Every finding on record at The Hills Nursing & Rehabilitation

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #1) reviewed for hospice services. The facility failed to ensure Resident #1, who was receiving hospice services, had a physician order for hospice care. This failure could place residents who receive hospice services at risk of receiving inadequate end-of-life care, coordination of care and communication of resident needs. Findings included: Record review of Resident #1's Face Sheet, dated [DATE], revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE].Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she was diagnosed with Senile Degeneration of the Brain (Cognitive decline /Dementia). The MDS also revealed that she had moderate cognitive impairment. Record review of Resident #1's discharge MDS, dated [DATE], revealed that she expired at the facility on [DATE].Record review of Resident #1's Care Plan, undated, revealed that she was receiving hospice services and had a terminal prognosis. Record review of Resident #1's Progress Notes, dated [DATE]-[DATE] revealed no hospice admission or transfer notes. Record review of Resident #1's Order Summary Report, dated [DATE], revealed no physician order for hospice care services. During a telephone interview on [DATE] at 11:42 AM, The Hospice Nurse stated that Resident #1 admitted to their hospice services on [DATE] as a transfer from a different hospice company. During a telephone interview on [DATE] at 12:11 PM, RN A stated Resident #1 was on hospice services when she passed at the facility. She stated there should be an order put in when residents were admitted to a new hospice company. RN A stated she was unsure of who was responsible for putting in the hospice orders but stated possibly the ADON or DON. RN A stated she could not recall if she reviewed Resident #1's orders. She stated the risk of not having a physician order for hospice was the staff may not be aware that Resident #1 was receiving hospice services. During a telephone interview on [DATE] at 12:21 PM, LVN B stated she did work with Resident #1 but was no longer employed with the facility. LVN B stated there should have been an admit to hospice order in Resident #1's physician orders because she was receiving hospice services. LVN B stated the order also provided the staff with the admitting diagnosis and the phone number to contact the hospice company. She stated the nurses were responsible for adding the order and that she was not sure why the order was not put in. LVN B stated the risk of not having the order was staff may not be aware that she was on hospice services which could affect her care. During an interview on [DATE] at 1:27 PM, the DON stated there should be an admit to hospice order for Resident #1. The DON stated Resident #1 switched hospice companies and the new order must not have been added. She stated the hospice order communicated to staff the diagnosis and phone number for the hospice company. The DON stated if there was no order, the nurses may not be aware that the resident was on hospice which could cause miscommunication or confusion. She stated it was the nursing team's responsibility to ensure that the orders were up to date and accurate. Record review of the facility's policy titled, Hospice Services undated, revealed the following: .11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include:.Current interdisciplinary notes to include nurses notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 residents (Resident #1) reviewed for change of condition. The facility staff failed to notify the NP or Physician when Resident #1 began to have a change of condition on [DATE] when he experienced lethargy, clammy skin, was unable to verbally talk to staff, and did not appear to be himself. Resident #1 continued to have a change of condition until [DATE] when he was sent to the hospital and passed away. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury for unreported changes of condition to the NP or physician. Findings included: Review of Resident #1's Quarterly MDS Assessment, dated [DATE], reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 6 which indicated severe cognitive impairment. His MDS indicated he did not have behaviors of rejection of care. His active diagnoses included heart failure, renal insufficiency/renal failure/or end-stage renal disease (a condition where the kidneys can no longer function adequately), and non-alzheimer's dementia (a cognitive disorder severe enough to interfere with daily life). Review of Resident #1's Discharge summary, dated [DATE], reflected he discharged on [DATE] as he was sent to ER in cardiac/respiratory failure. Resident receiving CPR at time of discharge and passed in ER. Review of Resident #1's SBAR, dated [DATE], reflected the following information:-His blood pressure read 90/40-His pulse read 156-His respirations were 32-His temperature read 100.2 F-His O2 saturation read 79-His symptoms or signs were: Change in condition with decreased level of consciousness, fever, tachypnea, tachycardia, oxygen saturation dropped to 79% on room air. Use of accessory muscles to breathe. Review of Resident #1's care plan, revised on [DATE], reflected the following: Focus: Cancelled: [Resident #1] has Congestive Heart Failure.Interventions: Cancelled: Monitor/document/report to MD PRN any s/sx of Congestive Heart Failure.cool skin, dry cough.weakness.Cancelled: Monitor/document/report to MD PRN any s/sx of hypokalemia in residents receiving diuretic therapy: Fatigue, muscle, weakness, diminished appetite, nausea and vomiting.Focus: Cancelled: [Resident #1] has renal insufficiency r/t Kidney disease Stage 4.Interventions: Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; seizures. Review of Resident #1's Progress Notes for [DATE] reflected:-LVN A wrote on [DATE] at 8:24 PM that Resident #1 had refused his Albuterol Sulfate Inhalation Nebulization Solution-LVN B wrote on [DATE] at 8:57 AM that Resident #1 refused his Breo Ellipta Inhalation Aerosol Powder Breath Activated since he wasn't feeling well-RN C wrote on [DATE] at 4:30 PM the following The hospital ER called to request information about health history because the paramedics did not leave them the information that was sent with the resident. I was informed that the resident had expired and the [family member] was present at the ER.-RN C wrote on [DATE] at 7:35 PM the following The resident had a change in condition and is non responsive. Oxygen placed at 2 LPM via mask, MD, [family member] and 911 were notified. Review of Resident #1's [DATE] MAR reflected he refused his morning medications on [DATE] which consisted of bupropion, folic acid, magnesium, metformin, metoprolol succinate, potassium chloride, sertraline, and Eliquis.Further review reflected his blood pressure on [DATE] was 137/78 and on [DATE] it was 110/68. His pulse was 108 on [DATE] and 88 on [DATE]. Resident #1's hospital and EMS records were requested but not received prior to exit. Interview on the telephone on [DATE] at 10:53 AM with Resident #1's RP who said she felt if things happened differently last weekend then there would have been a different outcome for Resident #1. Resident #1's RP said someone had called her last Sunday ([DATE]) at 9:20 AM letting her know he had not eaten or drank fluids through the weekend. Resident #1's RP said she told them to offer Resident #1 a shake so he could have some sustenance but never heard back from the staff to know if he accepted the shake or not. Resident #1's RP said she got another call at 4 PM on Sunday ([DATE]) from a nurse who said Resident #1 was struggling to breathe and was running a fever. Resident #1's RP said she requested Resident #1 be sent to the hospital which the facility had planned to do. Resident #1's RP said she was told Resident #1 had passed away by the hospital staff. Interview on [DATE] at 12:03 PM with MA D said she worked with Resident #1 from Friday ([DATE]) to Sunday ([DATE]). MA D said she passed Resident #1 his medications which he accepted on Friday and Saturday, but he refused his medications on Sunday. MA D said on Sunday Resident #1 appeared flushed and his skin color was orange and pinkish in color on his face which was the only part of him she could see. MA D said it was not normal for Resident #1 to look that way, nor was it normal for him to refuse his medications. MA D said she reported her observations to LVN B who was caring for Resident #1. MA D said she did not see Resident #1 any other time after passing his medications to him. MA D said she had been in-serviced to let the nurse know any time there was a change to a resident and if the nurse was not listening to go to the ADON or DON about her observations. Interview on [DATE] at 12:13 PM with CNA E who said she worked with Resident #1 from Friday ([DATE]) to Sunday ([DATE]). CNA E said she worked from 6 AM to 6 PM with Resident #1 on Saturday and she noticed he had a change in condition and went to tell the nurse he was not himself. CNA E said she noticed this change in him shortly after breakfast because he did not look right or act right. CNA E said he could hardly talk to her when he was normally very talkative. CNA E said she also noticed he looked flushed and the color in his face was off. CNA E said the nurse she reported the change to was LVN B. CNA E said she was not sure what LVN B did after she reported the changes to her since she was busy caring for other residents. CNA E said she was told by LVN B to offer him a shake since he did not eat his breakfast that morning but he had refused it. CNA E told LVN B Resident #1 had refused the shake. CNA E said sometimes Resident #1 would eat all of his meal and other days he would not, but it just depended on the day. CNA E said when she came in on Sunday to care for Resident #1 she noticed he was in the same state as before until after 4 PM. CNA E said LVN B was Resident #1's nurse for part of the shift on Sunday and she reported to her that morning that Resident #1 still did not seem like himself. CNA E said RN C took over the shift and care for Resident #1 and she told RN C that Resident #1 did not seem like himself which was why RN C and LVN F went to check on him around 4 PM. CNA E said she noticed he was struggling to breathe because he was taking shallow and quick breaths and was not opening his eyes or talking. CNA E said she had last checked on him at 2:45 PM and he seemed to be breathing well. CNA E said the nurses began to apply oxygen to Resident #1 and had planned to send him to the hospital. CNA E said the next thing she knew Resident #1 had CPR being performed on him and she was not sure what happened after that. CNA E said she knew to let the nurse know any time a resident had a change to their condition and if they were not listening then she was supposed to go the ADON or DON. Interview on [DATE] at 12:30 PM with MA G who said she did not care for Resident #1 from Friday ([DATE]) to Sunday (07/19.26) but she had cared for him in the past. MA G said CNA E asked her to check on Resident #1 on Saturday because she noticed he was not himself. MA G said when she saw Resident #1 he did not look good, he was not talking and the look on his face was not his normal. MA G said she saw Resident #1 was red in the face but it could have been from his breathing treatment. MA G said she could just tell by looking at someone they did not look good or like themselves after caring for them for a while. MA G said she did not check on Resident #1 the rest of the weekend because she was busy working on other hallways. MA G said she knew to report any change to the nurse and if they did not listen she would let the ADON and DON know. Interview on the telephone on [DATE] at 12:50 PM with RN C who said she was recently hired 2 months ago and only worked every other weekend. RN C said she worked at the facility on Saturday ([DATE]) and Sunday ([DATE]) as the weekend supervisor. RN C said she was not told about any changes of condition for any residents on Saturday ([DATE]). RN C said she went in to Resident #1's room to provide wound care to him that day and she noticed his color was normal and his skin was cool to the touch. RN C said she came to work on Sunday ([DATE]) and had to take over the shift after LVN B left in the afternoon. RN C said CNA E had reported to her Resident #1 had a change in condition but she was not familiar with the resident and she was conducting a tour of the facility with a prospective resident's family. RN C said she told CNA E that since the ADON was in the building and was more familiar with the resident she should let him know. RN C said when LVN B left for her shift nothing about Resident #1 was given in report. RN C said later on during the day she was asked by CNA E to check on him because she noticed he was not doing well. RN C said she and LVN F went together to Resident #1's room and found he had shortness of breath which was totally different than what he was like the day before. RN C said they began taking his vital signs which were 100.2 F, an O2 saturation of 79%, his pulse was 156 beats per minute, and his blood pressure was 90/50. RN C said they began calling the resident's daughter, the doctor, and 911 to send him out to the hospital. RN C said she got the resident set up with an oxygen concentrator to increase his O2 saturation and next thing she knew he was not breathing and started compression on him. RN C said she was in-serviced and knew to report any change to a resident to the provider immediately. Interview on [DATE] at 1:08 PM with CNA H who said she did not care for Resident #1 on Saturday or Sunday ([DATE] or [DATE]) but had assisted another aide in repositioning him in his bed both days. CNA H said when she saw him on Saturday he did not look like he felt good and was not his normal self. CNA H said she had not seen him in a while but could tell there was a big difference in him. CNA H said she saw CNA E tell LVN B the resident was not his normal self but she was not sure what LVN B did after that. CNA H said she helped to reposition him on both days and he was the same both days; he looked clammy and sick in general. CNA H said normally he was very talkative with staff but when she went in there to reposition him he was not talking to the staff. CNA H said she knew to report to the nurse when a resident had a change in condition and if they did not listen to go to the ADON or DON. Interview on [DATE] at 1:18 PM with CNA I who said she worked with Resident #1 on Saturday ([DATE]). CNA I said he seemed sleepy and ate a little at breakfast and lunch. CNA I said she told the nurse he was not fully awake and did not eat much since he was usually a big eater. CNA I said she was not sure what the nurse did with the information. CNA I said she reported any change to a resident to the nurse and if the nurse did not listen she would go to the ADON or DON. Interview on [DATE] at 1:28 PM with LVN F who said worked on Sunday ([DATE]) but was not Resident #1's assigned nurse. LVN F said he was not well when she saw him and his vital signs were poor; his heart rate was fast and his oxygen saturation was low, requiring oxygen to be applied. LVN F said she only saw him around 4 PM on Sunday after CNA E asked her to go and check on him. LVN F said RN C went to the room with her and they both began to assess him. LVN F said during their assessment they noted his O2 saturation was in the 70's so they applied oxygen to him at 2 or 3 liters to help him breathe. LVN F said they made the determination he needed to go to the hospital so they called the doctor, the RP, and 911. LVN F said before he left the facility he did not have a pulse and CPR was initiated. LVN F said she was in-serviced and knew to report any change to a resident to the provider immediately. Interview on the telephone on [DATE] at 1:46 PM with LVN B who said she worked with Resident #1 on Friday through Sunday ([DATE] to [DATE]). LVN B said on Friday she was told by the aide that he was not acting like himself, that he was weaker than normal but not that much. LVN B said she went to check on him, took his vital signs, and completed an assessment; she said everything was normal with Resident #1, including his vital signs. LVN B said nothing else was reported to her during her shift that day and she did not notice anything else wrong with him. LVN B said he had refused his nebulizer treatment that day but that was normal for him. LVN B said on Saturday he was about the same but she was told he had thrown up and thought it was because he had not been eating much and took his medications on an empty stomach. LVN B said she was not sure who reported to her that he had thrown up and it was already cleaned up by the time she was told about it. LVN B said she checked on Resident #1 after being told this and he was his normal self. LVN B said on Friday he was weak and tired and was the same on Saturday. LVN B said she did not take his vital signs or do an assessment on him because she thought it was related to him taking his medications on an empty stomach which would make anyone sick and possibly throw up. LVN B said she was told by the aide on Saturday that he was refusing to eat which was not normal for him. LVN B said she went to his room multiple times during her shift on Saturday to check on him and she never saw a major change in him. LVN B said she also did not document her assessments or check ins on him or any of the vital signs she took during her assessments. LVN B said on Sunday he was not any better or worse and he had reported to her he had felt about the same as the day before. LVN B said she did not take his vital signs or do an assessment on him on Sunday when she checked on him. LVN B said she did not report to the doctor any of the changes he experienced or that he had vomited on Saturday. LVN B said all the symptoms he experienced did not seem as if they were that much of a change for him to warrant reporting them to the doctor. LVN B said she knew he seemed weaker but it was not enough of a change to call the doctor about so she just kept monitoring him. LVN B said she left early on Sunday during her shift and gave report to RN C but did not say anything about Resident #1 to her. LVN B said she knew to report a significant change in condition to the doctor, or if the resident's vital signs were not within normal limits. LVN B said she had been in-serviced that any change in condition should be reported immediately to the doctor. Follow-up interview on [DATE] at 2:05 PM with CNA E who said she could not remember if Resident #1 had thrown up or not, but if he did she reported it to the nurse immediately. Interview on the telephone on [DATE] at 2:14 PM with HA J who said she worked with Resident #1 on Friday ([DATE]). HA J said she noticed he did not eat his dinner and she was worried about him not eating so she asked why he did not eat. HA J said no sound came out of his mouth and he just mouthed the word no. HA J said that was weird because he liked to eat, so she asked if wanted a shake instead and again he mouthed the word no. HA J said she reported this change to LVN A who said she would be down to his room in a bit to check on him. HA J said she told LVN A it seemed as if Resident #1 was running a fever because when she touched him he felt warm. HA J said LVN A told her she checked on him and his vital signs were good. HA J said normally Resident #1 was very talkative with staff so it was strange and not good that he was only able to whisper or mouth words to the staff. HA J said she cared for him Saturday ([DATE]) night as well and he was a little better than Friday but was still not talking and she could tell he was not feeling well. HA J said she reported the change to LVN A again because Resident #1 looked like he was about to die since he was so pale and sick looking. HA J said he was not bouncing back at all and she asked if he wanted to go to the hospital and he mouthed the word no. HA J said she was in-serviced to report any change in a resident to the nurse and if the nurse did not listen to tell the ADON or DON. Follow-up interview on [DATE] at 2:24 PM with CNA I who said Resident #1 did not throw up during her shift that she could recall, but if he did she reported it to the nurse immediately. Interview on the telephone on [DATE] at 2:27 PM with Resident #1's Physician who said he was on vacation so had limited information. Resident #1's Physician said he was contacted on Sunday ([DATE]) about a change in condition before he passed away later that day. Resident #1's Physician said he did not have the on-call phone the staff may have used to communicate at other times with the provider. Interview on the telephone on [DATE] at 2:41 PM with the ADON who said he was on vacation that week and was not at work. The ADON said he did go to the facility for a few hours on Sunday ([DATE]) to meet a new admission but he was not there to work. The ADON said he asked in general how the residents were doing and was told by CNA E Resident #1 had not been eating again but that was not uncommon for him. The ADON said he looked in Resident #1's chart and saw that the staff were documenting he was eating so he told CNA E to be sure to let the nurse know about it. The ADON said he left after that and was not involved in anything else. Interview on the telephone on [DATE] at 2:46 PM with LVN A who said she cared for Resident #1 from Friday to Sunday ([DATE] to [DATE]). LVN A said she noticed he had been declining for a while and someone commented to her on Saturday that he was not feeling well. LVN A said she talked with him for a while and offered a breathing treatment which he refused and pain medications which he refused as well. LVN A said while she was assessing him she went through all his systems and could not pin point what was wrong. LVN A said she offered to send him to the hospital and he did not want that. LVN A said she thought she had charted all of her assessments and check ins with him but had not. LVN A said on Friday while she was caring for Resident #1 she noticed he was quiet and did not have a lot to say, but his vital signs were good. LVN A said everything seemed fine and he was at his baseline. LVN A said she noted the same on Saturday as well. LVN A said HA J told her he was not feeling good but she had already taken his vital signs but she got another set and talked to him for a while. LVN A said on Sunday when she got to work he had already passed away. LVN A said she did not report anything to the doctor because no one had reported any changes to her and nothing was significant enough to tell the doctor about. LVN A said she had been in-serviced that when someone reported a change in a resident she was supposed to do an assessment and report it to the doctor immediately. Interview on the telephone on [DATE] at 2:52 PM with the NP who said he had the on-call phone last weekend from Friday to Sunday ([DATE] to [DATE]). The NP said the only time he heard from the facility regarding Resident #1 was on Sunday at 9:35 PM where he received a text saying he had passed away at the ER. The NP said he was not aware that Resident #1 went to the ER. The NP said normally he would be notified if a resident had a change in condition. The NP said staff were supposed to text if they had any resident who had a decline in health status that would require an intervention. The NP said it would have been appropriate to report any changes to him in Resident #1's status and he would have gone through the steps with staff to see what could have been done for him. The NP said he wanted to know when a resident had a change in their status even if it was slight or small. The NP said it was normal for staff to report to him if a resident was not eating, looking lethargic, appeared sleepy, or was looking pale/clammy/flushed. The NP said any change was important to report to him and he would have expected the staff to have reported any of those to him at the time they happened. Interview on [DATE] at 3:06 PM with the DON who said she was here on Friday ([DATE]) but did not work over the weekend ([DATE] and [DATE]). The DON said she had no contact with Resident #1 nor did anyone bring anything to her attention about him either. The DON said she was called on Sunday around 4 PM by the staff who said Resident #1's blood pressure was low and his pulse was high. The DON said staff confirmed they had already called the doctor and were sending him to the hospital. The DON said she was told when the EMT's walked into his room he was not breathing so they had to start CPR on him. The DON said later on, LVN A called to tell her he had passed away. The DON said the next day on Monday ([DATE]) she began to in-service the staff on change of condition and notifications to the doctor. The DON said she started reviewing Resident #1's chart and talking to staff which resulted in finding out they did not notify the doctor when Resident #1 had a change in condition beginning on Friday ([DATE]). The DON said LVN A and LVN B should have notified the doctor immediately when it was reported he had a change in condition. The DON said she was told Resident #1 did not look good on Sunday morning and LVN B should have notified the doctor. The DON said LVN B did not notify the doctor and different staff, RN C and LVN F, had called the doctor and sent him to the hospital. The DON said even if Resident #1's vital signs were within normal limits during assessments by the nurses after a change of condition was reported, LVN A and LVN B still should have called the doctor to report they symptoms he was experiencing. The DON said the symptoms should have made it obvious to LVN A and LVN B that something was going on with him. The DON said LVN A and LVN B told her they did not call the doctor because his vital signs were normal during their assessments so they did not think there was a problem with him. The DON said just because a resident had a habit of something did not mean that was their normal. The DON said during the investigation, both LVN A and LVN B were suspended pending termination. The DON said neither LVN A or LVN B documented any of their assessments or vital signs taken during assessments with Resident #1 so she was not sure what they did or what their assessments found. The DON said all nurses had the number to contact the doctor to report any change in condition to them immediately. The DON said all nurses were aware that any change in condition, whether it was considered significant or not, was supposed to be immediately reported to the doctor. The DON said the purpose of reporting any change in condition to the doctor was so that they could get orders for labs or x-rays or something else to try and figure out what was happening to the resident. The DON said the communication also helped so that if the resident's condition got worse the doctor was already aware of their previous condition. The DON said she expected staff to notify the doctor as soon as the resident was noted to have a change in condition. The DON said in this case, Resident #1 had a change in condition on Friday under the care of LVN A and LVN B who should have contacted the doctor but did not. The DON said both LVN A and LVN B had been told by multiple staff about Resident #1's changes in condition. The DON said if the nurses did not notify the doctor of a change in condition with a resident a lot of different things could happen, death was one of those, and others could be the resident not getting the care they needed. Review of the facility's policy, revised [DATE], and titled Notifying the Physician of Change in Status reflected the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention.1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. This was determined to be a Past Non-Compliance Immediate Jeopardy on [DATE] at 5:14 PM. The DON was notified. The DON was provided with the IJ template on [DATE] at 5:14 PM. The facility took the following actions to correct the non-compliance prior to the survey: An in-service dated [DATE] reflected the following information given to staff: Change of Condition! Any change of condition is a reason for concern. If you notice a resident is not themselves, they are eating less, not drinking as much. State [sic] that they do not feel well, if you look at them and they do not look the same you must report to the Charge nurse [sic] immediately if you feel [sic] the Charge Nurse is not responding timely call the DON immediately at [the DON's phone number]. 77 staff had signed off they had received the information. An undated in-serviced reflected the following information give to staff: .Change of condition.If you notice any change of condition in a resident you are to immediately report it to the charge nurse. Change could be they just don't look themselves [sic]; they seem agitated and it's not their normal, their appetite has decrease, they are not wanting to drink anything. If you feel charge nurse is not responding or addressing, you are to call DON [DON's phone number]. This information was sent as a text message to 89 staff. Resident safe surveys were completed on [DATE] that did not result in any findings where residents felt staff did not listen to their concerns and act on them appropriately. An in-service dated [DATE] reflected the following information given to staff: Change of Condition Notification.Notify DON, Notify MD, Notify RP, Notify hospice if appropriate.All changes in condition must be reported and SBAR completed. This is mandatory. No exception. 77 staff had signed off they had received the information. An in-service dated [DATE] reflected staff had been given the steps on where to find and how to complete an SBAR in a resident's chart. 58 staff had signed off they had received the information. Review of an Employee Disciplinary Report, signed [DATE], reflected LVN A had been suspended pending an investigation related to allegations of documentation from an incident that happened on [DATE]. Review of an Employee Disciplinary Report, signed [DATE], reflected LVN B had been suspending pending an investigation related to employee misconduct from an incident that happened on [DATE]. Interviews on [DATE] from 12:03 PM to 3:06 PM with the following staff: MA D, CNA E, MA G, RN C, CNA H, CNA I, LVN F, LVN B, HA J, LVN A, and the DON confirmed they had been in-serviced regarding the following: any change of condition to a resident must be reported to the charge nurse, any change in condition must also be reported to the MD, any change in condition required that a SBAR must be completed, staff were aware of where to locate the SBAR and how to fill it out.

Based on 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 resident's choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to assess and follow-up on Resident #1's change of condition which began on [DATE] when he experienced lethargy, clammy skin, was unable to verbally talk to staff, and did not appear to be himself. Resident #1 was found on [DATE] around 4 PM by staff to have shortness of breath and appeared to be in distress where he was sent to the hospital and passed away. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for worsening conditions that have not been assessed or followed up on by staff which could lead to respiratory illnesses, hospitalization, and death. Findings: Review of Resident #1's Quarterly MDS Assessment, dated [DATE], reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 6 which indicated severe cognitive impairment. His MDS indicated he did not have behaviors of rejection of care. His active diagnoses included heart failure, renal insufficiency/renal failure/or end-stage renal disease (a condition where the kidneys can no longer function adequately), and non-alzheimer's dementia (a cognitive disorder severe enough to interfere with daily life). Review of Resident #1's Discharge summary, dated [DATE], reflected he discharged on [DATE] as he was sent to ER in cardiac/respiratory failure. Resident receiving CPR at time of discharge and passed in ER. Review of Resident #1's SBAR, dated [DATE], reflected the following information:-His blood pressure read 90/40-His pulse read 156-His respirations were 32-His temperature read 100.2 F-His O2 saturation read 79-His symptoms or signs were: Change in condition with decreased level of consciousness, fever, tachypnea, tachycardia, oxygen saturation dropped to 79% on room air. Use of accessory muscles to breathe. Review of Resident #1's care plan, revised on [DATE], reflected the following: Focus: Cancelled: [Resident #1] has Congestive Heart Failure.Interventions: Cancelled: Monitor/document/report to MD PRN any s/sx of Congestive Heart Failure.cool skin, dry cough.weakness.Cancelled: Monitor/document/report to MD PRN any s/sx of hypokalemia in residents receiving diuretic therapy: Fatigue, muscle, weakness, diminished appetite, nausea and vomiting.Focus: Cancelled: [Resident #1] has renal insufficiency r/t Kidney disease Stage 4.Interventions: Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; seizures. Review of Resident #1's Progress Notes for [DATE] reflected:-LVN A wrote on [DATE] at 8:24 PM that Resident #1 had refused his Albuterol Sulfate Inhalation Nebulization Solution-LVN B wrote on [DATE] at 8:57 AM that Resident #1 refused his Breo Ellipta Inhalation Aerosol Powder Breath Activated since he wasn't feeling well-RN C wrote on [DATE] at 4:30 PM the following The hospital ER called to request information about health history because the paramedics did not leave them the information that was sent with the resident. I was informed that the resident had expired and the [family member] was present at the ER.-RN C wrote on [DATE] at 7:35 PM the following The resident had a change in condition and is non responsive. Oxygen placed at 2 LPM via mask, MD, [family member] and 911 were notified. Review of Resident #1's [DATE] MAR reflected he refused his morning medications on [DATE] which consisted of bupropion, folic acid, magnesium, metformin, metoprolol succinate, potassium chloride, sertraline, and Eliquis.Further review reflected his blood pressure on [DATE] was 137/78 and on [DATE] it was 110/68. His pulse was 108 on [DATE] and 88 on [DATE]. Resident #1's hospital and EMS records were requested but not received prior to exit. Interview on the telephone on [DATE] at 10:53 AM with Resident #1's RP who said she felt if things happened differently last weekend then there would have been a different outcome for Resident #1. Resident #1's RP said someone had called her last Sunday ([DATE]) at 9:20 AM letting her know he had not eaten or drank fluids through the weekend. Resident #1's RP said she told them to offer Resident #1 a shake so he could have some sustenance but never heard back from the staff to know if he accepted the shake or not. Resident #1's RP said she got another call at 4 PM on Sunday ([DATE]) from a nurse who said Resident #1 was struggling to breathe and was running a fever. Resident #1's RP said she requested Resident #1 be sent to the hospital which the facility had planned to do. Resident #1's RP said she was told Resident #1 had passed away by the hospital staff. Interview on [DATE] at 12:03 PM with MA D said she worked with Resident #1 from Friday ([DATE]) to Sunday ([DATE]). MA D said she passed Resident #1 his medications which he accepted on Friday and Saturday, but he refused his medications on Sunday. MA D said on Sunday Resident #1 appeared flushed and his skin color was orange and pinkish in color on his face which was the only part of him she could see. MA D said it was not normal for Resident #1 to look that way, nor was it normal for him to refuse his medications. MA D said she reported her observations to LVN B who was caring for Resident #1. MA D said she did not see Resident #1 any other time after passing his medications to him. MA D said she had been in-serviced to let the nurse know any time there was a change to a resident and if the nurse was not listening to go to the ADON or DON about her observations. Interview on [DATE] at 12:13 PM with CNA E who said she worked with Resident #1 from Friday ([DATE]) to Sunday ([DATE]). CNA E said she worked from 6 AM to 6 PM with Resident #1 on Saturday and she noticed he had a change in condition and went to tell the nurse he was not himself. CNA E said she noticed this change in him shortly after breakfast because he did not look right or act right. CNA E said he could hardly talk to her when he was normally very talkative. CNA E said she also noticed he looked flushed and the color in his face was off. CNA E said the nurse she reported the change to was LVN B. CNA E said she was not sure what LVN B did after she reported the changes to her since she was busy caring for other residents. CNA E said she was told by LVN B to offer him a shake since he did not eat his breakfast that morning but he had refused it. CNA E told LVN B Resident #1 had refused the shake. CNA E said sometimes Resident #1 would eat all of his meal and other days he would not, but it just depended on the day. CNA E said when she came in on Sunday to care for Resident #1 she noticed he was in the same state as before until after 4 PM. CNA E said LVN B was Resident #1's nurse for part of the shift on Sunday and she reported to her that morning that Resident #1 still did not seem like himself. CNA E said RN C took over the shift and care for Resident #1 and she told RN C Resident #1 did not seem like himself which was why RN C and LVN F went to check on him around 4 PM. CNA E said she noticed he was struggling to breathe because he was taking shallow and quick breaths and was not opening his eyes or talking. CNA E said she had last checked on him at 2:45 PM and he seemed to be breathing well. CNA E said the nurses began to apply oxygen to Resident #1 and had planned to send him to the hospital. CNA E said the next thing she knew Resident #1 had CPR being performed on him and she was not sure what happened after that. CNA E said she knew to let the nurse know any time a resident had a change to their condition and if they were not listening then she was supposed to go the ADON or DON. Interview on [DATE] at 12:30 PM with MA G who said she did not care for Resident #1 from Friday ([DATE]) to Sunday (07/19.26) but she had cared for him in the past. MA G said CNA E asked her to check on Resident #1 on Saturday because she noticed he was not himself. MA G said when she saw Resident #1 he did not look good, he was not talking and the look on his face was not his normal. MA G said she saw Resident #1 was red in the face but it could have been from his breathing treatment. MA G said she could just tell by looking at someone they did not look good or like themselves after caring for them for a while. MA G said she did not check on Resident #1 the rest of the weekend because she was busy working on other hallways. MA G said she knew to report any change to the nurse and if they did not listen she would let the ADON and DON know. Interview on the telephone on [DATE] at 12:50 PM with RN C who said she was recently hired 2 months ago and only worked every other weekend. RN C said she worked at the facility on Saturday ([DATE]) and Sunday ([DATE]) as the weekend supervisor. RN C said she was not told about any changes of condition for any residents on Saturday ([DATE]). RN C said she went in to Resident #1's room to provide wound care to him that day and she noticed his color was normal and his skin was cool to the touch. RN C said she came to work on Sunday ([DATE]) and had to take over the shift after LVN B left in the afternoon. RN C said CNA E had reported to her Resident #1 had a change in condition but she was not familiar with the resident and she was conducting a tour of the facility with a prospective resident's family. RN C said she told CNA E that since the ADON was in the building and was more familiar with the resident she should let him know. RN C said when LVN B left for her shift nothing about Resident #1 was given in report. RN C said later on during the day she was asked by CNA E to check on him because she noticed he was not doing well. RN C said she and LVN F went together to Resident #1's room and found he had shortness of breath which was totally different than what he was like the day before. RN C said they began taking his vital signs which were 100.2 F, an O2 saturation of 79%, his pulse was 156 beats per minute, and his blood pressure was 90/50. RN C said they began calling the resident's daughter, the doctor, and 911 to send him out to the hospital. RN C said she got the resident set up with an oxygen concentrator to increase his O2 saturation and next thing she knew he was not breathing and started compression on him. RN C said she was in-serviced and knew to report any change to a resident to the provider immediately. Interview on [DATE] at 1:08 PM with CNA H who said she did not care for Resident #1 on Saturday or Sunday ([DATE] or [DATE]) but had assisted another aide in repositioning him in his bed both days. CNA H said when she saw him on Saturday he did not look like he felt good and was not his normal self. CNA H said she had not seen him in a while but could tell there was a big difference in him. CNA H said she saw CNA E tell LVN B the resident was not his normal self but she was not sure what LVN B did after that. CNA H said she helped to reposition him on both days and he was the same both days; he looked clammy and sick in general. CNA H said normally he was very talkative with staff but when she went in there to reposition him he was not talking to the staff. CNA H said she knew to report to the nurse when a resident had a change in condition and if they did not listen to go to the ADON or DON. Interview on [DATE] at 1:18 PM with CNA I who said she worked with Resident #1 on Saturday ([DATE]). CNA I said he seemed sleepy and ate a little at breakfast and lunch. CNA I said she told the nurse he was not fully awake and did not eat much since he was usually a big eater. CNA I said she was not sure what the nurse did with the information. CNA I said she reported any change to a resident to the nurse and if the nurse did not listen she would go to the ADON or DON. Interview on [DATE] at 1:28 PM with LVN F who said worked on Sunday ([DATE]) but was not Resident #1's assigned nurse. LVN F said he was not well when she saw him and his vital signs were poor; his heart rate was fast and his oxygen saturation was low, requiring oxygen to be applied. LVN F said she only saw him around 4 PM on Sunday after CNA E asked her to go and check on him. LVN F said RN C went to the room with her and they both began to assess him. LVN F said during their assessment they noted his O2 saturation was in the 70's so they applied oxygen to him at 2 or 3 liters to help him breathe. LVN F said they made the determination he needed to go to the hospital so they called the doctor, the RP, and 911. LVN F said before he left the facility he did not have a pulse and CPR was initiated. LVN F said she was in-serviced and knew to report any change to a resident to the provider immediately. Interview on the telephone on [DATE] at 1:46 PM with LVN B who said she worked with Resident #1 on Friday through Sunday ([DATE] to [DATE]). LVN B said on Friday she was told by the aide that he was not acting like himself, that he was weaker than normal but not that much. LVN B said she went to check on him, took his vital signs, and completed an assessment; she said everything was normal with Resident #1, including his vital signs. LVN B said nothing else was reported to her during her shift that day and she did not notice anything else wrong with him. LVN B said he had refused his nebulizer treatment that day but that was normal for him. LVN B said on Saturday he was about the same but she was told he had thrown up and thought it was because he had not been eating much and took his medications on an empty stomach. LVN B said she was not sure who reported to her that he had thrown up and it was already cleaned up by the time she was told about it. LVN B said she checked on Resident #1 after being told this and he was his normal self. LVN B said on Friday he was weak and tired and was the same on Saturday. LVN B said she did not take his vital signs or do an assessment on him because she thought it was related to him taking his medications on an empty stomach which would make anyone sick and possibly throw up. LVN B said she was told by the aide on Saturday that he was refusing to eat which was not normal for him. LVN B said she went to his room multiple times during her shift on Saturday to check on him and she never saw a major change in him. LVN B said she also did not document her assessments or check ins on him or any of the vital signs she took during her assessments. LVN B said on Sunday he was not any better or worse and he had reported to her he had felt about the same as the day before. LVN B said she did not take his vital signs or do an assessment on him on Sunday when she checked on him. LVN B said she did not report to the doctor any of the changes he experienced or that he had vomited on Saturday. LVN B said all the symptoms he experienced did not seem as if they were that much of a change for him to warrant reporting them to the doctor. LVN B said she knew he seemed weaker but it was not enough of a change to call the doctor about so she just kept monitoring him. LVN B said she left early on Sunday during her shift and gave report to RN C but did not say anything about Resident #1 to her. LVN B said she knew to report a significant change in condition to the doctor, or if the resident's vital signs were not within normal limits. LVN B said she had been in-serviced that any change in condition should be reported immediately to the doctor. Follow-up interview on [DATE] at 2:05 PM with CNA E who said she could not remember if Resident #1 had thrown up or not, but if he did she reported it to the nurse immediately. Interview on the telephone on [DATE] at 2:14 PM with HA J who said she worked with Resident #1 on Friday ([DATE]). HA J said she noticed he did not eat his dinner and she was worried about him not eating so she asked why he did not eat. HA J said no sound came out of his mouth and he just mouthed the word no. HA J said that was weird because he liked to eat, so she asked if wanted a shake instead and again he mouthed the word no. HA J said she reported this change to LVN A who said she would be down to his room in a bit to check on him. HA J said she told LVN A it seemed as if Resident #1 was running a fever because when she touched him he felt warm. HA J said LVN A told her she checked on him and his vital signs were good. HA J said normally Resident #1 was very talkative with staff so it was strange and not good that he was only able to whisper or mouth words to the staff. HA J said she cared for him Saturday ([DATE]) night as well and he was a little better than Friday but was still not talking and she could tell he was not feeling well. HA J said she reported the change to LVN A again because Resident #1 looked like he was about to die since he was so pale and sick looking. HA J said he was not bouncing back at all and she asked if he wanted to go to the hospital and he mouthed the word no. HA J said she was in-serviced to report any change in a resident to the nurse and if the nurse did not listen to tell the ADON or DON. Follow-up interview on [DATE] at 2:24 PM with CNA I who said Resident #1 did not throw up during her shift that she could recall, but if he did she reported it to the nurse immediately. Interview on the telephone on [DATE] at 2:27 PM with Resident #1's Physician who said he was on vacation so had limited information. Resident #1's Physician said he was contacted on Sunday ([DATE]) about a change in condition before he passed away later that day. Resident #1's Physician said he did not have the on-call phone the staff may have used to communicate at other times with the provider. Interview on the telephone on [DATE] at 2:41 PM with the ADON who said he was on vacation that week and was not at work. The ADON said he did go to the facility for a few hours on Sunday ([DATE]) to meet a new admission but he was not there to work. The ADON said he asked in general how the residents were doing and was told by CNA E Resident #1 had not been eating again but that was not uncommon for him. The ADON said he looked in Resident #1's chart and saw that the staff were documenting he was eating so he told CNA E to be sure to let the nurse know about it. The ADON said he left after that and was not involved in anything else. Interview on the telephone on [DATE] at 2:46 PM with LVN A who said she cared for Resident #1 from Friday to Sunday ([DATE] to [DATE]). LVN A said she noticed he had been declining for a while and someone commented to her on Saturday that he was not feeling well. LVN A said she talked with him for a while and offered a breathing treatment which he refused and pain medications which he refused as well. LVN A said while she was assessing him she went through all his systems and could not pin point what was wrong. LVN A said she offered to send him to the hospital and he did not want that. LVN A said she thought she had charted all of her assessments and check ins with him but had not. LVN A said on Friday while she was caring for Resident #1 she noticed he was quiet and did not have a lot to say, but his vital signs were good. LVN A said everything seemed fine and he was at his baseline. LVN A said she noted the same on Saturday as well. LVN A said HA J told her he was not feeling good but she had already taken his vital signs but she got another set and talked to him for a while. LVN A said on Sunday when she got to work he had already passed away. LVN A said she did not report anything to the doctor because no one had reported any changes to her and nothing was significant enough to tell the doctor about. LVN A said she had been in-serviced that when someone reported a change in a resident she was supposed to do an assessment and report it to the doctor immediately. Interview on the telephone on [DATE] at 2:52 PM with the NP who said he had the on-call phone last weekend from Friday to Sunday ([DATE] to [DATE]). The NP said the only time he heard from the facility regarding Resident #1 was on Sunday at 9:35 PM where he received a text saying he had passed away at the ER. The NP said he was not aware that Resident #1 went to the ER. The NP said normally he would be notified if a resident had a change in condition. The NP said staff were supposed to text if they had any resident who had a decline in health status that would require an intervention. The NP said it would have been appropriate to report any changes to him in Resident #1's status and he would have gone through the steps with staff to see what could have been done for him. The NP said he wanted to know when a resident had a change in their status even if it was slight or small. The NP said it was normal for staff to report to him if a resident was not eating, looking lethargic, appeared sleepy, or was looking pale/clammy/flushed. The NP said any change was important to report to him and he would have expected the staff to have reported any of those to him at the time they happened. Interview on [DATE] at 3:06 PM with the DON who said she was here on Friday ([DATE]) but did not work over the weekend ([DATE] and [DATE]). The DON said she had no contact with Resident #1 nor did anyone bring anything to her attention about him either. The DON said she was called on Sunday around 4 PM by the staff who said Resident #1's blood pressure was low and his pulse was high. The DON said staff confirmed they had already called the doctor and were sending him to the hospital. The DON said she was told when the EMT's walked into his room he was not breathing so they had to start CPR on him. The DON said later on, LVN A called to tell her he had passed away. The DON said the next day on Monday ([DATE]) she began to in-service the staff on change of condition and notifications to the doctor. The DON said she started reviewing Resident #1's chart and talking to staff which resulted in finding out they did not notify the doctor when Resident #1 had a change in condition beginning on Friday ([DATE]). The DON said LVN A and LVN B should have notified the doctor immediately when it was reported he had a change in condition. The DON said she was told Resident #1 did not look good on Sunday morning and LVN B should have notified the doctor. The DON said LVN B did not notify the doctor and different staff, RN C and LVN F, had called the doctor and sent him to the hospital. The DON said even if Resident #1's vital signs were within normal limits during assessments by the nurses after a change of condition was reported, LVN A and LVN B still should have called the doctor to report they symptoms he was experiencing. The DON said the symptoms should have made it obvious to LVN A and LVN B that something was going on with him. The DON said LVN A and LVN B told her they did not call the doctor because his vital signs were normal during their assessments so they did not think there was a problem with him. The DON said just because a resident had a habit of something did not mean that was their normal. The DON said during the investigation, both LVN A and LVN B were suspended pending termination. The DON said neither LVN A or LVN B documented any of their assessments or vital signs taken during assessments with Resident #1 so she was not sure what they did or what their assessments found. The DON said all nurses had the number to contact the doctor to report any change in condition to them immediately. The DON said all nurses were aware that any change in condition, whether it was considered significant or not, was supposed to be immediately reported to the doctor. The DON said the purpose of reporting any change in condition to the doctor was so that they could get orders for labs or x-rays or something else to try and figure out what was happening to the resident. The DON said the communication also helped so that if the resident's condition got worse the doctor was already aware of their previous condition. The DON said she expected staff to notify the doctor as soon as the resident was noted to have a change in condition. The DON said in this case, Resident #1 had a change in condition on Friday under the care of LVN A and LVN B who should have contacted the doctor but did not. The DON said both LVN A and LVN B had been told by multiple staff about Resident #1's changes in condition. The DON said if the nurses did not notify the doctor of a change in condition with a resident a lot of different things could happen, death was one of those, and others could be the resident not getting the care they needed. Review of the facility's undated policy titled Completing an SBAR reflected the following: An SBAR is required when you are reporting a change in condition to the physician or NP.If not an emergent situation, the SBAR should be completed and read to the doctor or NP so that they are well informed of the resident's condition.Begin completing the SBAR as you would any other assessment. This was determined to be a Past Non-Compliance Immediate Jeopardy on [DATE] at 5:14 PM. The DON was notified. The DON was provided with the IJ template on [DATE] at 5:14 PM. The facility took the following actions to correct the non-compliance prior to the survey: An in-service dated [DATE] reflected the following information given to staff: Change of Condition! Any change of condition is a reason for concern. If you notice a resident is not themselves, they are eating less, not drinking as much. State [sic] that they do not feel well, if you look at them and they do not look the same you must report to the Charge nurse [sic] immediately if you feel [sic] the Charge Nurse is not responding timely call the DON immediately at [the DON's phone number]. 77 staff had signed off they had received the information. An undated in-serviced reflected the following information give to staff: .Change of condition.If you notice any change of condition in a resident you are to immediately report it to the charge nurse. Change could be they just don't look themselves [sic]; they seem agitated and it's not their normal, their appetite has decrease, they are not wanting to drink anything. If you feel charge nurse is not responding or addressing, you are to call DON [DON's phone number]. This information was sent as a text message to 89 staff. Resident safe surveys were completed on [DATE] that did not result in any findings where residents felt staff did not listen to their concerns and act on them appropriately. An in-service dated [DATE] reflected the following information given to staff: Change of Condition Notification.Notify DON, Notify MD, Notify RP, Notify hospice if appropriate.All changes in condition must be reported and SBAR completed. This is mandatory. No exception. 77 staff had signed off they had received the information. An in-service dated [DATE] reflected staff had been given the steps on where to find and how to complete an SBAR in a resident's chart. 58 staff had signed off they had received the information. Review of an Employee Disciplinary Report, signed [DATE], reflected LVN A had been suspended pending an investigation related to allegations of documentation from an incident that happened on [DATE]. Review of an Employee Disciplinary Report, signed [DATE], reflected LVN B had been suspending pending an investigation related to employee misconduct from an incident that happened on [DATE]. Interviews on [DATE] from 12:03 PM to 3:06 PM with the following staff: MA D, CNA E, MA G, RN C, CNA H, CNA I, LVN F, LVN B, HA J, LVN A, and the DON confirmed they had been in-serviced regarding the following: any change of condition to a resident must be reported to the charge nurse, any change in condition must also be reported to the MD, any change in condition required that a SBAR must be completed, staff were aware of where to locate the SBAR and how to fill it out.

Based on observations, interviews, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 2 of 8 residents (Residents #13, and 55) reviewed for ADL care. The facility failed to ensure nail care, to include trimming and cleaning, was provided to Residents #13, and #55. The failure placed the residents at risk of hygiene and safety risks such as nail tearing, injury, and functional difficulties. Findings included: 1.Record review of Resident #13's Face Sheet, dated 02/26/26, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #13's Quarterly MDS, dated [DATE], reflected the resident had diagnoses that included: Cerebral Infarction with hemiplegia (Stroke resulting in paralysis of one side of body), Diabetes Mellitus (chronic condition in which the body does not regulate blood sugar levels), Lack of coordination, and unspecified abnormalities of gait and mobility. The MDS reflected Resident #13 had a BIMS of 15, indicating he was cognitively intact. Record review of Resident #13's Care Plan, revised 02/20/26, revealed the resident had an ADL self-care performance deficit with the following intervention, .Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. The care plan also revealed the resident had hemiplegia (paralysis of one side of the body) with an intervention to assist with ADLs and mobility and Resident #13 had Diabetes Mellitus with interventions to check body for skin breakdown and refer to podiatrist/foot care nurse to monitor foot needs. Record review of Resident #13's progress notes revealed no documentation of refusal of fingernail care. Observation and interview on 02/24/26 at 11:40 AM revealed Resident #13 had long fingernails on both his hands, measuring approximately 1/4 - 1/2 inch long with jagged, sharp edges and dark debris underneath. Observation revealed a slight contracture to Resident #13's left hand with a missing fingertip to his left thumb. Resident #13 stated he was unable to move his left arm. Resident #13 stated he wished his fingernails were shorter and was unable to recall when they were last trimmed. He stated the Treatment Nurse usually trimmed his fingernails. Observation and interview on 02/25/26 at 4:17 PM revealed Resident #13 sitting in the lobby on a recliner. Resident #13 stated his nails had not been cut. He stated the Treatment Nurse typically trimmed them for him because she was good at it. Resident #13 stated no one had offered to trim them and he had told his aide. Resident #13 stated he had wanted them cut for a couple of weeks. Observation of fingernails revealed long fingernails on both hands with jagged edges. Observation and interview on 02/26/26 at 9:04 AM revealed Resident #13 with fingernails ranging from 1/4 - 1/2 inch long on both hands. Resident #13 stated he received a shower last night. Resident #13 stated he wanted his fingernails cut because they were sharp. No open areas or redness was observed. Interview on 02/26/26 at 11:40 AM with CNA A revealed she worked regularly with Resident #13. CNA A stated Resident #13 was diabetic, and the nurse trimmed his fingernails. During the interview, CNA A entered Resident #13's room and stated his fingernails were long and needed to be cut. CNA A stated fingernails were trimmed during their shower if the resident was not a diabetic. CNA A stated the nurse was responsible for trimming Resident #13's fingernails. CNA A stated she had noticed Resident #13's long fingernails and let nurses know. She stated she was unable to recall all the nurses she reported the long fingernails to, but she had told LVN B. CNA A stated Resident #13 did not refuse fingernail trims. CNA A stated the risk of long fingernails was the residents scratching themselves. Interview on 02/26/26 at 11:51 AM with the Treatment Nurse revealed Resident #13 preferred that she trimmed his nails. The Treatment Nurse stated Resident #13, or his CNA would let her know when he wanted them trimmed. She stated she was not aware that Resident #13's fingernails were long. The Treatment Nurse stated the CNAs were responsible for checking on his shower days and notifying her. The Treatment Nurse stated the nurses were responsible for trimming his fingernails because he was diabetic. She stated the risk of having long fingernails was skin tears and scratches. Interview on 02/26/26 at 11:54 AM with LVN B revealed she had not observed Resident #13's long fingernails because he was new to her hallway. LVN B stated Resident #13 did not refuse any care. LVN B stated she did not recall any CNAs that notified her of his long fingernails. LVN B stated the nurses were responsible for ensuring Resident #13's fingernails were trimmed because he was diabetic. LVN B observed Resident #13's fingernails and stated they were long and sharp. She stated the risk of long fingernails was an infection risk. Interview on 02/26/26 at 12:07 PM with HA C revealed she did evening showers for residents. HA C stated she did shower Resident #13 on 02/25/26. She stated she was not aware of Resident #13's long fingernails and must have missed them. HA C stated she would notify the nurse when the nails needed to be trimmed. HA C stated the risk of residents having long fingernails was skin tears and infection control. Interview on 02/26/26 at 3:20 PM with the ADON revealed he expected residents' nails to be kept short and clean. The ADON stated fingernails should be checked every shower. He stated he expected the aides to let the nurse know or cut them if the resident was not diabetic. The ADON stated he was not aware of Resident #13's long fingernails and stated Resident #13 did not refuse fingernail trims. The ADON stated the nurses were responsible for cutting Resident #13's fingernails since he was diabetic. The ADON stated the risk of long fingernails was scratching themselves or others. He also stated debris could get underneath and be an infection risk. 2.Record review of Resident #55's Quarterly MDS assessment, dated 11/14/25, revealed Resident #55 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #55 had cognition intact with a BIMS score of 13. Resident #55 required partial/moderate assistance from staff with shower/bathes and set up / clean up with personal hygiene. Active diagnoses included high blood pressure, high blood sugar, end – stage renal disease (when kidneys can no longer function adequately to sustain life without treatment). Review of Resident #55's care plan, undated, revealed Resident #55 had a Self-Care Performance Deficit. Goal: Resident will maintain or improve current level of function personal hygiene. Interventions included to praise all efforts at self-care. Encourage resident to discuss feelings about self-care deficit. Encourage resident to use bell to call for assistance. Review of Resident #55's care plan, undated, revealed he had Diabetes. Goal: Resident will have no complications related to diabetes. Interventions included to monitor/document/report to physician as needed for signs and symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation. Interview and Observation on 02/24/26 at 11:15 AM with Resident #55 revealed him laying in bed, Resident #55 stated, I wished they would cut my nails, they are too long. Resident #55 stated I have to have help to have them cut because I have nothing to cut them with. Observation of Resident #55's nails revealed they were at least one half inch long with black debris underneath each nail. According to Resident #55, he did not recall the last time anyone had trimmed his nails, or the last time he had washed his hands. Interview on 02/25/26 at 4:01 PM with LVN F revealed aides were responsible for resident nail care during shower days. According to LVN F Resident #55 refused showers a lot of the time. LVN F stated she had noticed the dark debris underneath Resident #55's nails and stated, [Resident #55] had dark debris underneath his nails because he scratched and dug in his bottom. LVN F stated not having clean hands and nails placed him at risk of infection and cross contamination. Interview on 02/26/26 at 11:50 AM with LVN B revealed CNAs are responsible for completing Resident #55's nail care on Monday, Wednesday, and Fridays during his shower. LVN B stated Resident #55 will refuse, however, when you return to ask him a second time he will agree to the shower. LVN B stated Resident #55 took a shower on 02/25/26 on the evening shift. LVN B stated if there was an issue with showers or nail care the aides were to inform the nurses so that they could address the issue with the resident and document. LVB stated she had noticed the debris under his nails. LVN B stated having debris under his nails placed him at risk of neglect, illnesses, and infections especially since he liked to eat finger foods. Interview on 02/26/26 at 2:58 PM with CNA A revealed Resident #55's shower days were Monday, Wednesday, and Fridays during the 2-10:00 PM shift. CNA A stated that CNAs providing the shower were responsible for ensuring resident nails were cleaned and trimmed. CNA A stated CNAs were supposed to indicate whether nailcare was completed or refused on the shower sheets so that the Charge Nurses could address any refusals. CNA A stated she worked with Resident #55 to complete hand hygiene and trim his nails however his hands shake and that makes him nervous and he will refuse you to trim his nails. CNA A stated Resident #55 dug in his bottom which caused him to have the debris under his nails. CNA A stated completing hand hygiene with Resident #55 was a daily thing to do, not doing so placed him at risk of health hazards, pink eye, touching others could cause infections. Interview on 02/26/26 at 4:09 PM with the Administrator revealed she expected all nails to be kept clean and trimmed if residents allowed. She stated the aides were responsible unless the resident was diabetic, then the nurse was responsible. The Administrator stated the risk of long nails was puncturing the skin, especially with Resident #13's paralyzed hand and with Resident #55's digging habits. She also stated it was an infection control risk because the nails could become dirty underneath. Record review of facility Nail Care policy, undated, reflected the following: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing , and cuticle care and is usually done during the bath.GoalsNail care with be performed regularly and safely. .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #86) and 1 of 3 staff (HA C) reviewed for infection control. 1. A medical equipment provider failed to put on PPE prior to entering Resident #86's room, while the resident was on isolation for COVID-19. 2. The facility failed to ensure HA C performed hand hygiene between residents while passing meal trays on E Hall.This failure could place residents at risk of being infected by staff/providers in contact with other residents with infections. Findings included: 1. Review of Resident #86's admission MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The residents' diagnoses included cancer, atrial fibrillation (rapid, irregular, uncoordinated beating of the heart's upper chamber), non-Alzheimer's dementia, and respiratory failure. The MDS reflected the resident had a BIMS of 13 which indicated his cognition was intact. Review of Resident #86's care plan initiated on 02/04/26 reflected the resident was at risk for signs and symptoms of COVID-19. Intervention included to follow facility protocol for COVID-19 screening/precautions. Interview on 02/24/26 at 9:35 AM with the Administrator revealed they had admitted 5 residents from their sister facility so they could be cohorted appropriately for COVID-19. The Administrator said 4 of the residents were warm (Resident #86), which meant they had been exposed to COVID-19 and 1 resident was hot, which meant he had confirmed COVID-19. Review of the sign outside of Resident #86's room reflected the following: STOP TRANSMISSION-BASED PRECAUTIONSBefore entering this room, you MUST:Wear N95 or higher-level respirator.Wear Eye Protection (goggles or face shield)Wear GownPerform Hand Hygiene when entering and exiting.Keep door closed (if possible)Limit resident movement outside the room-mask required if leaving.Use dedicated or disinfected equipmentVisitor: Check with nursing staff before entering. Observation on 02/24/26 at 11:44 AM revealed the door to Resident #86's room was open and the resident was laying in bed awake. There was a medical equipment provider observed to be inside Resident #86's room with no PPE on, as he was putting a bed together. The Regional Nurse Consultant approached the provider and asked him to put on PPE from a PPE cart outside the room which contained N95 masks, gowns, gloves, and face shields, because the resident was in isolation. The provider stepped out of the room and put the appropriate PPE on as directed by the Regional Nurse Consultant. Interview on 02/24/26 at 11:53 AM with the Medical Equipment Provider revealed he was not told Resident #86 was in isolation and he needed to wear PPE prior to entering the room and he also said he did not see the sign posted outside the room. Interview on 02/26/26 at 11:05 AM with the ADON revealed full PPE, such as gloves, gown, N95 mask, and shields should be worn prior to entering the COVID-19 isolation rooms and that included staff and outside providers. The ADON said PPE should be worn for protection of the residents and others to keep away the transmission of infections. 2. Observation on 02/25/26 from 1:30- 1:50 PM of lunch trays being passed on E Hall revealed that HA C passed meal trays to 3 rooms on the hall and failed to perform hand hygiene between each resident. HA C was observed to touch resident's floor mats, wheelchairs, and other personal items between each room, without any form of hand hygiene. Interview on 02/25/26 at 2:46 PM with HA C revealed that she worked at this facility as a Hospitality Aide for about a year and half. She revealed that she had had training on hand hygiene and thought that she used the hand sanitizer located on the hall between each tray. HA C revealed that hand hygiene should be performed between each resident, before leaving the room if you come in contact with the resident or their personal belongings, or after performing cares. She revealed that she did not sanitize between residents. Interview on 02/26/26 at 4:00 PM with the ADON revealed that all staff had been inserviced on using proper hand hygiene. The ADON stated it was expected that when staff were passing food trays or helping with meals each staff should use hand hygiene by washing their hands or using hand sanitizer between residents. ADON stated not using hygiene between residents would place residents at risk of cross contamination. Interview on 02/26/2026 at 4:16 PM with the Administrator revealed hand hygiene was expected to be completed while passing meal trays. The Administrator stated staff were to clean their hands before touching any tray and upon leaving resident rooms. The Administrator stated that not completing hand hygiene placed residents at risk of cross contamination and illness. Review of the facility's policy titled Infection Control Plan: Overview updated on 03/2024 reflected the following: Infection ControlThe facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. .1. Hand HygieneHand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:.Before and after eating or handling food.Before and after assisting a resident with meals.After handling soiled or used linens, equipment, or utensils. .Personal Protective EquipmentHCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use.N95 filters or higher, gown, gloves, eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #12) reviewed for care plans. The facility failed to ensure Resident #12's comprehensive care plan was updated to reflect his G-tube was changed in-house, as required. This failure could place the residents at risk of not receiving the necessary care and services needed. Findings included: Record review of Resident #12's Face Sheet, dated 02/26/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #12's Quarterly MDS Assessment, dated 12/2/25, reflected the resident had the following diagnoses: Cerebral Palsy (neurological disorder caused by damage to the developing brain), Severe intellectual disabilities (significant cognitive impairment in daily functioning), Dysphagia (Difficulty swallowing), Gastrostomy status (presence of a G-tube used for nutrition, hydration, or medication administration), Paraplegia (paralysis of lower half of the body). The MDS also reflected that the resident had a BIMS score of 0, indicating he was severely cognitively impaired. Record review of Resident #12's Care Plan, revised 02/23/26, reflected the resident had an ADL self-care performance deficit with an intervention that he had a G-tube and was fed by nurses. The care plan reflected Resident #12 had a terminal prognosis and was receiving hospice services. The care plan also reflected the following, [Resident #12] requires tube feeding r/t dysphagia. Sometimes he pulls tube out and sent to ER for replacement.Interview on 02/24/26 at 3:35 PM with RN D revealed she had replaced Resident #12's G-tube in the facility when it became dislodged. RN D stated she notified the physician to obtain an order and had previously completed competency training for G-tube replacement. RN D stated that Resident #12's family refused for him to be sent to the hospital, so it had been changed in the facility since she had been working with him. RN D reviewed the current care plan during interview and stated the care plan had not been updated to reflect the proper interventions to change in-house instead of transfer to the ER. RN D stated it was the nursing team's responsibility to ensure the care plan was accurate. RN D stated the risk of not updating the care plan could have resulted in Resident #12 being sent to the ER, which was against the family's wishes. She stated the care plan updates were important, so all staff were on the same page. Interview on 02/24/26 at 3:25 PM with Family Member #1 revealed she had no concerns with Resident #12's G-tube. She stated when Resident #12's tube needed replaced; the nurse replaced it at the facility. Family Member #1 stated she did not want Resident #12 sent to the hospital, as leaving his normal environment made his condition worse. Interview on 02/25/26 at 12:04 PM with the Regional Nurse Consultant revealed Resident #12 was not being sent to the ER for G-tube replacement. The Regional Nurse Consultant reviewed Resident #12's care plan and stated it had not been updated and continued to reflect transfer to ER for G-tube replacement. The Regional Nurse Consultant stated the care plan needed to follow the plan of care for Resident #12, which was replacing the G-tube in house if dislodged. She stated the care plan should be reviewed Quarterly and as needed with changes. She stated it was the whole IDT's responsibility to ensure care plans were updated, but since it was a nursing care issue, the supervising nurse was overall responsible. The Regional Nurse Consultant stated the risk of not updating the care plan could have caused confusion among staff and resulted in transfer to the ER against the family's wishes. Interview on 02/26/26 at 11:14 AM with the ADON revealed his expectation for Resident #12's G-tube replacement was if it became dislodged, the nurse could replace it with a physician order and after completing competency training. The ADON stated Resident #12's family refused transfer to the ER, so the G-tube was changed in-house since admission. The ADON stated care plans were to be reviewed quarterly and as needed. The ADON stated Resident #12's care plan had not been updated to reflect his current plan of care and continued to indicate transfer to ER if G-tube needed to be replaced. The ADON stated it was important to update the care plan, so all staff understood expectations and plan of care. He stated the risk of not updating the care plan was that a new nurse could have sent Resident #12 to the ER, causing distress to the family and possible trauma to Resident #12. The ADON stated it was all staff's responsibility to update the care plan, but the administrative nursing team held overall responsibility. Interview on 02/26/26 at 12:14 PM with MDS E revealed the care plans were developed as a team effort and each department completed their respective sections. She stated care plans were discussed with the IDT quarterly, and during morning meetings when changes were identified. MDS E stated she or the nursing team should have updated Resident #12's care plan to reflect the in-house G-tube replacement. MDS E stated it was important for care plans to be updated to stay current on the residents' needs to ensure they received proper care. Interview on 02/26/26 at 4:06 PM with the Administrator revealed that MDS and nursing managers were responsible for updating care plans. She stated it was important that the care plan be updated to accurately reflect the resident's plan of care and individual needs. The Administrator stated the nursing managers should have updated Resident #12's care plan when the G-tube began being replaced in the facility. The Administrator stated the care plans were reviewed quarterly and revised as needed. Record review of the facility's policy, Comprehensive Care Planning, undated, reflected the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #61) of three residents reviewed for pressure ulcers.The Wound Care Nurse failed to re-clean the wound to Resident #61's right heel after she put his foot down on the bed with the wound exposed to the drawsheet under the resident. This failure could place residents at risk for deterioration of existing wounds/skin injuries. Findings included:Review of Resident #61's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The residents' diagnoses included heart failure, paraplegia, cognitive communication deficit, pressure ulcer of right buttock, and pressure ulcer of right heel. Resident #61 had a BIMS of 6 which indicated his cognition was severely impaired. The MDS further reflected the resident had a pressure ulcer/injury, a scare over bony prominence.Review of Resident #61's care plan revised on 08/01/25 reflected the resident had a pressure ulcer and was at risk for impaired skin integrity related noncompliance with treatment plan, impaired mobility, and cognitive impairment; right heel-stage 4. Interventions included to administer treatments as ordered and monitor for effectiveness. Review of Resident #61's Order Summary Report for February 2026 reflected the following: Cleanse right heel stage IV with wound cleanser, pat dry with gauze 4X4, apply medi honey to slough, collagen to pink tissue and calcium alginate and cover with dry dressing 3x a week and PRN.Mon, Wed, Fri for wound healingObservation on 02/26/26 at 9:25 AM of Resident #61's wound care revealed the resident was alert and lying in bed. The Wound Care Nurse put on gloves, took/cut off the resident's bandage off the resident's right foot. The Wound Care Nurse took off her gloves and applied hand sanitizer and put on new gloves. The Wound Care Nurse cleansed the heel wound and applied gauze on the wound and put the resident's foot on the bed, and the gauze served as a barrier between the wound and the bed. The Wound Care Nurse picked up the resident's foot and cleansed the wound again and when she placed the foot back on the bed, the barrier gauze slipped up the foot, and the heel wound was placed the drawsheet under the resident. The Wound Care Nurse proceeded to apply the wound treatment and dress it and did not reclean the wound after it was placed on the drawsheet with no barrier. Interview on 02/26/26 at 2:15 PM with the Wound Care Nurse revealed she would have a CNA assist her and hold Resident #61's foot during wound care. The Wound Care Nurse said she put a gauze on the resident's heel to use as a barrier and did not notice the gauze move and thought it was still protecting the heel. The Wound Care Nurse said it was important for the wound not to touch the bed or drawsheet after it had been cleaned because it would introduce bacteria and cause infection. Interview on 02/26/26 at 11:00 AM with the ADON revealed open wounds should not touch surfaces until it is clean, treated and bandaged to prevent the introduction of new bacteria and keep the wound free of infection. Review of the facility's policy titled Pressure Injury: Prevention, Assessment and Treatment revised on 05/05/25 reflected the following: Procedure1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury and infection.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three of six residents (Residents #1, #3 and #2) reviewed for abuse.1. The facility failed to ensure Resident #3 did not kiss Resident #1 without her consent on 05/23/25.2. The facility failed to ensure LVN G did not yell at Resident #2. These failures could place residents at risk for injury or psychosocial harm. Findings included:1. Record review of Resident #1's admission Record, dated 07/17/25, reflected a [AGE] year-old female who admitted to the facility on [DATE].Record review of Resident #1's Quarterly MDS Assessment, dated 07/01/25, reflected she had a BIMS score of 06, which indicated moderate cognitive impairment. Her active diagnoses included non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform daily activities), anxiety disorder (a mental health condition characterized by excessive fear or anxiety that interferes with daily activities), and depression (a mood disorder that causes persistent feelings of sadness and loss of interest).Record review of Resident #1's care plan reflected the following: Focus: Resident has a history of attention seeking behaviors from the opposite sex.Interventions: Monitor resident for behaviors and report immediately. Date initiated: 05/23/25. Record review of Resident #1's Progress Notes reflected the following:- 05/23/25 at 11:57 AM, the DON made the following entry: Resident sitting on sofa in lobby with another resident behind her. Male resident was kissing all over resident's face and resident was holding her head down while male resident was attempting to raise resident's face by placing his hand underher [sic] chin. Resident states she told male resident to stop but he wouldn't. When male resident saw staff he immediately stopped and walked away from resident.- 05/23/25 at 12:30 PM, the SW made the following entry: This social worker asked resident to come to the social service office to discuss staff report of sexual assault with police officers. The social worker explained to the resident why the police were called and reassured her that she was not in trouble. Resident requested social worker stay in the room while the officers asked her questions. The resident struggled to discuss today's events and referenced an event that occurred last week in which another resident was trying to kiss her, but she told him to stop, at which point he did. Resident was tearful but emotionally stable while answering questions. After the officers were done social worker privately asked the resident if she had any more questions or if she needed anything and she said no. Social Worker returned resident to the dining room to finish her lunch.Record review of Resident #1's Trauma Informed PRN Assessment, dated 05/23/25, reflected she did not have any concerns related to the trauma she may have endured. Record review of Resident #3's admission Record, dated 07/17/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE].Record review of Resident #3's MDS Assessment, dated 05/23/25, reflected he had a BIMS score of 15, which indicated no cognitive impairment. It noted he had physical behavior towards others in the last 1 to 3 days. His active diagnoses included epilepsy (a neurological condition characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain) and transient cerebral ischemic attack (a stroke, which happens when something prevents your brain from getting enough blood flow).Record review of Resident #3's care plan reflected the following: Focus: Resident will be observed by staff for 1:1 monitoring.Interventions: Resident will be observed by staff at all times during 1:1 monitoring. Date Initiated: 05/23/25. Focus: Behavior: Sexually inappropriate AEB: Making unwanted advances towards other residents.Interventions: Evaluate the resident's ability to understand behavior and the consequences of that behavior. Explain to resident the acceptable expressions of sexuality based on the cognitive evaluation. Listen/talk to the resident- see if they will tell you why they do the behavior. Psychiatric Services consult as needed. Reinforce with staff that clear, firm limits are healthy and required when resident makes inappropriate gestures or statements. Report incidents of inappropriate sexual behavior to charge nurse. If other resident's are involved, immediately intervene to protect the safety of all residents involved. Staff to be inserviced [sic] on behavioral approaches designed to effectively manage unacceptable sexual advances (avoid self disclosing personal information).Record review of Resident #3's Progress Notes reflected the following:-RN F on 05/23/25 at 11:57 AM wrote: Staff reports coming into building from lunch, witness this resident standing behind couch reaching for another resident who was sitting on couch and kissing on her face. This resident was attempting to lift other resident's head up by the chin to kiss her on the lips. When this resident noticed staff member he stopped and walked away from female resident. Female resident removed from area, one on one started with this resident. Resident Statement: ‘I was just kissing her, she didn't sayno' [sic].-the SW on 05/23/25 at 2:03 PM wrote: Social worker called and notified resident's responsible party of immediate discharge due to inappropriate sexual behavior.Record review of a witness statement, dated 05/23/25, and signed by Housekeeper E reflected the following: I, [Housekeeper E], was walking through the lobby when I saw [Resident #3] leaning over the back of the couch with his arms around [Resident #1]. [Resident #3] was trying to lift [Resident #1's] head up. [Resident #3] was kissing on [Resident #1's] face through out trying to get [Resident #1's] head up. As soon as [Resident #3] saw me, he stopped what he was doing and walked off.Record review of Resident #3's Facility Initiated Discharge Protocol document reflected the following: 1. What are the specific resident needs the facility cannot meet? Resident has been sexually abusive to female that was not consensual. This type of behavior puts all nonconcentual [sic] residents at harm for sexual assault.Interview on 07/17/25 at 1:00 PM with Resident #1 revealed she felt safe in the facility, and no one had ever tried to kiss her, which included Resident #3.Interview on 07/17/25 at 11:43 AM with CNA B revealed she never saw or cared for Resident #3, but she never heard about him having any sexual behaviors towards anyone. CNA B said she had been in-serviced regarding abuse/neglect and residents who had sexual behaviors. Interview on 07/17/25 at 11:49 AM with LVN A revealed she never saw or cared for Resident #3, but she never heard about him having any sexual behaviors towards anyone. LVN A said she was in-serviced regarding abuse/neglect and residents who had sexual behaviors.Interview on 07/17/25 at 12:03 PM with CNA C revealed she never saw or cared for Resident #3 but she never heard about him having any sexual behaviors towards anyone. CNA C said she had been in-serviced regarding abuse/neglect and residents who had sexual behaviors.Interview on 07/17/25 at 12:16 PM with LVN D revealed she never saw or cared for Resident #3 but she never heard about him having any sexual behaviors towards anyone. LVN D said she had been in-serviced regarding abuse/neglect and residents who had sexual behaviors. Attempted phone interview on 07/17/25 at 1:20 PM with Housekeeper E was unsuccessful as she did not answer or call back prior to exit. Interview on 07/17/25 at 1:44 PM with the ADON revealed Residents #1 and #3 were friendly with each other that he knew of, sitting at the dining room table together during meals. The ADON said staff reported Resident #3 had kissed Resident #1 but she did not want him to do that to her. The ADON said Resident #1 seemed only upset that she would be in trouble if people found out Resident #3 kissed her. The ADON said Resident #3 was placed on 1:1 monitoring until he was discharged later that day. The ADON said Resident #3 did not have any sexual behaviors prior to this incident, that staff were aware of. The ADON said staff were in-serviced regarding abuse and neglect and residents who had sexual behaviors.Interview on 07/17/25 at 3:32 PM with the DON revealed from what she heard, Resident #1 was sitting down on the sofa in a common area with her head down. The DON said Resident #3 was behind the couch and pulling Resident #1's chin up to him so he could kiss all over her face. The DON said the facility separated the two residents immediately and placed Resident #3 on 1:1 monitoring until he left the facility. The DON said the facility also contacted the local police department to file a report about what happened. The DON said Resident #3 was issued an immediate discharge due to his behavior. The DON said Resident #3 never showed any sexual behaviors prior to this incident. The DON said the incident was considered sexual abuse because Resident #1 told him no and Resident #3 continued to try kissing her. The DON said all residents had the right to be free from abuse since they were vulnerable adults. The DON said all staff were responsible for ensuring residents were free from abuse. The DON said residents could suffer emotional damage or physical damage if they were not free from abuse. The DON said staff had to monitor residents to make sure no abuse occurred. The DON said staff were trained to identify and prevent abuse towards residents.Record review of a witness statement, dated 05/23/25, and signed by the DON reflected the following: On May 23, 2025, at approx. 1205 pm [sic] I [the DON] interviewed [Resident #1] about the event that was witnessed by staff in the lobby. [Resident #1] told me that [Resident #3] started kissing her and she told him to stop but he wouldn't, he kissed her face and was trying to kiss her on the mouth. [Resident #1] stated, ‘I told him to stop because we were going to get into trouble'. [sic] Later [Resident #1] was in my office with her [family member], and once again she told me ‘I told him to stop, but he didn't. [Resident #1's family member] stated she told [them] that during her doctor's appointment yesterday [Resident #1] told [them], ‘I think I have a problem, a guy keeps kissing me'. [sic] [Resident #1's family member] stated he had planned to come to the facility today to talk to use about the comment. During the Secure Care Consult assessment, when asked has anything negative or positive happened to you, [Resident #1] stated, ‘Yes negative' ‘Advancement from a guy I wasn't found of' [sic] when asked who the guy was, she stated ‘[Resident #3]'.Record review of a provider investigation report reflected the following: Description of the Allegation: Resident sitting on sofa in lobby with another resident behind her. Male resident was kissing all over resident's face and resident was holding her head down while male resident was attempting to raise resident's face by placing his hand under her chin.Investigation Summary: [Resident #3] was discharged . [Resident #1] remains in positive spirits with not [sic] emotional distress. Record review of the facility's Resident to Resident Sexual Behavior Monitoring Sheets reflected residents were asked if there were any inappropriate or sexual behaviors identified amongst each other from 05/26/25 to 07/17/25. Record review of an in-service dated 05/23/25, and titled Abuse/Neglect Policy and Trauma Informed Care reflected 23 staff had been in-serviced.Record review of an untitled piece of paper, dated 05/23/25, reflected an Ad Hoc QAPI Meeting was held regarding the incident between Residents #1 and #3.Record review of 23 Staff Safety Surveys reflected staff had not seen Resident #3 have any inappropriate or unwanted behaviors towards Resident #1.Record review of 55 Resident Safety Surveys reflected none of the residents reported being abused at the facility. Record review of untitled pieces of paper reflected Quality of Life rounds were completed from 05/26/25 to 07/11/25 with no findings.3. Record review of Resident #2's annual MDS, dated [DATE], reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, anxiety disorder, and depression. Resident #2 had a BIMS of 14, which indicated her cognition was intact. Record review of Resident #2's care plan revised on 03/19/25 reflected the resident had shortness of breath related to anxiety. Interventions reflected monitor/document changes in orientation, increased restlessness, anxiety, and air hunger. The resident's care plan further reflected she had a history of making false accusations towards the staff and making phone calls to the family late at night stating she could not breathe, and nobody would help her. Interventions included to assist resident care in pairs and staff to offer encouragement and emotional support and administer medications as ordered. Record review of the facility's Provider Investigation Report, dated 06/06/25, reflected the following: During resident safe surveys Resident #4 stated he heard charge nurse [LVN G] tell Resident #2 to ‘shut the fuck up'.Resident assessed and skin assessment performed. Resident could not recall incident. Resident had no signs of physical or emotional distress.Observation and interview on 07/17/25 at 10:33 AM with Resident #2 revealed she was in bed with continuous oxygen running at 2 liters. The resident stated the staff treated her well and were nice to her, and denied being yelled at or cursed at by LVN G. Resident #2 immediately began to say she could not breathe and wanted a nurse in the room. The charge nurse arrived shortly and took her vitals which were within normal limits but kept stating she knew she would die soon as the nurse stay and attempted to comfort the resident. Interview on 07/17/25 at 10:24 AM with Resident #5 revealed one night, did not recall the date, Resident #2 kept repeating she could not breathe and LVN G said you need to shut up cause you wouldn't be talking if you couldn't breathe and the resident continued to say she could not breathe. Resident #5 was asked if she overheard LVN G tell Resident #2 to shut the fuck up and Resident #5 said she didn't say those words but that was basically what she meant.Interview on 07/17/25 at 11:51 AM with LVN H revealed Resident #2 had increased anxiety and continuously said she could not breathe, and the nursing staff would enter her room to assess her and try to calm her down. LVN H said when Resident #2 was yelling she could not breathe she would yell out stating she needed her breathing pill. Interview on 07/17/25 at 12:17 PM with LVN I revealed Resident #2 had increased anxiety and would always say she could not breathe, and it appeared these statements were getting steadily worse. LVN I stated the resident did not want staff to leave her room and when they would Resident #2 would become very anxious and work herself up and begin to say she could not breathe. LVN I further stated they tried to increase her anxiety medications, but it made her drowsy and a high fall risk, so they had to lower the medication. LVN I said there were only certain nurses Resident #2 preferred to care for her but did not state which ones. Interview on 07/17/25 with the ADON revealed Resident #2 continuously stated she could not breathe, and it appeared her anxiety was getting worse, so staff often tried to comfort or calm her down. The ADON said he spoke with Resident #2, and she mentioned there was a nurse who appeared to have a bad day/attitude who spoke to her rudely, but did not say how, but he did not recall the resident saying she had been told to shut up. The ADON stated Resident #2 identified that charge nurse as being LVN G, but the resident did not appear to be in distress or have any lasting effects from the incident. The ADON further stated LVN G wore hearing aids therefore spoke loudly in, but he had never noticed or had any complaints regarding LVN G being rude or verbally abusive.Interview on 07/17/25 at 2:09 PM with Resident #4 revealed one night, did not recall the date, he overheard LVN G tell Resident #2 she did not have all damn night to stay in her room and she just needed to take her damn medicine because she was not going to return to the room. Resident #4 was asked if LVN G told Resident #2 to shut the fuck up and Resident #2 said she might have.Interview on 07/17/25 at 2:43 PM with CNA J revealed Resident #2 had an obsession saying she could not breathe due to her increased anxiety and when the nurse would check her oxygen levels, there were within normal limits. CNA J said LVN G could not hear well so therefore spoke loudly, but she never saw or heard LVN G be rude or yell at any residents nor did anyone complain about her. Interview on 07/17/25 at 3:12 PM with the DON revealed Resident #2 had increased anxiety and frequently repeated she could not breathe, and it appeared to get worse after a recent hospital stay. The DON said the nurses would often check her oxygen levels and find them within normal limits. The DON further stated they were doing safe surveys on all the residents when Residents #3 and #4 both said they had heard LVN G raise her voice at Resident #2, but she did not recall all the details because the Interim Administrator had conducted the investigation. Interview on 07/17/25 at 3:51 PM with the Interim Administrator revealed staff were conducting safe surveys on the residents when they were told by Resident #4 and #5 there was a night nurse that was heard yelling at night, especially directed to Resident #2 when she was told to shut the fuck up. The Interim Administrator said she followed up with Resident #2 and she had described the night nurse, and they concluded it was LVN G based on the resident's description. The Interim Administrator said Resident #2 did not give her specifics on what LVN G said to her but only said the nurse would get loud with her and yell and did not like to give her medications. The Interim Administrator further stated Resident #2 did not appear to be upset or in distress but because there had been two other residents with similar stories, LVN G was terminated. Attempts to interview LVN G via telephone on 07/17/25 were unsuccessful. Record review of LVN G's Employee Disciplinary Report, dated 06/03/25, reflected: LVN G wrote, I did not say what I am accused of saying. I will not sign this form! Corrective Plan of Action.[LVN G] will be terminated effective immediately.Staff of all disciplines and from various shifts were inserviced on abuse/neglect and customer service/bedside manor on 06/03/25. Record review of the facility's current, undated Abuse/Neglect policy reflected: The resident has the right to be free from abuse.Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents.The facility will provide and ensure the promotion and protection of resident rights.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #1 and #2) reviewed for accidents. 1. Driver A failed to secure Resident#1's wheelchair properly in the van, resulting in the resident hitting her head when the wheelchair tipped backwards during transport on 03/18/25. The resident was sent to the hospital but did not have any injuries. 2. Driver B failed to secure the safety strap on the lift when Resident #2 was being lowered. Driver B fell on to Resident #2 causing him to tip backwards in his wheelchair and hitting his head on the ground on 04/07/25. The resident was sent to the hospital where he was found to have an abrasion on his scalp but no serious injury. The noncompliance was identified as past noncompliance. The IJ began on 03/18/25 and ended on 04/07/25. The facility had corrected the noncompliance before the survey began. The failures placed residents who used the facility's transportation at risk for injury. Findings included: 1. Record review of Resident #1's undated Admission Record, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The Admission Record reflected Resident #1 was her own RP and had diagnoses which included diabetes, heart failure, and vision loss. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 14 indicating she was cognitively intact. Her Functional Status assessment indicated she was independent in her ADLs. Record review of Resident #1's care plan, dated 02/26/25, reflected she had a history of headaches, and making false allegations. Record review of the facility's Provider Investigation Report, completed by the Administrator on 03/25/25, reflected the following incident occurred on 03/18/25 at 3:15 PM in the facility's van: .Description of Allegation: [Resident #1] stated [her] wheelchair was not secure in transport van, and that it tipped back a few inches and she hit her head on ramp behind her. Transport Driver [Driver A] stated that she secured [the] wheelchair, but discovered it was loose when she started to drive. Immediately pulled over and re-secured it. .Name and title of person who completed assessment: [RN D] Description of assessment including extent of injuries No sign of bump, bruising, or redness on head where resident states she hit it. Sent to ED for additional evaluation due to c/o head injury. .Provider Response .Driver [Driver A] suspended pending investigation. Resident [Resident #1] assessed by DON and sent to ED for CT scan due to hitting head - no bruising, laceration, or raised a red noted. CT at ED negative. Physician, ombudsman notified. Resident is RP. Investigation Summary .DON was notified by COTA (Therapy) that [Resident #1] refused therapy due to headache pain resulting from hitting head during transport the previous day. COTA .immediately report this incident to DON (was in office next to therapy gym) and provided written statement and report to Admin. Driver provided statement to Administrator that she did fail to completely secure [Resident #1's] wheelchair prior to driving. She noticed the wheelchair tip back 3-5 inches and immediately pulled off the road and properly secured [Resident #1's] wheelchair. [Resident #1] stated that she hit her head on the ramp in the van when she tipped back. Driver was talking about this incident at the nurse[s'] station upon return to the facility, and Administrator was at the nurse[s'] station at the same time. Driver assumed Admin was aware. Admin was conducting in-service/monitoring with another staff member at the time and did not hear the report of an incident in the van. Admin provided to [sic] coaching to driver regarding reporting any and all incidents or potential for incident or injury directly to him, not just when it could be heard. Investigation revealed driver [Driver A] had reported complaint of pain by resident [Resident #1] - upon return to facility - to resident's nurse. Nurse stated that she was unable to provide prn pain medication at that time due to caring for another resident and then forgot to get back to it. Nurse did assess resident for pain a few hours later and there was no c/o of pain or signs of distress. Resident does receive routine pain medications and has order for PRN, which she used most days. PRN order was changed to routine in AM with additional PRN available later in the day as needed. Admin identified all residents who had been on transport in last 30 days (from appointment calendar) and Social Worker completed safe survey assessments with each of them as well as safe survey pain assessments with several residents. No additional transport or pain issues were reported in surveys. Investigation showed that driver [Driver A] had been properly and completely trained on all policies and procedures for properly securing residents in transport van and properly transporting them. Driver [Driver A] failed to follow proper procedures. Driver [Driver A] failed to report complaint of injury during transport and failed to report failure to properly secure resident and wheelchair prior to transport. Driver [Driver A] resigned her position and employment. .Provider Action Taken Post-Investigation: All staff in-serviced on recognizing, preventing, and immediately reporting abuse and neglect directly to Abuse Coordinator. Nursing staff in-serviced on pain management policies and procedures. All drivers of van retrained on pre and post trip inspections as well as safety attestations to be completed prior to each trip. Record review of Driver A's written statement, dated 03/19/25, reflected: On Tuesday March 18, 2025 at approximately 1515 [3:15 PM] hrs. I, [Driver A], was transporting [Resident #1] from a doctor apt. She had complained about having a headache. I loaded [Resident #1] into [the] back of transport van and secured the chair using the straps and seat belt. I started driving and her chair tipped backwards about 4 inches. I immediately pulled over and re-secured the straps to her chair. She claimed she hit her head, but I am not positive she did. We got back to [the] facility where she asked the nurse for tylenol. It was mentioned in front of [the Administrator] about her hitting her head. Interview on 04/30/35 at 9:50 AM with Resident #1 revealed she was in the van on 03/19/25 in her wheelchair when her wheelchair tipped backwards 4-5 inches. Resident #1 stated when Driver A accelerated it caused her to hit her head on the lift of the van. The resident stated she had a headache, but she had a headache prior to the incident, so she did not have any injury. Resident #1 stated she was more startled than anything. Resident #1 stated she had not been in the van since, but she was not afraid to be transported again. Record review of Resident #1's nursing notes reflected the resident was sent to the ER via ambulance since she stated she had hit her head on a piece of metal. Nursing assessment revealed no obvious injury. The resident returned from the ER with no abnormal findings after examination and CT scan of her head. Record review of text communications, undated but timed 1:55 PM, with Driver A reflected: Can you please clarify for me exactly what process you did to secure [Resident #1]? I attached the ratchet straps to the frame of her chair in the back and front. When I re-secured the chair, I adjusted the positions of the straps to better secure the chair in place, ensuring it did not move again. I secured the seat belt across her lap to ensure she did not slip from the chair in case of an incident. The seat belt was placed prior to initially moving the van the first time. This belt was not needed to be adjusted after the incident. Record review of an Employee Disciplinary Report Action Request, dated 03/19/25, reflected Driver A had a written counseling and investigatory suspension due to an infraction that occurred involving Resident #1. This was signed by the Administrator on 03/19/25. Record review of a Coaching Form, dated 03/19/25, signed by both Driver A and the Administrator reflected: Situation: Incident in van. Wheelchair not properly secured. Resident claims wheelchair tipped back and she hit her head on the ramp (she was in position closest to ramp). Specific Coaching/Education given to the Employee: All residents must be properly secured prior to vehicle movement. Auto transport training to be completed prior to return to transport. All incidents must be reported immediately to Administrator. Record review of a Vehicle Inspection Report, dated 03/19/25, reflected the facility completed an inspection of the van's interior to include seat belts and wheelchair tie-downs, and there were no issues identified. Record review of Life Satisfaction Rounds forms, dated 03/20/25, reflected the facility conducted interviews with residents to determine if they felt safe at the facility and if there were any issues with transportation. These interviews revealed no concerns regarding transportation. Record review of an In Service Training Attendance Roster, dated 03/19/25, reflected facility staff received in-service training on the topic of Vehicle Training/Secure Passengers/Report Immediately. Record review of an In Service Training Attendance Roster, dated 03/21/25, reflected facility staff received in-service training on the topic of Safety Attestation presented by the Administrator. Record review of the Employee Auto Attestation Form, which was the topic of the in-service Training, reflected: I, ____________, attest that all of the following safety checks have been completed before taking ________(resident) to their appointment. 1. Before driving a company automobile, the driver must be satisfied that it is in safe operating condition. Any defects or unsafe conditions should be reported to appropriate individual(s) immediately. 2. All safety devices, including seat belts/restraint devices/wheelchair tie downs, will be used by anyone operating or riding in a vehicle. There shall be no more passengers in a vehicle than the number of seat belts available. Driver will check straps by attempting to move wheelchair on all 4 corners. 3. Driver will conduct a final visual inspection to ensure all residents have been safely secured [in] the vehicle before driving. Interview on 04/30/25 at 3:45 PM with the Administrator revealed Driver A had been the primary driver and Driver B was the back up driver who covered when Driver A was off. Driver B took over the primary driving responsibilities after Driver A had been terminated. The Administrator stated Driver A had also failed to call him or the DON from the scene, instead she waited until she returned from the transport. Driver A stated in her interview she had told the nurse and himself when she returned, she had assumed he heard her tell the nurse, but he stated he was speaking with another employee and did not hear Driver A report to the nurse. The Administrator stated Driver B had participated in the in-service and training on 03/20/25 and she did not follow procedures on 4/07/25, so she was terminated as well. The Administrator stated they now have two drivers on the van when transporting to improve safety and reduce the risk of procedure violation. He stated the facility did not have a policy covering transporting the residents, they relied on the company's driver training manual. Record review of Resident #1's hospital record reflected she was treated for abrasions after a fall. An attempt was made to interview Driver A via telephone on 04/30/25 at 1:15 PM. A voicemail message was left for Driver A; however, she did not return the call. Record review of Drivers A's driver training revealed Driver A had been initially trained for driving the van on 04/13/23 and her last re-training had been completed on 01/30/25. 2. Record review of Resident #2's undated Admission Record, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney failure, diabetes, heart failure, and Parkinson's disease. Record review of Resident #2's quarterly MDS, dated [DATE], revealed he had a BIMS score of 15, indicating he was cognitively intact. His Functional Ability assessment reflected he required minimal assistance with his ADLs. Record review of Resident #2's care plan, dated 03/12/25, reflected he required the use of a wheelchair for mobility, he was on blood thinning medication, and he required assistance with transfers to and from his wheelchair. Record review of the facility's Provider Investigation Report, completed by the Administrator on 04/14/25, reflected the following incident occurred on 04/07/25 at 11:00 AM involving Resident #2 and Driver B: .Description of the Allegation: Driver [Driver B] was walking to take resident off of van, driver tripped and fell on resident causing the resident to flip backwards in wheelchair. Back ramp strap was not done. Resident complained of pain and was sent to ER [sic]. CT was negative and resident returned to facility. Driver suspended. .Description of assessment including extent of injuries Resident returning from doctors [sic] appt on facility van, Per the staff driver [Driver B] of the day, patient fell back while on the wheelchair. Resident [Resident #2] complained of head and neck pain. This LVN [LVN E] sent resident out EMS for eval. .Provider Response .Driver [Driver B] reported incident immediately, resident was assessed by nurse. All resident transports will require 2 staff members to be present to ensure resident safety. Investigation Summary .Driver [Driver B] immediately reported incident to DON (Admin Offsite) .per facility protocol. Resident was assessed by a nurse prior to being moved. Resident did not have any injuries but did complain of pain. Resident was transferred to ED for additional evaluation and treatment. CT negative for head and neck, resident returned to facility in stable condition. Driver was suspended pending investigation. It was determined that driver did fail to properly secure seatbelt on lift, and that driver stood on ramp with resident, both being failure to follow company policy and procedure. Driver [Driver B] had been fully trained and given additional training and in-services on van/transport protocols. Driver [Driver B] was terminated for failure to follow company policies. All drivers were re-trained on protocols and procedures prior to resuming transports. Facility has instructed all drivers that 2 staff members must be present for each transport to ensure safety. .Provider Action Taken Post-Investigation: Abuse and neglect in-service Van retraining completed for all drivers before van returns to driving. Record review of Resident #2's hospital records reflected he was treated on 04/07/25 for a fall and scalp abrasion. The hospital record reflected the resident did not sustain any serious injuries. Interview on 04/30/25 at 10:55 AM with Resident #2 revealed on 04/07/25 he was being unloaded from the facility's van. After he had been lowered to the ground on the lift, the driver fell on to him causing his wheelchair to roll backwards, and he tipped backwards. He stated he hit his head on the ground and had back pain. He denied losing consciousness. He was sent to the hospital via ambulance. He has been on the van three times a week since the incident for dialysis without incident. Interview on 04/30/25 at 11:05 AM with the Administrator revealed their investigation revealed Driver B failed to secure the safety strap at the back of the lift that is designed to prevent the resident from rolling off the back of the ramp. He stated Driver B had unlocked the wheelchair's locks, lost her balance, and fell on to the resident. The resident rolled backwards off the lift, at ground level, and tipped over backwards. Resident #2 was assessed by the nurse before being moved, he was found to have a minor abrasion to the back of his head and was sent to the hospital via ambulance. The Administrator stated Driver B was in-serviced on 03/20/25 on van transport procedures, after the incident with Resident #1, but still did not follow procedures with Resident #2. As a result she was terminated. The Administrator stated all six people authorized to drive the facility van were in-serviced again on 04/07/25, and all six were given the company's driving test again. The procedure had also been changed to have two drivers on the van for all transports in the future. Driver B was suspended on 04/07/25 and terminated on 04/08/25. Record review of the facility's in-services and training documents from 03/20/25 and 04/07/25 reflected six staff had been in-serviced by the regional trainer on transport procedures including loading and unloading the resident, and proper securement of the wheelchair in the van. All six staff had passed the company driving test administered by the regional trainer. Observation on 04/30/25 at 11:45 AM of van transport procedures, performed by Driver C, with Resident #3, revealed the resident was secured in his wheelchair with two straps to the front frame of the wheelchair, and two straps to the back frame of the wheelchair. A lap belt was placed and secured to the floor behind the wheelchair, and a chest strap was secured across the left shoulder to the lap belt, similar to a car seatbelt. The wheelchair locks were then secured. Unloading Resident #3 was accomplished by securing the safety strap across the back of the lift, rolling the wheelchair backwards onto the lift, securing the wheelchair breaks, and lowering the resident to ground level. The wheelchair locks were released before the safety strap was removed and the resident was rolled off the lift. Interview on 04/30/25 at 11:50 AM with Resident #3 revealed the procedure Driver C had performed for the transport was how all of his previous transports had been done. He stated he had no concerns with being transported via the facility van. Interview on 04/30/25 at 11:53 AM with Driver C revealed she had been re-trained on driving and transport procedures in March and April, and they now had two drivers present in the van to minimalize the risk for errors or injuries. Interviews on 04/30/25 from 12:00 PM-12:35 PM with four residents (Residents #3, #4, #5, and #6) that had been transported via the van on a regular basis for dialysis or other appointments revealed none had any concerns about how they were secured in the van, and all felt confident in the skills of the drivers. Interview on 04/30/25 at 4:23 PM with the Maintenance Director revealed his inspection of the van after both incidences revealed all equipment was in working order. An interview was attempted with Driver B via telephone; however, the attempt was unsuccessful. A voicemail message was left for Driver B, but Driver B did not return the call. Record review of Driver B's driver training revealed Driver B had initially been trained for driving the van on 05/17/23 and her last re-training was on 01/30/25. Record review of in-service training records reflected the facility provided Van Training to staff, who drove the facility van following the incident.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 to address him being at risk for constipation which he was at increased risk for due to his diagnosis of cerebral palsy. This failure resulted in the facility staff not being aware of these risk factors for constipation and not implementing interventions to prevent the resident from having a fecal impaction of the rectum with associated stercoral colitis, which is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually hardened stool formation. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk of serious harm or death. Findings included: Record review of Resident #1's Nursing Home Comprehensive Item Set MDS Record dated, 01/15/25, reflected an initial admitted [DATE] and readmitted [DATE]. Resident #1's diagnoses included: cerebral palsy (congenital disorder of movement, muscle tone, or posture), seizure disorder or epilepsy, sepsis (life-threatening complication of an infection), and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Resident #1's MDS also reflected that Resident #1's cognition was intact with a BIMS score of 15. Resident #1's MDS reflected that Resident #1 was dependent (helper does all the effort) on staff for toileting. Resident #1's MDS also reflected that Resident #1 was not on a bowel toileting program. Resident #1's MDS reflected that the resident was always incontinent of bowel. The MDS also reflected that Resident #1 showed no constipation present. Record review of Resident #1's undated Care Plan reflected that Resident #1 had not been placed at Risk of Constipation. Record review of Resident #1's undated Discontinued Orders reflected resident received Baclofen Oral Tablet 20 MG 1 tablet by mouth four times daily. Resident #1 was also ordered and received Clonazepam .5 MG tablet by mouth twice daily. Resident #1 received Probiotic Oral Capsule daily as well. Resident #1 had a PRN (as needed) order for Bisacodyl Rectal Suppository insert 10 mg rectally as needed for constipation. Resident #1's orders also reflected he received 2 Hydrocodone-Acetaminophen Oral Table 5-325 three times daily. Resident #1 received 1 Cyclobenzaprine HCl Oral Tablet 10 MG twice daily. Record review of Resident #1's undated MAR reflected that Resident #1 did not receive a dosage of his order for Bisacodyl Rectal Suppository for constipation as needed ordered by his primary care physician during the month of February 2025. Record review of Resident #1's Bowel Movement ADL 30-day documentation chart reflected no bowel movements between the days of 02/11/25 through 02/20/25. The ADL record reflected the resident had one bowel movement on 02/21/25 but had no other bowel movements before he was transferred to the hospital on 02/26/25 at 12:00AM. Therefore, the ADL record reflected the resident had one bowel movement from 02/11/25 until discharge on [DATE]. Record review of Resident #1's Progress Notes dated 02/26/25 at 6:47 PM reflected LVN A transferred Resident #1 to the hospital due to a change in condition and family request on 02/26/25 at 12:00 AM after Resident #1 spoke with his Responsible Party on 02/25/25. Record review of Resident #1's Progress Notes dated 02/28/25 at 10:32 AM reflected the DON was made aware of allegations of neglect. This Progress Note by the DON reflected Administrator, Medical Director, Area Director of Operations, and the Area DON were notified. Record review of Resident #1's Hospital Record dated 02/26/25 at 10:16 PM reflected, Prominent fecal impaction of the rectum with associated stercoral colitis. There is constipation, without bowel obstruction. Record review of Resident #1's Hospital Record dated 02/28/25 at 9:23 AM reflected, Severe Constipation: on 02/27 Disimpaction severe and Mag Citrate, Lactulose, and Go Lytely. Record review of Resident #1's Hospital Record dated 03/02/25 at 11:44 AM reflected Resident #1's diagnoses of Severe constipation with fecal impaction: Improving. S/P (Status Post Docusate) docusate, lactulose, soapsuds enema, manual disimpaction. Had watery stool. Record review of Resident #1's Hospital Record dated 03/03/25 at 9:20 AM reflected Resident #1's diagnosis of Severe constipation, fecal impaction. The same hospital notenotes also reflected, Noted stercoral colitis on CT, Initiate docusate, lactulose, Soapsuds enema x 2, and No BM despite manual disimpaction. Will obtain CT/AP with p.o. contrast (Computed tomography of Abdomen and pelvis with oral contrast). Record review of the National Libraray of Medicine at www.ncbi.nlm.nih.gov/books/NBK560608, Stercoral Colitis, dated 07/10/23, reflected: Stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma [hardened stool] formation Interview on 03/11/25 at 9:53 AM with the Administrator revealed that a family member put on social media that Resident #1 was being neglected in the areas of showering, oral care, and monitoring of bowel movements. The Administrator also revealed that the resident did not return to the facility after discharge from the hospital. The Administrator said that Resident #1 went to a sister facility for long-term care. The Administrator revealed he was not aware Resident #1 had gone 11 days with no bowel movements. The Administrator stated that on 02/28/25, he in-serviced all staff on abuse/neglect, patient rounding, resident rights, bowel and bladder documentation, bowel incontinence care, bath, tub/shower, bed bath complete, teeth care/oral hygiene, resident/resident incidents, Immediately in-service on the definition of Immediate, accurate documentation of refusals, and physician's orders. Interview on 03/11/25 at 1:46 PM with Resident #1's Responsible Party revealed that a family member placed a negative comment about the facility on social media the morning that the resident went out to the hospital. The Responsible Party stated that he saw Resident #1 on the morning of 02/25/25, and he could tell that something was wrong. The Responsible Party stated that he called the facility and requested that his family member be sent out to the hospital. The Responsible Party confirmed that the hospital did not do surgery on Resident #1, and Resident #1 was now at another facility. Interview on 03/12/25 at 11:18 AM with the Medical Director revealed that Resident #1 had risk factors for constipation due to his diagnosis of cerebral palsy, which was a neurological condition which led to his immobility. The Medical Director stated that he provided the facility with standing orders for the treatment of constipation if a resident did not have a bowel movement after three days. The Medical Director said that he expected the facility's nurses to notify him if his prescribed interventions did not work for residents. The Medical Director stated that he did not recall if he was notified of a change in condition for Resident #1. The Medical Director concluded by stating that he could not remember everything about every resident. Interview on 03/13/25 at 10:11 AM with MDS U revealed that she had been in training as the MDS Coordinator for two weeks, andweeks and had been in-serviced regarding care plans and the risk of constipation. MDS U stated that as the MDS Coordinator, she was trained to look at the resident's medications, diagnoses, the resident's hospital records, the physician's orders, and communication from the resident such as their last bowel movement to aide in developing the care plan and specifically the risk of constipation. The MDS Coordinator added that the admitting nurse conducted a head-to-toe assessment including listening to bowel sounds and palpating the resident's stomach to determine the resident's risk of constipation. MDS U also said that Resident #1 had a standing order for a medication to be given if he experienced constipation as well as a medication ordered to be administered if the resident was constipated. MDS U revealed that all residents' care plans had been updated to reflect their risk of constipation. The MDS Coordinator also stated that new risks were communicated to her to add to a residents' care plans in the daily clinical meetings and as needed due to residents' changes in condition to continue to daily develop the care plans. MDS U said that that it was important that all staff had access to residents' care plans so that they can provide the specific care needed to each resident. On 03/13/25 at 11:30 AM, the Administrator was notified that an Immediate Jeopardy in the area of Comprehensive Resident Centered Care Plans. Interview on 03/13/25 at 6:41 PM with the Administrator revealed that upon admission the admitting nurse should complete a full assessment including bowel/bladder. The Administrator stated that the admitting nurse develops the care plan based on the risk of constipation due to diagnoses and medications and develop the goals and interventions. The Administrator revealed that if the resident was not assessed timely, then complications such as discomfort, loss of appetite, or potential infection could occur. Interview on 03/14/25 at 11:42 AM with the ADON revealed that Resident #1's care plan had now been updated to reflect the resident's risk of constipation. The ADON stated that upon admission, the charge nurse should complete a head-to-toe assessment and listen for bowel sounds. The ADON said that the admission assessment in addition to the resident's orders and medications would be used to determine if there was a risk of constipation. The ADON revealed that if there was a risk of constipation, the MDS coordinator would include it on the care plan as well as goals and interventions specific to each resident. The ADON stated that the care plan gave the staff the opportunity to view the residents' needs and changes as well as how to provide care to each resident. The ADON revealed that he and the DON monitored the care plans and verified residents' orders, medications, alerts, and necessary items involved in the care plans. The ADON stated that the care plans were reviewed quarterly in the care plan meetings and any changes that were needed could be made at that time or as needed prior to the care plan meeting by the MDS Coordinator. The ADON said that the interdisciplinary team (Administrator, the DON, the ADON, Social Worker, the Activities Director, the Therapy director, the Dietary manager) and the family as well as the resident attended the care plan meeting to review the risks (focus), goals, and interventions of residents. The ADON concluded by stating that the importance of timely documentation in care plans was to ensure continuity of care for residents. The DON was out due to illness during the days the surveyor was in the building 03/11/25-03/14/25. Interview on 03/13/25 at 2:30 PM with the Area DON revealed the facility began to in-service all staff on 03/13/25 after notification of the immediate jeopardy at 11:30 AM on 03/13/25. The Area DON stated that all staff were in-serviced on abuse and neglect by the ADON. Area DON also stated that all staff were in-serviced on documentation of bowel movements, reporting changes, and notifying the ADON and the DON of changes in bowel movements by the ADON. The Area DON revealed that she in-serviced the nursing staff on how to access clinical alerts in the facility's software. The Area DON also stated that the ADON in-serviced the nursing staff administering PRN (as needed) medication to residents with no bowel movement for three days. The Area DON said that the ADON in-serviced all nursing staff on bowel movement monitoring and dashboard alerts and monitoring. The Area DON stated that the ADON also in-serviced all nursing staff on recognizing a change of condition and the requirement to notify the resident's primary care physician. The Area DON revealed that she in-serviced the Administrator, the DON, Area Director of Operations, and the ADON on recognizing a change of condition and bowel movement changes. The Area DON revealed that the in-service was completed via a text service that went to all facility staff and copies were provided evidencing it. The Area DON also said that she and the ADON spoke with the staff about the in-service topics before they began their shifts in addition to the text that went out to all facility staff. The Area DON stated the DON or the ADON would review all new admissions in the stand-up meeting 5 times a week for six weeks and then as needed addressing alerts for no bowel movements and if the nurse accurately responded. The Area DON also revealed that the DON/and or the ADON would ask five nurses per week if anyone reported not having a bowel movement in the last three days and document the intervention and monitor for six weeks as needed. The Area DON stated that the DON/and or ADON would ask five CNAs per week if they reported a resident that did not have a bowel movement to their nurse and the nurse's response. Record review of in-services reflected: Abuse and Neglect completed on 02/28/25, Patient rounding completed on 02/28/25, Resident Rights completed on 02/28/25, Bowel and Bladder Documentation completed on 02/28/25, Bowel Incontinence Care completed on 02/28/25, Bath Tub/Shower completed on 02/28/25, Bed Bath Complete completed on 02/28/25, Teeth Care/Oral Hygiene completed on 02/28/25, Resident/Resident Incidents completed on 02/28/25, Immediate Notification completed on 02/28/25, Accurate Documentation of Refusals completed on 02/28/25, and Physician's Orders completed on 02/28/25. Record review of the facility's undated Comprehensive Care Planning Policy reflected: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Record review of the facility's undated Physician's Orders policy reflected: To Monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Record review of the facility's undated Documentation policy reflected: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of the facility's revised Abuse and Neglect Policy dated 9/9/24 reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. .7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. The Administrator was informed of the Immediate Jeopardy in the areas of Quality of Care and Resident Care Plans. The Immediate Jeopardy template was provided to the Administrator via email on 03/13/25 at 11:30 AM. The plan of removal was accepted on 03/13/25 at 3:11 PM and included: Plan of Removal Action: 03/13/25 1. Resident #1 no longer resides in the facility as of 03/13/25. 2. All residents in the facility were assessed on 03/13/25 for risk of constipation or other bowel issues, comprehensive care plans updated to include interventions and monitoring by the DON and/or the ADON and/or the Regional Compliance Nurse. No additional residents were identified with no bowel movement within three days. 3. The Compliance Nurse in-serviced the Administrator, the DON, and ADON 1:1 on the following topics below on 03/13/25: a. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. b. Upon admission all residents will be assessed by a nurse on risk of constipation, history of constipation/fecal impaction, or other bowel related issues. c. Upon admission the nurse will be responsible for developing and implementing the care plan of risk of constipation based upon their assessment. d. The DON and/or the ADON/and/or the Designee will monitor care plans to ensure all resident care plans reflect their risk of constipation or other bowel issues. e. The DON and/or the ADON/and/or theDesignee will monitor admission assessment to ensure all resident care plans reflect their risk of constipation or other bowel issues. f. Upon admission, and as needed, all residents will be assessed for risk of constipation or other bowel issues. The care plan will reflect findings, interventions, and monitoring. g. InService on care plan location and how to access the care plan in software. 4. The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics on 03/13/25: a. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. b. Upon admission all residents will be assessed by a nurse on risk of constipation, history of constipation/fecal impaction, or other bowel related issues. constipation based upon their assessment. d. The DON and/or the ADON and/or the Designee will monitor care plans to ensure all resident care plans reflect their risk of constipation or other bowel issues. e. ensure all resident care plans reflect their risk of constipation or other bowel issues. f. Upon admission, and as needed, all residents will be assessed for risk of constipation or other bowel issues. The care plan will reflect findings, interventions, and monitoring. g. InService on care plan location and how to access the care plan in facility software. 5. The DON, the ADON, and the Regional Compliance Nurse in-serviced the non-licensed staff on the following on 03/13/25: a. InService on care plan location and how to access the care plan in facility software. b. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. 6. AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. No additional residents were identified with no Bowel movements within three days. Review of AD Hoc QAPI Completed on 03/13/25. 7. The QAPI committee will review findings and make changes as needed. Identified Residents at Risk: Only 1 resident was affected regarding this incident. The resident was treated with medication in the hospital. The resident did not require surgery. Systemic Changes: 1. Admitting nurse will assess all new residents for risk of constipation and/or bowel complications. 2. All residents at risk of bowel complications will have a care plan with interventions and goals developed upon admission. 3. The MDS Coordinator will review care plans with the interdisciplinary team at the resident's quarter care plan meetings and make necessary changes to the care plan. 4. Care Plans will be monitored by the DON and/or the ADON to ensure that changes are updated quarterly and as needed. 5. Licensed and Non-licensed staff know how to review residents' care plans in the facility software and will review resident's care plans for risk of constipation and monitor for risk of constipation. Responsibility: It is the Administrator, or designee, and the Director of Nursing, or designee's responsibility to follow the actions and the systematic changes listed above. The Administrator, or designee, and the Director of Nursing, or designee, will report their findings of the above actions and systematic changes through their QAPI [Quality Assessment Performance Improvement] Process. Monitoring interviews for the Immediate Jeopardy were started on 03/13/25 at 3:39 PM and continued through 03/14/25 at 11:15 AM with 20 nursing staff across all three shifts, including weekdays and weekends. The staff were interviewed about and abuse/neglect, the risk of constipation, assessing residents for the risk of constipation, developing care plans, monitoring admissions, care plan development and changes, and where care plans are located within the facility software. Record review of in-services reflected 32 staff attended the following in-services and all remaining staff were notified via cell phone text on the following in-services: Abuse/Neglect completed on 03/13/25, How to Access Clinical Alerts completed on 03/13/25, Care Plan/Assessment: Upon Admit Constipation or other bowel issues completed on 03/13/25, and Care Plans for all residents-Risk for Constipation completed on 03/13/25. Record review of facility monitoring tool reflected the DON and/or the ADON and/or the Designee and or the ADON and or the Designee will review all new admissions in stand-up meeting five times a week for six weeks, and then as needed completed 03/14/25 25 and reviewed 03/14/25. Record review of facility monitoring tool reflected the DON and/or the ADON and/or the Designee would review the 24-hour report and clinical alerts daily in stand-up meeting five times a week for five weeks, and then as needed completed 03/14/25 and reviewed 03/14/25. The following staff's in-service logs were reviewed, and they were interviewed during the monitoring time frame. They were able to articulate what they were taught including the correct protocols and procedures related to abuse/neglect, the risk of constipation, assessing residents for the risk of constipation, developing care plans, monitoring admissions, care plan development and changes, and where care plans are located within the facility software: LVN A, CNA B, CNA C, RN D, CNA E, CNA F, CNA G, CNA H, CNA I, MA J, LVN K, CNA L, LVN M, LVN N, Hospitality Aide O, LVN P, CNA Q, CNA R CNA S, RN T, Administrator, and the ADON. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interviews and record reviews, the facility failed to ensure that received residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of a resident for 1 of 10 residents (Resident #1) reviewed for quality of care. The facility failed ensure Resident #1, who was at increased risk for constipation due to having cerebral palsy, had measures in place to monitor his bowel activity and to ensure physician ordered interventions were implemented when the resident did not have a bowel movement within 72 hours. This failure resulted in the resident being diagnosed in the hospital with fecal impaction of the rectum with associated stercoral colitis, which is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually hardened stool formation. Prior to the hospitilization, the resident had only had one bowel movement between 02/11/25 and 02/26/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The failure placed residents at risk of serious harm or death. Findings included: Record review of Resident #1's Nursing Home Comprehensive Item Set MDS Record dated, 01/15/25, reflected an initial admitted [DATE] and readmitted [DATE]. Resident #1's diagnoses included: cerebral palsy (congenital disorder of movement, muscle tone, or posture), seizure disorder or epilepsy, sepsis (life-threatening complication of an infection), and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Resident #1's MDS also reflected that Resident #1's cognition was intact with a BIMS of 15. Resident #1's MDS reflected that Resident #1 was dependent (helper does all the effort) on staff for toileting. Resident #1's MDS also reflected that Resident #1 was not on a bowel toileting program. Resident #1's MDS reflected that the resident was always incontinent of bowel. The MDS also reflected that Resident #1 showed no constipation present. Record review of Resident #1's undated Care Plan reflected that resident #1 was at risk for bowel incontinence. Resident #1's goal was to not have any complications relating to bowel incontinence. Resident #1's interventions included: apply barrier cream after every incontinent episode, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode, report any skin change to the nurse immediately, see care plans on mobility, ADL, and cognitive deficit, Communication. Record review of Resident #1's undated Care Plan also reflected that resident #1 had an ADL Self Care Performance Deficit. Resident #1's goal was to maintain current level of function in bed mobility through the review date. Resident #1's interventions included: bathing-requires extensive assistance staff x 2 for assistance; bed mobility- requires extensive assistance staff x 2 for assistance; eating-requires staff x1; the resident requires a lift for all transfers; toilet use- requires extensive assistance staff x 2 for assistance; dressing-the resident requires (x2) staff participation to dress; the resident has contractures of the upper extremities. Record review of Resident #1's undated Discontinued Orders reflected resident received Baclofen Oral Tablet 20 MG 1 tablet by mouth four times daily. Resident #1 was also ordered and received Clonazepam .5 MG tablet by mouth twice daily. Resident #1 received Probiotic Oral Capsule daily as well. Resident #1 had a PRN (as needed) order for Bisacodyl Rectal Suppository insert 10 mg rectally as needed for constipation. Resident #1's orders also reflected he received 2 Hydrocodone-Acetaminophen Oral Table 5-325 three times daily. Resident #1 received 1 Cyclobenzaprine HCl Oral Tablet 10 MG twice daily. Record review of Resident #1's Progress Notes dated 02/26/25 at 6:47 PM reflected LVN A transferred Resident #1 to the hospital due to a change in condition and family request on 02/26/25 at 12:00 AM after Resident #1 spoke with his Responsible Party on 02/25/25. Record review of Resident #1's Progress Notes dated 02/28/25 at 10:32 AM reflected the DON was made aware of allegations of neglect. Progress Note by the DON reflected Administrator, Medical Director, Area Director of Operations, and Area DON notified. Record review of Resident #1's Bowel Movement ADL 30-day documentation chart reflected no bowel movements between the days of 02/11/25 through 02/20/25. The ADL record reflected the resident had one bowel movement on 02/21/25 but had no other bowel movements before he was transferred to the hospital on 02/26/25 at 12:00AM. Therefore, the ADL record reflected the resident had one bowel movement from 02/11/25 until discharge on [DATE]. Record review of Resident #1's undated MAR reflected that Resident #1 did not receive a dosage of his order for Bisacodyl Rectal Suppository for constipation as needed ordered by his primary care physician during the month of February 2025. Record review of Resident #1's Hospital Record dated 02/26/25 at 10:16 PM reflected, Prominent fecal impaction of the rectum with associated stercoral colitis (chronic constipation leading to stagnation of fecal matter). There is constipation, without bowel obstruction. Record review of Resident #1's Hospital Record dated 02/28/25 at 9:23 AM reflected, Severe Constipation: on 02/27 Disimpaction severe and Mag Citrate, Lactulose, and Go Lytely. Record review of Resident #1's Hospital Record dated 03/02/25 at 11:44 AM reflected Resident #1's diagnoses of Severe constipation with fecal impaction: Improving. S/P (Status Post Docusate) docusate, lactulose, soapsuds enema, manual disimpaction. Had watery stool. Record review of Resident #1's Hospital Record dated 03/03/25 at 9:20 AM reflected Resident #1's diagnosis of Severe constipation, fecal impaction. The same hospital progress notes also reflected, Noted stercoral colitis on CT, Initiate docusate, lactulose, Soapsuds enema x 2, and No BM despite manual disimpaction. Will obtain CT/AP with p.o. contrast [Computed tomography of Abdomen and pelvis with oral contrast]. Record review of the National Libraray of Medicine at www.ncbi.nlm.nih.gov/books/NBK560608, Stercoral Colitis, dated 07/10/23, reflected: Stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma [hardened stool] formation Interview on 03/11/25 at 9:53 AM with the Administrator revealed that a family member put on social media that Resident #1 was being neglected in the areas of showering, oral care, and monitoring of bowel movements. The Administrator also revealed that the resident did not return to the facility after discharge from the hospital. The Administrator said that Resident #1 went to a sister facility for long-term care. The Administrator revealed he was not aware Resident #1 had gone 11 days with no bowel movements. The Administrator stated that on 02/28/25 he in-serviced all staff on abuse/neglect, patient rounding, resident rights, bowel and bladder documentation, bowel incontinence care, bath, tub/shower, bed bath complete, teeth care/oral hygiene, resident/resident incidents, Immediately in-service, accurate documentation of refusals, and physician's orders. Interview on 03/11/25 at 10:42 AM with CNA B revealed that she worked three days on and four days off. CNA B stated that she documented the residents' activities of daily living in the facility kiosk. CNA B stated that she did not recall if Resident #1 had a bowel movement in the date range of 02/11/25-02/21/25 on the shifts that she worked. CNA B said that because the software system was supposed to trigger a warning if a resident went 72 hours without a bowel movement, she thought that the resident had a bowel movement on another aide's shift. CNA B revealed that she did not recall the resident having a bowel movement in the days prior to his discharge from the facility. CNA B stated she did not recall the system flagging a warning for Resident #1. CNA B revealed that she did not notify the nurse because she did not see a warning on her computer screen, though the resident had not had a bowel movement on her shift. CNA B stated that the resident did not complain of abdominal pain or have nausea and/or vomiting. However, CNA B revealed that Resident #1 had decreased appetite and intake prior to discharge. CNA B said that Resident #1 could communicate that he was in pain. CNA B also said that Resident #1's stomach did not appear distended. CNA B revealed that the facility's policy was that if a resident went more than 72 hours without a bowel movement, the CNA was supposed to report it to the charge nurse. The CNA stated that she did not report this because she never saw the software flag that the resident had gone 72 hours without a bowel movement. CNA B revealed that if a resident did not have a bowel movement within 72 hours, she was supposed to notify the nurse so that an as needed medication could be administered to the resident for constipation to prevent an obstruction which could lead to weight loss. Interview on 03/11/25 at 11:02 AM with CNA C revealed that she was also his regular aide. CNA C stated that his bowel movements were not regular. CNA C stated that Resident #1 was alert and would communicate if he had a bowel movement and needed assistance. CNA C said that she told a nurse at the nurses' station that Resident #1 had not had a bowel movement in 72 hours. However, CNA C could not recall which nurse she told. CNA revealed that the software system was supposed to flag the CNAs and the nurses if the resident had not had a bowel movement within 72 hours. CNA C stated the facility's policy was to tell the charge nurse if a resident did not have a bowel movement in 72 hours to prevent the resident from getting constipated which could lead to sepsis and other negative outcomes. Interview on 03/11/25 at 11:17 AM with LVN A revealed that she was one of Resident #1's charge nurses. LVN A stated that she was not told that Resident #1 did not have a bowel movement from 02/11/25-02/21/25 by any of the aides that provided care for Resident #1. LVN A said that Resident #1 could communicate, and the resident did not complain of pain or discomfort to her during that time. LVN A also revealed that the facility software system was supposed to flag the aides and nurses as a pop-up if a resident had not had a bowel movement within 72 hours. LVN A stated she never saw Resident #1's electronic health record flag the warning of no bowel movement for 72 hours. LVN A revealed that during her nursing assessments, in that time period, Resident #1's stomach was not distended. LVN A stated that she did not recall reviewing Resident #1's bowel movements in the electronic health record though he was a high risk for constipation due to his diagnoses and medications. Electronic Health Record reflected LVN A sent the resident out to the hospital on 02/26/25 because the resident was not talking, and the family wanted the resident sent out. LVN A revealed the importance of regular bowel movements was to prevent a bowel obstruction. LVN A stated that if a resident was at risk for constipation, she would encourage fluids. LVN also revealed that residents had standing orders for an as needed medication for constipation to be provided to the resident if the resident had not had a bowel movement within 72 hours. LVN A stated that it was everyone's responsibility to follow up with the CNAs to ensure that residents had a bowel movement within 72 hours after an as needed medication for constipation was administered. Interview on 03/11/25 at 11:45 AM with RN D revealed that Resident #1 was at high risk for constipation complications. RN D also revealed that Resident #1 did not have a bowel movement for 72 hours. RN D stated that the facility software should flag the nurses and aides if no bowel movement in 72 hours was documented. RN D said that the aides were pretty good at telling the nurses if a resident had not had a bowel movement in 72 hours. RN D stated that the software had a specific place that a nurse could go to review the resident's bowel movement history. RN D said that when she completed her assessments on Resident #1 during her daily shifts, she did not observe abdominal firmness, abdominal tenderness, nor distention. RN D stated that Resident #1 could communicate if he was in pain during an assessment. RN D revealed that 72 hours or greater without a bowel movement, put a resident at risk for bowel obstruction. RN D also revealed that she depended on the aides to tell her if the resident went 72 hours or longer without a bowel movement. The RN said that after an as needed medication for constipation was provided to the resident, she relied on the resident and the aides to communicate to her if the interventions were working. RN D also said that, during her daily assessments, she used her observations and nursing skills to determine if the interventions worked. RN D stated that it was the nurses' responsibility to ensure that a resident had a bowel movement and follow up with an assessment after an intervention was utilized. Interview on 03/11/25 at 1:46 PM with Resident #1's Responsible Party revealed that a family member placed a negative comment about the facility on social media the morning that the resident went out to the hospital. The Responsible Party stated that he saw Resident #1 on the morning of 02/25/25, and he could tell that something was wrong. The Responsible Party stated that he called the facility and requested that his family member be sent out to the hospital. The Responsible Party confirmed that the hospital did not do surgery on Resident #1, and, Resident #1 was now at another facility. Interview on 03/11/25 at 4:14 PM with the ADON revealed that he was unaware Resident #1 had no bowel movement from 02/11/25 to 02/21/25. The ADON stated that his expectation was that the aides report to their charge nurses if a resident had an abnormal bowel movement. The ADON said that the nurses should receive an alert on their software if a resident has gone 72 hours or longer without a bowel movement. The ADON also revealed that residents have a standing order for a medication to be administered if a resident is constipated and it has been 72 hours since the resident's last bowel movement. The ADON said that nurses should looks for signs of vomiting and distention as well as monitor for symptoms of constipation. The ADON revealed that constipation could lead to an obstruction which could further lead to other injuries such as a bowel perforation. Interview on 03/12/25 at 11:18 AM with the Medical Director revealed that Resident #1 had risk factors for constipation due to his diagnosis of cerebral palsy, which was a neurological condition which led to his immobility. The Medical Director stated that he provided the facility with standing orders for the treatment of constipation if a resident did not have a bowel movement after three days. The Medical Director said that he expected the facility's nurses to notify him if his prescribed interventions did not work for residents. The Medical Director stated that he did not recall if he was notified of a change in condition for Resident #1. The Medical Director concluded by stating that he could not remember everything about every resident. Interview on 03/12/25 at 1:25 PM with CNA E revealed that she provided care to Resident #1. CNA E stated that she could not recall if Resident #1 had a bowel movement from 02/11/25 to 02/21/25. CNA E said that the policy was to inform the nurse if a resident did not have a bowel movement within 72 hours. CNA E revealed her daily procedure when she worked was to review the resident's history. Then if the resident had missed a bowel movement within 48 hours and she arrived on the third day, she would report the abnormal bowel movement to the charge nurse verbally or write a note and hand it to them. CNA E stated that the importance of the policy was to ensure that a resident was provided their medication or treatment ordered by their physician for the constipation. CNA E confirmed that Resident #1 could communicate to her by using his tablet. CNA E said that Resident #1 did not complain pain. CNA E revealed that the resident's eating declined prior to discharge to the hospital. CNA E said that Resident #1 did not complain of vomiting, nausea, or stomach pain. CNA E stated that his stomach looked normal, without puffiness. Interview on 03/12/25 at 2:09 PM with CNA F revealed that Resident #1 was chronic for constipation. CNA F stated that Resident #1 had abnormal bowel movements, which was approximately once every two to four days. CNA F could not recall Resident #1's bowel movements for the month of February. CNA F stated that Resident #1 also had abnormal eating habits because he wanted to eat at night and not regular meals in the day. CNA F revealed that the resident did not complain of pain. CNA F stated that she did not observe distention of Resident #1's stomach. CNA F said that the documentation reviewed by her during the middle of shift depended on the individual she was working with. CNA F stated that she was not told that Resident #1 had not had a bowel movement in 72 hours when she last worked with the resident. CNA F said that she could not recall charting that the resident had no bowel movement during the time of 02/11/25 through 02/21/25 or if she had reported it to the nurse. CNA F stated that the standard protocol was that if a resident did not have a bowel movement within 72 hours, the nurse was supposed to be told by the aide. CNA F revealed that it was important to inform the nurse because the resident could be impacted or possibly have a bowel obstruction. Interview on 03/13/25 at 2:30 with Area DON revealed the facility began to in-service all staff on 03/13 after notification of the immediate jeopardy at 11:30 AM on 03/13/25. The Area DON stated that all staff were in-serviced on abuse and neglect by the ADON. The Area DON also stated that all staff were in-serviced on documentation of bowel movements, reporting changes, and notifying the ADON and DON of changes in bowel movements by the ADON. The Area DON revealed that she in-serviced the nursing staff on how to access clinical alerts in the facility software. The Area DON also stated that the ADON in-serviced the nursing staff administering PRN (as needed) medication to residents with no bowel movement for three days. The Area DON said that the ADON in-serviced all nursing staff on bowel movement monitoring and dashboard alerts and monitoring. The Area DON stated that the ADON also in-serviced all nursing staff on recognizing a change of condition and the requirement to notify the resident's primary care physician. The Area DON revealed that she in-serviced the Administrator, the DON, Area Director of Operations, and the ADON on recognizing a change of condition and bowel movement changes. The Area DON revealed that the in-service was completed via a text service that went to all facility staff and copies were provided evidencing it. The Area DON also said that she and the ADON spoke with the staff about the in-service topics before they began their shifts in addition to the text that went out to all facility staff. The Area DON stated the DON and/or the ADON will review all new admissions in the stand-up meeting 5 times a week for six weeks and then as needed addressing alerts for no bowel movements and if the nurse accurately responded. The Area DON also revealed that the DON and/or the ADON would ask five nurses per week if anyone reported not having a bowel movement in the last three days and document the intervention and monitor for six weeks as needed. The Area DON stated that the DON and/or the ADON would ask five CNAs per week if they reported a resident that did not have a bowel movement to their nurse and the nurse's response. The DON was out due to illness during the days the surveyor was in the building 03/11/25-03/14/25. Record review of the facility's undated Physician's Orders policy reflected: To Monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Record review of the facility's undated Documentation policy reflected: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of the facility's Abuse and Neglect Policy dated 09/09/24 reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of in-services reflected 32 staff attended the following in-services and all other staff were notified via cell phone text on the following in-services: Abuse/Neglect completed on 03/13/25, Documentation of Bowel Movements, Reporting Changes, Notify ADON/DON of Changes completed on 03/13/25, How to Access Clinical Alerts completed on 03/13/25, No Bowel Movement in 3 Days-Offer PRN (as needed) Intervention completed on 03/13/25, Bowel Movement and Monitoring/Dash Board Alerts and Monitoring completed 03/13/25, SBAR-Change of Condition/Notification to the Primary Care Physician completed 03/13/25, Change of Condition and Bowel Movements. Record review of in-services reflected 32 staff attended the following in-services and all other staff were notified via cell phone text on the following in-services:: Abuse/Neglect completed on 02/28/25, Patient rounding completed on 02/28/25, Resident Rights completed on 02/28/25, Bowel and Bladder Documentation completed on 02/28/25, Bowel Incontinence Care completed on 02/28/25, Bath Tub/Shower completed on 02/28/25, Bed Bath Complete completed on 02/28/25, Teeth Care/Oral Hygiene completed on 02/28/25, Resident/Resident Incidents completed on 02/28/25, Immediate Notification completed on 02/28/25, Accurate Documentation of Refusals completed on 02/28/25, and Physician's Orders completed on 02/28/25. Record review of facility monitoring tool that reflected the DON and/or the ADON would review the 24-hour report and clinical alerts daily in stand-up meeting five times a week for five weeks, and then as needed completed 03/14/25 and reviewed 03/14/25. Record review of the facility monitoring tool that reflected the DON and/or the ADON would ask five nurses per week if anyone reported a resident not having a bowel movement in the last three days, the nurses' response, and monitoring to continue for six weeks and as needed completed 03/14/25 and reviewed 03/14/25. Record review of the facility monitoring tool that reflected the DON and/or the ADON would ask five CNAs per week if anyone reported a resident not having a bowel movement in the last three days, the nurses' response, and monitoring to continue for six weeks and as needed completed 03/14/25 and reviewed 03/14/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. The Administrator was informed of the Immediate Jeopardy in the areas of Quality of Care. The Immediate Jeopardy template was provided to the Administrator via email on 03/13/25 at 11:30 AM. The plan of removal was accepted on 03/13/25 at 3:11 PM and included: Plan of Removal Action: 03/13/25 1. Resident #1 no longer resides at the facility as of 03/13/25. 2. The Compliance Nurse in-serviced the Administrator, the DON, and the ADON 1:1 on the following topics below on 03/13/25: a. The use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements in the past 72 hours, Nurses will document Interventions in the facility software. b. Promptly and correctly assessing a resident when a change of condition has been identified or reported. Assessing a resident's change in condition using a SBAR (Situation, Background, Assessment, Recommendations tool so that all necessary information is communicated to the physician or nurse practitioner. c. Abuse and /Neglect Policy. d. Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards, e. Residents who have not had a bowel movement within three days will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported. f. Potential complications of Bowel constipation. g. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. h. If the nurse does not assess timely, the DON is to be notified. i. Accurate and timely documentation in the facility software, including resident bowel movement. 3. The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics on 03/13/25: a. Abuse/Neglect Policy. b. The use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements in the past 72 hours, Nurses will document Interventions in the facility software. c. Promptly and correctly assessing a resident when a change of condition has been identified or reported. Assessing a resident's change in condition using a SBAR, so that all necessary information is communicated to the physician or nurse practitioner. d. Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards. e. Residents who have not had a bowel movement within three days will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported. f. Potential complications of Bowel constipation. g. All residents who are at risk of constipation will have an active care plan. 4. The DON, ADON, and Regional Compliance Nurse in-serviced the non-licensed staff on the following on 03/13/25: a. Abuse/Neglect Policy. b. Reporting changes in a resident's condition to a nurse immediately, including when a resident has not had a bowel c. If the nurse does not assess timely, the DON is to be notified. d. Accurate and timely documentation in the facility software, including resident bowel movements. 5. AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. No additional residents were identified with no Bowel movements within three days. Review of AD Hoc QAPI Completed on 03/13/25. 6. The QAPI committee will review findings and make changes as needed. Identified Residents at Risk: Only 1 resident was affected regarding this incident. The resident was treated with medication in the hospital. The resident did not require surgery. Systemic Changes: 1. Nursing Administration will monitor all residents at risk for bowel complications. 2. CNAs will monitor residents for no bowel movements and notify nurses and document it in the facility software. 3. Nurses will monitor the software dashboard for clinical alerts. 4. Nurses will contact the physician when a resident has a change in condition. 5. Nurses will provide a resident with an intervention medication if the resident has not had a bowel movement in 72 hours. Responsibility: It is the Administrator, or designee, and the Director of Nursing, or designee's responsibility to follow the actions and the systematic changes listed above. The Administrator, or designee, and the Director of Nursing, or designee, will report their findings of the above actions and systematic changes through their QAPI [Quality Assessment Performance Improvement] Process. Monitoring interviews for the Immediate Jeopardy were started on 03/13/25 at 3:39 PM and continued through 03/14/25 at 11:15 AM with 40 staff across all three shifts, including weekdays and weekends, including all departments. The staff were interviewed about and abuse/neglect, monitoring for risk of bowel complications, monitoring residents' bowel movements and notifying nurses and documenting it in the facility software, nursing monitoring the dashboard for clinical alerts, nurses contacting the physician when a resident has a change in condition, nurses providing a resident with an intervention medication if the resident has not had a bowel movement in 72 hours. The following staff's in-service logs were reviewed, and they were interviewed during the monitoring time frame. The were able to articulate what they were taught including the correct protocols and procedures related to documenting bowel movements, notifying nurse and nursing administration, administering intervention medication if a resident has not had a bowel movement for in 72 hours, the risk to bowel complications, and abuse/neglect: LVN A, CNA B, CNA C, RN D, CNA E, CNA F, CNA G, CNA H, CNA I, MA J, LVN K, CNA L, LVN M, LVN N, Hospitality Aide O, LVN P, CNA Q, CNA R CNA S, RN T, Administrator, and the ADON. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interviews and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medications. The facility failed ensure Resident #1, who was at increased risk for constipation due to having cerebral palsy, was administered his physician-ordered Bisacodyl Rectal Suppository when he had only one bowel movement between 02/11/25 and 02/26/25. This failure resulted in the resident being diagnosed in the hospital with fecal impaction of the rectum with associated stercoral colitis, which is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually hardened stool formation. Prior to the hospitilization, the resident had only had one bowel movement between 02/11/25 and 02/26/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The failure placed residents at risk of serious harm or death. Findings included: Record review of Resident #1's Nursing Home Comprehensive Item Set MDS Record dated, 01/15/25, reflected an initial admitted [DATE] and readmitted [DATE]. Resident #1's diagnoses included: cerebral palsy (congenital disorder of movement, muscle tone, or posture), seizure disorder or epilepsy, sepsis (life-threatening complication of an infection), and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Resident #1's MDS also reflected that Resident #1's cognition was intact with a BIMS of 15. Resident #1's MDS reflected that Resident #1 was dependent (helper does all the effort) on staff for toileting. Resident #1's MDS also reflected that Resident #1 was not on a bowel toileting program. Resident #1's MDS reflected that the resident was always incontinent of bowel. The MDS also reflected that Resident #1 showed no constipation present. Record review of Resident #1's undated Care Plan reflected that resident #1 was at risk for bowel incontinence. Resident #1's goal was to not have any complications relating to bowel incontinence. Resident #1's interventions included: apply barrier cream after every incontinent episode, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode, report any skin change to the nurse immediately, see care plans on mobility, ADL, and cognitive deficit, Communication. Record review of Resident #1's undated Care Plan also reflected that resident #1 had an ADL Self Care Performance Deficit. Resident #1's goal was to maintain current level of function in bed mobility through the review date. Resident #1's interventions included: bathing-requires extensive assistance staff x 2 for assistance; bed mobility- requires extensive assistance staff x 2 for assistance; eating-requires staff x1; the resident requires a lift for all transfers; toilet use- requires extensive assistance staff x 2 for assistance; dressing-the resident requires (x2) staff participation to dress; the resident has contractures of the upper extremities. Record review of Resident #1's undated Discontinued Orders reflected resident received Baclofen Oral Tablet 20 mg 1 tablet by mouth four times daily. Resident #1 was also ordered and received Clonazepam .5 mg tablet by mouth twice daily. Resident #1 received Probiotic Oral Capsule daily as well. Resident #1 had a PRN (as needed) order for Bisacodyl Rectal Suppository insert 10 mg rectally as needed for constipation. Resident #1's orders also reflected he received 2 Hydrocodone-Acetaminophen Oral Table 5-325 three times daily. Resident #1 received 1 Cyclobenzaprine HCl Oral Tablet 10 mg twice daily. Record review of Resident #1's Progress Notes dated 02/26/25 at 6:47 PM reflected LVN A transferred Resident #1 to the hospital due to a change in condition and family request on 02/26/25 at 12:00 AM after Resident #1 spoke with his Responsible Party on 02/25/25. Record review of Resident #1's Progress Notes dated 02/28/25 at 10:32 AM reflected the DON was made aware of allegations of neglect. Progress Note by the DON reflected Administrator, Medical Director, Area Director of Operations, and Area DON notified. Record review of Resident #1's Bowel Movement ADL 30-day documentation chart reflected no bowel movements between the days of 02/11/25 through 02/20/25. The ADL record reflected the resident had one bowel movement on 02/21/25 but had no other bowel movements before he was transferred to the hospital on 02/26/25 at 12:00AM. Therefore, the ADL record reflected the resident had one bowel movement from 02/11/25 until discharge on [DATE]. Record review of Resident #1's undated MAR reflected that Resident #1 did not receive a dosage of his order for Bisacodyl Rectal Suppository for constipation as needed ordered by his primary care physician during the month of February 2025. Record review of Resident #1's Hospital Record dated 02/26/25 at 10:16 PM reflected, Prominent fecal impaction of the rectum with associated stercoral colitis (chronic constipation leading to stagnation of fecal matter). There is constipation, without bowel obstruction. Record review of Resident #1's Hospital Record dated 02/28/25 at 9:23 AM reflected, Severe Constipation: on 02/27 Disimpaction severe and Mag Citrate, Lactulose, and Go Lytely. Record review of Resident #1's Hospital Record dated 03/02/25 at 11:44 AM reflected Resident #1's diagnoses of Severe constipation with fecal impaction: Improving. S/P docusate, lactulose, soapsuds enema, manual disimpaction. Had watery stool. Record review of Resident #1's Hospital Record dated 03/03/25 at 9:20 AM reflected Resident #1's diagnosis of Severe constipation, fecal impaction. The same hospital progress notes also reflected, Noted stercoral colitis on CT, Initiate docusate, lactulose, Soapsuds enema x 2, and No BM despite manual disimpaction. Will obtain CT/AP with p.o. contrast [Computed tomography of Abdomen and pelvis with oral contrast]. Record review of the National Libraray of Medicine at www.ncbi.nlm.nih.gov/books/NBK560608, Stercoral Colitis, dated 07/10/23, reflected: Stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma [hardened stool] formation Interview on 03/11/25 at 9:53 AM with the Administrator revealed that a family member put on social media that Resident #1 was being neglected in the areas of showering, oral care, and monitoring of bowel movements. The Administrator also revealed that the resident did not return to the facility after discharge from the hospital. The Administrator said that Resident #1 went to a sister facility for long-term care. The Administrator revealed he was not aware Resident #1 had gone 11 days with no bowel movements. The Administrator stated that on 02/28/25 he in-serviced all staff on abuse/neglect, patient rounding, resident rights, bowel and bladder documentation, bowel incontinence care, bath, tub/shower, bed bath complete, teeth care/oral hygiene, resident/resident incidents, Immediately in-service, accurate documentation of refusals, and physician's orders. Interview on 03/11/25 at 10:42 AM with CNA B revealed that she worked three days on and four days off. CNA B stated that she documented the residents' activities of daily living in the facility kiosk. CNA B stated that she did not recall if Resident #1 had a bowel movement in the date range of 02/11/25-02/21/25 on the shifts that she worked. CNA B said that because the software system was supposed to trigger a warning if a resident went 72 hours without a bowel movement, she thought that the resident had a bowel movement on another aide's shift. CNA B revealed that she did not recall the resident having a bowel movement in the days prior to his discharge from the facility. CNA B stated she did not recall the system flagging a warning for Resident #1. CNA B revealed that she did not notify the nurse because she did not see a warning on her computer screen, though the resident had not had a bowel movement on her shift. CNA B stated that the resident did not complain of abdominal pain or have nausea and/or vomiting. However, CNA B revealed that Resident #1 had decreased appetite and intake prior to discharge. CNA B said that Resident #1 could communicate that he was in pain. CNA B also said that Resident #1's stomach did not appear distended. CNA B revealed that the facility's policy was that if a resident went more than 72 hours without a bowel movement, the CNA was supposed to report it to the charge nurse. The CNA stated that she did not report this because she never saw the software flag that the resident had gone 72 hours without a bowel movement. CNA B revealed that if a resident did not have a bowel movement within 72 hours, she was supposed to notify the nurse so that an as needed medication could be administered to the resident for constipation to prevent an obstruction which could lead to weight loss. Interview on 03/11/25 at 11:02 AM with CNA C revealed that she was also his regular aide. CNA C stated that his bowel movements were not regular. CNA C stated that Resident #1 was alert and would communicate if he had a bowel movement and needed assistance. CNA C said that she told a nurse at the nurses' station that Resident #1 had not had a bowel movement in 72 hours. However, CNA C could not recall which nurse she told. CNA revealed that the software system was supposed to flag the CNAs and the nurses if the resident had not had a bowel movement within 72 hours. CNA C stated the facility's policy was to tell the charge nurse if a resident did not have a bowel movement in 72 hours to prevent the resident from getting constipated which could lead to sepsis and other negative outcomes. Interview on 03/11/25 at 11:17 AM with LVN A revealed that she was one of Resident #1's charge nurses. LVN A stated that she was not told that Resident #1 did not have a bowel movement from 02/11/25-02/21/25 by any of the aides that provided care for Resident #1. LVN A said that Resident #1 could communicate, and the resident did not complain of pain or discomfort to her during that time. LVN A also revealed that the facility software system was supposed to flag the aides and nurses as a pop-up if a resident had not had a bowel movement within 72 hours. LVN A stated she never saw Resident #1's electronic health record flag the warning of no bowel movement for 72 hours. LVN A revealed that during her nursing assessments, in that time period, Resident #1's stomach was not distended. LVN A stated that she did not recall reviewing Resident #1's bowel movements in the electronic health record though he was a high risk for constipation due to his diagnoses and medications. Electronic Health Record reflected LVN A sent the resident out to the hospital on 02/26/25 because the resident was not talking, and the family wanted the resident sent out. LVN A revealed the importance of regular bowel movements was to prevent a bowel obstruction. LVN A stated that if a resident was at risk for constipation, she would encourage fluids. LVN also revealed that residents had standing orders for an as needed medication for constipation to be provided to the resident if the resident had not had a bowel movement within 72 hours. LVN A stated that it was everyone's responsibility to follow up with the CNAs to ensure that residents had a bowel movement within 72 hours after an as needed medication for constipation was administered. Interview on 03/11/25 at 11:45 AM with RN D revealed that Resident #1 was at high risk for constipation complications. RN D also revealed that Resident #1 did not have a bowel movement for 72 hours. RN D stated that the facility software should flag the nurses and aides if no bowel movement in 72 hours was documented. RN D said that the aides were pretty good at telling the nurses if a resident had not had a bowel movement in 72 hours. RN D stated that the software had a specific place that a nurse could go to review the resident's bowel movement history. RN D said that when she completed her assessments on Resident #1 during her daily shifts, she did not observe abdominal firmness, abdominal tenderness, nor distention. RN D stated that Resident #1 could communicate if he was in pain during an assessment. RN D revealed that 72 hours or greater without a bowel movement, put a resident at risk for bowel obstruction. RN D also revealed that she depended on the aides to tell her if the resident went 72 hours or longer without a bowel movement. The RN said that after an as needed medication for constipation was provided to the resident, she relied on the resident and the aides to communicate to her if the interventions were working. RN D also said that, during her daily assessments, she used her observations and nursing skills to determine if the interventions worked. RN D stated that it was the nurses' responsibility to ensure that a resident had a bowel movement and follow up with an assessment after an intervention was utilized. Interview on 03/11/25 at 1:46 PM with Resident #1's Responsible Party revealed that a family member placed a negative comment about the facility on social media the morning that the resident went out to the hospital. The Responsible Party stated that he saw Resident #1 on the morning of 02/25/25, and he could tell that something was wrong. The Responsible Party stated that he called the facility and requested that his family member be sent out to the hospital. The Responsible Party confirmed that the hospital did not do surgery on Resident #1, and, Resident #1 was now at another facility. Interview on 03/11/25 at 4:14 PM with the ADON revealed that he was unaware Resident #1 had no bowel movement from 02/11/25 to 02/21/25. The ADON stated that his expectation was that the aides report to their charge nurses if a resident had an abnormal bowel movement. The ADON said that the nurses should receive an alert on their software if a resident has gone 72 hours or longer without a bowel movement. The ADON also revealed that residents have a standing order for a medication to be administered if a resident is constipated and it has been 72 hours since the resident's last bowel movement. The ADON said that nurses should looks for signs of vomiting and distention as well as monitor for symptoms of constipation. The ADON revealed that constipation could lead to an obstruction which could further lead to other injuries such as a bowel perforation. Interview on 03/12/25 at 11:18 AM with the Medical Director revealed that Resident #1 had risk factors for constipation due to his diagnosis of cerebral palsy, which was a neurological condition which led to his immobility. The Medical Director stated that he provided the facility with standing orders for the treatment of constipation if a resident did not have a bowel movement after three days. The Medical Director said that he expected the facility's nurses to notify him if his prescribed interventions did not work for residents. The Medical Director stated that he did not recall if he was notified of a change in condition for Resident #1. The Medical Director concluded by stating that he could not remember everything about every resident. Interview on 03/12/25 at 1:25 PM with CNA E revealed that she provided care to Resident #1. CNA E stated that she could not recall if Resident #1 had a bowel movement from 02/11/25 to 02/21/25. CNA E said that the policy was to inform the nurse if a resident did not have a bowel movement within 72 hours. CNA E revealed her daily procedure when she worked was to review the resident's history. Then if the resident had missed a bowel movement within 48 hours and she arrived on the third day, she would report the abnormal bowel movement to the charge nurse verbally or write a note and hand it to them. CNA E stated that the importance of the policy was to ensure that a resident was provided their medication or treatment ordered by their physician for the constipation. CNA E confirmed that Resident #1 could communicate to her by using his tablet. CNA E said that Resident #1 did not complain pain. CNA E revealed that the resident's eating declined prior to discharge to the hospital. CNA E said that Resident #1 did not complain of vomiting, nausea, or stomach pain. CNA E stated that his stomach looked normal, without puffiness. Interview on 03/12/25 at 2:09 PM with CNA F revealed that Resident #1 was chronic for constipation. CNA F stated that Resident #1 had abnormal bowel movements, which was approximately once every two to four days. CNA F could not recall Resident #1's bowel movements for the month of February. CNA F stated that Resident #1 also had abnormal eating habits because he wanted to eat at night and not regular meals in the day. CNA F revealed that the resident did not complain of pain. CNA F stated that she did not observe distention of Resident #1's stomach. CNA F said that the documentation reviewed by her during the middle of shift depended on the individual she was working with. CNA F stated that she was not told that Resident #1 had not had a bowel movement in 72 hours when she last worked with the resident. CNA F said that she could not recall charting that the resident had no bowel movement during the time of 02/11/25 through 02/21/25 or if she had reported it to the nurse. CNA F stated that the standard protocol was that if a resident did not have a bowel movement within 72 hours, the nurse was supposed to be told by the aide. CNA F revealed that it was important to inform the nurse because the resident could be impacted or possibly have a bowel obstruction. Interview on 03/13/25 at 2:30 with Area DON revealed the facility began to in-service all staff on 03/13 after notification of the immediate jeopardy at 11:30 AM on 03/13/25. The Area DON stated that all staff were in-serviced on abuse and neglect by the ADON. The Area DON also stated that all staff were in-serviced on documentation of bowel movements, reporting changes, and notifying the ADON and DON of changes in bowel movements by the ADON. The Area DON revealed that she in-serviced the nursing staff on how to access clinical alerts in the facility software. The Area DON also stated that the ADON in-serviced the nursing staff administering PRN (as needed) medication to residents with no bowel movement for three days. The Area DON said that the ADON in-serviced all nursing staff on bowel movement monitoring and dashboard alerts and monitoring. The Area DON stated that the ADON also in-serviced all nursing staff on recognizing a change of condition and the requirement to notify the resident's primary care physician. The Area DON revealed that she in-serviced the Administrator, the DON, Area Director of Operations, and the ADON on recognizing a change of condition and bowel movement changes. The Area DON revealed that the in-service was completed via a text service that went to all facility staff and copies were provided evidencing it. The Area DON also said that she and the ADON spoke with the staff about the in-service topics before they began their shifts in addition to the text that went out to all facility staff. The Area DON stated the DON and/or the ADON will review all new admissions in the stand-up meeting 5 times a week for six weeks and then as needed addressing alerts for no bowel movements and if the nurse accurately responded. The Area DON also revealed that the DON and/or the ADON would ask five nurses per week if anyone reported not having a bowel movement in the last three days and document the intervention and monitor for six weeks as needed. The Area DON stated that the DON and/or the ADON would ask five CNAs per week if they reported a resident that did not have a bowel movement to their nurse and the nurse's response. The DON was out due to illness during the days the surveyor was in the building 03/11/25-03/14/25. Record review of the facility's undated Physician's Orders policy reflected: To Monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Record review of the facility's undated Documentation policy reflected: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of the facility's Abuse and Neglect Policy dated 09/09/24 reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of in-services reflected 32 staff attended the following in-services and all other staff were notified via cell phone text on the following in-services: Abuse/Neglect completed on 03/13/25, Documentation of Bowel Movements, Reporting Changes, Notify ADON/DON of Changes completed on 03/13/25, How to Access Clinical Alerts completed on 03/13/25, No Bowel Movement in 3 Days-Offer PRN (as needed) Intervention completed on 03/13/25, Bowel Movement and Monitoring/Dash Board Alerts and Monitoring completed 03/13/25, SBAR-Change of Condition/Notification to the Primary Care Physician completed 03/13/25, Change of Condition and Bowel Movements. Record review of in-services reflected 32 staff attended the following in-services and all other staff were notified via cell phone text on the following in-services:: Abuse/Neglect completed on 02/28/25, Patient rounding completed on 02/28/25, Resident Rights completed on 02/28/25, Bowel and Bladder Documentation completed on 02/28/25, Bowel Incontinence Care completed on 02/28/25, Bath Tub/Shower completed on 02/28/25, Bed Bath Complete completed on 02/28/25, Teeth Care/Oral Hygiene completed on 02/28/25, Resident/Resident Incidents completed on 02/28/25, Immediate Notification completed on 02/28/25, Accurate Documentation of Refusals completed on 02/28/25, and Physician's Orders completed on 02/28/25. Record review of facility monitoring tool that reflected the DON and/or the ADON would review the 24-hour report and clinical alerts daily in stand-up meeting five times a week for five weeks, and then as needed completed 03/14/25 and reviewed 03/14/25. Record review of the facility monitoring tool that reflected the DON and/or the ADON would ask five nurses per week if anyone reported a resident not having a bowel movement in the last three days, the nurses' response, and monitoring to continue for six weeks and as needed completed 03/14/25 and reviewed 03/14/25. Record review of the facility monitoring tool that reflected the DON and/or the ADON would ask five CNAs per week if anyone reported a resident not having a bowel movement in the last three days, the nurses' response, and monitoring to continue for six weeks and as needed completed 03/14/25 and reviewed 03/14/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. The Administrator was informed of the Immediate Jeopardy in the areas of Quality of Care. The Immediate Jeopardy template was provided to the Administrator via email on 03/13/25 at 11:30 AM. The plan of removal was accepted on 03/13/25 at 3:11 PM and included: Plan of Removal Action: 03/13/25 1. Resident #1 no longer resides at the facility as of 03/13/25. 2. The Compliance Nurse in-serviced the Administrator, the DON, and the ADON 1:1 on the following topics below on 03/13/25: a. The use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements in the past 72 hours, Nurses will document Interventions in the facility software. b. Promptly and correctly assessing a resident when a change of condition has been identified or reported. Assessing a resident's change in condition using a SBAR (Situation, Background, Assessment, Recommendations tool so that all necessary information is communicated to the physician or nurse practitioner. c. Abuse and /Neglect Policy. d. Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards, e. Residents who have not had a bowel movement within three days will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported. f. Potential complications of Bowel constipation. g. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. h. If the nurse does not assess timely, the DON is to be notified. i. Accurate and timely documentation in the facility software, including resident bowel movement. 3. The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics on 03/13/25: a. Abuse/Neglect Policy. b. The use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements in the past 72 hours, Nurses will document Interventions in the facility software. c. Promptly and correctly assessing a resident when a change of condition has been identified or reported. Assessing a resident's change in condition using a SBAR, so that all necessary information is communicated to the physician or nurse practitioner. d. Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards. e. Residents who have not had a bowel movement within three days will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported. f. Potential complications of Bowel constipation. g. All residents who are at risk of constipation will have an active care plan. 4. The DON, ADON, and Regional Compliance Nurse in-serviced the non-licensed staff on the following on 03/13/25: a. Abuse/Neglect Policy. b. Reporting changes in a resident's condition to a nurse immediately, including when a resident has not had a bowel c. If the nurse does not assess timely, the DON is to be notified. d. Accurate and timely documentation in the facility software, including resident bowel movements. 5. AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. No additional residents were identified with no Bowel movements within three days. Review of AD Hoc QAPI Completed on 03/13/25. 6. The QAPI committee will review findings and make changes as needed. Identified Residents at Risk: Only 1 resident was affected regarding this incident. The resident was treated with medication in the hospital. The resident did not require surgery. Systemic Changes: 1. Nursing Administration will monitor all residents at risk for bowel complications. 2. CNAs will monitor residents for no bowel movements and notify nurses and document it in the facility software. 3. Nurses will monitor the software dashboard for clinical alerts. 4. Nurses will contact the physician when a resident has a change in condition. 5. Nurses will provide a resident with an intervention medication if the resident has not had a bowel movement in 72 hours. Responsibility: It is the Administrator, or designee, and the Director of Nursing, or designee's responsibility to follow the actions and the systematic changes listed above. The Administrator, or designee, and the Director of Nursing, or designee, will report their findings of the above actions and systematic changes through their QAPI [Quality Assessment Performance Improvement] Process. Monitoring interviews for the Immediate Jeopardy were started on 03/13/25 at 3:39 PM and continued through 03/14/25 at 11:15 AM with 40 staff across all three shifts, including weekdays and weekends, including all departments. The staff were interviewed about and abuse/neglect, monitoring for risk of bowel complications, monitoring residents' bowel movements and notifying nurses and documenting it in the facility software, nursing monitoring the dashboard for clinical alerts, nurses contacting the physician when a resident has a change in condition, nurses providing a resident with an intervention medication if the resident has not had a bowel movement in 72 hours. The following staff's in-service logs were reviewed, and they were interviewed during the monitoring time frame. The were able to articulate what they were taught including the correct protocols and procedures related to documenting bowel movements, notifying nurse and nursing administration, administering intervention medication if a resident has not had a bowel movement for in 72 hours, the risk to bowel complications, and abuse/neglect: LVN A, CNA B, CNA C, RN D, CNA E, CNA F, CNA G, CNA H, CNA I, MA J, LVN K, CNA L, LVN M, LVN N, Hospitality Aide O, LVN P, CNA Q, CNA R CNA S, RN T, Administrator, and the ADON. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern 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 immediately notify the resident's representative when there was a need to alter treatment for 1 of 3 residents (Resident #1) reviewed for notification of change. The facility failed to notify Resident #1's representative when the medication, Pramipexole (Mirapex), was added to her drug regimen on 01/01/25 to treat restless leg syndrome. This failure could place residents at risk for a delay in treatment and not receiving proper care due to failure to notify resident representative. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included coronary artery disease (a condition where the arteries that supply blood to the heart become narrowed or blocked), high blood pressure, hemiplegia (a condition that causes weakness or paralysis to one side of the body), anxiety disorder, depression, and pain. Resident #1 had a BIMS of 10, meaning her cognition was moderately impaired. Record review of Resident #1 care plan initiated on 12/13/24 reflected the resident had the potential for uncontrolled pain disease process related to neuropathy. Interventions included to notify the physician if intervention were unsuccessful or if current complaint was a significant change from resident's past experience of pain. Review of Resident #1's Facesheet printed on 02/19/25 reflected the resident's Family Member was the resident's Respnsible Party/Emergency Contact #1/Resident Representative. Record review of Resident #1's progress notes dated 12/31/24 documented by the Nurse Practitioner reflected the following: .Patient seen and examined at bedside today. She complains of bilateral leg pain/restlessness . Treatment Restless leg syndrome Clinical notes: on Baclofen, Duloxetine, Gabapentin and Tramadol. Will add Pramipexole 0.5mg at bedtime . Record review of Resident #1's monthly physician orders for January 2025 reflected the resident was on Pramipexole 0.5 mg; give one tablet by mouth one time a day for restless leg syndrome. The physician's orders further reflected the order had been put into the electronic health record by LVN B on 01/01/25 at 1:00 AM. Record review of Resident #1's January 2025 MAR reflected LVN C administered the first dose of the medication Pramipexole on 01/01/25. Record review of Resident #1's clinical record reflected there was no documented evidence reflecting Resident #1's responsible party had been notified that Pramipexole had been added to Resident #1's drug regimen. Record review of Resident #1's facesheet printed on 02/19/25 reflected the resident was discharged to the hospital on 01/14/25 and did not return to the faciltiy. Interview on 02/18/25 at 4:44 PM with Resident #1's Family Member revealed they were not made aware Resident #1 had been started on the medication Pramipexole. The Family Member stated they had noticed a decline in the resident and when they were asking about Resident #1's medication list, they were told the resident had began taken Pramipexole. The Family Member further stated they were never contacted about the resident's new medication. Interview on 02/19/25 at 2:35 PM with LVN A revealed she recalled the Resident #1 being up one night complaining of her legs and feet bothering her. LVN A stated Resident #1 reported she could not get comfortable due to her restless leg syndrome. Interview on 02/19/25 at 3:34 PM with LVN B revealed she did not recall Resident #1 or the circumstances under which the resident was prescribed the medication Pramipexole. LVN B said if the order was put in at 1:00 AM, she would not have called the family at that time. She stated she would have passed it on to the morning shift nurse to contact the family. Interview on 02/19/25 at 3:55 PM with LVN C revealed she did not recall giving Resident #1 her first dose of the medication Pramipexole. LVN C said if the night nurse would have told her to contact Resident #1's family about the added medication, she would have documented in the nurse's notes in Resident #1's record. LVN C further stated if it was not documented in the notes, she probably did not contact the family. Interview on 02/19/25 at 4:02 PM with the ADON revealed when a new medication was ordered for a resident, the nurse that took the order would be responsible for contacting the resident's responsible party. He was not aware Resident #1's responsible party had not been contacted about the resident's new medication Pramipexole. He stated since the order was put in at 1:00 AM, he would understand the nurse being polite and waiting until the morning to make the call. The ADON said any time a resident's responsible party was contacted about a medication order or change, it should be documented in the system because it was part of their compliance. Record review of the facility's Family Notification policy dated 2003 reflected the following: Objectives: 1. To keep families informed Procedure: 1. The family will be notified of any resident change .3. Notification will occur in a timely manner .

Based on observation, interview, and record review, the facility failed to prepare, store, distribute, and serve foods in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure pork chops stored in the facility freezer were covered to prevent contamination. This failure placed residents, who received food from the kitchen, at risk for food contamination and food borne illness. Findings included: Observation of the facility freezer on 11/18/24 at 9:04 AM revealed uncovered pork chops stored in a labeled, metal pan. Interview on 11/20/24 at 3:34 PM with the [NAME] revealed all items in the facility refrigerators and freezers should be covered, labeled, and dated. The [NAME] stated the importance of covering foods was to prevent contamination. The [NAME] added that residents could get sick if they ate contaminated food. The [NAME] said he would report uncovered, labeled, and dated to his dietary manager. The [NAME] stated he was last in-serviced on food storage about a month ago. Interview on 11/20/24 at 3:37 PM with the Dietary Manager revealed the pork chops should have been covered in the freezer per facility policy. The Dietary Manager stated the importance of items being covered or in sealed containers was so that germs did not fall into or on the food. The Dietary Manager said residents could get sick if food was placed in freezers or refrigerators uncovered. The Dietary Manager stated the dietary department was last in-serviced on food storage about a month and a half ago. Record review of facility's current Food Storage and Supplies Dietary Services Policy and Procedure Manual, dated 2012, reflected the following: .Procedure: .4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened

Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #3) reviewed for dignity. The facility failed to allow Residents #31 to keep his electric wheelchair when he admitted to the facility. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #31's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart disease, end stage renal disease (a terminal illness that occurs when the kidneys can no longer function properly), and stroke. Resident #31 had a BIMS of 12 which indicated his cognition was moderately impaired. The MDS further indicated the resident had impairment on one side to his upper and lower extremities and used a wheelchair. Record review of Resident #31's care plan revised on 07/19/24 reflected the resident had an ADL self-care performance deficit and required limited assistance of one staff member for ADLs. Observation and interview on 11/19/24 at 9:11 AM revealed Resident #31 was in a manual wheelchair. The resident said when he was admitted to the facility he had an electric wheelchair and was told by someone, whom he could not recall, that it was against the rules to have the electric wheelchair unless he was given a test so he was given a manual wheelchair. Resident #31 said he did not believe it was fair that he did not get to keep his electric wheelchair and was never given a test to see if he could keep it. He stated he was just told they did not have room for it. The resident said he was able to get around good with the manual wheelchair, but he preferred to have his electric one. Record review of a progress note for Resident #31, dated 07/05/24, and documented by the previous DON reflected the following: Resident arrived to the facility in electric wheelchair. Wheelchair is not a necessity and resident has not been approved for use. Manual w/c offered to resident and he is able to move w/c using legs. W/C seat added for additional height for legs. Explained reason electric w/c is not allowed and marketer to relay to family to have them pick electric w/c up Interview on 11/20/24 at 1:35 PM with Resident #31's family member revealed the resident admitted to the facility with an electric wheelchair. The family member was told, but did not recall by whom, that Resident #31 was able to use a manual wheelchair, therefore he did not need the electric chair. The family member said they did not question the request so they just took the electric chair home. They further stated they felt like Resident #31 was safe to use the electric wheelchair as he had been using it prior to being admitted to the facility. Interview on 11/19/24 at 9:30 AM with the Director of Rehabilitation revealed he had only been at the facility for about three weeks. He said if a resident was admitted to the facility and wanted to use an electric wheelchair, the resident would be given a test to ensure the resident were safe to use the electric wheelchair. He stated he was not aware Resident #31 once had an electric wheelchair. He stated if the resident wanted to use the electric wheelchair they would assess the resident for safety. He further stated he looked through the files, and he did not see that Resident #31 was ever assessed to use his electric wheelchair. Interview on 11/19/24 at 3:05 PM with the ADON revealed Resident #31 was admitted using an electric wheelchair. The ADON could not recall the situation around why the resident did not use it. The ADON said residents who admitted with electric wheelchairs were usually assessed to determine if they were safe to use it. He further stated he did not see any reason why Resident #31 would not be able to use it once he would be assessed. Record review of the facility's copy of the Resident [NAME] of Rights on 11/20/24 reflected the following: .A facility must treat each resident with respect and dignity and care for each resident in a manner an in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident

Based on observation, interview, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #47) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #47 after they returned from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care resulting in harm to the resident. Findings included: Record review of Resident #47's face sheet, dated 11/20/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnoses which included encephalopathy (brain disease that alters brain function or structure), end stage renal disease (when kidneys suddenly become unable to filter waste products from blood), acute kidney failure, fluid overload, and difficulty in walking. Record review of Resident #47's Nursing Home PA PPS Discharge Item Set, dated 11/04/24, reflected Resident #47 had a BIMS score of 12 reflecting the resident's cognition was mildly impaired. The MDS section O, related to special treatments, procedures, and programs, reflected Resident #47 received hemodialysis, which is ongoing dialysis (three to five times per week) that cleans your blood in a dialysis center. Record review of Resident #47's care plan, date initiated 08/22/24, reflected: Focus: The resident needs dialysis hemodialysis. Goals: The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Interventions: Encourage reside t to go for the scheduled dialysis appointments. Resident receives dialysis (specify frequency). Monitor for dry skin and apply lotion as needed. Monitor/document for peripheral edema. Monitor/document/report to MD PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations, and BP immediately. Record review of Resident #47's undated physician's order, reflected the resident was to have hemodialysis treatments performed via AV shunt on Tuesdays, Thursday, ans Saturdays. Record review of Resident #47's dialysis communication form in the facility's EHR, dated 11/07/24, reflected no pre-dialysis weight was documented, only a post-dialysis weight. Record review of Resident #47's dialysis communication from in the facility's EHR, dated 11/09/24, reflected no pre-dialysis weight was documented, only a post-dialysis weight. Record review of Resident #47's dialysis communication form in the facility's EHR, dated 11/14/24, reflected no post-dialysis weight was documented, only a pre-dialysis weight. Observation and interview on 11/18/24 at 10:52 AM revealed Resident #47 sitting in her wheelchair dressed and neat in appearance. The resident denied any pain. Resident #47 stated she received dialysis, and the facility transported her to dialysis three times per week on Tuesdays, Thursdays, and Saturdays. Resident #47 also stated the facility provided her with a sack lunch on her dialysis days. Interview on 11/20/24 at 3:03 PM with LVN B revealed it was the charge nurse's responsibility to ensure that vitals, including weights, were obtained and documented both before and after dialysis on the dialysis communication form. LVN B stated it was important to document the weights before and after dialysis to determine the amount of fluid pulled off the resident during dialysis. LVN B also said that if too much fluid was pulled off the resident, it could affect the resident's heart. LVN B stated it was the responsibility of the resident's nurse to ensure the dialysis forms were completed. LVN B also said if she noted an issue with the resident's weight, she would notify the DON. LVN B concluded by stating she did not recall the last in-service on dialysis policies and procedures provided by the facility. Interview on 11/20/24 at 3:14 PM with the ADON revealed nurses should ensure pre- and post-vitals, including weights, were completed for the dialysis residents. The ADON stated the risk to the resident if weights were not obtained would be that the resident's nurse would not know if the resident did not have sufficient fluid pulled off the resident. The ADON said that was important to the resident's health because it could make them toxic, and the resident could then become ill. The ADON further stated if the resident's nurse observed that vitals were not taken, that the nurse should report it to the primary care physician and the urologist. The ADON concluded by stating that he did not recall the last in-service on dialysis and vitals. Interview on 11/20/24 at 3:40 PM with the Regional Clinical Consultant revealed the resident's nurse was supposed to complete the communication form upon the resident's return from dialysis per facility policy. The Regional Clinical Consultant stated it was important to assess the resident upon returning from dialysis. The Regional Clinical Consultant said it was important to review the resident's vitals including pre- and post-dialysis weights because the resident could have fluid deficit or volume overload. The Regional Clinical Consultant stated she last in-serviced the nursing staff on dialysis around the 09/01/24. Record review of the facility's current Dialysis policy, dated November 2013, reflected the following: .Procedure .19. The facility will monitor departures and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed. The resident's clinical record will be documented with this information. The date and time of the resident's return to the facility will be recorded by the nurse.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 medication carts (Hall C Medication Cart) reviewed for storage, in that: MA A failed to ensure the Hall C Medication cart was locked when she left it unattended for approximately two minutes. This deficient practice placed residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed medications. Findings included: Observation on 11/19/24 at 8:00 AM revealed the Hall C medication cart was observed unlocked and unattended on Hall C outside of the dining room for approximately two minutes. The medication cart was not within view of the dining room. Approximately 100 different types of medications including medications such as antihypertensives, anticonvulsants, and anticoagulants, were accessible inside the unlocked cart including medications in blister packs, bottles, and vials. The narcotics were noted as locked in a drawer with a second lock and were not accessible. MA A returned to the cart from the dining room after approximately two minutes. Interview on 11/19/24 at 8:02 AM with MA A revealed she confirmed the medication cart was left unlocked while she was administering medications to a resident in the dining room. MA A stated she worked at the facility for about one year. She stated she typically locked the cart before leaving it because, I have medications, and anyone can get into it. I have dementia patients who could take something. I usually keep it locked. I don't know what happened today. Interview on 11/19/24 at 9:20 AM with the DON revealed MA A had already told her she left her cart unlocked. She stated nurses and aides locked their carts when they left the carts to keep the medications secure. She stated, A resident could get into it, and you wouldn't know what they had taken. Record review of the facility's Facility Medication Administration Policy, Pharmacy Policy & Procedure Manual, dated 2003 and revised 10/25/17, reflected: During the medication administration process, the unlocked side of the cart must always be in full view of the nurse and After the medication administration process is completed, the medication cart must be completely locked and stored in a locked medication room, or otherwise secured.

Based on interview and record review, the facility failed to ensure the residents comprehensive care plan was reviewed and revised after each assessment, including both the comprehensive and quarterly review assessments for 3 of 14 residents (Residents #5, #7 and #104) reviewed for care plans, in that: The facility failed to ensure Residents #5, #7, #104's selected resuscitaiton statuses were updated on their care plans. This deficient practice could affect residents at the facility and place them at-risk of their advanced directives not being honored. Findings included: Review of Resident #5's face sheet, dated 09/28/23, revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease with (acute) exacerbation, essential hypertension (high blood pressure), acute respiratory failure with hypoxia (low oxygen), and pneumonia. Resident #5 face sheet reflected advance directive of DNR. Review of Resident #5's quarterly MDS assessment, dated 07/23/23, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. MDS revealed the quarterly assessment was submitted on 07/28/23. Review of Resident #5's care plan, revised dated 08/12/23, revealed the care plan addressed the resident's code status as Full Code (choice to receive cardiopulmonary resuscitation). The date the care plan was initiated was 01/12/22. Record review of Resident #5's physician orders, date 01/17/23, revealed the resident had an order for DNR (order date 01/17/23). Record review of Resident #5 advance directive, revealed resident had an Out-of-hospital DNR dated 01/06/23. Review of Resident #7's face sheet, dated 09/28/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease, chronic kidney disease and essential hypertension (high blood pressure). Resident #7 face sheet reflected advance directive of DNR. Review of Resident #7's quarterly MDS assessment, dated 08/17/23, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. MDS revealed the quarterly assessment was submitted on 08/28/23. Review of Resident #7's care plan, revised dated 08/30/23, revealed the care plan addressed the resident's code status as Full Code (date initiated 12/07/21). Record review of Resident #7's physician orders, date 09/18/23, revealed the resident had an order for DNR (order date 09/18/23). Record review of Resident #7 advance directive, revealed resident had an Out-of-hospital DNR dated 09/15/23. Review of Resident #104's face sheet, dated 09/28/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included acute kidney failure, acute respiratory failure and diabetes mellitus. Resident #104 face sheet reflected advance directive of DNR. Review of Resident #104's admission MDS assessment, dated 09/07/23, revealed the resident had a BIMS score of 09, which indicated the resident was cognitively moderately impaired. MDS revealed the quarterly assessment was submitted on 09/19/23. Review of Resident #104's care plan, dated 09/01/23, revealed the care plan addressed the resident's code status as Full Code (date initiated 09/01/23). Record review of Resident #104's physician orders, date 09/18/23, revealed the resident had an order for DNR (order date 09/18/23). Interview on 9/27/23 at 1:35 PM with LVN B revealed a care plan was used to keep all staff updated on individual resident rationale/goals and measurable goals. LVN B revealed staff used care plans to determine interventions and determine outcome by assessing resident every shift. LVN B revealed a care plan would change with any new order or change in status. LVN B revealed nurses/therapy staff all used care plan information to determine resident need and current status. LVN B revealed the resident care plan would need to be adjusted when orders changed or were discontinued. LVN B revealed nurse assigned to resident was responsible for ensuring care plan was updated timely. LVN B revealed code status should be a reflection of the doctor's order on resident face sheet and care plan to ensure resident received intended services at critical time. She revealed potential for resident receiving DO NOT RESUSCITATE response when resident was actually a FULL CODE and vice versa. Interview on 9/28/23 at 9:45 AM with LVN C revealed she had been employed in facility 3 weeks. LVN C revealed nursing management were responsible for checking care plans to ensure plans reflected current physician orders and care LVN C revealed all charts were set to trigger quarterly for review by DON, ADON , corporate nurse and MDS coordinator. LVN C revealed she reviewed the resident chart to ensure orders were reflected in care plan. She revealed any changes, additions to resident care were discussed in morning stand-up and LVN C would follow-up by doing a care plan check. Interview on 09/28/23 at 9:52 AM with DON revealed she was ultimately responsible for ensuring Code Status was accurate across Face sheets, Care Plans, etc. DON revealed all should reflect physician order. The DON revealed failure to accurately document Code Status order could mean a resident that requested a Do Not Resuscitate could be provided full code, life-saving measures which could result in poor outcome for resident and ultimately, lawsuits. DON revealed all staff utilized resident care plans for information on resident care requirements. She revealed care plans should be updated quarterly and as needed. Interview on 09/28/23 at 12:55 PM with LVN A revealed a care plan was used by nursing staff to determine type of care. LVN A revealed she expected the care plan to reflect accurate code status. She revealed if any question of status she would perform full code. Interview on 09/28/23 at 4:25 PM with the Administrator stated she expected resident care plans, face sheets to accurately reflect Code Status as ordered by the physician. The administrator revealed failure to correctly document Code Status placed all residents at risk of not receiving requested/ordered code response services. Record review of the facility's current, undated Comprehensive Care Planning reflected the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #121 and #122) of ten residents observed during medication pass. Reviewed for infection control, in that: 1. Medication Aide C failed to clean the blood pressure wrist cuff after checking vitals of Residents #121 and #122. 2. Medication Aide C failed to disinfect the medication cart prior to it being used. These failures could affect the 4 residents on the Quarantine Hall who received medications by Medication Aide C by placing them at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Record review of Resident #121's undated face sheet, revealed that of a [AGE] year-old white female admitted [DATE] with a history that included Cerebrovascular accident, hypertension, Coronary Angioplasty implant and graft, Atherosclerotic heart disease, congestive heart failure, Angina, chronic obstructive pulmonary disease, Diabetes, Gastroparesis, chronic kidney disease (stage 4) , above knee amputation (left), below knee amputation (right), depression and dementia. Review of undated Face Sheet for Resident #122 revealed that of an [AGE] year-old female admitted [DATE] with a history that included hypertension, Atherosclerotic heart disease of native coronary artery, chronic combined systolic and diastolic congestive heart failure, chronic kidney disease (stage 4), Diabetes Mellitus, anxiety and depression. 1. Observation on 9/27/23 at 7:00 AM revealed Medication Aide C entered the room of Resident #121 with a blood pressure wrist cuff and obtained vitals of Resident #121 then returned to medication cart and placed the contaminated wrist cuff on top right of medication cart. Medication Aide C was observed to remove the wrist cuff from the cart, disinfect the wrist cuff using a disinfectant wipe and returned the cuff to the top of the cart in the same place the soiled cuff had rested without disinfecting the cart top. 2. Observation on 9/27/23 at 7:15 AM revealed Medication Aide C exit room [ROOM NUMBER] and temporarily place the contaminated wrist cuff on the PPE container and then returned to cart and placed the contaminated cuff on top right of cart. 3. Observation on 9/27/23 at 7:19 Am revealed Medication Aide C placed a dose cup containing Vitamin D on PPE container in the same spot the soiled cuff had rested and then enter room [ROOM NUMBER] and administer Vitamin D to Resident #122. 4. Observation on 9/27/23 at 7:29 AM revealed Medication Aide C enter room [ROOM NUMBER], place wrist cuff on Resident #122, obtained vitals, and return to cart where she placed the contaminated wrist cuff on top of the cart. Medication Aide C was observed to disinfect the wrist cuff and returned it to the top right of the medication cart without disinfecting the cart top. 5. There was no observation of Medication Aide C disinfecting the medication cart top during this medication administration. Interview with Medication Aide C on 9/27/23 at 7:35 AM revealed she was supposed to disinfect the wrist cuff after each use and before placing cuff on cart. Medication Aide C stated she should not have placed the wrist cuff or dose cup on the PPE container. Medication Aide C stated both actions placed residents at risk of infection. Interview with ADON on 9/27/23 at 3:02 PM the ADON stated equipment should be thoroughly cleaned after each resident use and following manufacturer's recommendations. The ADON stated contaminated equipment should be placed on some type of barrier such as Styrofoam trays, prior to cleaning to prevent further contamination. The ADON stated when Medication Aide C had placed the contaminated wrist cuff on the PPE container on the quarantine hall, everything should have been removed and the container thoroughly cleaned/sanitized. The ADON stated her intent to provide infection control in-service to Medication Aide C. The ADON stated she was responsible for staff training and staff performed return demonstration. The ADON stated she spent approximately 20 hours per week providing training and in-services, including infection control, to staff. Interview with DON on 9/27/23 at 1:55 PM the DON stated contaminated equipment should not be placed on medication carts. The DON stated re-usable equipment should be disinfected after each use. The DON stated failure to disinfect increased the risk of disease spread. Review of the facility's Infection Prevention and Control Program, Transmission-Based Precautions policy, dated December 2012, reflected: .Clean and disinfect objects and environmental surfaces that are touched frequently with an EPA-registered disinfectant for healthcare at least daily and when visibly soiled. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html 4.c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly).

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 2 residents (Resident #12) reviewed for tube feeding. The facility failed to follow physician order's for Resident #12 when cleaning the resident's enteral stoma site by not applying a gauze dressing. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalization s. Findings included: Record review of Resident #12's quarterly MDS assessment, dated 07/01/23, revealed the resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia oropharyngeal phase (difficulty swallowing) and gastrostomy status (surgical opening into the stomach). MDS revealed a BIMS score of 0 which indicated Resident #12 had severe cognitive impairment. The assessment reflected Resident #12 required extensive assistance with eating, two-person physical assist. Resident #12's weight was 160 pounds, and the resident's nutritional approach was feeding tube. Record review of Resident #12's Resident Care Plan, revised dated 04/13/23, revealed the following: Resident #12 requires tube feeding r/t dysphagia. The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: Clean insertion site daily as ordered, monitoring for s/s infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to MD if symptoms arise. Record review of Resident #12's physician order, dated 01/19/22, revealed an order for: Enteral Stoma Site Care: (With Dressing - Routine) Cleanse G-tube area and change dressing one time a day every Tuesday and Saturday for prevention. Observation on 09/27/23 at 11:10 AM revealed Resident #12 lying in bed. Observation of Resident #12's g-tube revealed there was no dressing around the g-tube site. There were no signs of infection or discharge noted. Observation on 09/28/23 at 12:45 PM with LVN A revealed Resident #12 lying in bed. Observation of Resident #12's g-tube revealed there was no dressing around the g-tube site. There were no signs of infection or discharge noted. An attempt was made to interview resident; however, the resident was unable to respond. Interview on 09/28/23 at 12:55 PM with LVN A revealed she was the nurse for Resident #12. She stated she cleaned Resident #12 g-tube daily; however, she did not put a dressing on the area and had not put one on the site since she had worked here. LVN A stated there was an order to clean the site; she stated she was unaware that she needed to put a dressing on. LVN A stated the risk of not putting a dressing on was that it could cause an infection. Interview with the DON on 09/27/23 at 3:46 PM revealed there was an order for cleaning the g-tube site and applying a dressing twice weekly for Resident #12. The DON stated there should be a dressing on the resident if there was an order. She also stated that physician's orders should be followed. Record review of the facility's Enteral Nutrition policy, dated 03/02/21, reflected the following: .9b. Cleans the skin area around the catheter or stoma with wound cleanser or normal saline in a circular motion from the center outward. c. If ordered, apply any ointments, creams or other skin treatments d. If ordered, place gauze dressing on the stoma and tape .

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Resident #1 and Resident #2) of six residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #1 received wound assessments, wound treatments, and on-going skin assessments in that: LVN A did not document that Resident #1 admitted on [DATE] with a deep tissue injury (DTI). Additionally, LVN A did not notify the physician or obtain treatment orders for the wound. The wound was not assessed or treated until 08/07/21. On 08/12/21 the resident was admitted to the hospital and passed away due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B and LVN C did not complete a skin assessment for Resident #1 as they documented on 08/03/21 - 08/06/21. 2. LVN B documented no skin issues for Resident #2 on 09/01/21. Resident #2 had a Stage III pressure ulcer on his coccyx. An Immediate Jeopardy (IJ) was identified on 09/01/21 at 4:20 PM. While the IJ was removed on 09/03/21, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal (POR). These failures placed residents at risk of life-threatening infection, which could manifest into other health complications, pain, worsening pressure ulcers and death. Findings included: 1. Review of Resident #1's MDS (minimum data set) assessment, dated 08/09/21, reflected the resident was a [AGE] year-old-female admitted on [DATE]. The resident was cognitively intact. She required extensive assistance of two staff with bed mobility, transfers, and toileting. She required partial assist in bathing with one staff. She was frequently incontinent of bladder and occasionally incontinent of bowel. The assessment reflected the resident had an unstageable pressure ulcer. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Physician Orders reflected: 08/08/21 5x5x.25 open pressure ulcer to right upper inner buttock clean with wound cleanser, pat dry and apply allevyn dressing daily and prn . Review of Resident #1's Care Plan dated 08/10/21 revealed the resident had an unstageable wound to her sacrum and right buttock. Her interventions included notify nurse immediately of any new areas of skin breakdown and assist resident to reposition every two hours. There was not a care plan for the wound prior to 08/10/21. Review of Resident #1's Braden Scale (predicts risk for pressure ulcer development) dated 08/02/21 reflected a score of 18, indicating the resident had a potential risk for the development of pressure ulcers. Completed by LVN A Review of Resident #1's Initial Skin assessment dated [DATE], and corrected on 08/11/21, reflected the resident admitted with redness to the peri-area and a dark red/purple spot to right upper buttocks that was very tender to touch. Completed by LVN A Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 08/03/21 - 08/05/21 reflected no skin issues on the skin assessment. Completed by LVN B Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 08/06/21 reflected no skin issues on the skin assessment. Completed by LVN C Review of Resident #1's Progress Notes reflected: 8/7/21 11:10 PM CNA reports a blister on the resident's buttocks on the right side. A necrotic wound 3.5 cm in length x 7.5 cm in width. Noted foul odor from drainage from wound on brief that was covering the wound. Nurse will clean and dress the wound when resident is able to lay on her bed and report finding to the wound care team. Completed by LVN F An interview was attempted on 09/03/21 at 11:40 AM with LVN F, but LVN F did not return the call of the State Surveyor. Review of Resident #1's Initial Wound Evaluation, dated 08/09/21, reflected the resident had an unstageable, necrotic wound to her sacrum which measured 5.5 cm x 6.0 cm x not measurable depth. The resident also had an unstageable DTI of the right, lateral buttock which measured 1.0 cm x 1.2 cm x not measurable depth. 8/12/21 1:24 PM Transfer Notification: Resident was transferred to a hospital on 08/12/21 at 1:30 PM related to debridement of pressure sore on buttock. Completed by LVN B Review of Resident #1's Hospital Records, Death Summary, dated 08/16/21, reflected: Resident #1 was admitted to the hospital on 08/12/21 and passed away on 08/14/21 with septic shock secondary to [CONDITION(S)] and [CONDITION(S)]. She admitted with a wound and severe pain to her right buttock. While at the hospital, a CT scan was performed and found the resident had a large open wound with soft tissue gas extending into the sacrum and coccyx indicating possible [CONDITION(S)]. The resident required two surgeries to debride the wound. Following the second surgery the resident was intubated and on minimal sedation. The resident wrote on a piece of paper that she was in too much pain and did not want to continue aggressive treatment. Per the resident request she was made a DNR (do not resuscitate), extubated, and passed away on 08/14/21. Interview with LVN A on 09/01/21 at 3:10 PM revealed she did the initial admission assessment for Resident #1 and documented no skin issues when she admitted . LVN A said Resident #1 admitted with a purplish spot to her buttocks, that looked like a DTI, and was really tender to touch. LVN A said she did not notify the physician about the wound because usually the WCN looked at wounds . She said she was not aware the WCN was not at the facility on 08/02/21. She said she forgot to document the wound on 08/02/21 and did not do any follow-up assessments because the wound was not open, it was just sore. She said she did go back and document the assessment later, but she was uncertain of the day. She said when a resident was admitted with a skin issue, she was supposed to document the issue on the 24-hour report for the WCN. An interview on 09/01/21 at 3:40 PM with the Regional Corporate Nurse (no facility DON) revealed LVN A did not document anything about Resident #1's wound on the 24-hour report and that wound information was not supposed to be documented on the 24-hour report. An interview on 09/01/21 at 11:00 AM with LVN B revealed she documented doing a skin assessment on 08/03/21 - 08/05/21 but did not actually assess the skin for Resident #1. She said she did not look at the resident's skin on those days because the resident liked to sit in her chair and not lay in bed. Additionally, LVN B said she worked the 6:00 AM - 2:00 PM shift and it was very busy, did not have time to do the assessment and she did not even have time to take a lunch break. LVN B said the resident did have a pillow she took to [CONDITION(S)] to sit on because the resident would say her bottom was sore. LVN B said she did not do a skin assessment on the daily skilled assessment because she thought the WCN had to do a weekly skin assessment. LVN B said she did not see the resident's skin until 08-09-21 and at that time she showed the wound to the physician. Interviews with the Regional Corporate Nurse on 09/01/21 at 11:45 AM and 3:00 PM revealed she did not know nurses were documenting that they did a skin assessment but did not actually complete the assessment. She said skin assessments were required daily on the Skilled Nurse Assessments completed by the floor nurses and she had the WCN validate the initial skin assessment. She said Resident #1 admitted on [DATE] and her initial assessment was completed by LVN A. The WCN was not in the facility at that time and so her assessment was not completed. She said the facility did a skin sweep on 08/09/21 or 8/10/21 because the WCN had a concern about the WCP ordering treatments on wounds that did not need them. The facility discovered LVN A admitted Resident #1 on 08/02/21 and said she found a dark purple area on her buttock but documented no skin issues. The Regional Corporate Nurse said she told LVN A that she needed to update her skin assessment. The Regional Corporate Nurse said she looked in the computer but did not see any skin issues documented for Resident #1 until 08/07/21. She said LVN A should have documented the skin issue on 08/02/21 and notified the physician about the skin issue. An interview on 09/01/21 at 1:30 PM with LVN C revealed she documented she did a skin assessment on her Skilled Nurse Assessment on 08/06/21 for Resident #1 but did not do the skin assessment because she was very busy. She said she never saw the wound. LVN B said she documented no skin issues on the assessment even though she did not do the assessment. An interview on 09/01/21 at 1:45 PM with CNA D revealed she documented that she gave Resident #1 a bath on 08/04/21 but did not actually bathe her or know who she was . She said she was probably just documenting it for someone else but did not remember who. She said she was not aware that any residents on her assignment had skin breakdown and asked the State Surveyor if she knew if any of the residents had skin breakdown. CNA D was asked if she was assigned to Resident #2 and she said yes. An interview on 09/01/21 at 1:50 PM with CNA E revealed she assisted the resident to stand on 08/09/21 for the WCP to see the resident's wound. CNA E said the wound had a rotten meat smell. An interview on 09/02/21 at 3:00 PM with the Unlicensed Aide revealed she vaguely remembered giving Resident #1 a bath on 08/06/21 and the resident told her she had a wound. The Unlicensed Aide said she was supposed to notify the nurse about wounds, but she did not think she notified the nurse about the wound but could not really remember. An interview on 09/02/21 at 3:05 PM with CNA F revealed she provided care to Resident #1. She said on 08/08/21 the Weekend RN and her were assisting the resident to the toilet and they smelled a rotten smell. They saw the purple area on the resident's bottom had opened and was draining everywhere. CNA F said it took a couple of days to get rid of the smell. She said Resident #1 would complain of pain because she had a purple area on the right side of her bottom. An interview on 09/02/21 at 4:15 PM with the Weekend RN revealed she first saw the resident sitting on the potty chair on 08/08/21. She said she noticed the resident had a very large, red, raised, hardened area that looked like an abscess on her bottom. The Weekend RN said she went back to see the resident after lunch and the area ruptured. She said the area had a large amount of foul-smelling drainage. The Weekend RN said the drainage was gray and blood streaked. She said she could not believe that no one had seen the wound prior to that because it was so large. She said she did not notify the physician about the wound but did leave a note for the doctor to see it the next day. She said normally she was supposed to fax a note to the doctor, but she did not have the WCP's number. Interviews on 09/01/21 at 10:55 AM and 2:05 PM with the WCN revealed she did not provide care to Resident #1 because she was not in the facility at that time. She said the charge nurses and ADON was supposed to cover when she was out. The WCN also revealed she did not know Resident #2 had a wound until she did his skin assessment on the day he admitted . She said no one reported to her that he admitted with a Stage III pressure ulcer. She said she always completed her own skin assessment when a resident admitted to the facility. Interviews on 09/01/21 at 3:00 PM and 3:40 PM with the Regional Corporate Nurse revealed she did not know there were facility nurses who documented completion of skin assessments but did not actually do the skin assessment. She said skin issues were not supposed to be documented on the 24-hour report as reported by LVN A. An interview on 09/01/21 at 4:45 PM with the Medical Director revealed he provided care to Resident #1 but did not see her wound and was not notified about the wound. He said if a resident had a skin issue the facility had a WCN and WCP who would go to the facility and make rounds. He said the staff were supposed to notify the WCN and WCP with wounds. An telephone interview on 09/02/21 at 10:45 AM with the ADON (not in the facility) revealed he was familiar with Resident #1 but was on vacation when she admitted . He said the first time he saw the wound was with the WCP and the resident had a large amount of necrotic tissue on her buttock. He said he did not know how she developed the wound. He said on 08/09/21, he assisted Resident #1 up for the WCP to see the wound. He said the WCP scored (cut the wound) and put ointment on it. He said he did not know why it took so long for Resident #1's wound to be discovered, but that she had been sitting on a cushion over the weekend. He said he was not aware nurses were documenting completion of skin assessments without actually completing them and that a CNA had documented giving the resident a bath but did not actually bathe the resident. 2. Review of New Admit, Resident #2's Face Sheet, dated 09/02/21, reflected the resident was admitted on [DATE] with pulmonary fibrosis and diabetes. Review of Resident #2's Initial Skin assessment, dated 08/31/21, reflected the resident had a Stage III pressure ulcer on his coccyx . Documented by the WCN. Review of Resident #2's Skilled Nurse Assessment with dated 09/01/21, reflected the resident had no skin issues. Documented by LVN B. An interview on 09/01/21 at 11:00 am with LVN B revealed she did not know Resident #2 had a pressure ulcer, even though she completed his Skilled Nurse Assessment on 09/01/21 and assisted to reposition the resident. An observation of wound care with the WCN for Resident #2 on 09/01/21 at 2:05 PM revealed the resident had an approximately 0.5 cm x 0.5 cm x unknown depth, Stage III pressure ulcer on coccyx. An interview with Resident #2's family on 09/01/21 at 2:10 PM revealed the resident had the wound since February 2021. Review of the Facility Policy for Pressure Injury: Prevention, Assessment, and Treatment, revised 08/12/16, reflected: . 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. 3. Upon assessment and identification of a pressure sore the staff will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician . Review of the Facility Policy for notifying the Physician of Change in Status, revised 03/11/13, reflected: .1. The nurse will notify the physician immediately with significant change in status . An Immediate Jeopardy (IJ) was identified on 09/01/21 at 4:00 PM. The IJ template was provided to the Regional Corporate Nurse on 09/01/21 at 4:20 PM when she was notified. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on 09/02/21 at 6:00 PM and reflected the following: Interventions: o 100% skin rounds completed 09/01/21. o Protocol was started after meeting with Medical Director on 09/01/21 for immediate treatments to begin as soon as skin issues were found. o All staff responsible for Resident #1 and Resident #2's care were 1:1 in-serviced. o The following in-services were initiated on 09/01/21: Any nurse not present or in-serviced on 09/01/21, will not be allowed to assume their duties until in-serviced. Licensed Nurses: Pressure ulcer prevention and treatment Notification of Physician with change of condition. PCC charting Skilled Notes Kiosk Alerts Validating skin assessments. Skin assessments will be validated by DON/Designee within 24 hours of admission. What to do when wound care nurse not available Pain assessments Licensed Nurses will have competency for performing skin assessments starting 09/02/21 and will continue until all staff is competent including, prn, agency, and weekend staff is completed. Admission assessments CNA: Pressure ulcer identification, notification, and documentation. Competency check off's will be conducted on performing skin observation on 09/02/21, and will continue until all staff is competent including, prn, agency, and weekend staff is completed Monitoring o The DON / designee will monitor all new ulcers, ensure treatments have been ordered, ensure assessments done daily, 7 days a week X's 6 weeks, to ensure compliance using the monitoring tool. o The DON / designee will view each pressure ulcer weekly X's 6 weeks using available monitoring tool. o The DON / designee will audit all skin assessments weekly to ensure all assessment match the resident's current condition for 6 weeks using current monitoring tool. o DON/designee will audit charting daily for accuracy of skilled nursing assessments x's 6 weeks. o DON/designee will monitor all treatments being done for accuracy per orders using monitoring tools, x's 6 weeks o DON/designee will monitor to ensure pain is being assessed properly with available monitoring tool x's 6 weeks. o The QA committee will review findings at the monthly QA meeting and makes changes as needed. Monitoring of the facility's Plan of Removal included the following: Interviews, and record reviews were conducted on 09/03/21 starting at 8:55 AM and continued through 09/03/21 at 12:30 PM with 13 staff members from various shifts. The in-services included the completing of skin assessments, competency checks for skin assessments, protocol to follow for skin issues, physician notification, nurse notification, false documentation, and wound care responsibilities when the WCN was not at the facility. Record reviews revealed residents with wounds were assessed accordingly and did not have no skin issues documented. The staff members were able to: Verbalize their understanding of the in-services related to the plan of removal. Interviewed staff members and shifts were: WCN - worked day and evening shift CNA G - worked day shift LVN H - worked day shift Unlicensed Aide - worked day shift LVN C - worked day shift LVN N - worked all shifts CNA F - worked all shifts CNA I - worked day shift CNA J - worked all shifts LVN K - worked day shift CNA D - worked day shift CNA L - worked night shift CNA M - worked all shifts An interview on 09/03/21 at 11:00 am with the Regional Corporate Nurse revealed the facility had a new DON who would be starting employment. She said her role in the POR was to ensure compliance was maintained and the facility would be conducting on-going monitoring with monitoring tools and Quality Assurance oversight to prevent the issues from occurring again. A telephone interview on 09/03/21 at 12:10 PM with the Administrator (not in the facility) revealed his role in the POR was to follow-up daily with the DON regarding skin issues and documentation. He said to prevent this issue from re-occurring the facility would continue with POR in-services, monitoring tools, and weekly skin checks. The Administrator was notified on 09/03/21 at 12:10 PM that the Immediate Jeopardy was removed. While the IJ was removed on 09/03/21, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure the resident maintained acceptable nutritional status, such as usual body weight or desirable body weight, unless the resident clinical condition demonstrated this was not possible, for one (Resident #5) of 13 residents reviewed for nutritional status. The facility did not develop and implement interventions to address Resident #5's unplanned significant weight gain. Resident #5 gained a total 42 pounds in six months since her admission to the facility, which caused the resident to be upset by her physical appearance. This failure placed the four residents, who were prescribed [MEDICATION NAME] for depression and also had a [DIAGNOSES REDACTED]. and not having their needs identified and/or met. Findings included: Resident #5's MDS assessment, dated 12/27/17, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #5's care plan, initiated on 07/12/17, reflected she had the potential for a nutritional deficit. The interventions included, weigh her weekly until weight remains stable and report 5% loss or gain to the physician and responsible party. A nutritional risk assessment completed by the Dietitian, dated 07/04/17, reflected the resident was 54 inches in height and weighed 108 pounds. The resident's ideal body weight was between 85 pounds and 125 pounds. The nutritional goal was to maintain weight within 5% of current body weight for the next 90 days. A physician order, dated 06/21/17, reflected to change Resident #5's antidepressant [MEDICATION NAME] to 15 mg [MEDICATION NAME] daily, and the [MEDICATION NAME] was discontinued at that time. A physician order, dated 07/25/17, reflected an order to add 5 mg [MEDICATION NAME] daily to Resident #5's drug regimen. A physician order, dated 09/12/17, reflected the [MEDICATION NAME] was increased from 5 mg to 10 mg daily. A physician order, dated 07/07/17, reflected an order to start Toujeo [MEDICATION NAME] Solution Pen-Injector 300 unit/ml (Insulin [MEDICATION NAME]) at 8 units subcutaneous injection daily. A physician order, dated 12/15/17, reflected the Toujeo insulin was increased from 8 units daily to 18 units subcutaneous injection daily. A physician order, dated 12/28/17, reflected the Toujeo insulin was increased from 18 units to 20 units subcutaneous injection daily. The Nursing 2015 Drug Handbook, published by WoltersKluwer, identifies [MEDICATION NAME] as a tetracyclic anti-depressant. Adverse reactions include an increased appetite. The Nursing 2015 Drug Handbook, published by WoltersKluwer, identifies [MEDICATION NAME] as an SSRI anti-depressant. Adverse reactions include: fatigue, lethargy, increased or decreased appetite, rash, palpitations, weight gain or loss, and tinnitus. The Nursing 2015 Drug Handbook, published by WoltersKluwer, identifies Toujeo [MEDICATION NAME] Solution Pen-Injector 300 units/ml as the equivalent to generic insulin [MEDICATION NAME]. [MEDICATION NAME] is long-acting insulin that has a duration of 24 hours. It is used for diabetics requiring basal (long-acting) insulin to control high blood sugars. Review of Resident #5's clinical record revealed there were no physician progress notes [REDACTED]. Resident #5's MARs for September 2017 through January 2018 reflected Resident #5's BS was checked four times daily. The review revealed the following: September 2017 - 19 incidences of BS greater than 200 and no incidences greater than 300. October 2017 - 29 incidences of BS greater than 200 and two incidences greater than 300. November 2017 - 55 incidences of BS greater than 200 and nine incidences of BS greater than 300. December 2017 - 72 incidences of BS greater than 200, 28 incidences of BS greater than 300, and seven incidences of BS greater than 400. January 2018 - eight incidences of BS greater than 200, seven incidences of BS greater than 300, and two incidences of BS greater than 400. The dates when Resident #5's blood sugars were above 300 were as follows: 01/01/18 6:00 a.m. - BS 367 01/01/18 11:00 a.m. - BS 431 01/02/18 6:00 a.m. - BS 320 01/02/18 11:00 a.m. - BS 392 01/02/18 4:00 p.m. - BS 343 01/03/18 11:00 a.m. - BS 411 01/03/18 7:00 p.m. - BS 389 01/04/18 6:00 a.m. - BS 396 01/04/18 7:00 p.m. - BS 359 There were no weekly weights documented in Resident #5's clinical record. Review of Resident #5's monthly weights revealed: June 2017 - 108 pounds July 2017 - 111 pounds August 2017 - 111 pounds September 2017 - 112 pounds October 2017 - 128 pounds November 2017 - 136 pounds December 2017 - 142 pounds Observation on 01/04/18 at 2:32 p.m. revealed Resident #5 being weighed by CNA A using a weight scale chair. The resident's weight at the time of this observation was 150 pounds. An interview with CNA A on 01/04/18 at 2:25 p.m. revealed the weight scale chair was the standard method used to obtain weights for Resident #5. CNA A did not know when the scale was last calibrated. An interview with Resident #5 on 01/05/18 at 4:15 p.m. revealed she felt ugly and doesn't like people to look at her when asked about her weight increase. Resident #5 began crying as she made these statements. She stated she told someone about her weight gain, but she could not remember whom she told. Review of Resident #5's clinical record revealed there was no Weight Watcher assessment for the resident. A nursing progress note, signed and dated by the ADON on 10/10/17, reflected a weight warning indicating the charting system had identified a significant weight change for Resident #5 and sent a warning note to notify the nurse. The noted reflected, Resident has snacks in her room and eats at will. Healthy appetite for most meals. Consumes meals in her room .no complaints to meals. An interview with the ADON on 01/05/18 at 3:20 p.m. revealed he was aware of Resident #5's significant weight gain. He stated he documented the progress note detailing the resident's increased weight. He stated he did not follow-up with the weight gain, and he wished he would have done so. He stated, She obviously would have triggered for weekly weights. I'm not sure why I didn't do it. I wish I would have caught her the first time. He stated when a resident admitted to the facility, they were weighed weekly for four weeks until the weight was deemed stable. If the resident triggered for weight gain/loss, then weekly weights were initiated. The ADON stated the system generated the trigger for weight loss/gain, which the DON monitored, and he (the ADON) was responsible for the follow-up. A weights and vitals summary for Resident #5 was faxed to the office of the Medical Director on 12/07/17. This documented all of Resident #5's weights since admission. Weekly weights were stopped on 08/02/17. The summary documented a weight change of 31.5%, or 34 lbs, since admission. A Dietary Profile completed by the Dietitian, dated 12/10/17, reflected a documented weight gain of 30 pounds within the last six months. Additional comments reflected, continue current diet, monitor intake. An interview with the Dietary Manager on 01/05/18 at 9:43 a.m. revealed she pulled weights out of the documentation system and counted back six months to create the dietary assessment quarterly. She stated if there was a significant weight gain or loss she would document it. If it was extremely high, she would tell the ADON. She stated the ADON monitored weights and created the Weight Watchers list for her to take to the kitchen. She also stated she notified the Dietitian for any significant weight loss or gains. She stated she did not remember if she notified the ADON about Resident #5's weight gain. An interview with the Dietitian on 01/05/18 at 10:48 a.m. revealed the DON or ADON informed her which residents to assess or re-assess for weight loss. She stated she usually did not see residents for weight gain, and she had not been told about any weight gains in this facility. An interview with the Medical Director 01/04/18 at 4:50 p.m. revealed Resident #5 was started on [MEDICATION NAME] in June 2017 for behaviors and depression, not as an appetite stimulant. He stated he was not sure if he had been contacted about her weight gain, but he was going to wean Resident #5 off the [MEDICATION NAME] since it was likely contributing to the increased weight. He stated she had been stable with [MEDICATION NAME] so the [MEDICATION NAME] could be weaned off. He also stated the increased weight was likely causing Resident #5's increased blood sugars and was the reason for the increasing doses of insulin. A physician order [REDACTED]. The facility's current, undated Resident Weights policy and procedure reflected a weight loss or gain of 10% within 180 days, 7.5% or greater within 90 days, and 5% or greater within 30 days is considered to be significant. Any resident who experiences a significant weight loss or gain must be placed on the Weight Watchers program. The Weight Watchers program consisted of Physician, resident, and family notification of the weight loss/gain; observation of the residents eating habits, weekly weights for at least 4 weeks, and initiation of the Weight Watchers assessment in PCC for at least 4 weeks or until the resident's weight has stabilized. A list obtained from the ADON on 01/05/18 identified four residents in the facility on [MEDICATION NAME] for depression and also have a [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary medications for one (Resident #5) of thirteen residents reviewed for unnecessary medications. The facility failed to monitor Resident #5 for adverse reactions when she was started on the antidepressants [MEDICATION NAME] and [MEDICATION NAME]. The resident experienced elevated blood sugar levels and had a significant unplanned weight gain of 42 pounds six months since her admission to the facility, which caused the resident to be upset about her physical appearance. The failures placed the 34 residents, who received antidepressants, at risk for adverse reactions to include the potential for unplanned, undesired weight gain. Findings included: Resident #5's MDS assessment, dated 12/27/17, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #5's care plan, initiated on 07/12/17, reflected she had the potential for a nutritional deficit. The interventions included, weigh her weekly until weight remains stable and report 5% loss or gain to the physician and responsible party. A nutritional risk assessment completed by the Dietitian, dated 07/04/17, reflected the resident was 54 inches in height and weighed 108 pounds. The resident's ideal body weight was between 85 pounds and 125 pounds. The nutritional goal was to maintain weight within 5% of current body weight for the next 90 days. A physician order, dated 06/21/17, reflected to change Resident #5's antidepressant [MEDICATION NAME] to 15 mg [MEDICATION NAME] daily, and the [MEDICATION NAME] was discontinued at that time. A physician order, dated 07/25/17, reflected an order to add 5 mg [MEDICATION NAME] daily to Resident #5's drug regimen. A physician order, dated 09/12/17, reflected the [MEDICATION NAME] was increased from 5 mg to 10 mg daily. A physician order, dated 07/07/17, reflected an order to start Toujeo [MEDICATION NAME] Solution Pen-Injector 300 unit/ml (Insulin [MEDICATION NAME]) at 8 units subcutaneous injection daily. A physician order, dated 12/15/17, reflected the Toujeo insulin was increased from 8 units daily to 18 units subcutaneous injection daily. A physician order, dated 12/28/17, reflected the Toujeo insulin was increased from 18 units to 20 units subcutaneous injection daily. The Nursing 2015 Drug Handbook, published by Wolters-Kluwer, identifies [MEDICATION NAME] as a tetracyclic anti-depressant. Adverse reactions include an increased appetite. The Nursing 2015 Drug Handbook, published by WoltersKluwer, identifies [MEDICATION NAME] as an SSRI anti-depressant. Adverse reactions include: fatigue, lethargy, increased or decreased appetite, rash, palpitations, weight gain or loss, and tinnitus. The Nursing 2015 Drug Handbook, published by WoltersKluwer, identifies Toujeo [MEDICATION NAME] Solution Pen-Injector 300 units/ml as the equivalent to generic insulin [MEDICATION NAME]. [MEDICATION NAME] is long-acting insulin that has a duration of 24 hours. It is used for diabetics requiring basal (long-acting) insulin to control high blood sugars. Review of Resident #5's clinical record revealed there were no physician progress notes [REDACTED]. Resident #5's MARs for September 2017 through January 2018 reflected Resident #5's BS was checked four times daily. The review revealed the following: September 2017 - 19 incidences of BS greater than 200 and no incidences greater than 300. October 2017 - 29 incidences of BS greater than 200 and two incidences greater than 300. November 2017 - 55 incidences of BS greater than 200 and nine incidences of BS greater than 300. December 2017 - 72 incidences of BS greater than 200, 28 incidences of BS greater than 300, and seven incidences of BS greater than 400. January 2018 - eight incidences of BS greater than 200, seven incidences of BS greater than 300, and two incidences of BS greater than 400. The dates when Resident #5's blood sugars were above 300 were as follows: 01/01/18 6:00 a.m. - BS 367 01/01/18 11:00 a.m. - BS 431 01/02/18 6:00 a.m. - BS 320 01/02/18 11:00 a.m. - BS 392 01/02/18 4:00 p.m. - BS 343 01/03/18 11:00 a.m. - BS 411 01/03/18 7:00 p.m. - BS 389 01/04/18 6:00 a.m. - BS 396 01/04/18 7:00 p.m. - BS 359 There were no weekly weights documented in Resident #5's clinical record. Review of Resident #5's monthly weights revealed: June 2017 - 108 pounds July 2017 - 111 pounds August 2017 - 111 pounds September 2017 - 112 pounds October 2017 - 128 pounds November 2017 - 136 pounds December 2017 - 142 pounds Observation on 01/04/18 at 2:32 p.m. revealed Resident #5 being weighed by CNA A using a weight scale chair. The resident's weight at the time of this observation was 150 pounds. An interview with CNA A on 01/04/18 at 2:25 p.m. revealed the weight scale chair was the standard method used to obtain weights for Resident #5. CNA A did not know when the scale was last calibrated. An interview with Resident #5 on 01/05/18 at 4:15 p.m. revealed she felt ugly and doesn't like people to look at her when asked about her weight increase. Resident #5 began crying as she made these statements. She stated she told someone about her weight gain, but she could not remember whom she told. Review of Resident #5's clinical record revealed there was no Weight Watcher assessment for the resident. A nursing progress note, signed and dated by the ADON on 10/10/17, reflected a weight warning indicating the charting system had identified a significant weight change for Resident #5 and sent a warning note to notify the nurse. The noted reflected, Resident has snacks in her room and eats at will. Healthy appetite for most meals. Consumes meals in her room .no complaints to meals. An interview with the ADON on 01/05/18 at 3:20 p.m. revealed he was aware of Resident #5's significant weight gain. He stated he documented the progress note detailing the resident's increased weight. He stated he did not follow-up with the weight gain, and he wished he would have done so. He stated, She obviously would have triggered for weekly weights. I'm not sure why I didn't do it. I wish I would have caught her the first time. He stated when a resident admitted to the facility, they were weighed weekly for four weeks until the weight was deemed stable. If the resident triggered for weight gain/loss, then weekly weights were initiated. The ADON stated the system generated the trigger for weight loss/gain, which the DON monitored, and he (the ADON) was responsible for the follow-up. A weights and vitals summary for Resident #5 was faxed to the office of the Medical Director on 12/07/17. This documented all of Resident #5's weights since admission. Weekly weights were stopped on 08/02/17. The summary documented a weight change of 31.5% or 34 pounds since admission. There was no documentation regarding Resident #5's increased blood sugars. A medication regimen review signed the Pharmacy Consultant, dated 12/20/17, reflected: The resident (Resident #5) is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident or trial dose reduction for [MEDICATION NAME] 15 mg HS (bedtime) (6/17). The medication regimen review reflected the Nurse Practitioner disagreed with the recommendation with no rationale documented. An interview with the Nurse Practitioner on 01/04/18 at 2:54 p.m. revealed she did not recall Resident #5 or the Pharmacy Consultant's recommendation regarding the use of [MEDICATION NAME]. She stated she worked under the Medical Director and his orders. An interview with the Dietitian on 01/05/18 at 10:48 a.m. revealed the DON or ADON informed her which residents to assess or re-assess for weight loss. She stated she usually did not see residents for weight gain, and she had not been told about any weight gains in this facility. A Dietary Profile signed by the Dietitian, dated 12/10/17, reflected a documented weight gain of 30 pounds within the last six months. Additional comments reflected, continue current diet, monitor intake. An interview with the Dietary Manager on 01/05/18 at 9:43 a.m. revealed she pulled weights out of the documentation system and counted back six months to create the dietary assessment quarterly. She stated if there was a significant weight gain or loss she would document it. If it was extremely high, she would tell the ADON. She stated the ADON monitored weights and created the Weight Watchers list for her to take to the kitchen. She also stated she notified the Dietitian for any significant weight loss or gains. She stated she did not remember if she notified the ADON about Resident #5's weight gain. Review of Resident #5's clinical record revealed there was no documentation reflecting the Dietitian or ADON were notified of any significant weight gain. An interview with the Medical Director 01/04/18 at 4:50 p.m. revealed Resident #5 was started on [MEDICATION NAME] in June 2017 for behaviors and depression, not as an appetite stimulant. He stated he was not sure if he had been contacted about her weight gain, but he was going to wean Resident #5 off the [MEDICATION NAME] since it was likely contributing to the increased weight. He stated she had been stable with [MEDICATION NAME] so the [MEDICATION NAME] could be weaned off. He also stated the increased weight was likely causing Resident #5's increased blood sugars and was the reason for the increasing doses of insulin. A physician order [REDACTED]. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the ADON on 01/05/18, reflected 34 residents received antidepressants.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Residents #1) of five residents reviewed for falls. CNA A failed to provide Resident #1 with adequate supervision when she left the resident unsupervised in the bathroom, which resulted in the resident falling and sustaining a hip fracture on 11/14/16. These failures could place 59 residents at risk that depend on the assistance of one or two staff members for assistance while toileting. Findings included: Resident #1's MDS assessment, dated 10/04/16, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident required the extensive assistance of two people for transfers, dressing, and toilet use. The resident was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position and moving on and off the toilet. Resident #1's current care plan addressing the resident's ADL self-care deficit revised on 06/16/14 reflected the resdient required the participation of one staff to use the toilet and for transfers. The resident also had a care plans initiated on 01/21/13 reflecting she had a history of [REDACTED]. A care plan initiated on 05/21/16 reflected the resident had a fall with injury with an intervention to provide frequent visual checks. An Event Nurses' Note, dated 11/14/16, reflected Resident #1 fell in her room on this date, and the resident complained of right hip pain. The fall was unwitnessed and unassisted. The facility's Provider Investigation Report, signed and dated by the DON on 11/16/16, reflected CNA A assisted Resident #1 to the toilet then left the resident and went to the nurses' station to retrieve a pen. When she returned to the resident's room, the resident was on the floor by the bathroom door. CNA A notified LVN B who assessed the resident. The resident complained of right hip pain, and the NP ordered an x-ray. The x-ray report showed a right hip fracture, and the resident was sent to the hospital for evaluation and treatment. An interview on 11/29/16 at 2:45 p.m. with CNA A revealed she helped Resident #1 to the toilet on 11/14/16. She stated she stood outside the door to give Resident #1 privacy then went to the nursing station when she heard Resident #1 calling for help. CNA stated usually when she told Resident #1 to stay on the toilet until she got back the resident would stay on the toilet until she returned. She said, Just this one time, and she falls after I left. CNA A stated she notified the nurse (LVN B) that the resident fell , but she did not tell her that she left the resident alone. An interview on 11/29/16 at 3:00 p.m. with LVN B revealed she was on duty when Resident #1 fell on [DATE]. She stated CNA A informed her that Resident #1 fell on the floor while trying to get to her recliner. LVN B stated she was not aware CNA A left the resident unattended on the toilet. An interview on 11/29/16 at 1:40 p.m. with CNA C revealed she had assisted Resident #1 to the bathroom before, and the resident was unable to transfer independently. An interview on 11/29/16 at 2:25 p.m. with CNA D revealed she had assisted Resident #1 to the bathroom before, and the resident could not be left by herself due to being cognitively impaired. She stated Resident #1 was not always cooperative and would try to stand up by herself. An interview on 11/29/16 at 2:30 p.m. with CNA E revealed Resident #1 was not safe to be alone in the restroom because she would try to stand up by herself. An interview on 11/29/16 at 2:15 p.m. with the DON revealed CNA A left Resident #1 alone on the toilet when the resident fell on [DATE]. She stated she considered this to be negligent, and CNA A was counseled and received in-service training. The facility's current Preventive Strategies to Reduce Fall Risk policy and procedure, dated 02/01/07, reflected there was nothing addressing staff supervision of residents during toileting to prevent falls. The Resident Census and Conditions of Residents Form CMS-672, signed and delivered by the DON on 11/29/16, reflected 59 residents needed Assistance of One or Two Staff for Toilet Use.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #4) of thirteen residents who were reviewed for pain management. The facility failed to coordinate, monitor and modify pain management interventions for hospice Resident #4 with hospice staff, resulting in inadequate pain control during care and turning/repositioning of the patient for incontinent care and wound care. Hospice staff was documenting increased signs of pain during care, but no pain medication was given for this pain. This failure resulted in Resident #4 experiencing uncontrolled pain on an on-going basis and had the potential to affect the 34 residents identified as receiving pain management resulting in uncontrolled pain. Findings included: 1) Resident #4's quarterly MDS assessment dated [DATE] reflected Resident #4 was a [AGE] year-old female, whose most recent re-admission to the facility was 07/10/13 from an acute hospital. The MDS assessment reflected Resident #4 weighed 76 pounds and measured 62 inches in height and had the following Diagnoses: [REDACTED]. The MDS assessment reflected Resident #4 had severe cognitive impairment. In regards to Resident #4's functional status, the assessment reflected Resident #4 required the extensive assistance of two or more persons for bed mobility and transfers. The assessment further reflected Resident #4 did not ambulate, and she was totally dependent upon one person for assistance with locomotion on and off the unit. In addition, the MDS assessment reflected Resident #4 had impaired range of motion in the lower extremity on one side of her body, and she used a wheelchair for mobility. The assessment also showed that she used bed rails daily for bed mobility. The Pain Assessment Interview portion of the assessment reflected Resident #4 reported having moderate, occasional pain during the past five days. 2) Review of a hospital Physician Discharge Summary dated 07/10/13 revealed Resident #4 was hosptalized on [DATE] with a primary [DIAGNOSES REDACTED]. The report reflected: "Significant Findings/Hospital Course: 90yo (year old) female with severe dementia,[MEDICAL CONDITION](Hypertension), [MEDICAL CONDITION], fell at nursing home, present to ED (Emergency Department) at other hospital with R (right) femur fracture, questionable cerebral hemorrhage. Surgical management was discussed, but family decided to place pt on DNR level A with no surgical interventions, comfort care only with discharge to nursing home. Pt received cerbral hemorrhage [MEDICATION NAME] (cerebryx). Pt initially in ICU (Intensive Care Unit) then downgraded to floor. Pt back to baseline mental status... Pertinent Imaging: XR (X-ray) right femur AP and Lateral: Brace immobilizer in place. [MEDICAL CONDITION] femur again noted. There is displacement and angulation of fracture fragment which appears slightly worse than on previous examination. [MEDICAL CONDITION] portion of the femur in stable position. Generalized osteopenia again noted. Prosthetic replacement of the right hip joint again noted...." 3) During initial tour of the facility with LVN B on 01/14/14 at 9:20 AM, LVN B informed the surveyor that Resident #4 had a fall, which resulted in a fracture. LVN B explained Resident #4 was currently receiving hospice services. She described the resident as being resistant to care at times, cognitively impaired and not always able to make her needs known. In addition, LVN B stated Resident #4 was mostly bedfast due to the pain the resident experienced when she was moved or transferred. She explained the resident's pain was localized to her leg which was fractured. LVN B stated Resident #4 received scheduled pain medications as well as additional pain medications as needed. 4) Observation of Resident #4 on 01/14/14 at approximately 1:50 PM revealed the resident was in bed awake and alert but confused. The head of the bed was elevated and quarter side rails were in the upright position. Resident #4 exhibited a grimaced facial expression. Resident #4's speech was garbled, and she appeared to be confused when asked if she needed help. When asked if she was hurting, Resident #4 replied, "Yes. I think so." The surveyor then reported the resident was in pain to the charge nurse at the nurses' station. 5) CNA D and CNA E were observed providing incontinent care to Resident #4 on 01/14/14 at 4:10 PM. Resident #4 was observed with a leg brace on her right leg, which appeared too large, and slid down to the resident's ankle. Resident #4 was lying on her back, and her right foot was rolled outwards on its side, touching the fitted sheet and resting on it. It appeared her foot was abnormally placed or malaligned with her leg. During the incontinent care, Resident #4 squinted and frowned, and she appeared to be uncomfortable. The resident's facial expressions revealed she was in pain. As CNA D and CNA E rolled her from side to side, they attempted to support the resident's right leg, as it was observed to not roll or move with the rest of her body below the knee. As she was moved from side to side, Resident #4 moaned. CNA D and CNA E were asked about the position of Resident #4's leg and foot, and they were asked to remove the leg brace so the resident's skin could be observed. CNA D revealed she had never seen the resident's leg without the brace on it, and she did not know what the leg looked like. CNA D proceeded to pull back the Velcro straps, and the resident's leg was exposed. The skin on Resident #4's right leg was dry and flaky. The resident's right knee appeared to be lying on the outer side of the leg like it was not connected to the femur (upper leg bone). The lower right leg had significant rotation, and the right leg appeared to be longer than the left leg due to the spacing around the knee. Immediately following observation of the incontinent care, the surveyor reported to the charge nurse Resident #4 was exhibiting signs and symptoms of pain. 6) An interview with CNA D on 01/14/14 at 4:20 PM revealed Resident #4 always moaned when they (the staff) tried to move her leg. CNA D stated she had never taken the brace off or seen what the resident's leg looked like during the three months she had worked at the facility. CNA D explained the brace was only removed for showers, and hospice was responsible for all of Resident #4's showers. CNA D stated she reported to the nurse if the Resident #4 was in pain, and the resident received [MEDICATION NAME] for pain. 7) During an interview with CNA E on 01/14/14 at 4:25 PM, CNA E revealed she felt like Resident #4 was in pain all the time. CNA E stated Resident #4 would say if she was in pain, and sometimes the resident moaned and said, "Ouch!" while trying to reach for her leg. CNA E revealed she tried not to move Resident #4 around too much to avoid causing the resident to experience pain. CNA E stated she would report to the nurse if a resident was in pain. 8) Resident #4's January 2014 Physician order [REDACTED]. [MEDICATION NAME] 500 mg 2 tablets by mouth every four hours PRN [MEDICATION NAME] 10 mg/5 ml Solution 0.5 ml to be given sublingually every hour PRN, and [MEDICATION NAME] 50 mg 1 tablet by mouth every six hours PRN. This review revealed Resident #4 did not have any routine pain medications ordered. 9) On 01/15/14, Resident #4's January 2014 MAR indicated [REDACTED]. This review revealed Resident #4 received [MEDICATION NAME], in a sublingual form, on 01/14/14 at 8:00 AM and 2:00 PM. There was no documentation reflecting Resident #4 received pain medication on 01/14/14 after the surveyor notified the charge nurse Resident #4 was experiencing pain during the incontinent care observed at 4:10 PM that day. Also, CNA D and CNA E both agreed Resident #4 was in pain during the care, and both stated they would report it to the nurse if they thought a resident was in pain. Further review of Resident #4's MARs revealed the following regarding pain management: January 2014 MAR - Resident #4 received one dose of [MEDICATION NAME] on 01/07/14 and two doses on 01/14/14. The resident also received one dose of [MEDICATION NAME] on 01/13/14. December 2013 MAR - Resident #4 received one dose of [MEDICATION NAME] on 12/27/13 and one dose of [MEDICATION NAME] on 12/24/13. November 2013 MAR - Resident #4 received one dose of [MEDICATION NAME] on 11/22/13. October 2013 MAR - Resident #4 received one dose of [MEDICATION NAME] on 10/22/13. September 2013 - Resident #4 received two doses of [MEDICATION NAME] on 09/23/13 and two doses of [MEDICATION NAME] on 09/29/13. August 2013 - Resident #4 received one dose of [MEDICATION NAME] on 08/06/13. In addition, Resident #4 had a routine pain medication ([MEDICATION NAME] 50 mg) administered three times a day at 8:00 AM, 2:00 PM, and 10:00 PM from 08/01/13 through 08/06/13. Beginning on 08/07/13, Resident #4 received the [MEDICATION NAME] 50 mg as a PRN medication on 08/07/13, 08/08/13, 08/10/13, 08/12/13 and 08/13/13. 10) On 01/15/14, Resident #4's January 2014 PRN Pain Flow Sheets were reviewed. This review revealed Resident #4 had pain to her right leg on 01/13/14, and she displayed non-verbal signs of pain as evidenced by frowning and grimacing. The documentation reflected she was administered [MEDICATION NAME]. There was no follow-up documentation on the Pain Flow Sheet reflecting if the medication was effective. In accordance with the sheet, documentation was supposed to be done 30 minutes after intervention, then 1 hour, and finally 3 hours following intervention. Further review of the January 2014 PRN Pain Flow Sheets reflected Resident #4 displayed non-verbal signs of pain as evidenced by grimacing and frowning on 01/14/14 at 8:00 AM and again at 2:00 PM, and she was administered [MEDICATION NAME] at both of those times. Follow-up documentation was recorded one hour after the [MEDICATION NAME] was administered, and it was noted that Resident #4 was asleep. 11) Review of Resident #4's Pain Assessment Forms revealed the following: 12/16/13 - Resident #4 was assessed to have no pain based on a pain scale of 0-10 where she scored a two, which equaled no pain. It was noted on the form she had an occasional moan or groan with sad, frightened, or frowning facial expressions. 09/05/13 - Resident #4 was assessed to have no pain based on a pain scale of 0-10 where she scored a two, which equaled no pain. However, the assessment reflected the resident had constant, aching pain, which was caused and/or exacerbated by turning, repositioning, and transferring. The current/previous treatment was documented as prescribed medication. 07/10/13 - Resident #4 was assessed to have moderate pain based on a pain scale of 0-10 where she scored a five, which equaled moderate pain. The assessment reflected the resident had sharp intermittent pain, which lasted less than 30 minutes and was caused and/or exacerbated by turning and repositioning. 12) Review of Resident #4's current Care Plan updated/reviewed 10/24/13 revealed the following care plans, which addressed the issue of pain and pain management: Care Plan - Focus Area (initiated 07/10/13): "The resident has had an actual fall with fracture(d) femur." The interventions listed for this focus area included: "Monitor/document/report PRN to physician any increase(d) pain, or new bruising, increase in confusion." Care Plan - Focus Area (initiated 11/06/13): "(Resident #4) has a terminal prognosis of senile [MEDICAL CONDITION] brain and admitted to (Hospice Agency)." The interventions listed for this focus area included: "Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team...." 13) An interview with CNA F on 01/15/14 at 7:15 AM revealed Resident #4 had a fall about three months ago when the resident was trying to get out of bed. CNA F explained Resident #4 was injured when her leg got trapped under the bed or in between the side rail and the bed. CNA F stated she was not working on the shift when the incident happened, but other staff members informed her Resident #4's leg was twisted outward at the knee like the leg had separated at the knee. CNA F stated Resident #4 experienced pain due to her injury and would try to grab her leg and brace it when staff tried to move her. She stated the brace was used to "keep her leg together." CNA F revealed she did not move the resident too much to avoid causing the resident to have pain. CNA F stated Resident #4 received [MEDICATION NAME] to control her pain. CNA F stated if a resident was experiencing pain, she reported it to the nurse. She stated she felt as though Resident #4's pain was not managed well, because she was still in pain. CNA F stated Resident #4 expressed facial signs of pain, such as making faces, closing her eyes, and groaning and moaning. She stated the resident would try and reach out toward her leg and grab it when she was in pain. CNA F stated two staff members were required when moving Resident #4 because one staff member had to support the resident's fractured leg. 14) The Administrator was interviewed on 01/15/14 at 8:50 AM regarding Resident #4's incident and fracture. The Administrator explained Resident #4 had fallen some time ago while she was trying to reach for something. He stated Resident #4 did not appear to be in pain, and the resident "even refuses pain medications." The Administrator added Resident #4 was placed on hospice services shortly after her return to the facility from the hospital following the fall. 15) An interview with LVN C on 01/15/14 at 11:20 AM revealed Resident #4 would not always verbalize when she was in pain. LVN C explained she had to use Resident #4's facial expressions, such as grimacing, to determine if Resident #4 was experiencing pain. LVN C stated Resident #4 would respond "yes" or "no" when asked if she was having pain. But, LVN C stated the resident's verbal response was not a good indicator to assessing her pain because the resident's facial expressions may not match her verbal response. LVN C added, "(Resident #4) looks like she hurts. How could she not?" 16) An interview with CNA G on 01/15/14 at 11:50 AM revealed Resident #4 complained of pain every time the resident's right leg was picked up to do care for the resident. CNA G stated the resident would say, "Ow! Watch my leg!" CNA G stated Resident #4 could express pain both verbally and through facial expressions, and she would report to the charge nurse when Resident #4 was in pain. 17) An interview was conducted with Hospice RN N on 01/15/14 at 12:02 PM, and she revealed she had been caring for Resident #4 for the past six months. Hospice RN N stated Resident #4 had not had pain recently, and nothing had been reported to her. She revealed the hospice aides showered Resident #4, and they had not reported Resident #4 experienced pain when being showered or repositioned. During her visits, Hospice RN N stated Resident #4 appeared calm and comfortable with no indications of pain. Hospice RN N stated Resident #4 had [MEDICATION NAME] ordered as needed for pain, and the medication was to be given by the facility's staff. In a subsequent interview with Hospice RN N on 01/15/14 at 4:40 PM, she revealed she had been caring for Resident #4 for the past 4-6 months and visited the resident every other week. When queried on how she would assess pain for a resident with cognitive impairment or [MEDICAL CONDITION], she stated she would check the resident's vital signs first because this provided an indication the resident was in pain. Hospice RN N stated she did not provide care (wound care or incontinent care) to the Resident #4, and she did not have to move her when she visited the resident. Hospice RN N stated Resident #4 had the leg brace on for a long time, and she had only seen the resident's leg once or twice during the time she had cared for Resident #4. Hospice RN N stated palliative care was all about the comfort of the care. She stated she coordinated the care with the Wound Nurse and received information about the resident from both the hospice and facility aides. Hospice RN N stated staff knew to report to her or the nurse if they ever felt the resident was uncomfortable. Hospice RN N stated Resident #4 was not on a routine, scheduled pain medication because the family did not want her to be "snowed." Hospice RN N was asked if she participated in care plan meetings for Resident #4. She revealed she had not participated for the past few months due to a change in management at the hospice company. Hospice RN N stated she was not aware of any time Resident #4 was in pain as it had not been reported to her. 18) Review of the hospice Certification Narrative for Resident #4 dated 08/06/13 revealed the resident was placed on hospice services with a [DIAGNOSES REDACTED]." The narrative, completed by Hospice RN M, reflected Resident #4 was easily confused and was only oriented to self. The nurse documented Resident #4 "does not remember that she has a fractured femur." In addition, the narrative reflected Resident #4's family did not want aggressive treatment and only wanted comfort measures to be provided. The hospice Certification Narrative for Resident #4 dated 10/29/13 reflected the facility's nursing staff were concerned Resident #4's fracture was not healed. Hospice RN M documented: "...Patient has frequent pain episodes with movement due to fracture...." 19) The hospice Nursing Facility Communication Log reflected Home Health Aide O documented the following entries regarding Resident #4's pain: 09/18/13 - "Complaining of leg hurting." 10/21/13 - "Complained of pain." 10/23/13 - "Complained of headaches." 11/26/13: "Hurting a lot today." Review of Resident #4's MARs for these dates Hospice Aide O recorded the resident was having pain revealed no pain medication was administered. 20) On 01/15/14 at 12:45 PM, the surveyor observed LVN C and the Wound Nurse provide Resident #4 with wound care. When asked if Resident #4 received pain medication prior to care, the Wound Nurse stated LVN C gave the resident sublingual [MEDICATION NAME] to the resident around 11:30 AM. The Wound Nurse stated she did the dressing change daily for Resident #4, and the resident "tolerates treatment pretty well." She stated the resident was pre-medicated before the treatment. During observation of the wound care, Resident #4 was turned to her left side, and she cried out, "Oooooh...It hurts so bad!" Resident #4's eyes were closed, and her right lower leg and foot were turned outward away from her body. The brace, which was on the right leg, was sliding down to her ankle with the top of the brace just above the right knee. Next, Resident #4 was turned to her right side, and she cried out, "It's hurting!" In doing so, she attempted to grab her lower right leg. 21) An interview was conducted with Resident #4's family member on 01/15/14 at 1:15 PM. The family member revealed Resident #4 had been at the facility for a couple of years, and she had been slowly declining. He/She stated the resident was not always able to communicate, and she garbled her words frequently. He/She stated Resident #4 did not recognize family anymore. The family member revealed Resident #4 had a fall at the facility, which resulted in a fracture. The family member explained surgery was not an option because the physician and family did not think the resident would make it through surgery. The family member stated Resident #4 had always been a strong woman and would not show emotion or pain. When asked about pain control, he/she stated hospice was in charge of pain control. The family member stated he/she relied on hospice to be in control of pain management, and this was not something he/she had been questioning. Resident #14's family member stated too much medication made the resident sick, but she was on "comfort care." He/she revealed hospice told him/her they would take care of everything, so he/she did not ask. The family member stated he/she "would guess she's (Resident #4's) getting pain medication often." He/she stated Resident #4 received [MEDICATION NAME] for pain, and he/she just wanted the resident to be comfortable. 22) An interview with the Medical Director on 01/15/14 at 2:00 PM revealed he was one of two Medical Directors for the facility. The Medical Director stated he was also the Medical Director for the hospice company, which provided Resident #4 with hospice care. When asked in general about pain and pain management, the Medical Director stated any resident accepted to hospice services, with a reason or diagnoses, which would indicate pain, would be on a scheduled pain medication unless there was a concern for over-sedation. 23) An interview with CNA H on 01/15/14 at 4:13 PM revealed Resident #4 "complains of pain when her broken leg is moved for care." She stated she could tell the resident was in pain based on the resident's facial expressions. CNA H stated she reported to the nurse when Resident #4 was in pain. CNA H asked, "Have you seen her leg? It's not straight, and the bottom sticks out. How could she not be in pain?" 24) During an interview with CNA I on 01/15/14 at 4:25 PM, CNA I revealed Resident #4 complained of pain when she was provided with care. CNA I stated the resident made facial expressions of pain during care. CNA I explained Resident #4 could verbalize she was in pain some days, and she would scream out on other days when she could not verbalize it. 25) An interview with CNA J on 01/15/14 at 4:33 PM revealed Resident #4 experienced pain whenever she moved the resident's leg. CNA J stated the resident's leg appeared to be painful. CNA J explained Resident #4 was able to verbalize when she was in pain, and she reported this to the charge nurse when Resident #4 complained of pain. 26) The facility's Resident Census and Conditions of Residents Form CMS-672 completed by RN Consultant on 01/14/14 reflected 34 residents were on a pain management program.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (Resident #7) of 16 residents reviewed for pain management. The facility failed to identify and assess Resident #7's need for pain management. The resident had severe, chronic pain associated with the [DIAGNOSES REDACTED]. The facility did not have an order for [REDACTED]. These failures could affect the 31 residents on a pain management program, including Resident #7, by placing them at risk for unrelieved pain and negatively impacting their quality of life. Findings included: On 11/08/11 at 9:50 a.m., Resident #7 was observed up in her wheelchair in her room just returning from the shower room. Resident #7 had an above-the-knee amputation. LVN B described Resident #7 as being a new Medicare admission, interviewable, having [MEDICAL CONDITION] to her lower leg and requiring moderate assistance with her activities of daily living. According to the MDS assessment, dated 11/07/11, Resident #7 was a [AGE] year-old female who was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Pylori), Unspecified [MEDICAL CONDITION], Other and Unspecified [MEDICAL CONDITION], and Other Chronic Pain. On 11/09/11 at 11:35 a.m., during an interview with Resident #7 she revealed she was in severe pain in her left arm and leg. She stated she had injured her shoulder recently getting in and out of her car. Further observation of Resident #7 revealed she was crying. She stated she had already taken a pain pill earlier that morning, but she was still in pain and it was not time for another pill. On 11/09/11 at 11:38 a.m., MA E confirmed Resident #7 had received pain medication at 9:30 a.m. and it was not time yet for another dose. Resident #7 could have another dose at 1:00 p.m. She went on to say the resident's nurse knew about her complaint and in fact had administered medication for swelling at 10:40 a.m. in hopes that would relieve some of her pain as she had [MEDICAL CONDITION]. On 11/09/11 at 11:40 a.m., LVN A was asked about Resident #7's pain. She stated she was aware of her pain and stated Resident #7 received pain medication, [MEDICATION NAME], at 9:30 a.m. but it was not time yet for another [MEDICATION NAME] until 1:00 p.m. She gave her [MEDICATION NAME] for swelling at 10:40 a.m. to reduce her pain. She stated she would call the doctor to get permission to administer a "one-time" dose of [MEDICATION NAME]. Review of Resident #7's November 2011 "PRN Pain Flow Sheet" revealed on 11/09/11 at 9:30 a.m. [MEDICATION NAME] was administered due to leg pain and the pain resolved 30 minutes after administration. The form also reflected at 10:44 a.m. on the same day [MEDICATION NAME] was administered for leg pain and 30 minutes later the pain had been completely resolved. On 11/09/11 at 12:10 p.m., Resident #7 stated to the surveyor she had a pain pump that dispensed [MEDICATION NAME] for the [DIAGNOSES REDACTED]. She stated it was not empty but was not sure how it worked. On 11/09/11 at 12:20 p.m., the Administrator stated Resident #7 was originally admitted on or about the middle of October 2011 and had discharged home over the weekend. The Administrator stated Resident #7's family member brought her back in his/her personal car Monday morning, 10/31/11, because he/she was unable to care for her. On 11/09/11 at 1:20 p.m., the DON stated Resident #7 had complained about her pain like the above before. The DON stated Resident #7 just completed a therapy session which probably caused the pain. She stated the doctor was called for a "one-time" order to get through this pain episode and to make the PRN pain medication into routine. The DON stated she was not aware of Resident #7 having a pain pump or the [DIAGNOSES REDACTED]. She thought Resident #7 was receiving PRN pain medication for [MEDICAL CONDITION] Arthritis (RA). She stated she called the family this morning and they told her they fill the pump with medication. However, the DON stated she was not aware of what medication the pump dispenses, how much medication was dispensed, how often it dispensed, or what maintenance the pump required. The DON stated she would call the resident's doctor and find out more about the pump as well as the [DIAGNOSES REDACTED]." At 2:50 p.m. on 11/09/11, Resident #7 stated today's pain was especially bad but the pain had been bad before and the oral PRN pain medication did not take care of it. She stated she had to endure the pain until it was time for the next dose. On 11/10/11 at 11:15 a.m. the DON stated the policies and procedures in the binder the Administrator provided were current, including the pain policy. She stated she found out this morning about the details of Resident #7's pain pump. The pump contained three different types of [MEDICATION NAME] and Lidacaine. The pump dispensed 1.542 mg/hour, 36.997 mg/day. Resident #7 also received oral pain medication and they communicated with the resident's pain doctor to better coordinate care. She obtained a [DIAGNOSES REDACTED]. The DON provided the surveyor with information/guidebook on RSD she obtained from Resident #7's doctor that was found at www.medifocus.com. Review of the information obtained from Resident #7's doctor, dated 11/10/11, revealed, "The medications in the pump system are as follows: [MEDICATION NAME] 120 mg [MEDICATION NAME] 160 mg Baclafen 202 mg Bupinocaine 50 mg [MEDICATION NAME] 12 mcg [MEDICATION NAME] 200 mcg The infusion is as follows: 1.542 mg/hr 36.997 mg/day 10 mcg/24 hours" According to the information provided, the recent pump fill for Resident #7's pump was 10/20/11. On 11/10/11 at 12:20 p.m., Therapists C and D confirmed Resident #7 had experienced severe pain yesterday (11/09/11.) They stated the resident's pain, "comes and goes." They stated Resident #7 injured her shoulder recently getting out of her car. However, the RSD had been the reason for her long-standing pain. Her leg was amputated in the 1970s as a treatment, to end the pain of RSD. Her pain was so great she was willing to lose a leg. On 11/10/11 at 1:40 p.m., the DON was not sure why Resident #7's leg was amputated and described the amputation as below-the-knee. However, the amputation was above-the-knee in the hip region. The only care plan available was the "Admission Care Plan," dated 10/20/11 which reflected nothing about pain or the [DIAGNOSES REDACTED]. Review of Resident #7's consolidated physician's orders [REDACTED]. Resident #7's November 2011 MARs reflected an order for [REDACTED]. The Admission/Readmission Nursing Assessment, dated 10/31/11, reflected Resident #7 was oriented, required one person assist to transfer, and was a right AKA. A skin assessment was documented. There was nothing mentioned about her pain pump. Review of the Pain Assessment Form, dated 10/21/11, reflected Resident #7's current pain medication included [MEDICATION NAME] 5/325. Her worst pain in the last 24 hours reflected an "8" in a 1 (low)-10 (high) scale. The next pain assessment was dated 11/09/11. Review of social services notes, dated 10/24/11, revealed, "Her (Resident #7) pain pump was filled & she feels much better." Nurses Notes dated 10/31/11 reflected, "Resident c/o (complain of) gen (general) discomfort. Med (medication) x 1 /c (with) 2 tabs of [MEDICATION NAME]." Nurses Notes dated 11/02/11 reflected, "c/o pain to LLE (left lower extremity)." Nurses Notes dated 11/03/11 at 2:00 a.m. reflected, "Pt. using [MEDICATION NAME] 10 mg 2 po q 4 hours PRN as often as allowed. With 'some' pain control. Alternate with [MEDICATION NAME] to relieve pain discussed." At 0730, "lower (L) ext red et warm to the touch and is painful for patient. She is currently taking [MEDICATION NAME] 100 mg po BID + [MEDICATION NAME] po PRN for swelling ...." Nurses Notes dated 11/04/11 reflected, "pain meds given PRN." Nurses Notes dated 11/05/11 reflected, "c/o of pain in (L) LE (left lower extremity)." Nurses Notes dated 11/07/11 reflected, "c/o pain at 'legs' medicate/c [MEDICATION NAME] 100 mg 2 po/c 4 hour PRN & is effective for short periods." Nurses Notes dated 11/09/11 at 10:40 a.m. reflected, "Up in w/c propels self to therapy; verbalizes (L) lower ext. pain around area of [MEDICAL CONDITION]. Pain meds were given at 130; med aide instructed to administer PRN anti-[MEDICAL CONDITION]." Review of the RSD guidebook, dated 06/27/11, revealed, "RSD is a complex, chronic pai[DIAGNOSES REDACTED] that can affect any part of the body; however, it occurs most frequently in the extremities...RSD is characterized by severe, chronic pain often described as stinging or burning, sensory abnormalities, motor impairment, [MEDICAL CONDITION], progressive trophic changes to skin, hair, nails, muscle, and bone, and increasing dysfunction of the affected limb...Because currently there is no known cure for RSD, treatment is aimed at controlling and reducing the severity of the symptoms...Understanding the treatments - and the treatment options - is critical for not only controlling the symptoms but also for preserving the patient's overall level of functional ability and quality of life." Review of the CMS Form 672 (Resident Census and Conditions of Residents) dated and signed by the DON on 11/10/11 revealed there were 31 residents on a pain management program.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #8) of six residents reviewed for pressure ulcers received the necessary care and services to prevent the development of a new pressure ulcers and to promote healing of the existing pressure ulcer. Resident #8 developed a pressure ulcer on her left heel while in the facility. Resident #8 was in bed lying on her left side. Her left heel was covered with a dressing and Resident #8 was rubbing her heels back and forth on the mattress. The facility failed to: 1) Provide pressure ulcer care using a clean technique to prevent the potential for infection in the pressure ulcer through cross-contamination and to promote healing; 2) Coordinate care of the resident's pressure ulcer through communication with other staff to ensure the resident was receiving the appropriate treatment to aid in healing of the pressure ulcer; and 3) Off-load heels and provide heel protectors ordered by the physician to relieve pressure on the heels and prevent a pressure ulcer on her left heel. These failures resulted in Resident #8 developing a pressure ulcer on her left heel; and could affect the five residents with pressure ulcers by placing them at risk of developing new pressure ulcers, worsening of current pressure ulcers and developing wound infections. Findings included: 1. Review of the quarterly MDS assessment dated [DATE] revealed Resident #8 was an [AGE] year-old female admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Resident #8 was severely impaired in her cognitive skills for daily decision-making, incontinent of bowel and bladder, required total assistance from staff for transfers, bathing, and dressing. The MDS assessment reflected Resident #8 did not have any type of pressure ulcer. An observation during initial tour on 11/08/11 at 9:42 a.m. revealed Resident #8 was in her room lying in bed on her left side with her knees bent toward her chest. Resident #8's left heel was covered with a dressing and the resident was observed rubbing her heels back and forth on an air-mattress. An observation on 11/09/11 at 10:00 a.m. revealed Resident #8 was in bed positioned on her left side. Resident #8's air-mattress was collapsed and her heels were resting on the mattress. The facility's only ADON (Assistant Director of Nurses) entered the room and the surveyor showed him Resident #8's air-mattress. The ADON then said, "No, no. We will move her to a different bed." The ADON said Hospice had provided the bed and he would notify Hospice the mattress was not inflated. At this time, Resident #8's knees were drawn up toward her chest and her heels continued to rest on the mattress. Resident #8 was observed continually rubbing her heels back and forth on the mattress. An observation on 11/09/11 at 10:20 a.m. revealed the facility's only Treatment Nurse was providing wound care to Resident #8. The resident's left heel was resting on a pillow. The Treatment Nurse did not place a barrier between the resident's heel wound and the pillow case before removing and discarding the soiled dressing. The pressure ulcer was touching the pillow case. The Treatment Nurse cleaned the wound three times with gauze saturated with normal saline. The resident's heel wound rested on the pillow case between each cleaning. During this time, the Treatment Nurse said Resident #8 had a pressure ulcer on her left heel a couple of months ago, but the wound had healed until she discovered the new wound on 11/01/11. The Treatment Nurse said Resident #8's wound had worsened. Review of Resident #8's Consolidated physician's orders [REDACTED]. Review of Resident #8's Nurses' Notes, dated 11/01/11 at 4:00 p.m., revealed while the Treatment Nurse was cleansing dry skin to the left heel, prior to application of [MEDICATION NAME], a piece of dry skin was inadvertently removed exposing an opened area. The wound measured 2.0 cm (centimeter) x 3.0 cm x 0.2 cm. The exposed tissue was beefy red in color. A treatment physician's orders [REDACTED]. Review of the facility's Facsimile Notification of Change located in Resident #8's clinical record dated 11/01/11, revealed Resident #8's physician was notified of her new left heel pressure wound. Further review revealed the physician returned the fax to the facility and Resident #8 needed to have heel protectors due to the resident constantly pushing herself with her heels in bed. An interview on 11/10/11 at 9:57 a.m. with the Treatment Nurse revealed she did not see until the day before (11/09/11, eight days later) that the physician had returned the fax on 11/01/11, reflecting Resident #8 needed heel protectors. An interview on 11/10/11 at 10:38 a.m. with LVN A revealed she did not know why the fax dated 11/01/11 was placed in Resident #8's clinical record before a physician's telephone order was written for heel protectors. LVN A said the Treatment Nurse should also have been made aware the physician wanted the resident to be provided heel protectors. Review of Resident #8's Nurses' Notes dated 11/09/11 at 10:45 a.m. revealed wound care was completed at this time. The notes reflected her left heel wound measured 3.0 cm x 2.8 cm with an 8.0 cm x 5.0 cm reddened area, the wound bed was red in color with a small amount of yellow slough on the wound, and a small amount of drainage was noted on the old dressing. The notes also reflected the physician would be notified of changes to the wound measurement and wound bed. Review of a Braden Scale - For predicting Pressure Sore risk, dated November 2011, revealed a total score of 12 indicating Resident #8 was at high risk for a pressure ulcer. 2. Review of the facility's current Wound care Policy and Procedure, dated 2003, Revised 01/30/11, revealed "...Nursing Action/Rationale: 5. Maintain body alignment with proper support for body parts; pillows... heel/elbow protectors... can be used to relieve pressure." 3. The CMS Form 672 (Resident Census and Conditions of Residents) dated 11/10/11, and signed by the DON, reflected five residents had pressure ulcers (excluding Stage I) and three residents had pressure ulcers on admission.