], discharged [DATE] to an acute care hospital, and readmitted on [DATE]. Record review of Resident #1's quarterly MDS assessment, dated 01/10/25, reflected a BIMS score of 15, which indicated his cognition was intact. His diagnoses included metabolic encephalopathy (alteration in consciousness), opioid dependence, chronic pain syndrome, muscle weakness, diabetes mellitus (high glucose), heart failure, hypertension (high blood pressure), and need for assistance with personal care. Record review of Resident #1's Nurses Notes, dated 12/28/24, reflected the following: Patient continued with increased confusion, altered mental status, could not allow this writer to touch him, patient screaming and yelling in the room. Restless and hurting self by scratching to skin to face. Patient had very filthy smell from his mouth. Abdominal areas were bleeding due to existing skin condition, this writer contacted MD on call via [phone number] and MD gave an order to send patent back to the ER 911 was called and patient send out to the Hospital. DON made aware. Record review of Resident #1's clinical record reflected there was no documentation showing the resident and the Ombudsman were notified in writing of the resident's discharge or the reason for the resident's discharge. Interview on 01/23/25 a 12:00 PM with Resident #1 revealed he was doing well. Resident #1 stated about 2-3 weeks ago he was transferred to the hospital. Resident #1 stated he could not recall the exact date of when he went to the hospital, but it was the end of December 2024. He stated he was at the hospital for over a week even though he was ready to be discharged two days after he had admitted to the hospital. Resident #1 stated the facility did not want to take him back, he stated the hospital staff were involved and assisted with getting him back to the facility. Resident #1 stated he could not recall much of why he was transferred to the hospital. He stated he was his own responsible party. Resident #1 stated he was never provided with any transfer or discharged paperwork from the facility only his 30-day discharge notice upon return from the facility. Interview on 01/23/25 at 2:53 PM with Unit Manager B revealed when a resident would go out to the hospital the expectations were for nurses to provide a face sheet, copy of current medication list, and any recent lab results. She stated the POA and the residents were notified verbally of a hospital transfer. Unit Manager B stated she was unaware of any other transfer paperwork that were given to residents or POA's or Ombudsman. She stated she had not been told otherwise. Interview on 01/23/25 at 4:01 PM with Administrator revealed Resident #1 was transferred to the hospital for a change of condition. She stated Resident #1 refused to go the hospital several times; he had an altered mental status, and he finally agreed to go to the hospital. She stated Resident #1 was sent to the hospital the Saturday after Christmas (12/28/24), he tested positive for amphetamines while at the hospital. She stated they received report from the hospital, and she informed the hospital they could not take any referrals of patients who have a history of drug use. She stated they accepted the Resident #1 back to the facility and a 30 discharged notice was provided to him and Ombudsman. She stated nothing in writing had been sent with the resident or family explaining the reason for his transfer/discharge to the hospital. She stated she was unaware that written forms needed to be provided to anyone. She stated they only provide the resident face sheet, medication list, and provide report to the hospital. Review of the facility's current Transfer and Discharge, facility - Initiated policy, revised October 2022, reflected the following: Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Notice of Transfer or Discharge (Emergent or Therapeutic Leave) 1. When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfer, NOT discharges, because the resident's return is generally expected. 2. Residents who are sent emergently to an acute care setting, such as hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility . .4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable. 5. Notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer. 6. Notices are provided in a form and manner that the resident can understand, taking into account the resident educational level, language, communication barriers, and physical or mental impairments.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one of two residents (Residents #2) reviewed for accidents. CNA C failed to obtain assistance from another staff member when using a mechanical lift to transfer Resident #2 from his bed to his wheelchair and then left the resident unsupervised mid-transfer to obtain assistance in completing the transfer. This failure place residents at risk for accidents and injuries. Findings included: Record review of Resident #2's face sheet, dated 01/23/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #2's admission MDS assessment, dated 11/04/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnosis included Type 2 diabetes mellitus without complication, pain, fluid overload, essential hypertension (high blood pressure), depression, and end state renal disease. The MDS further reflected the resident required substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair). Record review of Resident #2's care plan, revised date 12/24/24, reflected it did not address the resident's transfer needs. Observation on 01/23/25 from 10:15 AM to 10:20 AM revealed CNA C standing next to Resident #2's bed with a mechanical lift. Resident #2 was suspended above his bed approximately 3-5 inches in the lift sling. While Resident #2 was still in the sling, CNA C walked out of the room, leaving the resident alone, and walked to the nurses' station to ask for assistance to transfer resident from his bed to his wheelchair. The nurse's station was approximately 8-10 steps away from Resident #2's room. CNA C then returned to the room with CNA D, and they completed the transfer together. Interview on 01/23/25 at 1:08 PM with CNA C revealed she had been employed at the facility for seven years. She stated she was the CNA assigned to Resident #2. She stated she was getting Resident #2 ready for dialysis. She stated a mechanical lift was used to transfer Resident #2. She stated she lifted Resident #2 up with the mechanical lift alone and then she stepped out to get help. She stated there should be two staff when using the mechanical lift for transfers. She stated it was not okay to start the transfer and was not okay to leave the resident alone when the mechanical lift was in use. CNA C stated she should have asked for help from the beginning. She stated there was no risk to the resident because the mechanical lift was locked, and the bed was underneath him. Interview on 01/23/25 at 1:40 PM with CNA D revealed she assisted CNA C complete Resident #2's transfer. She stated when she entered Resident #2's room she observed CNA C had already started the transfer by lifting the Resident #2 up with the mechanical lift. She stated two staff were required when using a mechanical lift for transfers. She stated there should be two staff in the room before a resident was placed in the sling and being lifted. She stated residents should never be left alone in the room while in a sling. She stated the potential risks were that the resident could fall or the mechanical lift could flip over causing the resident to fall. Interview on 01/23/25 at 1:56 PM with Unit Manager A revealed when a resident transfers via mechanical lift there should be two staff completing the transfer. She stated her expectation was for two staff to complete the transfer from beginning to end. She stated resident should never be left alone in the room while being lifted with the mechanical lift. She stated it was not okay to leave a resident hanging from the mechanical lift just because the bed was underneath. She stated it was a safety risk and mechanical lifts tipped over easily. Unit Manager A stated even if there were two people, there was still a risk when using a mechanical lift, but two staff would have more control. Interview on 01/23/25 at 2:16 PM with RN E revealed she was the nurse assigned to Resident #2. She stated Resident #2 was a two-person assist for transfers. She stated when using a mechanical lift to transfer a resident there should be two staff completing the transfer for safety. She stated there should be two staff in the room before hooking the sling to the Hoyer lift. She stated the potential risk would be the resident falling from the mechanical lift. Interview on 01/23/25 at 3:30 PM with the DON revealed her expectation was for two staff to complete mechanical lift transfers from beginning to end. She stated there should be two staff in the room before hooking the sling to the mechanical lift and lifting the resident. She stated if assistance was needed staff should use the call light for assistance and not leave the resident alone in the room. She stated it did not matter if the mechanical lift was locked or a bed was underneath the resident, for safety there should always be two staff completing the transfer. She stated the potential risk would be injury to the resident. Record review of the facility's Lifting Machine, using a Mechanical policy, revised July 2017, reflected the following: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. General Guidelines 1. At least two (2) nursing assistants are needed to safety move a resident with mechanical lift

Based on observation, interview, and record review, the facility failed to ensure the facility provided food that was palatable, for one of one observed meal reviewed for dietary services. The facility failed to serve food that had a palatable texture during the lunch meal on 09/05/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Review of the facility's menu on 09/05/24 revealed the planned lunch consisted of soft tacos, refried beans, shredded lettuce, and diced tomato with alternate meal to include grilled chicken, Brussels sprouts, and mashed potatoes, brownie, bread. Observation on 09/05/24 at 12:51 PM of the soft taco to include ground beef with flour tortilla and refried beans, pureed texture ground beef, tortilla, Brussels sprouts, refried beans test tray with three surveyors, the Regional Dietitian and Dietary Manager revealed the food was warm; however, pureed Brussels sprouts, mashed potato, and pureed beans were without flavor and the grilled chicken patty was colorless, bland, and flavorless. Regional Dietitian and Dietary Manager stated they did not see concerns with the taste of the food, they had not received any concerns from staff about the bland taste of food. The Dietary Manager stated the cooks were responsible for the taste and presentation of the food. According to the Regional Dietitian the facility will look into different ways to add flavor to food without adding salt. Dietary Manager stated she would be responsible to ensure the cook was adding flavor to the food moving forward, not doing so placed residents at risk of not eating, weight loss and hungry if they are not eating because they don't like the food provided. A confidential interview with thirteen alert and oriented residents revealed the on a normal day, when state was not in facility food was served cold when eating both on the halls and in the dining room. It was also mentioned that food was not tasty and did not have any flavor. Review of the resident council meeting minutes dated June 2024-September 2024 did not mention anything about food being served cold or flavorless. Interview on 09/05/24 at 1:00 PM with the Dietitian and Dietary Manager revealed they had not received any complaints regarding the food being cold or bland. Review of the facility's policy titled Food Storage undated, reflected: facilities are to keep foods safe, wholesome, and appetizing.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on two of three medication carts (600 Hall and split hall) one medication room(central supply cabinent) and 4 of 4 (Residents #8, #21, #66 and #126 ) reviewed for pharmacy services. 1. The facility failed to ensure the 600 Hall nurses' medication cart contained accurate narcotic logs for Resident #126. 2. The facility failed to ensure the split hall nurses' medication cart contained accurate narcotic logs for Residents #8, #21, and #66. 3. The facility failed to ensure expired medications in Central Supply were removed and destroyed. These failures could place residents at risk for medication error, drug diversion,residnet reciving medications that were ineffective and delay in medication administration. Findings included: 1. Review of Resident# 8's Quarterly MDS Assessment, dated 07/19/24, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric fracture of left femur. The resident had moderately impaired cognition with a BIMS score of 9. Review of Resident #8's physician's orders dated 7/13/24 reflected an order for the resident to receive one tablet of Hydrocodone 5 mg/acetaminophen 325 mg (pain medication) by mouth as needed every four hours. 2. Review of Resident# 21's Quarterly MDS assessment, dated 08/30/24, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included pain. The resident had moderate cognitive impairment with a BIMS score of 8. Review of Resident #21's physician orders dated 04/13/24 reflected an order for the resident to received two tablets of Tramadol 50 mg by mouth three times daily for pain. 3. Review of Resident #66's entry MDS Assessment, dated 08/22/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had a diagnosis of pain. The resident's cognition was intact with a BIMS score of 15. Review of Resident #66's physician orders dated 08/27/24 reflected the resident had an order to receive the pain medication, Percocet 10 mg-325 mg tablet, one tablet by mouth every four hours while awake. 4. Review of Resident #126's entry MDS assessment, dated 08/09/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The resident had a diagnosis of wedge compression fracture T11-T12 vertebra. The resident had moderate cognitive impairment with a BIMS score of 8. Review of Resident #126's physician orders dated 08/27/24 reflected the resident had an order to receive one tablet of Tramadol 50 mg tablet by mouth three times daily. Observation and record review on 09/05/24 at 12:51 PM of 600 Hall nurses' medication cart and the Narcotic Administration Record, with LVN F, revealed Resident #126's Narcotic Administration Record for Tramadol 50 mg reflected a total of 20 pills remaining, while the blister pack count was 19 pills. It was last administered on 09/05/24 at 12:00 PM. Observation and record review on 09/05/24 at 1:16 PM, of split hall nurses' medication cart and the narcotic administration record, with LVN G, revealed the following: - Resident #8's Narcotic Administration Record sheet for hydrocodone-acetaminophen 5-325 mg was last signed off on 09/04/24 for one-tablet dose given at 10:18 PM, for a total of 14 pills remaining, while the blister pack count was 12 pills. - Resident #21's Narcotic Administration Record sheet for Tramadol 50 mg was last signed off on 09/04/24 for a two-tablet dose given at 9:00 PM for a total of 113 pills remaining while the blister pack count was 111 pills. - Resident #66's Narcotic Administration Record sheet for oxycodone 10-325 was last signed off on 09/5/24 for a one-tablet dose given at 12:30 AM for a total of 39 pills remaining while the blister pack count was 37 pills. Interview with LVN G on 09/05/24 at 1:35 PM revealed he administered oxycodone 5-235 mg 1 tablet to Resident #66 two times at 7:00 AM and 11:00 AM, hydrocodone -acetaminophen 5-325 mg 1 tablet to Resident #8 as needed every 4 hours and Tramadol 50 mg 2 tablets to Resident #21 and he had not signed off on the narcotic administration record log. He stated he gave the residents the medication, but he forgot to sign off on the narcotic administration log. He stated he knew he was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but he did not. LVN G stated he had no excuse for not signing off. He stated failure to log off would cause the narcotic count to show less on the next count, and it could lead to medication error. He stated he had done an in-service on medication administration. Interview with LVN F on 09/05/24 at 1:40 PM revealed she administered tramadol 50 mg 1 tablet to Resident #126, and she had not signed off on the narcotic administration record log. She stated she was aware she was supposed to administer and log on the narcotic log sheet at once, but she did not she forgot. She stated failure to log off would cause the narcotic count to show less on the next count, and it could lead to medication error. She stated she had not done in-service on medication administration. Observation on 09/05/24 at 2:01 PM of the facility's Central Supply over-the-counter cabinet with LVN R revealed 2 bottles of Vitamin A 3000 mcg (10000 units) with expiry date April 2024. Interview on 09/05/24 at 2:02 PM with LVN R revealed it was all nurses' responsibility to check the cabinet for expired medications. LVN R stated the central supplier was also responsible for ensuring there were no expired medication on the cabinet. He stated the risk of having expired medication in the cabinet was that if administered they will not be effective. He stated he had done an in-service on labelling and checking of expired medications. Interview was attempted with the Central Supply Staff on 09/05/24 at 2:23 PM by phone was not successful. Interview on 09/06/24 at 12:05 PM with the ADON revealed her expectation was when staff administer narcotics, they should document on medication administration record and log off on narcotic administration record. She was not able to say when she had last checked the carts. She stated failure to log off after administering could lead to medication error and medication diversion. Interview on 09/06/24 at 2:23 PM, the ADON revealed the Central Supply Staff was responsible for ensuring the cabinet was stocked, which included checking for expired medications. She stated it was her responsibility and the other ADONs to check the cabinet after the Central Supply Staff. Interview on 09/06/24 at 05:53 PM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log to prevent discrepancies and to have proof the medications were administered. The DON stated failure to document could lead to discrepancy and adverse effects. She stated it was her responsibility and the ADONs to audit the medication carts, and she stated she had checked in the morning. She stated she had started training of staffs on narcotic logs documentation.DON revealed the Central Supply Staff was responsible for ensuring the cabinet was free from expired medication. She stated it was her responsibility and the ADONs to check the cabinet after the Central Supply Staff. She stated she checked every morning on the carts, and she had checked that morning on 09/05/24. She was not asked on what they did with expired Medications. No training given to the Central Supply Staff. Review of the facility trainings reflected in services on all narcotics need to be signed as you give them on 08/02/24. Review of the facility's current Controlled Substances Medication Administration and Documentation- policy, dated January 2024, reflected: All administered controlled substance must be charted in medication administration record at the time of administration .if the medication is removed from the locked area, signed out on the inventory (count) sheet, but is not documented on the MAR it is considered a missing tablet which is open for interpretation as a diverted dose since it can't be definitely proven it was given to a resident without documentation on MAR to confirm. Record review of the facility's Medication Labeling and Storage policy, revised 2023, reflected: .Does not address the expired medications Recor review of the facility's Management of Controlled Medications policy, dated January 2024 reflected: .6. During drug destruction ,all narcotics will be removed from their container, placed in the biohazard bag/box and destroyed by applying liquids over them .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen and the 300-hall nutrition room. 1. The facility failed to ensure food items stored in the freezer were properly labeled with the contents after being removed from the original packages and not dated to reflect when the food items were opened. 2. The facility failed to ensure food items stored in the refrigerator were properly discarded. 3. The facility failed to ensure the 300-hall nutrition room's ice machine was cleaned prior to being used. These failures could place all residents at risk for food contamination and food borne illness. Findings included: Observation of the freezer on 09/04/24 beginning at 9:14 AM revealed the following were not properly labeled or dated for storage: - Two separate bags of breaded chicken patties, - 1 bag of meatballs, - 1 bag of French fries and fries wrapped in clear wrap. - 1 bag of breaded fish Observation and interview on 09/04/24 at 9:17 AM of the walk-in freezer revealed 2 separate bags of breaded chicken patties, 1 bag of meatballs, 1 bag of French fries and fries wrapped in clear wrap, and 1 bag of breaded fish. Interview with Dietary Manager revealed the food items were left over from preparing previous meals. The Dietary Manager stated these food items were taken from their original packing. The Dietary Manager stated the process when storing foods in the freezer included: to place left over food items in a storage bag labeled with name of food item, dated with open date, and concealed properly. The Dietary Manager stated it was the responsibility of the cooks to do walk thru daily to remove anything 10 days out from dates written on the stored food items. The Dietary Manager stated she also did a walk through to ensure cooks were not missing food items that required proper label and dating. Observation revealed the Dietary Manager removing items that were not properly labeled or dated. Observation and interview on 09/04/24 at 9:20 AM with the Dietary Manager revealed in the refrigerator a bag labeled ground meat that was dated 08/11/24 with no end date. According to the Dietary Manager the ground meat was used often and was kept in the refrigerator for easy access when needed. The Dietary Manager revealed all food items were dated when they were placed for storage, and she or the cooks were to do a walk through daily to remove items that were 10 days past their open date. The Dietary Manager stated an end date was not usually written on storage bags, and she could not confirm how long this ground meat had been in the refrigerator, she removed the bag of ground meat during the interview. The Dietary Manager stated the bag of ground meat was something that should not have been used due to it could cause food born illnesses if it had been in the refrigerator since 08/11/24. Review of the facility's undated policy titled Food Storage policy, reflected: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. Foods should be covered, labeled, and dated. 3. Observation on 09/04/24 at 2:12 PM of the 300-hall nutrition room's ice machine was filled with ice and had a white flap on the inside touching the ice. The white flap had a brown substance on it covering the entire bottom part of the white flap. Interview on 09/06/24 at 11:37 AM with CNA Y revealed the 300-hall nutrition room had an ice machine in it that had a white flap touching the ice that had a brown substance on it. CNA Y said the Maintenance Director normally cleaned it and she had not noticed the brown substance on the white flap before. CNA Y said this was the machine the staff used to get ice for the residents. Interview on 09/06/24 at 11:46 AM with the Maintenance Director revealed a contractor came to the facility to clean the ice machine and was last here about five months ago. The Maintenance Director said he saw the ice machine had a white flap on the inside that had a brown substance on it that was coming in contact with the ice. The Maintenance Director said he last checked the ice machine about a month ago and did not see the brown substance on there at that time. The Maintenance Director said no staff had mentioned it to him about the ice machine being dirty. Interview on 09/06/24 at 6:18 PM with the DON revealed staff got ice for the residents from the ice machines in the nutrition rooms. The DON said the ice machines were cleaned by the housekeeping and maintenance department. The DON said staff were supposed to report to the Executive Director (Administrator), Maintenance Director, and the DON immediately if they notice that the ice machine was dirty on the inside. The DON said the purpose of the ice machine being cleaned was to make sure residents have safe ice to consume. The DON said the risk was that the ice could be contaminated and put residents at risk for any type of being sick. Review of the maintenance logs from July 2024 reflected nothing for the ice machine needing to be cleaned. 44937

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #290) reviewed for ADL care. The facility failed to provide Resident #290 assistance with his personal hygiene by not providing scheduled showers. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection. Findings included: Record review of Resident #290's face sheet, dated 09/06/24, reflected the resident was an [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included hypertension (high blood pressure), hyperlipidemia (abnormally high levels of lipids in the blood), non-Alzheimer's dementia (loss of memory), and edema (fluid retention of the body). Record review of Resident #290's Admission MDS Assessment , dated 09/06/24, reflected Resident #290 had the ability to make himself understood and understood others, and his cognition was intact with a BIMS score of 13. Resident #290 had limited range of motion in both lower extremities, and he required partial/moderate assistance with shower/bathing, toileting, and personal hygiene. Record review of Resident #290's care plan, undated, reflected Resident #290 was admitted to the facility on [DATE]. The care plan reflected: Goal: Resident will participate in all activities of daily living and facility routines. Intervention included: Use cues to enhance participation in self-care. Observation and interview on 09/05/24 at 10:55 AM revealed Resident #290 in bed. The resident's bedding was soiled with stained dark amber circles (two the size of a [NAME]) and dark red smudges. Resident #290 had two pillows that were removed from bed and on nightstand with dark red smudges and small circles (the size of dimes) indicating evidence of blood stains. Resident #290 appeared disheveled with his hair greasy and facial hair grown out. According to Resident #290, he had not been showered due to having a PICC line in his left arm, but now that it had been removed, he hoped to get a shower. Resident #290 stated he would like to have a bath and shave. When asked about his sheets, Resident #290 revealed he could not recall the reason for the soiled sheets and bedding. Resident #290 could not recall the last time he showered. Observation and interivew on 09/06/24 at 10:09 AM revealed Resident #290 had a disheveled appearance, his hair was not combed but appeared wet/greasy. The resident had changed from a white shirt the day before to a black shirt. When asked if he received a shower, Resident #290 responded, No, but hoping to get one today. Resident #290's bedding was still soiled and discolored with dark red stains. Resident #290 stated he told an unknown staff person he would like to shower within the next hour. Interview on 09/06/24 at 1:40 PM with CNA A aide revealed she was not working with Resident #290 and did not know who was responsible for his care. CNA A stated residents were showered according to the scheduled shower days. According to CNA A, not assisting Resident #290 with a shower would place him at risk of skin breakdown and not being cleaned. Interview and record review on 09/06/24 at 1:41 PM with CNA A of the shower sheets revealed Resident #290's shower days were Monday, Wednesday, and Friday on the 2:00 PM-10:00 PM shift. CNA A revealed she documented in the computer once showers were completed. CNA A reported she could not identify the last time Resident #290 had taken a shower or bed bath, as there was no documentation that indicated he was showered since his return to the facility on [DATE]. Observation and interview on 09/06/24 at 1:43 PM with LVN B of Resident #290 revealed the resident was lying in bed, and his bedsheets had stains. The resident had a disheveled appearance. LVN B stated residents were showered according to the shower sheet list. LVN B stated it appeared Resident #290 had not been showered, and she would address this concern with aides who were responsible. LVN B stated nurses were to be notified if aides required assistance with care or activities of daily living to ensure residents had proper care. LVN B stated not providing showers, bed bath, personal hygiene, or changing bed sheets could place Resident #290 at risk of infection. LVN B stated it was important for Resident #290 to receive proper hygiene because he was recently cleared from isolation due to being admitted to the facility for a urinary tract infection and COVID. Interview on 09/06/24 at 6:36 PM with the DON revealed Resident #290 was newly admitted to the facility. The DON stated the resident transferred to the facility from the hospital where they were addressing an acute diagnosis. The DON stated CNAs were responsible for offering a shower on admission and got the residents in rotation to provide showers three days a week. The DON stated nursing staff should document any time residents refused to shower and inform their charge nurse. The DON stated not doing so placed Resident #290 at risk of him not thriving as well and could result in illness. The DON stated CNAs were responsible for ensuring residents were showered according to their schedule, and charge nurses were responsible for ensuring CNAs were doing their job. Review of the facility's current, undated Activities of Daily Living policy reflected: .every effort must be made to assure that assignments of the nurses and nurse aides to patients are as consistent as possible. A daily care guide must be prepared from the electronic medical record to assist direct care staff in providing assistance to patients in their activities of daily living. Certified Nurse Aide Activity of Daily Living Tracking Record must be maintained in accordance with the Minimum Date Set coding guidelines and specific to the Patient's individual needs. Certified Nurse Aide Activity of Daily Living Tracking Record must be regularly monitored by the DON or designee to ensure that task are being performed as scheduled.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mentla and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #45) reviewed for care plans. The facility failed to revise and update Resident #45's comprehensive care plan with new diet orders. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of the Admission Record dated 09/06/24 revealed Resident #45 was a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses including vascular dementia, acute kidney failure, alcoholic cirrhosis of the liver, Type II diabetes mellitus, and epilepsy. Record review of the Quarterly MDS assessment dated [DATE] reflected Resident #45 had severe cognitive impairment with a BIMS score of 6. The MDS reflected the resident received a therapeutic diet. Record review of the undated physician's diet orders reflected Resident #45's diet order was a regular diet with no salt on tray, no orange juice, no oranges, no tomatoes, no bananas, and no potatoes. The order start date was 06/13/24. Record review of Resident #45's undated care plan reflected: [Resident #45] has a diet order of a mechanically altered diet. Resident will maintain existing weight over the next 90 days. Insert dentures/bridges prior to meals. Monitor and document weight; report a weight loss greater than 3 pounds to dietician. Record food intake at each meal; offer appropriate substitutes for uneaten food. The care plan did not reflect the current order for no salt on tray, no orange juice, no oranges, no tomatoes, no bananas, and no potatoes Observation on 09/06/24 at 12:10 PM of Resident #45 revealed resident was eating a regular tray with no salt on the tray. There also were no oranges, no tomatoes, no bananas, no potatoes, and no orange juice on the tray. Interview on 09/06/24 at 10:13 AM with LVN C revealed Resident #45 received a renal diet daily. LVN C acknowledged Resident #45's care plan and diet order did not match. LVN C also said he had not noticed the discrepancy between the diet order and the care plan. LVN C stated Resident #45 previously received a mechanical soft diet before it was changed to a renal diet. Then LVN C revealed that Resident #45's diet order changed to NSOT and a regular diet with no orangs, bananas, potatoes, tomatoes, or orange juice. In addition, LVN C stated it was the ADON's responsibility to update care plans. LVN C stated he did not remember the last in-service on care plans and diet orders matching. Interview on 09/06/24 at 11:30 AM with the MDS Coordinator revealed upon admission, Resident #45's initial care plan was initiated. The MDS Coordinator stated that clinical meetings were held daily to update care plans as needed. The MDS Coordinator said that Resident #45 was overlooked. The MDS Coordinator also said that the importance of the diet matching the care plan was that the floor staff know the resident's diet while providing care. The MDS Coordinator revealed that she was responsible for the updated the care plans and that if the care plan was not updated, Resident #45 could receive the wrong diet which was important since Resident #45 was on dialysis. The MDS Coordinator stated she would update the care plan to match the diet order immediately. Interview on 09/06/24 at 11:37 AM with ADON A revealed care plans were updated with acute changes in the nursing daily clinical meetings by the MDS nurse as well as the infection preventionist and wound treatment nurse. She stated it was a collaborative effort to update the care plan, it was the responsibility of the whole team to update care plans. ADON A also said that the importance of care plans matching the diet orders was to ensure that the resident was cared for properly. ADON A revealed that the diet was important because a resident could refuse to eat, could choke, etc. ADON A stated that their policy stated that the care plan must match the resident's order. ADON A did not remember the last in-service held on care plans and diet orders matching. Interview on 09/06/24 at 6:14 PM with the DON revealed diet orders were updated by the MDS Coordinator, and it was their responsibility to adjust care plans for long-term changes. The DON stated that management adjusted care plans for short-term orders such as antibiotic. But it was the DON's responsibility to ensure care plans and orders match. The DON stated that if there were a discrepancy in the care plan, there could be confusion in the plan of care. The DON said that clinical meetings were held daily to ensure that care plans and orders were updated by nursing management. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated March 2022 reflected: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) eleven residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was attended and supervised while left in 96-degree heat for approximately 2 hours resulting in unresponsiveness, second degree skin burns, hospitalization , and heat stroke. The facility failed to ensure Resident #1 was safe from hazards when he sat on the facility's patio in 96-degree heat for at approximately 2 hours resulting in unresponsiveness, second degree skin burns, hospitalization , and heat stroke. An Immediate Jeopardy (IJ) was identified on 05/30/2024. While the IJ was removed on 05/31/2024 at 2:50 PM, 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 plan of removal. This failure could place the residents at risk of adverse health reactions and / or death. Findings include: Record review of Resident #1's Face Sheet dated 05/30/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included: vascular dementia (problems with reasoning, planning, judgement and memory), hemiplegia unspecified affecting left nondominant side (paralysis of the left side due to neurological injury), open-angle glaucoma - right eye (fluid in eye causing pressure on the optic nerve), cerebral infarction (disrupted blood flow to the brain), hyperlipidemia (elevated level of lipids like cholesterol in the blood), major depressive disorder (mood disorder causing persistent feelings of sadness and loss of interest), dysphagia (difficulty swallowing), muscle weakness, inflammatory liver disease (viral hepatitis), and chronic respiratory failure with hypoxia (respiratory failure). Record review of Resident #1's quarterly MDS Assessment, dated 04/15/2024, reflected a BIMS score of 9 indicating a mild cognitive impairment. He exhibited not physical or verbal behavior directed toward others and did not refuse care. He used a manual wheelchair to ambulate, had functional limitations on left side and required supervision during use. Functional Status indicated he required total dependence for, transfers, toileting and lower body dressing, substantial assist for showers, and partial assist for hygiene. Record review of Resident #1's Care Plan dated 09/01/2019 - Present, reflected, Problem: [Resident #1] is totally dependent on the staff with transfers - extensive (to/from: bed chair wheelchair, standing position). Intervention: [Resident #1] to be out-of-bed in chair at least two times daily. Interventions: Encourage PO and fluid intake. Problem: [Resident #1] is currently taking psychotropic medication as evidenced by, depression, cognitive impairment, and schizoaffective disorder. Interventions: Encourage appropriate behavior, discourage inappropriate behavior. Protect [Resident #1] from self-harm or harm to others. Monitor and record any displayed behavior or mood problems. Problem: [Resident #1] has cognitive impairment as evidenced by: Memory problems - short term, and impaired ability to make daily decisions r/t Dx Dementia. Interventions: assist with ADLs to the highest degree possible. Problem: [Resident #1] likes to go outside and sit in the courtyard. Intervention: Identify times/approaches/staff that result in least resistance. Communicate to all caregivers. Notify physician and Rp of noncompliance. When care is refused, remind [Resident #1] of potential risk. Coax but DO NOT FORCE compliance. Record review of the Facility's Investigation Report reflected, On 05/26/2024 at an unknown time, [Resident #1] had requested to go to courtyard and aide assisted him. [Resident #1] advised and educated about heat, and to not stay long because of the heat. [Resident #1] had a change of condition, was put back into the facility and 911 called. Resident was unresponsive but breathing. Resident's vitals obtained and 911 called. EMT's advised nurses on cooling rags until their arrival. Investigation initiated. In-services on abuse and neglect, and outside protocol for residents. A statement signed by LVN V and dated 05/26/2024, reflected, During med pass around 4:30 PM [Resident #4] came to this nurse and said to check on [Resident #1] because he was sitting outside. This nurse went out to check on [Resident #1] and he was unresponsive and was burning up hot. This nurse brought the resident back in from sitting outside and started a sternum roll but was unsuccessful. This nurse told the other nurse to call 911. We started getting water and ice packs to cool him off. This nurse and [CNA D] put the resident on the floor flat on his back with his head tilted up faced to the left side. This nurse assisted in filling ice in the trash cans for the EMTs to give him ice and water. Record review of the EMT Record, dated 05/26/2026 at 4:53 PM, reflected, EMT arrived on scene to a nursing home with Fire Department. [Resident #1] was found lying supine on the floor inside the cafe area of the nursing home. Facility called EMS for heat exposure, not responsive. Facility reported he went outside to the courtyard, and then must have fallen asleep out there and was outside for a couple hours. Unknown how long pt was outside, heat was over 90 degrees at the time. Also, unknown if the pt fell outside or was laying on the concrete or a wheelchair. Upon EMS arrival to the pt, he was unresponsive. Skin was very hot and dry to the touch. Pt was tachycardic, hypotensive, and hypoxic. Pt had secretions in his mouth and had agonal snoring respirations. Began to ventilate the pt via BVM. Established an IO in the left humerus head. Started pt on a fluid bolus. Placed 2 NPA's in the pt. Administered 10 mcg of push-dose EPI. Picked up pt on ground and onto the cot to get HOB elevated 30 degrees and ETSN. On the cot had already placed bag for ice immersion with some ice. Placed in bag and covered with more ice to cool him. Pt has some second degree burns to his arms abdomen and neck with some of the top layer of skin peeling off. Record review of the ER Hospital Record, dated 05/26/2026 at 8:31 PM, reflected, Chief Complaint: hyperthermia, unresponsive [Resident #1] was in his wheelchair outdoors for an unknown amount of time when he fell asleep and ended up falling from the wheelchair. On my exam he has a GCS of 3T, and physical exam is remarkable for second-degree burns to his chest, anterior neck and extremities. He was reported to be hyperthermic (106) on the scene and arrived surrounded by ice per EMS. In trauma bay found to be hypothermic requiring [NAME] and noted to have profound hypotensive shock requiring fluid resuscitation and vasopressors. CHIEF COMPLAINT: HEAT STROKE AND 13% TBSA PAVEMENT CONTACT BURNS HPI: 68M with PMH of a stroke, hemicraniectomy, and left sided hemiparesis who lives in a nursing home and was placed outside where he developed a heatstroke and fell on to the pavement and was on the pavement for quite some time. He presented with depressed mental status and hypotensive shock. He required intubation, fluid resuscitation, and vasopressors. He was found to have blistering of the skin and underwent debridement and was found to have at least 13% TBSA hot pavement contact burns which appear second degree at this point. Although at the scene he was apparently hyperthermic in heatstroke at 106F he then became hypothermic down to 92.3F in the ER. Record review of Resident #1's Nursing Note dated 05/26/2024 at 10:44 PM, signed by LVN A, reflected, Resident went to the courtyard in the afternoon and was brought back into the building by staff. At the time, he was not responding to name calling, or painful stimulus. Cold towels were applied to his body to cool him down while this nurse called 911 for assistance. Paramedics on the line assisted and gave instructions on stabilizing resident until first responders were on the scene to stabilize resident using Vasopressors and ambu [resuscitation] bag. Resident was transferred to [hospital] for further treatment. RP, DON, and administrator notified. In an interview on 05/30/2024 at 8:16 AM, the Executive Director stated, Resident #1 liked to sit outside and often did so after breakfast. She stated he always wore a hat and sunglasses and could get in / out of the patio on his own. She stated she was informed by staff on 05/26/2024 that Resident #1 was found outside unresponsive and sent to the hospital. She stated her investigation, thus far, concluded staff assisted him outside about 2:30 PM and was cautioned of the temperature and offered water. At about 4:30 PM Resident #4 asked LVN V to check on Resident #1 because he was unresponsive on the patio. She stated Resident #1's nurse, LVN A was on lunch break and LVN V was passing medications at the time. She stated LVN A called 911 and the dispatcher directed them on cooling Resident #1 down. She said they moved Resident #1 to the floor and covered with wet towels and ice packs. She stated EMS arrived quickly and took over then transported to the hospital. She said she was still working on her investigation but received the EMT transport record and they indicated Resident #1 was found on the ground outside. She stated said the EMT's reported Resident #1 fell asleep and fell from his wheelchair to the concrete and was on the floor for an unknown amount of time. She stated this was incorrect as he was found in his wheelchair. She said she had not received a medical update on Resident #1 from the hospital. She said the hospital reported 2nd degree burns and peeled skin to Resident #1's forehead and right side. She stated she spoke to the MD who said the burns likely occurred when the skin blistered when staff and EMTs attempted to cool Resident #1. She said it seemed that Resident #1 was not supervised as he could have been. When he refused water and warned of the temperature, staff still took him outside and the left him outside until the incident was brought to their attention. She said there was no documentation from staff that they did what they said they did. In an interview on 05/30/2024 at 9:51 AM, Resident #3 stated she saw Resident #1 sitting on the patio in the afternoon of 05/26/24. She said he liked to sit outside, and she often would tell him to come inside, and he would tell her to go away. She said at about 4:30 PM she saw Resident #4 on the patio trying to wake Resident #1 up. She said Resident #1 was in his wheelchair and not responding to Resident #4. She stated Resident #4 told LVN V who immediately brought Resident #1 back into the facility. She said he did not have any burns that she could see but was unresponsive to the nurses. She said the nurses placed Resident #1 on the floor and used ice and wet towels to cool Resident #1 down. She said the EMTs came shortly after and put Resident #1 in a bag with ice then took him to the hospital. In an interview on 05/30/2024 at 10:11 AM, LVN B said she worked on 100 Hall on 05/26/2024 but left the facility about 3:30 PM and did not notice if Resident #1 was outside or not. She said Resident #1 came to her about 1:45 PM and wanted to go outside but she told him to check with his nurse, LVN A. She stated she saw CNA D talk to Resident #1 but did not see them go outside. She stated she received a call from LVN A at 5:50 PM informing her that Resident #1 was taken to the hospital due to heat exposure. In a telephone interview on 05/30/2024 at 12:11 PM, CNA D said Resident #1 wanted to go outside after lunch and he did assist Resident #1 to the patio at about 2:30 PM. He said he checked on Resident #1, but he did not want to come in. CNA D said he offered Resident #1 water and tried to get him to come into the facility but Resident #1 refused both as he always did. CNA D said Resident #1 told him he would let him know when he wanted to come in. CNA D said he was busy with other residents and did not follow up with Resident #1. He said he did not know the time, but he saw LVN V bring Resident #1 into the facility. He said LVN V told him to get ice and wet towels to cool Resident #1 down. He said Resident #1 did not respond to LVN V and LVN A was on the phone to 911. He said they moved Resident #1 to the floor and place wet towels and ice on him until EMTs arrived. He said he was not sure but thought Resident #1 was outside for about 2 hours. In an interview on 05/28/2024 at 12:47 PM, LVN A stated she went for lunch and when she returned, as she walked down the hall, LVN V met her and told her that Resident #1 was not responding. She stated Resident #1 was in his wheelchair, hot to the touch, not really sweaty, and breathing heavily. She stated his eyes were closed and he was not moving. She said he did not respond to them calling his name. She stated she had staff get cold towels to wipe him down and to put on him to cool him down. She said she rubbed Resident #1's chest with her hand in a fist, palm on chest, but he did not respond, so she did it again with more pressure. She stated he still did not respond. She stated that was when she called 911. She said she told them Resident #1 was outside and was unresponsive. LVN A said they told her to lay Resident #1 on the floor. She said they laid him on the floor he started foaming at the mouth. She said they turned his head to the side and cleared his mouth. She stated just as they were done clearing his mouth, the EMTs arrived. She stated the EMTs checked his vitals and told staff to bring ice. She said Resident #1's temperature was 106.5 degrees F. She stated EMTs put a big plastic sheet under Resident #1 and poured all of the ice on and around him, lifted him on to the gurney, strapped him in and took him away in the ambulance. She stated she didn't not ask who found him or how long he had been outside. In an interview on 05/30/2024 at 1:30 PM, Family Member X said Resident #1 was in ICU at the hospital. Family Member X said the attending physician at the hospital told her on 05/27/24 at 9:47 AM that Resident #1 came to the hospital with a temperature of 106.5 degrees F. She said the physician told her Resident #1 had heat stroke and was in cardiovascular shock, required fluid and medication for blood pressure, was on a mechanical ventilator, had lung and renal failure and remained unresponsive. She said the physician told her to prepare because he did not think Resident #1 would survive. In an interview on 05/30/2024 at 2:32 PM, the Executive Director and DON stated they had started in-services on heat related risks and resident supervision. They said they did an audit if at risk residents who go outside. The ED said she ordered coolers and cups to place on the patio for hydration and made posters for all the patio entrances warning staff and residents of the dangers of sitting out in extreme weather. The DON stated there was no documentation indicating the CNA D or LVN A checked on Resident #1 of implemented any behavior interventions given that he often refused to come inside. The DON said the care plan should be specific when addressing behaviors because Resident #1 did have a right to stay on the patio as long as it did not pose a risk of harm to his wellbeing. She said that right needed to be balance with Resident #1's safety. In an interview on 05/30/2024 at 3:00 PM, Resident #4 stated he was going for supper at about 4:30 PM on 05/26/2024 but saw Resident #1 on the patio. He said he went to talk to Resident #1 but found him in his wheelchair and appeared to be asleep. Resident #4 said he poked Resident #1, and he did not respond. He stated he shook resident #1 and he was still unresponsive. Resident #4 said he called LVN V who came outside and brought Resident #1 into the facility. He said Resident #1 did not respond to LVN V either. He said the nurses called 911 and moved Resident #1 to the floor where they put ice and cold towels on him. He said the EMTs came quickly, and they took Resident #1 to the hospital. Resident #4 said Resident #1 liked it outside and often refused to come in even when it was hot. He said he could convince him to come in sometimes, but it depended on Resident #1's mood. An observation, at the hospital ICU, on 5/31/24 at 9:15 AM, revealed Resident #1 unresponsive to hospital staff's verbal commands. Resident #1 was on dialysis and a ventilator. He was missing skin on his forehead, right cheek / throat, and right arm. In an interview, at the hospital ICU, on 5/31/24 at 9:15 AM, the ICU RN and ICU Physician said although Resident #1 had been responding better to treatment, he still may not recover from his injuries. They said he was still non-responsive. The ICU Physician said EMTs brought Resident #1 to the hospital with a 106.5-degree F temperature. He said that puts the body in sever shock. They said it was their understanding that Resident #1 was found on the pavement and had been there for an unknown amount of time. This survey informed them of eyewitness accounts that Resident #1 was not on the ground while outside. The ICU Physician stated the burns could be cause from blistering caused when they placed cold towels and ice on Resident #1 to cool him down. He said it would be similar to frost bite and skin would come off. The ICU Physician said Resident #1 had a lot of underlying comorbidities and this incident amplified them. A telephone call to LVN V on 05/31/2024 at 1:25 PM revealed no response. A telephone call to LVN E on 05/31/2024 at 1:30 PM revealed no response. In an interview on 05/31/2024 at 2:14 PM, the Medical Director said he was aware that Resident #1 was found unresponsive on the patio. He said the ED called to discuss the burn marks reported by the hospital. He said they were likely from blistering which occurred when staff and EMTs placed cold towels and ice on Resident #1 to cool him. He said he could have got the burns from being outside for an extended period of time, but that time period was different for everyone. He said Resident #1 has a right to go outside but the facility was responsible to ensure his choice to do so was safe. The MD said Resident #1's labs completed on 04/12/2024 were normal. He said a chest x-ray was completed on 04/09/2024 and had no issues noted. In an interview on 05/31/2024 at 2:50 PM, the DON stated, she understood the failed to supervise and ensure Resident #1 was safe from hazards when he sat on the facility's patio in 92-degree heat for at approximately 1 3/4 - 2 hours. She stated there was no documentation that staff intervene in ensuring he came into the facility or that he was offered hydration. She stated the POR addressed the expectations on staff to ensure residents were safe in all weather conditions. Record review of the National Institute on Aging Website: https://www.nia.nih.gov/health/safety/hot-weather-safety-older-adults#:~:text=Get%20out%20of%20the%20sun,Lie%20down%20and%20rest, reflected Heat stroke is a medical emergency in which the body's temperature rises above 104 F. Signs of heat stroke are fainting; confusion or acting strangely; not sweating even when it's hot; dry, flushed skin; strong, rapid pulse; or a slow, weak pulse. When a person has any of these symptoms, they should seek medical help right away and immediately move to a cooler place, such as under shade or indoors. They should also take action to lower their body temperature with cool clothes, a cool bath or shower, and fans. Record review of the Accuweather website: https://www.accuweather.com/en/us/[NAME]/76248/may-weather/340873?year=2024 revealed the actual high temperature on 05/26/2024 was 96 degrees F. Record review of the facility's policy, titled, Care plans - comprehensive person-centered, revised March 2022, reflected, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . Record review of the facility's policy, titled, Charting and Documentation, revised April 2008, reflected, Policy Statement: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 2. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified Nursing Assistants may only make entries in the resident's medical chart as permitted by facility policy. 3. All incidents, accidents, or changes in the resident's condition must be recorded. 4. Information documented in the resident's clinical record is confidential and may only be released in accordance with state law and facility policy. Refer all requests for information to the Director of Nursing Services, Nurse Supervisor/Charge Nurse or to the business office. 5. To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records. 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided. b. The name and title of the individual(s) who provided the care. c. The assessment data and/or any unusual findings obtained during the procedure/treatment. d. How the resident tolerated the procedure/treatment. e. Whether the resident refused the procedure/treatment. f. Notification of family, physician, or other staff, if indicated. g. The signature and title of the individual documenting. In an interview on 05/31/2024 at 1:02 PM, the Executive Director was asked for the facility's policy on accidents and hazards and only an undated procedure guide was provided, titled, Accidents / Hazards. Record review of the facility's Accident and Hazards Guide, dated May 2016, outlined the steps to be taken in the event of an accident and did not reflect the facility's role in preventing accidents or hazards. The Administrator, DON and Regional Director of Clinical Services were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 05/30/2024 at 6:16 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 05/31/2024 at 2:50 PM and included: Assessment: The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 05/30/2024 at 7:00 p.m. An emergency QAPI meeting was held on 5/26/2024. All residents be audited to determine if they are at risk of being outside alone during unfavorable weather conditions. This will include determination of the desire for the residents to go outside and the decision-making capacity to be alone outside if weather conditions are unfavorable. This will be completed by the Director of Nurses, Assistant Director of Nurses, Social Worker, and/or Patient Care Coordinators on 5/31/2024. This will be used to identify any current patients that are at imminent risk for heat stroke due to extended time outside and related to their medical conditions. After completion of the resident audits, no other residents were found to be at imminent risk of being alone outside in unfavorable weather conditions. Who will be responsible: Nurse Managers. Who Will monitor: Executive Director and Regional Director of Clinical Services (RDCS). -Beginning 5/31/2024, Resident audits will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that is identified as wanting to be outside in unfavorable weather conditions. For any resident that identifies they would like to be outside, the weather conditions, their cognitive ability and physical ability will be reviewed by the charge nurse to determine the safety of the resident. If there is a safety concern and the weather conditions are unfavorable, a staff member or family member will remain with the resident while outside to ensure no adverse outcomes occur. Staff will be required to monitor with ongoing 15-minute checks for any resident who chooses to go outside in unfavorable weather conditions. The facility staff will progressively monitor the resident with 15-minute checks and if the resident is deemed in imminent danger the staff will also call 911. If a resident chooses to remain outside under unfavorable weather conditions despite attempts to coerce the resident to return inside, the staff will notify the DON and the ED and follow the plan of care including the following: Explain/Educate resident/family when times and conditions are appropriate and safe for resident exposure. Staff to ensure that the resident is dressed appropriately for the weather. Staff to round frequently to offer/assist with hydration, nutrition. Staff to round frequently to offer/provide ADL assist (positioning, toileting .) Confer with MD about a prn order for sunscreen. When weather not permitted, offer alternative activities of resident's preferences. Nursing to assess for any psychological, social, behavioral changes and document and follow up prn. Staff to provide level of supervision appropriate for resident. The DON will monitor for compliance daily by receiving report from the charge nurses for any resident deemed unsafe to be outside alone that requests to be outside. Audits will be completed weekly for 3 months until 8/31/2024 and then monthly on an ongoing basis by the Executive Director. Who will be responsible: Charge Nurses. Who Will monitor: Director of Nursing and Executive Director. All staff were educated to notify the Executive Director, Director of Nursing, or nursing management immediately when any resident goes outside in unfavorable weather conditions and to remain with the resident until further notice or the resident agrees to return inside the facility. This education was provided on 5/31/2024. This education was provided by the Director of Nursing and Assistant Director of Nursing. Staff will not be allowed to begin their shift until the education has been completed. Who will be responsible: Nurse Managers. Who Will monitor: Executive Director and RDCS. In-Services: All staff were in-serviced on residents going outside unsupervised during unfavorable weather conditions by the Director of Nursing and/or Nurse Managers. The ED and DON were educated by the RDCS on all in-service topics related to the IJ. All new clinical staff will receive the in services as part of the onboarding orientation process prior to being assigned and providing care to residents. All staff will be in-serviced on neglect, documenting behaviors, rounding and increased communication. No staff member will be allowed to work in the facility until the above required in-services are completed. The in-services with all staff will be completed by 5/31/2024. All staff were in-serviced by 8 am on 5/31/2024. Who will be responsible: Nurse Managers. Who Will monitor: Executive Director and RDCS. Monitoring: Starting 5/31/24 Director of nursing and/or Nurse Managers will review the 24-hour report for any incident of residents being outside during unfavorable weather conditions, each day for 4 weeks week, then weekly for 4 weeks. The Executive Director will review the documentation each week for compliance. Beginning 5/31/2024 no staff will be allowed to work until the required in servicing has been completed. Should Resident A return to the facility, he will not be allowed outside without supervision. Quality: Starting 5/31/2024 and ongoing monthly all concerns regarding adequately supervising residents will be taken to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. The Executive Director will monitor for compliance. Starting 5/31/2024 and ongoing monthly the Regional Director of Clinical Services and/or designee will monitor weekly to ensure compliance for four weeks and will review at the next Quality assurance meeting. On 05/31/2024 at 2:50 PM the surveyor began monitoring the facility's Plan of Removal. Interviews on 05/31/2024 between 3:00 PM and 4:00 PM with ADONs T and U, PTA H, OTA I, Housekeeper F and G, LVNs C and L, RNs O and P, and CNAs M, N, R, S, Maintenance Director, Social Worker, and Activities Director reflected staff representing 1st, 2nd, and 3rd shifts and all days of the week. Staff were able to convey appropriate knowledge of the POR inservice's including the identification of adverse weather exposure impacts on residents, care plans and interventions required to ensure resident's safety in any weather conditions. They demonstrated knowledge of documenting behaviors, strategies to address behaviors and notifying the DON, MD, and family members, when residents were non-compliant with interventions meant to ensure their safety. All staff stated the DON and nurse managers would monitor these actions. In an interview on 05/31/2024 at 2:50 PM, the DON stated, she was in-serviced regarding nursing staff communications and documenting efforts to ensure resident safety. She said she was also interview in writing comprehensive care plans that addressed specific resident behaviors, interventions, and tracking them. She stated the in-services were done by the Regional Director of Clinical Services and she, in turn in-serviced facility staff in all departments. She stated in-servicing would be ongoing until all facility staff had completed training. In an interview on 05/31/2024 at 2:40 PM, the Executive Director stated she and the DON, had been in-serviced on weather condition safety for all residents, by the Regional Director of Clinical Services. She stated all facility staff were educated on communication and notification of nursing staff regarding resident behaviors that may pose a risk of harm to them. She said she completed an audit of residents who were at risk of harm based on their behaviors and propensity to be outside. She said in-services were provided to nursing staff on comprehensive care planning to address specific behaviors in residents and provide specific strategies to ensure their safety. She said these will be monitored by the DON through assessment reports and nursing communication records. She said she would monitor this through the IDT and QUPI process. She stated in-servicing would be ongoing until all facility staff had completed training. Record review of the facility's in-service record addressed to nurses, dated 05/30/2024, and titled, Documentation of Behaviors, included the following topics. All services provided to the resident, or any changes in the resident's medical or mental condition, and behaviors shall be documented in the resident's medical record. A behavior is the way a person acts in response to a particular situation or event. Behaviors include but are not limited to: Going outside daily, yelling, repeating themselves, etc. 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 2. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified Nursing Assistants may only make entries in the resident's medical chart as permitted by facility policy. 3. All incidents, accidents, or changes in the resident's condition must be recorded. 4. Information documented in the resident's clinical record is confidential a [TRUNCATED]

Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of eleven residents reviewed for care plans. The facility failed to ensure Resident #1 was attended and supervised while left in 96-degree heat for approximately 2 hours resulting in unresponsiveness, second degree skin burns, hospitalization , and heat stroke. The facility failed to develop a comprehensive care plan to address Resident #1's behavior to ensure his safety while exercising his right to sit on the facility's patio during 96-degree heat, resulting in unresponsiveness, second degree skin burns, hospitalization , and heat stroke. The facility failed to implement/document the interventions that were in the care plan when Resident #1 refused hydration and to come inside the facility, during 96-degree heat, to ensure he did not overheat while sitting on the facility's patio. An Immediate Jeopardy (IJ) was identified on 05/30/2024. While the IJ was removed on 05/31/2024 at 2:50 PM, 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 plan of removal. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings include: Record review of Resident #1's Face Sheet dated 05/30/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included: vascular dementia (problems with reasoning, planning, judgement and memory), hemiplegia unspecified affecting left nondominant side (paralysis of the left side due to neurological injury), open-angle glaucoma - right eye (fluid in eye causing pressure on the optic nerve), cerebral infarction (disrupted blood flow to the brain), hyperlipidemia (elevated level of lipids like cholesterol in the blood), major depressive disorder (mood disorder causing persistent feelings of sadness and loss of interest), dysphagia (difficulty swallowing), muscle weakness, inflammatory liver disease (viral hepatitis), and chronic respiratory failure with hypoxia (respiratory failure). Record review of Resident #1's quarterly MDS Assessment, dated 04/15/2024, reflected a BIMS score of 9 indicating a mild cognitive impairment. He exhibited not physical or verbal behavior directed toward others and did not refuse care. He used a manual wheelchair to ambulate, had functional limitations on left side and required supervision during use. Functional Status indicated he required total dependence for, transfers, toileting and lower body dressing, substantial assist for showers, and partial assist for hygiene. Record review of Resident #1's Care Plan dated 09/01/2019 - Present, reflected, Problem: [Resident #1] is totally dependent on the staff with transfers - extensive (to/from: bed chair wheelchair, standing position). Intervention: [Resident #1] to be out-of-bed in chair at least two times daily. Interventions: Encourage PO and fluid intake. Problem: [Resident #1] is currently taking psychotropic medication as evidenced by, depression, cognitive impairment, and schizoaffective disorder. Interventions: Encourage appropriate behavior, discourage inappropriate behavior. Protect [Resident #1] from self-harm or harm to others. Monitor and record any displayed behavior or mood problems. Problem: [Resident #1] has cognitive impairment as evidenced by: Memory problems - short term, and impaired ability to make daily decisions r/t Dx Dementia. Interventions: assist with ADLs to the highest degree possible. Problem: [Resident #1] likes to go outside and sit in the courtyard. Intervention: Identify times/approaches/staff that result in least resistance. Communicate to all caregivers. Notify physician and Rp of noncompliance. When care is refused, remind [Resident #1] of potential risk. Coax but DO NOT FORCE compliance. Record review of the Facility's Investigation Report reflected, On 05/26/2024 at an unknown time, [Resident #1] had requested to go to courtyard and aide assisted him. [Resident #1] advised and educated about heat, and to not stay long because of the heat. [Resident #1] had a change of condition, was put back into the facility and 911 called. Resident was unresponsive but breathing. Resident's vitals obtained and 911 called. EMT's advised nurses on cooling rags until their arrival. Investigation initiated. In-services on abuse and neglect, and outside protocol for residents. A statement signed by LVN V and dated 05/26/2024, reflected, During med pass around 4:30 PM [Resident #4] came to this nurse and said to check on [Resident #1] because he was sitting outside. This nurse went out to check on [Resident #1] and he was unresponsive and was burning up hot. This nurse brought the resident back in from sitting outside and started a sternum roll but was unsuccessful. This nurse told the other nurse to call 911. We started getting water and ice packs to cool him off. This nurse and [CNA D] put the resident on the floor flat on his back with his head tilted up faced to the left side. This nurse assisted in filling ice in the trash cans for the EMTs to give him ice and water. Record review of the EMT Record, dated 05/26/2026 at 4:53 PM, reflected, EMT arrived on scene to a nursing home with Fire Department. [Resident #1] was found lying supine on the floor inside the cafe area of the nursing home. Facility called EMS for heat exposure, not responsive. Facility reported he went outside to the courtyard, and then must have fallen asleep out there and was outside for a couple hours. Unknown how long pt was outside, heat was over 90 degrees at the time. Also, unknown if the pt fell outside or was laying on the concrete or a wheelchair. Upon EMS arrival to the pt, he was unresponsive. Skin was very hot and dry to the touch. Pt was tachycardic, hypotensive, and hypoxic. Pt had secretions in his mouth and had agonal snoring respirations. Began to ventilate the pt via BVM. Established an IO in the left humerus head. Started pt on a fluid bolus. Placed 2 NPA's in the pt. Administered 10 mcg of push-dose EPI. Picked up pt on ground and onto the cot to get HOB elevated 30 degrees and ETSN. On the cot had already placed bag for ice immersion with some ice. Placed in bag and covered with more ice to cool him. Pt has some second degree burns to his arms abdomen and neck with some of the top layer of skin peeling off. Record review of the ER Hospital Record, dated 05/26/2026 at 8:31 PM, reflected, Chief Complaint: hyperthermia, unresponsive [Resident #1] was in his wheelchair outdoors for an unknown amount of time when he fell asleep and ended up falling from the wheelchair. On my exam he has a GCS of 3T, and physical exam is remarkable for second-degree burns to his chest, anterior neck and extremities. He was reported to be hyperthermic (106) on the scene and arrived surrounded by ice per EMS. In trauma bay found to be hypothermic requiring [NAME] and noted to have profound hypotensive shock requiring fluid resuscitation and vasopressors. CHIEF COMPLAINT: HEAT STROKE AND 13% TBSA PAVEMENT CONTACT BURNS HPI: 68M with PMH of a stroke, hemicraniectomy, and left sided hemiparesis who lives in a nursing home and was placed outside where he developed a heatstroke and fell on to the pavement and was on the pavement for quite some time. He presented with depressed mental status and hypotensive shock. He required intubation, fluid resuscitation, and vasopressors. He was found to have blistering of the skin and underwent debridement and was found to have at least 13% TBSA hot pavement contact burns which appear second degree at this point. Although at the scene he was apparently hyperthermic in heatstroke at 106F he then became hypothermic down to 92.3F in the ER. Record review of Resident #1's Nursing Note dated 05/26/2024 at 10:44 PM, signed by LVN A, reflected, Resident went to the courtyard in the afternoon and was brought back into the building by staff. At the time, he was not responding to name calling, or painful stimulus. Cold towels were applied to his body to cool him down while this nurse called 911 for assistance. Paramedics on the line assisted and gave instructions on stabilizing resident until first responders were on the scene to stabilize resident using Vasopressors and ambu [resuscitation] bag. Resident was transferred to [hospital] for further treatment. RP, DON, and administrator notified. In an interview on 05/30/2024 at 8:16 AM, the Executive Director stated, Resident #1 liked to sit outside and often did so after breakfast. She stated he always wore a hat and sunglasses and could get in / out of the patio on his own. She stated she was informed by staff on 05/26/2024 that Resident #1 was found outside unresponsive and sent to the hospital. She stated her investigation, thus far, concluded staff assisted him outside about 2:30 PM and was cautioned of the temperature and offered water. At about 4:30 PM Resident #4 asked LVN V to check on Resident #1 because he was unresponsive on the patio. She stated Resident #1's nurse, LVN A was on lunch break and LVN V was passing medications at the time. She stated LVN A called 911 and the dispatcher directed them on cooling Resident #1 down. She said they moved Resident #1 to the floor and covered with wet towels and ice packs. She stated EMS arrived quickly and took over then transported to the hospital. She said she was still working on her investigation but received the EMT transport record and they indicated Resident #1 was found on the ground outside. She stated said the EMT's reported Resident #1 fell asleep and fell from his wheelchair to the concrete and was on the floor for an unknown amount of time. She stated this was incorrect as he was found in his wheelchair. She said she had not received a medical update on Resident #1 from the hospital. She said the hospital reported 2nd degree burns and peeled skin to Resident #1's forehead and right side. She stated she spoke to the MD who said the burns likely occurred when the skin blistered when staff and EMTs attempted to cool Resident #1. She said it seemed that Resident #1 was not supervised as he could have been. When he refused water and warned of the temperature, staff still took him outside and the left him outside until the incident was brought to their attention. She said there was no documentation from staff that they did what they said they did. In an interview on 05/30/2024 at 9:51 AM, Resident #3 stated she saw Resident #1 sitting on the patio in the afternoon of 05/26/24. She said he liked to sit outside, and she often would tell him to come inside, and he would tell her to go away. She said at about 4:30 PM she saw Resident #4 on the patio trying to wake Resident #1 up. She said Resident #1 was in his wheelchair and not responding to Resident #4. She stated Resident #4 told LVN V who immediately brought Resident #1 back into the facility. She said he did not have any burns that she could see but was unresponsive to the nurses. She said the nurses placed Resident #1 on the floor and used ice and wet towels to cool Resident #1 down. She said the EMTs came shortly after and put Resident #1 in a bag with ice then took him to the hospital. In an interview on 05/30/2024 at 10:11 AM, LVN B said she worked on 100 Hall on 05/26/2024 but left the facility about 3:30 PM and did not notice if Resident #1 was outside or not. She said Resident #1 came to her about 1:45 PM and wanted to go outside but she told him to check with his nurse, LVN A. She stated she saw CNA D talk to Resident #1 but did not see them go outside. She stated she received a call from LVN A at 5:50 PM informing her that Resident #1 was taken to the hospital due to heat exposure. In a telephone interview on 05/30/2024 at 12:11 PM, CNA D said Resident #1 wanted to go outside after lunch and he did assist Resident #1 to the patio at about 2:30 PM. He said he checked on Resident #1, but he did not want to come in. CNA D said he offered Resident #1 water and tried to get him to come into the facility but Resident #1 refused both as he always did. CNA D said Resident #1 told him he would let him know when he wanted to come in. CNA D said he was busy with other residents and did not follow up with Resident #1. He said he did not know the time, but he saw LVN V bring Resident #1 into the facility. He said LVN V told him to get ice and wet towels to cool Resident #1 down. He said Resident #1 did not respond to LVN V and LVN A was on the phone to 911. He said they moved Resident #1 to the floor and place wet towels and ice on him until EMTs arrived. He said he was not sure but thought Resident #1 was outside for about 2 hours. In an interview on 05/28/2024 at 12:47 PM, LVN A stated she went for lunch and when she returned, as she walked down the hall, LVN V met her and told her that Resident #1 was not responding. She stated Resident #1 was in his wheelchair, hot to the touch, not really sweaty, and breathing heavily. She stated his eyes were closed and he was not moving. She said he did not respond to them calling his name. She stated she had staff get cold towels to wipe him down and to put on him to cool him down. She said she rubbed Resident #1's chest with her hand in a fist, palm on chest, but he did not respond, so she did it again with more pressure. She stated he still did not respond. She stated that was when she called 911. She said she told them Resident #1 was outside and was unresponsive. LVN A said they told her to lay Resident #1 on the floor. She said they laid him on the floor he started foaming at the mouth. She said they turned his head to the side and cleared his mouth. She stated just as they were done clearing his mouth, the EMTs arrived. She stated the EMTs checked his vitals and told staff to bring ice. She said Resident #1's temperature was 106.5 degrees F. She stated EMTs put a big plastic sheet under Resident #1 and poured all of the ice on and around him, lifted him on to the gurney, strapped him in and took him away in the ambulance. She stated she didn't not ask who found him or how long he had been outside. In an interview on 05/30/2024 at 1:30 PM, Family Member X said Resident #1 was in ICU at the hospital. Family Member X said the attending physician at the hospital told her on 05/27/24 at 9:47 AM that Resident #1 came to the hospital with a temperature of 106.5 degrees F. She said the physician told her Resident #1 had heat stroke and was in cardiovascular shock, required fluid and medication for blood pressure, was on a mechanical ventilator, had lung and renal failure and remained unresponsive. She said the physician told her to prepare because he did not think Resident #1 would survive. In an interview on 05/30/2024 at 2:32 PM, the Executive Director and DON, the DON stated there was no documentation indicating the CNA D or LVN A checked on Resident #1 of implemented any behavior interventions given that he often refused to come inside. The DON said the care plan should be specific when addressing behaviors because Resident #1 did have a right to stay on the patio as long as it did not pose a risk of harm to his wellbeing. She said that right needed to be balance with Resident #1's safety. In an interview on 05/30/2024 at 3:00 PM, Resident #4 stated he was going for supper at about 4:30 PM on 05/26/2024 but saw Resident #1 on the patio. He said he went to talk to Resident #1 but found him in his wheelchair and appeared to be asleep. Resident #4 said he poked Resident #1, and he did not respond. He stated he shook resident #1 and he was still unresponsive. Resident #4 said he called LVN V who came outside and brought Resident #1 into the facility. He said Resident #1 did not respond to LVN V either. He said the nurses called 911 and moved Resident #1 to the floor where they put ice and cold towels on him. He said the EMTs came quickly, and they took Resident #1 to the hospital. Resident #4 said Resident #1 liked it outside and often refused to come in even when it was hot. He said he could convince him to come in sometimes, but it depended on Resident #1's mood. An observation, at the hospital ICU, on 5/31/24 at 9:15 AM, revealed Resident #1 unresponsive to hospital staff's verbal commands. Resident #1 was on dialysis and a ventilator. He was missing skin on his forehead, right cheek / throat, and right arm. In an interview, at the hospital ICU, on 5/31/24 at 9:15 AM, the ICU RN and ICU Physician said although Resident #1 had been responding better to treatment, he still may not recover from his injuries. They said he was still non-responsive. The ICU Physician said EMTs brought Resident #1 to the hospital with a 106.5-degree F temperature. He said that puts the body in sever shock. They said it was their understanding that Resident #1 was found on the pavement and had been there for an unknown amount of time. This survey informed them of eyewitness accounts that Resident #1 was not on the ground while outside. The ICU Physician stated the burns could be cause from blistering caused when they placed cold towels and ice on Resident #1 to cool him down. He said it would be similar to frost bite and skin would come off. The ICU Physician said Resident #1 had a lot of underlying comorbidities and this incident amplified them. A telephone call to LVN V on 05/31/2024 at 1:25 PM revealed no response. A telephone call to LVN E on 05/31/2024 at 1:30 PM revealed no response. In an interview on 05/31/2024 at 2:14 PM, the Medical Director said he was aware that Resident #1 was found unresponsive on the patio. He said the ED called to discuss the burn marks reported by the hospital. He said they were likely from blistering which occurred when staff and EMTs placed cold towels and ice on Resident #1 to cool him. He said he could have got the burns from being outside for an extended period of time, but that time period was different for everyone. He said Resident #1 has a right to go outside but the facility was responsible to ensure his choice to do so was safe. The MD said Resident #1's labs completed on 04/12/2024 were normal. He said a chest x-ray was completed on 04/09/2024 and had no issues noted. In an interview on 05/31/2024 at 2:50 PM, the DON stated, she understood the failed to supervise and ensure Resident #1 was safe from hazards when he sat on the facility's patio in 92-degree heat for at approximately 1 3/4 - 2 hours. She stated there was no documentation that staff intervene in ensuring he came into the facility or that he was offered hydration. She stated the POR addressed the expectations on staff to ensure residents were safe in all weather conditions. Record review of the Accuweather website: https://www.accuweather.com/en/us/[NAME]/76248/may-weather/340873?year=2024 reflected the actual high temperature on 05/26/2024 was 96 degrees F. Record review of the facility's policy, titled, Care plans - comprehensive person-centered, revised March 2022, reflected, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . The Executive Director, DON and Regional Director of Clinical Services were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 05/30/2024 at 6:16 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 05/31/2024 at 2:50 PM and included: Assessment: The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 05/30/2024 at 7:00 p.m. An emergency QAPI meeting was held on 5/26/2024. All residents will have an audit completed to determine if they are at risk of being outside alone during unfavorable weather conditions. This will include determination of the desire for the residents to go outside and the decision-making capacity to be alone outside if weather conditions are unfavorable. This will be completed by the Director of Nurses, Assistant Director of Nurses, Social Worker, and/or Patient Care Coordinators on 5/31/2024. This will be used to identify any current patients that are at imminent risk for heat stroke due to extended time outside and related to their medical conditions. After completion of the resident audits, no other residents were found to be at imminent risk of being alone outside in unfavorable weather conditions. Who will be responsible: Nurse Managers. Who Will monitor: Executive Director and Regional Director of Clinical Services (RDCS). Beginning 5/31/2024, Resident audits will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that is identified as wanting to be outside in unfavorable weather conditions. For any resident that identifies they would like to be outside, the weather conditions, their cognitive ability and physical ability will be reviewed by the charge nurse to determine the safety of the resident. If there is a safety concern and the weather conditions are unfavorable, Nursing is to assess if the weather conditions are safe for resident exposure a staff member or family member will remain with the resident while outside to ensure no adverse outcomes occur. Staff will be required to monitor with ongoing 15-minute checks for any resident who chooses to go outside in unfavorable weather conditions. The facility staff will progressively monitor the resident with 15-minute checks and if the resident is deemed in imminent danger the staff will also call 911. If a resident chooses to remain outside under unfavorable weather conditions despite attempts to coerce the resident to return inside, the staff will notify the DON and the ED and follow the plan of care including the following: Explain/Educate resident/family when times and conditions are appropriate and safe for resident exposure Staff to ensure that the resident is dressed appropriately for the weather Staff to round frequently to offer/assist with hydration, nutrition Staff to round frequently to offer/provide ADL assist (positioning, toileting .) Confer with MD about a prn order for sunscreen When weather not permitted, offer alternative activities of resident's preferences Nursing to assess for any psychological, social, behavioral changes and document and follow up prn. Staff to provide level of supervision appropriate for resident The DON will monitor for compliance daily by receiving report from the charge nurses for any resident deemed unsafe to be outside alone that requests to be outside. Audits will be completed weekly for 3 months until 8/31/2024 and then monthly on an ongoing basis by the Executive Director. Who will be responsible: Charge Nurses. Who Will monitor: Director of Nursing and Executive Director. All staff were educated to notify the Executive Director, Director of Nursing or nursing management immediately when any resident goes outside in unfavorable weather conditions and to remain with the resident until further notice or the resident agrees to return inside the facility. This education was provided on 5/31/2024. This education was provided by the Director of Nursing and Assistant Director of Nursing. Staff will not be allowed to begin their shift until the education has been completed. Who will be responsible: Nurse Managers. Who Will monitor: Executive Director and RDCS. In-Services: All staff were in-serviced on residents going outside unsupervised during unfavorable weather conditions by the Director of Nursing and/or Nurse Managers. The ED and DON were educated by the RDCS on all in-service topics related to the IJ. All new clinical staff will receive the in services as part of the onboarding orientation process prior to being assigned and providing care to residents. All staff will be in-serviced on neglect, documenting behaviors, rounding and increased communication. No staff member will be allowed to work in the facility until the above required in-services are completed. The in-services with all staff will be completed by 5/31/2024. All staff were in-serviced by 8 am on 5/31/2024. Who will be responsible: Nurse Managers. Who Will monitor: Executive Director and RDCS. Monitoring: Starting 5/31/24 Director of nursing and/or Nurse Managers will review the 24-hour report for any incident of residents being outside during unfavorable weather conditions, each day for 4 weeks week, then weekly for 4 weeks. The Executive Director will review the documentation each week for compliance. Beginning 5/31/2024 no staff will be allowed to work until the required in servicing has been completed. Should Resident A return to the facility, he will not be allowed outside without supervision. Quality: Starting 5/31/2024 and ongoing monthly all concerns regarding adequately supervising residents will be taken to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. The Executive Director will monitor for compliance. Starting 5/31/2024 and ongoing monthly the Regional Director of Clinical Services and/or designee will monitor weekly to ensure compliance for four weeks and will review at the next Quality assurance meeting. On 05/31/2024 at 2:50 PM the surveyor began monitoring the facility's Plan of Removal. Interviews on 05/31/2024 between 3:00 PM and 4:00 PM with ADONs T and U, PTA H, OTA I, Housekeeper F and G, LVNs C and L, RNs O and P, and CNAs M, N, R, S, Maintenance Director, Social Worker, and Activities Director reflected staff representing 1st, 2nd, and 3rd shifts and all days of the week. Staff were able to convey appropriate knowledge of the POR inservice's including the identification of adverse weather exposure impacts on residents and care plans and interventions required address behavior changes and to ensure their safety in any weather conditions. They demonstrated knowledge of documenting behaviors, strategies to address behaviors and notifying the DON, MD, and family members, when residents were non-compliant with interventions meant to ensure their safety. All staff stated the DON and nurse managers would monitor these actions. In an interview on 05/31/2024 at 2:50 PM, the DON stated, she understood the failed to supervise and ensure Resident #1 was safe from hazards when he sat on the facility's patio in 92-degree heat for at approximately 1 3/4 - 2 hours. She stated there was no documentation that staff intervene in ensuring he came into the facility or that he was offered hydration. She said she was also interview in writing comprehensive care plans that addressed specific resident behaviors, interventions, and tracking them. She stated the in-services were done by the Regional Director of Clinical Services and she, in turn in-serviced facility staff in all departments. She stated in-servicing would be ongoing until all facility staff had completed training. In an interview on 05/31/2024 at 2:40 PM, the Executive Director stated she and the DON, had been in-serviced on weather condition safety for all residents, by the Regional Director of Clinical Services. She stated all facility staff were educated on communication and notification of nursing staff regarding resident behaviors that may pose a risk of harm to them. She said she completed an audit of residents who were at risk of harm based on their behaviors and propensity to be outside. She said in-services were provided to nursing staff on comprehensive care planning to address specific behaviors in residents and provide specific strategies to ensure their safety. She said these will be monitored by the DON through assessment reports and nursing communication records. She said she would monitor this through the IDT and QUPI process. She stated in-servicing would be ongoing until all facility staff had completed training. Record review of the facility's in-service record addressed to nurses, dated 05/30/2024, and titled, Documentation of Behaviors, included the following topics. All services provided to the resident, or any changes in the resident's medical or mental condition, and behaviors shall be documented in the resident's medical record. A behavior is the way a person acts in response to a particular situation or event. Behaviors include but are not limited to: Going outside daily, yelling, repeating themselves, etc.6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided. b. The name and title of the individual(s) who provided the care. c. The assessment data and/or any unusual findings obtained during the procedure/treatment. d. How the resident tolerated the procedure/treatment. e. Whether the resident refused the procedure/treatment. f. Notification of family, physician, or other staff, if indicated. g. The signature and title of the individual documenting. Record review of the facility's in-service record addressed to CNAs, dated 05/30/2024, and titled, Documentation of Behaviors, included the following topics. All services provided to the resident, or any changes in the resident's medical or mental condition, and behaviors shall be documented in the resident's medical record. A behavior is the way a person acts in response to a particular situation or event. Behaviors include but are not limited to going outside daily, yelling, repeating themselves, etc. C.N.A. documentation should include factual documentation, needs and conditions of the resident, on-going, and all observations made by care staff. What should be documented: 1. Documenting Activities of Daily Living (ADL's) that are outlined in each resident's care plan. 2. Any other activities in which assistance is provided. 3. Useful information that the family provides about the resident. 4: Any refusal of assistance by the resident. Observations that are made regarding the resident (examples: chilling, sweating, pain, heat, redness, swelling, coughing, skin changes, change in color of lips or nails, and mental status, etc). The C.N.A. is to communicate any observations regarding the resident to their nurse, and the nurse is to document and assess the resident. The nurse then notifies the appropriate individuals such as the responsible party, physician, etc Record review of the facility's resident risk audit addressing the following criteria: Behavior of seeking to go outside; physical ability to go outside without assistance; and poor judgement or safety awareness identified 27 residents. Care plans were updated for these residents. An Immediate Jeopardy (IJ) was identified on 05/30/2024. While the IJ was removed on 05/31/2024 at 2:50 PM, 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 plan of removal.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. The faciltiy failed to provide Resident #1, who had cognitive impairment and unsteady gait with a history of attempting to get up from her wheelchair unassisted, adequate supervision to prevent her falling. The resident was left alone in her room, and she fell sustaining lacerations to multiple sites on her scalp and neck and an injury to her wrist, which required the resident to be sent to the hospital where she received six staples to the back of her scalp, two staples on the left side of her scalp, and a brace to her wrist for a contusion. This failure could place residents at risk for serious injuries or harm, decline in health, and decreased quality of life. Findings included: Review of Resident #1's MDS dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebrovascular accident (stroke) and anxiety. The resident had long- and short-term memory and her daily decision making was severely impaired. Resident #1 used a wheelchair for mobility. Resident #1's most recent care plan printed on 04/16/24 reflected she was at risk for falls due to cognitive impairment and unsteady gait. Approaches included to anticipate needs and provide prompt assistance, encourage socialization, fall identifiers in place, keep bed in lowest position, move resident closer to the nurse's station, and keep Dycem (a sticky non-slip rubber that can be placed to stabilize objects) in the wheelchair. The care plan further indicated Resident #1 was on hospice services due to her diagnosis of dementia. Review of the facility's Provider Investigation Report dated 04/01/24 revealed Resident #1 was found on the floor and upon assessment was noted with open area to her head, so she was sent to the ER for evaluation and treatment. Resident #1 returned from the hospital with six staples to the back of the scalp, two staples on the left side of her scalp, and a brace to her wrist where she sustained a contusion. Review of Resident #1's nurses notes dated 04/01/24 documented by LVN A revealed the following: CNA called nurse to patient room noticed patient on the floor on the side of the bed head to toe assessment done observed an open area on patient head DON, NP, and RP, notified call placed to 911 patient to sent to [hospital] for further evaluation hospice nurse notified. Review of Resident #1's hospital records dated 04/01/24 reflected the resident had a fall and was diagnosed with laceration of multiple sites of scalp and neck with stitches or staples. Resident #1 could not be observed as she had been discharged to another facility with a secure unit. Interview on 04/16/24 at 10:52 AM with LVN A revealed Resident #1 was on hospice services and a hospice aide would come in daily and provide care. LVN A said Resident #1 moved around in her wheelchair, and staff tried to keep her at the nurse's station because the resident would try to get up and walk. LVN A said the day of the incident, 04/01/24, the hospice aide had come in to provide the resident care and the hospice aide had left her in her room alone where the aide had later found her on the floor. The LVN was on her break and was not at the nurse's station while the hospice aide cared for the resident or when the hospice aide left. Once the LVN was alerted that Resident #1 was on the floor, she went to assess her and noticed an open area to the left side of her head, so she called 911. The resident was complaining of pain but was not able to verbalize what happened. LVN A further stated it was the same hospice aide that cared for the resident and the aide knew Resident #1 was a fall risk. She stated she should have taken the resident back to the nurse's station instead of leaving her in the room alone. LVN A also said because she was on her break, she was not able to tell the hospice aide to take the resident back to the nurse's station . Interview on 04/16/24 at 3:43 PM with CNA B revealed she was on her way to her lunch break when she saw the Hospice Aide giving Resident #1 a shower. She stated when she was returned from lunch, she noticed the resident was on the floor of her room. CNA B called LVN A for assistance, and they noticed Resident #1 was bleeding. CNA B said Resident #1 was a fall risk and staff tried to keep her at the nurses' station, so they could keep an eye on her, but it appeared that the Hospice Aide left the resident unattended in the room. The CNA B said she did not know when the Hospice aide left after giving Resident #1 a shower. CNA B said there were some residents that had a red bracelet on the back of their wheelchairs and that meant those residents needed to be monitored more closely, as the bracelet indicated they were a fall risk, and Resident #1 had one on her chair. Attempts to contact the hospice aide on 04/16/24 were unsuccessful. Interview on 04/16/24 at 2:49 PM with LVN C revealed Resident #1 was very confused and required frequent redirection because she attempted to stand up from her wheelchair., Therefore the resident was kept at the nurse's station because she was a high fall risk. Resident #1 thought her wheelchair was a bicycle because she would move about with her feet and stated she was going to ride it home. LVN C further stated Resident #1 was on their high risk fall program and they kept a red bracelet on her wheelchair. This meant that resident had to be monitored more closely to ensure the residents were safe . Interview on 04/16/24 at 2:23 PM with the ADON revealed Resident #1 was put on their high fall risk program because of her confusion but was easily redirected. There was a green leaf placed on her door and a red bracelet on the back of the wheelchair to remind staff the resident needed to be monitored more closely. They kept Resident #1 at the nurse's station most of the time to monitor her more closely. The ADON was made aware of Resident #1's fall and the resident was sent to the hospital and returned with some staples to the back of her head and a brace to her wrist . Interview on 04/16/24 at 3:49 PM with the hospice RN revealed they had been made aware of Resident #1's fall and injury. The RN stated when she visited Resident #1, she was usually in her wheelchair in the hallway. The RN would take her to her room to assess her and usually take her back to where she had found her. They were aware the resident was a high fall risk because of her poor safety awareness. The RN did not know the rest of the details regarding Resident #1's fall. Interview on 04/17/24 at 11:15 AM with the DON revealed Resident #1 had a history of being very independent and did not want anyone helping her. The DON stated they were doing everything they could to maintain her dignity and pride while trying to keep her safe at the same time. Resident #1 was very mobile in her wheelchair and always sat in the cafe across the nurse's station and would also wander the halls. The DON was never notified the hospice aide had been caring for Resident #1 prior to the resident's fall. The DON further stated they could not hold Resident #1 to a certain area because she was always moving around. Resident #1 required moderate supervision which meant staff should have been checking on the resident more often as the resident was a high fall risk . Interview on 04/16/24 at 6:04 PM with the Administrator revealed they could not say if Resident #1 had indeed been left in her room alone because the resident was able to self-propel her wheelchair and who was to know if she did not take herself back there after she had been cared for. The Administrator further stated she was not aware if the hospice aide had indeed taken care of the resident the day of the incident, 04/01/24. The Administrator said Resident #1 had been discharged to another facility with a secure unit so she could be monitored more closely in a smaller environment . Review of the facility's policy titled Fall Management Guidelines dated 11/2022 reflected the following: .2. A Fall Risk Assessment will be initiated for each Patient upon admission, re-admission, quarterly, upon significant change in a Patient's condition or after a fall. The Fall Risk Assessment score will be used in conjunction with clinical judgement and review of risk factors determining a Patient's risk for falls. .9. Staff assigned to the units will conduct rounds for residents at risk for falls or who have experienced a fall to ensure their fall prevention interventions are implemented.

Based on interviews and record reviews the facility failed to ensure residents were free from significant medication errors for 2 of 3 residents (Resident #1 and Resident #2) reviewed for administration of medications. LVN B failed to ensure she administered medications to the correct resident. LVN B administered Resident #2's medications ([MEDICATION(S)] 25mg, [MEDICATION(S)] 600mg, [MEDICATION(S)] 2mg, Tylenol-[MEDICATION(S)] #3 300 mg-30 mg, Omeprazole 20 mg, [MEDICATION(S)] 5mg, acetaminophen 325mg) to Resident #1 on 04/15/22 in addition to the resident receiving her own medications that same morning. Resident #1 had nausea and vomiting and was admitted to the hospital for accidental overdose for several days. On 04/21/22 at 04:11 pm an actual harm that is not immediate jeopardy was identified. While the IJ was removed on 04/22/22 the facility remained out of compliance at a severity level of actual 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 requiring assistance with medication administration at risk for adverse effects and/or it may have resulted in subsequent medication errors. Findings Included: Review of Resident #1's face sheet, dated 04/15/22, indicated Resident #1 was an 87-old-female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged to an emergency department of an acute care hospital on 04/15/22. Review of Resident #1's MDS, dated [DATE], indicated Resident #1 scored a 15 on a Brief Interview for Mental Status test indicating the resident's mental status was determined to be intact in cognitive response cognition. Review of Resident #1's care plan, dated 04/15/22, indicated Resident #1 had the potential for side effects related to [CONDITION(S)] medications and use of anti- psychotics. It also revealed pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] XL (treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] (treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] (antihistamine) 180 mg tablet, 1 tablet, 1 time a day as needed for allergies. [MEDICATION(S)] (antidepressant) 20 mg tablet, 1 time a day. [MEDICATION(S)] (antidepressant) 15 mg tablet, 1 time, 1 time a day. [MEDICATION(S)] (lowers cholesterol) 10 mg tablet, 1 time a day. Aspirin (blood thinner) 81 mg tablet, 1 time a day. [MEDICATION(S)] (lowers blood pressure), 10 mg tablet, 1 time a day. [MEDICATION(S)] (treats heartburn) 40 mg capsule, 1 time a day; and Acetaminophen (pain reliever) 325 mg tablet, 2 tablets every 4 hours as needed for pain. Review of Resident #2's face sheet, dated 04/22/22, indicated Resident #2 was a 77-old-female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS, dated [DATE], indicated Resident #2 scored an 11 on a Brief Interview for Mental Status test indicating she had moderate impairment cognition, required supervision in walking, eating and assistance in bed mobility, transfer, dressing, toilet use and personal hygiene. Review of Resident #2's care plan, dated 03/29/22, indicated Resident #2 had the potential for side effects related to [CONDITION(S)] medications and use of anti- psychotics. Also, she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff were to administer medications as ordered, monitor and record side effects of medication, notify the physician and family as needed regarding concerns. She was a fall risk due to the use of anti-anxiety and anti-depressant medications; unsteady gait and balance, generalized weakness and poor safety awareness. Record review of Resident #2's consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (lowers blood pressure) 25mg tablet, 1 time a day. [MEDICATION(S)] (to relieve nerve pain)600 mg tablet, 1 time a day. [MEDICATION(S)] (for [CONDITION(S)]) 2 mg tablet, 1 time a day. Tylenol 3 (for pain)300 mg, 2 tablets; 2 times a day [MEDICATION(S)] (Blood thinner) 5 mg tablet, 1 time a day; and Tylenol (for pain) 325 mg tablet, 2 tablets, as needed. Review of Resident #1's hospital records, dated 04/15/22 at 8:00 p.m., indicated Resident #1 was brought to the emergency department for onset of a medication administration error. The document reflected the patient (Resident #1) was accidently given the wrong medication earlier on this day. The medications belonged to [Resident #2] and were the following, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Tylenol 3, omeprazole, [MEDICATION(S)], and Tylenol. The error caused the patient (Resident #1) to develop nausea and vomiting, become very sleepy prompting the family to call emergency services to transfer her to the emergency room . Resident #1 was admitted to the hospital for observation. Review of Resident #1's hospital plan of care after admission to the hospital dated 04/15/22 included holding aspirin due to high levels of anticoagulant (blood thinner) medicine detected in Resident #1's lab work. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders reflected for more lab work to be performed to check Resident #1's liver function, as well as, monitoring her blood pressure readings. Review of Resident #1's hospital records, dated 04/18/22, revealed a progress note written by Care Transition Manager F reflecting she spoke to Resident #1 at bedside and Resident #1's family member on the speakerphone. Resident #1's family member said Resident #1 would not be returning to the skilled nursing facility and she would accept the attending doctor's recommendation. Review of Resident #1's hospital record, dated 04/19/22, revealed Attending Doctor G stated, Resident is weaker, and below baseline, Plan to D/C (discharge) to SNU (skilled nursing facility). During an interview on 04/16/22 at 11:25 a.m. with LVN A revealed the DON told her that on the morning of 04/15/22 am she had a nurse call in sick, so the DON asked LVN A to take over medication administration for the off going night shift nurse. When LVN A came into the facility that morning, she began passing medications on the 600 halls. LVN A said around 8:30 a.m. an agency nurse, LVN B, met her on the 600 hall and informed her that she was there to relieve LVN A and would begin passing medications and caring for the residents herself. LVN A said she told LVN B that she had given medications to 4 residents in rooms 618, 617, 616 (Resident #1), and 615. LVN A said she gave verbal instructions to LVN B to begin administering medications to the rest of the residents on the 600 hall and LVN A said she went off with her own duties as the staffing coordinator. She denied orientating LVN B to the floor or the residents whom she was going to care for the rest of the 8-hour shift and said that the DON told her that LVN B had worked in the facility before and thought she could orientate herself. LVN A said, she went to lunch with the DON when a call came in from LVN B to the DON's cell phone and she informed the DON of nausea and vomiting experienced by Resident #1. LVN A said the DON informed LVN B she was returning to the facility soon. LVN A stated that after the phone call with the DON and LVN B she remembered a conversation she had previously to going to lunch with LVN B, she said, It was right before I went lunch, and then [LVN B] told me she had been looking for me, it was around 11:30 a.m., and she asked if me if [Resident #1] was one of the persons that I gave medications to and I said yes. So, I asked [LVN B] if [Resident #1] was okay, and [LVN B] said the resident was nauseated. So, I told her to go assess the resident again and she said she had done so already, and so I said, then call the doctor and then I went to lunch. LVN A was asked if she had told the DON about the conversation, she had with LVN B regarding Resident #1 and she said, The DON had told me that she assessed the resident herself, so I thought it had been taken care of. LVN A said while she was in the car with the DON, she began to think that LVN B might have given medications to Resident #1 by mistake but said she was not sure. LVN A said when she returned from lunch, she approached the 600 hall and noticed family was in Resident #1's room. She said, I went to [Resident #1's] room, and saw the [family member] was there and said that [Resident #1] told her [family member] that another nurse had given her a second cup of morning medications while she was in the physical therapy gym, and she (LVN A) told the [family member] that it had not been her, and [Resident #1's] [family member] said she knew that, that [Resident #1] said it was another nurse with a different name. LVN A said there was a lot of confusion at the time, and emergency medical personnel walked in the room and began to ask about medications and the name of LVN B, then the DON arrived in the room and LVN A said she left the room, to take over LVN B's responsibilities. She said the DON told her (LVN A) to take over the medication cart assigned to LVN B because she was to get off the floor and not provide any more resident care. Review of LVN B's nursing note dated 04/15/2022 at 01:02 pm relating to Resident #1's condition, she wrote, around noon CNA E notified this nurse that resident was complaining of nausea and vomiting Resident was safely transferred to bed from wheelchair and assessed, her vital signs were taken, and family was present at this time. Her vitals were: 109/59, p62, 94% r 18 oxygen saturation temp 98.0. [MEDICATION(S)] 4 mg was administered. LVN A had administered [MEDICATION(S)] 4 mg (for nausea) and then wrote, Around 1:20 pm, EMS arrived at resident room and took resident to the hospital at the request of family. Interview on 04/16/22 at 11:15 am with Resident #2, resident was sitting in her wheel chair in her room, she was asked whether she had received her medications the previous morning, she looked confused, said that the DON had come to her room on the evening of 04/15/22 and asked her the same question, she asked the surveyor if there was a problem, she was assured that there was not, and was asked again if she had received her morning medications the previous morning and she stated yes. Resident#2 if it there was a possibility that she might have forgotten and not received the medications, she said no, she had taken her morning medications. Interview on 04/21/22 at 12:35 pm with DON regarding whether Resident #2 had received her morning medications on 04/15/22 and the DON said she spoke to Resident #2 who told her that she was given her morning medications, but was told by LVN B that she gave Resident #1 the medications that belonged to Resident #2, so she said there was confusion and it was hard to know if Resident #2 had received her medications on 04/15/22, she said the doctor was notified and the family was called. An Observation on 04/15/22 at 12:25 pm of medication administration for Resident #4 by RN G provided [MEDICATION(S)] tab 50 mg (pain medication) and 20 units of [MEDICATION(S)] insulin injected on Resident #4's on right side of the abdomen. Record review of LVN A's statement, dated 04/15/22, provided an account of the beginning of the shift for that day. The statement reflected LVN A she began to work at 6:15 a.m. She went to Resident #1's room and the resident was up in her wheelchair, alert and oriented. LVN A noted the presence of Occupational Technologist C, reflecting, A therapy lady was in there talking to her as well. I took her blood pressure and then went to pull her meds. She took all of her meds and then I went back to the computer and signed them out. LVN A's statement reflected LVN B came to relieve her around 8:15 a.m. and she told LVN B the medications that she had given were signed out in the computer. Telephone interview on 04/16/22 at 1:00 p.m. with Occupational Therapist C, she stated Resident #1 was getting ready to exercise the morning of 04/15/22 around 8:30 a.m. and had to wait for LVN A to bring morning medications to her. Occupational Therapist C said LVN A brought in a medication cup full of medications and gave the cup to Resident #1 who took all the medications with water. Occupational Therapist C said she took Resident #1 to the physical therapy gym and helped with the exercise regimen and after the exercises Resident #1 was turned over to the physical therapy staff. Occupational Therapist C said later in the day around 12:00 p.m. on Resident #1's family member came into the gym looking for her and said, What happened to my mom? She sounded like she had a stroke, and OT C told her she had no idea what she meant. Occupational Therapist C said, It was not until I spoke to [Physical Therapy D], did we realize of the double dose given to Resident #1 by two different nurses. We decided to go inform the Administrator when we realized the error. Record review of Occupational Therapy C's statement, dated 04/16/22, given via e-mail at 12:48 p.m. to the Administrator's email revealed, OT C had picked up Resident #1 from her room after OT C observed her taking morning medications. OT C worked with Resident #1 for 30 minutes after which Physical Therapy began to continue with the therapy session. Telephone interview on 4/16/22 at 1:15 p.m. with Physical Therapist D, she said she worked with Resident #1 on 04/15/22. She said, I was with her in the gym, and it was close to 9:00 a.m. We were doing leg exercises, so then a nurse who I don't know came around 9:30 a.m. into the gym and brought medications in a cup, and [LVN B] asked [Resident #1] if she was [Resident #2], and [Resident #1] said yes, and then told [LVN B] that she had already taken them that morning, and [LVN B] told [Resident #1] that she would go double check and left the gym. PT D said LVN B returned and said to Resident #1, You have not taken your morning medications. I just took your blood pressure and did not give you the pills. PT D said Resident #1 did not look confused and took the medications given to her by LVN B. PT D said 04/15/22 was the first time she had worked with Resident #1 and was not very familiar with the resident. PT D said she asked LVN B if she meant to give Resident #1 the medications, telling LVN B that Resident #1's room number was 616, and LVN B said yes, she had the correct resident. PT D said she finished working with Resident #1 and took her back to room [ROOM NUMBER] around 11:00 am, set her up in a chair, heated up her breakfast and gave Resident #1 the call light and PT D said Resident #1 had no complaints of nausea or vomiting. Record review of Physical Therapy D's statement, dated 04/15/22, given via email at 2:32 p.m. to the Administrator's email revealed, PT D reported Resident #1 answered to the name voiced by LVN B, and was given a cup with medications and Resident #1 took all the medications contained in the cup. Interview on 04/16/22 at 11:00 a.m. with the DON revealed the morning of 04/15/22 the facility was short staffed for one nurse, so the DON called LVN A to come in and help by filling in on the floor and providing patient care. The DON said LVN A began administering the residents morning medications on the 600 hall, then the DON said she received a staff agency nurse, LVN B, and then both LVN A and LVN B counted the medications in the cart so that LVN B could take over the patient care. She said as far as she knew LVN A orientated LVN B to which rooms she had already given medications to and to which residents. The DON said around 11:15 a.m. she received a call from Resident #1's family member with concerns that Resident #1 was telling him she was dizzy, and that Resident #1 sounded drunk. The DON said the family member asked if she could go in Resident #1's room and assess her and take some vital signs. The DON said Resident #1's blood pressure was low, but not significantly so. She was asked what the normal blood pressure reading was, and she said based on her nursing education she believed a good blood pressure reading could range from110-120 over 70-80. The DON said she took the vital signs and assessed Resident #1 and told the resident she had been drained from working with physical therapy and informed Resident #1's spouse who was in the room. The DON said that she went off to pick up her lunch. She said while she was waiting in line for her food, she said Resident #1's family member called her again and told her the resident had said two different nurses gave her morning medications, and the family member told her (the DON) that Resident #1 might have gotten medications twice. The DON said the family member was assured that she was returning to the facility to sort out the problem She said after hanging up with the family member she called LVN B and asked her point blank if she had given Resident #1 a double dose of morning medications and the nurse said yes. The DON said when she returned to the facility which was close to 1:00 p.m. she noticed that an emergency medical ambulance was parked by the front door. The DON admitted that she did not record any of the phone calls she had LVN B, saying that she only documented a note on 04/15/2022 at 12:30 pm, writing that the DON had received a notification from the receptionist that said to assess Resident #1 and return call to her son. She wrote, Upon assessment, resident lying on her right side in her bed with husband at bedside. Resident interviewed and able to provide that she was feeling dizzy and nauseous. She stated she had gone to therapy and felt fine, then upon return she started feeling off. The DON wrote she took Resident #1's vital signs and then called the son to give him the information. The DON said she assured the son that Resident #1 was just tired from the therapy session and finished the note by writing, Discussed the DON would re-assess the resident after eating lunch. The DON said that after Resident #1 was sent to the hospital, she began an in-service education regarding the 7 rights of medication administration for nursing staff, record review of the attendance sheets that is undated reveals a total of 13 nursing staff members who participated. The DON was asked for the date of the participation of these nurses, and she said they all were in serviced on 04/15/22 and said that they would begin to have medication pass observations. Record review of an undated Facility licensed nurses and certified medication aids list revealed there are a total of 33 nursing staff who can administer resident medications. The list was provided by the administrator on 04/21/22 and compared with the medication pass observation sign off sheet, it is evident that not all staff employed by the facility had been checked off for proper medication administration. Interview on 04/16/22 at 11:50 a.m. with the Administrator revealed she was aware of the allegations of a possible medication error that had allegedly occurred on 04/15/22. She said initially two physical therapists came to her approximately at 12:00 pm and told her about what they had witnessed happened to Resident #1. The Administrator said that Occupational Therapist C and Physical Therapist D told her they were worried about the resident and a report they received from the family member of change of condition noticed by Resident #1's other family member. The Administration said the therapists suspected that Resident #1 had been double dosed. The Administrator said OT C told her one of Resident #1's family members came into the gym looking for her and asked what happened to Resident #1; she sounded like she had a stroke. The Administrator said she immediately called the DON around 12:30 pm who informed her that she was contacted by another one of Resident #1's family members who asked her to assess the resident because the family was concerned about the resident's health condition, and the DON told the Administrator that Resident #1's vitals were good, and she said, And I felt that at the time the resident was okay. The Administrator said she told the DON about what the therapists said they witnessed about the double dose and the DON said she had questioned LVN B, and the nurse denied giving Resident #1 morning medications. The Administrator said then when the ambulance arrived at the facility, the DON told the Administrator that LVN B told the DON that she had given Resident #1 another resident's medications, the medications belonging to Resident #2. The Administrator said the DON told her that she called Resident #1's family member and he became angry with her, and the family member told the DON that the family had called 911 because they wanted Resident #1 checked at the emergency room . The Administrator was asked if she knew if Resident #2 had received her morning medications and she denied knowing that information but said the DON had asked Resident #2 if she had taken any medications that morning and the resident said yes, she had received her morning medications. The Administrator said, It is impossible to know if [Resident #1] received [Resident #2's] medications, but I Immediately removed [LVN B] from the floor and made sure both [Resident #1] and [Resident #2's] medication list was given to the emergency medical staff. I then notified the temporary agency about the medication error and flagged [LVN B] not to return to the facility. The administrator said she called the temporary nursing agency on 04/15/22 and informed them that LVN B administered medications in error and caused a resident to be sent to the emergency room , and that LVN B was banned from returning to the facility. Interview on 04/18/22 at 3:00 p.m. with LVN B, she stated she arrived at the facility on 04/15/22 around 8:30 a.m. She said, So I went to the hall 600 and spoke to [LVN A]. I was going to take over for her 6 [AM]-2 [PM] shift, and she said LVN A told her she had given medications to the first four rooms on the 600 hall and that she should start at room [ROOM NUMBER] and back to 604. She said, So that is the report she gave me. She did not give me people's names, just room numbers. LVN B said she opened the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #2's] room, but she was not in the room. She said, I looked out for her down the hall but did not see her. I thought she might be in the gym, so I took the medication cup, and I went to the physical therapy gym, and looked to see if she is in there. She said based on Resident #2's picture, I thought the only resident that was in the gym was [Resident #2]. LVN B said she called out Resident #2's name and the resident in the gym acknowledged, and LVN B said she was not aware that this was a different resident at the time and approached Resident #1 who was working with PT D. LVN B said, I told [Resident #1] that she had medications to take, and the resident told me that she had already taken her morning medications. LVN B said she told Resident #1 he would check with LVN A if she had given the medications and left the gym. LVN B said she found LVN A and asked her if she had given morning medications to Resident #2, and LVN A told her that she had not given Resident #2 medications, and LVN B said, Based on the confirmation that I received from [LVN A], I went back to the gym and gave [Resident #1] medications believing it was [Resident #2]. LVN B said, After I finished giving medications, I went to the nurse's station to chart and around noon CNA G told her the resident in room [ROOM NUMBER] (Resident #1) was complaining of nausea, and said, So I went and assessed the resident. [Resident #1] complained of nausea and I still did not become aware of the medication error. I went and got some medication for her for nausea, and I put her in bed. LVN B said, I went back to charting; about 20 minutes later I went back to room [ROOM NUMBER], [Resident #1's] room and her [family member] was in the room. [Resident #1] was vomiting, and the [family member] told me that [Resident #1], [Resident #1's name], told her that two different nurses gave her medications in the morning. LVN B said, That is when I realized that she was the resident in the therapy gym, and that I had not recognized her at first because she was wearing a mask in the therapy gym and that I had medicated the wrong person. LVN B said she called the doctor, spoke to the nurse practitioner, and informed her about the double dose, error of administration. LVN B said that at 01:25 pm she had told the DON that she noticed that she gave the wrong patient medications due to an identification error. LVN B said the doctor gave an order to call 911. She said, But the family had called themselves. I notified the DON and emergency medical staff asked for the paperwork of the meds I had given [Resident #1]. I was ordered to sit in the DON's office. LVN B said that Complainant #3 came to ask her which were the medications she had given Resident #1, and that at the time LVN B felt very confused and told Complainant #3 that she would need to speak to the DON and LVN A to help with a list of the medications and left him to look for the nursing staff. After providing the Complainant #3 with a list of both the residents medications, Resident # 1, and Resident #2, she left the facility after giving the DON them a statement of the error around 03:00 pm. LVN B said, I was also educated on the 7 rights of giving medications by the DON. I am not sure exactly what I gave [Resident #1]; I was very confused and provided [Resident #2's] medication orders to see if the hospital could figure out what was given with the help of blood labs. LVN B denies knowing that the DON had assessed Resident #1 at the request of family concerns that the resident appeared to have had a change in condition. Interview on 04/21/22 at 5:05 p.m. with facility's Medical Director, she said, I am aware regarding the resident was given the medications for both of the residents, (named Resident #1 and Resident #2). She said her nurse practitioner told her LVN B had made a medication administration error. She was asked what the risks for as elderly person were if they received the types of medications that were listed on the emergency departments admission record and she said anyone who would receive that number of medications would have nausea and vomiting and other risks could be experiencing low or high blood pressure, and serious allergic reactions. She said, A person given a mixture of antidepressants, antipsychotics, blood pressure medications to raise or lower blood pressure and narcotics and they are not used to taking these types of medications could suffer from dizziness, drowsiness, heart rhythm problems, have an allergic reaction. She said, We just don't know, but the best thing for the resident was to go to the emergency room . She said the potential for death was difficult to assess and the adverse effects were different for all persons, and in this case, observation was the best thing to do to guard the resident's safety. She said, She had to go to the ER, at the facility it is not possible to do any procedures as soon as possible, in the hospital they can perform x-ray, labs and provide intravenous fluids. A review of the facility's policy on medication, dated 12/2017, reflected: A medication error occurs when a medication is administered in any manner that is inconsistent with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . rights of administering medication as right person, medication, route, time and dose, frequency, and documentation. On 04/21/22 at 5:30p.m. the Administrator and DON were notified an Immediate Threat was identified and a Plan of Removal was requested. The facility Administrator and the DON were notified on 04/22/22 at 4:50 pm. the Plan of Removal was accepted. An Immediate Jeopardy Plan of Removal dated 04/21/22 stated that facility Director of Nursing (DON) initiated an audit on 04/15/22 verifying residents' charts contained the correct identification for medication administration to include pictures and names of the residents. On 04/15/22 the DON began verifying licensed nursing staff listing for full time, part time and PRN nurses and medication aides to ensure education/in-servicing to be completed prior to working their next shift. The in-service subject matter reviewed was 7 Rights of Medication Administration, and the completed lists would be maintained by the abuse coordinator, the Administrator. Medication Pass observation audits for all staff who administer medications in the facility were started on 04/19/22, and the plan stated the skills checkoffs would be completed for all licensed nursing staff and medication aides by 12pm on 4/22/2022, except for one LVN (LVN AA), who was currently out of the country, and the DON would ensure LVN AA is educated on the 7 rights of medication administration and compliant with medication pass observation check off upon her return. The DON will conduct in-service training monthly for the next 30 days on the following topics: The additional training will cover 7 Rights of Medication Administration and observations of proper procedures and technique, of medication administration. On 04/21/22 at approximately 6:00 pm monitoring of nursing staff began to be conducted by the facilities administrative staff, medication administration observations and in services for education of the 7 rights of medication administration was started. During an interview on 04/21/22 at 1:15 pm the Administrator said the plan of correction to ensure medications would be given as prescribed had been implemented which included training for all nursing staff. The Administrator said the medication error would be placed on the agenda for the QAPI meeting and the plan would be monitored by the QAPI team. Monitoring of the Plan of Removal: During interviews with Medication aids, MA's (I, M, Z) s, Licensed vocation nurse, LVN's (A, B, H, N, O, P, Q, R, S, T, U, V, W, AA, X), and Registered nurse, RN's (G, J, K, L, M) on 04/21/22 and 4/22/22 said they received verbal in-service training on administering medications and observed medication administration by nursing management. They were able to identify the 7 rights of medication administration. Interview on 04/21/22 at 5:45 pm with MA M revealed she was educated on the 7 rights of medication administration, he was able to name all 7 rights, he said, give mediations to the right person, right medication, right dose, right route, right reason, and right documentation. MA M said she had been checked off for safe medication administration by the DON, she described drawing up insulin after getting a resident's blood sugar reading and administering safely. Interview on 04/21/22 at 5:55 pm with LVN N revealed she had been educated on the 7 rights of medication administration, she could name all 7 rights and knew the consequences of giving the wrong medications to a resident, and the risks of overdosing a person, she said, giving the wrong medications to a residents can cause a significant change in condition such as death, an allergic reaction, or a stroke. Interview on 04/21/22 at 6:00 pm with LVN P revealed she had been educated on the 7 rights of medication administration, she named all 7 rights, right person, right route, right medication

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #165) of 19 residents reviewed for accidents and supervision. LVN A failed to use a gait belt during a transfer with Resident #165, which resulted in the resident sustaining a fractured clavicle. This failure had the potential to affect residents by resulting in falls and injuries. Findings included: Resident #165's Face Sheet dated 09/05/18 revealed the resident was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #165's Care Plan Report dated 06/30/16 revealed she required extensive assistance of one to two staff for transfers. The facility's un-dated General Staff Guidelines - Gait Belt Policy revealed all employees were to have a gait belt while on duty and to use the gait belt for resident transfers and ambulation. The facility's Provider Investigation Report dated 08/28/18 revealed on 08/28/18 at 2:30 PM, Resident #165 complained of pain to her left shoulder, bruising, purple and red in color with swelling were present and it was extremely painful to the touch. The resident's physician and responsible party were notified. An x-ray was ordered. The x-ray revealed a left clavicle fracture and a [DIAGNOSES REDACTED]. The resident's room was video monitored. According to the video, on 08/27/18 the nurse (LVN A) moved her closer to the edge of the bed and transferred the resident to her chair in one motion. The nurse did not use a gait belt during the transfer, as policy stated. The ED and DON interviewed the nurse about why he did not follow policy, and the nurse said he thought the gait belt would do more harm than good because of the resident's frail state. The nurse was suspended pending the investigation. The resident received an order to follow-up with an orthopedic doctor. In-services were initiated on abuse/neglect, transfers, the gait-belt policy, safe lifting, transfer/mobility training, to include return demonstration, with all nursing staff. The LVN A gave a return demonstration on the transfer of the resident, with no issue noted other than the non-use of the gait belt. The nurse was brought back from suspension with a Final Warning, probation, skills check-off, and one on one transfer training. Follow-up rounds were conducted by the ED, DON and/or designee for the next four weeks. Any issue was immediately addressed and monitored during the monthly QA process. Review of the un-timed and un-dated video revealed LVN A was in Resident #165's room, the resident was lying in bed on her back, she was fully clothed. The LVN was observed taking the resident's left shoulder and left leg and dragging her to the edge of the bed. Once the resident was at the edge of the bed, the LVN placed his hands around her waist, under her arms and lifted her off the bed and into her wheelchair. During the transfer the resident's right leg remained on the bed until the LVN placed her in the wheelchair. The LVN can be heard asking the resident if she was okay after the transfer but the resident's reply could not be heard. Resident #165's Clinical Note dated 08/28/18 revealed the nurse noted the resident had bruising, purple and red in color with swelling to her left clavicle and shoulder; it was extremely painful to touch. The physician and responsible party were notified. The physician ordered an x-ray of the resident's left clavicle and shoulder. At 11:22 AM the x-ray was positive for a fracture, and the physician and responsible party were made aware of the results. An MRI with contrast was ordered. The resident was given PRN [MEDICATION NAME] for pain. The resident was showing signs of pain with groaning and wincing with touch. At 11:33 PM the resident was in bed resting quietly, no signs or symptoms of pain at this time, appeared comfortable. At 1:52 PM, an MRI was scheduled for 09/05/18, and the resident's responsible party was notified. Resident #165's Radiology Report dated 08/28/18 revealed a [MEDICAL CONDITION]-third of the clavicle with modest displacement. The joint was intact. There was osteopenia. In a telephone interview on 04/10/19 at 3:34 PM, LVN A said he was getting Resident #165 up for dinner on 08/27/18 between 4:00 PM and 5:00 PM. He said he was trained on the use of the gait belt, but he felt due to the resident's contractures, it was safer for him to transfer her without the gait belt. He said the resident did not report any pain during or after the transfer, but she was diagnosed with [REDACTED]. In an interview on 04/11/19 at 10:45 AM, the Administrator said Resident #165's fracture was caused by LVN A not using the gait belt. She said during her investigation of the incident LVN A said he felt it was safer to transfer the resident without the gait belt. She said the facility conducted re-training with LVN A, in-service training for all staff and monitored to ensure no further incidents. Review of the corrective measures taken by the facility to correct the non-compliance prior to entry on 04/09/19 revealed the following: Resident #165's Care Plan Report, updated 08/28/18, revealed the resident was totally dependent for transfers and a Hoyer Lift with staff was to be used. Resident #165's Clinical Note dated 09/10/18 at 6:31 AM revealed the resident was sent to the emergency room for testing due to kidney-related issues. She did not return to the facility. LVN A's Transfer Skills Checklist dated 08/31/18 revealed he followed and understood the procedures for transfers. Review of the in-service training conducted on 08/31/18 with all nursing staff revealed: -Transfer Training/Mechanical Lift with hands on training and check off -Gait belt Policy Review -Safe Lifting LVN A's Employee Coaching and Counseling Record dated 08/31/18 revealed the employee failed to follow the facility's gait belt policy in the transfer of a resident (Resident #165). The policy required all nursing employees to have and use a gait belt for all resident transfers and ambulation. LVN A not using a gait belt resulted in the resident having a fracture. The employee would receive further education and skill check-offs for safe transfers. The employee would remain on probation with regards to safe transfers and gait belt usage, for the next 60 days. LVN A's employee file revealed he was hired on 01/31/17 and resigned on 01/28/19. On 01/31/17 he received training on General Orientation Policies and Checklist which included safe resident handling and movement program, Eight steps to a safe lift and Gait belt policy.

Based on interview and record review, the facility failed to ensure each resident received adequate assistance devices to prevent accidents for one (Resident #1) of four residents reviewed who required staff assistance with transfers. CNAs A and B failed to transfer Resident #1, who was care planned to be transferred utilizing a mechanical lift, with a mechanical lift which resulted in the resident being injured and sustaining a fracture to his right hip. This failure placed residents at risk for falls, lacerations, fractures and the need for hospitalization . Findings included: Review of Resident #1's Face Sheet, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Face Sheet further reflected the resident was discharged on [DATE]. Review of Resident #1's quarterly MDS assessment, dated [DATE], revealed the resident had clear speech, was understood, and could understand others. The resident's cognition was moderately impaired. The MDS further reflected the resident required extensive assistance with one person for transfers. Review of Resident #1's Care Plan Report, printed [DATE] revealed the following: Problems, effective [DATE], Transfers (to/from: bed chair wheelchair, standing position (sic))- (Resident #1) requires extensive assistance. Goals: (Resident #1) will complete transfers with the assistance of (mechanical) lift x2 persons as required. Interventions, effective [DATE] to present, Transfer using the (mechanical) Lift x2 person assist. Review of Resident #1's Baseline Care Plan and Daily Care Guide, print date of [DATE], revealed he required mechanical lift transfer with assist of two or more. Interview on [DATE] at 1:07 PM with CNA A revealed on the day of the incident she was working another section and CNA B asked her to help put Resident #1 in the shower. She stated she went to Resident #1's room and CNA B told her she was going to use the sit to stand lift. She stated Resident #1 was sitting in his w/c and had a mechanical lift sling underneath him. CNA A stated she asked CNA B if Resident #1 was able to use the sit to stand lift and CNA B told her yes. She stated when they transferred him from his w/c to the shower chair the transfer went well. She stated after his shower she was called back to the room to help transfer him to his bed. She stated when she got to Resident #1's room he was in the shower chair with the sit to stand lift in front of him. She stated CNA B prepared him for the transfer. She stated Resident #1 was holding onto the grab bars on the lift and when she started to lift him he let go of the bars and dropped down to his knees. She stated she asked him if he was okay and he stated he was hurting and did not feel well. CNA A stated CNA B called out for help and LVN C came to the room and assessed the resident. She stated the resident said his knees were hurting. CNA A denied seeing any injuries and stated x-rays were done on his knees and no injuries were found. She stated later on an x-ray was done on his hip. She stated she was suspended from work and ultimately terminated. When asked how she would know how much assistance a resident required the aide stated she could ask the nurse or it was common sense as she had worked at the facility before. She stated she thought they had a care plan in the computer the staff could look at. Interview on [DATE] at 2:58 PM with CNA B revealed she thought Resident #1 required a mechanical lift transfer. She stated CNA A told her the resident was able to use the sit to stand lift. CNA B stated she wanted to use the mechanical lift. She stated on the day of the incident CNA A and she transferred Resident #1 from his w/c to the shower chair. She stated they used the sit to stand lift with no issues. She stated after his shower they were going to transfer him into bed. They got him hooked into the sit to stand lift and when CNA A started to lift the resident he was fine and then he let go of both bars. She stated he was on his knees and they lowered him to the floor. CNA B stated the resident had not complained of pain. She stated LVN C was notified and she assessed the resident. She stated they used a mechanical lift to get him into bed. CNA B stated LVN C did not know they were using the sit to stand lift to transfer the resident. CNA B stated at the time she did not know where to find a resident's ADL care info. She stated she worked at the NF (nursing facility) for two years and that was the first time she had transferred Resident #1. She stated she was terminated from the facility. Interview on [DATE] at 2:39 PM with LVN C revealed she was unable to recall the details of the incident involving Resident #1. She stated when she assessed him he complained of pain to his knees and x-ray was ordered. She stated she was not aware CNAs A and B were using a sit to stand lift to transfer Resident #1. She stated he required a mechanical lift and staff was able to find ADL care information in the resident's daily care guide which was located on the computer and tablet. Review of Resident #1's Clinical Notes Report revealed LVN C documented on [DATE] at 10:28 PM she was called to the resident room by the staff. She was informed the resident slid off the standing lift and was assisted to the floor. She observed the resident in a sitting position on both knees. She completed a head to toe assessment and the resident complained of pain to both knees. The resident was transferred to bed with the help of three staff. The nurse practitioner was notified and an x-ray was ordered. Resident #1 had a bilateral knee pain and pain medication was administered. The family and DON were notified. X-ray results were negative. Review of the provider investigation report, dated [DATE], revealed: -Description of Allegation: Resident fell during a transfer, using wrong assisted device. Resident complaint of pain on [DATE], and x-ray on [DATE] showed right intertrochanteric fracture (a [MEDICAL CONDITION] part of the femur) with impaction. -Description of Assessment: Head to toe assessment completed on [DATE], with pain to both knees noted. Pain medication provided to resident and x-ray ordered for bilateral knees on [DATE]. X-ray showed negative for fracture. Resident complained of hip pain on [DATE] and x-rays were ordered, showing a right intertrochanteric fracture with impaction. Resident sent to ER for evaluation. -Provider Action Taken Post-Investigation: The facility initiated in-servicing for all staff, on abuse/neglect, mechanical lifts, and following plan of cares (sic) for residents. The CNAs were terminated as a result of not following the careguides (sic) for this resident. Follow-up rounds to be conducted by ED, DON, and/or designee for the next four weeks. Any issue will be immediately addressed, and further monitored during monthly QA process. Resident #1's radiology report, dated [DATE], reflected an acute impacted right intertrochanteric fracture. Interview on [DATE] at 9:22 AM with the ADM and DON revealed Resident #1 was no longer at the facility as he had expired due to something relating to [MEDICAL CONDITION]. The DON stated, on the day of the incident, the aides were transferring him with a sit to stand lift and he was supposed to be transferred using a mechanical lift. She stated the aides were terminated. Interview on [DATE] at 11:32 AM with the ADM revealed Resident #1 was voluntarily bedbound. She stated he would get up on occasion. She stated on the day of the incident CNA A and CNA B used a sit to stand lift to transfer the resident. She stated the aides used the sit to stand lift to get him into the shower chair. Afterwards when they were transferring him back to bed he took his hands off the sit to stand lift bars and started sliding. The ADM stated she believed the incident happened on [DATE] and he complained of pain to both knees on the [DATE] and [DATE]. She stated on [DATE] he complained of pain to his right hip. She stated he sustained an impacted fracture to his hip. She stated they determine he sustained the fracture as a result of the way he was transferred and the aides not following his daily care guide. The ADM stated he was care planned for a mechanical lift transfer. She stated a resident's care needs are accessible on the computer and tablet. The ADM stated the care guide was established upon admission and updated as needed. She stated Resident #1 did not received surgery due to his health. Review of the In-Service Training Attendance Rosters attached to the provider investigation report, dated [DATE] and [DATE], revealed staff on various shifts were educated on the use of mechanical lifts, abuse/neglect, and checking the residents daily care guides. On [DATE] the ADM provided the follow-up log conducted as result of the incident with Resident #1. The log reflected various residents were checked for care issues from [DATE] through [DATE]. Interviews were conducted on [DATE] from 2:04 PM to 5:16 PM and [DATE] 9:07 AM to 3:31 PM with the following staff who worked various shifts: CNA D, LVN E, LVN F, CNA G, LVN H, RN I, LVN J, CNA K, LVN C, LVN L, CNA M, and CNA N. All were able to verbalize who the abuse prevention coordinator was, when to report abuse/neglect/exploitation, where to find ADL care for residents, and how many staff were required for a mechanical lift and sit to stand lift transfers. Interview on [DATE] at 1:38 PM with Resident #2 revealed he required a mechanical lift transfer. He stated there was always two or more staff present to help transfer him and he had no issues while being transferred. Resident #2 stated he was having pain and was unable to get out of bed at this time. Unable to observe this resident being transferred. On [DATE] at 1:41 PM Resident #3 revealed she required a mechanical lift transfer and there were always two staff present during transfers. She denied any issues related to transfers. Staff had just transferred Resident #3 to bed. On [DATE] at 1:47 PM Resident #4's responsible party revealed she had been present during transfers. She stated staff used a mechanical lift to transfer the resident and there were two staff present. She denied any issues related to transfers. Resident #4 had a visitor at this time and observation of her being transferred was unable to be done at this time.

Based on observation, interview and record review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing for two (Residents #12 and #23) of 21 residents reviewed for pressure ulcers. 1. The facility failed to complete a thorough head-to-toe assessment for Resident #12, which resulted in the facility failing to identify a DTI to on the resident's left great toe and a Stage IV pressure ulcer on the resident's abdomen. 2. The facility failed to document a Stage II pressure ulcer on Resident #23's left upper thigh crease; failed to notify the physician that the area was a pressure ulcer; and failed to obtain timely physician orders to treat the pressure ulcer. An Immediate Jeopardy (IJ) was identified on 05/12/16. While the IJ was removed on 05/15/16 the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of Plan of Removal. These failures placed ten residents, who were identified with pressure ulcers, at risk for further deterioration of existing pressure ulcers and the development of new pressure ulcers, which could result in increased healing time, infection,[MEDICAL CONDITION], discomfort, pain, and the potential need for hospitalization . Findings included: (1) Resident #12's MDS assessment, dated 03/22/16, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment, and she was totally dependent upon staff for assistance with bed mobility, transfer, and personal hygiene. In addition, the resident was feed by [DEVICE], and she was at risk for developing pressure ulcers; although, she did not have any pressure ulcers at the time of admission. An undated Care Plan reflected Resident #12 was at risk for skin breakdown related to incontinence, impaired bed mobility, history of pressure ulcers, fragile skin, and skin desensitized to pain from pressure. Care planned interventions included: - assisting the resident with repositioning as needed; - using padding between pressure areas; - monitoring for skin breakdown; - reporting skin breakdown to the physician and responsible party; - providing pressure relieving and positioning devices as needed; - assessing skin weekly and recording findings; - preventing shearing forces and friction during transfers; and - keeping the bed free of wrinkles, crumbs, and other sources of pressure. Review of Resident #12's May 2016 TAR revealed Unit Manager A completed a head-to-toe assessment on 05/09/16, and no skin problems were identified. The Wound Care Specialist Evaluation, dated 05/10/16, reflected: At the request of (Medical Director), this [AGE] year old female was seen and evaluated today. She presents with a stage 4 pressure wound of the abdomen of at least 1 days duration. There is light serous exudate. There is no indication of pain associated with this condition. The Wound Care Physician documented that the wound on Resident #12's abdomen was a Stage IV pressure ulcer which measured 2.0 cm x 1.0 cm x 1.0 cm with a surface area of 2.0 cm2. The wound was documented as being 10% yellow necrotic (dead) tissue and 90% granulation tissue. The Wound Care Physician documented that he performed a surgical excisional debridement of the muscle on the abdominal wound, which was described as Wound debrided via surgical excision and muscle removed along with necrotic tissue. The Wound Care Physician ordered the wound to be treated with a collagen dressing and a dry protective dressing to be applied once daily. The Wound Care Physician also recommended off-loading the wound. There was no further documentation by the Wound Care Physician regarding any other pressure ulcers for Resident #12. An observation on 05/11/16 at 1:30 p.m. of Resident #12 revealed the resident was lying in bed, and her bilateral feet were in direct contact with the blankets. An interview on 05/12/16 at 9:30 a.m. with Resident #12's charge nurse, LVN H, revealed when she returned from leave three weeks ago, Resident #12 had pressure ulcers on her toe and right foot. LVN H stated the pressure ulcers on the resident's feet were being treated with saline, but she did not know who was actually doing the treatment. She stated the charge nurses did the weekly skin assessments, and the 2:00 p.m. to 10:00 p.m. shift was responsible for completing Resident #12's assessment. LVN H added there should have been a bed canopy (a device to keep the sheets off of the resident's feet) over Resident #12's feet. Review of Resident #12's current electronic Physician Orders and TAR reflected there was no physician order for [REDACTED].>An interview on 05/12/16 at 10:00 a.m. with the Wound Care Nurse revealed she just returned from being on leave for a week. She stated she and the charge nurses were responsible for completing the weekly skin assessments. The Wound Care Nurse explained that all of the charge nurses had a communication form they were responsible for filling out, which they were supposed to give to her, with their findings from the weekly assessments. She stated if a charge nurse found a skin problem, the charge nurse was responsible for calling the physician for orders; however, the charge nurses would instead wait for her to return to call for orders and initiate treatment. The Wound Care Nurse stated Resident #12 was seen by the Wound Care Physician on 05/10/16, and the Wound Care Physician documented that Resident #12 had a Stage IV pressure ulcer on her abdomen. The Wound Care Nurse stated the pressure ulcer was probably caused by her [DEVICE]. She stated the nurses did not always use the split gauze underneath the resident's [DEVICE]. She stated Resident #12 should never have gotten the pressure ulcer. The Wound Care Nurse added that she had reported these concerns to the DON, and the charge nurses were provided with in-services addressing these issues. An observation on 05/12/16 at 10:48 a.m. with the Wound Care Nurse revealed Resident #12 had bilateral foot drop and a bed canopy was in place. Resident #12's arms were positioned away from the [DEVICE] site. LVN I removed the [DEVICE] dressing, dated 05/11/16, which contained a collagen dressing and dried greenish-brown drainage. Below the resident's [DEVICE] retention ring (a device used to keep the [DEVICE] in place) was a 0.5 cm x 2.0 cm unstageable scabbed wound. An observation of the resident's feet revealed there was an unstageable quarter-inch black scab on the top of the resident's big toe and a Stage II pressure ulcer that was open, red, and approximately a quarter-inch in size. The Wound Care Nurse stated, I haven't seen those sores before, and I haven't seen the foot cradle (bed canopy) being used before. An interview on 05/12/16 at 1:01 p.m. with CNA HH revealed she was aware of the pressure ulcer on Resident #12's left toe because it had been there for about a month. CNA HH stated she had not worked with Resident #12 recently so she was not aware of the area on the resident's right foot or abdomen. CNA HH stated she documented and reported any skin findings to the charge nurse. An interview on 05/12/16 at 1:14 p.m. with CNA J revealed she had reported the wound on Resident #12's abdomen to LVN H about a week ago. CNA J stated the wound had blood, puss, and an odor. She stated the wound looked like the plastic circle (retention ring) from the [DEVICE] had dug into the resident's skin. When she reported the wound to LVN H, she stated LVN H told her it was normal, and the odor she smelled was the gas passing through the [DEVICE]. CNA J stated she reported the wound to LVN H a week later, and LVN H told her it was an old scab. She stated she also reported a red shear wound on the resident's right foot, and LVN H told her that area was old too. CNA J stated she also reported wound on Resident #12's abdomen to a Student Nurse, who was assisting with care. She stated the Student Nurse notified her Nursing Instructor, who was also a Weekend Supervisor at the facility. CNA J stated the Weekend RN Supervisor stated the wound was not normal, and shortly afterwards Unit Manager B was notified. She stated the Weekend RN Supervisor and Unit Manager B cleansed and dressed the wound on Resident #12's abdomen. An interview on 05/12/16 at 1:53 p.m. with LVN H revealed LVN G made rounds with the Wound Care Physician on 05/10/16. LVN H stated Resident #12 was very contracted and would lay her arms over her [DEVICE]. She stated she changed the dressing on the resident's [DEVICE] last week, when it was soiled, but she had not changed it this week. She stated noticed that a Student Nurse, the Weekend RN Supervisor, and Unit Manager A entered Resident #12's room on 05/10/16. LVN H asked them what was wrong, and they informed her they found a wound on the resident's abdomen. She stated Unit Manager B cleansed and dressed the wound, but she did not see where Unit Manager A had documented the findings or the treatment in Resident #12's clinical record. LVN H stated Resident #12 often developed pressure ulcers on her feet and toes from as a result of shearing of her bedsheets. LVN H stated a canopy for the resident's bed was ordered last year around the fall to prevent the shearing. An interview on 05/12/16 at 3:31 p.m. with Unit Manager A revealed the Nursing Instructor/Weekend RN Supervisor notified her about the wound on Resident #12's abdomen on 05/10/16. She stated she observed the wound on that date, and she described it as the skin being broken, reddened, with serosanguinous drainage (drainage containing blood and fluid from the serum in the blood). Unit Manager A stated she reported her findings to Unit Manager B, and Unit Manager B cleansed and dressed the because she had been a wound nurse before and knew more about wounds. Unit Manager A stated she or Unit Manager B should have documented their findings in Resident #12's clinical record. Unit Manager A added that she completed Resident #12's head-to-toe assessment on 05/09/16, and she did not identify any skin concerns including the pressure ulcer on the [DEVICE] site. An interview on 05/12/16 at 4:40 p.m. with the DON revealed she was not aware there were problems with pressure ulcers in the facility. She stated she was recently informed about the areas on Resident #12's feet, and she had called the doctor and got treatment orders. She stated the Unit Managers (Unit Managers A, B, and L) would be doing a full sweep of skin assessments for all of the residents. An interview on 05/12/16 at 8:01 p.m. with the Nursing Instructor/ Weekend RN Supervisor revealed she had some Student Nurses in the building on 05/10/16, who were assisting the CNAs with resident care. She stated one of the Nursing Students approached her about something she had seen on Resident #12 so she went to observe the resident. She stated when she raised Resident #12's [DEVICE] anchor (retention ring) she saw an area that looked eroded and crusted. The Weekend RN Supervisor stated there was old blood on the wound with some drainage. She stated the wound appeared to be a pressure ulcer from the [DEVICE] anchor rubbing into the resident's skin, and the wound could not developed overnight. She stated she reported the wound to Unit Manager A and Unit Manager B, and the wound was cleansed and treated. A Skin Site Identification Form completed on 05/12/16 at 10:02 p.m. by Unit Manager B reflected Resident #12 had three skin concerns. The form further reflected the resident had an abrasion that measured 1.0 cm x .07 cm on her right foot, 0.7 cm x 0.5 cm DTI on her left great toe, and a scabbed area on the abdomen that measured .05 cm. An interview on 05/14/16 at 9:31 am with Unit Manager B revealed she was told by the Nursing Student Instructor/Weekend RN Supervisor about the wound to Resident #12's abdomen. The wound had some sanguineous drainage (bloody drainage) She did not notice any redness or infection. She called the doctor to get an order to treat and have the wound care physician see her. Resident #12's Braden Scale Assessment for Pressure Ulcers, completed following surveyor inquiry on 05/13/16, reflected a score of 9, which indicated she was at high risk for developing pressure ulcers. The Braden Scale assessment was completed after the facility initiated a skin assessment of all residents. (2) Resident #23's MDS assessment, dated 03/11/16, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact and required the extensive assistance of one to two people with ADLs. The resident was always incontinent of bowel and frequently incontinent of bladder. The resident was at risk of developing pressure ulcers, but did not have any at the time of the assessment. Resident #23's undated care plan reflected he required extensive assistance with turning/positioning, transfers, and dressing. The care plan further reflected Resident #23 was at risk for pressure ulcer development due to risk factors as identified on the Braden Scale. Resident #23's skin assessment completed by the DON on 05/12/16 reflected the resident had a blister on his left hip. No other pressure ulcers were noted. Resident #23's Braden Scale for Predicting Pressure Sore Risk, completed by Regional Nurse Consultant D on 05/12/16, reflected the resident was not a high risk for pressure ulcer with a score of 17. Resident #23's nurses notes, dated 05/14/16 at 12:14 a.m., reflected LVN KK documented: CNA notified this nurse resident had some skin issues. Upon assessment blister to right thigh and excoriation noted to left buttock. Notified MD. Order Pending. Resident #23's nurses' notes, dated 05/14/16 at 12:37 a.m., reflected LVN KK documented: Per Medical Director, Will check when in facility. Will continue to monitor. An observation on 05/15/16 at 11:17 a.m. revealed Resident #23 had an open area with excoriation around the area under the resident's left buttock. LVN K stated it appeared to be a Stage II pressure ulcer. CNA BB, who was assisting LVN K, stated the area looked bigger than the day before and had spread more. LVN K measured the wound and it was 0.8 cm x 0.7 cm. LVN K asked CNA BB if she had reported the findings to the charge nurse and, she said, Yes. LVN K cleansed the Stage II pressure ulcer and stated she would put a dry dressing on the wound until she notified the doctor. An interview on 05/14/16 at 2:19 p.m. with CNA BB revealed she provided Resident #23 with incontinence care on 05/13/16 around 8:30 p.m., and she noticed another wound on the fold of the resident's left buttock. She stated she reported this new wound to her charge nurse, LVN KK. An interview on 05/15/16 at 11:52 a.m. with LVN KK, revealed a CNA had reported on Friday 05/13/16 that Resident #23 had an area on his buttock. LVN KK stated the wound measured 0.5 cm x 0.5 cm; however, she forgot to document the measurements. She stated the area was open, without much depth, no drainage, and the resident did not appear to be in pain. LVN KK stated she contacted the Medical Director, and he called back with no new orders. She stated he told her he would check the resident when he visited, and he made rounds at the facility weekly on Tuesdays. An interview on 05/15/16 at 12:40 p.m. with the DON revealed she called the Medical Director and provided him with a description of the area on Resident #23's buttocks, and he ordered thick zinc. Resident #23's Clinical Notes dated 05/15/16 reflected the following: Spoke with the Medical Director regarding excoriated area to left upper thigh crease. New order received to cleanse with wound care cleaner, pat dry, apply Zinc Oxide every shift. (3) The facility's current Skin policy and procedure, dated January 2015, reflected the following: .1. A head to toe skin assessment must be completed by the Admitting Nurse upon admission (including re-admission) of every Patient and documented on the Nursing Assessment Form. In addition, the Admitting Nurse must notify the physician and responsible part of any identified areas and must implement treatment and interventions . 2. A Braden Scale must be completed the day of admission (including readmission), once weekly for a minimum of four weeks, and quarterly thereafter. A Braden scale must also be completed upon each significant change in a Patient's condition . 4. A Pressure Ulcer Prevention Care Plan must be completed and interventions implemented for all Patients based upon the Braden Scale Score. A new Pressure Ulcer Prevention Care Plan must be completed upon a change in Baden Scale score or a change in interventions. 5. A Weekly Head-to-Toe Skin assessment must be completed and documented on the Weekly Head-to-Toes Skin Form on the day of admission (including readmission), once weekly, and prior to discharge/transfer of a Patient. 6. A Wound Assessment For must be completed and a narrative of each site must be documented weekly for any pressure ulcer and non-pressure skin condition, including Arterial Ulcers, Diabetic [MEDICAL CONDITION] Ulcers, [MEDICAL CONDITION] Ulcers, Bruises, Skin Tears, and Surgical Wounds. 7. A Pressure Ulcer Plan of Care must be completed upon identification of pressure ulcers and updated with any changes to interventions. 8. Skin Site Identification monitoring must be documented by the CNA each shift and any new skin issues identified must be addressed by the charge nurse to include assessment and documentation of the skin site and initiating appropriate clinical interventions. The Director of Nursing or designee must monitor the care plan, the appropriateness of interventions and initiation of the significant change MDS, if applicable . (4) The Administrator and DON were notified that an IJ was identified on 05/12/16 at 5:20 p.m. They were asked to submit a Plan of Removal. On 05/13/16 at 4:03 p.m., the Administrator and DON were notified the Plan of Removal was accepted. The Plan of Removal reflected the following: .Summary of events leading up to the IJ. Resident #19 admitted on [DATE] at 2:37 p.m. from another skilled facility .and was admitted by LVN E. Upon admission resident was noted to have Stage II bilateral decubitus to the buttocks. The resident was admitted without current wound care orders. The admitting nurse failed to assess measure and ensure treatment orders where implemented. Above mentioned nurse stated that she passed the information on to oncoming charge nurse. To ensure that the deficient practices are not continued Education and In-servicing has been implemented .(DON, Unit Manager B, Unit Manager L, Weekend Supervisor) will ensure compliance of this standard by items identified in section f-q. Resident #12 is a long-term resident and has been affected by the IJ. Unit Manager A was notified on 5/11/16 by (Nursing Instructor) from (Vocational School) that Resident #12 was noted to have open wound under [DEVICE] [MEDICATION NAME]. Resident was assessed by the nurse reference above and orders where obtained at 3:24 p.m Orders indicated to cleanse [DEVICE] site and apply collagen to area. On 5/10/16 Wound Care Physician assessed and treated resident and indicated the wound was debrided via surgical excision and muscle removed. Duration >1 days. On 5/12/16 DON was notified at 4:20 pm that Resident #12 was noted to have 2 wounds to her bilateral feet. DADS surveyor stated that at approximately 0930 am the charge nurse LVN H was informed by a surveyor of sites and that the resident was lacking treatment orders in the chart. At that point DON contacted Medical Director and obtained orders to immediately initiate treatment of [REDACTED]. To ensure that the deficient practices are not continued Education and In-servicing has been implemented. (DON, Unit Manager B, Unit Manager L, Weekend Supervisor) will ensure compliance of this standard by items identified in section f-q. .The Medical Director reviewed and approved the Plan of Removal. The Medical Director will also assist with ensuring compliance with this plan during the monthly QAPI meeting. a. The facility will conduct a head to toe skin assessment on each resident in the facility to ensure all residents with Non Pressure/Pressure Ulcers are identified. Nurses to complete this task include: (DON, Unit Manager B, Regional Nurse Consultant D, RN P, Regional Nurse Consultant C, LVN Q, MDS Nurse R, MDS Nurse S, MDS Nurse T). This audit will be completed by 5/12/16 midnight. b. Residents with new non pressure/pressure areas identified will have Medical Director and responsible party notifications as well as orders obtained for treatment of [REDACTED]. This audit will be completed by 5/12/16 midnight. Audit results include: - Resident #3 noted with Stage 1 site to buttock - Resident #26 noted with Stage 1 to left great toe - Resident #27 noted with .Stage 1 left great toe .Resident #29 with DTI to right ankle; DTI to right foot; DTI to right second toe - Resident #30 with DTI to right and left foot - Resident #23 with Stage 2 left hip - Resident #31 with DTI to right heel and left ankle - Resident #24 with DTI to left heel, left 4th toe, left 5th toe, unstageable to right ankle For the above mentioned residents- The areas were assessed and Medical Director was notified of areas listed above. Treatment orders were obtained and initiated. The staffs that have been associated with the deficient practice will receive counseling; 1:1 in servicing as well as disciplinary action up to and including termination. (LVN H) was suspended pending investigation. c. For residents with non-pressure/pressure sites previously identified, the facility will notify the PCP/Medical Director of the current status of the wounds. Nurses to complete this task will include: (DON, Unit Manager B, Regional Nurse Consultant D, RN P, Regional Nurse Consultant C, LVN Q, MDS Nurse R, MDS Nurse S, MDS Nurse T). This audit will be completed by 5/13/16 7am. d. Nursing staff will be re-in serviced on the Patient Care Management System .the stop and watch tool .and skin identification form In servicing will be completed prior to nursing staff commencing their next assigned shift. Nurses to complete this task will include: (DON and Regional Nurse Consultant D). Nursing staff (licensed and certified) will be in serviced by 5/13/16 by midnight. If a staff member who has not received the in services referenced above, they will not be allowed to work their scheduled shift until education is completed. On-going competency will be monitored by asking oral/verbal questions. This in servicing will occur upon hire, quarterly and again annually. This will be tracked by the Administrator on a monthly basis to ensure standard are met. e. The facility will conduct an audit of all residents currently residing in the facility to ensure the Braden Risk assessment is current to reflect risk for Pressure Ulcers. Nurses to complete this task will include: (DON, Unit Manager B, Regional Nurse Consultant D, RN P, Regional Nurse Consultant C, LVN Q, MDS Nurse S, MDS Nurse S, MDS Nurse T). This audit will be completed by 5/13/16 7am. f. A head to toe skin assessment will be completed by the Admitting charge nurse upon admission (including re-admission) of every Patient and documented on the Nursing Assessment Form immediately. In addition, the Admitting Nurse must notify the physician and responsible party of any identified areas (non pressure/pressure sites) and must implement treatment and interventions immediately. g. A Braden Scale will be completed the day of admission (including readmission), once weekly for a minimum of four weeks, and quarterly thereafter. A Braden scale will also be completed upon each significant change in a Patient's condition. h. A Wound Assessment Form identifying non pressure/pressure sites will be completed and a narrative of each site will be documented weekly for any pressure ulcer . i. A Non Pressure/Pressure Ulcer Plan of Care will be completed upon identification of non-pressure/pressure ulcers and updated with any changes to interventions. This task will be completed by the charge nurse who identifies the site. j. The facility (Unit Manger B) will be responsible for monitoring wound size and condition and will report changes or deterioration to the Director of Nursing and the attending physician. DON and Administrator will ensure compliance of this standard during morning clinical meeting. k. New non pressure/pressure sites will be discussed at the morning clinical meeting to ensure that appropriate treatment and notification standards are in place. DON and Administrator will ensure compliance of this standard during morning clinical meeting. l (DON, Unit Manager B, Unit Manager L, Weekend Manager) to monitor for skin integrity and appropriate dressings in place as well as adaptive devices through the discussion at the morning clinical meeting as referenced above. In addition, charge nurses will monitor for turning and repositioning at least every two hours during their shifts. m. The (DON, Unit Manager B, Unit Manager L, Weekend Manager) will complete a weekly non pressure/pressure trending report to monitor the status of non-pressure/pressure sites, as well as their treatment plans. This report will be submitted to (Regional Nurse Consultant D) weekly on Wednesday's for review. n. The (DON, Unit Manager B, Unit Manager L, Weekend Manager) as well charge nurses will conduct weekly skin assessments on residents on their designated dates (based on the room occupied) to monitor appropriate identification of skin concerns. o. The (DON, Unit Manager B, Unit Manager L, Weekend Manager) will monitor for residents who were admitted for skin assessments by validated completion and accuracy once the admission skin assessment is completed within 24 hours. p. Skin Site Identification form .monitoring must be documented by the C.N.A. each shift and any new skin concerns identified must be addressed by the charge nurse immediately to include assessment and documentation of the skin site and initiating appropriate clinical interventions and notifications. The (DON, Unit Manager B, Unit Manager L, Weekend Manager) will monitor for skin assessments by validated completion and accuracy once the admission skin assessment is completed within 24 hours. q. The Monthly Quality Assurance & Performance Improvement Meeting (see attachment 4) will include a review of appropriate and timely completion of a head to toe skin record, the Braden tool; appropriate use of the Non Pressure/Pressure Ulcer Prevention Care Plan; accurate and timely weekly skin head-to-toe assessments; accurate and timely completion of the Wound Assessment form and the weekly narrative; the accurate and timely up-date to the care plans; Skin Site Identification monitoring; the utilization; and trends in the occurrence of skin break-down and skin treatment outcomes. (5) An interview on 05/13/16 at 2:46 p.m. with the Medical Director revealed the facility made him aware of the concerns regarding pressure ulcers. He stated the problem was due to the slackness of the staff to complete order entries. He stated the staff was focusing on making sure the medications were being added to the orders; however, the treatments were being left off. He stated he expected the admitting charge nurses to get orders once a resident was admitted to the facility. He stated he also expected to be informed of all wounds in the building whether he was the resident's attending physician or not, and there was no excuse for the weekend staff not getting orders and initiating treatment on the residents. The Medical Director stated if there was a problem he expected for everything to be completed right then and there, there was no such thing as passing it to the next shift to complete. An interview on 05/15/15 at 1:03 p.m. with the Administrator revealed the IJ was the result of a system breakdown and not following appropriate nursing policy and procedures. An interview on 05/15/16 at 1:13 p.m. with the DON revealed the IJ was the result of a failure in the system and a failure to follow nursing policy and procedure. (6) Interviews were conducted with staff, which included Unit Managers, RNs, LVNs and CNAs, beginning at 10:16 a.m. on 05/14/16 through 05/15/16 at 3:30 p.m. with the following staff: Unit Manager A, Unit Manager B, Unit Manager L, RN U, RN DD, RN PP, LVN F, LVN G, LVN M, LVN V, LVN AA, LVN EE, LVN FF, LVN KK, LVN JJ, CNA W, CNA X, CNA Y, CNA Z, CNA BB, CNA CC, CNA OO and CNA QQ. The staff represented staff from all three shifts. All of the CNAs stated they received in-services regarding the residents' skin. The interviewed staff stated, if they saw any new or old skin issues, they would document them on a shower sheet and bring the sheet to the resident's charge nurse. The nurse in turn would sign the shower sheet acknowledging he/she had been informed, and the shower sheet would be placed in the shower sheet binder. The CNAs also completed a Stop Watch form, when a resident any change in condition, including skin. This form was also given to the resident's charge nurse for follow-up All of the licensed nurses who were interviewed stated they received in-services on residents' skin, pressure and non-pressure ulcers (including surgical incisions). If a resident was admitted to the facility with a pressure or non-pressure ulcer, they all stated they were supposed to complete a full skin assessment, document their assessments, call the resident's physician, obtain treatment orders, initiate the treatment and write a care plan. All skin issues identified on their shift needed to be completed by them. If a CNA brought to their attention a new skin issue or the nurse discovered a skin issue, they were supposed to assess the skin immediately and follow the same protocol. The nurses stated they were supposed to leave the information for the Wound Care Nurse so she could follow up. Braden Scales were to be completed upon admission, every week for four weeks and then quarterly. The nurses' were assigned weekly resident head to toe skin assessments. This assignment was located on their To DO tab on their computer. (7) On 05/15/16 at 4:00 p.m. the Administrator and the DON were notified the IJ was removed. While the IJ was removed on 05/15/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility needed to monitor the effectiveness of the Plan of Removal. (8) The facility's Plan of Removal, dated 05/13/15, which included results of a skin audit, reflected ten residents were identified with pressure ulcers.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for two (Residents #12 and #23) of 21 residents reviewed for change of condition. 1. LVN H failed to immediately consult with the physician when she was notified that Resident #12 had wounds on her toe, foot, and abdomen. 2. LVN KK failed to document a Stage II pressure ulcer on Resident #23's left buttock; failed to notify the physician that the area was a pressure ulcer; and failed to obtain timely physician orders to treat the pressure ulcer. An Immediate Jeopardy (IJ) was identified on 05/12/16. While the IJ was removed on 05/15/16 the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of Plan of Removal. These failures placed ten residents, who were identified with pressure ulcers, at risk for further deterioration of existing pressure ulcers and the development of new pressure ulcers, which could result in increased healing time, infection,[MEDICAL CONDITION], discomfort, pain, and the potential need for hospitalization . Findings included: (1) Resident #12's MDS assessment, dated 03/22/16, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment, and she was totally dependent upon staff for assistance with bed mobility, transfer, and personal hygiene. In addition, the resident was feed by [DEVICE], and she was at risk for developing pressure ulcers; although, she did not have any pressure ulcers at the time of admission. An undated Care Plan reflected Resident #12 was at risk for skin breakdown related to incontinence, impaired bed mobility, history of pressure ulcers, fragile skin, and skin desensitized to pain from pressure. Care planned interventions included: - assisting the resident with repositioning as needed; - using padding between pressure areas; - monitoring for skin breakdown; - reporting skin breakdown to the physician and responsible party; - providing pressure relieving and positioning devices as needed; - assessing skin weekly and recording findings; - preventing shearing forces and friction during transfers; and - keeping the bed free of wrinkles, crumbs, and other sources of pressure. Review of Resident #12's May 2016 TAR revealed Unit Manager A completed a head-to-toe assessment on 05/09/16, and no skin problems were identified. The Wound Care Specialist Evaluation, dated 05/10/16, reflected: At the request of (Medical Director), this [AGE] year old female was seen and evaluated today. She presents with a stage 4 pressure wound of the abdomen of at least 1 days duration. There is light serous exudate. There is no indication of pain associated with this condition. The Wound Care Physician documented that the wound on Resident #12's abdomen was a Stage IV pressure ulcer which measured 2.0 cm x 1.0 cm x 1.0 cm with a surface area of 2.0 cm2. The wound was documented as being 10% yellow necrotic (dead) tissue and 90% granulation tissue. The Wound Care Physician documented that he performed a surgical excisional debridement of the muscle on the abdominal wound, which was described as Wound debrided via surgical excision and muscle removed along with necrotic tissue. The Wound Care Physician ordered the wound to be treated with a collagen dressing and a dry protective dressing to be applied once daily. The Wound Care Physician also recommended off-loading the wound. There was no further documentation by the Wound Care Physician regarding any other pressure ulcers for Resident #12. An observation on 05/11/16 at 1:30 p.m. of Resident #12 revealed the resident was lying in bed, and her bilateral feet were in direct contact with the blankets. An interview on 05/12/16 at 9:30 a.m. with Resident #12's charge nurse, LVN H, revealed when she returned from leave three weeks ago, Resident #12 had pressure ulcers on her toe and right foot. LVN H stated the pressure ulcers on the resident's feet were being treated with saline, but she did not know who was actually doing the treatment. She stated the charge nurses did the weekly skin assessments, and the 2:00 p.m. to 10:00 p.m. shift was responsible for completing Resident #12's assessment. LVN H added there should have been a bed canopy (a device to keep the sheets off of the resident's feet) over Resident #12's feet. Review of Resident #12's current electronic Physician Orders and TAR reflected there was no physician order for [REDACTED].>An interview on 05/12/16 at 10:00 a.m. with the Wound Care Nurse revealed she just returned from being on leave for a week. She stated she and the charge nurses were responsible for completing the weekly skin assessments. The Wound Care Nurse explained that all of the charge nurses had a communication form they were responsible for filling out, which they were supposed to give to her, with their findings from the weekly assessments. She stated if a charge nurse found a skin problem, the charge nurse was responsible for calling the physician for orders; however, the charge nurses would instead wait for her to return to call for orders and initiate treatment. The Wound Care Nurse stated Resident #12 was seen by the Wound Care Physician on 05/10/16, and the Wound Care Physician documented that Resident #12 had a Stage IV pressure ulcer on her abdomen. The Wound Care Nurse stated the pressure ulcer was probably caused by her [DEVICE]. She stated the nurses did not always use the split gauze underneath the resident's [DEVICE]. She stated Resident #12 should never have gotten the pressure ulcer. The Wound Care Nurse added that she had reported these concerns to the DON, and the charge nurses were provided with in-services addressing these issues. An observation on 05/12/16 at 10:48 a.m. with the Wound Care Nurse revealed Resident #12 had bilateral foot drop and a bed canopy was in place. Resident #12's arms were positioned away from the [DEVICE] site. LVN I removed the [DEVICE] dressing, dated 05/11/16, which contained a collagen dressing and dried greenish-brown drainage. Below the resident's [DEVICE] retention ring (a device used to keep the [DEVICE] in place) was a 0.5 cm x 2.0 cm unstageable scabbed wound. An observation of the resident's feet revealed there was an unstageable quarter-inch black scab on the top of the resident's big toe and a Stage II pressure ulcer that was open, red, and approximately a quarter-inch in size. The Wound Care Nurse stated, I haven't seen those sores before, and I haven't seen the foot cradle (bed canopy) being used before. An interview on 05/12/16 at 1:01 p.m. with CNA HH revealed she was aware of the pressure ulcer on Resident #12's left toe because it had been there for about a month. CNA HH stated she had not worked with Resident #12 recently so she was not aware of the area on the resident's right foot or abdomen. CNA HH stated she documented and reported any skin findings to the charge nurse. An interview on 05/12/16 at 1:14 p.m. with CNA J revealed she had reported the wound on Resident #12's abdomen to LVN H about a week ago. CNA J stated the wound had blood, puss, and an odor. She stated the wound looked like the plastic circle (retention ring) from the [DEVICE] had dug into the resident's skin. When she reported the wound to LVN H, she stated LVN H told her it was normal, and the odor she smelled was the gas passing through the [DEVICE]. CNA J stated she reported the wound to LVN H a week later, and LVN H told her it was an old scab. She stated she also reported a red shear wound on the resident's right foot, and LVN H told her that area was old too. CNA J stated she also reported wound on Resident #12's abdomen to a Student Nurse, who was assisting with care. She stated the Student Nurse notified her Nursing Instructor, who was also a Weekend Supervisor at the facility. CNA J stated the Weekend RN Supervisor stated the wound was not normal, and shortly afterwards Unit Manager B was notified. She stated the Weekend RN Supervisor and Unit Manager B cleansed and dressed the wound on Resident #12's abdomen. An interview on 05/12/16 at 1:53 p.m. with LVN H revealed LVN G made rounds with the Wound Care Physician on 05/10/16. LVN H stated Resident #12 was very contracted and would lay her arms over her [DEVICE]. She stated she changed the dressing on the resident's [DEVICE] last week, when it was soiled, but she had not changed it this week. She stated noticed that a Student Nurse, the Weekend RN Supervisor, and Unit Manager A entered Resident #12's room on 05/10/16. LVN H asked them what was wrong, and they informed her they found a wound on the resident's abdomen. She stated Unit Manager B cleansed and dressed the wound, but she did not see where Unit Manager A had documented the findings or the treatment in Resident #12's clinical record. LVN H stated Resident #12 often developed pressure ulcers on her feet and toes from as a result of shearing of her bedsheets. LVN H stated a canopy for the resident's bed was ordered last year around the fall to prevent the shearing. An interview on 05/12/16 at 3:31 p.m. with Unit Manager A revealed the Nursing Instructor/Weekend RN Supervisor notified her about the wound on Resident #12's abdomen on 05/10/16. She stated she observed the wound on that date, and she described it as the skin being broken, reddened, with serosanguinous drainage (drainage containing blood and fluid from the serum in the blood). Unit Manager A stated she reported her findings to Unit Manager B, and Unit Manager B cleansed and dressed the because she had been a wound nurse before and knew more about wounds. Unit Manager A stated she or Unit Manager B should have documented their findings in Resident #12's clinical record. Unit Manager A added that she completed Resident #12's head-to-toe assessment on 05/09/16, and she did not identify any skin concerns including the pressure ulcer on the [DEVICE] site. An interview on 05/12/16 at 4:40 p.m. with the DON revealed she was not aware there were problems with pressure ulcers in the facility. She stated she was recently informed about the areas on Resident #12's feet, and she had called the doctor and got treatment orders. She stated the Unit Managers (Unit Managers A, B, and L) would be doing a full sweep of skin assessments for all of the residents. An interview on 05/12/16 at 8:01 p.m. with the Nursing Instructor/ Weekend RN Supervisor revealed she had some Student Nurses in the building on 05/10/16, who were assisting the CNAs with resident care. She stated one of the Nursing Students approached her about something she had seen on Resident #12 so she went to observe the resident. She stated when she raised Resident #12's [DEVICE] anchor (retention ring) she saw an area that looked eroded and crusted. The Weekend RN Supervisor stated there was old blood on the wound with some drainage. She stated the wound appeared to be a pressure ulcer from the [DEVICE] anchor rubbing into the resident's skin, and the wound could not developed overnight. She stated she reported the wound to Unit Manager A and Unit Manager B, and the wound was cleansed and treated. A Skin Site Identification Form completed on 05/12/16 at 10:02 p.m. by Unit Manager B reflected Resident #12 had three skin concerns. The form further reflected the resident had an abrasion that measured 1.0 cm x .07 cm on her right foot, 0.7 cm x 0.5 cm DTI on her left great toe, and a scabbed area on the abdomen that measured .05 cm. An interview on 05/14/16 at 9:31 am with Unit Manager B revealed she was told by the Nursing Student Instructor/Weekend RN Supervisor about the wound to Resident #12's abdomen. The wound had some sanguineous drainage (bloody drainage) She did not notice any redness or infection. She called the doctor to get an order to treat and have the wound care physician see her. Resident #12's Braden Scale Assessment for Pressure Ulcers, completed following surveyor inquiry on 05/13/16, reflected a score of 9, which indicated she was at high risk for developing pressure ulcers. The Braden Scale assessment was completed after the facility initiated a skin assessment of all residents. (2) Resident #23's MDS assessment, dated 03/11/16, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact and required the extensive assistance of one to two people with ADLs. The resident was always incontinent of bowel and frequently incontinent of bladder. The resident was at risk of developing pressure ulcers, but did not have any at the time of the assessment. Resident #23's undated care plan reflected he required extensive assistance with turning/positioning, transfers, and dressing. The care plan further reflected Resident #23 was at risk for pressure ulcer development due to risk factors as identified on the Braden Scale. Resident #23's skin assessment completed by the DON on 05/12/16 reflected the resident had a blister on his left hip. No other pressure ulcers were noted. Resident #23's Braden Scale for Predicting Pressure Sore Risk, completed by Regional Nurse Consultant D on 05/12/16, reflected the resident was not a high risk for pressure ulcer with a score of 17. Resident #23's nurses notes, dated 05/14/16 at 12:14 a.m., reflected LVN KK documented: CNA notified this nurse resident had some skin issues. Upon assessment blister to right thigh and excoriation noted to left buttock. Notified MD. Order Pending. Resident #23's nurses' notes, dated 05/14/16 at 12:37 a.m., reflected LVN KK documented: Per Medical Director, Will check when in facility. Will continue to monitor. An observation on 05/15/16 at 11:17 a.m. revealed Resident #23 had an open area with excoriation around the area under the resident's left buttock. LVN K stated it appeared to be a Stage II pressure ulcer. CNA BB, who was assisting LVN K, stated the area looked bigger than the day before and had spread more. LVN K measured the wound and it was 0.8 cm x 0.7 cm. LVN K asked CNA BB if she had reported the findings to the charge nurse and, she said, Yes. LVN K cleansed the Stage II pressure ulcer and stated she would put a dry dressing on the wound until she notified the doctor. An interview on 05/14/16 at 2:19 p.m. with CNA BB revealed she provided Resident #23 with incontinence care on 05/13/16 around 8:30 p.m., and she noticed another wound on the fold of the resident's left buttock. She stated she reported this new wound to her charge nurse, LVN KK. An interview on 05/15/16 at 11:52 a.m. with LVN KK, revealed a CNA had reported on Friday 05/13/16 that Resident #23 had an area on his buttock. LVN KK stated the wound measured 0.5 cm x 0.5 cm; however, she forgot to document the measurements. She stated the area was open, without much depth, no drainage, and the resident did not appear to be in pain. LVN KK stated she contacted the Medical Director, and he called back with no new orders. She stated he told her he would check the resident when he visited, and he made rounds at the facility weekly on Tuesdays. An interview on 05/15/16 at 12:40 p.m. with the DON revealed she called the Medical Director and provided him with a description of the area on Resident #23's buttock, and he ordered thick zinc. Resident #23's Clinical Notes dated 05/15/16 reflected the following: Spoke with the Medical Director regarding excoriated area to left upper thigh crease. New order received to cleanse with wound care cleaner, pat dry, apply Zinc Oxide every shift. (3) The facility's current Skin policy and procedure, dated January 2015, reflected the following: .1. A head to toe skin assessment must be completed by the Admitting Nurse upon admission (including re-admission) of every Patient and documented on the Nursing Assessment Form. In addition, the Admitting Nurse must notify the physician and responsible part of any identified areas and must implement treatment and interventions . 2. A Braden Scale must be completed the day of admission (including readmission), once weekly for a minimum of four weeks, and quarterly thereafter. A Braden scale must also be completed upon each significant change in a Patient's condition . 4. A Pressure Ulcer Prevention Care Plan must be completed and interventions implemented for all Patients based upon the Braden Scale Score. A new Pressure Ulcer Prevention Care Plan must be completed upon a change in Baden Scale score or a change in interventions. 5. A Weekly Head-to-Toe Skin assessment must be completed and documented on the Weekly Head-to-Toes Skin Form on the day of admission (including readmission), once weekly, and prior to discharge/transfer of a Patient. 6. A Wound Assessment For must be completed and a narrative of each site must be documented weekly for any pressure ulcer and non-pressure skin condition, including Arterial Ulcers, Diabetic [MEDICAL CONDITION] Ulcers, [MEDICAL CONDITION] Ulcers, Bruises, Skin Tears, and Surgical Wounds. 7. A Pressure Ulcer Plan of Care must be completed upon identification of pressure ulcers and updated with any changes to interventions. 8. Skin Site Identification monitoring must be documented by the CNA each shift and any new skin issues identified must be addressed by the charge nurse to include assessment and documentation of the skin site and initiating appropriate clinical interventions. The Director of Nursing or designee must monitor the care plan, the appropriateness of interventions and initiation of the significant change MDS, if applicable . (4) The Administrator and DON were notified that an IJ was identified on 05/12/16 at 5:20 p.m. They were asked to submit a Plan of Removal. On 05/13/16 at 4:03 p.m., the Administrator and DON were notified the Plan of Removal was accepted. The Plan of Removal reflected the following: .Summary of events leading up to the IJ. Resident #19 admitted on [DATE] at 2:37 p.m. from another skilled facility .and was admitted by LVN E. Upon admission resident was noted to have Stage II bilateral decubitus to the buttocks. The resident was admitted without current wound care orders. The admitting nurse failed to assess measure and ensure treatment orders where implemented. Above mentioned nurse stated that she passed the information on to oncoming charge nurse. To ensure that the deficient practices are not continued Education and In-servicing has been implemented .(DON, Unit Manager B, Unit Manager L, Weekend Supervisor) will ensure compliance of this standard by items identified in section f-q. Resident #12 is a long-term resident and has been affected by the IJ. Unit Manager A was notified on 5/11/16 by (Nursing Instructor) from (Vocational School) that Resident #12 was noted to have open wound under [DEVICE] [MEDICATION NAME]. Resident was assessed by the nurse reference above and orders where obtained at 3:24 p.m Orders indicated to cleanse [DEVICE] site and apply collagen to area. On 5/10/16 Wound Care Physician assessed and treated resident and indicated the wound was debrided via surgical excision and muscle removed. Duration >1 days. On 5/12/16 DON was notified at 4:20 pm that Resident #12 was noted to have 2 wounds to her bilateral feet. DADS surveyor stated that at approximately 0930 am the charge nurse LVN H was informed by a surveyor of sites and that the resident was lacking treatment orders in the chart. At that point DON contacted Medical Director and obtained orders to immediately initiate treatment of [REDACTED]. To ensure that the deficient practices are not continued Education and In-servicing has been implemented. (DON, Unit Manager B, Unit Manager L, Weekend Supervisor) will ensure compliance of this standard by items identified in section f-q. .The Medical Director reviewed and approved the Plan of Removal. The Medical Director will also assist with ensuring compliance with this plan during the monthly QAPI meeting. a. The facility will conduct a head to toe skin assessment on each resident in the facility to ensure all residents with Non Pressure/Pressure Ulcers are identified. Nurses to complete this task include: (DON, Unit Manager B, Regional Nurse Consultant D, RN P, Regional Nurse Consultant C, LVN Q, MDS Nurse R, MDS Nurse S, MDS Nurse T). This audit will be completed by 5/12/16 midnight. b. Residents with new non pressure/pressure areas identified will have Medical Director and responsible party notifications as well as orders obtained for treatment of [REDACTED]. This audit will be completed by 5/12/16 midnight. Audit results include: - Resident #3 noted with Stage 1 site to buttock - Resident #26 noted with Stage 1 to left great toe - Resident #27 noted with .Stage 1 left great toe .Resident #29 with DTI to right ankle; DTI to right foot; DTI to right second toe - Resident #30 with DTI to right and left foot - Resident #23 with Stage 2 left hip - Resident #31 with DTI to right heel and left ankle - Resident #24 with DTI to left heel, left 4th toe, left 5th toe, unstageable to right ankle For the above mentioned residents- The areas were assessed and Medical Director was notified of areas listed above. Treatment orders were obtained and initiated. The staffs that have been associated with the deficient practice will receive counseling; 1:1 in servicing as well as disciplinary action up to and including termination. (LVN H) was suspended pending investigation. c. For residents with non-pressure/pressure sites previously identified, the facility will notify the PCP/Medical Director of the current status of the wounds. Nurses to complete this task will include: (DON, Unit Manager B, Regional Nurse Consultant D, RN P, Regional Nurse Consultant C, LVN Q, MDS Nurse R, MDS Nurse S, MDS Nurse T). This audit will be completed by 5/13/16 7am. d. Nursing staff will be re-in serviced on the Patient Care Management System .the stop and watch tool .and skin identification form In servicing will be completed prior to nursing staff commencing their next assigned shift. Nurses to complete this task will include: (DON and Regional Nurse Consultant D). Nursing staff (licensed and certified) will be in serviced by 5/13/16 by midnight. If a staff member who has not received the in services referenced above, they will not be allowed to work their scheduled shift until education is completed. On-going competency will be monitored by asking oral/verbal questions. This in servicing will occur upon hire, quarterly and again annually. This will be tracked by the Administrator on a monthly basis to ensure standard are met. e. The facility will conduct an audit of all residents currently residing in the facility to ensure the Braden Risk assessment is current to reflect risk for Pressure Ulcers. Nurses to complete this task will include: (DON, Unit Manager B, Regional Nurse Consultant D, RN P, Regional Nurse Consultant C, LVN Q, MDS Nurse S, MDS Nurse S, MDS Nurse T). This audit will be completed by 5/13/16 7am. f. A head to toe skin assessment will be completed by the Admitting charge nurse upon admission (including re-admission) of every Patient and documented on the Nursing Assessment Form immediately. In addition, the Admitting Nurse must notify the physician and responsible party of any identified areas (non pressure/pressure sites) and must implement treatment and interventions immediately. g. A Braden Scale will be completed the day of admission (including readmission), once weekly for a minimum of four weeks, and quarterly thereafter. A Braden scale will also be completed upon each significant change in a Patient's condition. h. A Wound Assessment Form identifying non pressure/pressure sites will be completed and a narrative of each site will be documented weekly for any pressure ulcer . i. A Non Pressure/Pressure Ulcer Plan of Care will be completed upon identification of non-pressure/pressure ulcers and updated with any changes to interventions. This task will be completed by the charge nurse who identifies the site. j. The facility (Unit Manger B) will be responsible for monitoring wound size and condition and will report changes or deterioration to the Director of Nursing and the attending physician. DON and Administrator will ensure compliance of this standard during morning clinical meeting. k. New non pressure/pressure sites will be discussed at the morning clinical meeting to ensure that appropriate treatment and notification standards are in place. DON and Administrator will ensure compliance of this standard during morning clinical meeting. l (DON, Unit Manager B, Unit Manager L, Weekend Manager) to monitor for skin integrity and appropriate dressings in place as well as adaptive devices through the discussion at the morning clinical meeting as referenced above. In addition, charge nurses will monitor for turning and repositioning at least every two hours during their shifts. m. The (DON, Unit Manager B, Unit Manager L, Weekend Manager) will complete a weekly non pressure/pressure trending report to monitor the status of non-pressure/pressure sites, as well as their treatment plans. This report will be submitted to (Regional Nurse Consultant D) weekly on Wednesday's for review. n. The (DON, Unit Manager B, Unit Manager L, Weekend Manager) as well charge nurses will conduct weekly skin assessments on residents on their designated dates (based on the room occupied) to monitor appropriate identification of skin concerns. o. The (DON, Unit Manager B, Unit Manager L, Weekend Manager) will monitor for residents who were admitted for skin assessments by validated completion and accuracy once the admission skin assessment is completed within 24 hours. p. Skin Site Identification form .monitoring must be documented by the C.N.A. each shift and any new skin concerns identified must be addressed by the charge nurse immediately to include assessment and documentation of the skin site and initiating appropriate clinical interventions and notifications. The (DON, Unit Manager B, Unit Manager L, Weekend Manager) will monitor for skin assessments by validated completion and accuracy once the admission skin assessment is completed within 24 hours. q. The Monthly Quality Assurance & Performance Improvement Meeting (see attachment 4) will include a review of appropriate and timely completion of a head to toe skin record, the Braden tool; appropriate use of the Non Pressure/Pressure Ulcer Prevention Care Plan; accurate and timely weekly skin head-to-toe assessments; accurate and timely completion of the Wound Assessment form and the weekly narrative; the accurate and timely up-date to the care plans; Skin Site Identification monitoring; the utilization; and trends in the occurrence of skin break-down and skin treatment outcomes. (5) An interview on 05/13/16 at 2:46 p.m. with the Medical Director revealed the facility made him aware of the concerns regarding pressure ulcers. He stated the problem was due to the slackness of the staff to complete order entries. He stated the staff was focusing on making sure the medications were being added to the orders; however, the treatments were being left off. He stated he expected the admitting charge nurses to get orders once a resident was admitted to the facility. He stated he also expected to be informed of all wounds in the building whether he was the resident's attending physician or not, and there was no excuse for the weekend staff not getting orders and initiating treatment on the residents. The Medical Director stated if there was a problem he expected for everything to be completed right then and there, there was no such thing as passing it to the next shift to complete. An interview on 05/15/15 at 1:03 p.m. with the Administrator revealed the IJ was the result of a system breakdown and not following appropriate nursing policy and procedures. An interview on 05/15/16 at 1:13 p.m. with the DON revealed the IJ was the result of a failure in the system and a failure to follow nursing policy and procedure. (6) Interviews were conducted with staff, which included Unit Managers, RNs, LVNs and CNAs, beginning at 10:16 a.m. on 05/14/16 through 05/15/16 at 3:30 p.m. with the following staff: Unit Manager A, Unit Manager B, Unit Manager L, RN U, RN DD, RN PP, LVN F, LVN G, LVN M, LVN V, LVN AA, LVN EE, LVN FF, LVN KK, LVN JJ, CNA W, CNA X, CNA Y, CNA Z, CNA BB, CNA CC, CNA OO and CNA QQ. The staff represented staff from all three shifts. All of the CNAs stated they received in-services regarding the residents' skin. The interviewed staff stated, if they saw any new or old skin issues, they would document them on a shower sheet and bring the sheet to the resident's charge nurse. The nurse in turn would sign the shower sheet acknowledging he/she had been informed, and the shower sheet would be placed in the shower sheet binder. The CNAs also completed a Stop Watch form, when a resident any change in condition, including skin. This form was also given to the resident's charge nurse for follow-up All of the licensed nurses who were interviewed stated they received in-services on residents' skin, pressure and non-pressure ulcers (including surgical incisions). If a resident was admitted to the facility with a pressure or non-pressure ulcer, they all stated they were supposed to complete a full skin assessment, document their assessments, call the resident's physician, obtain treatment orders, initiate the treatment and write a care plan. All skin issues identified on their shift needed to be completed by them. If a CNA brought to their attention a new skin issue or the nurse discovered a skin issue, they were supposed to assess the skin immediately and follow the same protocol. The nurses stated they were supposed to leave the information for the Wound Care Nurse so she could follow up. Braden Scales were to be completed upon admission, every week for four weeks and then quarterly. The nurses' were assigned weekly resident head to toe skin assessments. This assignment was located on their To DO tab on their computer. (7) On 05/15/16 at 4:00 p.m. the Administrator and the DON were notified the IJ was removed. While the IJ was removed on 05/15/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility needed to monitor the effectiveness of the Plan of Removal. (8) The facility's Plan of Removal, dated 05/13/16, which included results of a skin audit, reflected ten residents were identified with pressure ulcers.