Every finding on record at The Lev at Town Park

Based on interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1 of 10 residents (CR#1) reviewed for physician notification. 1. The facility failed to notify or seek medical guidance from the Medical Doctor or Nurse Practitioner for a change of condition after CR #1 complained of pain and a swollen knee on 11/5/25 at approximately 10:00pm. 2. The facility failed to immediately notify or seek medical guidance from the Medical Doctor or Nurse Practitioner after CR #1's left knee was observed swollen and painful at level 8 out of 10 (most severe) on 11/07/2025 at approximately 2:27 p.m, 3:41pm, and 4:18pm. 3. The facility failed to immediately seek medical guidance from the Medical Doctor or Nurse Practitioner for CR#1 after receiving results of an x-ray, which revealed, CR#1 had a Displaced distal femoral shaft spiral fracture. 4. The facility failed to immediately transport CR#1 to the hospital on [DATE] after becoming aware of the result of an x-ray, which reflected an acute fracture. The facility waited approximately 13 hours to transport CR#1 to the hospital, where CR#1 was diagnosed with a spiral fracture of his femur and required emergency surgery. An Immediate Jeopardy (IJ) was identified on 11/13/2025. The IJ template was provided to the facility (administrator) on 11/13/2025 at 1:00pm. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents by placing them at risk of delayed treatment and continued severe pain. Findings included: Reviewed Record of CR#1's undated face sheet, revealed CR#1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with active diagnosis of non-Alzheimer's Dementia (decline in cognitive function), and stroke (loss of blood flow in the brain). Reviewed Record of CR#1's Quarterly MDS (resident assessment) dated 8/11/2025 revealed CR#1's BIMS score of 00 indicated CR#1's cognition is severely impaired. The MDS further revealed CR#1 had severely impaired vision, he uses a wheelchair mobility resident totally dependent on staff for eating, oral and toileting hygiene, shower/bathing, upper and lower body dressing, personal care, and sit to lying in bed. Reviewed Record of CR#1's care plan dated 7/28/25 revealed the following:Focus: Resident has an alteration in hematological (clotting problem) status r/t receiving anticoagulant (Date Initiated: 7/21/25 and Revision 11/10/25).Goal: The resident will remain free of complications related to altered hematological (clotting problem) status through the review date (Date Initiated: 7/21/25, Revision date: 11/10/25, and Target date: 1/12/26).Interventions: Complete fall risk assessment and increase vigilance for falls (Date initiated: 7/21/25). Reviewed Record of CR#1's orders dated 7/28/25 revealed:-CR#1 is to be assessed for pain every shift (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); PRN (as needed) -Acetaminophen (Tylenol) oral table 325 MG- Give 2 tablet by mouth every 6 hours as needed for pain/fever (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Norco (Narcotic pain medication) Tablet 7.5-325 MG (PRN as needed)-Give 1 tablet by mouth every 8 hours as needed for pain (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Biofreeze Cool the pain external Gel to apply to affected areas for pain PRN (as needed) (order date 11/7/25 at 4:49pm-D/C 11/10/25 9:55am); x-ray to left femur, left knee, and left tibial/fibula once only for pain (order date 11/7/25 at 4:51pm-D/C 11/10/25 at 9:55am). Record Review of MAR dates of 11/5/25 - 11/8/25 revealed, CR#1 was administered pain medications on 11/7/25 only. Reviewed Record of CR#1'nursing notes dated 11/6/2025 thru 11/7/2025, revealed no nursing notes regarding CR#1's complaint of pain regarding his knee nor was there an assessment for the night shift on 11/6/2025. Reviewed Record of CR#1's nursing notes dated 11/7/25 at 2:27pm revealed CR#1 was administered Norco (325mg) for a swollen knee and pain level 8. The note on 11/7/25 at 3:41pm revealed CR#1 was administered 2-Tylenols (650mg total) for pain level 8. The nursing notes on 11/7/25 created 5:46pm effective 5:00pm revealed LVN A noted a change in condition for CR#1 due to ineffective pain medication, and notification of NP was made. Record review of CR#1's pain assessment revealed the following: 11/7/25 at 8:07am Pain level 0 11/7/25 at 1:18pm Pain level 0 11/7/25 at 2:27pm Pain level 8 11/7/25 at 3:41pm Pain level 8 11/7/25 at 4:18pm Pain level 8 11/6/25 at 8:21am Pain level 0 11/6/25 at 2:26pm Pain level 0 11/6/25 at 10:51pm Pain level 0 11/5/25 at 8:37am Pain level 0 11/5/25 at 3:31pm Pain level 0 11/5/25 at 11:49pm Pain level 0 Record review the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. Reviewed Record the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. On 11/10/25 at 3:33pm, a telephone interview with FM revealed on Wednesday evening 11/05/25, during a visit with CR #1, she was informed by CR#1 his left knee was hurting. FM observed the knee was noticeably swollen at which time she went to the nurses' station and spoke with LVN C, who had just arrived for her night shift (10pm-6am). FM stated she insisted LVN C come to CR#1's room to see his knee. After LVN C came to CR#1's room, FM removed the sheet exposing both knees, FM stated LVN C took a quick visual look (without touching), at both knees, then LVN C told FM that CR#1's knee looked okay to her and abruptly left the room. FM stated on Thursday 11/6/25, she telephoned the facility to let the nursing staff know CR#1 was still calling her and was still in a lot of pain. FM stated she could not recall the name of the person she spoke with, nor could she recall the time she called. FM stated on Friday, 11/07/25, CR#1 called and said his left knee was hurting so bad and no one had given him anything for pain. FM stated she called the facility and spoke with LVN A who told her he had given CR#1 a Norco pain medication. FM stated on Saturday, 11/08/2025 at 4:51pm, she received a call from LVN B indicating she was waiting for the doctor to return the call due to the result of CR#1's x-ray, which was a femur fracture, and she needed permission to send CR#1 out. FM stated it took the facility more than 2 hours before CR#1 was sent out to hospital. On 11/10/25 at 5:14pm, in an interview with LVN A, he stated he worked the 2:00pm - 10:00pm shift on 11/7/25 and CR#1 was assigned to him. LVN A stated CR#1 called for assistance and he went to CR#1's room. He stated CR#1 informed him his leg was hurting, and he was in pain. LVN A stated he observed CR#1's left knee and it was kind of swollen. He stated he completed an assessment and CR#1 stated the knee was painful when he touched it. LVN A stated at that time (2:27pm), he administered a PRN 325 mg Norco pain medication. LVN A stated he followed up with CR#1 who stated the Norco was not working and he was still in a lot of pain. LVN A stated at 3:41pm, he then administered 2-325mg Tylenol tablets. LVN A stated when he followed up with CR#1, he stated that he was still in pain. LVN A stated at 5:00pm, LVN stated he called the MD and NP that was assigned to CR#1 and did not get an immediate response. LVN A stated he waited over an hour for a call back before texting the afterhours NP services, which took an additional hour to receive a call back from the on-call NP who gave an order to call for an x-ray on CR#1's knee area. LVN A stated he called the mobile x-ray company the facility used, and they never arrived. He stated at 8:00pm, they still hadn't arrived. LVN A stated he followed up with the x-ray company and was informed someone was enroute but was not given an ETA. LVN A stated when he informed CR#1 that an x-ray tech was coming to the facility to x-ray his knee, CR#1 stopped calling for help. LVN A stated he left the facility after 10:00pm and the mobile x-ray still had not arrived at the facility. He stated he did not call the MD or NP at this time. LVN A stated even though CR#1 had a stroke, he was cognizant and understood when they speak to him, and staff were aware of his needs. On 11/10/25 at 5:45pm, in an interview with LVN B, LVN B stated she only worked on the weekend. LVN B stated on 11/8/25, she was scheduled to work 6:00am - 2:00pm. However, she was late and arrived to work sometime after 6:30am. LVN B stated because she was late, she was unable to have a shift change from the 10:00pm-6:00am nurse, but the nurse left a note that CR#1 had x-rays and results were pending. LVN B stated around 9:30am, she observed a paper on the fax machine and when she looked at it, it was CR#1's x-ray report. She stated when she read it, she immediately called the on-call answering services and was waiting for doctor to give her a call back. LVN B stated she observed CR#1's knee with some mild swelling. The call back was around 5:00pm, which she was authorized to send CR#1 out to hospital. She stated she also called and texted the ADON after receiving authorization to send CR#1 out. She stated transportation took 2 hours to transport CR#1. On 11/10/25 at 7:40pm, in an interview with the HN, he stated CR#1 arrived in the ER on [DATE] at 7:30pm and the admittance diagnosis revealed a close displace spiral fracture of shaft left femur. The HN stated CR#1 had emergency surgery on 11/09/25 for an open reduction internal fixation and according to the doctor's notes, CR#1 needed to be in a skilled nursing facility for rehab. On 11/11/25 at 10:00am, during a follow-up interview, at the local hospital, CR#1 revealed while in the facility he kept pushing his call button because his left leg was in pain for a few days. CR#1 stated LVN A came to his room, and it felt like he twisted his leg in the knee area, and he screamed. CR#1 stated he was in a lot more pain. He stated LVN A gave him Norco, but it (pain) didn't get any better. CR#1 stated LVN A did not give him a Tylenol nor put bio freeze on his leg. CR#1 stated he kept calling his wife letting her know he was in a lot of pain. During a telephone interview on 11/11/25 at 1:00PM with the MD, it was revealed he read the x-ray, and it showed CR#1 had a spiral fracture. He stated the spiral fracture could have been a result of a fall, someone twisting the knee or being mishandled or several other fractures. MD stated he could not say the fracture was the result of abuse because there were many factors that could cause this. However, CR#1was bedbound. During a telephone interview on 11/11/25 at 3:13pm with the RD. it was revealed the mobile x-ray records showed that on 11/7/25, a routine order was created for CR#1 at 4:51pm. On 11/8/25 at 6:33am, a fax was sent to the facility regarding CR#1's diagnosis of the spiral fractured femur (occurs when a long bone is broken by twisting force). The RD reported that an electronic medical record, which was part of point click care (nursing notes), was also submitted to CR#1's dashboard. During a telephone interview on 11/12/25 at 11:34am with CNA A revealed on 11/8/25 between 3:00pm - 4:00pm while providing care to CR#1, he told her he was experiencing pain on his, she believed, right side. She told her charge nurse, who said it was being handled. She stated she could not remember the nurse's name. In an interview on 11/12/25 at 1:27pm, DON, it was revealed she was initially notified of the Change in Condition on Saturday 11/8/25 regarding CR#1's leg being swollen. DON stated it was a common courtesy to notify her of a change in condition, but not all staff do it. The DON stated it should be a waiting period of 30 minutes to an hour, depending on doctor's orders, to administer additional pain medication after asking a resident if their pain has increased or decreased. The DON stated in her professional opinion, CR#1's change of condition should have been noted on 11/7/25 at 3:41pm when CR#1's pain level was 8, and the MD should have been notified at that same time. The DON stated the x-ray report did come into the facility fax machine at 6:33am and it was also in the electronic health record located on CR#1's dashboard. She stated when nursing staff signed in to the resident file, the dashboard immediately showed an alert and anything new or out of the ordinary was there. The DON stated it should not have taken 13 hours after the x-ray was noted to send CR#1 out. The DON stated CR#1 should have been sent out via 911 if transportation had taken more than 4 hours. The DON stated the situation with CR#1 could have been handled better and staff dropped the ball. DON stated the negative outcome could have been continued pain and an adverse reaction that could have caused death. On 11/15/25 at 8:23am, an interview with LVN C, revealed that she worked 11/5/25 and did speak with FM regarding CR#1's leg. LVN C stated she looked at both legs for a comparison since FM stated CR#1 was in pain and had a swollen knee. LVN C stated she asked the resident if he was in pain and he said no. She stated she did palpitations (pressing on his left leg with her fingers) to see the blood flow in that area. LVN C stated CR#1 pointed at his knee. She stated she asked CR#1 if he mentioned his knee to the nurse on 2p -10p, and he stated he did not. LVN C stated she didn't document, because she had just came on shift and it slipped her mind. She stated she did not normally work with CR#1 and that side was unfamiliar to her. LVN C stated she believed she should have documented immediately. LVN C stated the negative outcome was she learned CR#1 had a fracture and was in pain and his pain should have been addressed. An additional negative outcome was she failed to complete a change in condition, which also delayed CR#1's treatment and left other nursing staff uninformed. On 11/17/25 at 10:40am, during a telephone interview with NP, he stated he should have been called immediately. He stated he didn't work the weekend. However, the NP should have been notified after administering Norco. The NP stated for an acute fracture that CR#1 had, he should have been sent out within two hours of receiving the results of the x-ray. NP stated if transportation took longer than 2 hours, then CR#1 should have been sent out in emergency transportation. Record review of the Notifications of Changes policy dated August 2024 reflected: Compliance Guidelines:The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include: 1.Accidents Resulting in injury. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include: Life-threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment.This may include: A. New treatment. B. Discontinuation of current treatment due to:S Adverse consequences.S Acute condition.S Exacerbation of a chronic condition. An Immediate Jeopardy (IJ) was identified on 11/13/2025. The IJ template was provided to the facility (administrator) on 11/13/2025 at 1:00pm.and Plan of Removal requested. Review of the facility's Plan of Removal reflected: FACILITY: SURVEY TYPE: Complaint Survey ABATEMENT PLAN: F580 Notify of Changes 11/13/25 Plan to remove immediate jeopardyThe facility failed to meet one or more state health, safety, and/or quality regulations. F-580 Notify of ChangesThe facility failed to ensure CR#1 was free from neglect. CR #1 is currently in the hospital. On 11/13/25: DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition. Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification. Charge nurses were instructed to conduct and document a Pain Assessment. Notify the PCP immediately when a resident exhibits new or worsening pain or when contributes to a suspected change in condition. DON or designee (Unit Manager or Administrator) are to be notified of a change in condition. Implement and document physician orders in PCC. Reassess pain within one hour of pain medication and document effectiveness, if applicable.Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred. Residents with a change of condition will be noted on the 24-hour report for oncoming shifts. DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.On 11/13/25: Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter and new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.On 11/13/25 Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routing rounding.All residents have the potential to be affected by this alleged deficient practice. On 11/13/25 all residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified. No changes in condition noted during the assessments, all assessments completed.The facility will provide education regarding reporting recognition of chance of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months. This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.Charge Nurses, CNA's and Med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 11/13/25. The medical director was involved with the review and the plan of removal. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will ensure the plan is completed in full by 11/13/25.Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service. On 11/14/25 at 8:00am the Monitoring Began. All In-service sign-in sheets were requested and reviewed. Interviews were conducted on 11/14/25 through 11/15/25 on all shifts with Admin, DON, RC (physical therapy). LVN D and LVN E (6a-2p shift), LVN F (6a-2p and 2p-10p shifts), CMA A and CMA B (6a-2p & 2p-10p shifts), CNA B (6a-2p shift), LVN G (2p-10p shift), CNA C and CNA D (2p-10p shift), LVN H and LVN I (2p-10p shift), RN (10p-6a shift), CNA E and CNA F (10p-6a shift), LVN J (10p-6a shift) and LVN C (All shifts) to verify the in-services and competencies had been conducted, and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. All the staff interviewed were able to explain what constituted residents' change in condition that may be pain or anything new that happened to a resident. The nursing staff revealed that a notification to the MD/NP/Admin/DON and Unit Mangers and family were required. Each nursing staff were able to explain the pain assessment process on verbal and non-verbal residents and how to assess both. In the non-verbal resident a facial expression of grimacing, moaning or groaning during the physical assessment. They were able to explain the importance of documentation of all medications, even the PRN medications. Each nurse was able to explain when to send a resident out without authorization in an emergency. The nurses indicated that residents should be sent out if there was a fall, bleeding, a resident was on anticoagulants and if there was a break in the limbs. Each staff member relayed the importance and process for accurate documentation. The CNAs and CMAs were able to explain the Stop N Watch procedure, completing their documentation in the POC (plan of care) as well. Both were to immediately notify charge nurses when a resident appeared different than normal. All staff were able to identify three types of Neglect and give an example of Neglect. 11/15/25 at 1:00am IJ Lowered Administrator and DON notified. On 11/17/25 at 1:08pm, during an interview with the Admin, she stated she became aware of CR#1 hospitalization on 11/10/25 and was informed by nursing staff that CR#1 was in the hospital because it was medically related. Admin stated she started the Self Report on 11/10/25. The Admin started the IJ's have taught her to be more thorough in looking at systems in place and talking with families more. Admin stated if she had had a relationship with FM this issue may have been eliminated, and she may have known about CR#1's injury sooner. Admin stated the process now is to send residents out immediately if there is a suspected injury, communication forms to unit manager, DON and herself. She stated there are now systems in place to eliminate these issues in the future. An Immediate Jeopardy (IJ) was identified on 11/13/2025 at 4:34 p.m. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a pattern identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 10 residents (CR# 1) reviewed for quality of care. 1. The facility failed to immediately seek medical guidance or send CR#1 out for higher level of care (ER) after receiving results of CR#1's x-ray, which revealed a Left Displaced distal femoral shaft spiral fracture . 2. The facility failed to notify the physician or NP of CR#1's change in condition, failed to monitor, and complete assessments on 11/5/25 and 11/6/25. 3. The facility failed to immediately transport CR#1 to the hospital on [DATE] after becoming aware of the result of an xray, which reflected an acute fracture. The facility waited approximately 13 hours to transport CR#1 to the hospital, where CR#1 was diagnosed with a spiral fracture of his femur and required emergency surgery. These failures could place residents at risk for continued pain, serious injuries, harm and death to residents who require total supervision. An Immediate Jeopardy (IJ) was identified on 11/13/2025. The IJ template was provided to the facility (administrator) on 11/13/2025 at 1:00pm. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.Findings included: Reviewed Record of CR#1's undated face sheet, revealed CR#1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with active diagnosis of non-Alzheimer's Dementia (decline in cognitive function), and stroke (loss of blood flow in the brain). Reviewed Record of CR#1's Quarterly MDS (resident assessment) dated 8/11/2025 revealed CR#1's BIMS score of 00 indicated CR#1's cognition is severely impaired. The MDS further revealed CR#1 had severely impaired vision, he uses a wheelchair mobility resident totally dependent on staff for eating, oral and toileting hygiene, shower/bathing, upper and lower body dressing, personal care, and sit to lying in bed. Reviewed Record of CR#1's care plan dated 7/28/25 revealed the following:Focus: Resident has an alteration in hematological (clotting problem) status r/t receiving anticoagulant (Date Initiated: 7/21/25 and Revision 11/10/25).Goal: The resident will remain free of complications related to altered hematological (clotting problem) status through the review date (Date Initiated: 7/21/25, Revision date: 11/10/25, and Target date: 1/12/26).Interventions: Complete fall risk assessment and increase vigilance for falls (Date initiated: 7/21/25). Reviewed Record of CR#1's orders dated 7/28/25 revealed:-CR#1 is to be assessed for pain every shift (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); PRN (as needed) -Acetaminophen (Tylenol) oral table 325 MG- Give 2 tablet by mouth every 6 hours as needed for pain/fever (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); Norco (Narcotic pain medication) Tablet 7.5-325 MG (PRN as needed)-Give 1 tablet by mouth every 8 hours as needed for pain (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Biofreeze Cool the pain external Gel to apply to affected areas for pain PRN (as needed) (order date 11/7/25 at 4:49pm-D/C 11/10/25 9:55am); x-ray to left femur, left knee, and left tibial/fibula once only for pain (order date 11/7/25 at 4:51pm-D/C 11/10/25 at 9:55am). Record Review of MAR dates of 11/5/25 - 11/8/25 revealed, CR#1 was administered pain medications on 11/7/25 only. Reviewed Record of CR#1'nursing notes dated 11/6/2025 thru 11/7/2025, revealed no nursing notes regarding CR#1's complaint of pain regarding his knee nor was there an assessment for the night shift on 11/6/2025. Reviewed Record of CR#1's nursing notes dated 11/7/25 at 2:27pm revealed CR#1 was administered Norco (325mg) for a swollen knee and pain level 8. The note on 11/7/25 at 3:41pm revealed CR#1 was administered 2-Tylenols (650mg total) for pain level 8. The nursing notes on 11/7/25 created 5:46pm effective 5:00pm revealed LVN A noted a change in condition for CR#1 due to ineffective pain medication, and notification of NP was made. Record review of CR#1's pain assessment revealed the following: 11/7/25 at 8:07am Pain level 0 11/7/25 at 1:18pm Pain level 0 11/7/25 at 2:27pm Pain level 8 11/7/25 at 3:41pm Pain level 8 11/7/25 at 4:18pm Pain level 8 11/6/25 at 8:21am Pain level 0 11/6/25 at 2:26pm Pain level 0 11/6/25 at 10:51pm Pain level 0 11/5/25 at 8:37am Pain level 0 11/5/25 at 3:31pm Pain level 0 11/5/25 at 11:49pm Pain level 0 Record review the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. On 11/10/25 at 3:33pm in a telephone Interview with FM revealed on Wednesday evening 11/05/2025, during a visit with CR #1 she was informed by CR#1that his left knee was hurting. FM observed the knee was noticeably swollen at which time she went to the nurses' station and spoke with the LVN C who had just arrived for her night shift (10pm-6am). FM stated she insisted LVN C come to CR#1's room to see his knee. After LVN C came to CR#1's room, FM removed the sheet exposing both knees, FM stated LVN C took a quick visual look, without touching, at both knees, then LVN C told CR#1's knee looked okay to her and abruptly left the room. FM stated on Thursday 11/6/25, she telephoned the facility to let the nursing staff know CR#1 was still calling her and was still in a lot of pain. FM stated she could not recall the name of the person she spoke with, nor could she recall the time she called. FM stated on Friday, 11/07/25, CR#1 called and said his left knee was hurting so bad and no one had given him anything for pain. FM stated she called the facility and spoke with LVN A who told her he had given CR#1 a Norco pain medication. FM stated on Saturday, 11/08/25 at 4:51pm, she received a call from LVN B indicating she was waiting for the doctor to return the call due to the result of CR#1's x-ray, which was a femur fracture, and she needed permission to send CR#1 out. FM stated it took the facility more than 2 hours before CR#1 was sent out to hospital. On 11/10/25 at 5:14pm in an Interview with LVN A he stated he worked the 2:00pm - 10:00pm shift on 11/7/25 and CR#1 was assigned to him. LVN stated CR#1 called for assistance and he went to CR#1's room. He stated CR#1 informed him his leg was hurting, and he was in pain. LVN A stated he observed CR#1's left knee and it was kind of swollen. He stated he completed an assessment and CR#1 stated the knee was painful when he touched it. LVN A stated at this time (2:27pm) he administered a PRN 325mg Norco pain medication. LVN A stated he followed up with CR#1 who stated the Norco was not working and he was still in a lot of pain. LVN A stated at 3:41pm he then administered 2-325mg Tylenol tablets. LVN A stated he followed up with CR#1 and was informed that he was still in pain. LVN A stated at 5:00pm, he called the MD and NP that is assigned to CR#1 and waited over an hour for a call back. LVN A stated he texted the NP after hours service and after an hour received a call back from the on-call NP who gave an order to call for an x-ray on CR#1's knee area. LVN A stated he called the mobile x-ray company the facility uses, and they never arrived. He stated at 8:00pm they still hadn't arrived. LVN A stated he followed up with the x-ray company was informed someone was enroute but was not given an ETA. LVN stated when he informed CR#1 that an x-ray tech was coming to the facility to x-ray his knee, CR#1 stopped calling for help. LVN stated he left the facility after 10:00pm and the mobile x-ray still had not arrived at the facility. He stated he did not call the MD or NP at this time. LVN A stated even though CR#1 has had a stroke he is cognizant and understands when you speak to him and staff are aware of his needs. On 11/10/25 at 5:45pm in an interview with LVN B regarding CR#1. LVN B stated she only works on the weekend. LVN B stated on 11/8/25 she was scheduled to work 6:00am - 2:00pm; however, she was late and arrived to work sometime after 6:30am. LVN B stated because she was late she was unable to have a shift change from the 10:00pm-6:00am nurse, but the nurse left a note that CR#1 had x-rays and results were pending. LVN B stated around 9:30am she observed a paper on the fax machine and when she looked at it it was CR#1's x-ray report. She stated when she read it, she immediately called the on-call answering services and was waiting for doctor to give her a call back. LVN B stated she observed CR#1's knee with some mild swelling. The call back was around 5:00pm, which she was authorized to send CR#1 out to hospital. She stated she also called and texted the ADON after receiving authorization to send CR#1 out. She stated transportation took 2 hours to transport CR#1. Observation and interview on 11/10/25 at 7:00pm at the local hospital of CR#1 where CR#1 was lying in hospital bed. CR#1 initially stated that LVN A was rough with him and admitted he gave him pain medications. However, CR#1 began to fall asleep, at which time No further information could have been gathered regarding CR#1's injury at that time. On 11/10/25 at 7:40pm in an interview with HN who stated CR#1 arrived in the ER on [DATE] at 7:30pm and the admittance diagnosis revealed a close displace spiral fracture of shaft left femur. NH stated CR#1 had emergency surgery on 11/09/2025 for an open reduction internal fixation and according to the doctor's notes, CR#1 needed to be in a skilled nursing facility for rehab. On 11/11/25 at 10:00am during a follow-up interview, at the local hospital, CR#1 revealed while in the facility he kept pushing his call button because his left leg was in pain for a few days. CR#1 stated LVN A came to his room, and it felt like he twisted his leg in the knee area, and he screamed. CR#1 stated he was in a lot more pain. He stated LVN A gave him Norco, but it (pain) didn't get any better. CR#1 stated LVN A did not give him a Tylenol nor put bio freeze on his leg. CR#1 stated he kept calling his wife letting her know he was in a lot of pain. During a telephone interview on 11/11/25 at 1:00PM with MD it was revealed he read the x-ray, and it showed CR#1 had a spiral fracture. He stated the spiral fracture could have been a result of a fall, someone twisting the knee or being mishandled or several other fractures. MD stated he can't say the fracture was the result of abuse because there are many factors that could cause this; however, CR#1 is bedbound. During a telephone interview on 11/11/25 at 3:13pm with DR it was revealed the mobile x-ray records show that on 11/7/25 a routine order was created for CR#1 at 4:51pm. On 11/8/25 at 6:33am a fax was sent to the facility regarding CR#1 diagnosis of the spiral fractured femur (occurs when a long bone is broken by twisting force). The DR reported that an electronic medical record, which is part of point click care (nursing notes), was also submitted to CR#1's dashboard. During a telephone interview on 11/12/25 at 11:34am with CNA A revealed on 11/8/2025 while providing care to CR#1 told her he was experiencing pain on his, she believes, right side. She told her charge nurse who said it was being handled. She stated she could not remember the nurse's name. In an interview on 11/12/25 at 1:27pm with the DON revealed she was initially notified of the Change in Condition on Saturday 11/8/25 regarding CR#1's leg being swollen. The DON stated it is a common courtesy to notify her of a change in condition, but not all staff do it. The DON stated it should be a waiting period of 30 minutes to an hour, depending on doctor's orders, to administer additional pain medication after asking a resident if their pain has increased or decreased. The DON stated in her professional opinion, CR#1's change of condition should have been noted on 11/7/25 at 3:41pm when CR#1 pain level was 8, and the MD should have been notified at this same time. The DON stated the x-ray report did come in to the facility fax machine at 6:33am and it was also on the PCC dashboard. She stated when nursing staff sign in to the resident file, the dashboard immediately shows an alert and anything new or out of the ordinary is there. The DON stated it should not have taken 13 hours after the x-ray was noted to send CR#1 out. DON stated CR#1 should have been sent out 911 if transportation had taken more than 4 hours. The DON stated the situation with CR#1 could have been handled better and staff dropped the ball. DON stated the negative outcome could have been continued pain and an adverse reaction that could have caused death. On 11/15/25 at 8:23am in an interview with LVN C it was revealed that she worked 11/5/25 and did speak with FM regarding CR#1's leg. LVN C stated she looked at both legs for a comparison since FM stated stated CR#1 was in pain and had a swollen knee. LVN C stated she asked the resident if he was in pain and he said no. She stated she did palpitations (pressing on his left leg with her fingers) to see the blood flow in that area. LVN C stated the CR#1 pointed at his knee. She stated she asked CR#1 if he mentioned his knee to the nurse on 2p -10p and he stated he did not. LVN C stated she did not document, because she had just came on shift and it slipped her mind. She stated she does not normally work with CR#1 and this side was unfamiliar to her. LVN C stated she believes she should have documented immediately. LVN C stated the negative outcome was she learned CR#1 had a fracture and was in pain and his pain should have been addressed. Additional negative outcome was she failed to complete a change in condition, which also delayed CR#1's treatment and left other nursing staff uninformed. On 11/17/25 at 10:40am during a telephone interview with NP he stated he should have been called immediately. He stated he doesn't work weekends; however, NP should have been notified after administering the Norco. NP stated for an acute fracture that CR#1 had, he should have been sent out within two hours of receiving the results of the x-ray. NP stated if transportation would take longer than 2 hours, then CR#1 should have been sent out in emergency transportation. On 11/17/25 at 1:08pm during an interview with Admin stated she became aware of CR#1 hospitalization on 11/10/25 and was informed by nursing staff that CR#1 was in the hospital because it was medically related. Admin stated she started the Self Report on 11/10/25. The Admin started the IJ's have taught her to be more thorough in looking at systems in place and talking with families more. Admin stated if she had had a relationship with FM this issue may have been eliminated, and she may have known about CR#1's injury sooner. Admin stated the process now is to send residents out immediately if there is a suspected injury, communication forms to unit manager, DON and herself. She stated there are now systems in place to eliminate these issues in the future. Record review of the Facility's Provision of Quality-of-Care policy (dated: October 2022 revision) reflected:1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.2. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. An Immediate Jeopardy (IJ) was identified on 11/13/2025 at 4:34 p.m. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a pattern identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Review of the facility's Plan of Removal reflected: FACILITY: SURVEY TYPE: Complaint Survey ABATEMENT PLAN: F684 Quality of Care 11/13/25Plan to remove immediate jeopardy Noncompliance: The facility failed to meet one or more state health, safety, and/or quality regulations. F-684 Quality of CareThe facility failed to ensure CR#1 received treatment and are in accordance with professional stances of practice. CR #1 is currently in the hospital. On 11/13/25:DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition. Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification. Charge nurses were instructed to conduct and document a Pain Assessment. Notify the PCP immediately when a resident exhibits new or worsening pain or when contributes to a suspected change in condition. DON or designee (which will be the Unit Manager or Administrator), will be notified of a change in condition. Implement and document physician orders in PCC. Reassess pain within one hour of pain medication and document effectiveness, if applicable.Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred. Residents with a change of condition will be noted on the 24-hour report for oncoming shifts. DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.On 11/13/25:Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator) Document notification in PCC, Enter and new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.On 11/13/25 Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routing rounding. All residents have the potential to be affected by this alleged deficient practice. On 11/13/25 all residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified. No changes in condition noted during the assessments, all assessments completed.The facility will provide education regarding reporting recognition of chance of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months. This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.Charge Nurses, CNA's and med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 11/13/25. The medical director was involved with the review and the plan of removal. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will ensure the plan is completed in full by 11/13/25.Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service. On 11/14/25 at 8:00am the Monitoring Began. All In-service sign-in sheets were requested and reviewed. Interviews were conducted on 11/14/2025 through 11/15/2025 on all shifts with Admin, DON, RC (physical therapy). LVN D and LVN E (6a-2p shift), LVN F (6a-2p and 2p-10p shifts), CMA A and CMA B (6a-2p & 2p-10p shifts), CNA B (6a-2p shift), LVN G (2p-10p shift), CNA C and CNA D (2p-10p shift), LVN H and LVN I (2p-10p shift), RN (10p-6a shift), CNA E and CNA F (10p-6a shift), LVN J (10p-6a shift) and LVN C (All shifts) to verify the in-services and competencies had been conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. All the staff interviewed were able to explain what constitutes residents' change in condition that may be pain or anything new that has happened to a resident. The nursing staff revealed that a notification to the MD/NP/Admin/DON and Unit Mangers and family is required. Each nursing staff were able to explain the pain assessment process on verbal and non-verbal residents and how to assess both. In the non-verbal resident a facial expression of grimacing, moaning or groaning during the physical assessment. They were able to explain the importance of documentation of all medications, even the PRN medications. Each nurse was able to explain when to send a resident out without authorization in an emergency. The nurses indicated that residents should be sent out if there is a fall, bleeding, a resident is on anticoagulants and if there is a break in the limbs. Each staff member relayed the importance and process for accurate documentation. The CAN's and CMA were able to explain the Stop N Watch procedure, completing their documentation in POC (plan of care) as well. Both are to immediately notify charge nurses when a resident appears different than normal. All staff were able to identify three types of Neglect and give an example of Neglect. 11/15/25 at 1:00am IJ Lowered Administrator and DON notified.

Based on observation, interview, and record review the facility failed to maintain an infection program designed to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 2 (Resident #29, Resident #42) of 7 residents and two staff members reviewed for infection control in that: -CNA KK was observed on 06/10/24 coming out of Resident # 42's room with a folded sheet placing the sheet back on the clean cart. -CNA D and Restorative Aide CNA E did not wear a disposable gown when providing Foley catheter for Resident #42 who was on enhanced barrier precautions. -CNA D and CNA E was not familair with EBP. -Resident #29's bathroom there was a gray wash pan sitting on side of the commode on the floor and a urinal sitting on top of the sink countertop not labeled or bag. -LVN P was observed on 06/10/25 coming out of room with a packet of used disposable wipes placing them on her medication cart. -Resident #29 and Resident #42 did not have EBP infection control signage on their door. The failures placed residents at risk for cross contamination and infections. Findings: Resident #29 Record review of Resident #29's face sheet dated 06/13/25 reveled an [AGE] year-old female admitted to the facility on [DATE] and again on 08/16/23. The resident's diagnoses included the following: dysphagia (difficulty swallowing), protein calorie malnutrition, cerebral infraction (condition where the brain tissue dies due to lack of blood supply), Alzheimer's Disease (memory loss), gastro-esophageal reflux disease (digestive disease in which the stomach acid or bile irritates the food pipe lining), gastrostomy (a surgically placed tube through the abdominal wall into the stomach, providing a route for delivering nutrition, medications, and fluids directly into the digestive system when a person cannot eat or drink adequately by mouth), and adult failure to thrive. Record review of Resident #29's quarterly MDS dated [DATE] reflected a BIMS score of 3 indicating the resident's cognition was severely impaired. Section K-Swallowing/Nutritional of the MDS reflected the resident had a feeding tube. Record review of Resident #29's care plan did not reflect care plan for EBP Record review of Resident #29's Physician's Order Summary for the Month of June 2026 included the following orders: -Dated 08/13/24 Enteral Feed Isosource 1.5 (calorie dense completed nutrition formula with fiber for increase calorie needs) at 25ml/hr continuous with 25ml/hr water flush q 24 hours. Observation on 06/10/25 at 8:57AM of Resident #29 having no EBP sigange on door. Resident #42 Record review of Resident #42's face sheet dated 06/11/25 revealed an [AGE] year-old female admitted to the facility initially on 04/09/20 and again on 01/02/25. The resident's diagnoses included urinary tract infection, dementia (memory loss), acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), severe sepsis (a life-threatening complication of an infection), and neuralgia (pain resulting from damaged or irritated nerves). Record review of Resident #42's quarterly MDS dated [DATE] reflected a BIMS score of 7 indicating the resident's cognition was severely impaired. Record review section H-Bladder/Bowel reflected the resident had an indwelling Foley catheter. Record review of Resident #42's Physician's Order Summary Report for the month of June 2025 reflected the following order: -Dated 01/02/25 16Fr/10cc urethral indwelling urinary catheter (a tube that carries urine from the bladder to the outside of the body and held in place by a balloon inflated inside of the bladder). Dx stage 4 sacral wound with closed drainage system (when the catheter is retained in the bladder by an inflated balloon and the drainage of urine is totally dependent on gravity). Record review of Resident care plan did not reflect a care plan for EBP. Observation on 06/10/25 at 8:57AM Resident #42 was awake in bed resting on an air mattress. Resident #42 had an indwelling Foley catheter that was inside of a privacy bag. Further observation was made of the resident not having an EBP infection control sign on the room door. Further observation in resident bathroom revealed a gray wash basin sitting on the floor on the left side of the commode and there was a urinal sitting on the sink counter. The wash basin and urinal were not labeled and not inside of a plastic bag. Observation was made on 06/10/25 at 12:30PM revealed the wash basin was still sitting on the floor and urinal on bathroom rail. Observation on 06/10/25 at 9:50AM revealed CNA KK coming out of a room with a white flat folded sheet in her hand. CNA KK placed the sheet back on the clean linen cart. Interview on 06/10/25 at 9:50AM CNA KK said it was okay to place the sheet on the clean linen cart as long she bagged the linen. The CNA then retracted her comment and said it was not okay to come out of a resident room with linen and place it back on the clean linen cart because it was cross contamination. CNA KK said she had just finished providing incontinent care. Interview on 06/10/25 at 10:06AM LVN N said once linens went into a resident's room, the staff was not to bring the linen back out and place them on the clean linen cart even if the linen was not used. LVN N said that was cross contamination and infection control. Interview on 06/10/25 at 2:19PM the DON said the staff were not supposed to bring linen out of a room and place it back on the clean linen cart due to cross contamination and infection control. Observation on 06/11/25 at 9:08AM revealed in Resident #42's bathroom, the gray wash basin was still on the floor by the commode along with the urinal hanging on the rail. None of the items were bagged or labeled. Interview on 06/11/25 at 9:12AM LVN I said he was working as a CNA and was assigned to Resident #42. After LVN I observed the gray wash basin on the floor and the urinal hanging on railing not dated or bagged, LVN I said all residents' wash basins, urinals, etc. were supposed to be labeled and bagged for infection control. LVN I began to remove the wash basin and urinal from the room. Interview on 06/11/15 at 9:13AM LVN P said she was the nurse for residents #42. LVN P said all resident care items should be labeled and bagged for infection control. LVN P said the CNAs were supposed to label resident care items and bag them. LVN P said because she was the nurse, she was responsible for ensuring that the CNAs were carrying out those tasks. Observation on 06/11/25 at 10:13AM revealed LVN P coming out of Resident #42's room with a pack of disposable wipes in her hand walking up the hallway and placing them on a cart. Interview on 06/11/25 at 10:14AM LVN P said she had just finished providing incontinent care for Resident #42. LVN P said Resident #42 had a bowel movement. LVN P said she placed the disposable wipes pack on her medication cart. LVN P said it was not okay to place the wipes on her cart. LVN P said she did that to have what she needed when providing care for the residents because disposable wipes were not always accessible due to central supply sometimes not stocking the nurses station with disposable wipes. LVN P did not respond when asked if there was a lack of disposable wipes at the facility. Observation on 06/11/25 at 10:38AM with LVN P of the facility supply room revealed the supply room was observed having 24 boxes of disposable wipes (with a count of 64 wipes in each packet). Interview on 06/11/25 at 10:40AM the facility Central Supply Manager said she stocked each nurse's station with disposable wipes each shift and as needed. Observation on 06/11/25 on at 10:50AM with LVN P revealed the nurse station being stocked with disposable wipes. Interview on 06/11/25 at 10:55AM LVN P said she didn't want to take the time to get the disposable wipes out of the medication room behind the nurse station and therefore chose to put the used wipes on her cart. LVN P said taking resident care items from a room and placing them on her medication cart was wrong due to cross contamination and infection control. LVN P said she had received in-service on infection control. LVN P said it would not happen again. Observation on 06/11/25 at 1:46PM of Foley catheter care for Resident #42 by CNA D with the assistance of Restorative Aide CNA E revealed the resident did not have a EBP infection control signage on the room door. During the observation, CNA D and Restorative Aide CNA E did not wear full PPE that consisted of disposable gown and gloves (just washed their hands and placed on gloves). Interview on 06/11/25 at 2:09PM CNA D said she was not familiar with EBP as it related to infection control. CNA D said her last infection control in-service was at the beginning of the month and did consist of cross contamination. Interview on 06/11/25 at 2:11PM Restorative Aide CNA E said he was not familiar with EBP and that his last in-service on infection control was last month he believed. Interview on 06/11/25 at 2:16PM LVN P said she was not familiar with EBP. Interview on 06/11/25 at 2:20PM the facility Infection Control Preventionist said she had been working as the facility's Infection Control Nurse Preventionist since 2023. The Infection Control Nurse said she was familiar with infection control EBP. She said EBP was to prevent infections such as MDRO and that if the infection was colonized (the presence of bacteria on the body surface like the skin, mouth, intestines, or airway without causing the disease in the person). the staff just needed to wear gloves but if the infection was not colonized, the staff needed to be donned((put on) in both gloves and disposable gowns when performing direct care for the resident(s). Further interview with the Infection Control Preventionist revealed a resident's wash pan and urinal needed to be labeled with the resident's name, stored inside of a plastic bag, and kept in the resident's bathroom to prevent cross contamination. The Infection Control Preventionist said when the staff took items into a resident's room to care for a resident, that item should stay in the resident's room to prevent cross contamination and infections. The Infection Control Preventionist said she was going to place EBP infection control signs on all rooms doors of residents' that had wounds, Foley catheters, trach (tracheostomy-surgical procedure to create an opening in the neck directly into the windpipe to facilitate breathing), gastrostomy ((feeding tube inserted through the abdominal wall directly into the stomach), colostomy (surgical procedure that creates an opening in the abdomen, connecting the colon to the outer side of the body to allow stool to pass) , etc. and provide in-service to the staff about EBP and infection control. Interview on 06/11/25 at 2:34PM the DON said she learned on 06/11/25 about EBP and signage needing to be on all doors or residents that had wounds, IV's, colostomy bag, G-tubes, trachs, etc. The DON said when she read the information regarding EBP, she was under the impression it was for MDRO's and issues dealing with colonize vs not colonized infections. The DON said she was also an Infection Control Preventionist. Interview on 06/11/25 at 2:37PM the Administrator said after reviewing CMS recommendations on EBP, she realize that the facility had misread their recommendations on EBP thinking it meant for colonized and MDRO infections. The Administrator said the facility had begun a 100 % audit on all residents with Foley catheters, wounds, trach, colostomy, G-tubes, IV's, infection control as it related to EBP, PPE, and infection control signage on doors. The Administrator said the facility had initiated a PIP on the incident and spoke with the facility Medical Director regarding EBP and infection control. The Administrator said no staff would be allowed to work until in-serviced had be done with staff. Interview on 06/12/25 at 12:05PM Restorative Aide CNA E said he worked the 7AM-3AM full time and had been in-serviced on infection control/EBP. Restorative Aide CNA E said when providing direct care for a resident such as incontinent care, he had to wear a disposable gown and gloves, making sure the resident had an EBP sign on the door and PPE by the doorway or on the doorway. CNA E said residents that needed to be on EBP were residents with wounds, Foley catheters, trachs (surgical procedure that creates an opening in the neck and windpipe to allow breathing), gastrostomy feedings, and IV's (administering fluids, medications, nutrients through a vein. Interview on 06/11/25 at 12:09PM with LVN M who worked at the facility on the 6AM-2PM shift revealed she had received an in-service on infection control/EBP to wear disposable gowns and gloves when providing direct care for residents with infections, wounds, Foley catheters, gastrostomy, colostomy, receiving dialysis, and trachs. Interview on 06/12/25 at 12:11PM LVN N Unit Manager said she worked at the facility full time Monday-Friday form 9AM-5PM. LVN N said she had received in-service on infection control, and EBP to don with gloves and disposable gowns when providing direct care for residents with Foley catheters, wounds, gastrostomy tubes, colostomies, and intravenous, or any other artificial openings. LVN N said the EBP signage had to be on the resident's door with PPE being available. Intervention on 06/12/25 at 12:39PM via phone with LVN W said he worked on the 10PM-6AM and had received in-service on infection control as it related to EBP. LVN W said any resident with an artificial opening (G-tubes, colostomy), wounds, indwelling Foley catheters, etc. LVN W said the staff had to wear disposable gowns and gloves when providing direct care for the resident. LVN W said the infection control sign had to be placed on the resident(s) door with PPE available. Interview on 06/11/25 at 12:45PM via phone LVN Z said they worked the night shift form 10PM-6AM PRN. LVN Z said he had been in-serviced on EBP for residents with any wounds or artificial openings to ensure that the EBP signage were on their doors with PPE being accessible. LVN Z said he had to wear disposable gowns and gloves when providing direct care to protect themselves as a well as the resident. Interview on 06/12/25 at 12:47PM via phone LVN TT said she worked the night shift form 10PM-6AM full time. LVN TT said she had been in-serviced on making sure infection control signage was on resident doors with wounds, gastrotomy tubing, trachs, Foley catheters and to wear disposable gowns and gloves when providing care. LVN TT said PPE had to placed by the resident's door. LVN TT said the reason this was done was to protect the resident and the staff providing care for the resident. Interview on 06/12/25 at 5:03PM with LVN I said he worked at the facility full time from 2PM-10PM and had received in-service on EBP and PPE. Interview on 06/12/25 at 5:05PM with CNA RR who worked the 2PM-10PM shift. CNA RR said she had received in-service on EBP and PPE. Record review of the facility policy on Infection Control copyright 2022 reflected in part: .All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff adhere to standard precautions to prevent the spread of infection to residents, staff and visitors . Record review of the facility policy on Enhanced Barrier Precautions dated August 2022 reflected in part: .Enhanced barrier precautions (EBP's) are utilized to prevent the spread of multi-drug resistance organisms to residents .EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .EBP's remain in place for the duration of the resident's stay or until resolution of the wound or indwelling medical devices regardless of MDRO colonization .Signs are posted in the door or wall outside the resident room indication the type of precautions and PPE required .

Based on observation, interview, and record review the facility failed to protect the personal and medical records of residents reviewed for privacy and confidentiality in that: On 06/11/25 MA B was not at her medication cart when her computer screen was showing numerous profiles on the computer screen of resident's pictures. This failure placed residents at risk of breach in confidentiality of medical information. Findings: Observation on 06/11/25 at 10:43AM revealed MA B left her computer open with resident records easily accessible showing their photo and names. In an interview on 06/11/25 at 10:44AM MA B said she had forgotten to lock her computer when she walked away from it to go to the medication room to check for a medication. MA B said she should not have done that because it placed the resident at risk for their medical records being exposed to the public. MA B said this was a HIPAA violation. MA B said she had received in-service on protecting the residents' medical records and that she did not mean to leave her computer unlocked. In an interview on 06/11/25 at 3:15PM the Administrator regarding HIPPA said the staff needed to always protect resident medical records. The Administrator said when a staff did not always protect a resident's medical record, it placed the resident at risk of their privacy being invaded. Record review of the facility policy on Confidentiality of Personal and Medical Records copyright 2022 reflected in part: .This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's record regardless of the form of storage or location of the record . keep confidential is defined as safeguarding the content of information including written documentation, video. Audio, or other computer stored information from unauthorized disclosures without the consent of the individual and/or the individual surrogate or representative .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, mental, and psychosocial needs for 3 (Resident #17, Resident #31, Resident #48) of 5 residents reviewed for comprehensive care plans. - Resident #17 was not care-planned for exit-seeking when she was documented in her progress notes as pushing on the exit door by her room as a behavior. - Resident #31 did not have a comprehensive care plan in place with interventions to address oxygen use or anticoagulant use. -Resident #48 did not have a comprehensive care plan to address his advanced directive status of DNR This deficient practice could place residents at risk of their behaviors and needs being monitored and cared for at the facility. Findings included: Record review of Resident #17's face sheet dated 06/11/2025, reflected she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included basal cell carcinoma of the skin (skin cancer), schizophrenia (a mood disorder characterized by hallucinations, delusions, and disorganized thinking and behavior), insomnia, and pain. Record review of Resident #17's Comprehensive MDS dated [DATE], reflected Resident #17 had a BIMS score of 9 out of 15 which suggested she had moderate cognitive impairment related to memory and thinking skills. She required moderate assistance with toileting, dressing, footwear, and personal hygiene. Resident #17 was coded as having no impairments to her upper and lower extremities. Record review of Resident #17's care plan last revised 04/28/2025, reflected she was care-planned for impaired cognitive function/dementia or impaired thought processes related to dementia, with interventions including administering medications as ordered and monitoring/documenting for side effects and effectiveness and cueing, reorienting and supervising as needed. There was no care plan for Resident #17's behavior of pushing on the door. A later record review of Resident #17's care plan last revised 06/11/2025 after surveyor intervention, Resident #17 was care-planned for being a wanderer related to being disoriented to place, with interventions including assessing for fall risk, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation and television and monitoring Resident #17 for fatigue and weight loss. Record review of Resident #17's Order Summary Report, reflected she had an active order for Lorazepam (generic name of Ativan) Oral Tablet 1 MG, give 1 tablet by mouth three times a day related to Schizophrenia and to hold for excessive sedation with a start date of 06/06/2025. Record review of Resident #17's elopement evaluation on 4/2/2025, reflected she was documented as posing no risk for elopement. Record review of Resident #17's progress notes, reflected she made attempts to push on the door at the exit near her room on 5/1/2025, 5/7/2025, 6/2/2025, 6/3/2025, and 6/9/2025. Record review of Resident #17's medication consent form, reflected she was prescribed Ativan for anxiety and agitation on 6/6/2025. Observation and interview with Resident #17 on 06/10/2025 at 9:33am, revealed Resident #17 was in her room sitting on her bed and was holding her head with both hands and talking to herself. She appeared well-groomed and agitated. When asked how she was doing, Resident #17 said thank you and waved the surveyor off. When the surveyor walked past her bedroom, Resident #17 was heard talking progressively louder, Stop looking at me! Later observations of Resident #17 on 6/12/2025 at 10:59am, revealed she was walking around the facility away from the door and at 4:28pm, Resident #17 was in her room in bed. Observation on 6/11/2025 at 2:29pm, revealed LVN K pushed on the exit door on Resident #17's hallway, and the alarm rang for 15 seconds before the door fully opened. He turned off the alarm with a key which fit into the alarm box at the top of the doorframe. The door was observed with no damages or concerns. In an interview with MDS Nurse LVN F on 6/11/2025 at 1:20pm, she said she was not aware of Resident #17 and that she would care-plan the behavior of pushing on the door and document Resident #17's wandering behavior on her assessments. LVN F said that Resident #17 could get out the door or fall if she left. LVN F said nurses used the care plan to see how to provide care to the residents. In an interview with LVN M on 6/11/2025 at 2:29pm, she said Resident #17 would walk with her wheelchair and push it into the door. When the alarm would turn on, Resident #17 would get irritated but was easily redirected away from the door. Resident #17 would move away from the door when the alarm turned on. LVN M had in-services on elopement and resident behaviors such as redirection at the facility. In an interview on 6/11/2025 at 2:38pm, the DON said that Resident #17 would not be considered exit-seeking per se, but that she made attempts to push on the doors but would get scared and was easily redirected from the situation. In a later interview with the DON and Administrator on 06/11/2025 at 4:34pm, the Administrator said they were evaluating where they could move Resident #17 so she could be away from the door. The Administrator said the purpose of care plans was to document needs and try to meet them for residents, and that Resident #17's behavior of pushing on the door might need to be documented. The Administrator said Resident #17 had no exit-seeking behavior or the facility would have to find another building for her as they did not have a secured unit. In an interview with RN G on 6/11/2025 at 2:55pm, she said that Resident #17 had attempted to push on the door every few days but Resident #17 had not exited or left the building. After each attempt, RN G would give Resident #17 a PRN dose of anxiety medication. Resident #17's NP was notified of her behavior. Resident #17 never told RN G why she attempted to leave but would talk to herself. The facility had working alarms, and RN G and CNAs on the hall watched and redirected her. When Resident #17 would push on the door, RN G called Resident #17's Psychiatric NP, documented it in Resident #17's progress notes, and told the next shift's nurses and aides to continue monitoring. RN G had elopement and resident behavioral training. RN G said Resident #17's behavior should be in her care plan, but she would need to check. Behaviors should be in the care plan so a resident's condition was documented, and nurses could be aware. In an interview with the Unit Manager LVN N on 6/11/25 at 3:24pm, she said Resident #17 liked to go to the door but never left the building. LVN N was not aware why Resident #17 would go near the door. Resident #17's NP checked on her and would ask if her medications were effective. She said care plans highlighted resident's care, how they were, medications and behaviors. In an interview with NP B on 6/13/2025 at 8:16am, he said that he was Resident #17's Psych NP. NP B said the facility staff called him frequently for her behaviors, including trying to exit. NP B said medications did not treat a specific behavior but were used to treat Resident #17's condition in general. He recently changed her medication to help with her behaviors such as restlessness, anxiety, talking to herself, and getting her to put on her gown and talk to NP B. Resident #31 Record review of Resident #31's facility admission record dated 6/11/25 revealed that Resident #31 had an original admission date of 8/14/2015 and re-admission date of 2/9/25. Resident #31 was a [AGE] year-old male with diagnoses that included Ileus unspecified (a condition where the intestines don't move food and waste along as they should, but there's no physical blockage like a tumor or scar tissue) and Hydronephrosis with renal and ureteral calculous obstruction (the swelling of a kidney due to a blockage in the ureter (the tube carrying urine from the kidney to the bladder) caused by a kidney stone (calculus). Record review of Resident #31's Quarterly MDS dated [DATE], revealed a BIMS score of 12 out of 15 indicating a moderate cognitive impairment. Resident #31 was documented to require substantial/maximum assistance from staff for ADLs. He required supervision or touching assistance with eating and oral hygiene. He had an indwelling urinary catheter and was always incontinent with bowels. Section N-Medications indicated he used anticoagulants. Section O-Special Treatments indicated Resident #31 used oxygen. Record review of Resident #31's undated care plan, revealed there were no care plans with interventions to address anticoagulant or oxygen use. Record review of Resident #31s physician orders for May 2025 revealed an order for oxygen at 2 liters/min via nasal cannula PRN with a start date of 9/25/24. Record review of Resident #31's physician orders for May 25 revealed a physician order for Xarelto oral tablet 20 mg. Give 1 tab by mouth in the evening. Observation and interview on 6/10/25 at 10:10 AM with Resident #31, revealed the resident appeared to be clean, and had no odors, or visible signs of injury. He said that he felt very pleased with his care at the facility and had no concerns. In an interview on 6/11/25 at 9:24 AM with the Administrator, she said care plans for anticoagulants and oxygen should be in place for Resident #31 and the MDS coordinator was responsible for updating. A negative impact could be resident needs not being addressed. In an interview on 6/11/25 at 1:29 PM with LVN F/MDS Coordinator she confirmed that there were no comprehensive care plans to address anticoagulants or oxygen use for Resident #31 and there should have been. Care plans were important because nurses looked at them to provide care for residents. She added the responsibility lied with the IDT. In an interview on 6/11/25 at 2:37 PM with the DON, she said that Resident #31's oxygen and anticoagulants status should have been care planned. She said that without the care plan he could have bled out or needed oxygen and the care plans were used to provide care. She said that MDS Coordinator was responsible for updating the care plans. Resident #48 Record review of Resident #48's facility admission record dated 6/11/25 revealed that Resident #48 had an original admission date of 3/2/21 and re-admission date of 5/1/25. Resident #48 was a [AGE] year-old male with diagnoses that included lobar pneumonia (a type of pneumonia where a large portion or entire lobe of one or both lungs becomes inflamed and consolidated, meaning it fills with inflammatory fluid and/or pus) and Parkinson's Disease without Dyskinesia without fluctuations (a specific presentation of Parkinson's disease where patients do not experience involuntary movements (dyskinesia) or noticeable changes in the severity of their symptoms over time (fluctuations). Record review of Resident #48's Quarterly MDS dated [DATE], revealed a BIMS score of 8 out of 15 indicating a moderate cognitive impairment. Resident #48 was documented to require partial to moderate assistance to substantial/maximum assistance from staff for ADLs. He required set-up to or clean-up assistance with eating. He was always incontinent with bladder and bowel. Record review of Resident #48's undated care plan revealed there was no care plan to address his advanced Directive choice of DNR. Record review of Resident #48's physician orders dated 5/2025 revealed a physician order for DNR with OOH DNR signed 5/8/25. Record review of Resident #48's DNR dated 5/7/25 revealed that he elected for DNR status. Observation on 6/10/25 at 10:03 AM of Resident #48, revealed he appeared to be asleep, very frail, as he laid on his bed. In an interview on 6/11/25 at 9:24 AM with the Administrator, she said a care plan to address DNR for Resident #48 should be there to address the needs of the resident and the MDS coordinator was responsible for updating care plans. A negative impact could be resident needs not being addressed. In an interview on 6/11/25 at 1:29 PM with LVN F/MDS Coordinator she confirmed that there were no comprehensive care plans to address DNR status for Resident #48 and there should have been. She said the care plan would be added on 6/11/25. In an interview on 6/11/25 at 2:37 PM with the DON, she said that the care plan for Resident # 48's DNR status should have been updated. She said that without the care plan he could have been given CPR (lifesaving interventions) if the DNR status was not care planned. Record review of the facility's policy on Comprehensive Care Plans copyrighted 2025 read in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .3.The comprehensive care plan will describe, at a minimum . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .f. Resident specific interventions that reflect the resident's needs and preferences . Record review of the facility's policy on Elopements and Wandering Residents copyrighted 2022 read in part, The facility is equipped with door locks/alarms to help avoid elopements . Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff .

Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to provide necessary services to maintain good grooming and personal hygiene for 1 (Resident #21) of 6 residents reviewed for activities of daily living in that: -The NF failed to remove unwanted facial hair from Resident #21's chin area and above the resident's top lip. This failure placed resident at risk for psychological embarrassment, sadness, and decrease in quality of life. Findings: Record review of Resident #21's face sheet dated 06/12/25 revealed a [AGE] year-old female admitted to the facility initially on 12/02/2013 and again on 07/17/23. The resident's diagnoses included the following: Alzheimer's Disease (a disease that destroys memory and other important memory function), muscle weakness, Parkinson's disease (disorder that affects the brain that can cause tremor, slowness of movement, limb stiffness, and gait and balance problems), need for assistance with personal care, lack of coordination, and dementia (loss of memory and thinking skills). Record review of Resident #21's quarterly MDS dated [DATE] reflected a BIMS score of 13 indicating that resident cognition was intact. Further review section GG-Functional abilities reflected the resident required supervision or touching assistance with personal hygiene. Record review of Resident #21's Comprehensive Care Plan revised 08/15/24 revealed the resident was care planned for ADL self-care performance deficit r/t dementia (loss of memory and thinking skills) with an intervention that included resident was independent with personal hygiene and oral care. Further review revealed that resident was being care planned for the potential for impaired thought process r/t impaired decision making, dementia, Alzheimer's that included an intervention to cue (serve as a signal or a hint when to do something) for, reorient and supervise as needed. Observation on 06/10/25 at 8:58AM revealed Resident #21 was sitting up on the side of her bed dressed in street clothing. The resident had just finished eating breakfast. Further observation was made of the resident having a moderate amount of hair growing out of her chin appearing to be approximately a half inch long in some areas. The resident had hair growing above her top lip. Interview on 06/10/25 at 8:58AM Resident #21 said she would like the hair removed from above her lip as well as her chin. The resident said the staff had removed her unwanted facial hair before with a razor but did not know when the last time it had been done. The resident said she was unable to shave the unwanted facial hair because of her hands shook sometimes. Observation on 06/11/25 at 8:57AM revealed Resident #21 was sitting on side of bed with facial hair on her chin and above her top lip. Interview on 06/12/25 at 12:58PM the DON said the CNAs and nurses were responsible for keeping the residents groomed. The DON said it was the responsibility of the nurse to ensure the CNAs were keeping the residents groomed by shaving unwanted facial hair on residents . The DON said it was important to keep the residents groomed for their dignity and hygiene. The DON said if that was not being done, it placed the resident at risk of not feeling good about themselves, experiencing sadness, and feeling of self-consciousness. Observation on 06/12/25 at 1:09AM revealed Resident #21 was in her room sitting up on the side of her bed eating her lunch. The resident no longer had the facial hair on her chin and above her top lip. Interview on 06/12/25 at 1:15PM CNA C said the removal of any unwanted facial was provided with resident showers. CNA C said when the resident was not groomed it could make the resident feel bad or unhappy. Interview on 06/12/25 at 5:09PM Resident #21 said she felt better after the facial hair had been removed. The resident said when she had hair on her face it made her feel unclean. Record review of the facility's policy on Promoting/Maintaining Resident Dignity with copyright of 2022 reflected in part: .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each residents individuality .All staff members are involved in promoting care to residents to promote and maintain resident dignity and respect residents rights .Groom and dress residents according to resident preference .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Med Carts A and B) of 3 medication carts reviewed for pharmacy services. 1. Med Cart A had 3 blister packs of Tramadol 50 mg tablets totaling 68 tablets with an expiration date of 05/20/2025 for Resident #53. 2. Med Cart B had 1 blister pack with 9 tablets of Hyoscyamine Sulfate .125 mg tablets totaling 1 tablet and 1 blister pack of Haloperidol 1 mg oral tablet totaling 1 tablet with an expiration date of 05/25/2025 for Resident #68. This deficient practice could place residents at risk for not receiving the intended therapeutic benefit of their medications. Findings included: 1. Observation of Med Cart A and interview with RN G on 6/12/2025 at 4:28pm, revealed there were 3 blister packs of Tramadol 50 mg tabs (medication given to treat mild to moderate chronic pain), with instructions to take 1 tablet by mouth every 6 hours as needed. The packs had 29 tablets, 25 tablets and 14 tablets, respectively. The packs had the same expiration date of 05/20/2025. RN G said that nurses checked the carts for expired medications when they worked on them, and RN G missed this medication. RN G said having this expired medication presented no harm to Resident #53 because she had Tylenol PRN if she needed her medication. RN G removed the blister packs and took them to the medication storage room. Record review of Resident #53's face sheet dated 06/12/2025, reflected she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included cellulitis (infection of the skin tissue), Type 2 diabetes mellitus (high blood sugar), hyperlipidemia (high levels of fat in the blood), paranoid schizophrenia (a mental health condition making it hard for someone to tell what is real and what isn't, characterized by hallucinations, delusions and disorganized thinking), muscle weakness, history of stroke, and hypertension (high blood pressure). Record review of Resident #53's Order Summary Report, reflected she had an order for Tramadol HCl Oral Tablet 50 MG to be given by mouth every 6 hours as needed for pain with a start date of 8/19/2023 and was discontinued with no end date documented. Resident #53 had a new order for Tramadol HCl Oral Tablet 50 MG with a start date of 06/05/2025. Record review of Resident #53's MAR for May and June 2025, reflected Tramadol was not administered for May 2025 nor for 06/01/2025 to 06/12/2025. Resident #53 had documented pain levels of 0 for May and June 2025. Resident #53's Tramadol 50 mg had an order date of 08/19/2023 and a D/C date of 06/04/2025. Resident #53 had another order for Tramadol 50 mg with an order date of 06/05/2025. Record review of the Controlled Drug Administration Record Tablet for Resident #53's Tramadol 50 mg tab, reflected it had the same RX number as the blister packs. The record showed the last time Resident #53 took Tramadol was on 11/17/2024. 2. Observation of Med Cart B and interview with LVN H on 6/12/2025 at 4:49pm, revealed there was 1 blister pack containing 9 tablets of Hyoscyamine Sulfate oral 0.125 mg sublingual (administered under the tongue) tablet, with instructions to take 1 tablet by mouth every 8 hours as needed for secretion (medication given to produce more saliva) and another blister pack containing 1 tablet of Haloperidol 1 mg oral tablet with instructions to take 1 by mouth or under the tongue every 6 hours as needed for confusion, agitation or nausea/vomiting. Both blister packs had expiration dates of 05/25/2025. LVN H said that nurses should double-check the cart along with Unit Managers on a weekly basis, and that a negative outcome of residents possibly taking expired medication would be an adverse reaction or residents not getting the intended effect from expired medications. LVN H said those medications came from Resident #68's hospice and that LVN H did not think Resident #68 took those medications anymore. LVN H had in-services on checking for medication dates and medication administration. Record review of Resident #68's face sheet dated 06/12/2025, reflected she was a [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included Schizophrenia, Major Depressive Disorder, Anxiety Disorder, and pain. Record review of Resident #68's Order Summary Report, reflected she had an order for Haloperidol Oral Tablet 1 MG to be given as 1 tablet sublingually every 6 hours as needed for Agitation, with a start date of 02/26/2025 and was discontinued with no end date documented and a current order for Hyoscyamine Sulfate oral Tablet 0.125mg for 1 tablet to be given every 8 hours as needed for increased secretions, with a start date of 02/26/2025. Record review of Resident #68's MAR for May and June 2025, reflected she was not administered Haloperidol nor the Hyoscyamine for the months of May and June 2025. In an interview with the DON and Administrator on 06/12/2025 at 5:18pm, the DON said that Resident #68's Haloperidol came from her other facility and that Resident #68 did not take Haloperidol anymore because she did not have any behaviors warranting it. The DON said that nurses and unit managers were to check carts. The Unit Manager and DON were to make sure nurses were doing what they should. If residents took expired medications, they could have adverse reactions. The facility had medication training and in-services two weeks ago which covered medication management. Record review of the facility's policy on Medication Administration copyrighted in 2022 read in part, Medications are administered by licensed nurses or other staff who are legally authorized to do so . 12. Identify expiration date. If expired, notify nurse manager.

Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one resident (Resident #48) of 10 residents reviewed for resident call system in that: The facility failed to ensure Resident #48's call light was in working order. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Record review of Resident #48's facility admission record dated 6/11/25 revealed that Resident #48 had an original admission date of 3/2/21 and re-admission date of 5/1/25. Resident #48 was a [AGE] year-old male with diagnoses that included lobar pneumonia (a type of pneumonia where a large portion or entire lobe of one or both lungs becomes inflamed and consolidated, meaning it fills with inflammatory fluid and/or pus) and Parkinson's Disease without Dyskinesia without fluctuations (a specific presentation of Parkinson's disease where patients do not experience involuntary movements (dyskinesia) or noticeable changes in the severity of their symptoms over time (fluctuations). Record review of Resident #48's Quarterly MDS dated [DATE], revealed a BIMS score of 8 out of 15 indicating a moderate cognitive impairment. Resident #48 was documented to require partial to moderate assistance to substantial/maximum assistance from staff for ADLs. He required set-up to or clean-up assistance with eating. He was always incontinent with bladder and bowel. Record review of Resident #48's care plan revealed a care plan to address ADL self-care performance deficit r/t decreased mobility and unsteady gait Date Initiated: 6/1/21. Revision on: 4/10/2024 with a target date of 6/30/25. Interventions included requiring 2 staff to transfer and to encourage the resident to use bell to call for assistance. Observation and interview on 6/11/25 at 8:35 AM revealed Resident #48's sitting up in his bed eating breakfast. He said that the staff had not answered his call light for the past week. The surveyor requested Resident #48 to press his call light and when he pressed the call light the light outside the room failed to turn on. Resident #48 said that it made him feel scared when he pressed the call light, and no one responded because he needed help. Observation and interview on 6/11/25 at 8:37 AM revealed the surveyor found and asked CNA O to please check Resident #48's call light. CNA O and LVN P came into the room and checked the call light.The call-lights for both beds were unplugged and re-inserted and then the call-light worked. LVN P said that she placed a work order about the call-light immediately with the Maintenance Director. She said that a functional call light was important because the call light was the resident's way to communicate their needs, she also monitored the halls constantly and it was everyone's responsibility to monitor call-lights to make sure resident needs were addressed. Observation and interview on 6/11/25 at 8:48 AM with the Maintenance Director, revealed he said that the call light was very important because the residents needed help and all staff were responsible to make sure the resident needs were met. The surveyor observed the Maintenance Director when he gave the new cords for the call light to be replaced to CNA O and he said he would dispose of the faulty cords. In an interview on 6/11/25 at 8:55 AM with LVN A/Charge Nurse, she said that safety was number one and making sure the resident needs were met. She said the monitoring and reporting of needed repairs were all staff responsibilities. She said they communicated through an email system in the facility any work orders that needed to be addressed and the email reached all management. In an interview on 6/11/25 at 9:24 AM with the Administrator, she said that she was aware of Resident #48's call light and said that the call-light was repaired immediately. She said that she was also conducting a 100 percent audit on all call-lights. She said that all staff were responsible for monitoring call-lights and communicating needed repairs and ambassadors checked call lights daily. She added call lights were important to address and assist with help and a negative outcome could have been if the resident had fallen and required assistance. In an interview on 6/11/25 at 10:28 AM with the Infection Control Preventionist-LVN/Unit Manager she acknowledged that she was an ambassador for the residents and checked the call lights daily and that Resident #48's call light not working for approximately the last week was untrue because she always checked the call lights for safety and said all staff were responsible for checking call lights. An interview on 6/11/25 at 2:37 PM with the DON, revealed the DON said that if a resident's call light was not functional, the resident would not be capable of calling for help when needed and they could get hurt if they could not call. She said all staff were responsible for monitoring call-lights. Review of the facility's undated policy and procedure entitled Call Lights: Accessibility and Timely Response, read in part . The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response . Ensure the call system alerts staff members directly or goes to a centralized staff work area. .

Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #29) of 7 residents for the administration of medication via gastrostomy in that: -LVN A did not check for gastrostomy placement, per the facility policy, prior to administering Resident #29's medication on 06/10/25. This failure placed resident at risk for aspiration, unwanted hospitalization, and decrease in quality of life. Findings: Record review of Resident #29's face sheet dated 06/13/25 reveled an [AGE] year-old female admitted to the facility on [DATE] and again on 08/16/23. The resident's diagnoses included the following: dysphagia (difficulty swallowing), protein calorie malnutrition, cerebral infraction (condition where the brain tissue dies due to lack of blood supply), Alzheimer's Disease (memory loss), gastro-esophageal reflux disease (digestive disease in which the stomach acid or bile irritates the food pipe lining), gastrostomy (a surgically placed tube through the abdominal wall into the stomach, providing a route for delivering nutrition, medications, and fluids directly into the digestive system when a person cannot eat or drink adequately by mouth), and adult failure to thrive. Record review of Resident #29's quarterly MDS dated [DATE] reflected a BIMS score of 3 indicating the resident's cognition was severely impaired. Section K-Swallowing/Nutritional of the MDS reflected the resident had a feeding tube. Record review of Resident #29's Physician's Order Summary for the Month of June 2026 included the following orders: -Dated 08/13/24 Enteral Feed Isosource 1.5 (calorie dense completed nutrition formula with fiber for increase calorie needs) at 25ml/hr continuous with 25ml/hr water flush q 24 hours. -Dated 10/04/24 Hyoscyamine 0.125mg one tablet via G-tube every 4 hours for excessive secretions. -Dated 10/16/24 Sucralfate 1 gm via G-tube three times a day for gastric protection. Record review of Resident #29's Comprehensive Care Plan with an admission date 08/16/23 reflected the resident was care planned for PEG tube (same as G-tube) for nutrition r/t dysphagia and malnutrition. The interventions included to observe, document, report PRN any s/sx of: aspiration (accidental breathing in of food or fluids in a person's airway and eventually the lungs), fever, abdominal pain, distention (expansion of an organ or structure due to internal pressure), infection at tube site, SOB, tube dislodged .tube dysfunction of malfunction. Observation on 06/10/25 at 12:45PM of medication pass for Resident #29 by LVN A revealed LVN A entered the room without a stethoscope (a device used to listen to the internal sounds of the body) to administer medications hyoscyamine 0.125mg and medication sucralfate 1 gm via G-tube TID. Prior to administering the medications, LVN A did not check for gastrostomy tube placement or observe the G-tube site. LVN A used a syringe to check the G-tube for residual (the volume of food, liquid, or material that remains in the stomach at a particular time during or between enteral nutrition feedings). The resident did not have any residual from the G-tube. LVN A did push the air from the syringe she used to check for residual with no audible sounds heard (sound perceived by the human ear). LVN A proceeded by flushing the G-tube with 30ml of water followed by administering the medication that was mixed in 5 ml of water. After LVN A finished administering the medication, she then flushed the G-tube with 30 ml of water. Interview on 06/12/25 at 11:57AM LVN A said she worked the morning shift from 6AM-2PM full time. LVN A said she was told by the DON that if she checked the residual of a resident with gastrostomy tube feedings, she did not have to check for placement and just return the residual contents back to the resident. LVN A said in the past, she was taught to check for the placement of a gastrostomy tube by listening with her stethoscope. LVN A said by not checking for gastrostomy placement placed the resident at risk for aspiration. Interview on 06/12/25 at 12:58PM the DON said the staff checked for placement of a gastrotomy tube by aspirating for any gastric contents using a syringe. The DON said if the resident yielded any gastric contents when aspirating the nurse would hear a swishing sound to ensure proper placement and that the nurse did not have to listen with a stethoscope. The DON said that method of checking for gastrostomy placement was changed by the corporate team she thought in 2023. The DON said if placement was not confirmed, it placed the resident at risk for aspirations. The DON was asked for the facility policy on the care of gastrostomy tube when administering medications via gastrotomy tube. Interview on 06/12/25 at 1:15PM LVN K said he worked the 6AM-2PM full time. LVN K said prior to administering medications or feeding through a gastrostomy tube, he always checked for placement by using a stethoscope to listen and an irrigation syringe checking resident residual (gastric contents). LVN K said if the resident did not have a residual, he would then listen with the stethoscope to check placement. Observation on 06/12/25 at 3:00PM of Resident #29 resting in bed quietly with eyes closed receiving continuous gastrostomy feedings with Head of bed elevated. Resident respirations were even and unlabored with no distress observed. Record review of the facility policy on Medication Administration via Enteral Tube copyright 2024 reflected in part: .It is the policy of the facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines .Enteral tube placement must be verified prior to administering any fluids or medication. (See Flushing a Feeding Tube policy) . Record review of facility policy on Flushing a Feeding Tube copyright 2024 reflected in part: .Prior to flushing the feeding tube, administration of medication or providing tube feedings, the nurse verifies the proper placement by noting the length of the tube or performing a measure of the pH (measures the density of hydrogen ions {important component in acid-base chemistry in a substance) of gastric secretions, if performed in the facility. See Verifying Placement of Feeding Tube Policy. Record review of the facility policy on Verifying Placement of Feeding Tube copyright 2021 reflected in part: .For gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube .Measure length of tube and record the length. Check and record the length of the tube prior to feedings as per facility policy .

Based on observation, interview, and record review the facility failed to ensure resident who is incontinent of bladder receives appropriate treatment and service to prevent urinary tract infections for 1 (Resident #42) of 6 residents reviewed for incontinent care in that: -CNA D placed Resident #42s Foley bag on the bed during Foley catheter care. This failure placed resident at risk for urinary tract infection, unwanted antibiotic therapy, and decrease in quality of life. Findings: Record review of Resident #42's face sheet dated 06/11/25 revealed an [AGE] year-old female admitted to the facility initially on 04/09/20 and again on 01/02/25. The resident's diagnoses included urinary tract infection, dementia (memory loss), acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), severe sepsis (a life-threatening complication of an infection), and neuralgia (pain resulting from damaged or irritated nerves). Record review of Resident #42's quarterly MDS dated [DATE] reflected a BIMS score of 7 indicating that resident cognition was severely impaired. Record review of section H-Bladder/Bowel reflected the resident had an indwelling Foley catheter. Record review of Resident #42's Physician's Order Summary Report for the month of June 2025 reflected the following order: -Dated 01/02/25 16Fr/10cc urethral indwelling urinary catheter (a tube that carries urine from the bladder to the outside of the body and held in place by a balloon inflated inside of the bladder). Dx stage 4 (a severe and deep wound that extends through multiple layers of skin and tissue, potentially exposing muscle, tendon, or the bone) sacral (triangular bone at the base of the spine)with closed drainage system (when the catheter is retained in the bladder by an inflated balloon and the drainage of urine is totally dependent on gravity). Record review of Resident #42's Comprehensive Care Plan updated 05/27/25 reflected the resident was care planned for bladder incontinence that included an intervention to clean peri-area with each incontinent episode, hand washing before and after delivery of care. Observation on 06/11/25 at 1:46PM of Foley catheter care for Resident #42 by CNA D and CNA E revealed the resident's Foley catheter bag was inside a privacy bag and the resident had a stat-loc on her left thigh securing the Foley tubing. During the observation, CNA D took the residents Foley bag that was hanging on the left side of bed below the resident's bladder, and placed the Foley bag on the bed and began to provide Foley catheter care. When done providing care, CNA D placed the Foley bag back on the left side of bed below the resident's bladder. Interview on 06/11/25 at 2:09PM CNA D said she had received an in-service on Foley catheter. CNA D said she should not have placed the resident's Foley bag on the bed during Foley catheter care due to the risk of urine flowing back in the resident's bladder, placing the resident at risk for urinary tract infections. Interview on 06/11/25 at 2:20PM the facility's Infection Control Preventionist said when the staff provided Foley catheter care, the Foley bag should not be placed on the resident's bed but hung below the resident's bladder on the side of the bed to prevent the back flow of urine in the resident's bladder that could cause a urinary tract infection. Record review of the facility policy on Catheter care copyright date August 2024 reflected in part: .Ensure drainage bag is located below the level of the bladder to discourage back flow of urine . Record review of the facility policy on Quality of Care with a copyright 2022 reflected the in part: .Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choices .

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (CR #1) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure CR#1's behavior was coded on the quarterly MDS dated [DATE]. This failure could place residents with behavior at risk of not receiving care and intervention that could meet their behavioral needs. Findings included: Record review of CR #1's face sheet dated 05/16/2025 reflected CR#1 was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on [DATE]. CR#1's diagnoses included muscle wasting and atrophy (decrease or wasting of tissue, muscle or organs), lack of coordination (pattern walking or moving on foot), non- Alzheimer's disease (a type of dementia/neurodegenerative disease that affects the brain causing memory loss, confusion, and changes in behavior), hypertension (high blood pressure), diabetes (high blood sugar) hyperlipidemia (high levels of fat in the blood), seizure (uncontrolled jerking, loss of consciousness and blank stares), unspecified dementia (memory loss), and psychotic disorder (severe mental disorder that causes abnormal thinking and perception, lose touch with reality). Record review of CR#1's nurse's notes revealed the following. 4/2/2025 at 10:16am Resident observed in the hallway yelling and screaming help, when resident was asked what he needed resident began yelling out curse words towards the staff. Resident upset because he wanted to put the dirty clothes back on after his shower, staff attempted to redirect resident. This resident continued to yell out curse words calling the staff out calling them derogatory names. Resident continued to wheel himself up and down the hall yelling curse words to the top of his lungs. 4/2/2025 at 9:45pm Assisted the patient to bed and met all needs. The patient continued to shout loudly. Attempted redirection, but the patient was difficult to reorient and continued shouting. 4/3/2025 at 09:42am. Patient up in w/c, able to make needs known, pt is verbally abusive towards staff during care, constantly cussing at staff for no reason. Pt at nursing station telling staff member he wished death to her kids and wished staff a car wreck. Pt not easily redirected, attempt to redirect, the more he cusses staffs. wheeled self to dining area at this time with no other concerns. 4/3/2025 at 09:26pm. Assisted the patient to bed and met all needs. The patient continued to shout loudly, repeatedly calling out one resident's name, causing disturbance to others. Attempted redirection, but the patient was difficult to reorient and continued shouting. 4/4/2025 at 06:35am. Resident was sitting up in bed upon shift rounding, attempting to get out of bed. Writer attempted to redirect him he got so agitated, and was using F-- words, and stating he wants his chair back. Writer was able to redirect him. Resident was assisted, with his pant, reassured him that I 'will be checking on him. Resident stable. Bed low, and locked safety precaution in place. 4/4/2025 at 09:51am Pt is up in w/c, able to make needs known. Non complaint with use of safe coffee cup. Pt prefers to use plastic drinking cups. cussing staff and insisting to use plastic cup for safety even after pt education on burns safety. no other concerns. 4/7/2025 at 9:54 pm The patient was in the wheelchair and repeatedly shouted profanities, including the use of FXXX, at the staff. Attempted redirection was made, but the patient continued to verbally abuse all staff members. As a result, staff were unable to assist the patient with getting to bed. 4/9/2025 at 5:56 am [CR #1] had a behavior this morning during care. He was cursing the aide during care using F- words. Record review of CR#1's quarterly MDS dated [DATE] revealed the following: Section C 500: CR #1 was coded as having a BIMS score of 14 indicating he was cognitively intact. Section E Potential Indicators of Psychosis: E100: Hallucination and delusional: he was coded, as having no hallucinations or delusion. E200: Behavioral Symptoms: Physical behavior, verbal behavior, and other behavioral symptoms such as (screaming, yelling and verbal/vocal) was coded as it did not happen. Record review of CR #1's comprehensive care plan dated 5/14/2025 reflected: Focus:CR#1 is resistive to care, refuses care at times: Goal: CR#1 will, cooperate with care through the next review Intervention: Allow CR#1 to make decision. Educate resident/family caregiver of the possible outcome(s) of not complying with treatment or care. Praise the resident when behavior is appropriate. In an interview on 5/16/2025 at 1:45pm with SW C she said she worked with CR#1 and the staff reported he had behavior issues. She said she did not actually witness his behavior, but it was reported to her. She said she heard that he cursed the staff and his family member out. In an interview on 5/16/2025 at 2:00pm with RN B she said CR#1 was alert and oriented and could make his needs known. She said CR#1 had behavior of yelling and shouting and cursing at staff. In an interview on 5/16/2025 at 2:05pm Nurse Manager LVN A said that CR#1 had behavior of yelling and cursing at staff and his family member. She said CR#1 was alert and oriented and could make his needs known. She said there was an incident with CR#1 and his family member and CR#1 cursed the family member. In an interview on 5/16/2025 at 3:15 pm with RN P she said she worked with CR#1 and he was alert but sometimes he was delusional. She said sometimes the resident would be yelling and shouting and he would be telling them there were rats, snakes and racoons in his room. She said he screamed and cursed at the staff. In an interview on 5/16/2025 at 4:30pm with CNA B she said she worked with CR#1, and he cursed at the staff and his family member. She said sometimes he would be saying there were rats, snakes, and racoons in his room. In an interview with SW C on 5/16/2025 at 5.01 pm she said she was aware of CR #1 having behaviors. She said, however when she assessed CR#1 for the quarterly MDS CR#1 did not display any inappropriate behaviors and that was why she did not code CR#1's behavior section on the MDS as CR#1 having any behavior. Further interview with SW C revealed she did not check the nurse's notes or talk to the nurses and aides. In an interview on 5/16/2025 at 5:07pm with the DON she said her expectation of the nurses was to do proper assessment that included talking with the CNAs, and looking at the nurse's progress notes so they can capture all the changes of the resident. She said she will be in- servicing the staff (nurse and social worker) on reviewing nurses notes, CNA's documentations, and interviewing aides when they are completing the MDS. In an interview with MDS E on 5/16/2025 at 5:10pm she said she was made aware of the coding for behavior on the MDS and she was going to correct the MDS. She said that the different disciplines should look at the nurse's notes and the CNA's documentation before completing their section of the MDS. Record review of the MDS policy and procedures dated 2024 read in part . Policy: Residents are assessed, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: 1.According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 4. Care Plan Team Responsibility for Assessment Completion: Coding of Assessment: I All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 18% based on 6 errors out of 32 opportunities, which involved 3 of 9 residents (Resident #57, Resident #55 and Resident #13) reviewed for medication errors. MA A did not administered Metoprolol (a prescription medicine used to lower blood pressure and heart rate) and Metformin ( medication used to decrease the amount of glucose - a type of sugar released into the blood stream) to Resident #57 as ordered by the physician. MA B administered Levetiracetam ( a drug used to treated seizures( involuntary muscle movements -caused by epilepsy ( a group of brain disorders) to Resident #55 instead of Levetiracetam 5ml as ordered by the Physician. MA C administered Minocycline ( a drug works by killing bacteria or preventing their growth), with one daily Multi-Vitamin and Iron tablet to Resident #13 when the label indicatted: While taking Minocycline avoid taking vitamins/mineral, iron because it bind with Minocycline, preventing your body from fully absorbing the drug. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings included: Record review of Resident #57's face sheet revealed a female admitted on [DATE] readmitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus ( blood sugar too high) without complications, cerebral infarction,( a stroke, sometimes call a brain attack, happens in one of two ways. A blocked artery or a ruptured artery) unspecified, cellulitis ( bacterial skin Infection)of right lower paranoid schizophrenia( Unreasonably suspicious of other) morbid (severe) obesity due to excess calories, ( over weight) unspecified intellectual disabilities( when there are limits to a person's ability to learn at an expected level and function in daily life) ,chronic ischemic heart disease( deficient of blood supply to the heart), unspecified, hyperlipidemia( high fat in the blood), unspecified, type limb. Record review of Resident #57's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. She needed extensive assistance of 1-2 staff for ADLs. Record review of Resident #57's Physician Order Report for 08/202023 revealed an order for Metformin (Glucophage) 1000 mg 1 tablet two times daily and Metoprolol tartrate 50 mg ( 0.5 mg) 1 tablet twice daily order was dated 10/04/23. 1.In an observation and interview on 5/5/24 at 4:45 PM MA A prepared and administered Metformin (Glucophage) 1000 mg 1 tablet from the blister packet had Take with meal and Metoprolol tartrate 50 mg ( 0.5 mg= 25 mg) 1 tablet blister packet had Take with or immediately following meals) along with other additional medications to Resident #57. Resident #57 was not eating meal and was not given any snacks before administering medications. In interview on 5/5/24 at 4:49 PM MA A was asked if Resident #57 has had dinner, MA A said very soon about 5:00PM,. MA A was shown the blister packets of (Metoprolol tartrate and Metformin (Glucophage) that indicated to be given with meals, MA A said I gave Resident #57 snacks. In an interview with Resident #57 on 5/5/24 at 4: 56 PM when the surveyor asked her if she had snacks earlier, Resident #57 said she had not eaten anything, dinner would be served at 5:30PM sometimes 6:00PM Record review of facility posted menu on 5/6/24 revealed dinner was served at 5:00 PM daily. 2. Record review of Resident #55's face sheet revealed a [AGE] years-male admitted on [DATE] to the facility. His diagnoses included(lack of oxygen) acute respiratory failure with hypoxia , acute upper respiratory infection, unspecified, age-related physical debility, alcohol abuse, uncomplicated, altered mental status, unspecified, anxiety disorder, unspecified, cutaneous abscess of right lower limb, encephalopathy (any disease, disorder, or damage that affects the brain's structure or function), unspecified, cutaneous abscess of right lower limb. Record review of Resident #55's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. He needed extensive assistance of 1-2 staff for ADLs. Record review of Resident #55's Physician Order Report for 08/20/2023 revealed an order of Levetiracetam 100mg/ml /5mls three times daily. In an observation on 5/6/24 at 8:56 AM, MA B, poured Levetiracetam 100mg/ml 6.5 mls in a medication cup. MA B kept saying it was 5cc Resident #55 is supposed to take. The surveyor pointed to the calibrated line on the medication cup for 5cc;, MA then poured out excess med to another cup and wasted it. In an interview with MA B on 5/8/24 at 11:49 AM regarding pouring the medication accurately she said she did not place the medication cup on a flat surface. She did not look at the line on the cup correctly. She said she knew to verify the line on the cup to ensure accuracy. She said the order on the MAR and the pharmacy label on the bottle told her how much liquid to give. MA B said she had training on medication monthly by the ADON and she monitors her pass medication. 3. Record review of Resident #13's face sheet revealed a [AGE] years-male admitted on [DATE] and readmitted on [DATE] to the facility. His diagnoses included lymphedema, not elsewhere classified, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, epilepsy, unspecified, not intractable, without status epilepticus, chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity. Record review of Resident #13's annual MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicatedcognition was intact; no impairment. He needed extensive assistance of 1-2 staff for ADLs. Record review of Resident #13's Physician Order Report for 04 /22/2023 revealed an order of Minocycline 100mg 1 capsule PO every 12 hours for wound infection until 05/10/2024, One daily multi-vitamin with mineral 1 tablet per oral PO daily and Iron tablet 325 mg 1 tablet PO daily. In an observation on 5/6/24 at 9:20 AM, of medication administration, MA C, picked up Minocycline 100mg capsule blister packet (had Take with full glass water. No antacid/vits/iron/dairy within2 hours. May cause increased photosensitivity.) blister packet from the medication cart, punched 1 capsule in a medication cup with One daily multi-vitamin with mineral 1 tablet and Iron tablet 325 mg 1 tablet and other medications and to Resident #13 by mouth. Resident #13 complained of taking too many medications at the same time. MA C said, that what I go through every time. In an interview with MA C on 5/7/24 at 2:30 PM, MA C said she has been working with facility for over 1 year and she knows the five right of meds administration, she had in-services with the unit manager and was monitored during med pass and was not aware of not taking antacid/vits/iron/dairy within 2 hours after taking minocycline and she did not read it the nurse surveyor showed it to her . In an interview on 5/8/24 at 12:38 PM the DON said the staff should read the MAR and blister packet before medication administration to Residents. She said she expected nursing staff to ensure the medication order and inventory matched because the correct dosage needed to be provided to the resident and not pharmacy recommendation could cause stomach cramps and could cause drug interaction. In an interview on 5/8/23 at 12:30 PM the facility's policy on Medication Administration was requested from the DON but was not received prior to exit. In an interview on 5/8/23 at 12:46 PM the Administrator said he expected nursing staff to follow the physician orders. She said charge nurses, or the nurse managers oversaw medication administration

Based on observation, record review and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to maintain proper temperature for leftover food from the breakfast tray line serving cart. 2. The facility failed to ensure frozen food was safely thawed. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation and record temperature of the facility's food saved from the breakfast tray line serving cart on 05/05/24 at 1:15 PM revealed it was below the recommended temperature. During the observation dietary cook A took food temperature. Temperature of food taken were as follow: 1. A plastic bag of Scrambled eggs stored in the refrigerator since 8:00 AM with a temperature of 72 degrees Fahrenheit. 2. A plastic bag of Hard-Boiled Eggs stored in the refrigerator since 8:00 AM with a temperature of 49.2 degrees Fahrenheit. Observation of the facility Kitchen on 05/06/24 at 8:05 AM revealed a pan of frozen Pork Chops and a pan of frozen cubed pork immersed in stagnant water in the sink. The temperature of the pork chops was 69.1- and 64.2-degrees Fahrenheit. The temperature of the pork cubes was 48 degrees Fahrenheit. The temperature of the water was 75.6 degrees Fahrenheit. Interview with the Dietary Food Service Manager on 05/06/24 at 8:25 AM she stated that she is responsible in making sure that proper food temperature is always maintained. The food temperature was in the danger zone' indicating bacteria and other foodborne pathogen can grow quickly in the temperature - The Danger Zone' was 41 to 135 degrees Fahrenheit. Proper holding temperature of food is critical for resident safety and wellness. During observation and interview with the Dietary Food Service Manager on 05/06/24 at 8:30 AM she stated that frozen food must be thawed the proper way to make sure that the proper temperature is always maintained to prevent/minimize food temperature at the danger zone. Record review of the facility's policies and procedures for Cooling and heating Foods dated 10/01/18 read in part 1.Cooling Foods: Rapidly cool all potentially hazardous food requiring refrigeration after preparation to an internal temperature of 41 degrees Fahrenheit or below with in six hours or less. All foods are stored, prepared, and served at temperatures that prevent bacterial growth. Hot foods are maintained at 140 degrees Fahrenheit or higher and cold foods are maintained at 40 degrees Fahrenheit or below. At point of service. Record review of the facility's policies and procedures for Food Preparation & Handling dated 05/10/18 read in part .Foods may also be thawed using the following procedures: 1. Completely submerged under cold potable running water (less than 70 degrees Fahrenheit) with sufficient water velocity to agitate and float off loosened food particles into overflow. b. For a period that does not allow thawed portions of a raw animal food requiring cooking to be above 41 degrees Fahrenheit for more than 4 hours including the time the food is exposed to the running water and the time needed for preparation for cooking.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 Residents (Residents #46, and #16) and 2 of 2 staffs (CNA A and LVN A) reviewed for infection control. 1. CNA A failed to perform hand hygiene between glove changes when providing incontinent care for Resident #46. 2. LVN A failed to maintain a sterile technique while providing tracheostomy care to Resident #16. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #46 was an [AGE] year-old who was originally admitted to the facility on [DATE]. Her medical diagnoses included diverticulitis of the intestine (inflammation of the pockets, called diverticula, located in your colon), Type 2 diabetes mellitus, cognitive communication deficit, recurrent depressive disorders, unspecified dementia, acute kidney failure, chronic pain syndrome, neuralgia and neuritis (pain and inflammation of the nerves), neuromuscular dysfunction of the bladder, primary hypertension, and dysphagia( difficulty swallowing) Record review of Resident #46's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a measure of cognitive function, with 15 being the highest cognitive function), Resident # 46's BIMs score of 7 means she was severely cognitive impaired. Record review of Resident #46's care plan revised 10/04/2022 revealed resident was care-planned for the following: 1. Resident #46 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity intolerance, impaired balance -Interventions for Toilet Use: The resident is totally dependent on (x 1) staff for toilet use 2. Resident #46 has bowel incontinence r/t immobility, poor gait & balance -Interventions: Check resident frequently and assist with toileting as needed, Provide peri care after each incontinent episode Observation of Resident # 46's Foley catheter care on 05/07/24 at 10:59 AM with CNA A and C.NA D assisting, revealed CNA A washed hands and don( put on) clean gloves during incontinent/Foley catheter care. Using the wet wipes, CNA A cleaned the Foley catheter tubing and she changed gloves x 4 times and did not wash her hands or used hand sanitizer. Interview with CNA A (Lead C.NA) on 05/07/24 at 12:20 PM regarding her technique of cleaning the indwelling catheter, she said she did a good job. C.NA A said she forget to wash hands or use hand sanitizer, she knew not washing hands or using hand sanitizer after gloving dirty could result to reinfecting resident, C.NA A said she was sorry. C.NA A said she had training for incontinent care and hand washing monthly and she monitors other C.NA for incontinent care. During an interview with the DON on 05/07/2024 at 2:25 PM., the DON stated that during the incontinent care, Staff should wash hands or use hand sanitizer with each gloves change. The DON said the facility staffs had monthly in-services with skilled check. The DON said she was going to start incontinence care and hand washing skill checks. Record review of Resident #16's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE]. His medical diagnoses His medical diagnoses included cerebral palsy,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck) gastrostomy status,( opening and inserting tube used to feed) neuromuscular dysfunction of bladder,( lacks bladder control due to brain, spinal cord or nerve problem),Congenital Hydrocephalus ,( a rare brain malformation that occurs when too much cerebrospinal fluid builds up in the brain at birth )recurrent depressive disorders( feeling of sadness or loss of interest), and Epilepsy( abnormal electrical brain activity also known as a seizure). Record review of Resident #16's MDS dated [DATE] revealed the BIMS assessment was not done because the resident is rarely or never understood. Further review revealed the staff assessed Resident #16 on mental status and found he has short-term, long-term and memory/recall ability problems. Further review revealed that Resident #16 is dependent on staff for care, which means the resident does none of the effort to complete the activity., Record review of Resident #16's Physician Orders reviewed 5/7/2024 revealed the following: 1. Tracheostomy Care every shift and PRN. Clean or change inner cannula when needed Shiley 4.5 2.Tracheostomy site dressing change every DAY and PRN if soiled. 3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes 4. Trach suctioning every (Q) shift and PRN 5. Oxygen at 4-6L/min via Tracheostomy Record review of Resident #16's Care plan revised 01/24/2024 revealed resident was care-planned for: 1. Resident #16 has a Tracheostomy r/t respiratory failure -Interventions: Suction as necessary, use Universal Precautions as appropriate Interview and observation of Resident #16 on 5/6/2024 at 10:00am revealed the resident was observed laying in bed with the head at a 30-degree angle. The resident said How are you doing when surveyor greeted him. He was able to answer yes or no to some questions but stopped responding afterward. Resident was seen smiling and moving his head up and down. Resident #16's oxygen concentrator read 3.5L/min. Resident did not appear to be in distress. Observation of Resident #16 on 5/6/2024 at 2:57pm, resident was observed lying in bed with the head at a 30-degree angle. Resident #16's oxygen concentrator read 3.5L/min. The resident had foam coming out of his mouth but did not appear to be in distress. Observation on 05/08/2024 at 10:54 AM revealed Resident #16 was in bed with audible moist breath sounds. LVN A stated resident was not usually this moist and they changed the resident's inner cannula every day. LVN A set up a clean field on the bedside table, checked oxygen saturation checked and it was 96%. LVN A donned a clean gloves, picked up Trach Care Kit without changing gloves. LVN A opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, brush and sterile gloves placed on the bedside table. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doffed (take off)gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #16's bed side, poured it in the tray. LVN A picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #16's bed side. LVN A then used the sterile gloved right hand removed oxygen mask on Resident #16's trach, then inserted suction catheter into the tracheostomy tube x 2 times, then rinsed tubing with normal saline. LVN A, using the same gloves, removed tracheostomy inner canula, then picked a syringe 10 ml normal saline (NS) covered with plastic wrap, LVN A unwrapped NS the rinsed tracheostomy inner cannula x 2 times, then re-inserted it to trach site. In an interview on 05/08/2024 at 11:30 AM, LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used sterile technique throughout, and she had last in-service on tracheostomy care in September 2023 and not suctioning tracheostomy with cleaned technique could result infection or cardiac arrest. She stated she works with Resident #16 most of the time. In an interview on 05/08/2024 at 12:45 PM, with the DON, when Surveyor described the observed during trach care, suctioning for Resident #16, the DON stated she brought in an RT that had not been in the facility for a while, because the facility changed company and she would be looking for another company to perform in-services on tracheostomy. The DON said the last in-services on tracheostomy was in September 2023 . The DON said LVN A always worked with Resident #16. 48923

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 5 residents (Resident #46) reviewed for incontinent care and indwelling catheter. 1.The facility failed to ensure CNA A cleaned Resident #46's indwelling Foley catheter properly and followed proper hand hygiene during incontinent care. These failures could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #46's face sheet revealed an [AGE] year-old who was originally admitted to the facility on [DATE]. Her medical diagnoses included diverticulitis of the intestine (inflammation of the pockets, called diverticula, located in your colon), Type 2 diabetes mellitus, cognitive communication deficit, recurrent depressive disorders (lack interest with daily activities), unspecified dementia, acute kidney failure, chronic pain syndrome, neuralgia and neuritis (pain and inflammation of the nerves), neuromuscular dysfunction of the bladder, primary hypertension( high blood pressure), and dysphagia (difficulty swallowing). Record review of Resident #46's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status, a measure of cognitive function, with 15 being the highest cognitive function). BIMS score of 7 meaning Resident # 46 was severely impaired. Record review of Resident #46's care plan revised 10/04/2022 revealed resident was care-planned for the following: 1. Resident #46 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity intolerance, impaired balance -Interventions for Toilet Use: The resident is totally dependent on (x 1) staff for toilet use 2. Resident #46 has bowel incontinence r/t immobility, poor gait & balance -Interventions: Check resident frequently and assist with toileting as needed, Provide peri care after each incontinent episode Record review of Resident #46's MAR (Medication Administration Record) for December 2023 to January 2024 revealed resident was given Doxycycline Hyclate Oral Tablet 100 MG, 1 tablet via G-tube every 12 hours for infection for 7 Days until finished. The medication was administered from 12/28/2023 to 1/4/2024. Record review of Resident #46's hospital records dated 02/29/2024 revealed they were hospitalized from 02/21/2024 to 02/29/2024 due to UTI. At the hospital, she completed intra venous (IV )meropenem + Sodium Chloride 0.9% IV 100 mL 500 mg IVPB ABXQ8H. 33.33 ml/hr from 02/22/2024 to 02/29/2024. Observation of Resident # 46's Foley catheter care on 05/07/24 at 10:59 AM with CNA A and CNA D assisting, revealed CNA A washed hands and donned( put on) clean gloves and she did not open the labia to clean. Using the wet wipes, CNA A cleaned the Foley catheter tubing not in a circular motion, C.NA A used the wet wipes, cleaned catheter tubing straight and she changed gloves x 4 times and did not wash her hands or used hand sanitizer. Interview with CNA A (Lead C.NA) on 05/07/24 at 12:20 PM regarding her technique of cleaning the indwelling catheter, she said she did a good job. C.NA A said she forget to open and clean Resident #46's labia and forgot to clean the indwelling catheter from the insertion site in a circular motion. C.NA A said not opening the labia to clean and not cleaning the Foley catheter could result in infection. C.NA A said she had training for incontinent care and hand washing monthly and she monitors other C.NA for incontinent care. C.NA A said she forget to wash her hands or use hand sanitizer, she knew not washing hands or using hand sanitizer after gloving dirty could result to reinfecting resident, C.NA A said she was sorry. During an interview with the DON on 05/07/2024 at 2:25 PM., the DON stated that during the incontinent care of a female resident, Staff should wipe the peri area, then open the labia and clean downward and clean the indwelling catheter in a circular motion. The DON said she was going to start incontinence care skills checks . DON said the ADON and the lead C.NA A does incontinent monitoring. The DON stated that if staff performed peri care deviating from policy, residents risked possible urinary infections. The DON did not have policy for incontinent and Foley catheter care. In an interview on 05/08/2024 at 2:35 PM, the Administrator stated her expectation was that incontinent care and hand washing were always done to prevent infection.

Based on observation, interview and record review, the facility failed to ensure that a who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for tracheotomy care (Resident #16) A) The facility failed to ensure LVN A used sterile technique during tracheotomy suctioning for Resident #16. B) The facility failed to ensure Resident #16's oxygen was set per physician orders. These failures placed residents with tracheostomies requiring suctioning at risk for respiratory infections, hospitalization s, and a decline in their quality of life. Findings included. Record review of Resident #16's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE]. His medical diagnoses included cerebral palsy,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck) gastrostomy status,( opening and inserting tube used to feed) neuromuscular dysfunction of bladder,( lacks bladder control due to brain, spinal cord or nerve problem),Congenital Hydrocephalus ,( a rare brain malformation that occurs when too much cerebrospinal fluid builds up in the brain at birth )recurrent depressive disorders( feeling of sadness or loss of interest), and Epilepsy( abnormal electrical brain activity also known as a seizure). Record review of Resident #16's MDS dated [DATE] revealed the BIMS assessment was not done because the resident is rarely or never understood. Further review revealed the staff assessed Resident #16 on mental status and found he has short-term, long-term and memory/recall ability problems. Further review revealed that Resident #16 is dependent on staff for care, which means the resident does none of the effort to complete the activity, Record review of Resident #16's Physician Orders reviewed 08/24/2016 revealed the following: 1. Tracheostomy Care every shift and PRN. Clean or change inner cannula when needed Shiley 4.5 2.Tracheostomy site dressing change every DAY and PRN if soiled. 3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes 4. Trach suctioning Q shift and PRN 5. Oxygen at 4-6L/min via Tracheostomy Record review of Resident #16's Care plan revised 01/24/2024 revealed resident was care-planned for: 1. Resident #16 has a Tracheostomy r/t respiratory failure -Interventions: Suction as necessary, use Universal Precautions as appropriate Interview and observation of Resident #16 on 5/6/2024 at 10:00am revealed the resident was observed laying in bed with the head at a 30-degree angle. The resident said How are you doing when surveyor greeted him. He was able to answer yes or no to some questions but stopped responding afterward. Resident was seen smiling and moving his head up and down. Resident #16's oxygen concentrator read 3.5L/min. Resident did not appear to be in distress. Observation of Resident #16 on 5/6/2024 at 2:57pm, resident was observed lying in bed with the head at a 30-degree angle. Resident #16's oxygen concentrator read 3.5L/min. The resident had foam coming out of his mouth but did not appear to be in distress. Observation on 05/08/2024 at 10:54 AM revealed Resident #16 was in bed with audible moist breath sounds. LVN A stated resident was not usually this moist and they changed the resident's inner cannula every day. LVN A set up a clean field on the bedside table, checked oxygen saturation checked and it was 96%. LVN A donned clean gloves, picked up Trach Care Kit without changing gloves. LVN A opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, brush and sterile gloves placed on the bedside table. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doff gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #16's bed side, poured it in the tray. LVN A picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #16's bed side. LVN A then used the sterile gloved right hand removed oxygen mask on Resident #16's trach, then inserted suction catheter into the tracheostomy tube x 2 times, then rinsed tubing with normal saline. LVN A, using the same gloves, removed tracheostomy inner canula, then picked a syringe 10 ml normal saline (NS) covered with plastic wrap, LVN A unwrapped NS the rinsed tracheostomy inner cannula x 2 times, then re-inserted it to trach site. In an interview on 05/08/2024 at 11:30 AM, LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used sterile technique throughout, and she had last in-service on tracheostomy care in September 2023 and not suctioning tracheostomy with cleaned technique could result infection or cardiac arrest. She stated she works with Resident #16 most of the time. In an interview on 05/08/2024 at 12:45 PM, when Surveyor described the observed trach care, suctioning for Resident #16, the DON stated she brought in an RT that had not been in the facility for a while, because the facility changed company and she would be looking for another company to perform in-services on tracheostomy. The DON said the last in-services on tracheostomy was September 2023. The DON said LVN A always worked with Resident #16. Review of the website www.tracheostomyeducation.com dated 09/21/2022 reflected The upper airway plays an important role in immune defenses of the lung by filtering, humidifying, and warming inspired gases before they reach the trachea, preventing dehydration of airway secretions. The nose and oropharynx perform most of this conditioning. For the lower airways and alveoli to properly function, it is important that inspired gases are fully saturated with water vapor .With a cuffed tracheostomy tube, the airflow is redirected out through the tracheostomy tube and air does not flow through the nose or nasopharynx. The natural warming, humidification and filtration system are bypassed resulting in cool and dry air entering directly through the tracheostomy tube which can easily result in: damage to the ciliated tracheal mucosa, thickening and retention of airway secretions, impaired mucociliary transport, inflammatory changes and necrosis of epithelium, impaired [NAME] activity, destruction of cellular surface of airway causing inflammation, ulceration and bleeding , reduced lung function (atelectasis/pneumonia), increased risk of bacterial infiltration. 48923

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 9 residents (Resident #13) reviewed for medication administration. MA C administered Minocycline ( a drug works by killing bacteria or preventing their growth), along with one daily Multi-Vitamin and Iron tablet to Resident #13, which the medication label warned against it. This failure could place residents at risk of not receiving the therapeutic benefits of their medications. Findings included: Record review of Resident #13's face sheet revealed a [AGE] years-male admitted on [DATE] and readmitted on [DATE] to the facility. His diagnoses included lymphedema,( swelling due to build-up of lymph fluid in the body) not elsewhere classified, methicillin resistant staphylococcus aureus infection( germ(bacteria) that does not got better with the type of antibiotics that uaslly cure staph infections) as the cause of diseases classified elsewhere, chronic embolism and thrombosis ( blood clot ) of unspecified deep veins of unspecified lower extremity, epilepsy(abnormal electrical brain activity also known as a seizure), chronic venous hypertension (idiopathic) (high blood) with ulcer and inflammation of bilateral lower extremity. Record review of Resident #13's annual MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated cognition was intact; no impairment. He needed extensive assistance of 1-2 staff for ADLs. Record review of Resident #13's Physician Order Report for 04 /22/2023 revealed an order of Minocycline 100mg 1 capsule per oral/by mouth( PO) every 12 hours for wound infection until 05/10/2024, One daily multi-vitamin with mineral 1 tablet PO daily. and Iron tablet 325 mg 1 tablet PO daily. In an observation on 5/6/24 at 9:20 AM, of medication administration, MA C, picked up Minocycline 100mg capsule blister packet ( had Take with full glass water. No antacid/vits/iron/dairy within2 hours . May cause increased photosensitivity( is a condition in which skin becomes extremely sensitive to the sun causing skin to the sun causing skin to burn more easily). blister packet from the medication cart, punched 1 capsule in a medication cup with One daily multi-vitamin with mineral 1 tablet and Iron tablet 325 mg 1 tablet and other medications and to Resident #13 by mouth. Resident #13 complained of taking too many medications at the same time. MA C said that what I go through every time. In an interview with MA C on 5/7/24 at 2:30 PM, MA C said she has been working with facility for over 1 year and she knows the five right of meds administration, she had in-services with the unit manager and was monitored during med pass and was not aware of not taking antacid/vits/iron/dairy within 2 hours after taking minocycline and she did not read it the nurse surveyor showed it to her . In an interview on 5/8/24 at 12:38 PM the DON said the staff should read the MAR and blister packet before medication administration to Residents. She said she expected nursing staff to ensure the medication order and inventory matched because the correct dosage needed to be provided to the resident and not pharmacy recommendation could cause stomach cramps and could cause drug interaction. In an interview on 5/8/23 at 12:30 PM the facility's policy on Medication Administration was requested from the DON but was not received prior to exit. In an interview on 5/8/23 at 12:46 PM the Administrator said he expected nursing staff to follow the physician orders. She said charge nurses, or the nurse managers oversaw medication administration.

Based on interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (Resident #2) of 8 residents reviewed for abuse. The facility failed to ensure each resident was free from abuse when Resident #2 was physically abused by CNA E on 10/16/2023 during her shift. This failure placed residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect. The noncompliance was identified as past noncompliance and began on 10/16/2023 and ended on 10/18/2023. The facility corrected the noncompliance before the investigation began. Findings Include: Record review of Resident #2's face sheet dated 04/11/2024 revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including cellulitis (deep infection caused by bacteria), in of right lower limb, cerebral infarction (disrupted blood flow to the brain), type 2 diabetes mellitus (when cells in your muscles, fat, and liver do not respond well to insulin) without complications, atrial fibrillation (irregular heart rate), hyperlipidemia (deposit in blood vessel walls and restricted blood flow), hypertension (high blood pressure), paranoid schizophrenia (brain disorder causing delusion), pain in right ankle and joints of right foot, muscle weakness, lack of coordination, weakness, chronic ischemic heart disease (heart weakening caused by reduced blood flow to heart), morbid (severe) obesity due to excess calories (overweight), intellectual disabilities (limited ability to learn), adjustment disorder with mixed anxiety (restlessness) and depressed mood. Record review of Resident #2's annual MDS assessment dated [DATE] revealed a BIMS score of 09 (suggests moderately impaired). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was not accurate when asked about the current month, resident was able to recall prior questions after cueing, able to recall a color with cueing. Record review of Resident #2's undated Care Plan revealed, Focus: Resident was dependent on staff for meeting intellectual, physical, and social needs related to (r/t) cognitive deficits. Date Initiated: 11/28/2022. Goal: Resident will be escorted to activities 3-5 times weekly by next review date. Date Initiated: 11/28/2022 Revision on: 02/15/2024 Target Date: 05/24/2024. Intervention: Invite the resident to scheduled activities. Focus: Resident has an activity of daily living (ADL) self-care performance deficit r/t activity intolerance, impaired balance date initiated: 11/21/2022 revision on: 03/28/2023. Goal: Resident will improve current level of function in through the review date. Date Initiated: 03/28/2023 Revision on: 02/15/2024, Target Date: 05/24/2024. Intervention: Toilet use: The resident requires extensive assistance by 1 staff for toileting. Date Initiated: 11/21/2022 Revision on: 03/28/2023 Focus: Resident has a communication problem r/t cognitive deficit. Date initiated: 11/21/2022 Revision on: 03/28/2023. Goal: Resident will be able to make basic needs known on a daily basis through the review date. Date Initiated: 11/21/2022 Revision on: 02/15/2024 Target Date: 05/24/2024. Intervention: Anticipate and meet needs. Date Initiated: 11/21/2022. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 11/21/2022. Communication: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off television/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, and use alternative communication tools as needed. Date Initiated: 11/21/2022. During an interview on 04/10/2024 at 12:02 p.m., Resident #2 stated that staff do not always respect her and are rude, but she would not say anything else because every time she had someone was fired. She stated she knows she can report ANE to the Administrator, because she had before, and the Administrator had fired everyone who was not doing their job or not being respectful. During an interview on 04/11/2024 at 03:05 p.m., Resident #2 stated that she remembered something happened one evening in her bathroom with a staff, but she could not remember what or if a nurse made her feel unsafe or if she had been slapped or hit. She stated the next thing she had known that staff was fired. She stated she feels safe and was not worried about ANE. During an interview on 04/11/2024 at 03:17 p.m., LVN A stated that on 10/18/2023 at about 10:15 a.m., she was called to Resident #1's room and resident told her that CNA E had slapped her in the face for pulling the call bell. She stated resident told her that the CNA E told her I am not playing with you, you going to wake everyone up. She stated the resident told her she was upset and had been crying. She stated that the resident was physically assessed finding no injuries or pain, and the resident stated she had no injuries or pain. She stated she immediately reported the incident to the Administrator who completed the incident report, and an investigation was started. The Administrator ultimately terminated CNA E. During an interview on 04/11/2024 at 03:35 p.m., the DON stated that she was not on shift when it was reported CNA E slapped Resident #2. She stated it happened on the night shift and the resident reported it to certified medical technician (CMT) the next day. She stated it was found that CNA E hit Resident #2 in the face and scared her, making the resident feel unsafe. She stated that CNA E had no previous allegations of ANE against her and no previous disciplinary actions in her employee file. She stated the incident was reported to the resident's family. She stated that the resident had made complaints about likes and dislikes and wanting to discharge home but had not made any similar allegations of that kind in the past. She stated that CNA E was terminated based on the Administrator's investigation. During an interview on 04/11/2024 at 04:45 p.m., the Administrator stated that she was the Abuse Coordinator. She stated on 10/18/2023 in the morning from LVN A that Resident #2 had something that she wanted to tell her. She stated she interviewed Resident #2 who told her that CNA E had slapped her in the face while helping her in the bathroom. She stated Resident #2 told her she was crying and waving her hands and the staff tried to stop her from crying and pulling the call bell and slapped her. She stated that she interviewed CNA E and CNA E told her that on 10/23/2023 in the earlier morning, Resident #2 was in the bathroom crying, acting confused and constantly pulling the bathroom call bell. She stated that CNA E told her that the resident had been waving her hands and acting confused and she accidently hit Resident #2 in the face. She stated CNA E believed that there were active cameras recording her and apologized that the hit was an accident. She stated that CNA E was immediately suspended, and Resident #2's family and physician were contacted. She stated the incident investigation was started, the incident report was completed and called in to the state. She stated that Resident #2 had a history of making false accusations, but never against a staff for abuse. She stated she believed what the resident had told her, and she terminated CNA E. She stated she did not call the police and there were no marks or bruises on the resident's face. She stated that it was her expectation that staff kept their hands off residents. During an interview on 04/11/2024 at 04:59 p.m., CNA B stated the facility provided an in-service on ANE a couple of weeks ago (exact dates and times unknown). She stated if an ANE was reported to her or witnessed she would immediately report to the Administrator. During an interview on 04/11/2024 at 05:15 p.m., CNA C stated that she was provided an in-service on ANE and incontinent care last week 04/01/2024 and 04/04/24. She stated that if she witnessed or ANE was reported to her she would immediately report to the Administrator. During an interview on 04/12/2024 at 10:03 a.m., CNA E stated that she had worked at the facility about a year. She stated on 10/23/2023 in the middle of the morning she was at the nurse's station when the call bell went off in Resident #2's bathroom. She stated the bell was very loud and she rushed to the resident's room. She stated when she entered the room, the resident's bed was covered in blood and the resident was in the bathroom screaming, also covered in blood from the waist down. She stated that the resident had come on her monthly menstrual cycle. She stated she turned off the call bell and asked the resident what was wrong. She stated that the resident continued to scream and pulled the call bell again and again. She stated that she told the resident not to pull the call bell because it made a very loud sound that would wake everyone up in the facility. She stated then she wiped down the resident's bed and cleaned and changed the resident and helped her get back to bed. She stated that later in the morning before leaving shift, the resident allowed her to change her, and the resident never made mention of what happened or voiced any concerns. She stated, the resident was a lot of personality, and never had any problems voicing her concerns. She stated the next day she was approached by LVN A and surprised that she was being suspended for allegations of abuse. She stated that the resident was not swinging her hands and she did not try to stop the resident's hands nor purposefully or accidently hit her in the face, and she did not tell the Administrator that she had accidently hit the resident in the face. She stated that she would never abuse or hit a resident. She stated that the resident and her were friends. She stated that she was then terminated. She stated all the staff would at the facility would say she was a good employee. She stated that she received training all the time on ANE, and she knew not to abuse residents. During an interview on 04/23/2024 at 02:13 p.m., CMT stated she did not recall an incident where Resident #2 reported being slapped by CNA E. Record review of the facility's in-service training dated 10/20/2023 revealed an in-serviced on ANE was conducted by Director of Social Services (DSS) was signed by several of the facility's staff acknowledging the in-service. Record review of CNA E's typed and signed statement dated 10/18/2023 revealed, CNA E rushed to Resident #2's room. Resident sitting on the toilet seat, covered with blood. CNA E asked resident to turn off the light because it was going to wake up everyone and CNA E turned off the light. Resident started crying, CNA E asked why she was crying, what was the problem, did I touch you? CNA stated that she held the resident and told her she was there to help her. CNA E standing at the door, and resident sitting on toilet. CNA E cleaned resident up and resident's bed. Record review of the facility's Staff Disciplinary Action Record against CNA E dated 10/18/2023 revealed, Suspended. List below an account of the actions leading to counseling: including dates, times, and any other supposing information: Administrator received a report that employee hit resident in the face. Employee statement attached that there was no physical contact. This was reported to have occurred on 10/16/2023 at 10 p.m. to 6 a.m. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetables for follow-up. Suspended pending abuse investigation. Signed by Supervisor LVN A and witnessed by Administrator. Record review of the facility's Staff Disciplinary Action Record against CNA E dated 10/20/2023. Category III, Disciplinary Level: Termination. List below an account of the actions leading to counseling: including dates, times and any other supposing information: Investigated for claim of abuse. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetables for follow-up. Terminated via telephone. Signed by Supervisor LVN B and witnessed by the DON. Record review of Resident #2's Progress Notes dated 10/20/2023 15:45 Behavior Note Text created by LVN C: Resident made remark to CMT on duty stating, you're the one that hit me that night. CMT informed this nurse, facility Administrator and the DON made aware. When this nurse asked resident if CMT on duty hit her resident stated no, it wasn't her. When asked resident why she made that statement resident replied Hell, I don't know! why don't you go get me some more juice! Resident education conducted regarding safety and reporting abuse, resident displayed understanding. Record review of the facility's self-report dated 10/24/2023 revealed, an abuse incident occurred on 10/18/2023 at 3:00 a.m. and learned by facility on 10/18/2023 at 10:15 a.m. that Resident #2 was sitting on toilet covered in blood, CNA E came into the bathroom and turned off the light said you going to wake everyone. Resident started crying and CNA E told the resident she was there to help her, cleaned resident, and assisted residents to bed. Description of allegation: Resident stated that she was in restroom and pulled the call light button. According to resident, CNA E was mad and was yelling at her and hit her in the face on her left cheek. The resident started crying and CNA E told the resident, You know I am just playing with you. Resident reported to administration 2-days later. There was not bruising on resident's face. Provider response: CNA E was called into the office, a statement was taken, employee immediately suspended until investigation was complete. Resident payee, physician notified, and resident interviewed. Record review of the facility's conducted. Investigation Summary: After investigation, employee terminated. Unable to confirm abuse. Provider Action Taken Post-Investigation: Staff in-serviced on abuse and neglect. Signed and dated by Administration on 10/23/2024. Record review of the facility's Policy: Abuse, Neglect and Exploitation, undated revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. Record review of the facility's Policy Promoting-Maintaining-Resident-Dignity. Compliance Guidelines copy right date of 2022 revealed: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 5. When interacting with a resident, pay attention to the resident as an individual. 10. Speak respectfully to residents.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #3 and Resident #4) of 2 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #3, who required extensive assistance, was provided with timely incontinence care on 01/01/2024. 2. Resident #4 was provided with timely incontinence care on 01/01/2024. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #3's face sheet dated 04/11/2024 indicated he was an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including repeated falls, osteoarthritis (wear down of flexible tissue), protein-calorie malnutrition (underweight), benign prostatic hyperplasia with lower urinary tract symptoms (increased urgency to urinate), difficulty in walking, muscle weakness, dementia (impaired ability to remember, think, or make decisions) severity, without behavioral disturbance, psychotic disturbance (disconnection from reality), mood disturbance, and anxiety (restlessness), acute respiratory failure with hypoxia (not enough oxygen in the tissues in body), osteomyelitis (swelling of bone tissue causing an infection, age-related osteoporosis (loss of bone mass) without current pathological fracture (broken bone caused by a disease), and metabolic encephalopathy (chemical imbalance in the brain that causes confusion), Record review of Resident #3's Care Plan undated indicated Focus: Resident has bowel and bladder incontinence r/t Prostate enlargement Date Initiated: 07/25/2021 Revision on: 07/25/2021. Goals: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Date Initiated: 07/25/2021 Revision on: 03/06/2024 Target Date: 6/07/2024. Interventions: Clean peri-area with each incontinence episode. Date Initiated: 07/25/2021. Incontinent: Check frequently and as required for incontinence. Focus: Resident has potential for pressure ulcer development Date Initiated: 07/25/2021 Revision on: 07/25/2021. Goal: Resident will have intact skin, free of redness, blisters, or discoloration by/through review date. Date Initiated: 07/25/2021 Revision on: 03/06/2024 Target Date: 06/07/2024. Interventions: Complete a full body check weekly and document Date Initiated: 07/25/2021. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 07/25/2021. Provide incontinence care after each incontinence episode, or per established toileting plan. Date Initiated: 07/25/2021. Reposition in chair frequently for comfort and pressure reduction. Provide resident/family education as needed. Date Initiated: 07/25/2021. Revision on: 10/05/2022. Record review of Resident #3's annual MDS assessment dated [DATE] indicated he had a BIMS score of 03 which suggested severe cognitive impairment. Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was not accurate when asked about the current month, resident was not able to recall prior questions after cueing, was not able to recall a color with cueing. Under Section GG Functional Abilities and Goals: revealed that resident required partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. Under section H Bladder and Bowel: revealed Urinary Continence: Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Bowel Continence: Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement), and with no toileting program was being used. Record review of Resident #4's face sheet dated 04/11/2024 indicated she was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses wedge compression fracture (collapsed bone in the front of the spine) of lumbar vertebra (spine bones behind the chest), hypertension (high blood pressure), type 2 diabetes mellitus (cells in your muscles, fat, and liver don't respond well to insulin) without complications, dementia (impaired ability to remember, think, or make decisions) severity, without behavioral disturbance, psychotic disturbance (disconnection from reality), mood disturbance, and anxiety (restlessness), history of falling, muscle weakness, and difficulty in walking. Record review of Resident #4's Care Plan undated revealed Resident #4 had the potential for pressure ulcer development r/t of ulcers, immobility, and incontinence. Date Initiated: 01/10/2020 Revision on: 01/10/2020. Resident was to have intact skin, free of redness, blisters, or discoloration by/through review date. Date Initiated: 01/10/2020 Revision on: 09/12/2023 Target Date: 04/07/2024. Resident was to receive complete a full body check weekly and document Date Initiated: 01/10/2020. Staff to follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 01/10/2020. Provide incontinence care after each incontinence episode, or per established toileting plan Date Initiated: 01/10/2020. Reposition in chair/bed frequently for comfort and pressure reduction. Record review of Resident #4's annual MDS assessment dated [DATE] indicated he had a BIMS score of 03 which suggested severe cognitive impairment. Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was not accurate when asked about the current month, resident was not able to recall prior questions after cueing, was not able to recall a color with cueing. Under Section GG Functional Abilities and Goals: revealed that resident required partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. Under section H Bladder and Bowel: revealed Urinary Continence: Occasionally incontinent (less than 7 episodes of incontinence). Bowel Continence: Occasionally incontinent (one episode of bowel incontinence), and with no toileting program was being used. Observation on 04/10/2024 at 11:21 a.m., revealed Resident #4 was sitting in a wheelchair in the common area watching television, smiled, and waved. Observation on 04/10/2024 at 11:50 a.m., revealed Resident #3 was lying in bed low to ground, fall mat in place. The resident was receiving oxygen and tube-feeding and fluids at bedside, legs propped up on wedge, asleep, did not response and covered with blankets. During an interview on 04/11/2024 at 09:07 a.m., the Administrator stated on 01/01/2024 she received a call from CNA G when CNA G she came on shift at 10:00 p.m. and informed that Resident #3 and Resident #4 were left soiled. She stated she asked LVN A who was assigned to those residents, to determine which staff had left residents soiled. She stated that LVN A confirmed that CNA F had worked and was assigned to Resident #3 and Resident #4. During an interview on 04/11/2024 at 09:43 a.m., LVN A stated that she was the unit manager on duty on 01/01/2024 and assigned to Resident #3 and Resident #4. She stated on 01/01/2024, the Administrator called and stated that Resident #3 and Resident #4 were left horribly wet and soiled at 9:45 p.m. and that CNA G had to come on shift and clean them up immediately. She stated that CNA G stated it was not just wet it was feces and food on the residents. She stated that she spoke with CNA F who admitted that she missed the two residents but provided no good reason. She stated that CNA F had been terminated for poor work performance. She stated this was not the first time CNA F had failed to perform resident's ADL care. She had left a resident without a shower and left a resident without making sure they had eaten. During an interview on 04/11/2024 at 10:29 a.m., CNA F stated she began her employment in April of 2024 and was terminated in January 2024. She stated she was responsible for taking care of Resident #3 and Resident #4 on 01/01/2024. She stated that she had fallen behind and had not change Resident #3 before leaving shift and had not informed the oncoming shift or charge nurse that Resident #3 had not been changed before leaving shift. She stated that residents were to have been checked and changed every 2-hours and before leaving shift. She stated she had changed the residents during her shift but had not provided a time when the residents were changed. She stated she had issues with getting to residents on time, but she would get there as quickly as possible. She stated that the facility put a lot of responsibility on CNAs and nitpicked her unfairly when it came to completing tasks. She stated she never addressed her concerns with any of her superiors about not getting her tasks completed or being nitpicked at. She had not provided a response why she had not addressed her concerns with her superiors. She stated she received training on ANE, incontinent care, and resident rights during her onboarding process with the facility. She stated the importance of not leaving resident soiled for long periods was to avoid rashes and skin irritations. During an interview on 04/11/2024 at 10:58 a.m., CNA G stated she had [AGE] years of experience as a CNA and worked for the facility about 7-months before she resigned in February 2024. She stated she came on shift on 01/01/2024 at 09:34 p.m. and took over the care of residents that CNA F was responsible for on the previous shift of 2 p.m. to 10 p.m. She stated it was routine when she came on shift to put eyes on each of her residents to see if there were any immediate needs of the resident that needed to be addressed first. She stated that when she went to check on Resident #3 and Resident #4, they were both heavily soiled in urine and feces. She stated that their briefs, clothing, and beddings were completely soiled. She stated that was a clear indication that they had not been changed in several hours and that CNA F had not followed policy and procedure by checking and changing residents before leaving shift and before the next shift took over. She stated when she found the resident in that soiled condition, she took pictures of the residents, cleaned, and changed the residents and their bedding, and sent the pictures to the Administrator along with a text message describing the resident's condition upon her arrival coming on shift. She stated that she had pictures in an old phone that she would forward. She stated that she could not remember which resident was which, but the pictures showed the resident's beds soiled in urine and one of the resident's back covered in food crumbs. She stated that she resigned from the facility because of high staffing turn over, and it being custom for her to find residents heavily soiled when she came on shift. She stated that staff that worked the 10 p.m. to 6 a.m. shift did not receive a lot of training in-services and she could not recall ever being in-serviced on ANE or incontinence care. She stated when she resigned, she wrote the Administrator a 3-page letter voicing all her concerns along with the pictures she took of the soiled and uncleaned residents. She stated the importance of checking and changing resident's every 2-hours was to prevent skin breakdowns. During an interview on 04/11/2024 at 03:35 p.m. the DON stated that she was on leave when Resident #3 and Resident #4 were discovered soiled. She stated that CNA F was responsible for changing the residents during her shift. She stated that LVN C was responsible for overseeing CNA F. She stated CNA F had disciplinary actions taken against her for failure to address care areas on a few occasions and had been given a chance to make corrective actions. She stated that it was not uncommon for staff to run behind or feel overwhelmed during their shift, but it was their responsibility to notify their unit manager on shift for assistance. She stated that CNA F had never voiced concerns with feeling overwhelmed and had been given several opportunities to make corrective actions and this incident caused her employment to be terminated with the facility. She stated that the resident's family was notified of the incident. During an interview on 04/11/2024 at 04:45 p.m., the Administrator stated that she had received a text on 01/01/2024 from CNA G who worked the 10 p.m. to 6 a.m. shift. She stated that CNA G told her she followed shift after CNA F who had left Resident #3 and Resident #4 in unchanged briefs before leaving shift. She stated she had spoken to CNA F on several occasions in-servicing her and reminding her to take care of the residents like they were her own mother and father. She also told the staff that if she felt she could not perform the tasks as such, she could not be a part of the team. She stated that all her staff know that if they need to text her, they can do so at any time and they knew there were no exceptions for leaving shift without completing their duties without informing the unit managers that they had fallen behind. During an interview on 04/11/2024 at 04:59 p.m., CNA B stated the facility provided an in-service on ANE and incontinent care a couple of weeks ago (exact dates and times unknown). She stated that residents were to be checked on and changed if needed every two hours to avoid skin breakdowns. She stated if she found a resident excessively soiled, she would change the resident and report the to the unit manager on shift. During an interview on 04/11/2024 at 05:15 p.m., CNA C stated at shift change there was an overlap of 10-15 minutes where staff consult with each other any concerns to be noted from the previous shift. She stated at that time it should be identified if a resident had not been changed prior to that staff leaving shift. She stated that if she found a resident heavy soiled and was not informed by the previous shifts staff, she would assume that the previous shift neglected to change the resident. She would change the resident and report to the unit manager and/or charge nurse that the previous staff had not completed their rounds before leaving shift. She stated that she was provided an in-service on ANE and incontinent care last week 04/01/2024 and 04/04/2024. Record review of the facility's self-report incident dated 01/02/2024 revealed: On 01/01/2024: Description of allegation: Employee failed to perform job duties as assigned. CNA F left Resident #3 and Resident #4 soiled and wet. Beds were wet as well. This was reported to the Administrator. Description of injury: None. Provider response: CNA F was terminated for failure to complete job responsibilities. Investigation Summary: Resident interviews conducted. Employee in-services conducted. Provider Action Taken Post-Investigation: Employee terminated. Signed and dated by Administration on 01/09/2024. Record review of the facility's staffing schedule dated 01/01/2024 revealed LVN B was responsible for supervising CNA F during her shift. Record review of Policy copy right date of 2022 revealed Promoting-Maintaining-Resident-Dignity. Compliance Guidelines: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 14. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source. Record review of the facility's Policy: Abuse, Neglect and Exploitation, undated revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs. Neglect means 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. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #1) reviewed for resident rights. The facility failed to ensure certified nursing assistant (CNA) A knocked on Resident #1's door prior to entering his room. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth. Findings included: Record review of Resident #1's face sheet dated 04/10/2024 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses including obstructive and reflux uropathy (urine cannot drain from the urinary track), cellulitis (deep infection caused by bacteria), of unspecified part of limb, chronic embolism and thrombosis of deep veins (blood clots) of lower extremity hypothyroidism (lack of thyroid hormones causing the feeling of cold, pain, skin paleness and sadness), essential hypertension (high blood pressure), essential tremor (shakes), lymphedema (built up of fluid in the body), epilepsy (seizures), pain, ulcer and inflammation (swollen sores), and muscle weakness. Record review of Resident #1's annual (Minimum Data Set) MDS assessment dated [DATE] indicated he had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. Record review of Resident #1's Care Plan undated indicated Focus: He had cussed out staff and turned over bedside table when upset on occasions. Goals: Resident will have fewer episodes by review date. Date Initiated: 6/11/2021 Revision on: 08/17/2022 Target Date: 04/22/2024. Interventions: Allow choices within individual's decision-making abilities: Date Initiated: 06/11/2021 Revision on: 10/24/2022 Certified Nursing Assistant (CNA). Anticipate and meet the resident's needs. Date Initiated: 06/11/2021 Revision on: 10/24/2022 CNA. During an observation on 04/10/2024 at 12:49 p.m. while interviewing Resident #1 in resident's room, CNA A opened resident's room door without knocking, walked into the room, and stated, Oh, I did not know anyone was in here, I was making sure that his lunch tray was picked up, looked around the room, exited and closed the door. During an interview on 04/10/2024 at 12:50 p.m., Resident #1 stated that staff enter his room all the time without knocking or introducing themselves. During an interview on 04/10/2024 at 12:54 p.m., CNA A stated that he had worked with the facility since February 2024. He stated that he had been a CNA for many years in another state and was familiar with the responsibilities and duties of a CNA. He stated that he realized that he entered Resident #1's room without knocking and he apologized. He stated he knew to knock before entering a resident's room to give them privacy. He stated he received training during onboarding with the facility that covered resident's rights and just last week on resident rights and abuse, neglect, and exploitation (ANE). He stated that he had come into Resident #1's room to pick up his lunch tray. During an interview on 04/10/2024 at 01:19 p.m., RN A stated that he was CNA A's supervisor. He stated that he had trained CNA A and in-serviced him during onboarding, which covered entering residents' rooms by knocking, introducing oneself and informing the resident what services that staff would be providing. He stated that CNAs were also randomly reminded all the time to knock and announce themselves before entering a resident's room. He stated that CNA A would be written up for failing to knock before entering a resident's room. He stated that CNA A should have made it a practice and he would not have made the mistake. During an interview on 04/11/2024 at 03:35 p.m., the DON stated that all staff were to knock and introduce themselves before entering a resident's room. She stated that residents deserve privacy because the facility was their home, and they need to know who was coming into their space. She stated that CNA A should have knocked before entering Resident #1's room. During an interview on 04/11/2024 at 04:45 p.m., the Administrator stated that there were no exceptions, the staff were to knock before entering resident rooms. During an interview on 04/11/2024 at 04:59 p.m., CNA B stated that they received in-services a couple of weeks ago (exact date and time unknown) on resident rights which included knocking and introducing oneself when entering a resident's room. During an interview on 04/11/2024 at 05:15 p.m., CNA C stated that she had worked at the facility for 2-years. She stated that staff were to knock and announce themselves before entering a resident's room. During an interview on 04/11/2024 at 05:21 p.m., CNA D stated that staff received an in-service on resident rights last week (exact date and time unknown) about knocking before entering a resident's room. Record review of facility's in-service dated 03/08/2024 revealed, Resident rights . you should always knock before entering a resident's room, signed by CNA A 03/08/2024. Record review of facility's in-service dated 04/10/2024 revealed, Knock on resident's door before entering and resident rights and dignity. Conducted by Licensed Vocational Nurse (LVN) A and signed by CNA A on 04/10/2024. Record review of facility's Policy copy right date of 2022 revealed Promoting-Maintaining-Resident-Dignity. Compliance Guidelines: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 7. Explain care or procedures to the resident before initiating the activity. 12. Maintain resident privacy. Knock before entering a resident's room.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility staff failed to immediately assess Resident #1 when he was observed to have a distended abdomen and an empty Foley catheter on 6/23. The facility staff failed to immediately assess Resident #1 when blood was observed in his catheter tubing on 6/24 around 6 am. The facility failed to identify a change in Resident #1's condition and failed to provide on-ongoing assessment of his continued worsening conditions. The facility failed to accurately identify, and report blood amount observed in Resident #1's catheter bag to Resident #1's physician on 6/24. The facility failed to provide Resident #1's feeding and water flushes as ordered by his physician. The facility staff failed to accurately conduct weekly skin assessments as outlined in Resident #1's comprehensive person-centered care plan. The facility staff failed to accurately assess and stage Resident #1's pressure ulcer to his left heel and communicate those findings to the physician. The facility's wound care nurses inaccurately documented Resident #1's wounds as a deep tissue injury. He was transferred to the emergency room where it was identified as a stage III pressure ulcer and was diagnosed with [REDACTED]. Resident remained in the intensive care unit . An Immediate Jeopardy was identified on 7/10/20. While the IJ was lowered on 7/14/2020, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to educate their staff and monitor the effectiveness of the Plan of Removal. These failures affected Resident #1 and placed any resident who experiences a change in their condition at risk of complication from delay in medical intervention. Findings include: Resident #1 Record review of Resident #1's face sheet dated 7/11/20 revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. the sacral, buttock, and head. Record review of Resident #1's significant change MDS dated [DATE] revealed he was in a persistent vegetative state. He was totally dependent on one staff for all ADLs. He had range of motion impairments on both sides on both upper and lower extremities. He had a [MEDICAL CONDITION] bag, urinary catheter, [MEDICAL CONDITION], and feeding tube. Record review of Resident #1's care plan dated 6/11/20 revealed he had an indwelling catheter due to a sacral pressure ulcer. The goal was that he would remain free of catheter related trauma through the review date. Interventions included anchoring the catheter to prevent excess tension and observing/recording/reporting unusual symptoms to his physician including blood tinged urine and no output. Further review revealed he was NPO and dependent on a peg tube for nutrition and hydration. The goals were that he maintained his weight and remained free of dehydration symptoms. Interventions included implementing RD recommendations and monitoring for weight loss and dehydration. Record review of Resident #1's nursing note dated 6/23/20 revealed he was observed with a distended abdomen and empty Foley catheter bag. The nurse flushed the catheter and noted the catheter was draining yellow clear urine. There was no mention that Resident #1's physician was notified regarding the distended abdomen and empty Foley catheter. The note was signed by LVN A. Record review of Resident #1's clinical chart revealed there was no SBAR related to his distended abdomen on 6/23/20. During an interview on 7/11/20 at 1:43 pm, LVN A said a change in condition was anything abnormal for that resident. When asked if she saw Resident #1 with a distended abdomen she said 6/23 was the first time she saw him like that. When asked why an SBAR was not conducted and the physician was not contacted she said there was a standing order for any sediment buildup so a SBAR did not need to be done. She said if the PRN order was ineffective after some time then the physician should be notified. Record review of Resident #1's physician orders [REDACTED]. Observation on 6/24/20 at 10:15 am Revealed Resident #1 lying in bed asleep. He appeared thin with sunken in cheeks. His lips were chapped, mouth open, and receiving oxygen via trach. His feeding tube and water pump were turned off. His catheter bag was lying on the floor full of dark red blood. Observation on 6/24/20 at 11:30 am revealed Resident #1 lying in bed asleep. His feeding tube was turned off and the catheter bag was empty. There was a scant amount of bloody urine in the bag and tubing. During an interview on 6/24/20 at 11:36 am, LVN A was asked to describe Resident #1's care. She said he was bed bound and alert but not oriented. She said he had a Foley catheter, a [MEDICAL CONDITION] bag and received continuous feeding via [DEVICE]. She said the bowel rest was customary from 6 am - 10 am for residents who received continuous feeding. She said his feeding bag was changed at 6 am when she arrived by the previous nurse and she had not turned on the feeding tube that day. When asked why it had not been turned on she said she was addressing other issues first. She said she made rounds around 6 am shortly after arriving for her shift and saw Resident #1's Foley catheter bag was empty. She said she then saw him around 10 am when she drained the Foley catheter bag. She called the doctor at 10:48 am and wanted to have him sent out because he had sediments in this urine. When asked to describe the sediments she said the urine had a cloudy concentration. When asked if she saw any blood, she said there were little little bloods in it. She said she told the NP Resident #1's vitals were within normal limits but did not give his exact numbers because she misplaced the paper she wrote them down on. She said the NP told her to flush the catheter and change the bag. When asked why she did not do an SBAR she said the Unit Manager did it because she was busy. Record review of Resident #1's physician orders [REDACTED].#1's feeding from 10 am - 1 pm for one day only. During an interview on 7/14/20 at 1:23 pm the Unit Manager, was asked who she received the hold order from. She said on 6/24 she was confused why the surveyor was asking questions about why Resident #1's feeding was off. She said there were various reasons why you don't turn the feeding on. She asked Why would you turn the feeding on? There's no reason to have the feeding on the patient. At the hospital they don't feed you until they figure out what's going on with you. It doesn't have to be an order. They're nursing interventions. She said she received the order from the NP. She was informed LVN A first spoke with the NP at 10:48 am and the hold order was from 10 am - 1 pm. She was also informed the previous interview with the Unit Manager only mentioned speaking with the NP when order to send out to the ER. The Unit Manager said she spoke with the NP three times that day. She said at 8 am the NP called her and told her to monitor Resident #1's catheter bag. She was asked to clarify when she first saw the catheter bag and she said after 10 am when the bag was already changed. She said the second time she got an order from the NP to hold the feeding and the third time the feeding was discontinued. She said the NP said since they were monitoring him the feeding did not need to be off. During an interview 6/25/20 at 8:36 am NP said the standard protocol for residents receiving nutrition via [DEVICE] was they were on 22 hours and off 2 hours. She said there was no set two hours that it's off but it considered changing, cleaning, and any care provided to the resident. She said she could not recall Resident #1's specific nutrition order, but she had not altered the orders recently. During an interview on 6/24/20 at 12:54 pm, CNA K said she had been working in the facility for less than a month. She said around 6 am she made rounds with LVN A. She said there were particles in Resident #1's catheter tube and some blood, but the bag was empty. She said LVN A told her to monitor the bag and inform her of any changes. She said around 8 am she observed Resident #1 again and said there was not much urine in the bag, but it was still nearly red. She said around 10 am she was rounding with nurse and saw blood. Record review of Resident #1's vitals revealed Blood pressure: - 6/23/2020 06:24 132 / 80 mmHg - 6/23/2020 14:16 128 / 77 mmHg - 6/23/2020 21:04 132 / 82 mmHg - 6/24/2020 05:59 138 / 80 mmHg - 6/24/2020 10:00 107 / 72 mmHg Oxygen saturation - 6/22/2020 11:01 98.0 % - 6/23/2020 04:53 98.0 % - 6/23/2020 07:34 97.0 % - 6/24/2020 04:16 98.0 % - 6/24/2020 08:02 97.0 % - 6/24/2020 10:00 95.0 % - Pulse - 6/23/2020 06:24 78 bpm - 6/23/2020 14:16 84 bpm - 6/23/2020 21:04 80 bpm - 6/24/2020 05:59 76 bpm - 6/24/2020 10:00 67 bpm Record review of Resident #1's SBAR dated 6/24/20 and effective at 1:57 pm. It was noted he had hematuria that was observed that day. It said, since this started it has stayed the same. The vital signs were recorded as: - Blood pressure 107/72 - from 10:00 am - Pulse 67 - from 10:00 am - Respirations 18 - from 10:00 am - Temperature 97.8 - from 10:00 am - Oxygen saturation 95% - from 10 am. Further review revealed he had no mental, functional, respiratory, or abdomen changes. He was noted to have bright red urine in his Foley. His family member and physician were notified. He was sent out to the ER. The SBAR was signed by the Unit Manager on 6/24/20 at 4:25 pm. Record review of Resident #1's nursing note dated 6/24/20 and written at 2:41 pm revealed Resident was noted with bright blood mixed with urine in his Foley. NP and emergency contact were notified. Vital sign at this time are: BP 107/72, p: 67, T: 97.8, O2 Sat:95%, R: 18. New order to flush and change Foley bag was received. Order was carried out, after less than an hour, resident continued to drain bright red blood mixed with urine. NP was called back, and resident was sent out to (hospital) and resident's RP notified. The note was signed by LVN A. During an interview on 6/24/20 at 11:36 am, LVN A said she called Resident #1's NP at 10:48 am because he had sediments in this urine. She said she told the NP Resident #1's vitals were within normal limits but did not give his exact numbers because she misplaced the paper she wrote them down on. When informed his O2 sats, pulse, and blood pressure were running lower than usual she said it could have been because he received blood pressure medicine on the previous shift. She said the NP told her to flush the catheter and change the bag. When asked why she did not do an SBAR she said the Unit Manager did it because she was busy. Record review of Resident #1's physician orders [REDACTED]. - Chronic catheter flush with 30 mL to reduce sedimentation build up in tubing as needed ordered 5/21/20 - Change Foley drainage bag as needed for soiled/dislodged ordered 5/29/20 During an interview 6/25/20 at 8:36 am NP said she had been over Resident #1's care for nearly 2 months, but only physically saw him once. She described him as being bed bound and requiring total assistance for all ADLs. She said he had a [MEDICAL CONDITIONS], [DEVICE], and Foley catheter. She said the Foley frequently had sediment build up, so he had orders for basic flushing of the Foley twice a day as well as PRN. She said on the morning of 6/24, LVN A called about a small amount of bright red blood in Resident #1's catheter tubing. She told LVN A to change the bag and flush the catheter and monitor the bleeding. She said if there continued to be bright red blood then Resident #1 should be sent out to the emergency room . She said she got a call back from the Unit Manager who said there was still blood and did not think it was safe for Resident #1 to stay in the facility, so he was sent out. A picture of the full Foley bag on the ground was sent to the NP who said LVN A only told her there was blood in the catheter tubing. She said she was not aware there was blood in the catheter bag nor was she informed the blood was profuse. Record review of Resident #1's Emergency Department record dated 6/25/20 revealed he arrived with a fever of 100.4 F, [MEDICAL CONDITION], and [MEDICAL CONDITION] Admitting [DIAGNOSES REDACTED]. He was also found to have, hydro[DIAGNOSES REDACTED], staph aureus, acute blood lose [MEDICAL CONDITION], and pneumonia. Further review revealed 2 pressure ulcers to the sacral and left heel both stage 3. He was transferred to the ICU where he currently resided. Observation on 7/7/20 at 12:00 pm revealed Resident #1's bed was removed from his room and he could not be located on the unit. Record review of Resident #1's physician orders [REDACTED]. During an interview on 7/7/20 at 12:15 pm the Unit Manager, said she was responsible for the East Wing where Resident #1 resided. She said Resident #1 required total care of 2 staff and had a Foley catheter due to a sacral wound. She said the catheter would get clogged possibly due to having the catheter inserted for a long period of time. When asked about the incident on 6/24 she said the Sediment would clog up to where he couldn't pass the urine. I believe that's what happened that day. I can't say how the blood came into it. She said, I don't know if it was trauma from removing the catheter and replacing it. She said LVN A got orders from Resident #1's NP to switch out the Foley and then follow-up if bleeding persisted. When asked if she saw the catheter bag before or after it was drained she said, I saw it after she had already changed it. She said when she observed the catheter she saw there was blood in the urine but there was only a small amount of liquid in the bag. She said she saw the bag again when there was 200-300 ccs of urine and blood and called the NP. She said she told the NP she did not feel it was safe for Resident #1 to stay in the facility and got an order to send him out. During an interview on 7/9/20 at 8:35 am, Resident #1's RP said she was not informed of the catheter being clogged on 6/23. She said Nobody called and told me he was gone to the hospital on 6/24 either. She said on 6/24 she called the facility to get an update on him. She said she usually called every other day since she was not allowed to visit due to COVID-19. She said LVN A informed her there was a little blood in his urine and she was going to call the physician. LVN A told her there was nothing to worry about, but she would call her back with an update. The family member said she had not heard back from LVN A after hours, so she called LVN K who she had a relationship with. She said she asked LVN K to check on Resident #1. She said LVN K walked down to his room and saw he was not there. She said LVN K informed her that Resident #1 had been sent out to the hospital. During an interview on 7/9/20 at 1:40 pm the DON said the when there was a change in condition, the nurse should complete the SBAR and relay the information to the physician and receive any new orders. Record review of Resident #1's care plan dated 6/11/20 revealed he had a stage 4 pressure ulcer and a deep tissue injury to his left heel. The goal was the pressure ulcers would show signs of healing and remain free of infection. Interventions included a full body skin assessment every week. Further review revealed weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Record review of Resident #1's weekly pressure ulcer record dated 6/11/20 revealed a facility acquired left heel pressure ulcer with the onset date of 6/11/20. It was measured at 5 x 5 x .1 and was recorded as a suspected deep tissue injury which was described as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. There was a scant amount of serosanguineous drainage. The assessment was signed by the Wound Care Nurse. Record review of Resident #1's weekly pressure ulcer record dated 6/18/20 revealed the left heel pressure ulcer was measured at 5 x 5 x .1 cm and was noted to be improving. There was no drainage noted. The assessment was signed by the Wound Care Nurse. During an interview on 7/14/20 at 12:23 pm the Wound Care Nurse said she had been in the position since March. She said she trained with 3 different wound care companies but did not have a wound care certification. She said she provided daily wound care for Resident #1's sacral and left heel. She said the sacral was a healing stage 4 and the left heel was a deep tissue injury that started to ooze. When asked to describe a deep tissue injury she said, discoloration or bruising. When asked if a wound could be classified a deep tissue injury if it had depth she said, It wasn't really open but it was boggy in places. When asked how depth could be obtained if the wound was not open she said she did not know how to classify the wound if most of it was hard. During an interview on 7/14/20 at 12:37 pm , the DON said the Wound Care Nurse was responsible for completing the pressure ulcer record. She said the Wound Care Nurse received training prior to taking the role and rounded with the Wound Care Doctor. She said the Wound Care Doctor had not been in the facility due to COVID-19. Record review of Resident #1's head to toe skin assessment dated [DATE] revealed the only skin issues documented were a healing stage 4 sacral pressure ulcer and a healing left great toe ulcer. The assessment was signed by LVN A. During a follow-up interview on 7/11/20 at 1:43 pm, LVN A said for skin assessments she usually went in with an aide to examine the resident's entire body to see if there were any new skin problems. When asked if she remembered doing Resident #1's skin assessment on 6/19 she said no. She was unable to identify where his pressure ulcers were but said they were ongoing wounds. Record review of Resident #1's discharge MDS dated [DATE] revealed he had 1 stage 4 pressure ulcer and 1 deep tissue injury. During an interview on 7/14/20 at 12:37 pm the DON said the nurses were expected to complete skin assessments per the schedule. She said the nurse should remove everything and assess the resident's entire body and document it on the weekly skin assessment form. When asked to describe a deep tissue injury she said it looks like a big bruise. When asked if a deep tissue injury could have depth she said, You won't know because it's not open. When informed Resident #1's heel wound was documented as a deep tissue injury by the Wound Care Nurse but had depth she said wounds were not her expertise and did not want to say if a deep tissue injury can have depth or not. Record review of Resident #1's Emergency Department record dated 6/25/20 revealed he arrived with a fever of 100.4 F, [MEDICAL CONDITION], and [MEDICAL CONDITION] Admitting [DIAGNOSES REDACTED]. He was also found to have, hydro[DIAGNOSES REDACTED] (swelling of a kidney due to urine build up), staph aureus (a dangerous bacteria infection that can lead to pneumonia), acute blood lose [MEDICAL CONDITION], and pneumonia. Further review revealed 2 pressure ulcers to the sacral and left heel both stage 3. He was transferred to the ICU where he currently resided. Record review of the facility's policy on change in condition dated April 2005 revealed The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Prompt notification is required when there is an accident involving the resident which results and has the potential for requiring physician intervention; a significant change in the resident's attending physical, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. The SBAR Communication Form and the Progress Note are used to assess and document changes in condition in an efficient and effective manner, provide assessment information to the physician, and provide clear comprehensive documentation. Record review of the facility's skin management policy dated July 2017 revealed Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. The facility Administrator and DON were notified on 7/10/20 at 10:00 am that immediate jeopardy was identified due to the above failures. A copy of the IJ template was provided at this time and a plan of removal was requested. The final plan of removal was accepted on 7/11/20 at 8:13 pm after several revisions were made. IJ plan of removal includes: Immediate action: 100% audit was initiated 7/10/2020 by DON and Nurse Managers on residents with Foley catheters. These audits will include an assessment of the resident's urine, catheter bag and abdomen. All findings will be reviewed by the medical director and interventions will occur as needed. These audits will be completed 7/10/2020. 100% audit was initiated 7/10/2020 by Don and Nurse Managers on residents with [DEVICE]s. These audits will include assessing the resident for following physician orders [REDACTED]. All findings will be reviewed by the medical director and interventions will occur as needed. These audits will be completed 7/10/2020. Facilities Plan to ensure compliance quickly: DON initiated in-servicing for licensed nursing staff on 7/10/2020 on Physical Assessment. This in-service will include a focus on Urinary Catheter Assessment, care and signs and symptoms of UTI [MEDICAL CONDITION] (Urinary Characteristics, Color, Presence/Amount of blood / sediment and odor). DON initiated in-servicing for licensed nursing staff on 7/10/2020 on Change in Condition. This in-service will include a focus on documenting current vital signs and reporting new findings to the resident's physician and responsible party. DON initiated in-servicing for all nursing staff on 7/10/2020 on Catheter Care. This in-service will include a focus on ensuring the catheter bag is anchored to the bed and not touching the floor to promote proper infection control procedures. DON initiated in-servicing for all nursing staff on 7/10/2020 on staff communicating changes of condition. This in-service will include a focus on resident care specialist reporting urinary changes to the charge nurse; charge nurse reporting urinary changes to NP/Physician timely however; will highlight overall changes in condition. DON initiated in-servicing for licensed nursing staff on 7/10/2020 on documenting and identify changes in condition. Changes of condition will be documented in an SBAR user defined assessment in Point Click Care under assessments. Vital signs to include blood pressure, pulse, respirations, temperature and o2 saturation will be current for each change in condition. Focus will include ensuring nurses are competent and can clearly report changes to physician. If a nurse is unsure of an assessment, another nurse should be consulted. DON initiated in-servicing for licensed nursing staff on 7/10/2020 on ensuring licensed nurses are following physician orders [REDACTED]. All CNA/CMA staff will be in-serviced on notifying charge nurse should they identify a pump is off, not functioning, or disconnected. These trainings will continue every shift until 100% completion of designated staff. Any staff member failing to attend the training will be removed from the schedule until completion of the required training. ADHOC QAPI meeting held 7/10/2020 to review the training and processes implemented 7/10/2020. Tools/Forms developed to perform audits. Don/Designee will perform daily physical audits of residents with Catheters to assess for any changes of condition. Any changes of condition will be documented in an SBAR format with current vitals and physician documentation. These audits will occur for two weeks daily. DON/Designee will perform daily audits of residents with [DEVICE]s to assess for following orders appropriately. Any adverse findings will be immediately corrected. These audits will occur for two weeks daily. The administrator will be responsible for the plan and ensure that staff has completed training by 7/11/2020 or not be permitted to work. Monitoring Record review of the immediate jeopardy binder reviewed on 7/12/20 revealed in-services initiated on urinary catheters, enteral feedings, documentation, and reporting change in condition. Attached to the training were policies on change in condition, nursing rounds, indwelling catheter care, and enteral nutrition. Tools attached were a blank SBAR, stop and watch tool, and the urinary catheter or urinary tract infection critical element pathway. Further review revealed an ad hoc QAPI meeting was conducted on 7/10/20 Observations made on 7/12/20 revealed no concerns noted with the residents with Foley catheters or [DEVICE]s. Interviews conducted on 7/12/20 with 4 LVNS on the 2nd shift revealed they had a comprehensive understanding of the trainings and in-services received. Interviews conducted on 7/13/20 with 3 LVNs and 1 CNA on the 3rd shift revealed they had a comprehensive understanding of the trainings and in-services received. Observation on 7/13/20 at 11:35 pm revealed the DON, Administrator, and Unit Manager in the facility. Observation on 7/13/20 at 11:37 pm revealed Resident #2 lying in bed asleep. His pump was set at 100 mL/HR with a 275 mL/HR flush. The pump read 173 mL had been fed and 275 mL had been flushed. During an interview on 7/13/20 at 11:40 pm, LVN C said Resident #2's flush order was 275 mL/hour. Record review of Resident #2's physician order [REDACTED]. He also had an order for [REDACTED]. During an interview on 7/14/20 at 12:37 pm the DON was asked how Resident #2's incorrect flush order was not caught she said, I can't tell you how that was missed, because I didn't do that audit. She said, It was identified when you mentioned it. Record review of Resident #1's nursing note dated 7/14/20 and written at 12:36 am revealed Notification made to (physician) about this resident's incorrect amount of flush entered on feeding pump. Resident has been stable. No signs and symptoms of fluid overload. Respirations are even and unlabored. Resident is resting comfortably in his bed on his back with eyes closed. Resident urine is amber, with no order noted. The note was signed by the Unit Manager. During an interview on 7/14/20 at 1:23 pm the Unit Manager was asked about the note written on 7/14 in Resident #1's nursing notes. She said she called LVN A, the 2 - 10 pm nurse, to see why the pump was incorrect. She said the flush order was 275 mL every 12 hours but LVN A apparently put a 1 instead of a 12. She said LVN C brought it to her attention last night and told her it was entered wrong. When informed LVN C read the order as 275 mL/hour she said No that's not right. She read it wrong and could have been nervous. She said there was 550 mL flushed when the error was caught. She said she notified Resident #1's physician, the DON, and input the correct order on the pump. Interviews conducted on 7/14/20 with 1 RN, 2 CNA, 1 med aide, and 1 LVN on the 1st shift revealed they had a comprehensive understanding of the trainings and in-services received. Observations made on 7/14/20 revealed no concerns noted with the residents with Foley catheters or [DEVICE]s. On 07/14/20 at 2:17pm, the facility Administration were notified the IJ was lowered. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continuing to educate their staff and monitor the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when there was a change in condition for 1 of 5 residents (Resident #1) reviewed for notification of changes. The facility staff failed to immediately notify Resident #1's physician when he was observed to have a distended abdomen and an empty Foley catheter on 6/23. The facility staff failed to immediately notify Resident #1's physician when blood was observed in his catheter tubing on 6/24 around 6 am. The facility failed to report accurate blood amount observed in Resident #1's catheter bag or his drop-in vitals to Resident #1's physician on 6/24. The facility staff failed to immediately notify Resident #1's responsible party when he was transferred to the hospital. He was transferred to the emergency room where he was diagnosed with [REDACTED]. These failures placed all residents who experience a change in their at-risk complication from delay in medical intervention. Findings include: Resident #1 Record review of Resident #1's face sheet dated 7/11/20 revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. the sacral, buttock, and head. Record review of Resident #1's significant change MDS dated [DATE] revealed he was in a persistent vegetative state. He was totally dependent on one staff for all ADLs. He had range of motion impairments on both sides on both upper and lower extremities. He had a [MEDICAL CONDITION] bag, urinary catheter, [MEDICAL CONDITION], and feeding tube. Record review of Resident #1's care plan dated 6/11/20 revealed he had an indwelling catheter due to a sacral pressure ulcer. The goal was that he would remain free of catheter related trauma through the review date. Interventions included anchoring the catheter to prevent excess tension and observing/recording/reporting unusual symptoms to his physician including blood tinged urine and no output. Further review revealed he was NPO and dependent on a peg tube for nutrition and hydration. The goals were that he maintained his weight and remained free of dehydration symptoms. Interventions included implementing RD recommendations and monitoring for weight loss and dehydration. Record review of Resident #1's nursing note dated 6/23/20 revealed he was observed with a distended abdomen and empty Foley catheter bag. The nurse flushed the catheter and noted the catheter was draining yellow clear urine. There was no mention that Resident #1's physician was notified regarding the distended abdomen and empty Foley catheter. The note was signed by LVN A. During an interview on 7/9/20 at 8:35 am, Resident #1's RP said she was not informed of the catheter being clogged on 6/23. During an interview on 7/11/20 at 1:43 pm, LVN A said a change in condition was anything abnormal for that resident. When asked if she saw Resident #1 with a distended abdomen she said 6/23 was the first time she saw him like that. When asked why an SBAR was not conducted and the physician was not contacted she said there was a standing order for any sediment buildup so a SBAR did not need to be done. She said if the PRN order was ineffective after some time then the physician should be notified. Observation on 6/24/20 at 10:15 am Revealed Resident #1 lying in bed asleep. He appeared thin with sunken in cheeks. His lips were chapped, mouth open, and receiving oxygen via trach. His feeding tube and water pump were turned off. His catheter bag was lying on the floor full of dark red blood. Observation on 6/24/20 at 11:30 am revealed Resident #1 lying in bed asleep. His feeding tube was turned off and the catheter bag was empty. There was a scant amount of bloody urine in the bag and tubing. During an interview on 6/24/20 at 11:36 am, LVN A was asked to describe Resident #1's care. She said he was bed bound and alert but not oriented. She said he had a Foley catheter, a [MEDICAL CONDITION] bag and received continuous feeding via [DEVICE]. She said she made rounds around 6 am shortly after arriving for her shift and saw Resident #1's Foley catheter bag was empty. She said she then saw him around 10 am when she drained the Foley catheter bag. She called the doctor at 10:48 am and wanted to have him sent out because he had sediments in this urine. When asked to describe the sediments she said the urine had a cloudy concentration. When asked if she saw any blood, she said there were little little bloods in it. She said she told the NP Resident #1's vitals were within normal limits but did not give his exact numbers because she misplaced the paper she wrote them down on. She said the NP told her to flush the catheter and change the bag. During an interview on 6/24/20 at 12:54 pm, CNA K said she had been working in the facility for less than a month. She said around 6 am she made rounds with LVN A. She said there were particles in Resident #1's catheter tube and some blood, but the bag was empty. She said LVN A told her to monitor the bag and inform her of any changes. She said around 8 am she observed Resident #1 again and said there was not much urine in the bag, but it was still nearly red. She said around 10 am she was rounding with nurse and saw blood. During a follow-up interview on 7/11/20 at 1:43 pm, LVN A said when she saw Resident #1 when doing rounds around 6 am she said the bag was empty but things of blood in the tubing. Record review of Resident #1's vitals revealed Blood pressure: - 6/23/2020 06:24 132 / 80 mmHg - 6/23/2020 14:16 128 / 77 mmHg - 6/23/2020 21:04 132 / 82 mmHg - 6/24/2020 05:59 138 / 80 mmHg - 6/24/2020 10:00 107 / 72 mmHg Oxygen saturation - 6/22/2020 11:01 98.0 % - 6/23/2020 04:53 98.0 % - 6/23/2020 07:34 97.0 % - 6/24/2020 04:16 98.0 % - 6/24/2020 08:02 97.0 % - 6/24/2020 10:00 95.0 % - Pulse - 6/23/2020 06:24 78 bpm - 6/23/2020 14:16 84 bpm - 6/23/2020 21:04 80 bpm - 6/24/2020 05:59 76 bpm - 6/24/2020 10:00 67 bpm Record review of Resident #1's SBAR dated 6/24/20 and effective at 1:57 pm. It was noted he had hematuria that was observed that day. It said, since this started it has stayed the same. The vital signs were recorded as: - Blood pressure 107/72 - from 10:00 am - Pulse 67 - from 10:00 am - Respirations 18 - from 10:00 am - Temperature 97.8 - from 10:00 am - Oxygen saturation 95% - from 10 am. Further review revealed he had no mental, functional, respiratory, or abdomen changes. He was noted to have bright red urine in his Foley. His family member and physician were notified. He was sent out to the ER. The SBAR was signed by the Unit Manager on 6/24/20 at 4:25 pm. Record review of Resident #1's nursing note dated 6/24/20 and written at 2:41 pm revealed Resident was noted with bright blood mixed with urine in his Foley. NP and emergency contact were notified. Vital sign at this time are: BP 107/72, p: 67, T: 97.8, O2 Sat: 95%, R: 18. New order to flush and change Foley bag was received. Order was carried out, after less than an hour, resident continued to drain bright red blood mixed with urine. NP was called back, and resident was sent out to (hospital) and resident's RP notified. The note was signed by LVN A. During an interview on 6/24/20 at 11:36 am, LVN A said she called Resident #1's NP at 10:48 am because he had sediments in this urine. She said she told the NP Resident #1's vitals were within normal limits but did not give his exact numbers because she misplaced the paper she wrote them down on. When informed his O2 sats, pulse, and blood pressure were running lower than usual she said it could have been because he received blood pressure medicine on the previous shift. She said the NP told her to flush the catheter and change the bag. When asked why she did not do an SBAR she said the Unit Manager did it because she was busy. Record review of Resident #1's physician orders [REDACTED]. - Chronic catheter flush with 30 mL to reduce sedimentation build up in tubing as needed ordered 5/21/20 - Change Foley drainage bag as needed for soiled/dislodged ordered 5/29/20 During an interview 6/25/20 at 8:36 am NP said she had been over Resident #1's care for nearly 2 months, but only physically saw him once. She described him as being bed bound and requiring total assistance for all ADLs. She said he had a [MEDICAL CONDITIONS], [DEVICE], and Foley catheter. She said the Foley frequently had sediment build up, so he had orders for basic flushing of the Foley twice a day as well as PRN. She said on the morning of 6/24, LVN A called about a small amount of bright red blood in Resident #1's catheter tubing. She told LVN A to change the bag and flush the catheter and monitor the bleeding. She said if there continued to be bright red blood then Resident #1 should be sent out to the emergency room . She said she got a call back from the Unit Manager who said there was still blood and did not think it was safe for Resident #1 to stay in the facility, so he was sent out. A picture of the full Foley bag on the ground was sent to the NP who said LVN A only told her there was blood in the catheter tubing. She said she was not aware there was blood in the catheter bag nor was she informed the blood was profuse. Record review of Resident #1's Emergency Department record dated 6/25/20 revealed he arrived with a fever of 100.4 F, [MEDICAL CONDITION], and [MEDICAL CONDITION] Admitting [DIAGNOSES REDACTED]. He was also found to have, hydro[DIAGNOSES REDACTED] (swelling of a kidney due to urine build up), staph aureus (a dangerous bacteria infection that can lead to pneumonia), acute blood lose [MEDICAL CONDITION], and pneumonia. Further review revealed 2 pressure ulcers to the sacral and left heel both stage 3. He was transferred to the ICU where he currently resided. Observation on 7/7/20 at 12:00 pm revealed Resident #1's bed was removed from his room and he could not be located on the unit. Record review of Resident #1's physician orders [REDACTED]. During an interview on 7/7/20 at 12:15 pm the Unit Manager, said she was responsible for the East Wing where Resident #1 resided. She said Resident #1 required total care of 2 staff and had a Foley catheter due to a sacral wound. She said the catheter would get clogged possibly due to having the catheter inserted for a long period of time. When asked about the incident on 6/24 she said the Sediment would clog up to where he couldn't pass the urine. I believe that's what happened that day. I can't say how the blood came into it. She said, I don't know if it was trauma from removing the catheter and replacing it. She said LVN A got orders from Resident #1's NP to switch out the Foley and then follow-up if bleeding persisted. When asked if she saw the catheter bag before or after it was drained she said, I saw it after she had already changed it. She said when she observed the catheter she saw there was blood in the urine but there was only a small amount of liquid in the bag. She said she saw the bag again when there was 200-300 ccs of urine and blood and called the NP. She said she told the NP she did not feel it was safe for Resident #1 to stay in the facility and got an order to send him out. During an interview on 7/9/20 at 8:35 am, Resident #1's RP said she was not informed of the catheter being clogged on 6/23. She said Nobody called and told me he was gone to the hospital on 6/24 either. She said on 6/24 she called the facility to get an update on him. She said she usually called every other day since she was not allowed to visit due to COVID-19. She said LVN A informed her there was a little blood in his urine and she was going to call the physician. LVN A told her there was nothing to worry about, but she would call her back with an update. The family member said she had not heard back from LVN A after hours, so she called LVN K who she had a relationship with. She said she asked LVN K to check on Resident #1. She said LVN K walked down to his room and saw he was not there. She said LVN K informed her that Resident #1 had been sent out to the hospital. During an interview on 7/9/20 at 1:40 pm the DON said when there was a change in condition, the nurse should complete the SBAR and relay the information to the physician and receive any new orders. During an interview on 7/15/20 at 3:13 pm, the Administrator said he thought the nurse did what she was supposed to do. He said he saw the picture of the catheter bag but if a drop of red dye was put into water it could look similar. He said he did not see there was an issue with how the situation was handled. Record review of Resident #1's Emergency Department record dated 6/25/20 revealed he arrived with a fever of 100.4 F, [MEDICAL CONDITION], and [MEDICAL CONDITION] Admitting [DIAGNOSES REDACTED]. He was also found to have, hydro[DIAGNOSES REDACTED], staph aureus, acute blood loss [MEDICAL CONDITION], and pneumonia. Further review revealed 2 pressure ulcers to the sacral and left heel both stage 3. He was transferred to the ICU where he currently resided. Record review of the facility's policy on change in condition dated April 2005 revealed The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Prompt notification is required when there is an accident involving the resident which results and has the potential for requiring physician intervention; a significant change in the resident's attending physical, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. The SBAR Communication Form and the Progress Note are used to assess and document changes in condition in an efficient and effective manner, provide assessment information to the physician, and provide clear comprehensive documentation.

Based on interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when there was a change in condition for 1 of 8 residents (CR #1) reviewed for notification of changes . -The facility staff failed to consult CR #1's physician of numerous breathing treatment refusals when he was diagnosed with [REDACTED]. -The facility failed to update the CR #1's physician and RP of continued change in condition and deterioration and did not inform his responsible party of chest x-ray results and treatments. -The facility staff failed to immediately notify CR #1's physician of abnormal labs (complete blood count) on [DATE]. - CR #1 was found unresponsive on [DATE] with unreadable oxygen saturation level and was pronounced dead one hour later in the facility. An immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continuing to educate their staff and monitor the effectiveness of the Plan of Removal. These failures could affect any resident who experiences a change in their condition in the facility placing them at risk complication from delay in medical intervention. Findings include: CR #1 Record review of CR #1's face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was a full-code. Record review of CR #1's Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. He required extensive assistance of one staff for toileting and hygiene, limited assistance of one staff for dressing, and was independent of all other ADLs. He ambulated without any devices. He was always incontinent of bowel and bladder. He was not on hospice. Further review of MDS revealed the resident was not coded as having any behaviors. Record review of CR #1's care plan dated [DATE] revealed he had a respiratory infection related to [MEDICATION NAME] pneumonia. The goal was he would be free of signs and symptoms of infection by the review date. interventions included antibiotics and treatments per the physician orders, recording vitals, documenting side effects, and changing positions at regular and frequent intervals especially if in bed. Record review of CR #1's chest x-ray dated [DATE] revealed Bilateral perihilar fullness, nonspecific in nature, possibly due to perihilar atelectasis ( Collapse of lungs) , adenopathy (disease of the lymph nodes), developing [MEDICATION NAME] (acute inflammation of the bronchi, accompanied by inflamed patches in the nearby lobules of the lungs). Consider central venous congestion or [MEDICAL CONDITION] arterial hypertension if indicated by symptomatic presentation, other testing or medical history. Continued follow-up recommended. Minimally worse compared to [DATE]. During an interview on [DATE] at 4:05 pm CNA A said she worked with CR #1 frequently and knew his usual behaviors/care needs. She said in February he was breaking out in sweats, and she asked the nurse to check his vitals. She said CR #1's physician ordered a chest x-ray. She said he was diagnosed with [REDACTED]. She said he was getting antibiotics and got better, but the sweating returned the week of ,[DATE] and got progressively worse than the previous time. Record review of CR #1's physician's orders [REDACTED]. -Inhale [MEDICATION NAME]-[MEDICATION NAME] Solution .5 - 2.5 (3) MG/3ML every 8 hours ordered [DATE]. Record review of CR #1's MAR/TAR dated February 2020 revealed he refused breathing treatments on ,[DATE] at 6 am, ,[DATE] at 6 am, ,[DATE] at 10 pm, ,[DATE] at 2 pm, ,[DATE] at 6 am and 2 pm, ,[DATE] at 6 am, and ,[DATE] at 6 am. Record review of CR #1's nursing notes for February 2020 revealed no documentation indicating his physician was notified of the missing breathing treatments. During an interview on [DATE] at 11:53 am, the Physician said she was the point of contact for any changes in condition regarding CR #1's care. She said when he was receiving breathing treatments in February due to [MEDICATION NAME] she was never informed of any treatment refusals. During an interview on [DATE] at 2:28 pm, CR #1's guardian said he last visited [DATE]th, 2020 and CR #1 was in bed sleep. When asked if he was aware of the pneumonia and treatments from a month prior he said he was not made aware of the [DIAGNOSES REDACTED]. Record review of CR #1's SBAR dated [DATE] 2:07 pm revealed Patient alert with coughing noted. Upon auscultating lungs sounds, wheezing is noted. (Physician) notified and assessed resident and gave order for STAT chest X RAY and [MEDICATION NAME] Treatments- ( Breathing inhalation treatment ) V/S BP ,[DATE] P 78 RR 18 O2 SAT 98% at RA T 98.6. RP notified. The respirations were dated ,[DATE] and the blood pressure, O2 SATs and pulse were dated ,[DATE]. The statement This condition, symptom, or sign has occurred before was coded with no. He had no mental status changes and no functional status changes including needing more assistance, decreased mobility, or weakness. Under respiratory, abnormal lung sounds, wheezing and a productive cough were documented. There were no urine changes indicated including decreased urine output. It was documented that CR #1's RP was notified at 2:10 pm. The assessment was signed by RN A. During a telephone interview on [DATE] at 11:25 am RN A said she was new to the facility. When asked about CR #1's SBAR she completed on [DATE] she said, I don't remember that person. She said she was shadowing a nurse (LVN C) who was showing her how to enter the information, but she could not recall if she did the assessment or notified the Physician and responsible party. During an interview on [DATE] at 4:05 pm CNA A said around [DATE] CR #1 was sweating needing more assistance with ADLs when he usually followed cues. She said when changing his brief, he would not roll like usual and she would have to assist him. She said he was also slow with eating and drinking which was abnormal. She said she informed the nurses for several days of his changes in condition, and kept asking and kept asking for CR #1 to be assessed ( LVN C and LVN Z) . She said there was never any follow up from the nurses. She said she reported changes again to the charge nurse on an unknown date and took his temperature and she said, well he doesn't have a fever. On ,[DATE] The physician was in the building and ordered another chest x ray. The results came back that he had [MEDICATION NAME]. She said the nurse LVN Z informed her he would be started on antibiotics and breathing treatments. She asked LVN Z what about IV fluids, because he hasn't been drinking much. She said LVN Z responded, Oh so you're a doctor now? She said the Wound Care Nurse was present during this and told LVN Z Sometimes when these CNAs tell yall something, they know what they're talking about. During an interview on [DATE] at 12:45 pm the Wound Care Nurse said she was responsible for treating CR #1's wound. She said on ,[DATE] she noticed he did not look good. She said he had been sleeping more, talking less, and did not ask for a soda as he usually did. She said CNA A told her LVN Z was already informed of the changes. She said LVN Z Took CR #1's vitals and said they looked good. She said CNA A again told LVN Z that CR #1 was still not looking like himself although his vitals were not abnormal. She said she told LVN Z that the vital signs were not the only indicator that something was wrong and the CNAs knew the residents best . She said the physician was called and new orders were received. She said she did not notice any other changes on ,[DATE] and ,[DATE]. Record review of CR #1's physician notes revealed the following: [DATE] I was asked to evaluate patient with wheezing. Today seen patient resting in bed in no acute distress. She noted he had scattered wheezes all throughout . Further review revealed Later in the evening around 6 pm I was called with chest x ray results that reported [MEDICATION NAME] and was started on [MEDICATION NAME]. The note was signed by the Physician. [DATE] Today seen patient resting in bed no acute distress. Received first dose of [MEDICATION NAME] -antibiotic today. The note indicated he had wheezing and cough, but also said clear to auscultation without wheezes or rhonchi. The last labs that were reviewed were from [DATE]. The note was signed by the Physician. Record review of CR #1's physician orders [REDACTED]. [MEDICATION NAME] tablet 875 125 mg one tablet by mouth every 12 hours for 7 days ordered [DATE] [MEDICATION NAME] Solution .5 2.5 (3) MG/ML 3 ML orally four times a day for wheezing for 7 days ordered [DATE]. Record review of CR #1's lab results dated [DATE] revealed a high white blood count of 10.9( high, indicative of infection) . The normal range was 4.2 - 9.1. Record review of CR #1's MAR/TAR dated [DATE] revealed he started [MEDICATION NAME] on the second shift on ,[DATE] at 9 pm. Further review revealed he had wheezing after receiving the nebulizer after each treatment except the last treatment on [DATE] and the one on [DATE]. During an interview on [DATE] at 11:53 am, the Physician said she was the point of contact for any changes in condition regarding CR #1's care. When asked if she was informed of any recent changes in condition she said she was called when CR #1 had a cough and wheezing. She said his chest x ray came back positive for [MEDICATION NAME] and she started him on [MEDICATION NAME] twice a day and breathing treatments four times a day. She said he had a standing weekly CBC order and she reviewed the labs on Mondays. She said if labs were abnormal the nursing staff would call her, but she was unaware of his abnormal labs on ,[DATE]. She said she last visited on that day and he was his usual self. She said he still had a cough but no wheezing. She said facility staff did not inform her of changes in condition including eating less, drinking less, taking off clothes, sweating, sleeping, and wheezing any time after ,[DATE]. She said had those changes been reported to her she would have changed the treatment, to include IV fluids, broader lab work, and vital checks every 4 hours. Record review of CR #1's care plan dated [DATE] revealed he had [MEDICATION NAME] infection and receiving antibiotics. The goal was he would be free of complications related to the infection through the review date. interventions included antibiotics treatments per the physician order [REDACTED]. Record review of CR #1's point of care documentation completed by aides dated [DATE] revealed his fluid intake on the three shifts as follows: ,[DATE] 480 cc, 480 cc, 240 cc ,[DATE] 480 cc, 240 cc, 120 cc ,[DATE] 240 cc, 240 cc, nothing documented ,[DATE] 480 cc, 360 cc, 240 cc ,[DATE] 240 cc, 240 cc, 240 cc During an interview on [DATE] at 4:05 pm CNA A said the last shift she worked with CR #1 was on ,[DATE] from 6 am 2 pm. She said he usually ate 100% of his meals, but only ate half at breakfast and lunch. She said he also had not been drinking much. She said he usually needed at least two brief changes during a shift but had not had much urine output. She said she reported changes to the Unit Manager some time during the week of ,[DATE] but never received follow up. She said CR #1 was still not looking good and brought the information up to the Administrator because she felt that the nurses were not listening to her. She said, I'm the main one that works with him and this is not him. She said the Administrator said they would just monitor CR #1. During an interview on [DATE] at 4:54 pm, the Unit Manager said he had been in the role since February 20th. He described CR #1 as alert and oriented, independent but needing supervision. He said within the last week CR #1 started developing a cough and wheezing. The physician was notified and ordered a STAT chest x ray. The chest x ray revealed [MEDICATION NAME]. The physician ordered antibiotics and breathing treatments. He said he was not aware of any other symptoms. When asked if staff had reported any changes in condition to him he said he remembered somebody saying he was eating less. He said he did not remember who told him that. He said following the treatments he was getting better and eating more. During a follow up interview on [DATE] at 1:40 pm, Unit Manager said the Administrator told him sometime last week that an aide reported a change in condition (coughing, wheezing, low appetite.) He said he informed the Administrator that a chest x ray was ordered, and CR#1 was confirmed to have [MEDICATION NAME] and had already started antibiotics. He said the physician was aware of the coughing and wheezing and he did not call the physician to report any other changes because he thought CR #1 was getting better. During an interview [DATE] at 3:50 pm, CNA F said she worked on [DATE] on CR #1's hall on the day shift. She said she was not assigned to him but remembered walking past his room around 11:,[DATE] pm and noticed he was lying in bed. When asked if she noticed any changes in his condition she said he had not been screaming for a bag of chips and a coke for a couple of days, which he usually did. She said CNA A also mentioned he had not produced much urine the past couple of days. During an interview on [DATE] at 2:20 pm CNA K said she was assigned to CR #1 on the evening shift of ,[DATE]. She said she did not normally work that wing but came in to cover a shift and no changes of condition were reported to her at shift change. She said CR #1 normally walked around at night, but he did not that night. She said he demanded food at midnight when she was rounding and provided him a snack which he ate. The aides further said not report this to the charge nurse . During an interview on [DATE] at 2:28 pm, LVN Z said she last worked with CR #1 on ,[DATE] and described his condition as good. She said his treatments were effective and his wheezing had calmed down. She said no changes in condition were reported to her that shift. She said she remembered being informed he ate 20% one day but could not recall what day it was. She said the Physician was not notified because for the most part He was eating but Sometimes he wanted you to feed him. She said it had not been reported that he was not drinking fluids. When asked how his change in condition was being monitored she said his O2 SATs and temperature were being checked 2 3 times per shift and documented in his clinical chart. During an interview [DATE] at 3:56 pm, CNA J said she worked with CR #1 on ,[DATE] from 6 am 2 pm. She said no changes of condition were reported to her at shift change and she did not observe any changes in CR #1's condition until his breathing was abnormal. She said she saw him around 8 am, changed his brief, and assisted him back to bed. She said around 8:30 am 9:30 am she passed his breakfast tray. When she picked up his tray she noted he ate around 75% of his meal and drank both milk and juice. Around 10 am he was naked in the hallway and she assisted back to his room and put on a new brief. She said while doing rounds around 11 am she was across the hallway caring for another resident and noticed CR #1's breathing was not good. She said she had never seen him breathing that way and immediately called LVN P who checked his O2 sat but they could not be read. She said CPR was started, EMS was called, but he was pronounced dead. Record review of CR #1's nursing note dated [DATE] and written at 5:02 pm revealed At 1030am The pt was seen naked outside the room and I rushed to him with a gown and asked the pt if he is ok and he said he wants to watch TV at the dinning so I walked with him so he wouldn't fall. At 1047am , I saw him walking toward his room and I helped him to his room and I asked if he is ok and he said yes thank you. At 1100am, I told my colleague (LVN P) I was going for break, At 11.10am I heard code blue and I rushed to his room, on getting there CPR was in process and 911 was called. At 12.03pm, he was pronounced dead. The doctor was notified of the situation and the guardian was called and I was given the (phone number) to call for them to come pick him up. At 1245pm the (police department) arrived and asked me questions. The note was signed by LVN C. During an interview on [DATE] at 5:34 pm, LVN C said she alternated between all wings. She said the last time she worked was ,[DATE] from 6 am 2 pm. She said she was familiar with CR #1 and described his condition as okay on ,[DATE]. She said no changes in condition were reported to her. She said when she made her initial rounds that morning he was sleeping. She said around 8 am he was in the restroom. She said she checked his vital signs around 9 am before administering his breathing treatment. When asked if she remembered his vitals she said they were Very stable and around 130 something. She said around 10:30 am she saw him naked and went to put a gown on him and walked him down to the TV room. She said he doesn't have a steady gait and was afraid he was going to fall. She said he had a behavior of walking around naked, but it was the first time she witnessed it. She said she did not do any assessment following that. She said at 10:45 am she saw him coming from the dining room and ran to him and helped him to the room. She said she saw him at 11 am and he said he was okay. She said she told LVN P she was going for a break and heard code blue shortly after. She said she ran to see what happened and saw a nurse perfuming CPR. She said she called CR #1's physician to give an update on his condition and was informed to send him to the emergency room , but he was pronounced dead around 12:03 pm. She said she called CR #1's guardian and was given a phone number to call to have the body picked up. When asked how his change in condition was being monitored she said his vitals were taken before and after breathing treatments. During an interview on [DATE] at 2:28 pm, CR #1's guardian said he last visited [DATE]th, 2020 and CR #1 was in bed sleep. He said he spoke with facility nursing staff who reported he had a [MEDICAL CONDITION] on ,[DATE] and shortness of breath. He said a voicemail was left from a facility staff member that said he died on ,[DATE] from pneumonia. He said, I did not know he had pneumonia. During an interview on [DATE] at 10:07 am, when asked how changes of condition were to be reported , the DON said we would like them to do the stop and watch form and give one to the nurse and unit manager. The nurse should go assess the resident and call the physician with the findings. She said nursing staff were responsible for informing resident's responsible party of any change in condition and updates to the treatment plan and documenting the communication in the clinical chart. Record review of the facility's policy on Changes in Condition dated February 2017 revealed Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring intervention; a significant change in the resident's attending physical, mental, or psychosocial status including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. If the attending physician cannot be reached, nursing attempts to contact the following providers in this order until a physician has been contacted. The facility DON, District Director of Clinical Services, and the Director of Operations were notified on [DATE] at 4:25 pm that immediate jeopardy was identified due to the above failures, a copy of the IJ template was provided at this time and a plan of removal was requested. The final plan of removal was accepted on [DATE] at 4:37 p.m. after several revisions were made. IJ/IT/SQC [DATE] Plan of Removal In services were immediately initiated [DATE] 6 PM by the Director of Nursing on the following topics to include all nursing staff and managers and will be completed [DATE] at 6 pm. Change In Condition (to include what a change in condition is, documentation, physical assessment and notifications of Resident Physician and Responsible Party) Monitoring of Resident's with a recent Change of Condition Laboratory Result Review and Notifications that includes ensuring all changes are communicated accurately and timely to Physician and Responsible Party. Laboratory Results are faxed to facility once results are available. Results are delivered to charge nurse responsible for residents care. Abnormal or Critical results are reported to physician immediately. Results and Interventions are then communicated to the responsible party. Abuse / Neglect Prohibition Interact / Stop and Watch for Resident Care Specialist and Medication Aides to alert Licensed Nurses of Changes in Condition and ensure adequate follow up. Training will include notifying Charge Nurses of changes in behavior, skin, bowel and bladder, mental / physical wellness, refusal of care and meal intakes. Training will also include reporting to Nurse Managers and DON when staff feels appropriate action has not been taken. 24 Hour Summary Reports (Auto Generated) from Point Click Care will be utilized for shift to shift report to ensure continuity of care. *Staff unable to attend by set date will be educated prior to the start of their subsequent shift. DON/Nurse Managers / Designees reviewed all residents in the facility to ensure there were no unidentified changes of condition not appropriately addressed after receiving change in condition education from the District Director of Clinical Services on [DATE]. This will be done by reviewing residents temp, oxygen saturation and signs and symptoms of respiratory illness (cough, sore throat, fever). Grand Rounds were conducted by DON and Nurse Managers which included assessing residents for any possible change in condition. This was completed [DATE] 9 pm with no adverse findings. DON/Nurse Managers/Designees will review all lab work performed from [DATE] to present day. Critical/Abnormal results will be reviewed and ensure physician was notified, interventions obtained as indicated and Responsible Party aware. This will be completed by [DATE] 6 PM. Residents with noted changes in condition will be reviewed from [DATE] to present day to ensure the change in condition was appropriately addressed and that the resident's Responsible Party and Physician were notified of the change in condition. This will be completed by [DATE]. ADHOC QAPI meeting with Medical Director held [DATE] at 8 PM to discuss the following processes: DON / Designee will review and log all Changes of Condition. Changes of Condition will be reviewed for accurate assessments including vital signs, physical assessment, interventions and notifications of Responsible Party and Physician. Staff will document findings of a change in condition in an SBAR format. DON / Designee will review all lab results in morning meeting and stand down meeting. Abnormal / Critical lab values will be reported to Physician immediately, interventions will be obtained as indicated and RP will be notified. Residents logged with changes of condition will receive follow up documentation minimally daily until the condition is resolved. Staff will document findings in the progress notes. These findings will be reviewed by the DON/Nurse Managers in the morning meeting and stand down meetings to ensure compliance. Licensed Nurses will utilize 24 Hour Summary Report out of Point Click Care for shift to shift reporting to ensure continuity of care. This 24 hour summary report includes all residents noted with a change in condition, progress notes noted during the reporting time frame and UDAs completed during the reporting time frame. Nurse Managers will utilize 24 hour Summary reports to conduct morning meetings and discuss any residents with changes in condition. Resident Care Specialist will utilize the INTERACT / Stop and Watch Program to alert licensed nurses of changes in condition in residents. Licensed Nurses will follow the Change in Condition Protocols and DON / Nurse Managers will receive a copy of the Stop and Watch to ensure adequate follow up. DON/Designee will conduct ground rounds on residents identified with a change in condition to validate assessment findings and intervention effectiveness. Monitoring Monitoring of the plan to remove the immediate jeopardy was conducted daily at various times from [DATE] until [DATE]. Interviews with 4 CNAs on ,[DATE] and ,[DATE] revealed they were able to identify what a change in condition was and the process for reporting the changes. They were able to state what to do if reported changes had not been followed up with. They were able to state the types of abuse and examples of abuse and neglect. They were able to identify the Abuse Prohibition Coordinator and when he should be notified. Interview with 6 licensed nursing staff on ,[DATE] and ,[DATE] revealed they were able to state their responsibility when a change in condition was reported to them and who to notify. They stated they were responsible for documenting on the SBAR, and nurse's notes when communication with the physician and responsible party were made. They said how they plan to monitor residents with identified changes in condition and communicate to the following shift. They were able to state how lab results are received, documented, and communicated to physicians especially if results are abnormal. They said the 24 hour report was utilized to identify changes in condition and reviewed each shift. Record review of documents provided revealed training in services dated [DATE] and [DATE] were conducted with nursing staff on all shifts which included change in condition, lab results, and abuse/neglect. The lab sheets revealed residents with labs were logged. Those whose labs were already drawn had the proper entities notified and documentation in the resident's clinical chart. Those with upcoming labs were also logged. Residents with identified changes of condition were logged. Their clinical records were reviewed and revealed documentation that there was continued follow up. On [DATE], the facility DON was notified that IJ was lowered but the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continuing to educate their staff and monitor the effectiveness of the Plan of Removal.

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person centered care plan for one of 8 residents (CR #1) reviewed for quality of care. The facility staff failed to assess CR#1 , obtain and document current vitals when CR #1 was identified to have a change in condition. The facility staff failed to inform CR #1's physician of abnormal lab (Complete blood count) results. The facility staff failed to assess and monitor CR #1 when changes in his condition were reported to the charge nurses, unit manager, and the facility administrator. The changes were not reported to the physician , communicated to in coming staff and were not documented on the residents' change in condition assessment form. CR #1 was found unresponsive on [DATE] with unreadable O2 saturation level and he was pronounced dead one hour late at the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures could affect any resident who experiences a change in their condition in the facility placing them at risk complication from delay in medical intervention. Findings include: CR #1 Record review of CR #1's face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was a full-code. Record review of CR #1's Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. He required extensive assistance of one staff for toileting and hygiene, limited assistance of one staff for dressing, and was independent of all other ADLs. He ambulated without any devices. He was always incontinent of bowel and bladder. He was not on hospice and was not coded as having any behaviors. Record review of CR #1's care plan dated [DATE] revealed he had a respiratory infection related to [MEDICATION NAME] pneumonia. The goal was he would be free of signs and symptoms of infection by the review date. interventions included antibiotics and treatments per the physician orders, recording vitals, documenting side effects, and changing positions at regular and frequent intervals especially if in bed. Record review of CR #1's chest x-ray dated [DATE] revealed Bilateral perihilar fullness, nonspecific in nature, possibly due to perihilar atelectasis ( Collapse of lungs) , adenopathy (disease of the lymph nodes), developing [MEDICATION NAME] (acute inflammation of the bronchi, accompanied by inflamed patches in the nearby lobules of the lungs). Consider central venous congestion or [MEDICAL CONDITION] arterial hypertension if indicated by symptomatic presentation, other testing or medical history. Continued follow-up recommended. Minimally worse compared to [DATE]. During an interview on [DATE] at 4:05 pm CNA A said she worked with CR #1 frequently and knew his usual behaviors/care needs. She said in February he was breaking out in sweats, and she asked the nurse to check his vitals. She said CR #1's physician ordered a chest x-ray. She said he was diagnosed with [REDACTED]. She said he was getting antibiotics and got better, but the sweating returned the week of ,[DATE] and got progressively worse than the previous time. Record review of CR #1's physician's orders [REDACTED]. -Inhale [MEDICATION NAME]-[MEDICATION NAME] Solution .5 - 2.5 (3) MG/3ML every 8 hours ordered [DATE]. Record review of CR #1's MAR/TAR dated February 2020 revealed he refused breathing treatments on ,[DATE] at 6 am, ,[DATE] at 6 am, ,[DATE] at 10 pm, ,[DATE] at 2 pm, ,[DATE] at 6 am and 2 pm, ,[DATE] at 6 am, and ,[DATE] at 6 am. Record review of CR #1's nursing notes for February 2020 revealed no documentation indicating his physician was notified of the missing breathing treatments. During an interview on [DATE] at 11:53 am, the Physician said she was the point of contact for any changes in condition regarding CR #1's care. She said when he was receiving breathing treatments in February due to [MEDICATION NAME] she was never informed of any treatment refusals. During an interview on [DATE] at 2:28 pm, CR #1's guardian said he last visited [DATE]th, 2020 and CR #1 was in bed sleep. When asked if he was aware of the pneumonia and treatments from a month prior he said he was not made aware of the [DIAGNOSES REDACTED]. Record review of CR #1's SBAR dated [DATE] 2:07 pm revealed Patient alert with coughing noted. Upon auscultating lungs sounds, wheezing is noted. (Physician) notified and assessed resident and gave order for STAT chest X RAY and [MEDICATION NAME] Treatments- ( Breathing inhalation treatment ) V/S BP ,[DATE] P 78 RR 18 O2 SAT 98% at RA T 98.6. RP notified. The respirations were dated ,[DATE] and the blood pressure, O2 SATs and pulse were dated ,[DATE]. The statement This condition, symptom, or sign has occurred before was coded with no. He had no mental status changes and no functional status changes including needing more assistance, decreased mobility, or weakness. Under respiratory, abnormal lung sounds, wheezing and a productive cough were documented. There were no urine changes indicated including decreased urine output. It was documented that CR #1's RP was notified at 2:10 pm. The assessment was signed by RN A. During a telephone interview on [DATE] at 11:25 am RN A said she was new to the facility. When asked about CR #1's SBAR she completed on [DATE] she said, I don't remember that person. She said she was shadowing a nurse (LVN C) who was showing her how to enter the information, but she could not recall if she did the assessment or notified the Physician and responsible party. During an interview on [DATE] at 4:05 pm CNA A said around [DATE] CR #1 was sweating needing more assistance with ADLs when he usually followed cues. She said when changing his brief, he would not roll like usual and she would have to assist him. She said he was also slow with eating and drinking which was abnormal. She said she informed the nurses for several days of his changes in condition, and kept asking and kept asking for CR #1 to be assessed ( LVN C and LVN Z) . She said there was never any follow up from the nurses. She said she reported changes again to the charge nurse on an unknown date and took his temperature and she said, well he doesn't have a fever. On ,[DATE] The physician was in the building and ordered another chest x ray. The results came back that he had [MEDICATION NAME]. She said the nurse LVN Z informed her he would be started on antibiotics and breathing treatments. She asked LVN Z what about IV fluids, because he hasn't been drinking much. She said LVN Z responded, Oh so you're a doctor now? She said the Wound Care Nurse was present during this and told LVN Z Sometimes when these CNAs tell yall something, they know what they're talking about. During an interview on [DATE] at 12:45 pm the Wound Care Nurse said she was responsible for treating CR #1's wound. She said on ,[DATE] she noticed he did not look good. She said he had been sleeping more, talking less, and did not ask for a soda as he usually did. She said CNA A told her LVN Z was already informed of the changes. She said LVN Z Took CR #1's vitals and said they looked good. She said CNA A again told LVN Z that CR #1 was still not looking like himself although his vitals were not abnormal. She said she told LVN Z that the vital signs were not the only indicator that something was wrong and the CNAs knew the residents best . She said the physician was called and new orders were received. She said she did not notice any other changes on ,[DATE] and ,[DATE]. Record review of CR #1's physician notes revealed the following: [DATE] I was asked to evaluate patient with wheezing. Today seen patient resting in bed in no acute distress. She noted he had scattered wheezes all throughout . Further review revealed Later in the evening around 6 pm I was called with chest x ray results that reported [MEDICATION NAME] and was started on [MEDICATION NAME]. The note was signed by the Physician. [DATE] Today seen patient resting in bed no acute distress. Received first dose of [MEDICATION NAME] -antibiotic today. The note indicated he had wheezing and cough, but also said clear to auscultation without wheezes or rhonchi. The last labs that were reviewed were from [DATE]. The note was signed by the Physician. Record review of CR #1's physician orders [REDACTED]. [MEDICATION NAME] tablet 875 125 mg one tablet by mouth every 12 hours for 7 days ordered [DATE] [MEDICATION NAME] Solution .5 2.5 (3) MG/ML 3 ML orally four times a day for wheezing for 7 days ordered [DATE]. Record review of CR #1's lab results dated [DATE] revealed a high white blood count of 10.9 ( high, indicative of infection) . The normal range was 4.2 - 9.1. Record review of CR #1's MAR/TAR dated [DATE] revealed he started [MEDICATION NAME] on the second shift on ,[DATE] at 9 pm. Further review revealed he had wheezing after receiving the nebulizer after each treatment except the last treatment on [DATE] and the one on [DATE]. During an interview on [DATE] at 11:53 am, the Physician said she was the point of contact for any changes in condition regarding CR #1's care. When asked if she was informed of any recent changes in condition she said she was called when CR #1 had a cough and wheezing. She said his chest x ray came back positive for [MEDICATION NAME] and she started him on [MEDICATION NAME] twice a day and breathing treatments four times a day. She said he had a standing weekly CBC order and she reviewed the labs on Mondays. She said if labs were abnormal the nursing staff would call her, but she was unaware of his abnormal labs on ,[DATE]. She said she last visited on that day and he was his usual self. She said he still had a cough but no wheezing. She said facility staff did not inform her of changes in condition including eating less, drinking less, taking off clothes, sweating, sleeping, and wheezing any time after ,[DATE]. She said had those changes been reported to her she would have changed the treatment, to include IV fluids, broader lab work, and vital checks every 4 hours. Record review of CR #1's care plan dated [DATE] revealed he had [MEDICATION NAME] infection and receiving antibiotics. The goal was he would be free of complications related to the infection through the review date. interventions included antibiotics treatments per the physician order [REDACTED]. Record review of CR #1's point of care documentation completed by aides dated [DATE] revealed his fluid intake on the three shifts as follows: ,[DATE] 480 cc, 480 cc, 240 cc ,[DATE] 480 cc, 240 cc, 120 cc ,[DATE] 240 cc, 240 cc, nothing documented ,[DATE] 480 cc, 360 cc, 240 cc ,[DATE] 240 cc, 240 cc, 240 cc During an interview on [DATE] at 4:05 pm CNA A said the last shift she worked with CR #1 was on ,[DATE] from 6 am 2 pm. She said he usually ate 100% of his meals, but only ate half at breakfast and lunch. She said he also had not been drinking much. She said he usually needed at least two brief changes during a shift but had not had much urine output. She said she reported changes to the Unit Manager some time during the week of ,[DATE] but never received follow up. She said CR #1 was still not looking good and brought the information up to the Administrator because she felt that the nurses were not listening to her. She said, I'm the main one that works with him and this is not him. She said the Administrator said they would just monitor CR #1. During an interview on [DATE] at 4:54 pm, the Unit Manager said he had been in the role since February 20th. He described CR #1 as alert and oriented, independent but needing supervision. He said within the last week CR #1 started developing a cough and wheezing. The physician was notified and ordered a STAT chest x ray. The chest x ray revealed [MEDICATION NAME]. The physician ordered antibiotics and breathing treatments. He said he was not aware of any other symptoms. When asked if staff had reported any changes in condition to him he said he remembered somebody saying he was eating less. He said he did not remember who told him that. He said following the treatments he was getting better and eating more. During a follow up interview on [DATE] at 1:40 pm, Unit Manager said the Administrator told him sometime last week that an aide reported a change in condition (coughing, wheezing, low appetite.) He said he informed the Administrator that a chest x ray was ordered, and CR#1 was confirmed to have [MEDICATION NAME] and had already started antibiotics. He said the physician was aware of the coughing and wheezing and he did not call the physician to report any other changes because he thought CR #1 was getting better. During an interview [DATE] at 3:50 pm, CNA F said she worked on [DATE] on CR #1's hall on the day shift. She said she was not assigned to him but remembered walking past his room around 11:,[DATE] pm and noticed he was lying in bed. When asked if she noticed any changes in his condition she said he had not been screaming for a bag of chips and a coke for a couple of days, which he usually did. She said CNA A also mentioned he had not produced much urine the past couple of days. During an interview on [DATE] at 2:20 pm CNA K said she was assigned to CR #1 on the evening shift of ,[DATE]. She said she did not normally work that wing but came in to cover a shift and no changes of condition were reported to her at shift change. She said CR #1 normally walked around at night, but he did not that night. She said he demanded food at midnight when she was rounding and provided him a snack which he ate. The aides further said not report this to the charge nurse . During an interview on [DATE] at 2:28 pm, LVN Z said she last worked with CR #1 on ,[DATE] and described his condition as good. She said his treatments were effective and his wheezing had calmed down. She said no changes in condition were reported to her that shift. She said she remembered being informed he ate 20% one day but could not recall what day it was. She said the Physician was not notified because for the most part He was eating but Sometimes he wanted you to feed him. She said it had not been reported that he was not drinking fluids. When asked how his change in condition was being monitored she said his O2 SATs and temperature were being checked 2 3 times per shift and documented in his clinical chart. During an interview [DATE] at 3:56 pm, CNA J said she worked with CR #1 on ,[DATE] from 6 am 2 pm. She said no changes of condition were reported to her at shift change and she did not observe any changes in CR #1's condition until his breathing was abnormal. She said she saw him around 8 am, changed his brief, and assisted him back to bed. She said around 8:30 am 9:30 am she passed his breakfast tray. When she picked up his tray she noted he ate around 75% of his meal and drank both milk and juice. Around 10 am he was naked in the hallway and she assisted back to his room and put on a new brief. She said while doing rounds around 11 am she was across the hallway caring for another resident and noticed CR #1's breathing was not good. She said she had never seen him breathing that way and immediately called LVN P who checked his O2 sat but they could not be read. She said CPR was started, EMS was called, but he was pronounced dead. Record review of CR #1's nursing note dated [DATE] and written at 5:02 pm revealed At 1030am The pt was seen naked outside the room and I rushed to him with a gown and asked the pt if he is ok and he said he wants to watch TV at the dinning so I walked with him so he wouldn't fall. At 1047am , I saw him walking toward his room and I helped him to his room and I asked if he is ok and he said yes thank you. At 1100am, I told my colleague (LVN P) I was going for break, At 11.10am I heard code blue and I rushed to his room, on getting there CPR was in process and 911 was called. At 12.03pm, he was pronounced dead. The doctor was notified of the situation and the guardian was called and I was given the (phone number) to call for them to come pick him up. At 1245pm the (police department) arrived and asked me questions. The note was signed by LVN C. During an interview on [DATE] at 5:34 pm, LVN C said she alternated between all wings. She said the last time she worked was ,[DATE] from 6 am 2 pm. She said she was familiar with CR #1 and described his condition as okay on ,[DATE]. She said no changes in condition were reported to her. She said when she made her initial rounds that morning he was sleeping. She said around 8 am he was in the restroom. She said she checked his vital signs around 9 am before administering his breathing treatment. When asked if she remembered his vitals she said they were Very stable and around 130 something. She said around 10:30 am she saw him naked and went to put a gown on him and walked him down to the TV room. She said he doesn't have a steady gait and was afraid he was going to fall. She said he had a behavior of walking around naked, but it was the first time she witnessed it. She said she did not do any assessment following that. She said at 10:45 am she saw him coming from the dining room and ran to him and helped him to the room. She said she saw him at 11 am and he said he was okay. She said she told LVN P she was going for a break and heard code blue shortly after. She said she ran to see what happened and saw a nurse perfuming CPR. She said she called CR #1's physician to give an update on his condition and was informed to send him to the emergency room , but he was pronounced dead around 12:03 pm. She said she called CR #1's guardian and was given a phone number to call to have the body picked up. When asked how his change in condition was being monitored she said his vitals were taken before and after breathing treatments. During an interview on [DATE] at 2:28 pm, CR #1's guardian said he last visited [DATE]th, 2020 and CR #1 was in bed sleep. He said he spoke with facility nursing staff who reported he had a [MEDICAL CONDITION] on ,[DATE] and shortness of breath. He said a voicemail was left from a facility staff member that said he died on ,[DATE] from pneumonia. He said, I did not know he had pneumonia. During an interview on [DATE] at 10:07 am, when asked how changes of condition were to be reported , the DON said we would like them to do the stop and watch form and give one to the nurse and unit manager. The nurse should go assess the resident and call the physician with the findings. She said nursing staff were responsible for informing resident's responsible party of any change in condition and updates to the treatment plan and documenting the communication in the clinical chart. Record review of the facility's policy on Changes in Condition dated February 2017 revealed Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring intervention; a significant change in the resident's attending physical, mental, or psychosocial status including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. If the attending physician cannot be reached, nursing attempts to contact the following providers in this order until a physician has been contacted. The facility DON, District Director of Clinical Services, and the Director of Operations were notified on [DATE] at 4:25 pm that immediate jeopardy was identified due to the above failures, a copy of the IJ template was provided at this time and a plan of removal was requested. The final plan of removal was accepted on [DATE] at 4:37 p.m. after several revisions were made. IJ/IT/SQC [DATE] Plan of Removal In services were immediately initiated [DATE] 6 PM by the Director of Nursing on the following topics to include all nursing staff and managers and will be completed [DATE] at 6 pm. Change In Condition (to include what a change in condition is, documentation, physical assessment and notifications of Resident Physician and Responsible Party) Monitoring of Resident's with a recent Change of Condition Laboratory Result Review and Notifications that includes ensuring all changes are communicated accurately and timely to Physician and Responsible Party. Laboratory Results are faxed to facility once results are available. Results are delivered to charge nurse responsible for residents care. Abnormal or Critical results are reported to physician immediately. Results and Interventions are then communicated to the responsible party. Abuse / Neglect Prohibition Interact / Stop and Watch for Resident Care Specialist and Medication Aides to alert Licensed Nurses of Changes in Condition and ensure adequate follow up. Training will include notifying Charge Nurses of changes in behavior, skin, bowel and bladder, mental / physical wellness, refusal of care and meal intakes. Training will also include reporting to Nurse Managers and DON when staff feels appropriate action has not been taken. 24 Hour Summary Reports (Auto Generated) from Point Click Care will be utilized for shift to shift report to ensure continuity of care. *Staff unable to attend by set date will be educated prior to the start of their subsequent shift. DON/Nurse Managers / Designees reviewed all residents in the facility to ensure there were no unidentified changes of condition not appropriately addressed after receiving change in condition education from the District Director of Clinical Services on [DATE]. This will be done by reviewing residents temp, oxygen saturation and signs and symptoms of respiratory illness (cough, sore throat, fever). Grand Rounds were conducted by DON and Nurse Managers which included assessing residents for any possible change in condition. This was completed [DATE] 9 pm with no adverse findings. DON/Nurse Managers/Designees will review all lab work performed from [DATE] to present day. Critical/Abnormal results will be reviewed and ensure physician was notified, interventions obtained as indicated and Responsible Party aware. This will be completed by [DATE] 6 PM. Residents with noted changes in condition will be reviewed from [DATE] to present day to ensure the change in condition was appropriately addressed and that the resident's Responsible Party and Physician were notified of the change in condition. This will be completed by [DATE]. ADHOC QAPI meeting with Medical Director held [DATE] at 8 PM to discuss the following processes: DON / Designee will review and log all Changes of Condition. Changes of Condition will be reviewed for accurate assessments including vital signs, physical assessment, interventions and notifications of Responsible Party and Physician. Staff will document findings of a change in condition in an SBAR format. DON / Designee will review all lab results in morning meeting and stand down meeting. Abnormal / Critical lab values will be reported to Physician immediately, interventions will be obtained as indicated and RP will be notified. Residents logged with changes of condition will receive follow up documentation minimally daily until the condition is resolved. Staff will document findings in the progress notes. These findings will be reviewed by the DON/Nurse Managers in the morning meeting and stand down meetings to ensure compliance. Licensed Nurses will utilize 24 Hour Summary Report out of Point Click Care for shift to shift reporting to ensure continuity of care. This 24 hour summary report includes all residents noted with a change in condition, progress notes noted during the reporting time frame and UDAs completed during the reporting time frame. Nurse Managers will utilize 24 hour Summary reports to conduct morning meetings and discuss any residents with changes in condition. Resident Care Specialist will utilize the INTERACT / Stop and Watch Program to alert licensed nurses of changes in condition in residents. Licensed Nurses will follow the Change in Condition Protocols and DON / Nurse Managers will receive a copy of the Stop and Watch to ensure adequate follow up. DON/Designee will conduct ground rounds on residents identified with a change in condition to validate assessment findings and intervention effectiveness. Monitoring Monitoring of the plan to remove the immediate jeopardy was conducted daily at various times from [DATE] until [DATE]. Interviews with 4 CNAs on ,[DATE] and ,[DATE] revealed they were able to identify what a change in condition was and the process for reporting the changes. They were able to state what to do if reported changes had not been followed up with. They were able to state the types of abuse and examples of abuse and neglect. They were able to identify the Abuse Prohibition Coordinator and when he should be notified. Interview with 6 licensed nursing staff on ,[DATE] and ,[DATE] revealed they were able to state their responsibility when a change in condition was reported to them and who to notify. They stated they were responsible for documenting on the SBAR, and nurse's notes when communication with the physician and responsible party were made. They said how they plan to monitor residents with identified changes in condition and communicate to the following shift. They were able to state how lab results are received, documented, and communicated to physicians especially if results are abnormal. They said the 24 hour report was utilized to identify changes in condition and reviewed each shift. Record review of documents provided revealed training in services dated [DATE] and [DATE] were conducted with nursing staff on all shifts which included change in condition, lab results, and abuse/neglect. The lab sheets revealed residents with labs were logged. Those whose labs were already drawn had the proper entities notified and documentation in the resident's clinical chart. Those with upcoming labs were also logged. Residents with identified changes of condition were logged. Their clinical records were reviewed and revealed documentation that there was continued follow up. On [DATE], the facility DON was notified that IJ was lowered but the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continuing to educate their staff and monitor the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and ensure each resident received adequate supervision and assistance to prevent accidents for 5 of 8 residents (Residents #1, #2, #3, #4 and #5) reviewed for accidents and hazards. The facility failed to ensure Resident #1, who had a [DIAGNOSES REDACTED].#5 and punching Resident #4 causing skin tears to her forehead. The facility failed to ensure Resident #1 was properly supervised to prevent reoccurring altercations with other residents. The facility failed to ensure Resident #2, whose vision was impaired and who had a known fall history, had necessary assistance and supervision to prevent her from falling out of the bed . Resident #2 sustained right globe ( Eye socket ) rupture . The facility failed to ensure Resident #3, who had a history of [REDACTED]. Resident #3 had a fall and sustained facial bruising. These failures could affect any resident who require assistance or supervision. Findings included: Resident #1 Record review of Resident #1's face sheet dated 1/13/20 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's nursing note dated 11/20/19 revealed It was brought to nurse's attention today that yesterday evening, resident slapped another resident (Resident #5) in the face while she was wheeling past her room out of nowhere. NP was notified via call center. Spoke with (physician) at Deer Oaks whom stated that she will notify clinical nurse whom will come out to visit resident and assess. Resident has not had any behavior problems this shift, will continue to monitor. The note was signed by LVN #2. Record review of Resident #1's social services note dated 11/21/19 revealed Social Worker spoke with resident regarding behaviors. Resident informed (social worker) that she does not recall any inappropriate behaviors that had taken place over the last week. (Social Worker) will attempt to speak with resident again regarding inappropriate behaviors. The note was signed by the Social Worker. Record review of Resident #1's nursing note dated [DATE] revealed (Psych physician) gave written orders to start resident on [MED] 10mg PO daily d/t [MEDICAL CONDITION] and disorganized behavior. (Psych physician) also gave verbal orders to send resident out if aggressive behavior towards staff/ resident is observed. The note was signed by LVN #2. Record review of Resident #1's social services note dated 1/14/20 revealed Resident had a care plan meeting with the IDT. It was discussed that nursing home placement may no longer be appropriate for resident due to her noncompliance and aggressive behavior. Resident's guardian was open to transferring resident to either an independent setting, personal care home or long-term psychiatric inpatient. The note was signed by the Social Worker. Record review of Resident #1's quarterly MDS dated [DATE] revealed she had unclear speech but was usually understood by others. She had a BI[CONDITION] score of 9 indicating moderate cognitive impairment. She continuously had disorganized thinking. She had physical and verbal behaviors 4-6 days out of the 7 day look back period and other behavioral symptoms not directed toward others 1-3 days. She required limited assistance for dressing, toileting, and personal hygiene. She was independent with all other ADLs. She used a wheelchair to ambulate and was able to stand without staff assistance. Record review of Resident #1's care plan dated 1/7/20 revealed had physical behaviors towards staff and other residents on occasions. The goal read I will be safe from wandering and other behaviors through the next review period. Interventions did not include anything related to physical behaviors. Further review revealed she had the potential to be verbally aggressive. Interventions included documenting observed behavior and attempted interventions. She was also care planned for refusing to take medications. Record review of Resident #1's monthly physician order [REDACTED]. Observation on 2/4/20 at 9:05 am Resident #1 was in the hallway near her room yelling. There were no residents/staff in the vicinity. She was unable to be understood. After a few minutes of no staff intervention she stopped yelling. Record review of Resident #1's incident report dated 1/12/20 revealed Resident #1 alleged Resident #4 came into her room and punched her in the head, so she retaliated by punching Resident #4 back. Further review of incident report revealed no one saw Resident #4 go into Resident #1's room. Observation and interview on 2/4/20 at 10:05 am revealed Resident #1 sitting in a wheelchair outside of her room. When asked how long she lived in the facility she said a long time. She was hard to understand due to her tongue protruding out of her mouth and no observed teeth. When asked if she had any altercations with other residents she said she got along with everyone. During an interview on 2/4/20 at 12:41 pm, RN #1 said Resident #1 was recently readmitted to the facility following hospitalization . She said Resident #1 was still very aggressive. She said their interventions were to just keep documenting whenever she got aggressive and watching her. When asked what should be documented as a behavior on the behavior monitoring log she said if Resident #1 was physically aggressive. Record review of Resident #1's behavior monitoring for January 2020 revealed no documented behaviors. Examples of behaviors included agitation, kicking, cursing, delusions, hallucinations, [MEDICAL CONDITION], and refusing care. Record review of Resident #1's nursing note dated 1/6/20 revealed Resident in (room number) and transportation personnel were passing by Resident #1's room and resident un-provokingly threw coffee at them. Hitting the side of Resident #1's face and the left side of the transportation driver's arm. Resident was assessed and no complaints of pain were noted and no redness noted on face. Nurse asked resident why did she throw coffee at them and she stated because they were talking about her. Nurse was a few feet away from the incident when it happened and notes that resident did not say anything to her. NP was notified via call center and (psych service) was notified as well. Resident currently in room with the door closed. Will continue to monitor. The note was signed by LVN #2. Record review of Resident #1 's care plan revealed update to her care plan following above incident of aggressive behavior towards orders. Record review of Resident #1's nursing note dated 1/8/20 revealed 2 RCS witnessed Resident #1 wheeling herself towards Resident #4 room and hit her in the face with her bare hands. After hitting her, Resident #1 then pushed Resident #4 wheelchair into the room of Resident #4. By the time both RCS got to the scene, Resident #1 had already wheel herself away from the room. RCS then wheeled Resident #4 to the nursing station to call attention to the nurses on duty. Resident #4 was assessed and noted to have a small cut on her forehead. Area was cleaned with NS and band-aid applied. When asked if resident was in pain, resident shook her head and said no. No hematoma noted, no swelling or bruising at the moment. NP was notified of incident and did not give orders to send out but stated to clean area with NS until healed. DON as well as Administrator was notified. CIT (crisis intervention team) was called to have resident escorted out of facility d/t aggressive behavior towards other residents. Nuero VS will be initiated Q4hrsX24hrs per facility policy for Resident #4. Resident #1 was transported by wheelchair by 2 CIT members whom then placed resident on public transportation. Nurse was told that resident will be going to (hospital) for eval. Face sheet was given to transporters and resident left around 10:30am. Both RP's were contacted but could not reach so nurse left message. The note was signed by LVN #2. Record review of Resident #1's nursing note dated 1/8/20 revealed Resident noted to have this morning resident to resident negative contact, 2 HPD officers on site to investigate complaint. Dr. notified order received to send to hospital NPC at local hospital . Public transportation. left transportation here to pick this resident up for transport. Resident was escorted out of the building by the 2 HPD officers. Resident departed at 10:22am. The note was signed by Nurse A. Record review of the facility's provider investigation report dated 1/8/20 revealed Resident #1 and Resident #4 were involved in a resident-to-resident altercation on 1/8/20 near the hallway by their rooms. Resident #1 required no special supervision, needed minimal assistance, non-interviewable and was not independently ambulatory. She had a history of [REDACTED]. Resident #4 required extensive assistance and required no special supervision. She was not interviewable or independent ambulatory. She did not have the capacity to make informed decisions. Resident #1 wheeled herself towards Resident #4's room and hit her in the face with her first. Resident #1 then pushed Resident #4's wheelchair pushing her into the door. Resident #4 was assessed, and a cut was observed on her forehead. She was treated in-house. Resident #1 was sent out for a psychiatric evaluation. During an interview on 2/4/20 at 12:50 pm, CNA #5 said she was responsible for Resident #1 on the 6am - 2pm shift. She said Resident #1 made a lot of noise and was always angry. She said she did not interact so much to avoid Resident #1 becoming aggressive. When asked about physical behaviors she said she heard a worker was walking by and Resident #1 threw coffee on them. She said she also saw Resident #1 beat another resident. She said Resident #1 punched Resident #4 in the forehead after alleging Resident #4 went into her room. CNA #5 said staff avoid her to not cause further agitation. She said if visitors got too close she warned them of her behaviors and possible escalation. Record review of Resident #1's behavior monitoring for February 2020 revealed no documented behaviors. Examples of behaviors included agitation, kicking, cursing, delusions, hallucinations, [MEDICAL CONDITION], and refusing care. Observation on 2/4/10 at 3:00 pm revealed Resident #1 sitting in the lobby entrance in her wheelchair. She had a styrofoam cup of coffee and was talking to herself. She could not be understood. During an interview on 2/6/20 at 1:45 pm, the Social Worker said she had been employed at the facility since January 2019. Social Worker said Resident #1 had a communication barrier due to her tongue hanging out of her mouth, but she was able to understand [AGE]% of what Resident #1 said. When asked about her behaviors she said, Some days she's up to here and we can't figure out why. She said Resident #1 had psychiatric [DIAGNOSES REDACTED]. She said Resident #1 was usually more verbally aggressive than physically aggressive. She can stand up and be in your face in a minute. When she's sweet she's sweet and when she's not she's not. When asked about her physical aggression she said the last reported incident was when Resident #1 hit Resident #4. Resident #1 was transferred to a hospital and was supposed to go to the neuro part but it was full so they took her to the hospital part. She said it was also reported to her by staff that Resident #1 threw coffee on transportation personnel shortly before that incident. She said they have been trying to find her another placement but has been denied because of her behaviors When asked about the interventions put into place regarding her behaviors she said although Resident #1 was in a room to herself, although she should have a roommate. She was also being seen by the psychologist and psychiatrist. When asked how residents are being protected from Resident # 1, she said If anything goes on we pretty much try to address it. When asked how staff ensure that no other altercations happen she said, Being available and doing frequent checks. She said no residents have voiced being afraid of her. During an interview on 2/10/20 at 11:20 am the NP said she had been over Resident #1's care for 5-6 years. She said Resident #1's behaviors had been on and off for the past year following her medication refusals. She said Resident #1's aggression worsened towards the end of 2019 and was reported by the facility following any incidences. She said she would sometimes order [MEDICATION NAME] and requested staff send her out if she became physically aggressive. She said the first physical aggression incident reported to her that she remembered was a recent incident when Resident #1 poured coffee on someone. The NP said, She was not really aggressive until recently. When asked if she was informed about an incident in November where Resident #1 slapped another resident she said, I have to pull my notes. Usually they would call us when she does something. After reviewing her notes, she said she did not find any indicating she slapped a resident. She said she was informed of her punching another resident in which she was sent out to the hospital. The NP said, She's been calm since she came back. When asked if she provided any interventions to staff she said some of Resident #1's behaviors could be provoked by little things. She advised staff to walk away because the behaviors would escalate when trying to engage with her. During an interview on 2/10/20 at 10:45 am, the Administrator said Resident #1 was usually verbally abusive not physical. He said following the incident with Resident #4, Resident #1 was handcuffed by officers and sent to the hospital due to behaviors. He said she refused everything and was readmitted days later. When asked why she was not sent to a psych hospital he said they usually did not accept patients without current behaviors. When asked what interventions were put in place to prevent reoccurrence he said, she pretty much stays in her room, but we monitor them frequently. He said they were working with Resident #1's guardian to get an appropriate placement. The incident report from Resident #1's altercation in November was requested. The DON said CNAs could get patient care information from the nurse. When asked if a in-service was conducted regarding Resident #1's behaviors the Administrator said the in-service covered managing behaviors in general but not specific to Resident #1. The DON said her expectations for documenting behaviors were that the nurse document anything erratic, physical, or verbal or anything that's disturbing in a behavioral note. She said she had not been informed by nursing staff of any behaviors from Resident #1. She said she had been at the facility for 3 weeks. During a follow-up interview on 2/10/20 at 11:10 am, RN #1 said when Resident #1 began refusing medications she would say I don't want it! I don't need it! She said they kept the physician aware who eventually discontinued all medications. During an interview on 2/10/20 at 1:20 pm, the Administrator said there was not an incident report or investigation report submitted to state agency for the incident in November. Observation on 2/11/20 at 10:36 am revealed Resident #5 She was curled in a ball lying in the bed making noises. She did not respond to questions. Resident #2 Record review of Resident #2's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Significant change in status MDS dated [DATE] revealed her vision was severely impaired. She had a BI[CONDITION] score of 0 indicating severe cognitive impairment. She was not coded as having any behaviors. Further review revealed she required extensive assistance of two people for transfers and extensive to total dependence of 1-2 staff on all other ADLs. She had upper extremity and lower extremity impairments on one side and used a wheelchair for ambulation. She was coded as having 1 fall with no injury and 1 fall with a non-major injury. Record review of Resident #2's care plan dated [DATE] revealed she had an ADL self-care performance deficit related to [MEDICAL CONDITION] and dementia. Further review revealed she required assistance of 1 staff for toileting, personal hygiene, and dressing. She required 1-2 staff for bathing, bed mobility, and transfers. Further review revealed she had falls on 12/14/18, 1/8/19, [DATE], 3/1/19, 3/3/19, 3/11/19, 8/28/19, 9/25/19 resulting in a laceration to the forehead, and 1/22/20 with a laceration above her right eye. Interventions included fall mats on the side of the bed, scoop mattress, and the bed in a low position. There were no new interventions following the 1/22 fall. Observation on 2/4/20 at 9:10 am, Resident #2 was lying in bed with a hospital gown on. Her eyes were squeezed closed. The base of the bed was about waist length height from the floor with fall mats on both sides. Record review of the facility's investigation report dated [DATE] revealed Resident #2 was sent to ER, staff was (educated) on fall prevention methods, witness was interviewed and was made to reenact the incident for clearer picture, he stepped away from bed to obtain brief from chest, resident was attempting to get up by hoisting her body over side of bed and raising her legs, before he could get to her, she had fallen over on the floor, the bed was in low position. (Family member) initially reported to facility resident had a facial fracture and lens displacement, ER records state a right ocular laceration without prolapse or loss of intraocular tissue, no fracture noted. Further review revealed staff were educated on fall prevention and safety. Precautions taken following the fall were the bed would remain in low position with fall mats next to the bolstered mattress. Record review of in-service dated [DATE] revealed the topic was fall prevention. There were 39 signatures. Record review of in-service dated [DATE] revealed the topic was understanding abuse and neglect. There were 56 signatures. Observation on 2/11/20 at 10:50 am revealed Resident #2 sitting in her wheelchair by the nurse's station. Her eyes were closed, and her right eye appeared darker than the left eye. There was a healing scar above her right eye. During an interview on 2/11/20 at 12:45 pm, LVN #5 Said Resident #2's fall interventions included fall mats and 2-person assistance for ADLs. During an interview on 2/11/20 at 1:30 pm, Resident #2's family member said she had frequent falls with 1/26/20 being the most recent fall. She said a CNA was caring for her and tried to get something off the counter when she fell off the bed causing a hole in her eye. She said she was hospitalized for [REDACTED]. They decided not to do surgery but she had heart problems that would further complicate the surgery according to family member. She said the fall was pretty bad this last time. She said she was confused because Resident #2 doesn't move around a lot when she's in the bed. She said she on most of her visits Resident #2 would stay in the same position the entire time. During an interview on 2/11/20 at 2:30 pm, CNA #2 said she worked in the facility for [AGE] years. When asked about how CNAs were informed about the resident's needs she said there was a RCS book at the nurse's station. When asked how much assistance Resident #2 required and she said usually 2-person assistance to prevent falls for transfers, and 2 people to change her. An unidentified CNA interjected and said Resident #2 was total assistance of 1 staff. When asked about safety precautions CNA #2 said having the bed in the lowest position and floor mats on both sides of the bed. The RCS book was requested and provided by CNA. LVN #5 said the RCS book CNA was referring to was something she did with her CNAs, but it was not something facility wide. During an interview on 2/11/20 at 3:00 pm, CNA #1 said he had worked in the facility for 1 year. He said one day around 2:15pm last month he wheeled Resident #2 back from the nurse's station. He said he moved one fall mat out of the way so she could transfer easier into the bed. He then assisted her into bed alone and undressed her to provide incontinent care. He said he went to her roommate's dresser to get a brief when he saw her swing her legs and fall off the side of the bed where there was no fall mat. He said he went to get the nurse who did an assessment. He described the bed as being all the way down when she fell . When asked how many staff should assist Resident #2 with her ADLs he said Preferably two, but mostly 1 because She's not that heavy of a person. He said Resident #2's left arm doesn't work but her right hand does. When asked how staff are aware of her care needs he said Resident #2's family member used to work in the admissions office and informed staff of her needs. When asked about her vision he said, She has good vision, but 90% of the time her eyes are closed. Record review of witness statement dated [DATE] revealed CNA #1 transferred Resident #2 into the bed, stepped away to get supplies and noticed her swing her legs over the bed and fall. Record review of Resident #2's SBAR dated 1/22/20 revealed Resident had a witness fall, assessment done, noted with blood and hematoma to right eye area, checked v/s and assisted resident to bed. Notified NP and obtained an order to transfer resident to (emergency room ) for evaluation. RP notified, resident picked up at this time. The form indicated there were no changes following the fall. Record review of Resident #2's pain evaluation dated 1/22/20 revealed she rated her pain 5/10 following the fall. Record review of Resident #2's Hospital records dated [DATE] revealed the reason for visit was right globe rupture. Further review revealed Patient sustained right-sided open globe injury with periorbital [MEDICAL CONDITION]. Ophthalmology was consulted and was initially planning surgical intervention for the open globe injury however given high risk for anesthesia and surgery without expectation for visual recovery, plan changed to non-operative management. At baseline patient is totally dependent on ADLs. During an interview on 2/11/20 at 4:11 pm the DON and Administrator were present. When asked how CNAs are aware of the needs of their residents, the DON said aides should go to the KARDEX which pulled information from the MDS. She said anything new should come from the nurse. The DON and Administrator were notified that SQC was identified in the area of Quality of Care. Resident #3 Record review of Resident #3's face sheet dated 2/12/20 revealed a [AGE] year-old female admitted to the facility 5/9/12. Her [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS dated [DATE] revealed she could not understand others or make herself understood. She had a BI[CONDITION] score of 6 indicating severe cognitive impairment. Further review revealed she required limited assistance of one person for dressing, toileting, and personal hygiene. She required supervision and setup help only for all other ADLs. She was coded as being occasionally continent of bowel and bladder and having one fall with an injury. Record review of Resident #3's Incident Report dated 1/20/20 and revised 2/12/20 revealed Housekeeper reported resident sitting on the floor with a (bloody) nose. Upon entering the room resident sitting on the floor with dried blood coming from the right nare, and a raised area on the right side of her forehead. The resident was noted to be wearing sweat socks. The resident does not speak English, but it appears that she may have been returning from the bathroom based on the position of the resident on the floor. The resident is unable to communicate how long she was sitting on the floor due to the dried blood on her face and head. The area raised to her forehead, had a slight abrasion with no active bleeding noted. Her teeth were intact, none noted to be loose, and her tongue was not bitten. Resident was able to visually tract and pupil response was good. Complaints of headache when asked. Denies dizziness. Further review revealed immediate actions included a head to toe assessment, neuro assessment, pain assessment, skin assessment, notify RP/MD/NM, updated care plan, safety interventions in place. She had an injury to her scalp and was not taken to the hospital. Record review of Resident #3's Care Plan dated 2/5/20 revealed I require walker and/or wheelchair with supervision/set-up of 1 staff assistance for transfers. I require supervision/limited assist of 1 staff with ambulating. Further review revealed I am at risk for falls because I have dementia which makes it hard for me to walk safely, I lose my balance, I often have an urgent need to go to the bathroom and rushing to get there sometimes causes me to fall, I sometimes choose not to ask for help when getting up or walking, I trip, and I refuse to wear non skid socks. The interventions included assisting her to the restroom and helping her walk. She was at risk for falls. She had a fall on 1/20/20 while ambulating in non-skid socks resulting in facial trauma, bruising and swelling. She had a fall on 2/10/20 with no injuries. Interventions included a PT evaluation ordered 1/20/20, ensure walker is in place, non-skid socks following fall on 11/9/19 Observation and interview on 2/11/20 at 12:45 pm, Resident #3 was sitting on the opposite side of the nurse's station with no other residents near. During interview with LVN #5, Resident #3 stood up. LVN called Resident #3's name and asked her to sit down so she would not fall. Resident #3 sat down. When asked what interventions were in place to ensure Resident #3 did not have any further falls, LVN said Resident #3 had gripper socks. When asked what kind of socks Resident #3 was currently wearing she said those were not the proper socks but Resident #3 would put those on. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the facility's fall policy dated November 2017 revealed When a fall occurs, the resident is assessed for injury by the nurse. The nurse communicates resident falls to the attending physician and the resident's representative.The nurse will discuss recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the care plan and progress notes.

Based on interview, and record review, the facility failed to ensure each resident was free from neglect for one of 14 residents (CR#1) reviewed for neglect The facility failed to promptly implement physician order [REDACTED]. The facility failed to coordinate service of the podiatrist to assess and treat CR#1 arterial ulcer to left great toe and left fifth toe as ordered by the physician in (MONTH) (YEAR) which caused a delay in acquiring needed tests to proceeded with treatment to affected left foot. CR#1 was diagnosed with [REDACTED]. These failures affected one resident and placed additional 138 in the facility at risk of neglect and decline in psychosocial, mental and health decline. Findings include: Intake # 1 and Intake # 8 Record review of CR#1's face-sheet revealed a [AGE] year old female, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's admission MDS dated [DATE] revealed a BIMS score of 1, indicating severe cognitive impairment. Further review of MDS revealed the resident required limited assist of one staff for bed mobility, and extensive assist of one staff for dressing, toilet use, and personal hygiene. MDS also revealed the resident was at risk for developing pressure ulcers. Record review of CR#1's significant change MDS dated [DATE] revealed a BIMS score of 1, indicating severe cognitive impairment. The MDS revealed the resident required extensive assist of one staff for bed mobility, dressing, and personal hygiene, and required extensive assist of two staff for transfers. The resident also required total assist of one staff for toilet use. Further review of the MDS revealed the resident was at risk for developing pressure ulcers and had [MEDICAL CONDITION]. Interview on 3/7/18 at 11:05am, MDS Coordinator said CR#1 significant change MDS dated [DATE] which indicated the resident had a [MEDICAL CONDITION] was inaccurate. She stated the resident did not have [DIAGNOSES REDACTED]. Record review of CR#1's Skin - Head to Toe Skin Checks dated 9/29/17 revealed in part .Skin Integrity: 1.p. Describe new or existing other issues: Existing scar on the chest and right knee . Further review revealed the resident did not admit to the facility with bruises, skin tears, abrasions, rashes, or pressure ulcers. Record review of CR#1's Physicians' order dated 10/2/17 revealed in part . Order summary: Consult: (MONTH) be seen and treated by a podiatrist . Further review revealed order confirmed by LVN #1. Interview with LVN #1 on 3/6/18 t 4:45 PM, he stated that CR#1's order dated 10/2/17 was a standing order which meant CR#1's could be seen by the podiatrist when needed. Record review of CR#1's SBAR Communication Form and Progress Note dated 11/12/17 revealed: S. Situation: 1 . The change in condition, symptoms, or signs I am calling about is/are: Black discoloration/dry gangrene noted to right great toe. Skin intact. Resident complains of pain two on zero to ten scale. Verbalized pain tolerable. B. Background: 2. This started: 11/12/17. 4. Things that could make the condition or symptoms worse are: low blood circulation and lack of infection control. 5. Things that could make the condition or symptom better are: Infection interventions and leg elevation. 3. A. Assessment (RN) or Appearance (LPN): What do you think is going on with the resident? 1. For RNs: I think the problem may be Black discoloration/dry gangrene noted to right great tow. Skin intact. Resident complains of pain two on zero to ten scale. Verbalized pain tolerable. R. Request: J. Nursing notes: Family member was made aware, NP was notified. Needs follow up with wound nurse. Record review of CR#1's Nurse Practitioner's note dated 11/13/2017 revealed in part .Chief complaint/Nature of Presenting Problem: Evaluate weight loss, [MEDICAL CONDITION], debility, [MEDICAL CONDITION] . Further review revealed .Review of systems: Skin/Breast: No rashes or skin breakdown . Additional review revealed .Physical exam: [MEDICAL CONDITION]/Varicosities of Extremities: No [MEDICAL CONDITION] in lower extremities. Skin: Palpation: No palpable [MEDICAL CONDITION] . Record review of CR#1's MAR indicated [REDACTED].Keflex Capsule 500MG ([MEDICATION NAME]). Give 500 MG by mouth every 12 hours for [MEDICATION NAME] for seven days. Further review of MAR indicated [REDACTED]. Interview with DON on 3/7/18 at 11:38 AM, she stated that she was unsure of the reason the resident was put on Keflex and did not know who wrote the order. DON was also unsure why the facility did not do a Doppler on CR #1 when staff noted discoloration to left foot. Interview on 3/7/18 at 11:56 AM with LVN/Unit Manager, she stated staff should not have documented gangrene on CR#1's SBAR because no one diagnosed the resident with gangrene. She further stated the resident was put on Keflex for her foot as preventative measures and was unsure why the Keflex was started 12 days after the SBAR was completed. Interview with DON on 3/7/18 at 12:53 PM, she stated that CR#1's SBAR should not have stated gangrene, only discoloration to right toe. DON further stated that resident was to wear boots, and that Keflex was started as a [MEDICATION NAME] after the heel protectors had been used. Interview on 3/7/18 at 1:10 PM with LVN/Unit manager, she stated CR#1's ulcer was venous, and the facility did what we could have done. We elevated her legs and gave the antibiotics as ordered. Record review of CR#1's physician's orders [REDACTED]. Confirmed by RN/Wound nurse. Interview with RN/Wound nurse on 3/6/18 at 3:17 PM, she stated she remembered CR#1 had a wound on the first toe and either the third or second toe as well. She stated the charge nurse asked her to evaluate the resident because of her toe nail, and that she informed the nurse then that the resident needed a consultation with a podiatrist. RN/Wound nurse further stated the resident was eventually seen by a podiatrist, and she consulted with a wound care doctor who Informed her that the resident's toe was dry eschar and that nothing could be done. Facility then consulted with a vascular doctor, as well as completed a Doppler. Record review of CR#1's physician's orders [REDACTED].Order summary: Podiatrist consult. Confirmed by RN #1 . Interview with RN #1 on 3/7/18 at 9:45 AM, she stated that the podiatry order written on 12/5/17 was for a podiatry consult, and that she verbally notified the social worker of the order on the same day. Record review of CR#1's Nurse Practitioner's note dated 12/8/18 revealed in part .Chief complaint/Nature of presenting problem: Evaluate ongoing issues with weight loss, onychomycosis, arterial ulcer to lower extremities. History of present illness: Patient has an arterial ulcer that is open to the left great toe. Wound care team following. Patient self to continue to monitor first signs and symptoms of infections. Skin: Right great toe arterial ulcer . Record review of CR#1's physician's orders [REDACTED].Order summary: Right great toe ulcer: clean with normal saline solution, pat dry, apply [MEDICATION NAME] ointment, cover with dry dressing every shift. Discontinue: 12/8/17. Discontinue reason: change order. Confirmed by: RN/Wound nurse . Record review of CR#1's physician's orders [REDACTED].Order summary: Right great toe ulcer: clean with normal saline solution, pat dry, apply [MEDICATION NAME] and cover with absorptive dressing every day shift. Confirmed by: RN/Wound nurse. Record review of CR#1's physician's orders [REDACTED].Order summary: Podiatrist evaluation and treat for elongated toe nails. Confirmed by RN #1. Interview with RN #1 on 3/7/18 at 9:45 AM, she stated the podiatry order written on 12/12/17 was due to elongated toenails, and she made the social workers aware as well. RN #1 also said the RN/wound nurse stressed to her that the resident needed a podiatry consultation and she told the social workers about this. She further stated that she was unsure of how long it takes for the podiatrist to come to the facility because she was not the one who arranged podiatrist appointments. She only informed social services about the order. RN #1 explained nail care was done on all residents who need it. RN#1 said CNA's would do nail care unless the resident was diabetic then Nurse would trim them. She said she did not notice anything wrong with CR#1's toe nails. RN #1 expressed that she did weekly skin assessments on CR#1, but she did not notice any skin discoloration to her feet until the wound nurse brought it to her attention. Record review of e-mail sent to the podiatrist provided by Social service assistant dated 12/13/17 revealed in part .Here is the order for CR#1. Thank you . Interview with social service assistant on 3/6/18 at 3:15 PM, she stated she referred CR#1 to the podiatrist on 12/13/17 when social services received the order from the nurse. Interview with Social Services Director on 3/6/18 at 4:05 PM, she stated the procedure for making podiatry referral was in the daily morning meeting, the resident would be added to the list to be seen, and social services then asks that an order be put in, once there's an order, social services then faxes or emails the order to the podiatrist. In regards to CR#1, social services was informed on 12/12/17, and the resident was referred, and seen by the podiatrist on 12/13/17. Social Services Director further stated that social services was not made aware of the orders that were written on 10/2/17or 12/5/17. Record review of CR#1's Podiatry consult dated 12/13/17 revealed in part .Patient seen for thickened toenails and lesion left great toe .Unknown history of duration of lesion left great toe .Integ: cool, dry. Ischemic ulcer tip of left hallux without drainage. No [DIAGNOSES REDACTED]. No mal odor. No acute signs of infection. Necrotic dry wound base 2 CM x 3 CM. Dry ischemic eschar tip of left fifth toe. Dry and stable. No drainage. No [DIAGNOSES REDACTED]. Mycotic, elongated thickened toenails 1-10 bilateral. Vascular: non-palpable pedal pulses. Cool. Dry. Absent nail growth. Neuro: Absent sharp/dull sensation bilateral. 1. Ischemic wound left great toe and left 5th toe. Consult treatment nurse and wound physician. Arterial Doppler's ordered. Will defer further vascular work-up to wound physician. Discussed with staff and family. Keep wounds clean and dry . Record review of CR#1's wound care note completed by wound care physician, Dated 12/13/17 revealed in part .History of present illness: * Location: left toe wounds * Duration: Since 11/12/17 * Associated signs and symptoms: no pain * Description: Past medical history: Dementia, [MEDICAL CONDITION], stroke, hypertension, [MEDICAL CONDITION]. Anticoagulants: none. Wound number: 1: o Wound location: Left great toe. o Date acquired: 11/12/17. o Acquired at facility: Yes. o Wound condition: Chronic. o Wound status: not healed. o Length: 3 CM o Width: 3 CM o Thickness: Eschar covered. o S/S present: S/S of infection. Wound number 2: o Wound location: left fifth toe o Wound type: Arterial ulcer. o Date acquired: 11/12/17. o Acquired at facility: Yes. o Wound condition: Chronic. o Wound status: Not healed. o Length: 1 CM o Width: 1 CM o Thickness: Eschar covered. o S/S present: S/S of infection. Wound orders: Wound #1 Left great toe: o Skin prep and leave open to air dry daily o Attach cradle at foot of bed to keep blankets off feet. Wound orders: Wound #1 Left great toe: o Skin prep and leave open to air dry daily o Attach cradle at foot of bed to keep blankets off feet. Record review of CR#1's physician's orders [REDACTED].Order summary: Wound care - left 5th toe ulcer: clean with normal saline solution, pat dry, apply skin prep and leave open to air every day shift. Confirmed by RN/Wound care nurse . Record review of CR#1's physician's orders [REDACTED].Order summary: Wound care - left great toe ulcer: clean with normal saline solution, pat dry, apply skin prep and leave open to air every day shift. Confirmed by RN/Wound care nurse . Record review of CR#1's Ultra sound report dated 12/14/18 revealed: o Examination: Duplex lower extremity arterial unilateral left. o Clinical indications: Contusion of left lower leg. Initial encounter. o Findings: Left lower extremity arterial duplex ultrasound: there is calcific plaquing. o Impression: [MEDICAL CONDITIONS] with poor blood flow in the left lower extremity. Findings suggest moderate to severe stenosis at the common femoral artery. Record review of CR#1's Treatment Administration Record dated (MONTH) (YEAR) revealed no treatment of [REDACTED]. Record review of CR#1's Treatment Administration Record dated (MONTH) (YEAR) revealed: Right great toe ulcer: clean with normal saline solution, pat dry, apply [MEDICATION NAME] ointment, and cover with dry dressing every day shift. Order date: 12/4/17. D/C date: 12/8/17. Record review of CR#1's Treatment Administration Record dated (MONTH) (YEAR) revealed: wound care- left great toe ulcer: clean with normal saline solution, pat dry, [MEDICATION NAME], and cover with absorptive dressing every day shift. Order date: 12/8/17. D/C date: 12/14/17. Record review of CR#1's Treatment Administration Record dated (MONTH) (YEAR) revealed: Wound care - left fifth toe ulcer: clean with normal saline solution, pat dry, apply skin prep, and open to air every day shift. Order date: 12/14/17. D/C date: 1/30/18. Record review of CR#1's Treatment Administration Record dated (MONTH) (YEAR) revealed: Attach cradle at foot of bed to keep blankets off feet every shift. Order date: 12/20/17. D/C date: 1/30/18 Record review of CR#1's Treatment Administration Record dated (MONTH) (YEAR) revealed: Wound care - left 5th toe ulcer: clean with normal saline solution, pat dry, apply skin prep and leave open to air every day shift. Order date: 12/14/17. D/C date: 1/30/18. Record review of CR#1's Treatment Administration Record dated (MONTH) (YEAR) revealed: Wound care - left great toe ulcer: clean with normal saline solution, pat dry, apply skin prep and cover with absorptive dressing every day shift. Order date: 12/14/17. D/C date: 1/30/18. Record review of CR#1's progress notes dated 1/27/18 at 12:50 AM revealed Resident found unresponsive. Skin warm and dry to touch. Respiration even and labored. Vital signs BP-162/84, P -87, R- 26, T- 97.4, and O2 sat 88%. O2 via nasal cannula initiated at 4-5 l/min. 911 called. 911 arrived and took resident to hospital ER. Record review of CR#1's hospital records dated 1/27/18 at 1:42 AM revealed: Physical examination: Dry gangrene on left great toe and left 5th toe with skin necrosis and skin peeling. Record review of CR #1's hospital podiatry consultation dated 1/27/18 revealed in part .Physical examination: Lower extremities: Right foot is asymptomatic, heel protection in place. Left foot with dry distal gangrene of left hallux and a spot area of gangrene of the plantar tip of the 5th toe, left foot. Impression: It appears that she has a pressure causing changes to the distal left hallux, because unknown, but it appears she has been bedridden, possibly from the end of the bed or tight cover. There is no drainage on exam during palpitation and manipulation. No drainage, fluctuance or [DIAGNOSES REDACTED] to the left great toe . Record review of facility's policy Changes in Resident Condition (revised (MONTH) (YEAR)) revealed in part .Guidelines: 4. Changes in the resident status that affect the problem(s)/ goal(s) or approach(s) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers . Record review of facility's Abuse and Neglect prohibition (revised (MONTH) (YEAR)) revealed in part .Definitions: Neglect means a 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 facility's Skin management policy (revised (MONTH) (YEAR)) revealed in part .Policy: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk of skin compromise are identified, assessed, and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes . CMS form 672 dated 3/6/18 revealed a census of 139.

Based on observation, interview and record review, the facility failed to ensure each resident was free from neglect for two of 26 residents (Residents #1 and #2) reviewed for neglect. The facility failed to provide sufficient supervision for Resident #1 who eloped and fell outside on the sidewalk and sustained a fractured wrist. The facility failed to check Resident #2's wander guard for proper functioning. These failures affected two residents and placed 11 other residents at risk for elopement and injuries. Findings include: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year-old female admitted to the facility 1/17/17. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed a BIMS score of 3, indicating severe cognitive deficit. Further review of this MDS revealed Resident #1 required limited assistance from staff for ADLs. Record review of Resident #1's Care Plan (ND) revealed I am an elopement risk/wanderer r/t impaired safety awareness and dementia. Further review revealed Check placement and function of safety monitoring device every shift. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's MAR for May 2017 revealed initials indicating her wander guard was checked every day. Record review of Resident #1's Progress Notes dated 5/28/17 at 2:01 p.m. revealed a note which read Verbal report that resident had wandered out of facility & brought back by staff members with w/c for mobility. Overall assessment done resident c/o pain left wrist with out limited movement, noted superficial abrasion on posterior forearm. V/S as follows B/P 115/66; R 20; P 62; T 98(TA). O-2 Sat 98%, F/S reading 518; NP of attending MD was notified & new orders rec'd CMP; BMP; X-RAY left wrist . Record review of Resident #1's Progress Notes dated 5/28/17 at 10:20p.m. revealed a note which read X-ray report of left wrist with fracture, NP (name) RN was notified new order per T/O to transfer out to (local) ER, was able to reach R/P of resident wandered out of facility, & on return noted wander guard was not working, due to the fact upon entering facility door the alarm did sound off . Record review of the facility's investigation report dated 6/5/17 revealed on 5/28/17 at 2:00 p.m. Resident #1 left out the front entrance of the facility and was seen walking on the sidewalk beside the facility by a community bystander. She was witnessed falling and the bystander, seeing the wanderguard on her wrist notified the facility, where she was assisted inside by staff members and assessed by a nurse. An abrasion was noted to left forearm. She had full mobility of left wrist, but complained of pain with movement. X-ray was positive for simple fracture of left wrist. Resident was transferred to the ER and returned with her wrist in a splint. Resident has a [DIAGNOSES REDACTED]. Her BIM score is 3 and has an Elopement Score of a 10. She is exit seeking at times, however, is easily redirected. She has had a wangerguard in place since admission and it was present at the time of the incident. However upon reentering the facility from outside, the wanderguard did not alarm, when it had previously that day. The wanderguard was replaced with a new one. Record review of Resident #1's Emergency Department Discharge Note dated 5/29/17 revealed Based on the [DIAGNOSES REDACTED]. Record review of Resident #1's Progress Note dated 6/2/17 revealed Patient seen in her room in bed with left arm splint. Interview on 6/13/17 at 12:15pm the Administrator said on 5/28/17 the wander guard system was working, but Resident #1's bracelet was not. The Administrator further said a bystander on the street alerted staff about Resident #1 falling outside of the facility. The Administrator said a statement was not received from the bystander. Observation on 6/18/17 at 1:36pm revealed Resident #1 sitting up in her bed, asleep. Resident #1's food tray was in front of her on the over-bed table. She was holding a fork in her hand, and her hand was resting in her food. Resident #1's food appeared untouched. Interview on 6/18/17 at 5:10pm revealed Resident #1 was unable to answer questions and was not interviewable. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year old female admitted to the facility 3/24/14. Her [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Record review of Resident #2's care plan revised on 6/15/17 revealed she used a wander guard r/t dementia and wandering. Goals included Resident to remain free of complications related to wander guard use. Interventions included: Check function of wander guard daily and change PRN. Further review of this care plan revealed Resident #2 was at high risk for falls r/t [MEDICAL CONDITION] disease and gait and balance problems. The goal was for Resident #2 to be free from minor injuries r/t falls. Interventions included anticipating and meeting Resident #2's needs and monitoring for safety while ambulating. Record review of Resident #2's physician's orders [REDACTED]. Record review of Medication Administration Record [REDACTED]. Interview on 6/18/17 at 1:55pm the Weekend Supervisor said nurses were responsible for checking resident's wander guards. Interview on 6/18/17 at 2:00pm with LVN A said resident's wander guards were checked by wheeling them close to the door and seeing if the alarm sounded. LVN A stated Resident #1's wander guard was checked around 7:30am this morning. He was unable to identify any other residents who had wander guards. When questioned who all he wheeled to the door this morning besides Resident #1, he was unable to respond. Record review of the North Wing Residents at Risk for Elopement (ND) revealed 8 residents in North Wing with LVN A responsible for 6 of them. Interview on 6/18/17 at 2:14pm with LVN B said he had one resident currently in the facility with a wander guard. LVN B stated he pushed this resident to the door to check the functioning of the wander guard. Interview on 6/18/17 at 2:20pm with LVN C said he checked residents' wander guards by taking them to the door about once a week to make sure the alarm sounded. LVN C also stated Resident #2's wander guard was not checked today either. Interview on 6/18/17 at 2:30pm with LVN D said she was unsure of how many residents were wander risk under her care. LVN D showed the surveyor the signaling device tester box used to test wander guards. LVN D stated the wander guard bracelets were tested every day with this signaling device tester box and if the box blinked when the wander guard bracelet was held to it, that indicated the bracelet was working properly. Interview on 6/18/17 at 2:34pm when LVN E was asked if she had tested wander guards on her wing today she said I have not done one today, and I have not signed for it because I have been so busy. I plan on doing it though. Interview on 6/18/17 at 2:40pm the Weekend Supervisor, said I think if you press it (the wander guard box) is going to show if the battery is dead or you can push the resident toward the door. The Weekend Supervisor said he did not know there was a box to test wander guards. Interview on 6/18/17 at 3:50pm the DON said all wander guards were checked every day shift by a machine. The DON further said after the incident with Resident #1, the Weekend Supervisor gave an in-service, but failed to go over proper functioning. Interview on 6/20/17 with CNA A said there were no residents who wandered on the East wing. CNA A was unable to give a definition or example of neglect. Record review of the East Wing Residents at Risk for Elopement (ND) revealed 5 residents. Record review of the Attendance Form for Elopement In-service dated 5/28/17 and 5/29/17 revealed LVNs B, C, and E were present for the training. Record review of Testing the WanderGuard System Policy dated 2/2010 revealed Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester. Use the Daily Checklist for Signaling Devices in the WanderGuard Instruction Manual. Further review revealed Nurses will record the test was conducted in the resident's record. Record review of Elopement Management Policy dated 2/2010 revealed Unsafe wandering may occur when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards (e.g., chemicals, tools and equipment, etc.). Further review revealed Alarms do not replace necessary supervision. Record review of Abuse & Neglect Prohibition dated 1/2017 revealed Neglect means a 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. Injuries of an unknown origin may occur as a result of neglect. According to the facility's lists of residents at risk for elopement, which were not dated, 13 resided on the North and East Wings.

Based on record review and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being by not providing daily wound care as ordered for one of four residents (Resident #9) reviewed for wound care. Resident #9 was not provided wound care for two consecutive days by LVN B and developed an infection in the wound requiring antibiotic therapy. This failure affected one resident and placed four other residents with wounds at risk of experiencing pain and discomfort from possible infection. Findings include: Incident # 2 Review of Resident #9's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with [REDACTED]. Record review of Resident #9's Care Plan (ND) revealed he had actual skin issues related to 2 [MEDICAL CONDITION]. One on his lateral/distal left food and the other on his left medial 5th toe. The goal was for Resident #9's wounds to show signs of healing with the area decreasing in overall size and depth by the next review. The interventions included .Provide wound care/preventative skin care per order . Review of Resident #9's Treatment Administration record (TAR) for May 2017 revealed the following orders for treatment: Diabetic wound of left medial 5th toe - daily Left lateral distal foot - daily Further review of the TAR revealed no missed treatments for the month of May 2017. Record review of Resident #9's progress notes, dated, 5/15/17 revealed Resident #9 was prescribed [MEDICATION NAME] 100 mg by mouth two times daily for 14 days for a left foot wound infection. Record review of Provider Investigation Report, dated, 5/23/17, revealed on 5/15/17, LVN G reported to the DON that Resident #9's dressing had not been changed over the weekend as ordered. The same dressing from 5/12/17 was on the area of the foot. Upon assessment, the wound appeared with purulent drainage, foul smell, and the foot was swollen. The wound showed signs of infection. LVN G contacted the wound care doctor and obtained orders for an antibiotic. When LVN B was contacted and questioned about changing the dressing, he said he changed the dressing. It was pointed out to LVN B that the dressing was dated 5/12 and he could not argue the fact. LVN B was given a disciplinary action by the DON and placed on final warning with the facility. An attempt was made to contact LVN B by phone for interview on 5/24/17 at 12:15 p.m. and on 6/20/17 at 10:30 a.m. Voicemail messages were left but the calls were not returned. Record review of the staff records revealed that LVN B was hired by the facility on 1/4/16. His background checks and training were adequate. In an interview on 6/20/17, at 12:30 p.m., the DON stated there were five residents on the north hall who would have required wound care while LVN B was on duty on 5/13/17 and 5/14/17, Resident #9 and four other random residents. She stated that Resident #9 was the only resident negatively affected by LVN B's failure to provide wound care that weekend. She said when LVN B was questioned about not changing the dressing, he denied intentionally failing to provide Resident #9 with wound care. In an interview on 6/20/17, at 1:09 p.m. LVN G said she provided wound care for the facility's north hall. When she returned to work on Monday, 5/15/17, she noted that most of the residents on the north hall still had the same dressings on their wounds from 5/12/17. She knew this because her initials were still written on the dressings. LVN G said there were no wound care nurses on duty on the weekends, so the nurses had to do their own wound care for their halls. She could not recall which wounds or how many still had her initials on them. She could not say that any of the dressings had been changed. She specifically recalled Resident #9 because the wound was swollen and infected. She contacted the nurse practitioner who sent in an order for [REDACTED]. An attempt was made to interview Resident #9 on 5/23/17 at 2:50 p.m. The resident closed his eyes and did not respond to questions. Another attempt was made on 6/20/17, at 1:00 p.m. to interview Resident #9. He was cognitively unable answer questions and participate in an interview. Record review of the facility's Skin Management policy revealed that it read in part, .Residents who are at risk or with wounds and /or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes . According to the DON, five residents had wounds that required treatment.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free from accident hazards as possible for two of 13 Residents reviewed for supervision. The facility failed to provide sufficient supervision for Resident #1 who eloped and fell outside on the sidewalk and sustained a fractured wrist. The facility failed to check Resident #2's wander guard for proper functioning. These failures affected two residents and placed 11 other residents at risk for elopement and injuries. Findings include: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year-old female admitted to the facility 1/17/17. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed a BIMS score of 3, indicating severe cognitive deficit. Further review of this MDS revealed Resident #1 required limited assistance from staff for ADLs. Record review of Resident #1's Care Plan (ND) revealed I am an elopement risk/wanderer r/t impaired safety awareness and dementia. Further review revealed Check placement and function of safety monitoring device every shift. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's MAR for May 2017 revealed initials indicating her wander guard was checked every day. Record review of Resident #1's Progress Notes dated 5/28/17 at 2:01 p.m. revealed a note which read Verbal report that resident had wandered out of facility & brought back by staff members with w/c for mobility. Overall assessment done resident c/o pain left wrist with out limited movement, noted superficial abrasion on posterior forearm. V/S as follows B/P 115/66; R 20; P 62; T 98(TA). O-2 Sat 98%, F/S reading 518; NP of attending MD was notified & new orders rec'd CMP; BMP; X-RAY left wrist . Record review of Resident #1's Progress Notes dated 5/28/17 at 10:20p.m. revealed a note which read X-ray report of left wrist with fracture, NP (name) RN was notified new order per T/O to transfer out to (local) ER, was able to reach R/P of resident wandered out of facility, & on return noted wander guard was not working, due to the fact upon entering facility door the alarm did sound off . Record review of the facility's investigation report dated 6/5/17 revealed on 5/28/17 at 2:00 p.m. Resident #1 left out the front entrance of the facility and was seen walking on the sidewalk beside the facility by a community bystander. She was witnessed falling and the bystander, seeing the wanderguard on her wrist notified the facility, where she was assisted inside by staff members and assessed by a nurse. An abrasion was noted to left forearm. She had full mobility of left wrist, but complained of pain with movement. X-ray was positive for simple fracture of left wrist. Resident was transferred to the ER and returned with her wrist in a splint. Resident has a [DIAGNOSES REDACTED]. Her BIM score is 3 and has an Elopement Score of a 10. She is exit seeking at times, however, is easily redirected. She has had a wangerguard in place since admission and it was present at the time of the incident. However upon reentering the facility from outside, the wanderguard did not alarm, when it had previously that day. The wanderguard was replaced with a new one. Record review of Resident #1's Emergency Department Discharge Note dated 5/29/17 revealed Based on the [DIAGNOSES REDACTED]. Record review of Resident #1's Progress Note dated 6/2/17 revealed Patient seen in her room in bed with left arm splint. Interview on 6/13/17 at 12:15pm the Administrator said on 5/28/17 the wander guard system was working, but Resident #1's bracelet was not. The Administrator further said a bystander on the street alerted staff about Resident #1 falling outside of the facility. The Administrator said a statement was not received from the bystander. Observation on 6/18/17 at 1:36pm revealed Resident #1 sitting up in her bed, asleep. Resident #1's food tray was in front of her on the over-bed table. She was holding a fork in her hand, and her hand was resting in her food. Resident #1's food appeared untouched. Interview on 6/18/17 at 5:10pm revealed Resident #1 was unable to answer questions and was not interviewable. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year old female admitted to the facility 3/24/14. Her [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Record review of Resident #2's care plan revised on 6/15/17 revealed she used a wander guard r/t dementia and wandering. Goals included Resident to remain free of complications related to wander guard use. Interventions included: Check function of wander guard daily and change PRN. Further review of this care plan revealed Resident #2 was at high risk for falls r/t Parkinsons disease and gait and balance problems. The goal was for Resident #2 to be free from minor injuries r/t falls. Interventions included anticipating and meeting Resident #2's needs and monitoring for safety while ambulating. Record review of Resident #2's physician's orders [REDACTED]. Record review of Medication Administration Record for June 2017 revealed no initials on 6/3/17 indicating whether Resident #2's wander guard was checked. Interview on 6/18/17 at 1:55pm the Weekend Supervisor said nurses were responsible for checking resident's wander guards. Interview on 6/18/17 at 2:00pm with LVN A said resident's wander guards were checked by wheeling them close to the door and seeing if the alarm sounded. LVN A stated Resident #1's wander guard was checked around 7:30am this morning. He was unable to identify any other residents who had wander guards. When questioned who all he wheeled to the door this morning besides Resident #1, he was unable to respond. Record review of the North Wing Residents at Risk for Elopement (ND) revealed 8 residents in North Wing with LVN A responsible for 6 of them. Interview on 6/18/17 at 2:14pm with LVN B said he had one resident currently in the facility with a wander guard. LVN B stated he pushed this resident to the door to check the functioning of the wander guard. Interview on 6/18/17 at 2:20pm with LVN C said he checked residents' wander guards by taking them to the door about once a week to make sure the alarm sounded. LVN C also stated Resident #2's wander guard was not checked today either. Interview on 6/18/17 at 2:30pm with LVN D said she was unsure of how many residents were wander risk under her care. LVN D showed the surveyor the signaling device tester box used to test wander guards. LVN D stated the wander guard bracelets were tested every day with this signaling device tester box and if the box blinked when the wander guard bracelet was held to it, that indicated the bracelet was working properly. Interview on 6/18/17 at 2:34pm when LVN E was asked if she had tested wander guards on her wing today she said I have not done one today, and I have not signed for it because I have been so busy. I plan on doing it though. Interview on 6/18/17 at 2:40pm the Weekend Supervisor, said I think if you press it (the wander guard box) is going to show if the battery is dead or you can push the resident toward the door. The Weekend Supervisor said he did not know there was a box to test wander guards. Interview on 6/18/17 at 3:50pm the DON said all wander guards were checked every day shift by a machine. The DON further said after the incident with Resident #1, the Weekend Supervisor gave an in-service, but failed to go over proper functioning. Interview on 6/20/17 with CNA A said there were no residents who wandered on the East wing. CNA A was unable to give a definition or example of neglect. Record review of the East Wing Residents at Risk for Elopement (ND) revealed 5 residents. Record review of the Attendance Form for Elopement In-service dated 5/28/17 and 5/29/17 revealed LVNs B, C, and E were present for the training. Record review of Testing the WanderGuard System Policy dated 2/2010 revealed Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester. Use the Daily Checklist for Signaling Devices in the WanderGuard Instruction Manual. Further review revealed Nurses will record the test was conducted in the resident's record. Record review of Elopement Management Policy dated 2/2010 revealed Unsafe wandering may occur when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards (e.g., chemicals, tools and equipment, etc.). Further review revealed Alarms do not replace necessary supervision. Record review of Abuse & Neglect Prohibition dated 1/2017 revealed Neglect means a 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. Injuries of an unknown origin may occur as a result of neglect. According to the facility's lists of residents at risk for elopement, which were not dated, 13 resided on the North and East Wings.

Based on interview, and record review, the facility failed to notify the resident's physician when a change of condition occurred for four of 24 residents (Residents #85, #73, #76, and #66, who were reviewed for changes in conditions. The facility failed to promptly notify Resident #85's physician of her change in condition and elevated blood pressure of 217/126 on 01/05/16. Resident #85's physician was not promptly consulted on 01/11/16 and 01/12/16 when she complained of eye pain, blurry vision and generalized body shaking. The facility failed to notify Resident #73's physician of her elevated blood pressure of 174/134 on 01/05/16. The facility failed to promptly notify Resident #76's physician of her elevated blood pressure of 160/125 on 01/05/16. The facility failed to notify Resident #66's physician when her heart rate was 144 on 01/05/16. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 01/14/2016. While the IJ was removed on 01/16/2016, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy and a scope of a pattern. These failures affected four residents and placed 98 residents with hypertension at risk of not having their physicians made aware of a change in their medical condition for prompt intervention. Findings include: Resident #85 Record review of Resident #85's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #85's MDS dated [DATE] revealed her cognition score was 12, indicating she was moderately impaired for daily decision making skills. She required limited assistance with transfers and extensive assistance with dressing, hygiene, bathing and supervision for ambulation and eating. Record review of Resident #85's care plan dated 12/31/15 revealed Resident #85 had a history of [REDACTED]. Goal was the resident would maintain optimal quality of life within limitations imposed by visual function through the review date. Approaches includes: arrange consultation with eye care practitioner as required, review medications for side effects which affect vision, tell the resident where you are placing items and be consistent. Record review of Resident #85's monthly physician order dated January 2016 revealed the following medications: [REDACTED] [MEDICATION NAME] 100mg tablet, one by mouth two times daily [MEDICATION NAME] tablet 1mg by mouth at bed time. [MEDICATION NAME] tablet 4mg by mouth at bed time; take with [MEDICATION NAME] 1mg tablet to equal 5mg. [MEDICATION NAME] HCL 10mg tablet, give one tablet by mouth every 6 hours as needed for SBP greater than 60. [MEDICATION NAME] HCL 100mg, one tablet by mouth twice daily. [MEDICATION NAME] 100mg tablet by mouth twice daily. Hold for SPB less than 100 and heart rate less than 60. [MEDICATION NAME] 2.5mg tablet, give 2 tablets by mouth daily. Record review of Resident #85's MAR indicated [REDACTED] [MEDICATION NAME] 100mg tablet, one by mouth two times daily [MEDICATION NAME] tablet 1mg by mouth at bed time. [MEDICATION NAME] tablet 4mg by mouth at bed time; take with [MEDICATION NAME] 1mg tablet to equal 5mg. [MEDICATION NAME] HCL 10mg tablet, give one tablet by mouth every 6 hours as needed for SBP greater than 60. [MEDICATION NAME] HCL 100mg, one tablet by mouth twice daily. [MEDICATION NAME] 100mg tablet by mouth twice daily. Hold for SPB less than 100 and heart rate less than 60. [MEDICATION NAME] 2.5mg tablet, give 2 tablets by mouth daily. Further review of Resident #85's January 2016 MAR indicated [REDACTED]. This was the highest blood pressure reading documented for her in the month of January 2016. Record review of Resident #85's Nurse's notes dated 01/05/16 at 3:16p.m., revealed today residents blood pressure was 217/126 before medication administration for blood pressure management and after a while resident was reassessed and her blood pressure was 137/70. At that time she complained of a headache at a pain level of 9/10 (10 being the most severe pain) and [MEDICATION NAME] 50mg was administered for pain as ordered. Medication effective as she was monitored later and she expressed relief . There was no documentation indicating Resident #85's physician was notified of the above elevated blood pressure or headache. Interview on 01/14/16 about 9:40a.m., LVN#12 said she was charge nurse for Resident #85 on 01/05/16. She stated LVN #4 administered Resident #85's morning medications on 01/05/16. LVN#12 said later in the morning of 01/05/16, (not sure of exact time), while she was charting on the resident, she noted from the resident's vital sign record Resident #85 had a documented blood pressure of 217/126 prior to getting her medications. LVN#12 said she rechecked the resident's blood pressure and it was 137/70. LVN#12 said she documented this on the resident's record but did not notify her physician. Observation and interview on 01/12/16 at 10:30a.m., Resident #85 was in her bed alert and oriented. She reported her entire body was shaking, her vision was very blurry (images appeared double) and she just did not feel good. When asked how long she felt that way, Resident #85 reported it started last night 01/11/16 between 9-10 pm. Resident #85 said she notified the nurse during shift change last night and was told to relax and sleep, maybe she was just anxious and should feel better after sleeping. Resident #85 said her condition did not change but had gotten worse. The above observation and interview were witnessed by LVN #12. During an interview and observation with LVN #12 on 01/12/16 at 10:30a.m. in Resident #85's room, LVN #12 stated she was informed by the night nurse that Resident #85's blood sugar was 305, but this was the only change communicated to her from the previous shift. LVN #12 stated she did not notify the physician. LVN#12 listened to Resident #85's complaint about feeling shaky with blurry vision and generally not feeling well and then she said she would immediately asses the resident. Interview on 01/12/16 about 11:10a.m., LVN#12 reported Resident #85's vitals as: blood pressure of 127/72, temperature of 98.3 and heart rate of 104. LVN#12 further reported she received an order for [REDACTED]. Interview on 01/14/16 at 10:01am, LVN#4 said she passed medications to Resident #85 on 01/05/16. LVN#4 further said prior to administrating Resident #85's morning medications her blood pressure was checked and registered 217/126. LVN #4 said she administered Resident #85's medications and notified the charge nurse of the elevated blood pressure. LVN#4 was not certain what time she notified the charge nurse. Interview on 01/15/16 about 10:40 a.m., the DON said she was not aware of Resident #85's blood pressure reading documented in the resident's chart. She agreed the elevated values should have been addressed and should have warranted consultation with the resident's physician. The DON said the facility was auditing all residents' charts and would ensure parameters were added for all blood pressure medications. The DON further expressed she was in-servicing staff on implementing the added blood pressure parameters. The DON said she was not informed of Resident #85's elevated blood pressure on 01/05/16 or her complaints on 01/12/16. She said usually staff discussed such occurrences during their morning meetings. She stated LVN #12 failed to follow up with the information when she became aware of it. Interview on 01/15/2016 at 11:00 am the DON stated she had interviewed Resident #85 concerning her change in condition. The DON expressed she felt the resident had not told the truth to the surveyor. During the interview the DON stated the resident had [DIAGNOSES REDACTED]. The DON reported Resident #85 would often report pain at a level of 9 out of 10 but then would deny that she had the pain a short time later. The DON did state that the resident did experience an elevated blood pressure and heart rate and staff should have consulted the physician. During the same interview on 01/15/2016 at 11:00 a.m. the DON stated in a nursing facility there should not be STAT EKGs ordered by the physicians due to the time it would take the facility to get the test completed and read. She stated if a resident needed such a test immediately, the resident should be transfered to the hospital. She stated there was a delay in getting the EKG completed and the results to the physician. The DON stated staff training had been initiated to train staff on the identified areas of concern. Resident #73 Record review of Resident #73's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #73's monthly physician order dated January 2016 revealed the following medications: [REDACTED] [MEDICATION NAME] 5mg tablet, give one tablet by mouth daily. [MEDICATION NAME] 50mg tablet, give 3 tablets by mouth twice a day. Record review of Resident #73's MAR indicated [REDACTED]. Further review of MAR indicated [REDACTED] [MEDICATION NAME] 5mg tablet, give one tablet by mouth daily. [MEDICATION NAME] 50mg tablet, give 3 tablets by mouth twice a day. Record review of Resident #73's Nurse's notes on 01/05/16 did not reveal any documentation regarding Resident #73's blood pressure of 174/134. Resident #76 Record review of Resident #76's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #76's monthly physician order dated January 2016 revealed the following medications: [REDACTED] [MEDICATION NAME] 10mg tablet, give one tablet by mouth daily. [MEDICATION NAME] HCL 100mg tablet, one by mouth three times daily. Hold for SBP less than 110 and hear rate less than 60. Record review of Resident #76's MAR indicated [REDACTED] [MEDICATION NAME] 10mg tablet, give one tablet by mouth daily. [MEDICATION NAME] HCL 100mg tablet, one by mouth three times daily. Hold for SBP less than 110 and hear rate less than 60. Further review of Resident #76's January 2016 MAR indicated [REDACTED]. This was the highest blood pressure reading documented for her in the month of January 2016. Record review of Resident #76's Nurse's notes dated 01/05/16 did not reveal any documentation regarding Resident #73's blood pressure of 160/125. There was no indication the resident's physician was notified of the elevated blood pressure. Resident #66 Record review of Resident #66's face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review of the care plan dated 12/31/15 revealed the resident had hypertension related to stroke with a goal the resident would remain free of complications related to hypertension through review date. Approaches included: give anti-hypertensive medications as ordered, observe for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate and effectiveness, observe for and document any [MEDICAL CONDITION] and notify MD, observe and document abnormalities for urinary output, report significant changes to the MD. Record review of Resident #66's monthly physician order revealed the following blood pressure medications: [REDACTED] [MEDICATION NAME] Besyate 10mg by mouth daily [MEDICATION NAME] 0.3mg 24 hour patch once a week [MEDICATION NAME] 40mg tablet, by mouth daily. Hold for systolic blood pressure less than 100 and Pulse less than 60. [MEDICATION NAME] 50mg, by mouth twice daily. Hold for systolic blood pressure less than 100 and Pulse less than 60. Record review of Resident #66's MAR indicated [REDACTED]. Further review of MAR indicated [REDACTED] [MEDICATION NAME] Besyate 10mg by mouth daily [MEDICATION NAME] 0.3mg 24 hour patch once a week [MEDICATION NAME] 40mg tablet, by mouth daily. Hold for systolic blood pressure less than 100 and Pulse less than 60. [MEDICATION NAME] 50mg, by mouth twice daily. Hold for systolic blood pressure less than 100 and Pulse less than 60. Record review of Resident #66's Nurse's notes on 01/05/16 did not reveal any documentation regarding Resident #66's heart rate of 144. Record review of facility policy on resident rights dated June 2008 revealed the facility protects and promotes the right of each resident. The resident has a right to a dignified existence, self -determination and communication with and access to persons and services inside and outside the facility. Facility staff will assist residents in exercising these rights. Record review of the facility policy on Changes in Resident Condition dated April 2005 revealed The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit . The facility Administrator was notified on 01/14/2016 at 12:10 p.m. that an Immediate Jeoparty (IJ) situation had been identified due to the above failures. Plan of Removal of the IJ: 1. On January 14, 2016 the RN Director of Nursing, RN Staff Development Coordinator/ADON and RN Case Management Coordinator assessed residents with orders for hypertensive medication to validate parameters were available. If parameters were not available the licensed nurses were contacting the physician to request parameters. Physician instructions would be documented in the medical record. 2. Effective January 14, 2016 once a change of condition was identified, qualified staff would evaluate the resident and initiate the appropriate protocol utilizing Interact 4.0. The decision support tool provided guidance to nursing staff on whether to report specific signs and symptoms based on the evaluation completed by the nurse. Standardized parameters were established using the guidelines from Interact 4.0 : · Systolic BP > 200 mmHg or <90 mmHG · Diastolic BP > 115 mmHG · Resting Pulse > 100, < 50 3. The licensed nurse would evaluate each situation based on individual resident condition at the time of the event. The licensed staff would continue to provide care and monitor the resident until emergency personnel arrived. 4. Effective January 15, 2014 the clinical team including the Director of Nursing, Assistant Director of Nursing, Unit Managers, MDS nurses, would review the previous day's 24-hour Nursing Report during the morning meeting to assure all physician orders were reconciled and to assure that appropriate parameters were followed in the event of an elevated blood pressure or in the event of an abnormal test result. 5. The District Director of Clinical Services re-educated the Director of Nursing Services who then conducted re-education training for all licensed nurses and certified medication aides who were on duty January 14, 2016. The re-education included the following: · Change of Condition including completion of focused assessment. Staff was to immediately contact the attending physician for changes of condition and administer any medications, particularly PRN medications, specifically related to the change of condition. If the physician or extender did not return the call within 30 minutes, the licensed nurse would notify the Medical Director for further instructions. · Blood pressures were to be monitored. In the event of elevated blood pressures, the licensed nurses were required to follow the parameters noted or specific to the medication. · Documentation of orders or instructions would be entered in the medical record once instructions were given by the physician or physician extender. 6. Licensed nurses and certified medication aides that were not able to attend any of the training offered would not be allowed to work with residents until they had been re-educated on the facility's process. The surveyors monitored the current Plan of Removal on 01/16/2016 as follows: Record review of 24 standardized blood pressure parameter orders revealed all necessary changes, clarifications, and additions had been made. Record review of the in-service records revealed courses on blood pressure, documentation of vital signs, physician orders to include parameters of when to hold medication and when to notify the physician, identifying a change in condition and utilizing the decision support tools. Interviews were conducted with nine staff members (2 RNs, 5 LVNs, and 2 CMAs) who stated they had received education on documenting blood pressures and vital signs, recognizing a change in resident condition, notifying a nurse of elevated or abnormal vital signs, assessing the resident using the decision support tool, and notifying the physician if needed. Training provided also included the use and calibration of glucose testing devices/glucometers. Training provided also included the process for notifying the Medical Director if the physician had not returned a phone call within 30 minutes. All stated they felt comfortable caring for residents with hypertension and those requiring blood pressure medications. On 01/16/2016 at 11:21 a.m., the facility Administrator was informed the IJ had been removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of a pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess and consult physicians concerning changes in condition, elevated blood pressures and STAT lab results. The Facility reported 98 residents with hypertension.

Based on observation, interview, and record review 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 four of 24 sampled residents (Resident #85, #73, #76, and #66) reviewed for quality of care. The facility failed to thoroughly assess Resident #85 who experienced a change in condition including shakiness, headache and blurred vision on 01/11/16 which was not documented and the staff did not consult the physician concerning the resident's symptoms until 01/12/16. Resident #85 had a physician ordered STAT (urgent, rush) EKG (Electrocardiogram) on 01/12/16 to address her change in condition. The abnormal results of the EKG were not received until 25 hours later by the facility. Resident #85's physician was left a message concerning the abnormal results but was not verbally consulted. The facility failed to consult Resident #85's physician when she was on five blood pressure medications and had a blood pressure of 217/126 on 01/05/16. The facility failed to train staff to identify and monitor when Resident #85 experienced an elevated blood pressure. No parameters on her blood pressure medications had been identified by the facility or the physician. The facility failed to notify Resident #73's physician of her elevated blood pressure of 174/134 on 01/05/16. The facility failed to promptly notify Resident #76's physician of her elevated blood pressure of 160/125 on 01/05/16. The facility failed to notify Resident #66's physician when her heart rate was 144 on 01/05/16. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 01/14/2016. While the IJ was removed on 01/16/2016, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy and a scope of a pattern. This deficient practice affected four residents and placed 98 residents with a [DIAGNOSES REDACTED]. Findings include: Resident #85 Record review of Resident #85's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #85's MDS dated [DATE] revealed a BIMS score of 12, indicating she was moderately impaired for daily decision making skills. She required limited assistance with transfers and extensive assistance with dressing, hygiene, bathing and supervision for ambulation and eating. Record review of Resident #85's care plan dated 12/31/15 revealed Resident #85 had a history of [REDACTED]. Approaches included: give anti hypertensive medications as ordered, observe for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate ([MEDICAL CONDITION] and effectiveness, observe for and document any [MEDICAL CONDITION], notify MD, observe/document abnormalities for urinary output, report significant changes to the MD, and obtain blood pressure readings per MD order. Further review of the care plan dated 12/31/15 revealed the resident had another care plan with the identified area of hypertension related to stroke. The goals listed were the same as the goals listed on the care plan for hypertension which was the resident would remain free of complications related to hypertension through review date. Approaches were also the same and included: give anti-hypertensive medications as ordered, observe for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate and effectiveness, observe for and document any [MEDICAL CONDITION] and notify MD, observe and document abnormalities for urinary output, report significant changes to the MD. Further review of the care plan dated 12/31/15 revealed Resident #85 had another care plan for Diabetes Mellitus. The goal listed was Resident #85 would have no complications related to diabetes through the review date. Approaches included: diabetes medication as ordered by doctor, Observe/document for side effects and effectiveness, If infection is present, consult doctor regarding any changes in diabetic medications, observe/document/report PRN compliance with diet and document any problems. Further review of the care plan dated 12/31/15 revealed Resident #85 had no care plan to address heart failure. Record review of Resident #85's monthly physician's order dated January 2016 revealed the following medications: [REDACTED] [MEDICATION NAME] 100 mg tablet, (used to treat high blood pressure), one by mouth two times daily. [MEDICATION NAME] tablet 1 mg (used to treat high blood pressure), one by mouth at bed time. [MEDICATION NAME] tablet 4 mg (used to treat high blood pressure), one by mouth at bed time; take with [MEDICATION NAME] 1mg tablet to equal 5mg. [MEDICATION NAME] HCL 10 mg tablet (used to treat high blood pressure), give one tablet by mouth every 6 hours as needed for SBP(systolic blood pressure) greater than 60. [MEDICATION NAME] HCL 100 mg, (used to treat high blood pressure), one tablet by mouth twice daily. [MEDICATION NAME] 100 mg tablet (used to treat high blood pressure), by mouth twice daily. Hold for SBP less than 100 and heart rate less than 60. [MEDICATION NAME] 2.5mg tablet, give 2 tablets by mouth daily. Record review of Resident #85's MAR indicated [REDACTED] [MEDICATION NAME] 100 mg tablet, one by mouth two times daily. [MEDICATION NAME] tablet 1 mg by mouth at bed time. [MEDICATION NAME] tablet 4 mg by mouth at bed time; take with [MEDICATION NAME] 1mg tablet to equal 5mg. [MEDICATION NAME] HCL 10 mg tablet, give one tablet by mouth every 6 hours as needed for SBP greater than 60. [MEDICATION NAME] HCL 100 mg, one tablet by mouth twice daily. [MEDICATION NAME] 100 mg tablet by mouth twice daily. Hold for SBP less than 100 and heart rate less than 60. [MEDICATION NAME] 2.5 mg tablet, give 2 tablets by mouth daily. Record review of the January 2016 physician's orders and MARs revealed only [MEDICATION NAME] and [MEDICATION NAME] HCL 10mg had one parameter each for a low blood pressure. None of the five blood pressure medications had parameters for high blood pressure. Further review of the January 2016 MAR indicated [REDACTED]. Further record review of Resident #85's January 2016 MAR indicated [REDACTED]. Record review of Resident #85's Nurse's notes dated 01/05/16 at 3:16 p.m. (six hours after resident's elevated blood pressure was observed), revealed today resident's blood pressure was 217/126 before medication administration for blood pressure management and after a while resident was reassessed and her blood pressure was 137/70. At that time she complained of headache of 9/10 (10 being the most severe pain) and [MEDICATION NAME] 50 mg was administered for pain as ordered. Medication effective as she was monitored later and she expressed relief. There was no documentation in Resident #85's medical record indicating that Resident #85's physician was consulted of the above elevated blood pressure. Interview with LVN#12 on 01/14/16 at 9:40 a.m. she said she was the charge nurse for Resident #85 on 01/05/15. She stated LVN #4 administered Resident #85's morning medications on 01/05/16. LVN#12 said later in the morning of 01/05/16, (not sure of exact time), while she was charting on the resident, she noted from the resident's vital sign record that Resident #85 had a documented blood pressure of 217/126 prior to getting her medications. LVN#12 said she rechecked the resident's blood pressure and it was 137/70. LVN#12 said she documented this on the resident's record but did not consult the physician. Interview on 01/14/16 at 10:01 am, LVN #4 said she passed medications to Resident #85 on 01/05/16. LVN #4 further said prior to administered Resident #85's morning medications her blood pressure was checked and registered 217/126. LVN #4 said she administered Resident #85's medications and notified the charge nurse of the elevated blood pressure. LVN #4 was not certain what time she notified the charge nurse. Observation and interview on 01/12/16 at 10:30 a.m., Resident #85 was in her bed alert and oriented. She reported her entire body was shaking, her vision was very blurry (images appeared double) and she just did not feel good. Resident #85 reported her symptoms started last night 01/11/16 between 9-10 p.m. Resident #85 said she notified the nurse during shift change last night and was told to relax and sleep. She stated she was told by staff she may be just anxious and should feel better after sleeping. Resident #85 said her condition did not change but had gotten worse. The above observation and interview were witnessed by LVN #12. Record review of Resident #85's nursing notes revealed no documentation that an assessment was done on 01/11/16 after the Resident reported the change in condition. During the interview and observation with LVN #12 on 01/12/16 at 10:30 a.m. in Resident #85's room, LVN #12 stated she was informed by the night nurse that Resident #85's blood sugar was 305, but this was the only change communicated to her from the previous shift. LVN #12 stated she did not notify the physician about this change in condition reported to her by the night nurse. LVN#12 listened to Resident #85's complaint about feeling shaky with blurry vision and generally not feeling well and said she would immediately asses the resident. Interview on 01/12/16 about 11:10 a.m., LVN#12 reported Resident #85's vitals as: blood pressure of 127/72, temperature of 98.3 and heart rate of 104. LVN#12 further reported she received a physician's order for a STAT EKG and to monitor the resident every 30 minutes. Record review of Resident #85's Nurse's notes dated 01/12/16 at 1:04 p.m., revealed today resident complained of having double vision and uneasy feeling. She reported feeling nervous last night but was not sure of reporting it to nurse. After she reported not feeling well, vital signs assessed and noted blood pressure-121/68, temperature of 98.3, heart rate of 104 (elevated) and her blood sugar 352. 8 units of insulin was administered per sliding scale and a call was made to NP and she ordered a STAT EKG, labs: CBC,CMP,TSH and also ordered [MEDICATION NAME] 0.25 mg one tablet every 8 hours as needed. A call was placed to advanced diagnostic to schedule the EKG and a confirmation number was received. NP also to monitor resident every 30 minutes for 2 hours due to elevated heart rate and resident was monitored. Record review of Resident #85's Nurse's notes dated 01/13/16 at 5:53 a.m., revealed EKG results and blood work reports were still pending. Interview on 01/13/16 at 9 a.m., LVN#12 reported according to the previous shift, a STAT EKG was ordered on [DATE] about 11:00 a.m. The EKG was done last night, but the results were still pending. Record review of Resident #85's Nurse's notes dated 01/13/16 at 10:09 p.m., revealed left message with Resident #85's MD re-abnormal EKG. Record review of Resident #85's radiology report dated 01/13/16 at 12:22 p.m., revealed diffuse nonspecific T wave abnormality. Interview on 01/14/16 at 8:20 a.m., LVN#12 reported the EKG results came in during her shift change on 01/13/16. She explained she normally works from 6 a.m. until 2 p.m. but left early yesterday and handed the result to the charge nurse who took over for her. Interview on 01/14/16 at 9:40 a.m., LVN #12 reported she was not aware that Resident #85's MD had not returned the call regarding her EKG report. She explained, she was not informed of this but was aware of the EKG abnormal reading. LVN #12 said she would follow up on it. Interview on 01/15/16 about 10:40 a.m., the DON said she was not aware of Resident #85's blood pressure reading documented in the resident's chart. She agreed the elevated values should have been addressed and should have warranted consultation with the resident's physician. The DON said the facility was auditing all residents' charts and would ensure parameters were added for all blood pressure medications. The DON further expressed she was in-servicing staff on implementing the added blood pressure parameters. The DON said she was not informed of Resident #85's elevated blood pressure on 01/05/16 or her complaints on 01/12/16. She said usually staff discussed such occurrences during their morning meetings. She stated LVN #12 failed to follow up with the information when she became aware of it. Interview on 01/15/2016 at 11:00 am the DON stated she had interviewed Resident #85 concerning her change in condition. The DON expressed she felt the resident had not told the truth to the surveyor. During the interview the DON stated the resident had [DIAGNOSES REDACTED]. The DON reported Resident #85 would often report pain at a level of 9 out of 10 but then would deny that she had the pain a short time later. The DON did state that the resident did experience an elevated blood pressure and heart rate and staff should have consulted the physician. During the same interview on 01/15/2016 at 11:00 a.m. the DON stated in a nursing facility there should not be STAT EKGs ordered by the physicians due to the time it would take the facility to get the test completed and read. She stated if a resident needed such a test immediately, the resident should be transfered to the hospital. She stated there was a delay in getting the EKG completed and the results to the physician. The DON stated staff training had been initiated to train staff on the identified areas of concern. Resident #73 Record review of Resident #73's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #73's monthly physician order dated January 2016 revealed the following medications: [REDACTED] [MEDICATION NAME] 5mg tablet, give one tablet by mouth daily. [MEDICATION NAME] 50mg tablet, give 3 tablets by mouth twice a day. Record review of Resident #73's MAR indicated [REDACTED]. Further review of MAR indicated [REDACTED] [MEDICATION NAME] 5mg tablet, give one tablet by mouth daily. [MEDICATION NAME] 50mg tablet, give 3 tablets by mouth twice a day. Record review of Resident #73's Nurse's notes on 01/05/16 did not reveal any documentation regarding Resident #73's blood pressure of 174/134. Resident #76 Record review of Resident #76's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #76's monthly physician order dated January 2016 revealed the following medications: [REDACTED] [MEDICATION NAME] 10mg tablet, give one tablet by mouth daily. [MEDICATION NAME] HCL 100mg tablet, one by mouth three times daily. Hold for SBP less than 110 and hear rate less than 60. Record review of Resident #76's MAR indicated [REDACTED] [MEDICATION NAME] 10mg tablet, give one tablet by mouth daily. [MEDICATION NAME] HCL 100mg tablet, one by mouth three times daily. Hold for SBP less than 110 and hear rate less than 60. Further review of Resident #76's January 2016 MAR indicated [REDACTED]. This was the highest blood pressure reading documented for her in the month of January 2016. Record review of Resident #76's Nurse's notes dated 01/05/16 did not reveal any documentation regarding Resident #73's blood pressure of 160/125. There was no indication the resident's physician was notified of the elevated blood pressure. Resident #66 Record review of Resident #66's face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review of the care plan dated 12/31/15 revealed the resident had hypertension related to stroke with a goal the resident would remain free of complications related to hypertension through review date. Approaches included: give anti-hypertensive medications as ordered, observe for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate and effectiveness, observe for and document any [MEDICAL CONDITION] and notify MD, observe and document abnormalities for urinary output, report significant changes to the MD. Record review of Resident #66's monthly physician order revealed the following blood pressure medications: [REDACTED] [MEDICATION NAME] Besyate 10mg by mouth daily [MEDICATION NAME] 0.3mg 24 hour patch once a week [MEDICATION NAME] 40mg tablet, by mouth daily. Hold for systolic blood pressure less than 100 and Pulse less than 60. [MEDICATION NAME] 50mg, by mouth twice daily. Hold for systolic blood pressure less than 100 and Pulse less than 60. Record review of Resident #66's MAR indicated [REDACTED]. Further review of MAR indicated [REDACTED] [MEDICATION NAME] Besyate 10mg by mouth daily [MEDICATION NAME] 0.3mg 24 hour patch once a week [MEDICATION NAME] 40mg tablet, by mouth daily. Hold for systolic blood pressure less than 100 and Pulse less than 60. [MEDICATION NAME] 50mg, by mouth twice daily. Hold for systolic blood pressure less than 100 and Pulse less than 60. Record review of Resident #66's Nurse's notes on 01/05/16 did not reveal any documentation regarding Resident #66's heart rate of 144. Record review of facility policy on resident rights dated June 2008 revealed the facility protects and promotes the right of each resident. The resident has a right to a dignified existence, self-determination and communication with and access to person and services inside and outside the facility. Facility staff will assist residents in exercising these rights. Record review of the facility policy on Changes in Resident Condition dated April 2005 revealed The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit . The facility Administrator was notified on 01/14/2016 at 12:10 p.m. that an Immediate Jeoparty (IJ) situation had been identified due to the above failures. Plan of Removal of the IJ: 1. On January 14, 2016 the RN Director of Nursing, RN Staff Development Coordinator/ADON and RN Case Management Coordinator assessed residents with orders for hypertensive medication to validate parameters were available. If parameters were not available the licensed nurses were contacting the physician to request parameters. Physician instructions would be documented in the medical record. 2. Effective January 14, 2016 once a change of condition was identified, qualified staff would evaluate the resident and initiate the appropriate protocol utilizing Interact 4.0. The decision support tool provided guidance to nursing staff on whether to report specific signs and symptoms based on the evaluation completed by the nurse. Standardized parameters were established using the guidelines from Interact 4.0 : · Systolic BP > 200 mmHg or <90 mmHG · Diastolic BP > 115 mmHG · Resting Pulse > 100, < 50 3. The licensed nurse would evaluate each situation based on individual resident condition at the time of the event. The licensed staff would continue to provide care and monitor the resident until emergency personnel arrived. 4. Effective January 15, 2014 the clinical team including the Director of Nursing, Assistant Director of Nursing, Unit Managers, MDS nurses, would review the previous day's 24-hour Nursing Report during the morning meeting to assure all physician orders were reconciled and to assure that appropriate parameters were followed in the event of an elevated blood pressure or in the event of an abnormal test result. 5. The District Director of Clinical Services re-educated the Director of Nursing Services who then conducted re-education training for all licensed nurses and certified medication aides who were on duty January 14, 2016. The re-education included the following: · Change of Condition including completion of focused assessment. Staff was to immediately contact the attending physician for changes of condition and administer any medications, particularly PRN medications, specifically related to the change of condition. If the physician or extender did not return the call within 30 minutes, the licensed nurse would notify the Medical Director for further instructions. · Blood pressures were to be monitored. In the event of elevated blood pressures, the licensed nurses were required to follow the parameters noted or specific to the medication. · Documentation of orders or instructions would be entered in the medical record once instructions were given by the physician or physician extender. 6. Licensed nurses and certified medication aides that were not able to attend any of the training offered would not be allowed to work with residents until they had been re-educated on the facility's process. The surveyors monitored the current Plan of Removal on 01/16/2016 as follows: Record review of 24 standardized blood pressure parameter orders revealed all necessary changes, clarifications, and additions had been made. Record review of the in-service records revealed courses on blood pressure, documentation of vital signs, physician orders to include parameters of when to hold medication and when to notify the physician, identifying a change in condition and utilizing the decision support tools. Interviews were conducted with nine staff members (2 RNs, 5 LVNs, and 2 CMAs) who stated they had received education on documenting blood pressures and vital signs, recognizing a change in resident condition, notifying a nurse of elevated or abnormal vital signs, assessing the resident using the decision support tool, and notifying the physician if needed. Training provided also included the use and calibration of glucose testing devices/glucometers. Training provided also included the process for notifying the Medical Director if the physician had not returned a phone call within 30 minutes. All stated they felt comfortable caring for residents with hypertension and those requiring blood pressure medications. On 01/16/2016 at 11:21 a.m., the facility Administrator was informed the IJ had been removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of a pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess and consult physicians concerning changes in condition, elevated blood pressures and STAT lab results. The facility 672 dated 01/12/2016 indicated 98 residents had a [DIAGNOSES REDACTED].

Based on observations, record review, and interviews, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being of one of 24 residents (Residents #85) reviewed for quality of care. The Administrator failed to oversee and assist with the development and implementation of effective policies and procedures on blood pressure parameters and notifying physicians of adverse signs of hypertension, identifying and documenting a resident's change of condition and promptly consulting the physician, arranging ordered diagnostic testing and reporting results to physicians. The Administrator failed to supervise the DON on training and monitoring the nursing staff to monitor and assess resident's conditions and consult physicians concerning changes in a resident's condition, adverse blood pressure readings of residents with hypertension and testing results. The DON failed to ensure all staff were trained to monitor and assess resident conditions, and consult physicians timely concerning changes in residents' condition, adverse blood pressure readings and testing results. The DON failed to ensure clinical documentation regarding blood pressure parameters were accurate and available to staff/providers in the event of an emergency situation. This failure resulted in the identification of an Immediate Jeopardy (IJ) situation on 01/14/2016. While the IJ was removed on 01/16/2016, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy and a scope of widespread. The facility continued to train its staff to monitor, assess, and consult physicians concerning blood pressures, blood pressure parameters, changes in condition and STAT testing orders. These failures affected one resident who experienced elevated blood pressure, headache, blurry vision and had an abnormal EKG and placed 98 residents with a [DIAGNOSES REDACTED]. Findings include: Resident #85 Resident #85 was on five blood pressure medications and experienced an elevated blood pressure of 217/126. The physician was not consulted concerning the elevated blood pressure. Interviews and record reviews revealed staff were not trained to identify and monitor when Resident #85 experienced an elevated blood pressure on 1/5/2016. No parameters on her blood pressure medications had been identified by the facility or the physician. Staff were not trained to consult the physician when a resident experienced high blood pressure. Resident #85 experienced a change in condition including shakiness, headache and blurred vision on 01/11/16 which was not documented and the staff did not consult the physician concerning the resident's symptoms until 01/12/16. Resident #85 had a physician ordered STAT (urgent, rush) EKG (Electrocardiogram) on 01/12/16 to address her change in condition. The abnormal results of the EKG were not received until 25 hours later by the facility. Resident #85's physician was left a message concerning the abnormal results but was not verbally consulted. Interview on 01/14/16 at 12:15 p.m. the DON stated she had numerous ways on how she checked the competency of the nursing staff including return demonstration and in-servicing. She stated she was unsure how this situation happened and was unsure why there was no documentation regarding Resident #85's change in condition on 01/11/16. The DON further stated the facility did not have set blood pressure paramenters of when to notify a physician of an adverse blood pressure reading. She stated the nurses were to just use their professional judgment as to when to consult the physician. Interview on 01/14/16 at 12:17 p.m. the Administration stated she was unaware of the situation concerning Resident #85 or that residents did not have blood pressure paramenters that assisted staff as to when to consult physicians. She stated she believed these failures were an exception to the norm in the facility and occurred due to having two new nurses on the evening shift. The Administrator stated the nurses at the facility were usually thorough, but had missed documentating the changes of Resident #85 on 01/11/16. She stated she monitored the effectiveness of the DON through various ways including morning meetings with charge nurses, IDT meetings, and risk management meetings every Friday. She stated she also monitored through competency checks with staff and random audits of charts, records and reports to ensure staff were being trained effectively by the DON. During the same interview on 01/14/2016 the Administrator stated the company provided numerous resources for the Administrator and DON to utilize to assist in training and monitoring staff. She stated the company had a Medical Director, Regional Clinical Nurse, and Divisional Operations Manager to assist the facility. Interview on 01/15/16 about 10:40 a.m., the DON said she was not aware of Resident #85's blood pressure reading on 01/ 16 that was documented in the resident's chart. She agreed the elevated values should have been addressed and should have warranted consultation with the resident's physician. The DON said the facility was auditing all residents' charts and would ensure parameters were added for all blood pressure medications. The DON further expressed she was in-servicing staff on implementing the added blood pressure parameters. The DON said she was not informed of Resident #85's elevated blood pressure on 01/05/16 or her complaints on 01/12/16. She said usually staff discussed such occurrences during their morning meetings. She stated LVN #12 failed to follow up with the information when she became aware of it. Interview on 01/15/2016 at 11:00 am the DON stated she had interviewed Resident #85 concerning her change in condition. The DON also stated the resident stated she felt she was drilled by the surveyor. The DON expressed she felt the resident had not told the truth to the surveyor. During the interview the DON stated the resident had [DIAGNOSES REDACTED]. The DON reported Resident #85 would often report pain at a level of 9 out of 10 but then would deny that she had the pain a short time later. The DON did state that the resident did experience an elevated blood pressure and heart rate and staff should have consulted the physician. During the same interview on 01/15/2016 at 11:00 a.m. the DON stated in a nursing facility there should not be STAT EKGs ordered by the physicians due to the time it would take the facility to get the test completed and read. She stated if a resident needed such a test immediately, the resident should be transfered to the hospital. She stated there was a delay in getting the EKG completed and the results to the physician. The DON stated staff training had been initiated to train staff on the identified areas of concern. Record review of the facility policy on Changes in Resident Condition dated April 2005 revealed The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit . The facility Administrator was notified on 01/14/2016 at 12:10 p.m. that an Immediate Jeoparty (IJ) situation had been identified due to the above failures. Plan of Removal of the IJ: 1. On January 14, 2016 the RN Director of Nursing, RN Staff Development Coordinator/ADON and RN Case Management Coordinator assessed residents with orders for hypertensive medication to validate parameters were available. If parameters were not available the licensed nurses were contacting the physician to request parameters. Physician instructions would be documented in the medical record. 2. Effective January 14, 2016 once a change of condition was identified, qualified staff would evaluate the resident and initiate the appropriate protocol utilizing Interact 4.0. The decision support tool provided guidance to nursing staff on whether to report specific signs and symptoms based on the evaluation completed by the nurse. Standardized parameters were established using the guidelines from Interact 4.0 : · Systolic BP > 200 mmHg or <90 mmHG · Diastolic BP > 115 mmHG · Resting Pulse > 100, < 50 3. The licensed nurse would evaluate each situation based on individual resident condition at the time of the event. The licensed staff would continue to provide care and monitor the resident until emergency personnel arrived. 4. Effective January 15, 2014 the clinical team including the Director of Nursing, Assistant Director of Nursing, Unit Managers, MDS nurses, would review the previous day's 24-hour Nursing Report during the morning meeting to assure all physician orders were reconciled and to assure that appropriate parameters were followed in the event of an elevated blood pressure or in the event of an abnormal test result. 5. The District Director of Clinical Services re-educated the Director of Nursing Services who then conducted re-education training for all licensed nurses and certified medication aides who were on duty January 14, 2016. The re-education included the following: · Change of Condition including completion of focused assessment. Staff was to immediately contact the attending physician for changes of condition and administer any medications, particularly PRN medications, specifically related to the change of condition. If the physician or extender did not return the call within 30 minutes, the licensed nurse would notify the Medical Director for further instructions. · Blood pressures were to be monitored. In the event of elevated blood pressures, the licensed nurses were required to follow the parameters noted or specific to the medication. · Documentation of orders or instructions would be entered in the medical record once instructions were given by the physician or physician extender. 6. Licensed nurses and certified medication aides that were not able to attend any of the training offered would not be allowed to work with residents until they had been re-educated on the facility's process. The surveyors monitored the current Plan of Removal on 01/16/2016 as follows: Record review of 24 standardized blood pressure parameter orders revealed all necessary changes, clarifications, and additions had been made. Record review of the in-service records revealed courses on blood pressure, documentation of vital signs, physician orders to include parameters of when to hold medication and when to notify the physician, identifying a change in condition and utilizing the decision support tools. Interviews were conducted with nine staff members (2 RNs, 5 LVNs, and 2 CMAs) who stated they had received education on documenting blood pressures and vital signs, recognizing a change in resident condition, notifying a nurse of elevated or abnormal vital signs, assessing the resident using the decision support tool, and notifying the physician if needed. Training provided also included the use and calibration of glucose testing devices/glucometers. Training provided also included the process for notifying the Medical Director if the physician had not returned a phone call within 30 minutes. All stated they felt comfortable caring for residents with hypertension and those requiring blood pressure medications. On 01/16/2016 at 11:21 a.m., the facility Administrator was informed the IJ had been removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of widespread. The facility was continuing to monitor to ensure all staff were trained to monitor, assess and consult physicians concerning changes in condition, elevated blood pressures and STAT lab results. The facility 672 dated 01/12/2016 indicated 99 residents had a [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to provide necessary services to prohibit neglect of one of seven residents (CR#1) reviewed for abuse and neglect: CR# 1 incurred a fall while two aides were utilizing a Hoyer lift in transferring him from a bed in his room to a shower bed (stretcher) in the hallway. The Hoyer lift tilted and caused CR #1 to fall and sustain an acute [MEDICAL CONDITION] tibia and fibula on [DATE]. CR #1 was transferred to the hospital following the fall where he died on [DATE]. This failure affected CR# 1 who sustained fractures and placed 51 residents at risk of not receiving safe assistance with Hoyer lift transfers which could lead to injuries. Intake # 1 and # 0 Findings include: Record review of CR# 1's face sheet revealed a [AGE] year old year male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR# 1's care plan not dated revealed CR#1 had self-care performance deficit related to [MEDICAL CONDITION]. Goal was to maintain current level of function on ADLs through review date. Approach include: transfer- the resident requires mechanical lift (Hoyer) with two staff assistance for transfer. Record review of CR # 1's MDS dated [DATE] revealed a cognition score of zero which meant the resident was severely impaired. CR#1 required extensive assistance with bed mobility, transfer, dressing, eating, personal hygiene and was dependent on staff for toilet use and bathing. Record review of CR # 1's nursing notes dated [DATE] at 10:53 a.m., revealed Resident was being transferred from his bed to the shower bed via Hoyer lift. Due to the improper positioning of the Hoyer base the Hoyer lift began to tilt. The resident was lowered to the floor by the two aides present. Upon assessment by RN, a reddened area (possible bruising) was noted to the left knee. Resident did not display any sign and symptoms of distress. MD was notified of the incident and orders for X-Ray were received . Record review of CR # 1's nursing notes dated [DATE] at 2:50 p.m., revealed Resident X-Ray result returned post fall acute fracture in proximal tibia and fibula; called MD and gave order to transfer resident to ER . Record review of CR # 1's X-ray result dated [DATE] revealed acute fracture in proximal tibia and fibula. Record review of facility ' s incident report for CR#1 dated [DATE] revealed Resident was being transferred from the shower bed to his bed. The resident was wheeled out from the bed and when the caregivers were about to wheel him back to his bed , the wheel of the Hoyer tilted over and they lowered the resident to the floor. resident sustained [REDACTED]. Record review of facility investigation report revealed a fracture of unknown origin. The incident date was [DATE] at 10:30 a.m. Further review of the incident description revealed the resident was being transferred by two CNAs from his bed to the shower bed. During the transfer the Hoyer lift tilted and the CNAs had to lower the resident to the floor. Upon initial head to toe assessment a bruise was noted on the resident ' s left knee. The physician was notified and an order was given for an X-Ray which indicated an acute fracture in the proximal tibia and fibula. Summary revealed written statements were obtained from the two CNAs and both individuals were trained on proper transfer procedure with Hoyer lift. Fracture was likely caused by lowering of the resident to the floor and his history of brittle bones. Further review of the investigation report dated [DATE] revealed post action taken post investigation- the two CNAs transferring the resident at the time of the incident were given additional training in transferring with a Hoyer lift. A nursing in-service was given on [DATE] for nursing department on lift and transfers. Record review of witness statement written by CNA#1 dated [DATE] revealed I was assisting CR#1 with a shower along with co-worker CNA#2. As we began to lift him in the air my co-worker guided the sling and I had the Hoyer lift. As he was in the air, I turned to the shower bed and the whole lift fell over . I have never seen anything like it. Prior to the lift I checked to make sure the weight was correct which 500 pounds was . Record review of witness statement written by CNA#2 dated [DATE] revealed CNA#2 would like to state the day of the fall of CR#1 was very tragic. I was helping another aide to put CR#1 onto the shower bed, when we hooked CR#1 onto the Hoyer lift. We pulled him close to the shower bed but before we could put him on it, somehow the Hoyer lift tilted over . It was an accident but both of us did everything correct due to my knowledge of the lift and transferring . Record review of facility training after the incident dated ,[DATE]-[DATE] revealed proper lift and transfer and reporting any broken sling or lift. CNA#1 and #2 were the only attendants. Further review of training details provided revealed Both CNAs were in-serviced and watched video on lift transferring , they were also verbally in serviced on proper alignment of a resident prior to turning , repositioning or transferring . No other staff education or in-services were provided at that time. Two attempts to interview CNA#1 on [DATE] were unsuccessful. He was a part time staff of the facility, and calls made to his phone were not returned. Interview on [DATE] at 11:20 a.m., CNA#2 stated she was called to assist CNA#1 in transferring CR#1 from the bed to the shower bed. Both aides placed a shower bed outside of the resident ' s room entrance because there was not enough space for the long shower bed in the room. She said they put the resident on the Hoyer lift and pulled the lift backward out of the room to the hallway where the shower bed was. CNA #2 held the resident and the sling while CNA#1 controlled the Hoyer and the remote. As CNA#1 was about to turn the Hoyer lift to be in a parallel position with the shower bed, the Hoyer lift tilted over and the resident came down with his back to the ground. She said she was trained on how to use the Hoyer lift but stated they did everything right and did not know what happened. CNA#2 said she received no one on one demonstration after the incident but was asked to watch a video on how to use the Hoyer lift. Interview on [DATE] about 12:20 p.m., CNA#3 said the Hoyer lifts in the facility have acceptable weights allowed. She explained that some of Hoyer lifts will tilt over if the weight was not evenly distributed. She illustrated with a 400 pound maximum Hoyer lift would shake and could tilt over if used on residents of 314 LBS despite the manufactures instruction. She further stated staff had to know which one to use on certain residents to be safe. Interview on [DATE] at 3:40 p.m., the DON said the facility determined the aides did not properly use the Hoyer lift during the transfer of CR#1 which resulted in the Hoyer lift tilting over. She said she was of the opinion that the aides lowered the resident to the floor and the fall occurred while the resident was being transferred back to bed from the shower bed. The DON further said the aides should not use the Hoyer lift as a mode of transportation. She said it was determined the base of the Hoyer lift was closed instead of open which caused the lift to tilt over. The DON agreed there were lots of inconsistent documentation regarding the incident which the facility should have identified during their investigation. The DON said the two aides were re-educated and she would continue to educate staff on proper use of the lift. She explained the two aides were given verbal education and they watched a video on Hoyer lift use. The DON was asked why other facility staff were not trained and if a return demonstration was conducted with the staff using the facility Hoyer lifts, and she said no. Interview on [DATE] at 4:35 p.m., the facility Administrator agreed the incident could have been avoided if staff used the right technique during CR#1 ' s transfer. She further said the facility identified the staff needed additional training which was given. The Administrator agreed the facility did not ensure the safety of the residents dependent on Hoyer lift for transfer when they failed to train staff on the proper use of the Hoyer lifts in the facility instead of a video and also to ensure understanding of training with return demonstration. Record review of facility policy on abuse and neglect prohibition dated [DATE] revealed each resident has the right to free from mistreatment , neglect , abuse , involuntary seclusion, injuries of unknown origin and misappropriation of property . Facility census dated [DATE] listed 51 residents required the use of the Hoyer lift for transfers.

Based on observation , interview and record review, the facility failed to implement their written policies and procedures concerning the reporting of neglect for two of seven residents (CR# 1 and Resident #5) reviewed for abuse and neglect The facility failed to timely report to state office when CR# 1 incurred a fall while two aides were utilizing a Hoyer lift in transferring him from a bed in his room to a shower bed (stretcher) in the hallway. The Hoyer lift tilted and caused CR #1 to fall and sustain an acute [MEDICAL CONDITION] tibia and fibula on [DATE]. CR #1 was transferred to the hospital following the fall where he died on [DATE]. The facility reported the incident on [DATE]. The facility failed to investigate and report to the state agency when Resident #5 was diagnosed with [REDACTED]. This failure affected two residents who suffered fractures and placed 17 residents who had a history of [REDACTED]. Findings include: Intake # 1 and # 0 Record review of facility policy on abuse and neglect prohibition dated [DATE] revealed each resident has the right to free from mistreatment , neglect , abuse , involuntary seclusion, injuries of unknown origin and misappropriation of property . Further review of policy revealed the facility would report all allegations and substantiated occurrence of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by the state law. Record review of CR# 1's face sheet revealed a [AGE] year old year male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR# 1's care plan not dated revealed CR#1 had self-care performance deficit related to [MEDICAL CONDITION]. Goal was to maintain current level of function on ADLs through review date. Approach include: transfer- the resident requires mechanical lift (Hoyer) with two staff assistance for transfer. Record review of CR # 1's MDS dated [DATE] revealed a cognition score of zero which meant the resident was severely impaired. CR#1 required extensive assistance with bed mobility, transfer, dressing, and eating, personal hygiene and was dependent on staff for toilet use and bathing. Record review of CR # 1's nursing notes dated [DATE] at 10:53 a.m., revealed Resident was being transferred from his bed to the shower bed via Hoyer lift. Due to the improper positioning of the Hoyer base the Hoyer lift began to tilt. The resident was lowered to the floor by the two aides present. Upon assessment by RN, a reddened area (possible bruising) was noted to the left knee. Resident did not display any sign and symptoms of distress. MD was notified of the incident and orders for X-Ray were received . Record review of CR # 1's X-ray result dated [DATE] revealed acute fracture in proximal tibia and fibula. Record review of facility investigation report dated [DATE] revealed fracture of unknown origin; incident date was [DATE] at 10:30a.m. Further review of incident description revealed the resident was being transferred by two CNAs from his bed to the shower bed. During the transfer the Hoyer lift tilted and the CNAs had to lower the resident to the floor. Upon initial head to toe assessment a bruise was noted on the resident ' s left knee, physician was notified and order was given for X-Ray which indicated an acute fracture in proximal tibia and fibula. Summary revealed written statements were obtained from the two CNAs and both individuals were trained on proper transfer procedure with Hoyer lift. Fracture was likely caused by lowering of the resident to the floor and his history of bristle bones. Investigation finding was confirmed. Interview on [DATE] at 4:35 p.m., the facility Administrator said the facility reported the incident to the state agency on [DATE]. She further said the facility was aware of how the injury was sustained and therefore did not think it was reportable incident. She however said after the facility ' s investigation, it was determined the CNAs did not use the appropriate technique during transfer and required additional training. Resident #5 Record review of Resident # 5 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 5 ' s MDS dated [DATE] revealed cognitive score of one, and required extensive assistance for bed mobility, transfer, dressing, eating, and personal hygiene. Ambulation did not occur and she was dependent with toilet use and bathing. Record review of Resident # 5 ' s left knee X-Ray dated [DATE] revealed reason for X-ray was pain for 2 days. Further review of result revealed fracture mid-portion of patella was seen. Record review of facility ' s incident/accident log revealed Resident # 5 had falls on [DATE]-no incident report, [DATE]-fall in resident ' s room; Resident ' s outcome was fracture and action taken - hospitalization . State notified (checked). [DATE], and [DATE]. Further review of incidents reports revealed on [DATE] at 2:30p.m., resident was sitting in a Geri chair outside of room, the resident appears to have gotten out and attempted to walk towards shower room, and she was observed on the floor , upon assessment, no injury and complaint of pain was noted. Observation and interview on [DATE] at 9:38 a.m., revealed Resident #5 in bed, alert but very confused. Resident # 5 was Spanish speaking and did not speak English .She was noted with brace to left leg. Unit manger #1 reported the resident had injury (left knee fracture) from a fall. Interview on [DATE] at 3:40 p.m., the DON said she did not know why Resident #5 ' s fracture of unknown origin was not reported. She said the Administrator handled the issue because she was on vacation. Interview on [DATE] at 4:40 p.m., The facility Administrator said she did not think Resident# 5 ' s fracture of unknown origin was reportable. She said the facility believed it must have been caused by one of her numerous falls. She said the resident was constantly attempting to ambulate and staff cannot restrain her. She said the facility did not think it had anything to do with abuse or neglect. The facility DON reported 17 residents had historys of falls.

Based on interview and record review, the facility failed to emsure resident's environment remained as free of accident hazards as was possible, and each resident received adequate supervision and assistance devices to prevent an accident for one of seven residents (CR#1) reviewed for accidents and supervision. CR# 1 incurred a fall while two aides were utilizing a Hoyer lift in transferring him from a bed in his room to a shower bed (stretcher) in the hallway. The Hoyer lift tilted and caused CR #1 to fall and sustain an acute fracture of the proximal tibia and fibula on [DATE]. CR #1 was transferred to the hospital following the fall where he died on [DATE]. This failure affected CR# 1 who sustained fractures and placed 51 residents at risk of not receiving safe assistance with Hoyer lift transfers which could lead to injuries. Intake # 1 and # 0 Findings include: Record review of CR# 1's face sheet revealed a [AGE] year old year male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR# 1's care plan not dated revealed CR#1 had self-care performance deficit related to [DIAGNOSES REDACTED]. Goal was to maintain current level of function on ADLs through review date. Approach include: transfer- the resident requires mechanical lift (Hoyer) with two staff assistance for transfer. Record review of CR # 1's MDS dated [DATE] revealed a cognition score of zero which meant the resident was severely impaired. CR#1 required extensive assistance with bed mobility, transfer, dressing, eating, personal hygiene and was dependent on staff for toilet use and bathing. Record review of CR # 1's nursing notes dated [DATE] at 10:53 a.m., revealed Resident was being transferred from his bed to the shower bed via Hoyer lift. Due to the improper positioning of the Hoyer base the Hoyer lift began to tilt. The resident was lowered to the floor by the two aides present. Upon assessment by RN, a reddened area (possible bruising) was noted to the left knee. Resident did not display any sign and symptoms of distress. MD was notified of the incident and orders for X-Ray were received . Record review of CR # 1's nursing notes dated [DATE] at 2:50 p.m., revealed Resident X-Ray result returned post fall acute fracture in proximal tibia and fibula; called MD and gave order to transfer resident to ER . Record review of CR # 1's X-ray result dated [DATE] revealed acute fracture in proximal tibia and fibula. Record review of facility ' s incident report for CR#1 dated [DATE] revealed Resident was being transferred from the shower bed to his bed. The resident was wheeled out from the bed and when the caregivers were about to wheel him back to his bed , the wheel of the Hoyer tilted over and they lowered the resident to the floor. resident sustained [REDACTED]. Record review of facility investigation report revealed a fracture of unknown origin. The incident date was [DATE] at 10:30 a.m. Further review of the incident description revealed the resident was being transferred by two CNAs from his bed to the shower bed. During the transfer the Hoyer lift tilted and the CNAs had to lower the resident to the floor. Upon initial head to toe assessment a bruise was noted on the resident ' s left knee. The physician was notified and an order was given for an X-Ray which indicated an acute fracture in the proximal tibia and fibula. Summary revealed written statements were obtained from the two CNAs and both individuals were trained on proper transfer procedure with Hoyer lift. Fracture was likely caused by lowering of the resident to the floor and his history of brittle bones. Further review of the investigation report dated [DATE] revealed post action taken post investigation- the two CNAs transferring the resident at the time of the incident were given additional training in transferring with a Hoyer lift. A nursing in-service was given on [DATE] for nursing department on lift and transfers. Record review of witness statement written by CNA#1 dated [DATE] revealed I was assisting CR#1 with a shower along with co-worker CNA#2. As we began to lift him in the air my co-worker guided the sling and I had the Hoyer lift. As he was in the air, I turned to the shower bed and the whole lift fell over . I have never seen anything like it. Prior to the lift I checked to make sure the weight was correct which 500 pounds was . Record review of witness statement written by CNA#2 dated [DATE] revealed CNA#2 would like to state the day of the fall of CR#1 was very tragic. I was helping another aide to put CR#1 onto the shower bed, when we hooked CR#1 onto the Hoyer lift. We pulled him close to the shower bed but before we could put him on it, somehow the Hoyer lift tilted over . It was an accident but both of us did everything correct due to my knowledge of the lift and transferring . Record review of facility training after the incident dated ,[DATE]-[DATE] revealed proper lift and transfer and reporting any broken sling or lift. CNA#1 and #2 were the only attendants. Further review of training details provided revealed Both CNAs were in-serviced and watched video on lift transferring , they were also verbally in serviced on proper alignment of a resident prior to turning , repositioning or transferring . No other staff education or in-services were provided at that time. Two attempts to interview CNA#1 on [DATE] were unsuccessful. He was a part time staff of the facility, and calls made to his phone were not returned. Interview on [DATE] at 11:20 a.m., CNA#2 stated she was called to assist CNA#1 in transferring CR#1 from the bed to the shower bed. Both aides placed a shower bed outside of the resident ' s room entrance because there was not enough space for the long shower bed in the room. She said they put the resident on the Hoyer lift and pulled the lift backward out of the room to the hallway where the shower bed was. CNA #2 held the resident and the sling while CNA#1 controlled the Hoyer and the remote. As CNA#1 was about to turn the Hoyer lift to be in a parallel position with the shower bed, the Hoyer lift tilted over and the resident came down with his back to the ground. She said she was trained on how to use the Hoyer lift but stated they did everything right and did not know what happened. CNA#2 said she received no one on one demonstration after the incident but was asked to watch a video on how to use the Hoyer lift. Interview on [DATE] about 12:20 p.m., CNA#3 said the Hoyer lifts in the facility have acceptable weights allowed. She explained that some of Hoyer lifts will tilt over if the weight was not evenly distributed. She illustrated with a 400 pound maximum Hoyer lift would shake and could tilt over if used on residents of 314 LBS despite the manufactures instruction. She further stated staff had to know which one to use on certain residents to be safe. Interview on [DATE] at 3:40 p.m., the DON said the facility determined the aides did not properly use the Hoyer lift during the transfer of CR#1 which resulted in the Hoyer lift tilting over. She said she was of the opinion that the aides lowered the resident to the floor and the fall occurred while the resident was being transferred back to bed from the shower bed. The DON further said the aides should not use the Hoyer lift as a mode of transportation. She said it was determined the base of the Hoyer lift was closed instead of open which caused the lift to tilt over. The DON agreed there were lots of inconsistent documentation regarding the incident which the facility should have identified during their investigation. The DON said the two aides were re-educated and she would continue to educate staff on proper use of the lift. She explained the two aides were given verbal education and they watched a video on Hoyer lift use. The DON was asked why other facility staff were not trained and if a return demonstration was conducted with the staff using the facility Hoyer lifts, and she said no. Interview on [DATE] at 4:35 p.m., the facility Administrator agreed the incident could have been avoided if staff used the right technique during CR#1 ' s transfer. She further said the facility identified the staff needed additional training which was given. The Administrator agreed the facility did not ensure the safety of the residents dependent on Hoyer lift for transfer when they failed to train staff on the proper use of the Hoyer lifts in the facility instead of a video and also to ensure understanding of training with return demonstration. Record review of facility policy on abuse and neglect prohibition dated [DATE] revealed each resident has the right to free from mistreatment , neglect , abuse , involuntary seclusion, injuries of unknown origin and misappropriation of property . Facility census dated [DATE] listed 51 residents required the use of the Hoyer lift for transfers.

Based on interview and record review the facility failed to ensure 3 of 11 residents (Resident #10, 5 and 12) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: --Resident #10's pain was not effectively controlled. He had 4 Pressure Ulcers, 2 of which were Stage IV and the other 2 were Stage 3. He was not receiving scheduled pain medication, as needed pain medication was not being administered and he was not turned every 2 hours as per care plan. Resident # 5 and #12 were not provided adequate pain management to address their pain. This failure affected 3 resident whose pain were uncontrolled and placed 57 residents on pain management at risk of not receiving adequate assessments, medical care and services which could have a negative impact on their health and well-being. Findings include: Resident #10: Record review of Resident #10 ' s face sheet revealed an admitted [DATE]. His [DIAGNOSES REDACTED]. Resident #10 was [AGE] years old. Record review of Resident #10 ' s Annual MDS assessment dated [DATE] revealed that he was dependent on staff for bed mobility, transfers, dressing, eating, toilet use and hygiene/bathing. He was coded as having impairment on both sides of the upper and lower extremities. He was always incontinent of bowel and he had an indwelling catheter. Under Section C, Resident #10 scored 10 of 15 on Brief Interview for Mental Status, indicating he was able to make needs known. On Section J Health Condition, Resident #10 had occasional presence of pain with an intensity level of 4 on a 0-10 scale with zero being with no pain and 10 as the worst pain you can imagine. Under Section M, Resident #10 was coded as having 3 Stage IV Pressure Ulcers. Record review of Resident #10 ' s summary of Physician orders [REDACTED]. -[MEDICATION NAME] with APAP 5 mg-325 mg take 1 tab by mouth every 8 hours as needed for pain. -Left Ischial DTI (Deep Tissue Injury) Ulcer- apply skin prep and leave open to air everyday. -Right Ischial Ulcer Stage 3, Clean with Normal Saline, Pat Dry and apply Calcium Alginate dressing and change daily. -Every 2 hours change position and turning Record review of Resident #10 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Resident #10 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation on 12/16/13 at 1:00 pm, Resident #10 was lying in bed facing the window, he was wearing a hospital gown. He had contractures to his bilateral lower extremities and his right upper extremity. Resident #10 had an indwelling catheter that had white sediments in the tubings and 1200 cc of cloudy urine in urine bag. Interview with Resident #10 on 12/16/13 at 3:30 pm he said he was in pain. Resident #10 said that he had not been repositioned since he had an incontinent care at around 1 pm. Observation on 12/17/13 at 8:42 am, Resident #10 was lying on his back. He said the last time he was repositioned was at around 6:00 am. Observation on 12/17/13 at 11:07 am, Resident #10 was lying on his back. Observation and interview on 12/17/13 at 1:49 pm, Resident #10 was lying on his back. He said that he had not been turned. He said " my behind hurts, it feels like pus might come out or something. Sometimes I have a lot of pain in my legs and bones. " Resident #10 was asked why he didn ' t ask for a pain pill. Resident #10 said " they don ' t respond to it. They ' ll tell you they will do something but nothing gets done." Interview with ADON LVN DD on 12/17/13 at 3:00 pm revealed that she was not sure why Resident #10 was not on routine pain medication. She said that " they ' re supposed to assess for pain - verbal and non-verbal " . Interview with ADON LVN DD on 12/17/13 at 4:30 pm revealed that she interviewed Resident #10 and he told her that he was in a lot of pain at around 2:00 am at night. He said that it kept him from resting at night. ADON LVN DD said that she would call the physician and get an order for [REDACTED]." Interview with Resident #10 on 12/18/13 at 8:33 am revealed that he was in pain " last night " . He said that he slept on and off. He said that he got repositioned twice all night, " my side and my back too " . He said that he got repositioned where he had his sore on his foot. Resident #10 said that sometimes he told them not to repositioned where his sores were, " I tell them, sometimes they will listen. I ' ve been like this since 6:00 am this morning. I ate breakfast like this, they just raised my head up " . Resident #10 was lying on his right side. Interview with CNA GG on 12/18/13 at 9:14 am revealed that Resident #10 should be turned every 2 hours. She said that if a resident had a sacral wound, the resident shouldn ' t be lying on his back. Interview with ADON LVN DD on 12/18/13 at 9:45 am revealed that CNAs should reposition Resident #10 every 1 hour because of pressure sores. She said that according to Resident #10 ' s care plan, Resident #10 should not lie on his back. Record review of Resident #10 ' s care plan undated revealed " Avoid positioning the resident on back " . Further review of Resident #10 ' s care plan on PressureUlcers dated 11/1/13 revealed " Treat pain as per orders prior to treatment/turning etc to ensure the resident ' s comfort. Resident #10 ' s goal for pain stated, " ...will be free of any discomfort or adverse side effects from pain medication through the review date. Record review of Resident #10 ' s Pain Evaluation dated 12/4/13 revealed that Resident #10 was not on scheduled pain management regimen. It stated that Resident #10 had received PRN (as needed) pain medications in the last 5 days and he had not received non-medication intervention for pain. Resident #10 had experienced occasional pain that made it hard for him to sleep at night and pain had limited his day to day activities. Resident #10 had pain in his joints, back, wound/ulcer, muscle pain, back and lower back. Resident #10 had prior history of pain. The potential underlying causes were identified as arthritis, immobility, contracture, ulcer/wound, [MEDICAL CONDITION] and vascular disorder. Under pain intensity, it was documented that Resident #10 ' s pain rating was 4 on the scale of 0-10 with zero equaling no pain and 10 being the worst possible pain they have ever been in. Under pain relief, it identified rest, positioning, ROM/Mobility, Meditation. The type of pain was described as heaviness, tenderness, pins and needles and throbbing. Under manner of expressing pain, the following were checked: verbalization, frowning, tearfulness, rocking and [MEDICAL CONDITION]. It further identified that pain had interfered in Resident #10 ' s sleep, appetite and physical activity. Resident # 5 Record review of Resident #5 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]with the following Diagnoses: [REDACTED]. Record review of Resident #5 ' s MDS assessment dated [DATE] revealed the resident was severely impaired for cognition, dependent on staff for all ADLs , incontinent of bowel and had an indwelling urinary catheter. Resident #5 also had limitation in range of motion on one side of lower extremity. Record review of the resident ' s care plan dated 11/7/13 revealed the resident had pain related to general discomfort, goal was the resident to verbalize relief of pain through the review date. Approaches include; staff to anticipate the resident ' s needs for pain relief and respond immediately to any complaint of pain, notify physician if interventions were unsuccessful or if current complaints was a significant change from residents past experience of pain. Record review of the resident ' s MAR indicated [REDACTED] [MEDICATION NAME] APAP 10/325mg one tablet per [DEVICE] twice daily for pain. Medication was to be administered at 8am and 8pm. [MEDICATION NAME] APAP5/325mg one tablet per [DEVICE] every 6 hours as need for pain. Medication was administered on 12/3, 12/4, 12/13 and 12/16. Observation on 12/17/13 at 10:11 am during incontinent care, the resident was yelling out loud when moved and was pulling and holding his left leg. Resident # 5 ' s left leg was noted to be contracted as he was unable to completely extend the leg.The resident continued to yell each time he moved and when asked if he was hurting, he responded yes. Interview on 12/17/13 at the time of the above observation CNA H said the resident always complained when moved but she was surprised to hear the resident talking. She said she thought he could be in pain. Interview on 12/17/13 at 2:00P.M., RN A said the resident was known to yell when moved but he had never verbalized the presence of pain. RN A said she would notify the doctor for review of his pain medication . She explained the resident received pain medication twice daily and received as needed pain medication ordered when family members requested. She said the resident will never request for the as needed medications. RN A was asked how often the resident was assessed for pain and what was done for break through pain during the day and she said the resident was not perceived to be in pain. Record review of the resident ' s pain assessment record dated December 2013 revealed there were only three days when the resident ' s facial expression was coded as 0 (meaning no hurt) according to the Wong-Baker faces pain rating scale used. For non-verbal pain indicators, the resident had facial grimacing, and verbal complaints and non- verbal indicators. Non-pharmacological intervention provided was reposition/ support. There were no pain assessment documented on 12/13/13 and no documentation of as needed pain medication administered. Interview with Resident #5's family member on 12/18/13 at 10:30A.M., revealed the resident started yelling out when moved and they had requested the facility to ask the physician for order to do X-ray to see what was wrong. The family member stated the resident yelled out a lot and staff did not offer additional pain medication since the resident would not ask. Interview on 12/18/13 about 12:50P.M., Resident # 5 ' s physician said he will review his medication and offer some medication to be administered between morning and the night doses of his pain medication. Resident # 12 Record review of Resident # 12 ' s face sheet revealed a [AGE] year old male with a re-admitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident # 12 ' s MDS assessment dated [DATE] revealed intact cognition, received scheduled pain medication , pain was occasional in frequency and about two out of 10 in intensity. Record review of the residents care plan dated 12/6/13 revealed the resident had chronic pain related to Arthritis. Goal was the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Approaches ' include- notify physician if interventions were unsuccessful or if current complaint of pain is a significant change from the resident past experience of pain , observe, record and report to nurse residents complaint of pain or request for pain treatment. Record review of the resident ' s pain assessment record dated December 2013 revealed according to the Wong-Baker faces pain rating scale used, the resident had pain scores ranging from 1 to 4 (in scale of 1 through 10) throughout the month of December and for non-verbal pain indicators, the resident made verbal complaints. There were inconsistencies in the pain assessment documented - no record of assessment were found on 12/6/13 for 8 AM, 12 noon, 12/5/13 for 4pm dose (pain assessment documented was with pain medication doses given). Record review of Resident #12 ' s MAR indicated [REDACTED]. Medication times were 8am, 12pm and 4pm. Further review of Resident #12 ' s record revealed no documentation of as needed pain medication. Observation on 12/17/13 at 7:50A.M., the resident was found in the wheel chair by the hallway, he said he was in pain and stayed up all night due to pain in legs. Resident was rubbing his right knee, he appeared apprehensive and flushed. He reported pain to bilateral legs. Further interview following the above observation , Resident # 12 said the pain was "a lot last night" , he said the pain was 8 in a scale of 10, he said he asked the charge nurse for pain medication and did not get any medications. He said his head hurt from his leg pain. The resident said he wanted something right away to help him because he could no longer bear the pain. RN A was notified of the resident ' s complaints and the resident was given his 8am pain medication dose. Resident # 12 said the medication currently given to him did not control his pain and wanted something done. Interview on 12/17/13 at 2:43P.M., RN A said the resident was been seen by an orthopedic doctor for his pain, she said the resident had chronic pain to legs and he complained frequently of pain. She further said he received scheduled pain medication three times daily. RN A said the resident 's physician will be contacted to address the issue as the resident had no as needed pain medication ordered for break through pain. Interview on 12/18/13 at 10:15A.M., the DON said she was notified the staff followed up on Resident # 12 ' s pain issue, and he now had an order for [REDACTED]. Record review of the facility's policy and procedure on Pain Management dated February 2010 revealed, read in parts, "...3. Additionally, any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain, or identified through the RAI process or otherwise will have a full evaluation of the pain conducted using the Pain Evaluation Form. 4. Following the pain evaluation, notify the physician of the findings and document on the Change of Condition form. Implement new ordrs as received. 5. Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan should include both pharmacological and non-pharmacological pain management interventions. 6. The Licensed Nurse will implement a Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 7. The Licensed Nurse will communicate any new onset of resident pain or change in resident pain through the 24 Hour Report process. 8. The IDT will discuss the new onset of pain at the daily stand-up meeting and the IDT Team conference. 9. The Pain Management Care Plan with interventions will be updated as indicated and discussed at the IDT stand up meetings, as needed. 10. The staff will implement the Care Plan, monitor the resident, and administer therapetic interventions for pain, if ordered. .." According to CMS form 672 the facility had 60 residents receiving pain management.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent the development of and promote the healing of pressure sores for 1 of 5 resident (Resident #5) who were reviewed for pressure sores. Resident # 5 entered the facility without pressure ulcers on 10/21/13. Resident #5 developed a pressure ulcer on the left heel. A pressure ulcer to the sacral area was documented on readmission from the hospital on [DATE] as a Stage II and worsened to a Stage IV. The resident was not provided wound care as ordered which lead to worsening and contamination of the wound. This failure affected 1 resident and placed 20 other residents with pressure sores at risk of worsening of the sores and decrease of new skin growth and infections. Also lack of preventative measures could place all residents at risk of pressure ulcer development. Findings included: Intake # 7 Record review of Resident #5 face sheet revealed a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was readmitted from the hospital on [DATE]. Record review of Resident #5 ' s MDS assessment dated [DATE] revealed the resident was severely impaired for cognition, was dependent on staff for all ADLs , was incontinent of bowel . MDS identified the resident as being at risk of developing pressure ulcers . Record review of Resident # 5 ' s nurse ' s progress notes dated 10/21/13 revealed no presence of pressure ulcers. Record review of Resident # 5 ' s progress notes dated 10/23/13 revealed the resident was transferred to the facility from another nursing facility, and pressure ulcers were not identified. Record review of Resident #5's nurses notes dated 11/21/13 revealed the resident had altered mental status and was sent out to the hospital. Record review of the resident ' s hospital assessment notes dated 11/17, 11/18, 11/19 till 11/23/13 revealed the resident was admitted to the hospital with [REDACTED]. Further review of Resident #5's nurse ' notes dated 11/23/13 at about 4:39 P.M., revealed the resident was re-admitted to the facility on [DATE] with a stage II pressure ulcer to sacral area-4X4 dressing on the sacral area . There was no additional documentation to indicate that the wound was assessed, or actual size documented. Record review of Resident #5 ' s wound consult report dated 11/27/13 revealed right medial heel measured 2cm by 2cm with an area of 4 square centimeter. Sacral wound has necrotic tissue (unstageable) pressure ulcer measuring 6cm in length by 4.5cm width, area of 27 square centimeters. There was moderate amount of foul purulent drainage noted which had a strong odor; wound bed had 100% Eschar. Record review of the Resident #5's nurse ' s notes dated 11/30/13 at 7:05 P.M., revealed the residents family member visited and requested to see the wound, the dressing was dated 11/28/13. Record review of the resident ' s wound culture result dated 12/8/13 revealed many growths (infection). Record review of the resident ' s weekly pressure ulcer record dated 12/16/13 revealed onset of two pressure ulcer (right heel measuring 2.0 in length, 2.5 cm width and no depth) and sacrum wound measuring (8.0cm in length, 5.0cm in width and 1.0 depth) . This wound was 30% slough, 70% bright red granulation and had undermining. Wound was thereafter debrided with the following recommendation: Right heel- clean with normal saline, granule daily and change dressing every day and as needed. Sacral wound -clean with normal saline, clean or irrigate with 0.125% Dakin ' s solution, pack wound with 4x4 gauze moistened with Dakin ' s solution, change dressing every day and as needed. Recommendation -Aggressive offloading of these areas at all times. Observation on 12/17/13 about 10:39A.M., revealed Resident # 5 had a stage IV pressure ulcer to sacral area and unstageable pressure area on his right heel which were being treated. Request of Resident # 5 ' s November 2013 treatment records as well as his weekly skin assessments and wound progress reports were requested by the surveyor but not provided. Interview on 12/18/13 about 10.00A.M., the DON said she was made aware of the resident ' s wound, and was aware that the resident had unstageable wounds to his heel upon transfer from the facility to the hospital. She said the wound consultant was seeing and treating the resident. The DON said she was aware of contamination from feces and believed the wound was looking better, she said the wound consultant had performed multiple debridement which made the wound bigger. Interview on 12/18/13 at 10:28A.M., RN C said the resident was readmitted with sacral pressure ulcers, and that she was unsure of the onset of both the right heel and sacral wounds. She said that according to her records the wounds were found on 11/30/13. Resident # 5 was re-admitted to the facility on [DATE] with a stage II and was sent out on 11/17/13 with unstageable wound on his right heel. Interview on 12/18/13 at 10:30A.M., Resident # 5 ' s family member said the facility was unable to tell them how and when the resident developed the pressure ulcer to his sacral area; and that the sacral wound first came to their knowledge from hospital staff on 11/17/13 following transfer from the facility. The family member reported that facility staff said the resident got the wound from the hospital which was not true. Family member further said the facility also failed to treat the wound daily as ordered, the resident's wound was not treated two days in row on 11/28/13 and 11/29/13, as the family found the resident on 11/30/13 with a dressing dated 11/28/13. The Family member reported that Resident #5 went into the facility with clear skin and that in two months he had a very big stage IV. Family member believes the wound to the resident ' s sacral area was caused from staff leaving the resident in the Geri-chair for long periods of time after the fall he had on 10/30/13. The Family member said upon the resident's transfer to hospital, the wound was found and they took pictures of it. A care plan to address skin breakdown risk and for actual pressure ulcers was requested but not provided before exit. Facility ' s policy on pressure ulcer prevention revised January 2010 revealed did not address pressure ulcer preventative and promotion measures. Facility list of Residents with pressure ulcers dated 12/16/13 revealed 21 residents with pressure ulcer, 8 residents were admitted with their pressure ulcers.