Every finding on record at The Phoenix Post-Acute

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication and potential overmedication in accordance with professional standards of practice for 1 of 12 (Resident #79) residents reviewed for pharmacy services.The facility failed to ensure Resident #79 was free from duplicate medication therapy as evidenced by Resident #79's two active orders of the same medication with two different dosages. This failure could place residents at risk for adverse drug events. Record review of Resident #79's face sheet dated 5/14/2026 revealed a [AGE] year old male admitted to the facility originally on 7/14/2023 and readmitted on [DATE] with diagnoses which included Tourette's Disorder (a nervous system condition that causes people to make uncontrollable, repetitive movements or sounds, known as tics), Cognitive Communication Deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes, rather than a primary problem with language or speech), and Ataxic Gait (unsteady, wobbly, or staggering walking pattern caused by poor muscle coordination and lack of balance).Record review of Resident #79's most recent MDS assessment completed on 4/22/2026 revealed Resident #79 had a BIMS score of 15 which indicated intact cognition. Record review of Resident #79's Order Summary Report dated 5/13/2026 included the following;1. Baclofen Oral Tablet 10 mg - Give 1 tablet by mouth three times a day for pain with an order start date of 1/30/2026 and no end date.2. Baclofen Orab Tablet 15 mg- Give 1 tablet by mouth three times a day for muscle relaxation with an order start date of 5/12/2026 and no end date. Record review of Resident #79's Medication Administration Record dated 5/13/2026 revealed Resident #79 received Baclofen 10 mg on 5/12/2026 at 8:00 a, m., 2:00 p.m., and 8:00 p.m. Resident #79 also received Baclofen 15 mg on 5/12/2026 at 11:00 a.m., and 3:00 p.m. Record review of Resident #79's Medication Administration Record dated 5/13/2026 revealed Resident #79 received Baclofen 10 mg on 5/13/2026 at 8:00 a.m. and 2:00 p.m. Resident #79 also received Baclofen 15 mg on 5/13/2026 at 7:00 a.m., 11:00 a.m. During an observation on 5/13/2026 at 2:10 p.m., CMA B was observed as she prepared to administer medication to Resident #79. CMA B placed Baclofen 15 mg in a medication administration cup, proceeded to enter Resident 79's room, and was stopped by Surveyor and asked to return to hallway. During an interview on 5/13/2026 at 2:11 pm, CMA B stated she had worked at the facility for two years. CMA B stated she did not know the last time Resident #79 received Baclofen. CMA B stated she did not usually look at previous doses of when a medication was given and only looked at medication times. CMA B returned to her medication cart and reviewed Resident #79's Baclofen medication orders. CMA B stated she could see Resident #79 had two orders for Baclofen with two different dosages. CMA B stated that that she would clarify the Baclofen order with the nurse. CMA B stated the risk to the residents who received excessive doses of Baclofen was overly medicated . CMA B was unable to elaborate on what overly medicated meant.During an interview on 5/13/2026 at 2:16 p.m., LVN C stated that she worked at the facility for five years. LVN C stated CMA B would not be able to view previous doses of a medication that had been administered to a resident. LVN C stated that whoever placed the order of Baclofen 15 mg three times a day in Resident #79's record should have reviewed the previous order of Baclofen 10 mg three times a day and clarified the order with the provider. LVN C stated that the risks of giving extra doses of Baclofen to a resident included oversedation and falls.During an interview on 5/14/2026 at 3:12 p.m., the DON stated that PA entered the orders for her residents which included Resident #79. The DON stated she was the only provider who entered and discontinued her own orders in the resident's electronic record. The DON stated that usually orders were received verbally or were written down. The nurses entered the orders in the electronic record and received clarification if needed. The DON stated that the PA did not discontinue Baclofen 10 mg and should have. The DON stated the risk to Resident #79 was none since the maximum dosage was 80 mg daily. During an interview on 5/14/2026, the PA stated she had worked at the facility for seven months. The PA stated that Resident #79 was under her care. The PA stated she thought she had discontinued the Baclofen 10 mg three times a day order after she entered the new order for Baclofen 15 mg three times a day. The PA stated that apparently, she had not discontinued it. The PA stated she would normally go over the new medication orders and medication administration record before she submitted her orders and notes. The PA stated that the risk to Resident #79 for receiving duplicate doses of Baclofen was nothing urgent. The PA stated the risks were nothing bad system wise, as the dosage had not hit the maximum daily dosage, but could have caused increased sedation. Record review of the facility's policy titled Identifying and Managing Medication Errors and Adverse Consequences dated 2001 and revised in April 2007, read in part Staff and practitioner shall strive to minimize adverse consequences by following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication.

Based on interview, and record review the facility failed to ensure the resident's had the right to have reasonable access to the use of telephone, including TTY and TDD services, and a place in the facility where calls could be made without being overheard for 1 of 3 (Resident #1) residents reviewed for telephone use. The facility failed to provide a place for Resident #12 to make telephone calls without being overheard. This failure could place residents at risk of conversations being overheard and privacy right's not being respected and could result in a decline in resident's psychosocial well-being and quality of life. Findings include: Record review of Resident #12, dated 01/14/2021, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #12's History and Physical, dated 01/28/23, reflected a diagnosis which included depression (a common mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning.) Record review of Resident #12's quarterly MDS , dated 10/23/24, reflected a BIMS of 15, which indicated the resident was cognitively intact. During interview with Resident #12 on 03/11/2025 at 10:30AM revealed Resident #12 said she called friends or family on the phone at the nursing station she was told that was the only place to make a telephone call or if you had a cell phone. Resident #12 said the facility did not have cordless phones to use and most of the resident's conversations were heard by the nurses or anyone walking by. Resident #12 said the residents only got 15 minutes due to the nursing staff needing to use the phone. Resident #1 said she had not been offered any other phone to use in private. Resident #12 said he knew how to use the phone; however staff would call the number for her. Resident #12 said she did not feel secure in her conversations and speaking in an open area, and she knew the nurse could hear her conversation. Resident #12 said it made her feel like she did not have any privacy. During interview with the DON on 03/11/2025 at 11:20 AM, the DON said the nurse's station was the only area for residents to use the phone. Many of the alert residents had their own personal cell phones. The DON said unfortunately the facility did not have an area for the residents to use for privacy. During interview with the facility Administrator on 03/11/2025 at 12:00 PM, the Administrator said the residents were able to use the phone at the nurse's station or at the receptionist desk if need be. The Administrator stated he had a phone by his office, or the residents could use the phone in the Administrator's office, if needed, but as of now the facility did not have designated area for the resident to use and the facility was currently working on designating the physician office into the resident's phone area. The Administrator said the facility did not have a policy on resident phone use and privacy.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 4 medication carts observed. The facility failed to dispose of Levothyroxine 88 mcg blister pack with expiration date of 1/31/25 for Resident #55 from 2 [NAME] nurse medication cart on 3/11/25. This failure could place residents at risk of receiving expired medications or inaccurate dosage of medication which could lead to resident not receiving full therapeutic benefits of a medication or possible side effects. Findings include: Record review of Resident #55's face sheet, dated 3/11/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #55 had diagnoses which included Other Alzheimer's Disease (progressive brain disorder that destroys memory and thinking skills), Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities) with Mood Disturbance, Schizoaffective Disorder/Bipolar Type (Disorder with abnormal thought processes and an unstable mood), and Hypothyroidism (Underactive Thyroid). Record review of Resident's #55's quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #55's Order Audit Report, dated 3/12/25, revealed Levothyroxine Sodium Oral Tablet Give 88 mcg by mouth in the morning was discontinued on 10/29/2024 at 7:59 p.m. Record review of Resident #55's Order Audit Report, dated 3/11/25, revealed Synthroid Oral Tablet 100 mcg (Levothyroxine Sodium) Give 1 tablet by mouth in the morning was created 10/29/24 at 7:48 p.m. and was an active order. Record review of Doctor's Progress Note, dated 10/28/24, revealed start levothyroxine 100 mcg p.o. daily, discontinue levothyroxine 88 mcg p.o. daily. Record review of Resident #55's Location of Administration Report, for October 2024 printed on 3/12/25, revealed Resident #55 was last administered Levothyroxine Sodium Oral Tablet 88 mcg on 10/29/24 and was administered Synthroid Oral Tablet 100 mcg (Levothyroxine Sodium) on 10/31/24. Record review of Resident #55's Location of Administration Report for March 2025, printed on 3/11/25, revealed Synthroid Oral Tablet 100 mcg (Levothyroxine Sodium) was administered from 3/1/25 through 3/11/25. Record review of Resident #55's Care Plan, printed 3/11/25, revealed has hypothyroidism and interventions included: Give thyroid replacement therapy as ordered. Observation on 3/11/25 at 9:22 a.m. of 2 [NAME] nurse medication cart revealed Levothyroxine 88 mcg blister pack with expiration date of 1/31/25 for Resident #55 was found on 2 [NAME] nurse medication cart. LVN A immediately removed the Levothyroxine 88 mcg blister pack from the 2 [NAME] nurse medication cart. During interview on 3/11/25 at 9:22 a.m., LVN A said Levothyroxine 88 mcg blister pack for Resident #55 was expired. LVN A said she went through the medication cart weekly to make sure there were no expired medications, and the Levothyroxine 88 mcg blister pack must have gotten missed. During interview on 3/11/25 at 2:11 p.m., ADON A said when a medication is discontinued the nurse or CMA should take the medication off the cart. ADON A said the RN supervisor (RN A) on the weekend did medication cart audits once a month. During interview on 3/11/25 at 2:13 p.m., ADON B said cart checks for expired medications should be done weekly. ADON B said she tried to look at the medication carts monthly. ADON B said the weekend supervisor (RN A) checked the medication carts this past weekend. ADON B said the CMAs and nurses were ultimately responsible for expired medications on their carts. Attempted interview with RN A on 3/11/25 at 3:00 p.m. was unsuccessful. Attempted interview with RN A on 3/11/25 at 5:20 p.m. the State Surveyor sent RN A a text message after receiving voicemail from RN A to coordinate contact. During interview on 3/12/25 at 8:59 a.m., LVN B said she checked the nurse medication cart for expired medication on Saturdays which included blister packs. During interview on 3/12/25 at 9:05 a.m., MA A said she checked the medication carts once a week for expired medications which included blister packs. During interview on 3/12/25 at 9:08 a.m., the Pharmacist said he performed medication cart checks biweekly. Medication cart checks included checking for expired medications which included blister packs. The Pharmacist said Levothyroxine may have been left on a medication cart in case they were adjusting the resident's dose. During interview on 3/12/25 at 10:15 a.m., Resident #55 said there was not anything wrong with him when he was asked if he took a thyroid medication. Resident #55 said the facility would try to give him four or five pills, but he refused to take them. During interview on 3/12/25 at 10:23 a.m., MA B said she usually checked her medication cart for expired medications two times a week on Tuesdays and Thursdays which included blister packs. MA B said the nurse would also check the medication aide medication cart, but she was not sure how often. During interview on 3/12/25 at 10:25 a.m., LVN C said she checked the nurse and medication aide medication carts once a week which included blister packs usually on night shift. During interview on 3/12/25 at 10:27 a.m., LVN D said she checked the nurse medication cart every other weekend for expired medications. LVN D said she would check the top drawer of the medication aide medication cart for medications like eye drops. The top drawer of the medication aide medication cart also included the over -the-counter medications. During interview on 3/12/25 at 2:30 p.m., Clinical Resources (who was acting as DON) said the nurses and CMAs were to check the medication carts they were assigned weekly and as needed for expired medications. Clinical Resources also said the pharmacy performed monthly checks to medication carts for expired medications. Record review of the facility's policy Storage of Medications with revision, dated April 2007, revealed The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (CR #1) reviewed for supervision. The facility failed to provide sufficient supervision to CR#l on [DATE] at 1:30am, when he was found unresponsive behind the facility, with blood coming from his mouth. CR#l was transported to the hospital via emergency services, where he was pronounced deceased on [DATE]. Multiple staff working the night shift (CNA E, CNA A, CNA M, CNA C and Nurse T), were unaware CR#1 was missing from the facility and an elopement code was not initiated. There was not an effective system in place to track residents entering and exiting the building. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:45p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. These failures could result in residents not receiving appropriate supervision leading to elopement, injuries, hospitalization , or death. Findings included: Record Review of CR #1's face sheet, dated [DATE] revealed that he was a [AGE] year-old male admitted on [DATE], with a primary diagnosis of encephalopathy (a brain disease affecting cognitive function). Record Review of CR #1's MDS assessment dated [DATE] indicated that CR #1 had a BIMS score of 7 out of 15, reflecting severely impaired cognition. He had no behaviors, including wandering, and required substantial/maximal assistance with transfers from bed to chair. Record review of the elopement risk assessment for CR #1, dated [DATE], reflected the elopement risk assessment failed to reveal that CR #1 was a low risk for elopement. The comprehensive care plan initiated on [DATE] did not include a care plan for impaired cognition or address wandering or elopement. Record review Observation on [DATE], at 11:45am revealed upon the surveyor's arrival, no receptionist or staff member was present at the desk to monitor exit-seeking residents at the front door. On [DATE] starting at 12:55pm, in phone Interviews with two-night CNAs (CNA E and CNA C), they stated that they did not see CR #1 at all during their shift on [DATE] and [DATE] and did not know CR #1 was missing. They stated they would usually see CR #1 through their shift, but lately he had not been his usual self. Both stated they were in- serviced on elopement process on [DATE] following the incident. Neither could explain why an elopement code was not called on [DATE] in the morning. Observation on [DATE] starting at 12:30pm, revealed residents (later identified as Resident #2 and Resident #3) exiting without signing out or being accommodated by staff. It was unclear if residents were leaving to smoke or leaving to go out on pass. On [DATE] at 12:55pm, in an interview with receptionist, she stated that there was no desk coverage after 10:00 p.m., and all residents should be in after the last smoke break. The receptionist stated staff (activity director or receptionist) typically accompanied residents while in the smoking area, but there was no clear way to distinguish residents leaving for smoke breaks from those leaving for other reasons. The receptionist stated that there is no coverage at the receptionist desk when accompanying residents while they are smoking. In interviews on [DATE] starting at 1:10pm, Three CNAs (CNA K, CNA D and CNA T) and two nurses (LVN A and RN L) revealed staff had been recently in-serviced on resident sign-in/sign-out procedures. They conducted resident rounds every two hours and were required to call a Code 20 for elopements. However, staff were unfamiliar with the Resident Roster list, which identified residents needing assistance when exiting, and could not explain who was responsible for escorting these residents. In an interview on [DATE] at 2:00pm, The Operations Leader stated he was notified of the incident at 5:30 a.m. on [DATE] by the Clinical Resources Nurse. He reported that CNA A found CR #1 unresponsive on a nearby sidewalk at 1:30 a.m. CNA A, who was not assigned to Resident #1, discovered him while returning from lunch. She left him on the sidewalk to call 911 from the facility. Staff were unaware that CR #1 had left, as he had not signed out. He stated that CR #1 had a history of leaving without signing out. The Operations Leader stated nothing had been done to address CR #1 not signing out. The Operations Leader stated that the residents are responsible to sign-in/sign-out. The Operations Leader was not able to identify who was responsible for reviewing the sign in and out sheets. The Operations Leader was aware that there is no receptionist at the front desk after 10:00pm. He stated that he was not aware of any staff training provided to address what to do after 10:00pm when the receptionist leaves. The administrator stated he reviewed video surveillance on [DATE], which showed CR #1 leaving at 10:38pm on [DATE], but there was no footage of him returning. The administrator could not provide a timeline of the incident or identify the system failure. He stated the facility had implemented a Resident Roster list that will remain at the front desk with the receptionist, which identified residents needing assistance when exiting, but could not explain who was responsible for escorting these residents. He could not explain how care staff would be made of aware of the list and how the list prevented future incidents form occurring. In an interview on [DATE] at 4:00pm, The DON said she was informed of the incident at 1:47 a.m. on [DATE]. She stated that Nurse T had last seen CR #1 at 11:00pm on [DATE] during medication rounds, and CR #1 had said he was going to bed. The DON stated that Nurse T did not follow up to ensure CR #1 was in bed as she was new at the facility and was not familiar with CR #1. The DON stated that she was aware that CR #1 was not compliant with signing in and out. The DON did not reveal who was responsible for checking to ensure that the sign in and out sheet were being completed daily. The DON stated nothing had been done to address CR #1 not signing out. The DON was aware that there was no receptionist at the front desk after 10:00pm daily. She stated she had not provided staff trainings to address what to do after 10:00pm when the receptionist leaves. The DON stated there was no policy specifying how frequently staff should round on residents. She stated another resident previously eloped in [DATE], and the facility implemented a sign-out form, but no additional measures were taken. She stated the form was implemented by in servicing the residents and staff that residents are to sign out when leaving the facility on a leave pass. She could not explain how the implementation of the acknowledgment form had been reviewed for its effectiveness in keeping the residents safe and preventing future elopements. She could not explain the facility's expectations of the staff in the identified implementation. The DON stated that residents have the right to leave the facility when they like, but she could not identify the facility's role in ensuring the safety and account of residents leaving or returning. The DON could not explain how the facility ensured the daily accurate census if residents leave without signing out. The DON said an elopement code was not initiated during the incident as staff were unaware CR #1 had gone missing. The DON stated staff was trained on elopement code and process on [DATE], following the incident. She also noted that while a Resident Roster was created based on cognitive levels, staff had not been trained on its use. She stated the facility had implemented a Resident Roster list that will remain at the front desk with the receptionist, which identified residents needing assistance when exiting, but could not explain who was responsible for escorting these residents. She could not explain how care staff would be made aware of the list and how the list prevented future incidents from occurring. On [DATE] at 8:49am, in an interview with CNA M, who was assigned to CR #1 the night of the incident, CNA M stated she had last seen CR #1 around 6:00pm on [DATE], when she provided his dinner tray to him. She stated that the shifts started at 2:00pm on [DATE] and the resident was lying in bed at that time. She stated this was not unusual as the resident seemed to be depressed for the past two months, after losing his roommate. She stated that nursing staff was aware that he was not his usual self, but she was unaware if anything had been done to address the decline. She stated that at 12:30am on [DATE] (while on her lunch break) she noticed that CR #1's room light was on. She stated that that she had not check on CR #1 from 6:00pm on [DATE] and 12:30pm on [DATE] because CR #1 was independent and could communicate his needs. She stated that she noticed that CR #1 was not in his room, and she informed Nurse T. She stated that Nurse T stated that she had last seen him at 10:45pm when she gave him his nightly medication and he stated he was going to bed. CNA M stated the staff did not assist him in transferring from his chair to bed or ensure that CR #1 was in bed. CNA M stated she was not aware that CR #1 required assistance to bed. She also stated that Nurse T as new and was not familiar with CR #1. She stated that an elopement code was not called as she recalled everything happening so fast. She stated another staff, CNA A, who was not assigned to CR #1 came to the unit at 1:30am on [DATE] stating that CR #1 was off the premises on the ground and unresponsive. CNA A left CR #1 and called 911. CNA A and CNA M returned to the location of the resident. CNA M stated it is unknown how long CR #1 had been unresponsive. She stated the facility for notified that CR #1 was pronounced deceased at the hospital at 2:11am on [DATE]. CNA M stated the resident left the facility all the time without signing in and out and the facility administration was aware of it. She stated there is no keypad code required to exit the build afterhours, but a keypad code is required to re-enter. She stated that resident have the key code (a number code required to be entered in a keypad before entered the facility) and there is no system to account for residents. She stated there is no receptionist after the last scheduled smoke break at 10:00pm each day. She stated that CR #1 was a smoker. She stated that even when there is a receptionist there is no system to account for the residents. She stated that the care staff and receptionist did not communicate when a resident was leaving. She stated if the resident did not sign out there is no way for staff to know the resident whereabouts. CNA M stated the facility system is not designed to keep the residents safe. During the interview on [DATE] at 4:30am, Nurse T stated that she had worked at the facility for only a week and was not familiar with resident CR #1. Nurse T stated that she was the nurse assigned to CR#1 on [DATE] thur [DATE], at the time of te incident. She mentioned that she was unsure whether the resident had full code status or was an elopement risk. Throughout her shift, she only reviewed CR #1's MAR records and did not look at CR #1's care plan or orders regarding code status. She noted that this information could be found in the clinical record under physician orders, but she had not had the chance to review it. On the night of the prior to the incident ([DATE]), Nurse T recalled last seeing CR #1 at 11:00pm when she administered his medication. After this, CR #1 indicated he was going to bed, but Nurse T did not assist him in returning to his room or transferring from his wheelchair to his bed. She admitted she did not check on CR #1 between 11 PM and 1 AM and denied being asleep at any point during her 12-hour shift. Nurse T stated that she is currently CPR certified, but she was uncertain whether the facility had received documentation confirming this. During handoff report at the start of her shift, she was informed that CR #1 was independent and did not require assistance. At 1:00 AM on [DATE], CNA A informed her that CR #1 was missing from his room. Nurse T stated that she did not call an elopement code but could not explain why. During the interview on [DATE] at 4:15am, CNA A reported that on the night prior to the incident ([DATE]), she saw CR #1 a local barbecue bar near the facility during her 15-minute break at approximately 10:45pm. She noted that CR #1 frequently left the facility independently and did not notify anyone of his whereabouts. At 1:30am on [DATE], she found CR #1 on the ground behind the facility near a barbecue bar, out of his wheelchair, bleeding from the mouth and unresponsive. She immediately returned to the facility called 911 and notified Nurse T and another CAN M who was the assigned staff to CR #1. She stated that Nurse T appeared to be sleeping at the time. CNA A and CNA M then returned to CR #1's location but did not initiate CPR, although she did not specify why it was not started. CNA A stated that she and CNA M did not take AED to the location of CR #1 upon returning. CNA A stated that she was not BLS certified, and the facility had not provided CPR training since she's been employed at the facility. She stated that EMS arrived approximately 10 minutes after being called. She stated that upon EMS arrival, EMS initiated CPR and transported CR #1 to the hospital where he was later pronounced dead. Record review of review of CR #1 the sign out sheet revealed that there was no record of CR #1 signing out on [DATE] and [DATE]. Record review of nursing noted for [DATE] and [DATE] revealed no documentation of the timeline of the incident. An IJ was identified on [DATE] at 7:45pm The IJ template was provided to the Operations Leader and DON via email on [DATE] at 7:45pm. The facility's Plan of Removal was accepted on [DATE] at 3:46pm, and included the following interventions: The Immediate Jeopardy findings were identified in the following area: F 689 Quality of Care The facility failed to ensure adequate supervision to prevent accidents for 1 of 5 residents (CR#1) reviewed for supervision. The facility failed to provide sufficient supervision to CR#1 on [DATE] at 1:30am, when he was found unresponsive behind the facility, with blood coming from his mouth. CR#1 was transported to the hospital via emergency services, where he was pronounced deceased on [DATE]. Immediate Actions 1. The Medical Director was notified of IJ on [DATE] at 8:06 PM. 2. Education initiated with all staff on [DATE] on Abuse: Prevention of and Prohibition Against to include Neglect with a post test. Reeducation initiated [DATE]. Completion date [DATE]. Training provided by DON/ designee. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 3. The Out-on-Pass policy was reviewed by the IDT and revised. The three strike rule will be implemented in cases of repeated non-compliance to this policy. Upon the third strike, the Business Office and Administrator may choose to initiate the process of issuing a 30-day discharge notice to the resident. An ad hoc QAPI was held. [DATE]. Policy was approved in the Ad hoc QAPI. 4. Education initiated with all staff on [DATE] on Out-on-Pass Policy and residents will be required to sign out to go out on pass; with a census of residents that identifies which residents are independent and which require supervision when out on pass. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. [DATE] Training was conducted by DON/ designee and Staffing Coordinator. 5. ,d+[DATE] receptionist staffing initiated on [DATE]. Reeducation on receptionist protocol initiated on [DATE], including policy that if the receptionist needs to step away, another staff member will relieve the receptionist. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. [DATE] Training provided by DON/ designee; Operations Manager and Staffing Coordinator. Sister facility DONs/ ED or Ops Manager will be scheduled to completed knowledge checks daily x 2 weeks, then weekly x 2 weeks to monitor effectiveness. DON/ designee will monitor effectiveness weekly in Systems Review. 6. Social Services and Medical Records will ensure that the Out-on-Pass acknowledgement is signed by residents, this will include a three strike rule for compliance. [DATE]. Social Services will be responsible for reviewing with the effectiveness of this protocol with oversight from the Operations Manager. This will be reviewed weekly during the Systems Review by the DON/ ADONs/ Social Services. 7. Education initiated with all staff on [DATE] on elopement policy and identifying residents at risk for elopement and when to initiate and elopement response. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. The training is being provided by the DON/ ADON/ Staffing Coordinator with a knowledge check. Elopement drills will be conducted at a minimum of monthly by the Maintenance Director and reviewed by the DON, effectiveness will be reviewed at the time of the drill. 8. Elopement assessments of all residents were reviewed to identify which residents are elopement risks on [DATE]. Binders were placed at each nurse station and the receptionist desk for identification purposes on [DATE]. Residents who scored high for elopement risk, currently reside in the secured units (2nd floor); no residents on 3rd floor were identified as at risk for elopement. 9. Elopement drills were held twice a day from [DATE]-14, and will continue three times a week x 4 weeks, then weekly x 4 weeksXXX[DATE] The DON/ ADONs/ Staffing Coordinator conducted the drills. An elopement drill form will be completed for each drill. The Elopement policy was reviewed by DON, Operations Manager, Clinical Resource, Clinical Market Leader and Medical Director [DATE]. No changes were made. Education initiated with all nursing staff on [DATE] regarding making rounds routinely. Approximately every 2 hours, dependent on resident needs and or preference. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. [DATE] Training provided by DON/ ADONs/ Staffing Coordinator. Charge nurses will perform census count every shift. [DATE] The shift census will be tracked utilizing a census sheet with the charge nurse signing off, indicating all residents are accounted for. Charge Nurses will report absent/ missing residents at the time of the census check to the DON/designee. ADONs/ designee will be responsible for collecting daily, when on duty and reviewing. These trainings and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Ad hoc meetings regarding items in the IJ template completed [DATE]. Attendees included the Medical Director, Operations Manager, DON, ADONs, Clinical Resources, and Clinical Market Leader, and included the plan of removal items and interventions. The ad hoc QAPI was acknowledged and the plan with the interventions were agreed upon. Monitoring: Observations on [DATE] at 12:30 pm and 2:30pm and on [DATE] at 4:00am and 12:00pm - 2:30pm revealed someone sat in the receptionist area, and coverage was provided when the receptionist was gone on break. Observations on [DATE] stating at 4:00am thru 6:00am and 8:00am thru 10:00am revealed were completing frequent rounding on by checking on the residents there in the units. Interviews on [DATE] - [DATE] with staff on both shifts (6am - 6 pm) and (6pm to 6am) for CNAs and 6 a.m.-6 p.m. included the DON and Operations Leader, Nurse T, LVN B, and LVN J all on night (6pm to 6am) shift and the receptionist were able to verify in-services elopement drills were provided. Nursing staff were able to appropriately define elopement risk, identify the location of the resident elopement book, provided the procedure for a resident found trying to leave the facility without supervision (report to the charge nurse). The Receptionists said they were to let nursing staff or administrative staff, if available, know when they were going on break. All the receptionists knew to check the census sheet who was able to verify resident who were able to leave out on pass. The receptionist said she was to let nursing staff know she was going on break so someone could relieve her to cover the front desk while on break. All interviewed nursing staff stated that they were aware that 24-hour coverage would be maintained at the receptionist desk. CNA stated that they were made aware that they would rotate the responsibility of relieving the receptionist for bathroom and lunch breaks. Nursing and CNA staff stated they were in-serviced on rounding at least every 2 hours. Interview on [DATE] at 10:30am with Social Services Staff, she stated that she had been in-serviced on the policy for residents going out on pass and three-strike rule for noncompliance. She stated that if residents were non-compliant with the going out on pass policy, a IDT meeting would be held to determine the next best step for the resident. Record review Reeducation on receptionist protocol initiated on [DATE], including policy. Record reviews revealed an Elopement Risk binder was located at the nursing station with the face sheets of all current residents and the elopement risk assessments for each resident. Record reviews of the charts were completed for Resident #s 2, 3, 4 and 5 and reflected elopement assessments. Resident care plans included their elopement status. Record review of training sign in sheet dated [DATE] thru [DATE] revealed that elopement in-services were completed with nursing staff who were scheduled to work on [DATE] thru [DATE]. Record review of census counts was verified on [DATE] and revealed that a census count was completed and sign off on by the charge nurse. Record review of trainings and in-services revealed that elopement drills were completed on [DATE] and [DATE] with nursing staff scheduled to work on [DATE] and [DATE]. Record review of trainings and in-services dated [DATE] revealed that social service staff had been in-serviced on the resident going out on pass and three strike rule for resident who were noncompliant. The Operations Leader was informed the Immediate Jeopardy was removed on [DATE] at 10:00 am The facility remained out of compliance with a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interview and record review the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 5 residents (CR#1) reviewed for CPR. CNA A and CNA M failed to initiate life-saving measures (CPR) when CR#1 who had a full code status (all resuscitation procedures provided if their heart stops beating or they stop breathing) immediately when he was found unresponsive on [DATE] around 1:30 AM. EMS was called around 1:40 AM, arrived at 1:45 AM, and began CPR. CR#1 was transported to the hospital via emergency services, where he died on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 8:35p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. These failures placed residents at risk of experiencing worsening of condition, pain and death from possible delays in the initiation of an emergency response and improper implementation of CPR. Findings Included: Record review of facility census dated [DATE] revealed there were 74 residents. A review of Resident CR #1's face sheet, dated [DATE], revealed that he was a [AGE] year-old male admitted on [DATE], with a primary diagnosis of encephalopathy (a brain disease affecting cognitive function). Record review of Resident CR #1's care plan dated [DATE] and revised on [DATE] revealed the following care areas: CR#1 Full Code Status. Goal: Inform staff of code status, Full Code. Interventions: Monitor for decrease in change of condition Review of physician order, dated [DATE], revealed CR#1 was designated as full code status. Record review Phone interview attempt with Nurse M on [DATE] at 3:00pm, but surveyor was unsuccessful. Phone interview attempt with CNA M on [DATE] at 3:30pm, but surveyor was unsuccessful. Phone interview attempt with CNA A on [DATE] at 3:45pm, but surveyor was unsuccessful. In a phone interview on [DATE] at 8:49am with CNA M, she said when she returned to work if a lunch break on [DATE] around 1:30 AM, CNA A came to the unit stating that CR #1 was off the premises on the ground and unresponsive. She said CNA A left CR #1 where she found him outside, to notify other staff and call 911 at approximately 1:40am. She said CNA A and CNA M returned to the location of the resident but did not initiate CPR because everything was happening so fast. CNA M stated she and CNA A did not have the AED or crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations). She said that when she and CNA A arrived at the location where CR #1 was found, CR #1 was unresponsive with blood coming from his mouth. She said no one knew how long CR #1 had been unresponsive. She stated that EMS arrived about ,d+[DATE] minutes after CNA A called 911. She stated that CPR was initiated by EMS staff upon arrival. CNA M could not explain why CPR was not initiated prior to EMS arrival around 1:45am on [DATE]. She stated the facility was notified that CR #1 was pronounced deceased at the hospital at 2:11am on [DATE]. CNA M stated she was not suspended was still allowed to work following the incident. CNA M stated that she was not CPR certified, and she had not received CPR training while employed at the facility. Phone interview attempt with CNA A on [DATE] at 9:30am, but surveyor was unsuccessful. In interviews on [DATE] at various times with five CNAs, (CNA E, CNA C, CNA K, CNA D, and CNA T) they said they were unfamiliar with CPR response times and how to work an AED machine. All stated the facility had not provided CPR training in the last year, and it was not a requirement for employment. In an interview on [DATE] at 3:00pm, The DON stated she could not explain the facility's expectations of the staff implementation of a Code Blue (an emergency code used in a healthcare facility where a patient's life is at immediate risk due to cardiac arrest or respiratory failure). The DON stated staff should not leave a resident alone if found unresponsive. The DON stated that the facility had not provided CNA A and CAN M with CPR training. She stated that the facility did not require the CNAs and Nurses to be CPR certified. She stated that she was not aware of any CPR trainings or in-services provided recently. She stated that CR#1 was a full code status and CPR should have been initiated if CR#1 was unresponsive. The DON stated that a CODE Blue was not called. The DON did not explain who was responsible for ensuring that all staff were trained on code status and when to implement CPR. She did not explain how similar incidents would be prevented in the future. The DON stated that CNA M and CNA A had not been suspended or reprimanded following the incident. Interview on [DATE] at 4:45pm, The Operations Manager stated he was notified of the incident at 5:30 a.m. on [DATE] by the Clinical Resources Nurse. CNA A left CR #1 on the sidewalk to call 911 from the facility. He stated that he was not aware of any staff training provided. The Operations Manager could not provide a timeline of the incident or identify the system failure. He did not explain how care staff would prevent future incidents from occurring. The Operations Manager stated he is responsible for managing the operations at the facility. He stated that the facility administrator was notified of the incident on [DATE] afternoon. Record review of CNA A and CNA M's employee files revealed no record of CPR training and certification for CNA A and CAN M. Record review of cardio-pulmonary resuscitation policy original date ,d+[DATE] with Revision/Review Date(s) ,d+[DATE] and ,d+[DATE] stated in part: It is the policy of this facility to provide basic life support (BLS), including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advance directives or a Do Not Resuscitate (DNR) order. Only staff members with current CPR certification for Healthcare Providers should perform the procedure. The facility will have staff certified in CPR available 24 hours/day to provide basic life support and CPR prior to the arrival of emergency medical services (EMS) personnel . Staff will maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes hands-on practice and in-person skills assessment . Record review of in-services revealed no documented CPR training provided in the one year look back period ([DATE] thru ,d+[DATE]//2024). Record review of CNA job description read in part: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors. There was not referenced information related to CPR education requirement for CNA staff. An IJ was identified on [DATE] at 8:35p.m. The IJ template was provided to the Operations Leader and DON via email on [DATE] at 8:35p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 2:38pm The Immediate Jeopardy findings were identified in the following area: F678 Cardio-Pulmonary Resuscitation: The facility failed to ensure that nursing staff provided CPR in accordance with professional standards, failed to provide on-going monitoring of a resident after a change in condition was identified and reported, failed to immediately and properly assess a resident after a change in condition was identified and reported, failed to document assessments performed after a change in condition was identified and reported, failed to immediately contact EMS when a resident was found unresponsive, and failed to thoroughly investigate an incident. The facility failed to immediately initiate life-saving measures (CPR) when CR#1 when was found unresponsive on [DATE] around 1:30 AM. EMS was called around 1:40 AM, arrived at 1:45 AM, and EMS began CPR on CR#1. CR#1 was transported to the hospital via emergency services, where he was pronounced deceased on [DATE]. Immediate Actions 1. The Medical Director was notified of IJ on [DATE] at 8:46pm. 2. Review of licensed nursing staff personnel files was completed by Business Office Manager and Staffing Coordinator and validated by RN, Director of Nursing to ensure current licensed nurses held a current CPR card completed [DATE] and [DATE]. 3. CPR policy reviewed by DON, ED, Operations Manager, Clinical Resource, Clinical Market Leader, Medical Director and RT, Certified CPR Instructor [DATE]. No changes were made. 4. Education initiated with nursing staff [DATE] to provide basic life support, including CPR, and use of AED to any resident requiring such care, and alert EMS. Completion date [DATE]; training provided by RT, Certified CPR Instructor. Staff is trained prior to their next shift. Any staff unavailable will not be allowed to work until training is completed. 5. All nursing staff will complete CPR competency [return demonstration and BLS posttest] conducted by RT, Certified CPR Instructor, initiated [DATE]. Completion date [DATE]; training provided by RT, Certified CPR Instructor. Staff is trained prior to their next shift. Any staff unavailable will not be allowed to work until training is completed. 6. Education initiated with Therapy staff on [DATE] to provide basic life support, including CPR and the use of AED to any resident requiring such care and alert EMS. Completion date [DATE]; training provided by RT, Certified CPR Instructor. Staff is trained prior to their next shift. Any staff unavailable will not be allowed to work until training is completed. 7. All staff will be offered the opportunity to become CPR certified. [DATE] Nursing and Therapy staff are receiving CPR certification training; all other non-licensed staff will be offered CPR training. Completion date [DATE]; training provided by RT, Certified CPR Instructor. Staff is trained prior to their next shift. Any staff unavailable will not be allowed to work until training is completed. 8. This training and competencies - CPR training will be completed in-person with staff prior to the start of their next shift. A member of management [ADONs or Staffing Coordinator] will be at the facility at each change of shift to ensure staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff members will not be allowed to work unless they have received their training and knowledge check. [DATE] 9. To maintain compliance, HR will monitor CPR certification with DON oversight. [DATE] CPR certification will be maintained in a binder and reviewed at least monthly and/ or upon hire of licensed nursing/ therapy staff. Ad hoc QAPI meetings regarding items in the IJ template completed [DATE]. Attendees included the Medical Director, Clinical Resource, Operations Manager, DON, ADON, Clinical Resources, and Clinical Market Leader, and included the plan of removal items and interventions. The Operations Manager and DON were reeducated on CPR process by RN, Clinical Resource on [DATE]. Monitoring of the plan of removal included the following: Record review of employee files who worked on [DATE] (6pm -6am), CNA M, CNA A, CNA E CNA C, Nurse T and LVN P revealed no record of staff being BLS certified, or CPR trained. Record review of education in-service training dated [DATE] and [DATE] revealed basic life support, including CPR competency and CPR in-services was provided to all staff scheduled on [DATE] and [DATE]. Record review of QAPI sign-in sheet date [DATE] reflected MD participated via telephone, operations Leader, DON, Wound Care Nurse, Social Services, HR, MDS coordinator, Therapy Services, Clinical Resource Staff were in attendance. Record review of nursing staff personnel files was completed and revealed CPR competency as [DATE] all staff scheduled on [DATE] and [DATE]. During the interview on [DATE] at 4:30am, Nurse T stated that she had worked at the facility for only a week and was not familiar with resident CR #1. Nurse T stated that she was the nurse assigned to CR#1 on [DATE] thur [DATE], at the time of te incident.She mentioned that she was unsure whether the resident had full code status or was an elopement risk. Throughout her shift, she only reviewed CR #1's MAR records and did not look at CR #1's care plan or orders regarding code status. She noted that this information could be found in the clinical record under physician orders, but she had not had the chance to review it. On the night of the prior to the incident ([DATE]), Nurse T recalled last seeing CR #1 at 11:00pm when she administered his medication. After this, CR #1 indicated he was going to bed, but Nurse T did not assist him in returning to his room or transferring from his wheelchair to his bed. She admitted she did not check on CR #1 between 11 PM and 1 AM and denied being asleep at any point during her 12-hour shift. Nurse T stated that she is currently CPR certified, but she was uncertain whether the facility had received documentation confirming this. During handoff report at the start of her shift, she was informed that CR #1 was independent and did not require assistance. At 1:00 AM on [DATE], CNA A informed her that CR #1 was missing from his room. Nurse T stated that she did not call an elopement code but could not explain why. During the interview on [DATE] at 4:15am, CNA A reported that on the night prior to the incident ([DATE]), she saw CR #1 a local barbecue bar near the facility during her 15-minute break at approximately 10:45pm. She noted that CR #1 frequently left the facility independently and did not notify anyone of his whereabouts. At 1:30am on [DATE], she found CR #1 on the ground behind the facility near a barbecue bar, out of his wheelchair, bleeding from the mouth and unresponsive. She immediately returned to the facility called 911 and notified Nurse T and another CAN M who was the assigned staff to CR #1. She stated that Nurse T appeared to be sleeping at the time. CNA A and CNA M then returned to CR #1's location but did not initiate CPR, although she did not specify why it was not started. CNA A stated that she and CNA M did not take AED to the location of CR #1 upon returning. CNA A stated that she was not BLS certified, and the facility had not provided CPR training since she's been employed at the facility. She stated that EMS arrived approximately 10 minutes after being called. She stated that upon EMS arrival, EMS initiated CPR and transported CR #1 to the hospital where he was later pronounced dead. Interviews on [DATE] - [DATE] with staff on both shifts (6am - 6 pm) and (6pm to 6am) for CNAs and 6 a.m.-6 p.m. included the DON and Operations Leader, Nurse T, LVN B, and LVN J all on night (6pm to 6am) shift were able to verify in-services and to validate their understanding basic life support, including CPR, and use of AED. They were able to identify what was neglect and provide examples of some signs and symptoms of respiratory distress, the code for emergency (code blue) used. CNAs were able to explain they were in-serviced on calling the nurse when there is an emergency. LVN's and CNAs were able to explain the importance of calling a code blue promptly in response to emergencies; and how to check the code status in the clinical record to ensure they were able to conduct CPR. Staff was able to return demonstrations related to the process for providing CPR and using the AED. Staff was able to verbalize and understanding of the facility's CPR policy related to CPR implementation. The Operations Leader was informed the Immediate Jeopardy was removed on [DATE] at 10:00 am. The facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interviews and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #37) of 3 residents reviewed for pressure ulcers. The facility failed to notify Resident #37's physician and modify his interventions when he refused to wear his protective boot on his left foot and when he refused to be repositioned in bed. The facility failed to accurately assess and modify interventions for Resident #37, whom the facility said prefers to lie on his abdomen, and he had a suprapubic catheter. Resident #37 developed a stage 4 pressure ulcer on his left medial foot and on left abdomen and right groin. An IJ was identified on 01/24/24. The IJ template was provided to the facility on [DATE] at 3:00 p.m. While the IJ was removed on 01/26/24 at 3:55 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all staff had not been trained on reporting and assessing for changes of condition. These failures placed residents at risk for new development or worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: Record review of Resident #37's face sheet dated 01/03/24 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #37 had diagnoses which included cardiac arrest (heart suddenly stops pumping), muscle wasting and atrophy (a condition in which muscles begin to waste away due to disuse), paraplegia (inability to voluntarily move lower parts of the body), dependence on renal dialysis (removing of waste and excess fluid from the body with kidney failure) and peripheral vascular disease (a slow and progressive circulation disorder). Record review of Resident #37's quarterly MDS assessment, dated 11/20/2023, revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Further review of Resident #37's MDS revealed the resident developed a pressure ulcer after admission. The intervention for the pressure ulcer such as pressure reducing device for bed, turning, and/or repositioning program was not indicated. Record review of Resident #37's undated care plan revealed: Resident #37 developed a stage 4 pressure ulcer on left medial foot. Interventions: administer treatments as ordered and monitor for effectiveness, offload pressure as much as possible. Further review of Resident #37's care plan revealed Resident #37 had an actual impairment to skin integrity related to non - pressure wounds on: left abdomen, and right groin. Interventions: educate resident on the importance of turning and repositioning, treatment per MD orders. It also read the resident desires to lay on his stomach. Record review of Resident #37's admission/readmission skin evaluation dated 07/11/23 revealed Resident #37 did not have any skin issues on his left foot, or any skin issues on his abdomen or groin. Record review of Resident # 37's Braden scale dated 11/7/23 revealed resident was at high risk for a pressure ulcer and further review revealed the resident had very limited mobility: could make slight changes in body or extremity independently. Record review of Resident #37's weekly skin evaluations from 08/28/23, 09/05/23, and 09/11/23 did not reveal the resident had any skin issues on the left medial foot. Record review of Resident #37's weekly skin evaluation dated 9/19/23 revealed a stage 4 pressure ulcer was first observed on the resident's left medial foot and it measured 1.0 X 1.0 cm. Record review of Resident #37's weekly skin evaluation from 12/11/23 and 12/18/23 did not reveal the resident had any skin issues on the left abdomen or right groin area. Record review of Resident #37's wound evaluation and management summary report for the left medial foot by the wound care doctor dated 09/19/23 described the wound duration greater than 13 days, measured 1.0 X 1.0 cm at stage 4 with thick adherent devitalized necrotic tissue (this tissue cannot be savaged and must be removed to allow wound healing to take place). The wound was debrided. Record review of Resident #37's wound evaluation and management summary report for the right groin by the wound care doctor dated 12/26/23 described the wound duration greater than 1 day, measured 2.5 X 2.5 X 0.1 cm, light serous and 100 % granulation tissue (the stage for epithelial tissue to be laid on of a wound bed). Record review of Resident #37's wound evaluation and management summary report for the left abdomen by the wound care doctor dated 12/26/23 described the wound duration greater than 4 days, measured 2.0 X 2.0 cm depth was not measurable due to presence of nonviable tissue and necrosis. The non pressure wound was debrided. Record review of Resident #37's physician order date January 2024 revealed the following orders: cover suprapubic catheter port with an island border gauze every night shift on Sunday, offload wound as resident would allow, float heels in bed as the resident would allow, reposition as resident would allow was started on 01/04/24. Record review of Resident #37 physician order date January 2024 read pressure wound stage 4 of left foot medial, cleanse with NS/WC pat dry, apply collagen powder, and cover with an island border gauze. Record review of Resident #37's order summary report dated January 2024 revealed the following orders: cover suprapubic catheter port with an island border gauze every night shift on Sunday, offload wound as resident would allow float heels in bed as the resident would allow, and reposition as resident would allow was started on 01/04/24. Record review of Resident # 37's progress notes dated 12/22/23 revealed entry by the wound care nurse which read in part during routine wound care resident was observed to have an unstageable pressure wound to the left stomach related to pressure applied to the resident by laying on the catheter . Record review of Resident #37's progress notes from 12/05/23 to 01/04/24 did not reveal any documentation of Resident #37's refusal for turning and repositioning, physician notification of Resident # 37 refusal to wear the boot on his left foot, alternate intervention in place, or any education given to Resident #37. During an interview on 01/03/23 at 9:15 a.m., the Wound care nurse said Resident # 37 had a wound on the left medial foot because he refused to wear the boot on his foot. Resident #37 laid on his abdomen because that was the only way he could lay down. He had stage four pressure ulcer on both ischia and Resident#37 was admitted to the facility with two wounds. The wound care nurse said he had been lying on his abdomen since she became the wound care nurse about four months ago. The Wound care nurse said she found the wound on Resident #37's left abdomen on 12/22/23 when she made her usual wound rounds. The wound on the right groin was discovered when she made wound rounds with the wound care doctor and the wound care doctor said the non-pressure wound was from the catheter tubing. She said there was no intervention in place before and after the wound occurred. The wound care nurse said she did not call Resident #37's physician and told him that Resident #37 preferred to lay on his abdomen because this was on going before she became the wound care nurse. During an interview on 1/3/24 at 4:35 p.m., the DON said Resident #37 likes to lie on his abdomen. The DON said the staff tried encouraging him to lie on his sides and back, but he would not. The DON said she had to investigate his plan of care to find out if there was an intervention put in place since the resident had a suprapubic catheter and preferred to lie on his abdomen. The DON said she did not notify Resident #37's physician that the resident chose to lay on his stomach. She was not sure if any alternative intervention was put in place by the nurses before Resident #37 developed the two non -pressure wounds. The DON said the nurses do the weekly skin assessment, and the wound care nurse does the wound assessments. The DON said the wound care nurse and the nurse managers were responsible for putting interventions in place and education the nursing staff. The DON did not respond when she was asked what a negative outcome for Resident #37 could be when she was not turned and repositioned. During an interview on 1/4/23 at 8:30 a.m., the DON said that Resident #37 wanted to get up, and the wound care nurse was ready to provide the wound treatment. The state surveyor told the DON she was on her way to observe the wound care treatment. During an interview on 01/04/24 at 8:38 a.m., the DON said the ADON told her that Resident #37 did not want the state surveyor to observe his wound care. During an interview on 01/04/24 at 3:46 p.m., the Wound Care doctor said Resident #37 preferred to sleep on his abdomen and did document that on his notes. He communicated to the nursing staff about turning and repositioning Resident #37. The Wound care doctor said the two non-pressure wounds were caused by Resident #37 laying on the tube. He stated Resident#37 had an air mattress, and he was not aware if an alternate intervention was put in place to prevent the wounds. The wound care doctor said the unstageable wound could develop within four hours from the tubing, without showering, any sign of skin breakdown or discoloration, and he thinks the facility did all they could do for Resident #37. During an interview on 01/4/24 at 3:54 p.m., ADON L said Resident #37 laid on the suprapubic tube while he was lying on his abdomen, and it had been ongoing since she started to work in the facility. ADON L said the areas (left abdomen and right groin) developed non-pressure wounds. ADON L said the staff told her Resident #37 refused to turn, she did not call Resident #37's physician or educate the resident. The facility did not have any other intervention except for turning and repositioning in place before and after the wound developed. ADON L said after the wound care nurse talked to the state surveyor, they put in a new order to wrap the Suprapubic catheter tubing to prevent it from touching the resident's skin. ADON L said the nurse management monitors the nurses when they make random rounds and in - service on catheter. ADON L the Wound Care Nurse and nurse managers were responsible for modifying intervention and when asked while there was no intervention in place when the staff was aware Resident #37 preferred to lay on his, ADON L did not respond. During an interview on 01/04/24 at 3:58 p.m., the Wound care nurse said she initiated an order yesterday (01/03/24) to wrap the tubing weekly to prevent the tubing from coming in contact with Resident #37's skin. During an interview on 01/04/24 at 4:04 p.m., the wound care nurse said Resident #37 was supposed to wear a boot on his left foot, and he refused to wear the boot. The wound care nurse said there was no other intervention put in place since Resident #37 declined the boot. She stated this could have contributed to the development of the pressure ulcer because the foot may not have been relieved from pressure. The wound care nurse said she did not tell the DON or the resident physician that Resident # 37 refused to wear the boot on his foot or document the refusal. The wound care nurse said the wound on Resident #37's left medial foot started on September 19th, 2023. The wound care nurse said the nurse does the head-to-toe assessment, and she does the wound assessment. The wound care nurse said she did not notice any change in color on Resident # 37's left medial foot until she was made aware of the wound. The wound care nurse said she did not offer to float Resident #37's left foot on a pillow because there was no order to float his foot. During an interview on 01/04/24 at 4:09 p.m., the DON said the staff told her that Resident #37 refused to turn and preferred to lay on his abdomen. The DON said she did not educate Resident #37, but the nurses said they educated him. The DON said she did not call Resident #37's physician to inform him about the resident's refusal to turn and reposition and that he preferred to lie on his abdomen. The DON said she was the wound care nurse for the facility about two years ago. She used to prop Resident #37 legs on pillows and Resident #37 had no problem with it at that time. She was not aware he refused to wear the boot. The DON said she had told the nurses to use pillows to elevate Resident #37's leg, and she did not know why the nurses did not do it. The DON said she would research and see if the nurses documented that Resident #37 refused to elevate his legs even with a pillow and if Resident #37's physician was notified about his refusal before he developed the pressure ulcer and non - pressure Ulcer. The DON said she would research and see if the nurses documented that Resident #37 refused to turn and reposition and if the nurses notified Resident #37's physician about his refusal before he developed the non-pressure wounds. The DON said she was still determining if the facility implemented any intervention other than turning and repositioning. The DON said the areas could develop non-pressure wounds if pressure was not relieved. During an interview on 01/05/24 at 12:36 p.m., LVN M said Resident #37 refused to turn on his side, but he does turn for her. LVN M said she would go back to the resident's room about 30 minutes later, and he would go back to his abdomen. LVN M said she was unsure if any intervention was put in place since he preferred to lie on his stomach. LVN M said she would call the NP and ask if there was any intervention to prevent the tube from giving the resident wounds. She was not aware the wound on his abdomen was from the Suprapubic tubing. LVN M said she did not tell Resident #37's physician about the resident's refusal and she did not respond when she was asked why she did not notify the physician. LVN M said there was no alternative intervention in place to prevent the non-pressure wounds, and she did not inform the DON of the resident refusal or document any refusal. LVN M said Resident #37 gets up early in the morning and stays up throughout her shift (12 hours). LVN M said the nurse monitors the aides, and she had in-service and skills check-off on wound care and prevention. LVN M said the ADON monitored the nurse's when she made random rounds. During an interview on 01/05/23 at 1:46 p.m., CNA C said Resident #37 gets up in the morning at various times, and Resident #37 stays up through his shift. CNA C said he does not turn Resident #37 when he was in bed because Resident#37 turns himself and lies on a different side of his body. CNA C said Resident #37 wore a boot on his left foot, where he had a wound. CNA C could not remember if he started to wear the boot before or after Resident #37 developed a wound on his foot. CNA C said he provided incontinent care to Resident # 37 every two hours, and sometimes he showered the resident, and he did not notice any wound on his abdomen or groin area. CNA C said he came to work about two weeks ago and saw the patch(dressing) on the resident's abdomen. During an interview on 01/05/24 at 2:53 p.m., the DON said she could not find any refusal documentation for turning and repositioning Resident #37. The DON said there was no documentation that Resident #37's physician was notified of his refusal by the nurses. The DON stated there was no other intervention put in place to help prevent non-pressure and pressure ulcer wounds from developing, except Resident #37 had an air mattress. The DON said Resident #37 was started on zinc sulfate tablet 220 mg on 01/04/24 and other supplements. The DON said the facility does not do labs for Resident #37 because the dialysis center does his labs. She did not know what Resident #37's pre-albumin was. The DON said the dialysis should contact the facility if there were any issues with Resident #37's lab. The DON said she would contact the dialysis center and get back to the state surveyor. During an interview on 1/5/24 at 4:47 p.m., LVN H said she started working on the second floor in December 2023. The aides usually turned Resident #37 every two hours and Resident #37 was changed every two hours. LVN H said Resident #37 also turns himself. LVN H said Resident # 37 was up most of the day, and she worked 6 a.m. to 6 p.m. LVN H said the aides had not complained to her that the resident refused to wear the boot. LVN H said Resident #37 was on the B bed, and the nurse assessed his skin at night. LVN H said there was no intervention put in place that she could remember to prevent or relieve Resident #37 from developing a pressure ulcer. LVN H said she did not notify Resident #37's physician about any refusal because she did not see any need for it because Resident #37 did not refuse to wear the boot or turn and repositioned on her shift. Record review of the facility policy on skin and wound monitoring and management dated 03/2015, revisions: 12/2019, 1/2022 read in part the purpose of this policy is that the facility provides care and services to . #1 . promote interventions that prevent pressure injury development . procedure C . identify risk factors which relate to the possibility of skin breakdown and/ or the development of pressure injury which include, but are not limited to: resident refusal of some aspects of care and treatment . prevention . #3b . monitor impact of intervention and modify intervention as appropriate . #8 response to resident choices that differ from plan of care #8a if the resident is not able to or chooses not to participate in the care plan to prevention of skin breakdown, or treatment of exiting wound . the nursing staff shall communicate with the resident's physician to discuss an appropriate intervention or response . if the resident's physician is unavailable, the nursing staff shall contact the medical director . This was determined to be an Immediate Jeopardy (IJ) on 7/29/23 at 6:16 p.m. The DON and Administrator were notified. The Administrator was provided with the IJ template on 01/24/24 at 3:00p.m. The following Plan of Removal submitted by the facility was accepted on 01/25/26 at 10:59 a.m.: The Medical Director was notified by the Executive Director on 01/24/2024 at 3:32 p.m. 1. The Attending Physician was notified by the Executive Director, of the IJ on 1/24/2024 at 3:32 p.m. 2. The Wound Care Specialist was notified by the Executive Director, of the IJ on 1/24/2024 at 3:53 p.m. 3. New Braden scales for the total census initiated 01/24/2024 and will be completed 01/24/2024 by Clinical Resources, Clinical Leaders MDS Nurse, ADON and DON. 4. Audit completed by DON on 01/24/2024 of all residents who are at risk for PU/PI, Care plans and care profiles were updated for all residents at high risk to include personalized/individualized interventions/prevention. This was also completed 01/24/2024. 5. Skin assessments were completed on all high risk Bradens 01/24/2024- no new areas were identified. These were conducted by the DON, ADON, MDS Nurse and Clinical Resource. 6. Education initiated 01/24/2024 by Clinical Resource with DON, ADON, Nurses, CMAs, and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, turning and repositioning notification of changes in wounds, interventions and preventions, as well as communication between Nursing staff and health care professionals; will be completed by 1/25/2024. Any staff unable to attend will not be allowed to work unless they have received their training and knowledge check. 7. All licensed nurses will complete competency on skin assessments started on 01/24/24 and will be completed 01/25/2024 by DON, ADON, and Clinical Resource 8. All CNA's will complete competency on skin check started on0l/24/2024 and will be completed on 01/25/2024 by DON, ADON, MDS Nurse, and Clinical Resource 9. MDS Coordinator will be reeducated on proper coding of MDS 01/24/2024 o completed by Clinical resource 01/24/2024. 10. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 11. An ad hoc QAPI meeting regarding items in the IJ template will be completed on 01/24/2024. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions. 12. The DON, ADON or Clinical Resource will verify staff competency with 10 staff weekly using the skin check competency checklists. 13. All residents with pressure ulcers be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director and Wound Nurse. The DON and Administrator will be responsible for ensuring this meeting is held weekly and all residents with pressure ulcers/pressure injury are reviewed. 14. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Resident #37 was reevaluated by the Wound Care Specialist on 1/23/2024, he does not recommend applying any appliances to the suprapubic site as this will increase the pressure to the site; resident will be encouraged to turn side to side as he tolerates or will allow. Resident has a low air loss mattress; wheelchair cushion when up and heels are to be floated when he is in the bed as he will allow. RD and Therapy will reevaluate for any other interventions, completed by 1/25/2024. Psych evaluation to be scheduled, resident consented 1/25/2024. Surveyor monitored the plan of removal for effectiveness as follows: Record review of the plan of removal #15 read Resident #37 was reevaluated by the Wound Care Specialist on 1/23/2024, and he does not recommend applying any appliances to the suprapubic site as this will increase the pressure to the site; resident will be encouraged to turn side to side as he tolerates or will allow. Resident has a low air loss mattress, wheelchair cushion when up, and heels are to be floated when he is in the bed as he will allow. RD and Therapy will reevaluate for any other interventions completed by 1/25/2024. The psych evaluation is to be scheduled; the resident consented on 1/25/2024. Record review of in-service records dated 1/24/24 revealed the MDS Coordinator was trained on proper coding of MDS. Record review of in-service records dated 1/24/24 and 1/25/24 revealed Multiple nurse aides from multiple shifts completed competency checks on skin checks during care. They reported to the nurse if there were any skin issues and documented on-point click care. In service on prevention and interventions: turning and repositioning resident in the bed and wheelchair every two hours and report to the nurse if resident refused and document on point click care. Record review of in-service records dated 1/24/24 and 1/25/24 revealed. Multiple nurses from both shifts completed competency checks on the Braden scale: done on admission, weekly for four weeks, and whenever there was a change in skin condition. Skin assessment is started on admission and weekly by the charge nurse, who reports any change in skin condition to the resident's physician. In service on prevention of pressure ulcers, turning and repositioning and reporting any refusal to the physician and documenting on residents' progress notes, also reporting to nurse managers of any refused intervention, and the resident responsible party should be notified. The nurse managers would update the care plan. Record review of the Braden scale revealed that 15 Residents were documented as having a high or very high risk for developing pressure ulcers. Record review of skin assessments revealed that the DON, ADON, MDS Nurse, and Clinical Resource completed the evaluation on all high-risk Braden 01/24/2024, and no new areas were identified. Interviews on 01/25/24 with four nurses (2 LVN and 2 RN) between 12:44 p.m. and 2:38 p.m. on the above training: Braden scale should be done upon admission, weekly for 4 weeks, and quarterly, and when there was a change in any skin condition. They were also in service on weekly skin assessments, notifying resident physicians about any change in a resident's skin condition or refusal of skin intervention, and documenting in the resident progress note. They said the nurse should notify nurse management of any refusal and any change or modification of intervention so that it would be updated in the care plan. Interviews on 01/25/24 between 2:00 pm and 2:19 pm, two-day staff (CNAs) were interviewed, and they said they were in serviced and trained on skin check: they should check the resident's skin during all care and notify the charge nurse if there was any skin impairment and document on point click care. They also said they were trained on measures to prevent pressure ulcers: turning and repositioning every two hours, floating heels on the pillow, reporting to the nurse if any resident refused, and documenting the refusal on point clock care. All interviewed staff expressed understanding of the training provided above. Interview on 01/25/24 at 1:24 p.m., ADON E said she was retrained and had in service on the facility's Braden scale, skin assessment, resident physician notification for refusal, intervention modification, and updating care plan. She expressed understanding of the plan of removal training provided to her. Interview on 1/25/24 between 7:29 p.m. and 7:50 p.m., two nurses (LVNs night shift) were interviewed on the facilities in service and training on skin assessment, intervention, and reporting to a resident physician about change in skin condition, refusal of intervention, and documentation. All staff interviewed expressed adequate understanding of the plan of removal training provided to them. Interview on 1/25/24 between 8:00 p.m. and 8:33 p.m., five-night staff (CNAs) were interviewed on the facility in-service and training on skin assessment, intervention, and reporting to a resident physician about change in skin condition, refusal of intervention, and documentation. All staff interviewed expressed adequate understanding of the plan of removal training provided to them. Interview on 1/26/24 between 10:14 a.m. and 10:30 a.m., two nurses (LVNs) were interviewed on the above training: Braden scale should be done upon admission, weekly for 4 weeks, and quarterly, and when there was a change in any skin condition. They were also in-service on weekly skin assessments, notifying resident physicians about any change in a resident's skin condition or any refusal of skin intervention, and documenting on the resident progress note. They said the nurse should notify nurse management of any refusal and any change or modification of intervention so that it would be updated in the care plan. All staff interviewed expressed adequate understanding of the removal training plan provided to them. Interview on 1/26/24 between 10:35 a.m. and 10:50 a.m., two - staff (CNAs) were interviewed on the facility's in-service and training on skin assessment, intervention, and reporting to the resident nurse about changes in skin condition, refusal of intervention, and documentation. All staff interviewed expressed adequate understanding of the plan of removal training provided to them. Interview on 1/26/24 at 11:10 a.m., ADON L was interviewed on the facility in-service training on skin assessment, intervention, and reporting to a resident physician about changes in skin condition, refusal of intervention, and documentation, and updating the care plan. ADN L expressed adequate understanding of plan of removal trainings provided to them. Interview on 01/26/24 at 11:37 a.m., the MDS coordinator said she had training on Thursday on correctly coding interventions, and she also trained on pressure ulcers on Relias yesterday. The MDS said she uses UDA (user-defined assessment) and shows if the resident has a pressure ulcer. Then, she would interview the wound care nurse and the floor nurse about the resident's wound treatment and interventions. The MDS coordinator said she would also review the wound care doctors' notes and assess the resident. The MDS coordinator said these would determine how she would code for the resident after the assessment, interview, and record review. She said the care intervention is done as a team during IDT (interdisciplinary team} and morning meetings. The MDS coordinator said she was also told to consult with DON during the retraining when unsure of any intervention. Interview on 01/26/24 at 12:00 p.m., the DON said all the staff were retrained and in service on the Braden scale, skin assessment, reporting to the physician for any skin impairment, refusal of intervention and care, reporting to nurse managers and the managers with come up with a different or modified intervention and care plan it. She said the nurses and the aides were in service on documentation and notifying the resident responsible party. Interview on 01/26/22 at 12:10 p.m., the Administrator said all staff were in-serviced on the removal plan and the facility's new system. The DON will monitor as mentioned in the removal plan. The Administrator said he would oversee the plan of removal completion and implementation. On 01/26/24 at 3:55 p.m., the Administrator and the DON were notified the Immediate jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure pain management provided for one resident (Resident #25) of five residents reviewed for pain was consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -The facility did not have Resident #25's pain medication (Norco 7.5/325 mg) available. -Resident #25 missed 9 doses of Norco 7.5/325 mg over 5 days. -Resident #25 said her pain level was high during the time of the missed doses. The deficient practice caused Resident #25 to experience unnecessary pain. Findings included: Record review of the Admission Record (printed 01/05/2023) for Resident #25 revealed she was [AGE] years old and was originally admitted to the facility on [DATE]. Diagnoses included, but were not limited to, left sided hemiparesis (loss of use of the left arm and leg), history of healed fracture, and uterine cancer. Record review of the Care Plan dated 12/19/2023 revealed Resident #25 experienced acute and chronic pain in her left shoulder and from wounds on both legs. The 'Interventions' read, in part, .Administer analgesia [pain] medication as per orders. Monitor for side effects and effectiveness. Record review of the Physician Order dated 10/24/2023 revealed Resident #25 had an order for Norco 7.5/325 mg to be given two times daily from 10/26/2023 to 12/26/2023. Record review of the Physician Order dated 12/26/2023 revealed the Norco 7.5/325 mg was to be increased to three times daily. Record review of the December 2023 and January 2024 MAR revealed Resident #25 was not administered the following doses of Norco 7.5/325 mg: 12/29/2023 at 7:00 p.m. (1 dose) 12/30/2023 at 7:00 a.m. and 7:00 p.m. (2 doses) 12/31/2023 at 7:00 a.m., 3:00 p.m., and 7:00 p.m. (3 doses) 01/01/2024 at 7:00 a.m. and 3:00 p.m. (2 doses) 01/02/2024 at 7:00 a.m. (1 dose) In an interview with Resident #25 on 01/02/2024 at 10:43 a.m. revealed she said she had constant pain in her left hip. She said she has been out of the Norco 7.5/325 mg since yesterday and would need Tylenol. She said the nurse, LVN A, said she was out of the Norco 7.5/325 mg, and she told the nurse Tylenol was not effective. She reported her pain was currently 7 of 10, and constant. She said the pain level with Norco would be 3 or 4 of 10. She said it hurt more with movement. She said she had a left hip fracture but did not have a fall. She said she had reported pain and an x-ray confirmed a fracture. That occurred just before Christmas. She said she had not received any pain medication that morning but had not told anyone she was in pain. In an interview on 01/02/2024 at 11:13 a.m. RN B acknowledged Resident #25 was out of Norco 7.5/325 mg. He said the resident had a hip fracture, but also had osteoporosis and osteoarthritis. He said there was no Norco 7.5/325 mg in the emergency dispenser machine. He said he had called the pharmacy and they would be delivering the Norco 7.5/325 mg. He said he would administer the Norco 7.5/325 mg when it arrived. He said he had been unaware the resident was out of Norco 7.5/325 mg. In an interview on 1/2/2024 at 11:18 am RN B said he had notified the physician on Tuesday (12/26/2023) that Resident #25 had a three-day supply at that time. He said the physician changed the order to three times daily because the resident was having increased pain at night. He said he re-ordered the medication but did not work the next day. He said the nurse was responsible for ordering the narcotics. He said he was then unable to contact the physician or Nurse Practitioner. He said he had not reported it to the DON or Unit Manager. In an interview on 01/02/2024 at 11:34 a.m., MA C said she was assigned to administer Resident #25's Norco 7.5/325 mg, but it was not available. She said she notified the nurse. MA C had not worked during the previous four days. In an interview on 01/02/2024 at 2:13 p.m. Resident #1 said a nurse had administered her Norco 7.5/325 mg just before 2:00 p.m. She rated her pain level as between 5 and 6. In an interview on 01/02/2024 at 2:34 p.m. the DON said she was not aware of Resident #25's Norco 7.5/325 mg being unavailable. She said the nurse was responsible for ordering medications. She said if the medication was a controlled medication (Norco 7.5/325 is a controlled medication) the nurse was to call the physician for a prescription. She said there was a 'blocked out area' on the medication blister package to show when to reorder. She said the weekend nurse should have called the physician. Observation and interview on 01/03/2024 at 10:35 a.m. revealed Resident #25 was lying in her bed, awake. She said she had received her Norco 7.5/325 earlier that morning. She said her pain level was 4 or 5. She said her pain increased when the staff moved her. She said she was very relaxed. In a telephone interview on 01/03/2024 at 12:32 p.m. LVN M said she could not remember what day MA T told her she was giving the last medication of Norco 7.5/325 mg. She called NP B and she said she would tell Resident # 25's doctor to write a script for refill. LVN M said she texted Resident #25's doctor twice and NP B three times and none of them returned her text or called her. LVN M said Resident # 25 gets the pain medication three times a day. LVN M said the pain medication was in the emergency medication dispenser, but she needed to have an order to be able pull the medication. She said she did not call the medical director or the DON because she was under the impression that the doctor would call her back. LVN M said she failed to call the DON and it was her fault. In a telephone interview on 01/03/2024 at 1:05 p.m. NP B said she did not recall getting a call from the nursing staff after the medication was increased on 12/26/23. NP B said the medication was increased to three times a day because of unrelieved pain. She said she told the nurses to call her before Resident #25's medication finished so she could tell the doctor to send in a script for refill. In a telephone interview on 01/03/2024 at 3:00 p.m. the physician said he did not receive a call from the facility until Monday (01/01/2024) at 10:30 a.m. He said the facility told him the resident was completely out of Norco 7.5/325 mg and she was in pain. He said the facility needed to give him 24 hours to return their call for medication refills.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 2 of 5 residents (Resident #6 and #26) reviewed for respiratory therapy. The facility failed to ensure Resident # 6's concentrator filter was covered and clean with a substantial amount of brown substance, undated nasal cannula, and the humidifier was empty and dated 12/17/23. The facility failed to follow the physician orders for Resident #26's oxygen administration and the nasal cannula was not dated. These failures placed residents who received oxygen therapy at risk of respiratory complications. Findings included: Record review of Resident #6's face sheet dated 01/03/24 revealed a [AGE] year-old male initial admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses which included shortness of breath (an intense tightening in the chest, air hunger or difficulty breathing), heart failure (heart that cannot keep up with its workload), chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in the body) and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing related problems). Record review of Resident #6's quarterly MDS assessment, dated 12/06/2023, revealed a BIMS score of 08 out of 15, which indicated the resident's cognition was moderately impaired. Further review did indicate he was on oxygen therapy. Record review of Resident #6's care plan dated 10/18/23 revealed: Resident #6 required oxygen therapy related to hypoxia. Interventions: change O2 tubing, and humidifier bottle every Sunday night shift. Record review of Resident #6's order summary report dated January 2024 read change O2 tubing, and humidifier bottle every Sunday night shift. 2L - 4L (liter) of 02 (oxygen) to keep 02 SAT (saturation) greater than 90% (percent) or greater every shift order dated 12/01/23. During an observation on 01/02/24 at 11:49 a.m., revealed Resident #6's concentrator filter on the back of the concentrator was covered with a substantial amount of brown substance. The humidifier bottle was dated 12/17/23. During an observation and interview on 01/02/24 at 11:52 a.m., LVN O said she saw the humidifier bottle was dated 12/17/23, and it was empty. LVN O said the nasal cannula was not dated, and she could not tell if it was changed weekly because it was not dated. LVN O said Resident #6's humidifier bottle and nasal cannula should be changed every Sunday by the nurse. LVN O said the filter was covered with dust and that the filter should be cleaned weekly and as needed. LVN O said the water gives Resident #6 moist air. LVN O said the filter should not have dust because it could cause respiratory problems for the resident. LVN O said the concentrator should be checked during rounds at least twice during the shift. LVN O said she did the walk-through with the night nurse during shift change but did not pay attention to the date on the humidifier or the filter. LVN O said without the moisture from the humidifier, Resident #6 would be breathing dry air. It could irritate Resident #6's nostrils, which could cause bleeding. LVN O said the unit manager monitors the nurses when she makes random rounds. During an interview on 1/04/24 at 11:16 a.m., LVN J said the nasal cannula and the humidifier bottle should be dated when it was changed weekly and PRN. This was done to make sure the nasal cannula and the humidifier were patent and there were no infection control issues. LVN J said Resident #6's concentrator, which required a humidifier, should have one to prevent Resident #6's nostrils from being dry and prevent bleeding. LVN J said if the filter was not cleaned, Resident #6 may breathe in the particles from the air, which could cause respiratory problems. LVN J said the filter should be cleaned weekly and as needed by the nurses. During an interview on 01/04/23 at 1:59 p.m., ADON E said the humidifier bottle and the nasal cannula for Resident #6 were scheduled to be changed on Sunday night, and it should be dated to show the nurse changed them. ADON E said the humidifier keeps the nostrils moist. When there is no moisture, it could cause the nostrils to become dry, which could cause irritation and bleeding for Resident #6. ADON E said the filter area on the concentrator should be cleaned, which makes the concentrator work better. ADON E said she does not know if a dirty air filter would affect air flow or have any adverse outcomes for Resident #6. She stated that it was the facility protocol to date the NC tubing and humidifier, which was changed weekly by the nurse. ADON E said if the NC was not changed, it could be kinked or clogged, and all the managers monitored the nurses when they made rounds. During an interview on 01/04/24 at 2:08 p.m., the DON said the nurses were responsible for checking the concentrator and ensuring the machine was functioning. The DON said the humidifier bottle and the oxygen tubing were changed and dated weekly and PRN. The DON said the humidifier bottle and the nasal cannula were changed and dated every week and as needed for patency and infection control issues. The DON said the air filter should be cleaned weekly and as necessary to help filter airborne contaminants. Resident #26 Record review of Resident #26's face sheet dated 01/03/24 revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses which included heart failure (heart that cannot keep up with its workload), cardiomegaly (enlargement of the heart) and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing related problems). Record review of Resident #26's quarterly MDS assessment, dated 12/08/2023, revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Further review did indicate she was on oxygen therapy. Record review of Resident #26's care plan dated 09/11/18 revealed: Resident #26 receives oxygen therapy related to pulmonary edema and CHF (congested heart failure). Interventions: change O2 tubing and administer oxygen per MD orders. Record review of Resident #26's order summary report dated January 2024 read change O2 tubing, and humidifier bottle every Sunday night shift. 2L (liter) of 02 (oxygen) to keep 02 SAT (saturation) at 90% (percent) or greater for SOB (shortness of breath) order dated 04/15/23. During an observation and interview on 01/02/24 12:38 p.m., it revealed Resident # 26's oxygen was set at 5 L, and the nasal cannula was not dated. Resident #26 said her oxygen should be set at 2L, and she changed the setting about two weeks ago when she had a panic attack. Resident #26 said the nurses do not come and check her oxygen daily. Only when they come to change the oxygen tubing once a week, and she was not sure if the nurses dated the nasal cannula or not. Resident #26 said the nurse had not told her to stop increasing the oxygen setting on the concentrator or educated her on why she should not change the settings. During observation and interview on 01/02/24 at 12:43 p.m., LVN O said she observed the oxygen setting between 4 and 5 L. LVN O said Resident #26 had been changing the setting on the concentrator. All the nurses, the DON, and the ADON were aware of her changing the setting. LVN O said she could not remember if she notified Resident #26's physician or documented it. LVN O said she should have notified Resident #26's physician because the oxygen was increased above 2 liters. Which meant the physician's order was not followed, and Resident #26 could have had a negative respiratory outcome. LVN O said she had an in-service and skills check-off on how to work with a resident with oxygen. LVN O said the resident nasal cannula should be changed on Sunday and dated, proving it was changed. LVN O said it would prevent Resident #26 from using one cannula for an extended period. LVN said it also ensured the nasal cannula was not clogged up and it would deliver the oxygen appropriately. During an interview on 1/04/24 at 11:18 a.m., LVN J said the nasal cannula should be dated when changed weekly and PRN. She stated make sure the nasal cannula was patent, and there were no infection control issues. LVN J said Resident #26 does increase the setting of the oxygen on the concentrator, and the management is aware of it. LVN J said she told Resident #26 not to change the setting, and she could not remember if she notified the doctor about Resident #26 changing the setting. LNV J said if the set was increased above the physician's order, then the nurse should inform the physician and may get an order for a range if it would not cause any adverse outcome for Resident #26. During an interview on 01/04/23 at 2:19 p.m., the DON said if Resident #26's O2 was set on 5 L instead of 2, then the physician order was not followed, and Resident #26's physician should be notified. The DON said the nurses had told her not to touch the oxygen, and she had been educated about it, too. The DON said she would review the progress notes to see if the nurses notified the doctor that Resident #26 kept turning up her oxygen and the education documentation given to Resident #26. The DON said Resident #26 CO2 levels would be high, and it could affect her respiration. The DON said the NP would be the best person to talk to because she had worked with the two doctors who had taken care of Resident #26, and the nurses also reported to her about any Resident #26 issues. During an interview on 01/04/23 at 2:32 p.m., NP said none of the nurses had told her about Resident #26 adjusting her oxygen concentrator setting. The DON intervened and said the NP did not understand what the state surveyor said. The DON asked the NP if the nurses had told her about Resident #26 increasing her oxygen setting, and the NP replied none of the nurses had informed her about Resident #26 increasing the oxygen setting. NP said the nurses should check the setting on the oxygen when they made rounds according to the physician's order. During an interview on 01/04/23 at 3:50 p.m., ADON E said the nurse had told her Resident #26 does increase the oxygen setting, and the nurses educated Resident #26. ADON E said she was unsure if the nurses had notified the doctor. ADON E said if the oxygen setting was increased above the physician's order, the nurses should have reported to the physician because it could affect the resident negatively. During an interview on 01/05/23 at 1:30 p.m., the DON said she could not find any documentation that Resident #26's doctor was notified that Resident #26 was increasing her oxygen or any education documented. She had in-serviced the nurses about informing doctors if there were any issues with resident care. Record review of the facility policy on oxygen equipment revised 05/2007 read in part . it is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner . procedures . C. pre - filled humidifiers, when used are to bed dated and replaced every 10 days .tubing should be replaced every week . Requested oxygen administration policy and it was not provided upon exit.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable, environment for residents, staff and the public for two (Floor 200 & 300) of two floors reviewed for environment. The facility failed to ensure walls, floor, baseboard, ceiling, and sheetrock were clean and in good repairs for: Rooms on the second Floor 201, 202, 205, 206, 207, 220, 221, 223, 228, 230, 233, 234 & common area. Rooms on the third Floor 316, 330, & 335 and lounge area. This failure could affect all residents living in the facility by placing them at risk for diminished quality of life due to the lack of a well-kept environment Findings included: Observation on 7/28/2023 of the 2nd floor between 3:12pm and 4:00pm revealed the following: The Window at the entrance of room [ROOM NUMBER] had peeling paint and cracked sheetrock. The baseboard was off the wall at the entrance door of room [ROOM NUMBER]. No strip was at the floor between the closet and room tile. There was a strong urine odor in the bathroom. room [ROOM NUMBER] had a leak in the bathroom and the ceiling tiles were missing in the bathroom. Baseboard was missing at the bathroom door and the window blind was broken. room [ROOM NUMBER]'s sheetrock was broken, and the cable outlet cover was broken. room [ROOM NUMBER] had missing baseboard at the bathroom entrance. room [ROOM NUMBER]'s baseboard at the sink was not affixed to the wall. room [ROOM NUMBER] had cracked sheetrock, baseboard off the wall at the bathroom entrance and the wall behind the bed had peeling paint. room [ROOM NUMBER] had no blinds at the window. room [ROOM NUMBER] had no blinds at the window, baseboard was off the wall at the bathroom door and peeling paint in the room. The blue mattress was stripping, exposing the white fabric under the blue plastic. The pillow on the bed was torn exposing the sponge in the pillow. room [ROOM NUMBER], the metal strip at the wall at the bathroom was not affixed to the wall and the sheetrock was broken. The baseboard of the hallway parallel to room [ROOM NUMBER] and the side opposite to the exit door was off the wall. room [ROOM NUMBER]'s baseboard was off the wall at the bathroom and the blind was broken. room [ROOM NUMBER]'s floor had brown stains rooms [ROOM NUMBERS] had missing strips on the floor between the room and the closet. room [ROOM NUMBER] baseboard was off the wall under the sink. The floor dining room had marks and brown stains on it In an interview and observation on 7/28/2023 at 3:30pm with Resident #1, he said that the sheets and towels on the floor was due to a leak in the bathroom. He said they were going to fix it. No maintenance personnel were observed in the room at the time of the interview. No leak was observed at the time of interview. In an interview on 7/28/2023 at 4:00pm LVN C said she did not know what time the general cleaning was done. She said housekeeping usually comes after each meal and sweep and clean the floor. She said the floor looked like it needed cleaning. Observation on 7/28/2023 between 4:10pm - 4:45pm of the 3rd floor revealed the following: room [ROOM NUMBER]'s sheetrock was torn behind the bed, the cover of the cable was broken, and the sheetrock was cracked. The baseboard was not affixed to the wall. room [ROOM NUMBER]'s baseboard was off the wall at the bathroom door. In an interview on 7/28/2023 at 5:30pm with the Administrator, he said they were doing repairs but it's a whole lot and it will take time to address all the maintenance issues. He said the floors were old and they were going to replace them. He said he had the approval for repairs to be done and was working on getting more help to get the repairs done faster. In an interview on 8/01/2023 at 11:00am with the Plant Manager, he said they were working on doing repairs to the building, but it's an ongoing project and they had gotten the approval. He said they were trying to get things done as quickly as possible. Observation on 8/1/2023 at 1:30pm of room [ROOM NUMBER] revealed a hole in the sheetrock at the entrance to the bathroom. The wall beside the window had torn sheet rack like it was punched. There was a hole at the bottom near the baseboard. The floor had brown stains on it. In an interview on 8/1/2023 at 1:35 pm with Resident #2, he said he was admitted about three weeks ago to the facility and the wall was like that when he was admitted . He said they told him they were going to fix the wall. Observation on 08/01/2023 at 1:55pm of the lounge area of the 300 floor revealed peeling paint on the walls and brown stains on the floor. In an interview with the Housekeeping Supervisor on 8/1/2023 at 2:00pm she said that they check the rooms daily and if repairs needed to be done, they report it to maintenance. In an interview on 8/1/2023 at 2:15pm, Contractor A said he usually comes in to do repairs. He said was in to do repairs on the sheetrock and replacing the baseboards. Observation on 8/1/2023 at 4:30pm of the area to the elevator on the 2nd floor to the west side revealed peeling paint and damaged sheetrock. In an interview on 8/1/2023 at 4:55pm with Maintenance Man B said there was a book at each nurse's station and the staff were expected to document repairs that needed to be done. He said they would check the book daily and would address repairs as needed. He said repairs were prioritized and completed as needed. In an interview on 08/1/2023 at 5:45pm with the Administrator he said that he was going to ensure that the repairs were done a quickly as possible. He said he had the funds to do repairs but needed to get some more help. Record review of the Facility Repairs and Maintenance Service dated December 2009 read in part . Maintenance service shall be provided to all areas of the building grounds and equipment. This is to ensure the upkeep and maintaining of a safe environment and aesthetics for all facility interior and exterior areas. Policy Interpretation and Implementation The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include, but are not limited to: . Maintaining the building in compliance with federal, state and local laws, regulations and guidelines. . Maintaining the buildings in good repair and free from hazards. . Establishing priorities in providing repair service. . Provide routinely scheduled maintenance service to all areas. . Maintaining walls and ceilings in good repairs by way of Maintenance Personnel and contracted vendor.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for one (RM 319) of 6 rooms observed in the third floor reviewed for environment. The facility failed to ensure that the floors and walls in room [ROOM NUMBER] were in good repair . This failure could affect all residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: An observation on 06/14/2023 at 2:00PM, of RM 319 revealed the ceiling on the right-hand side had an opening estimated about 24 by 24 Square feet and approximately 14-inches wide from the floor to the ceiling section of drywall, was removed from the wall and several scratches in the drywall by the hand washing sink on the right side of the room. Observation also revealed exposed building pipes and wirings . On the floor were pieces of sheet rocks against the wall. Observation of the bathroom revealed there was no light in the bathroom. The light was not visible when turned on. Observation revealed Resident #2 was in B bed awake watching television she was alert and oriented but was not communicative due to dysphasia (a condition that affects the ability to speak or express self) . Attempt was made to have an interview with Resident #2 on 06/14/2023 at 2:00PM but was unable to explain. She put her responsible party on the phone. An interview on 06/14/2023 at 2:05PM, Resident # 2's responsible party said the room had been like that for some times about two to three months ago (since March). She said at first there was no water coming to the room and she complained to the administrator several times. She said since the facility repaired the water, the wall has been open from the ceiling blowing everything on Resident #2's face and food. The RP said she had asked for the wall to be repaired several times and no one seems to care about it. Observation and interview with the facility's Administrator on 06/15/23 at 9:30AM, he looked at the wall and said that was his first time of seeing the wall and he would take care of it. The Administrator pick some of the sheet rocks up from the floor and said, this is my first time seeing this He said he would tell the facility maintenance Director to take care of it During an interview on 06/15/2023 at 10:00AM. LVN B said the wall has been like that for a while . She said the facility was aware of the wall being open. During an interview with CNAs D on 06/15/2023 at 11:00 PM , she said the wall had been like that for a while. She said she does not remember the exact date and time but for a while and the facility was aware of it. During an interview with the facility's Maintenance Director on 06/15/2023 at 11:00AM, he said the project was given to a contractor who did the repairs . He said he had reached out to them several times and the contractors keep giving excuses. He said he would take care of it. An invoice for the job and facility's policy on clean and comfortable environment was requested. He said he would contact the contractors for the invoice and would ask the administrator for the policy on environment . During an interview with Maintenance Director on 06/15/2023 at 3:00PM, he said he had covered the wall and was waiting on the contractor to send the invoice and the Administrator to give him the policy on facility's maintenance. Facility's policies on repairs and keeping a clean, comfortable environment for residents, staffs, and the public together with the invoice from the contractor was requested from the Administrator on 06/15/2023 at 3:500PM. He said he would try to find the policy and was waiting on the contractors for any invoice. He said he would e-mail it as soon as he gets them. None was provided prior to exit on 06/15/2023 at 4:10PM.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of three ( CR #1) records reviewed for documentation The facility failed to document in CR # 1 clinical records, how, when and where she was sent\discharged to. This failure places all could place residents at the facility at risk of their records being incomplete and inaccurately documented. being sent out without documentation and at risk of not knowing where they are. Findings include: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and was discharged on [DATE]. Her diagnoses included unspecific psychosis (collection of symptoms that affect the mind and loss of contact with reality) bipolar disorder ( a mental disorder that causes extreme mood swings), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms) and anemia (low levels of red blood cells) Record review of CR #1's clinical record, reflected no documentation of how, when and where she was sent to. Record review reflected the last documented notes in CR #1's clinical record read in part- Record review of CR #1's clinical record revealed a note titled Administrative Note dated 02/13/2023 1:08PM read in part- Had a care conference/IDT meeting with Physician on 2/13/2023 per telephone. DON, ADON, SSD, and Administrator was on the phone with physician. IDT team determined to suggest behavioral hospital may help resident. Also, to speak to psychiatrist to reach out to collaboration physician to receive more feedback for facility. During an interview with the DON on 06/14/2023 at 2:00PM, she said she was out sick during the time of CR #1's discharged but remember being called about resident's behavior. She said there was no documentation of when and how CR # 1 was sent out, but her understanding was that CR #1's physician gave the facility a phone # to the county sheriff department. She said the sheriff department was called due to resident's behavior of fast walking and speaking to herself and refusing her medication that someone was trying to kill her. She said the sheriff came and transferred CR # 1 to a psychiatric hospital. The DON said the psychiatric hospital send sent CR#1 to an assisted living facility that was recommended by the Social Service Director. She said it was her understanding that the facility was a licensed facility. The DON said she would have an in-service with staff on documentation. She said all information should have been documented. She said she does not know how CR # 1 left the facility. During an interview with the Facility Administrator on 06/13/2023 at 2:40Pm, he said the facility did not take CR#1 back because CR#1 was her own responsible party and the facility wanted CR # 1 to get a legal guardian before being admitted back to the facility. He said he expect all information about resident's medical condition to be in their clinical records. Record review of the Facility's policy titled Criteria for Transfer and Discharge read in part: It is the policy of the facility that each resident will remain in the facility and not transfer or discharge unless the discharge or transfer is appropriate as per the existing criterial . When the facility transfers or discharge a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and the appropriate information is communicated to the receiving health care institution or provide.

Based on record review and interview, the facility failed provide and document sufficient preparation and orientation for one of three (CR #1) records reviewed for safe and orderly transfer or discharge . The facility did not provide or document adequate and sufficient preparation and orientation for one of 3 (CR #1) closed records reviewed for prope and orderly discharged to the community. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services, and denying them a voice regarding their treatment plan. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and was discharged on [DATE]. Her diagnoses included unspecific psychosis (collection of symptoms that affect the mind and loss of contact with reality) bipolar disorder (a mental disorder that causes extreme mood swings), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms) and anemia (low levels of red blood cells) Record review of CR #1's discharge MDS dated [DATE] revealed returned not anticipated. Discharge destination was to a psychiatric hospital. Record review of CR #1's last Quarterly MDS assessment dated [DATE] reflected a BIMSs Score of 12 indicated she was mildly impaired cognition. Record review of CR #1's comprehensive care plan undated read in part- Potential for a psychosocial well-being problem r/t Illness/Disease schizoaffective disorder , mood disorder, bipolar, psychosis, Ineffective coping. Resident has history of psychosis, grandiose delusions (lose touch with reality). Goal: 1. Will effectively cope with his/her feelings of (SP isolation, unhappiness, anger by the review date. Intervention: 2-Allow time to answer questions and to verbalize feelings perceptions, and fears. assist/encourage/support to set realistic goals. Consult with: Pastoral care, social services , Psych services. Increase communication between resident/family/caregivers about care and living environment: 3 Explain all procedures and Treatments, Medications , Results of labs/tests , Condition , All changes , Rules , Options. Monitor/document resident's feelings relative to isolation, unhappiness, anger. 4 Observe for side effects and adverse reactions of psychoactive medication: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person . Record review of CR # 1's care plan records revealed no evidence of discharge care plan. Record review of CR #1's discharge MDS dated [DATE] revealed returned not anticipated. Discharge destination was to a psychiatric hospital. Record review of CR'#1's clinical record revealed no discharge orders and no documentation of where CR# 1 was discharged to , why and when she was discharged from the facility. Record review of CR #1's clinical record revealed a note titled Administrative Note dated 02/14/2023 1:08PM read in part- Had a care conference/IDT meeting with Physician on 2/14/2023 per telephone. DON, ADON, SSD, and Administrator was on the phone with physician. IDT team determined to suggest behavioral hospital may help resident. Also, to speak to psychiatrist to reach out to collaboration physician to receive more feedback for facility. In an interview with the facility's Social Service Director on 06/14/2023 at 11:20AM, she said CR#1 was discharged to a personal care home. She said CR #1 was having behavioral problem and was sent to a local psychiatric hospital. She said CR#1's behavior was talking to herself, walking around the facility, and talking to other residents not to take their medication. She said CR#1 was not hurting herself and not hurting anyone. She said that was her usual behavior. She said CR#1 was discharged from the hospital to an assisted living facility that she provided to the hospital. She said the assistant living was a licensed facility. She said provided the name and phone # of the assisted living facility. During an interview with the DON on 06/14/2023 at 2:00PM, she said she was out sick during the time of CR #1's discharged but remember being called about resident's behavior. She said there was no documentation of when and how CR # 1 was sent out, but her understanding was that CR #1's physician gave the facility a phone # to the county sheriff department. She said the sheriff department was called due to resident's behavior of fast walking and speaking to herself and refusing her medication that someone was trying to kill her. The DON said her understanding when she came back was that CR #1's Physician gave the facility a phone # to the sheriff department to call if CR #1 was in crisis. The DON said the facility called the sheriff who came and transferred CR # 1 to a psychiatric hospital. She said the psychiatric hospital sent CR#1 to an assisted living facility and it was her understanding that the facility was a licensed facility that was recommended by the Social Service Director . She said her expectation was to document all information in resident's clinical records why she\he was being transferred by whom, when and to where. She said there should be an order from the attending physician. During an interview with the Facility Administrator on 06/13/2023 at 2:40Pm, he said the facility did not take CR#1 back because CR#1 was her own responsible party and the facility wanted CR # 1 to get a legal guardian before being admitted back to the facility. He said CR #1 had always wanted to go to an independent living and the facility was in the process of assisting her to get into an independent living. He said he expect all information about resident's medical condition to be in their clinical records. He said CR #1's physician had an emergency and may not be reachable. He provided a number for the NP that work with CR #1's physician. A phone call was made to the NP on 06/15/2023 at 2:50PM; there was no answer. A message was left with a returned phone number. A Phone call was made to the Assistant Assisted living facility provided by the facility on 06/15/2023 at 3:50PM. There was no answer. A message was left with a returned phone number. Record review of HHS web site for active assistant Assisted living facility and Nursing homes revealed the name of the facility provided by the social Service Director did not appear as a licensed facility in the directory.

Based on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record for one (CR #1) of one 3 close records reviewed for discharge requirements. The facility discharged CR #1 without Physician documentation to address why the resident was being discharged , what needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. This failure could place residents at risk for inappropriate discharge from the facility and cause psychological harm. The findings included: Record review of intake ID # 411222 read in part . last week CR #1 called . to say she was transferred out of the facility and did not know where she was. she was not told she was being moved. Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and was discharged on [DATE]. Her diagnoses included unspecific psychosis (collection of symptoms that affect the mind and loss of contact with reality) bipolar disorder ( a mental disorder that causes extreme mood swings), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms) and anemia (low levels of red blood cells) Record review of CR #1's discharge MDS dated [DATE] revealed returned not anticipated. Discharge destination was to a psychiatric hospital. Record review of CR #1's last Quarterly MDS assessment dated [DATE] reflected a BIMSs Score of 12 out of 15 reflected mildly impaired cognition. Record review of CR #1's comprehensive undated care plan revealed Potential for a psychosocial well-being problem r/t Illness/Disease schizoaffective disorder , mood disorder, bipolar, psychosis, Ineffective coping. Resident has history of psychosis, grandiose delusions . Goal: 1- Will effectively cope with his/her feelings of (isolation, unhappiness, anger by the review date. Intervention: 2 - Allow time to answer questions and to verbalize feelings perceptions, and fears. assist/encourage/support to set realistic goals. 3 Consult with: Pastoral care, social services , Psych services. Increase communication between resident/family/caregivers about care and living environment: 4- Explain all procedures and Treatments, Medications , Results of labs/tests , Condition , All changes , Rules , Options. Monitor/document resident's feelings relative to isolation, unhappiness, anger. 5- Observe for side effects and adverse reactions of psychoactive medication: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person . Record review of CR'#1's clinical record revealed no discharge orders and no documentation of where she was discharged to , why and when she was discharged from the facility. Record review of CR #1's clinical record revealed a note titled Administrative Note dated 02/13/2023 1:08PM read in part- Had a care conference/IDT meeting with Physician on 2/13/2023 per telephone. DON, ADON, SSD, and Administrator was on the phone with physician. IDT team determined to suggest behavioral hospital may help resident. Also, to speak to psychiatrist to reach out to collaboration physician to receive more feedback for facility. In an interview with the facility's Social Service Director on 06/14/2023 at 11:20AM, she said CR#1 was discharge to a personal care home. She said CR #1 was having behavioral problem and was sent to a local psychiatric hospital. She described CR#1's behavior was talking to herself, walking around the facility, and talking to other residents not to take their medication. She said CR#1 was not hurting herself and not hurting anyone. She said the behavior on 02/13/23 was her usual behavior. She said CR#1 was discharge from the hospital to an assisted living. She said the assistant living was a licensed facility. She provided the name and phone # to a local assisted living facility. She said she verify verified and the facility was a licensed facility During an interview with the DON on 06/14/2023 at 2:00PM, she said she was out sick during the time of CR #1's discharged but remember being called about the resident's behavior. She said there was no documentation of when and how and where CR # 1 was sent out, but her understanding was that CR #1's physician gave the facility a phone # to the county sheriff department. The DON said the sheriff department was called due to resident's behavior of fast walking and speaking to herself and refusing her medication stating that someone was trying to kill her. The DON said she was told that the sheriff came and transfer CR # 1 to a local psychiatric hospital. The DON said the psychiatric hospital send sent CR#1 to an assisted living facility and it was her understanding that the facility was a licensed facility. The DON said she would have an in-service with staff on documentation. The DON said her expectation would be to document all activity that included CR #1's behavior, what lead to calling the sheriff department, any attempt made to assist CR#1, who took CR #1 out of the facility, to where and when. She said all information should have been documented. She said she would have an in-service with all staff. She said the nurse on duty during the time of the incident was an agency nurse. During an interview with the Facility Administrator on 06/14/2023 at 2:40PM, he said the facility did not take the CR#1 back because CR#1 was her own responsible party and the facility wanted CR # 1 to get a legal guardian before being admitted back to the facility. He said CR #1 had always wanted to go to an independent living and the facility was in the process of assisting her to get into an independent living. He said he expect to see documentation on CR #1's clinical records and was not sure who was on duty during the time of the incident. He said CR #1's physician had an emergency and may not be reachable on 06/15/2023. He provided a number to the NP that works with CR #1's physician. A phone call was made to the NP on 06/15/2023 at 2:40PM no answer message was left with a returned phone # . Phone call was made to CR#1's physician on 06/15/23 at 2:43PM. No answer; a message was left. During a phone conversation with the sheriff department on 06/15/2023 at 3:30PM, the Sheriff department said their function was to respond to calls from the community and assist individuals in need of assistance. She said if the resident was in crisis, they will transfer the resident to the psychiatric hospital or hospital. She said in this case the resident might have been transferred to a psychiatric hospital. She looked up resident's information and said CR #1 was transported to a local psychiatric hospital. Record review of the Facility's policy titled Criteria for Transfer and Discharge read in part: It is the policy of the facility that each resident will remain in the facility and not transfer or discharge unless the discharge or transfer is appropriate as per the existing criterial . When the facility transfers or discharge a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and the appropriate information is communicated to the receiving health care institution or provide.

Based on observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpster's reviewed in that: Two of the dumpster side doors were open. This failure could place residents at risk for infection and a decreased quality of life due to an exterior environment which could attract flying pests, rodents, and animals. The Findings included: Observation on 9/27/2022 at 9: 14 AM of the outside of the kitchen area revealed 2 dumpster side doors were open. Observation on 9/28/2022 at 11:31 AM of the outside of the kitchen area revealed 2 dumpster side doors were open. Interview on 9/28/2022 at 11:33 AM with the Dietary Manager, stated dumpster 1 and 2 side doors were open. The dietary manager stated all staff come out to dump garbage but forget to close the side doors. He stated he will in-service staff to make sure the dumpster doors are closed. Record review of the facility policy Environmental Services (no date) revealed All garbage will be disposed of daily and as needed throughout the day. 1. if waste container is the type with doors, doors should remain closed if not in use. 2. All dumpsters' lids and doors shell be closed .at all times.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 8 (Resident's #13, #43, #194) residents with advanced directives in that: 1. Resident #13's advanced directive of full code was not care planned. 2. Resident #43's advanced directive of full code was not care planned. 3. Resident #194's advanced directive of full code was not care planned. This failure could place all residents that had a right for advanced directive and could result in misunderstandings with the staff on residents' choices. The findings included: 1. Record review of Resident #13's face sheet dated 9/30/2022 revealed he was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's 5-day MDS (minimum data set) revealed section C Cognitive Patterns was a 11/15 on his BIMS score, indicating cognitively intact. Record review of Resident #13's care plan dated 8/1/2022 revealed no care plan for advanced directive. Interview on 9/29/2022 at 3:02 PM with the SW stated, she did not see the advanced directive for Resident #13 in his care plan. The SW stated the interdisciplinary team meeting were responsible for resident care plans. The SW stated that each discipline needed to input information about resident. 2. Record review of Resident #43's face sheet dated 9/30/2022 revealed she was admitted on [DATE] and readmitted on [DATE] revealed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #43's care plan dated 9/26/2022 revealed no care plan for advanced directive. Record review of Resident #43's [NAME] MDS dated [DATE] revealed section C Cognitive Patterns was a 05/15 on his BIMS score, indicating severely impaired. Interview on 9/29/2022 at 3:27 PM with the SW, she stated she did not see Resident #43's advanced direction full code in her care plan. 3. Record review of Resident #194's face sheet dated 9/30/ revealed he was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #194's significant change MDS dated [DATE] revealed section C Cognitive Patterns indicated he was severely impaired. Record review of Resident #194's care plan dated 9/3/2022 revealed no care plan for advanced directive. Interview on 9/29/22 at 3:35 PM with the SW, she stated she did not see Resident #194's advanced directive full code in his care plan. Interview on 9/29/2022 at 4:19 PM, the Administrator stated the SW, and the IDT team were responsible, for ensuring the resident care plans had advanced directive of resident choice and right. Record review of the facility Policy on Advanced Directives for Car Plan review dated 7/2017 revealed It is the policy of this facility to inform each resident upon move-in, of their right to implement Advanced Directive. 4 A copy of each residents' Advance Directive will be kept in the resident's medical record. Comprehensive person-centered care planning- A initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Citation Text for Tag 0584, Regulation FF11 [NAME], [NAME] R. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 rooms (Room 217) reviewed for safety and sanitation in that: Resident Room 217 window blind was broken, overhead lamp was missing one light bulb, wall near the headboard had and exposed wall electrical socket, and the wall near the headboard had numerous scratches and damage to the sheet rock. These failures could place the residents at risk for a diminished quality of life. The findings included: Observation on 9/28/22 at 11:00 AM of Room 217 revealed: broken window blind, wall near bedside headboard had exposed plaster and electrical wall socket was not covered with plaster. The wall behind the bed board needed painting and repairs due to numerous scratches to the sheetrock. There was a missing light bulb in the overhead light lamp. During an interview on 9/28/22 at 11:00 AM, Resident #49 in room 217 was alert and not oriented and could not provide any responses to direct questions involving the physical environment of the room. During an interview on 9/28/22 at 11:01 AM with the DON, she revealed that, there was a broken window blind, wall near bedside headboard had exposed plaster and electrical wall socket was not covered with plaster. The wall behind the bed board needed painting and repairs due to numerous scratches to the sheetrock. There was a missing light bulb in the overhead light lamp. The DON also revealed that staff assigned to Angel Rounds were responsible to check on the environment and submit work orders to the Maintenance Director. [She provided no explanation for the environmental issues found in room 217.] During an interview on 9/28/22 at 11:14 AM with the Maintenance Director, he stated the walls and window screens should not be that way .it is their (residents' homes) .staff making rounds have not reported these issues noticed in room 217 to me . He stated that the window blinds would be immediately replaced with a new one. The wall would be repaired and painted. The Maintenance Director revealed there was no overall maintenance policy instead the facility used the TELS (technology-based system for delivering life safety) computer system for monitoring the maintenance of the facility. The Maintenance Director was responsible for the environmental safety and repair of the facility. During an interview on 9/28/22 at 12:23 PM with the Administrator, he revealed that facility had a guardian angel round system where the environment was checked every day and work orders were sent to the Maintenance Director for repairs; and environment issues were discussed at morning meetings. The Administrator added that he made environment rounds in the morning and evening. The Administrator stated that he had no excuse for the environmental issues found in room 217. The Administrator revealed there was no overall maintenance policy instead the facility used the TELS computer system for monitoring the maintenance of the facility. The Administrator revealed that he expected staff assigned as Guardian Angels to observe the homelike and physical appearance of rooms and to report needs for repair to the Maintenance Director. Record review of facility Unit log for the month of September 2022 did not reveal a work order for room 217. Record review of facility's Guardian Angel round assignments revealed Guardian Angels rounds were documented for the month of September 2022; no information documented on the environmental issues in room 217 Record review of facility's policies, some dated and others not dated, did not reveal an overall policy on the maintenance of the facility.

Based on observations, record review, and interviews, the facility failed to store all drugs and biologicals in locked compartments in 1 of 8 medication storage carts (2nd Floor East Wing Nurses' Medication Cart) observed for drug security in that: The 2nd Floor East Wing Nurses' Medication Cart was left unattended and unlocked in the pass-through area between the common dining and activities area and the hallway to resident rooms. This failure could place all residents who have medications in the 2nd Floor East Wing Nurses' Medication Cart at risk for lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. The findings included: In an observation on 9/27/22 at 12:31 PM, the 2nd Floor East Wing, the Nurses' Medication Cart was observed unlocked and unattended in the pass-through area. The medication cart was full; contained many prescription and over-the-counter medications for a multitude of residents. This area was used by all staff, residents, and visitors as means to access the main common area that included the dining and activities area to resident rooms. Staff, residents, and visitors were observed in the immediate area. In an interview on 9/27/2022 at 12:31 PM, LVN B stated the cart was unlocked and unattended. LVN B stated the cart was her responsibility. LVN B stated it was the facility policy not to leave carts unlocked. LVN B stated she did not intend to leave it unlocked. LVN B stated, she had left it unlocked when she was distracted obtaining supplies per resident request (a straw during mealtime). LVN B stated it had been left unlocked and unattended for less than 5 minutes. LVN B stated a negative outcome could occur if a medication were ingested inappropriately by any person. In an interview on 9/27/2022 at 4:30 PM, the DON stated medication carts were to be secured at all times when not actively in use. The DON stated staff responsible for medication carts, such as nurses and medication aides were trained not to leave the carts unlocked when not in use. The DON stated she had already started an In-servicing to all staff on duty that might be responsible for a medication cart. Record review of an undated policy entitled Medication Storage in the Facility, revealed the policy was medication and biologicals are stored safely and securely. Procedures included: b.) Medication rooms, carts, and medication supplies are locked or attend by persons with authorized access. In a record review of an In-service Attendance Record dated 9/27/2022 with a subject of Medication carts should be locked when not in use. Narcotics should be locked behind two key access. Included the above policy on Medication Storage in the Facility and 5 staff signatures.

Based on interview and record review the facility failed to incorporate the recommendations from a PASARR (Preadmission Screening and Resident Review) evaluation report into a resident's assessment, care planning, and transition of care for 1 of 1 resident (Resident #1) reviewed for PASARR services. The facility failed to submit and obtain approval for the NFSS (Nursing Facility Specialized Services) authorization request for PT and ST for Resident #1, per PASARR recommendations made at the IDT (Interdisciplinary Team) meeting held on 10/13/2021 in the required timeframe. This failure could place residents at risk of not receiving specialized PASARR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental and psychosocial well-being. Findings include: Record review of Resident #1's, undated, face sheet revealed she was a [AGE] year old female with an initial admission to the facility on [DATE] and readmission on 3/15/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's admission MDS Assessment, dated 9/27/21, revealed a BIMS of 15/15, which indicated the resident was cognitively intact. Further review revealed Resident #1 required extensive Physical 2-person assistance for bed mobility, walk in room, walk in hallway, locomotion on and off unit/room, dressing, toilet use, and transfer. The resident required setup help only for eating. Record review of a screen shot of the error message on the TMHP portal revealed 3 lines of activities, dated 10/26/2021, 3/22/2022, 3/22/2022, all 3 entries showed with status of Form Not Accepted. Interview with the facility's Director of Rehab on 4/7/2022 at 3:42 PM, she said she was the person responsible of submitting NFSS requests to the TMHP portal. She was not able to get the NFSS request submitted due to issues with Resident #1's identifying information, such as last name, she tried to separate the last name or submit it as one word, the system would not accept it. She said she tried to submit the form on 3/22/2022 and it was still giving her the same error message. Interview with the MDS Nurse on 4/14/2022 at 9:57 AM, she said the Director of Rehab was not in the facility, she would try to help get information regarding the TMHP transmission summary. She said they utilized a third-party service for TMHP submission, and she believed the attempted submissions came back with errors. She asked if surveyor could get the error resolved, surveyor said it would be a discussion with their IT or the third-party provider. Interview with the Administrator on 4/14/2022 at 11:03 AM, he said he wanted to clarify they had 20 days after the IDT meeting for submission. Record review of the facility's, undated, PASARR policy revealed in part .A PASRR shall be completed on every resident upon admission. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR. Social services shall contact the appropriate State Agency for referral of specialized care and services the resident may require .

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 facility units reviewed for home like environment. -The facility failed to maintain hot water temperatures on the two east memory care unit in rooms 227, 230, 231 and shower room This deficient practice placed residents at risk of decreased quality of care. Findings included: Record review of the two east maintenance repair logbook dated June 2021 and July 2021 did not have hot water concerns. Observations on 07/15/2021 with the Maintenance Director at the following times revealed the following hot water temperatures on the memory care unit: 8:55AM room 227 with 2 non interviewable residents the hot water temperature was 70.5 degrees after running 4 minutes; 9:10AM room 230 with 1 non interviewable resident the hot water temperature was 71.1 degrees after running 5 minutes; 9:27AM room 231 with 2 non interviewable residents the hot water temperature was 71.4 degrees after running 4 minutes; 9:41 AM Two East shower room hot water temperature was 89.4 degrees after running 6 minutes. In an interview on 07/15/2021 at 9:45AM with the Maintenance Director he stated these hot water temperatures were not dangerous to the resident, but the required range was 100-110 and these temperatures were not in the required range, He stated it was possible the failure occurred because we recently changed boilers and we had interruptions in the software program. He stated the boiler was under warranty and he will contact the company to have it checked. The maintenance director continued and stated the water temperatures were checked weekly and there was no identified problem before. The Maintenance Director stated there were two ways for staff to notify maintenance of the need for a repair. They can document in the maintenance log bok which is monitored daily or we can be notified during the morning meeting. There had not been any recent notifications of a problem with the hot water. In an interview on 07/15/2021 at 9:50AM with LVN A she stated she thinks the hot water was too cold in some rooms. She stated she had not notified maintenance of the cold water. In an interview on 07/15/2021 at 9:58AM with CNA B she stated it could take a while for the water to get warm. She stated she did not remember reporting the issue. In an interview on 07/15/2021 at 10:05AM with CNA C she stated it takes a long time for the water to get warm. She starts to run the water when she arrives on the floor in the morning to get it warm. CNA C stated she did not report this. In an interview on 07/15/2021 at 10:15AM the Administrator stated he thinks the failure may have occurred due to the new boilers that were installed and the staff's failure to report when the notified a problem. The administrator stated any staff member can report any maintenance problem and these hot water temperatures were too cold. Record review of Hot Water Temperature Policy revised dated 05/2007, read in part .standards for water temperatures: 100 degrees F, minimum - 110 degrees F maximum .

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers (injuries) received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection based on the comprehensive assessment for one (Resident #24) of two residents reviewed for pressure injuries. The facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #24 was administered the full dose of Juven (supplement for wound healing) as ordered by physician. The facility failed to monitor Resident #24 's [MEDICATION(S)] levels to determine if within normal range. This failure placed the two residents, who had pressure injuries, at risk for wound deterioration and infection. Findings include: Record review of Resident #24's clinical record revealed a [AGE] years old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further noted history of [CONDITION(S)] and [CONDITION(S)]-resistant staph aureus (MRSA) infection. Record review of Resident #24 's weekly wound physician notes dated 5/03/21 read in part, a thorough wound care assessment/evaluation was performed. Sacral wound size 8.9 x 10.9 x 1.4 cm, stage IV with moderate serous exudate, sloughing 30%, granulation 60%. Indication for surgical excision debridement procedure was performed, to remove the necrotic tissue and establish the margins of viable tissue. Further noted stage IV, Lt heel wound size 3 x 4 x 0.4 cm, and Rt heel wound size 1 x 1 x 0.4 cm. Record Review of Resident #24's minimum data set (MDS) assessment dated [DATE] revealed he was totally dependent on staff for most ADLs and required 1-2 persons assist. A total BIMS score of 6, indicating cognitively impaired. Further noted he had stage IV pressure ulcers and treatments included turning or repositioning program, nutrition and hydration intervention to manage skin problems and pressure ulcer care. Record review of Resident #24's Braden Scale for Predicting Pressure Sore Risk dated 4/27/21 revealed a Braden score of 12 indicating High Risk for developing pressure sores. Record review of nurse's progress notes dated 7/05/21 revealed Resident #24 completed the oral antibiotic therapy, for bacterial infection. Further review noted contact isolation precautions was discontinued on 7/05/21, for wound MRSA. Record review of care plan dated 4/27/21 revealed Resident #24 with stage IV pressure ulcers on the sacrum, Lt heel and Rt heel due to disease process and immobility, incontinent of bowel. Administer treatments as ordered and monitor for effectiveness. Encourage good nutrition and hydration. Prostat and Juven supplement as ordered. Assess or monitor wound healing, abnormal lab values, report results to MD and follow-up as indicated. Interventions noted he needs assistance to turn or reposition, avoid positioning on pressure points, float heels. The goal was that his pressure ulcers will show signs of healing and remain free from infection by review date. Observation and interview on 7/13/21 at 8:00 am revealed Resident #24 was lying approximately 35 degrees on his back on low air mattress, no float heels with tube feeding via gastrostomy (G-tube). A foley catheter was in place. Further observed at 8:35 a.m., 9:40 am., 10:35 am., 11:30 am., 12:20 pm., 1:30 pm surveyor observed Resident lying in bed with an air mattress, positioned on his back and heels not offloaded. Observation and interview on 7/14/21 at 11:00 am revealed Resident #24 yelling out while staff turning him for wound care. ADON B/ wound nurse stated it would be difficult to turn and conduct his wound care if he was not pre-medicated for pain due to generalized, chronic pain. She said she took the wound nurse position over 2 weeks ago and recent ADON (B) position for 200 hall. Observation and interview on 7/14/21 at 11:00 am revealed ADON B conducted wound care to Resident's stage IV, sacral wound measured 8.5 x 9 x 0.5 cm. ADON B stated her description of the sacral wound with moderate purulent discharge and slight foul odor with 30 % sloughing. She stated she would follow-up on his wound and inform MD. Observed ADON B cleansed the wound with saline, pat dried, applied collagen powder and calcium alginate with silver to wound bed and covered with absorptive dressing per MD order. She stated wound MD conducted weekly rounds and debrided his sacral wound two days ago due to necrotic tissue present. Interview on 7/14/21 at 2:00 pm ADON A stated she was assigned to hall 300. She acknowledged the staff did not turn the Resident every two hours like they were supposed to. She said will move him closer to the nurses station, since his room located at the end of hall 300, far from the station. She added the Resident should not remain in lying supine, but he had to be to be repositioned at least every 2 hrs. She said will conduct a referral for P.T rehab to provide him positioning devices like pillow wedges, float heels or body pillow to offload pressure wounds. Record review of Resident #24 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Turn and reposition every 2 hrs and as needed while in bed. Use pillows for positioning and offloading pressure wounds. Record review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further noted he only consumed 50 % amount of Juven packet or half the dose and noted four times supplement was refused. Interview on 7/14/21 at 2:30 pm LVN A stated the MAs had not told her Resident could not consume full dose of Juven supplement as ordered by physician. She said the Resident required tube feeding since he resist eating, on pleasure tray meals. She stated he did not like to drink water, but preferred coke. LVN A stated Resident pressure wounds Lt and Rt heels were done by night nurse, since prior we did not have a wound care nurse. Interview on 7/15/21 at 11:30 am MA B acknowledged next time MAs need to communicate with charge nurse, since the Resident could not consume a full dose of Juven supplement by mouth as ordered. She stated adequate size cups were also not available in the unit, and Juven packet should be mixed with at least 240 ml-300 ml water. She said he did not like to drink water and staff had to be patient with him. Interview on 7/15/21 at 11:30 am DON stated will ensure appropriate size cups were readily available in the unit, since Juven should be mixed with adequate amount of liquids 8 oz or 10 oz=300 ml water. She stated will reach out to the dietician and MD regarding alternative options to increase his supplement consumption for wound healing. DON stated the Juven should have been given via G-tube since he could not consume full dose of Juven by mouth (oral). Interview on 7/15/21 at 11:45 am Dietician stated she hoped staff had communicated and obtained an MD order for his Juven supplement given via G-tube, not orally by MAs. She stated Juven should be mixed with adequate amount of 300 ml water and for him to get the full dose had to be given via G- tube. She said she recommended Resident's Juven packet for wound healing and was a substitute for the [MEDICATION(S)] packet she recommended for his wound healing. Interview on 7/15/21 at 11:45 am Dietician stated Resident had low [MEDICATION(S)] level=2.9, date on 6/15/21 (normal range=3.5 - 5.4) and stage IV pressure wounds. She stated she will re-assess his protein needs today, by providing 1.5 - 2 gm /protein/kg and increase his tube formula if needed including his protein supplement Prostat and the Juven via G-tube for wound healing. She stated she was in the facility only twice a month or as needed. Interview on 7/15/21 at 12:00 pm DON stated will educate staff on reporting including resident's refusals. She stated that she was new to the facility as interim DON. She added staff need to be attentive to follow-up and inform DON to get those changes to their plan of care. Record review of Resident #24 's weekly wound physician notes dated 7/12/21 read in part, a thorough wound care assessment/ evaluation was performed. Sacral wound size 6.0 x 5.0 x 0.3 cm., stage IV wound progress: no change. The indication for surgical excisional debridement procedure was performed, to remove the necrotic tissue and establish the margins of viable tissue. Further noted wound progress: improved stage IV, Lt heel wound size 1.0 x 2.0 x 0.3 cm, and Rt heel wound size 2.0 x 1.5 x 0.3 cm. Further noted factors complicating his wound healing, diabetes mellitus II. Record review of facility provided policy, titled Pressure Ulcers dated May 2007, read in part, facility provides care and services to promote the healing of pressure ulcers that are present, include prevention of infection to the extent possible. Resident assessment identify risk factors such as impaired mobility, co-morbid conditions . resident refusal of some aspects of care and treatment, exposure of skin to urine or fecal incontinence, malnutrition and hydration deficits. Stabilize, reduce or remove underlying risk, monitor impact of interventions and modify interventions as appropriate . repositioning, pressure relieving devices, heel protectors, friction and shear prevention. Assess, treat and monitor pain.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for two (CR#1 and CR #2) of eleven residents reviewed for neglect in that: The facility failed to appropriately verify LVN A's nursing license when she was hired on 03/29/2018. LVN A had stipulations on her license that required her to work under the supervision of another licensed nurse. The facility failed to ensure nursing stipulations were followed once they became aware of the stipulations on LVN A's license. LVN A was a charge nurse on a hall with 22 residents without supervision of another nurse. LVN A failed to assess CR#1 when he was found to have blood in his indwelling catheter bag LVN A failed to consult the physician when CR #1 had a change in condition, which contributed to delay in care and treatment. He was admitted to a local hospital and placed in ICU with [DIAGNOSES REDACTED]. LVN A failed to report to oncoming nursing staff the change in CR#1's condition LVN A failed to appropriately assess CR#2 when he had slurred speech and shortness of breath LVN A failed to consult the physician when CR #2 had a change in condition when he exhibited slurred speech and shortness of breath, which led to a delay in care. CR #2 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 07/11/2018. While the IJ was lowered on 07/15/2018, the facility remained out of compliance at a severity level of Actual harm that is not immediate jeopardy and a scope of pattern due to needing to train staff and monitor their implementation of the Plan to Lower the Immediate Jeopardy. These failures affected 2 residents and had the potential to affect 19 additional residents at the facility who were cared for by LVN A, placing them at risk of not having needs met which could result in injury or harm. Findings Included: Record review of LVN A's license online from the Board of Nurse Examiners revealed the following which read in part . License Type: LICENSED V[NAME]ATIONAL NURSE Resides in: TEXAS CITY TX Issued on: 7/7/2009 Licensure Status: CURRENT - 9/30/2019 Compact License: NO Current Disciplinary Action: REPRIMAND W/STIPS - 11/10/2015 Record review of online of Board of Nurse Examiners findings with an effective date of 09/11/2012 read in part . On or about (MONTH) 19, 2010, while employed as a private duty nurse with Home Health, in Jefferson, Texas, Respondent abandoned Patient (Medical Record Number), by leaving her at home alone, unsupervised. Respondent's conduct was likely to injure the patient in that leaving the nursing assignment could have resulted in the patient not getting the care that he needed, and placed the patient at risk for injury due to lack of adult supervision. In response to the incident in Finding of Fact Number Seven (7), Respondent states that she did in form the grandmother of patient (Medical Record Number) that she had to leave at 5:30p.m. to pick up her daughter from a park across town. Respondent was loading her bags into the car when she saw the patients grandmother pull into the driveway and made eye contact prior to leaving. The patient was asleep in his hospital bed. Feedings had been administered and his diaper was clean and dry. Then at 5:45, as she was leaving the park, she received a call from staff at the Home Health company saying RP called at 6:06p.m, stating that her grandchild had been left alone. The evidence received is sufficient cause pursuant to Section 30 l.452(b), Texas Occupations Code, to take disciplinary action again. Vocational Nurse License Number ------, heretofore issued to LVN A, including revocation of Respondent's license(s) to practice nursing in the State of Texas. IT IS THEREFORE AGREED and ORDERED, subject to ratification by the Texas Board of Nursing, that RESPONDENT SHALL receive the sanction of a WARNING WITH STIPULATIONS, and RESPONDENT SHALL comply in all respects with the Nursing Practice Act, Texas Occupations Code, §§301.001 et seq., the Rules and Regulations Relating to Nurse Education, Licensure and Practice, 22 TEX. ADMIN. CODE §211.1 et seq. and this Order. RESPONDENT SHALL notify each present employer in nursing of this Order of the Board and the stipulations on RESPONDENT'S license(s). RESPONDENT SHALL present a complete copy of this Order and all Proposals for Decision issued by the Administrative Law Judge, if any, to each present employer within five (5) days of receipt of this Order. RESPONDENT SHALL notify all future employers in nursing of this Order of the Board and the stipulations . RESPONDENT SHALL be supervised by a Registered Nurse, if licensed as a Registered Nurse, or by a Licensed Vocational Nurse or a Registered Nurse, if licensed as a Licensed Vocational Nurse, who is on the premises. The supervising nurse is not required to be on the same unit or ward as RESPONDENT, but should be on the facility grounds and readily available to provide assistance and intervention if necessary. The supervising nurse shall have a minimum of two (2) years' experience in the same or similar practice setting to which the Respondent is currently working. RESPONDENT SHALL work only regularly assigned, identified and predetermined unit(s). RESPONDENT SHALL NOT be employed by a nurse registry, temporary nurse employment agency, hospice, or home health agency. RESPONDENT SHALL NOT be self-employed or contract for services. Multiple employers are prohibited. Record review of LVN A's online Board of Nurse Examiners findings with a date of 09/03/2015 revealed the following stipulations which read in part . On or about (MONTH) 11,2012, Respondent was issued the sanction of WARNING WITH STIPULATIONS by the Texas Board of Nursing On or about (MONTH) 12,2014, while employed at a nursing home in Texas City, Texas Respondent was non-compliant with the Agreed Order issued to her on (MONTH) 11, 2012, by the Texas Board of Nursing. Noncompliance is the result of Respondent's failure to notify her employer of this Board Order. COMPLIANCE WITH PRIOR ORDER .The Order of the Board issued to RESPONDENT on (MONTH) 11, 2012 is still in effect in its entirety and RESPONDENT SHALL be responsible for completing the terms of that Order. Interview with Administrator on 07/06/2018 at 2:00PM, he said that he and the Director of Nurses (DON) had found out a few days ago prior to the incident with CR#1 that LVN A had stipulations on her license. Administrator said he was not sure of the day but said it was just a few days ago and he found out because LVN A had slid paperwork under the DON's office door that said she (LVN A) had license stipulations. Administrator said he notified the Board of Nurses and they said it was ok for her to work and she had previously worked at another facility where she failed to disclose that she had stipulations on her license. Administrator said the incident involving CR#1 occurred a few days after he and the DON found out about LVN A's stipulations and she was going to be fired but they have had a hard time reaching her by phone to terminate her. Administrator did not disclose what the stipulations were and what they were for. Interview with the Director of Nurses (DON) on 07/06/2018 at 7:15PM, she said that she found out that LVN A had licensure stipulations because she slid a letter from the board under her (DON) door and she found it when she opened the door and informed the Administrator shortly after. DON said the Board of Nurses was called and said she could still work. DON said LVN A was fired following a lack of assessment and not notifying the provider of a change in condition. DON said she has not terminated the nurse yet as she has not been able to reach her by phone but that she will be terminated. In an interview with DON on 07/09/2018 at 5:45PM, she said she remembered when she found out about the nursing stipulations and it was on 07/03/2018. DON verified LVN A did work on 07/04/2018-07/05/2018 and had acted as a charge nurse on occasion and she was responsible for her own residents. Interview with ADON C on 07/09/2018 at 7:00PM, she said that there is always 2 nurses working every shift on the 3rd floor. ADON C said she did not work with LVN A the night CR #1 had blood in his catheter bag. ADON C said she has worked with LVN A prior but did not work with her the night of 07/04/2018. ADON C said that each nurse on the floor is responsible for their own residents. ADON C said that LVN A did not report to any other staff and she was unaware of any stipulations on her license and that LVN A was in charge of her own residents. Interview on 07/09/2018 at 7:15PM with Regional Nurse, he said that LVN A was hired when the facility had no Administrator and no DON. Regional Nurse said that the Operations Manager was responsible for hiring LVN A. Regional Nurse said the facility was short on staff so the Operations Manager started hiring people. Interview on 07/09/2018 at 3:00PM with DON and Administrator, they said that LVN A was terminated on 07/06/2018 after surveyor had left facility. Interview with DON on 07/11/2018 at 12:10PM she said that the facility had not audited all employee records to see if there are any other employees with license stipulations. Interview with Human Resource Coordinator on 07/12/2018 at 12:35PM she said that she had employed by the facility for 2-3 months. Human Resource Coordinator said she performs background checks on new hires and has done so since she started working at the facility. Human Resources Coordinator said that if any background check issues come up she refers to the DON, and the administrator. Interview with DON on 07/12/2018 at 1:01PM, she said all employee records had been audited and 2 staff were found that had previous stipulations on them that have since been resolved and 1 current Registered Nurse (RN) T who currently has stipulations. DON said they were aware that RN T had stipulations when they hired him and that he does not work as a charge nurse and only works when another RN is on duty. Record review Of RN T license online from the Board of Nurse Examiners revealed the following which read in part . License Type: REGISTERED NURSE Resides in: GALVESTON TX Issued on: 8/31/1990 Licensure Status: CURRENT - 5/31/2019 Compact License: NO Current Disciplinary Action: SUSPEND/PROBATE - 7/21/2016 Record review of online RN T's Board of Nurse Examiners findings dated 09/09/2009 read in part . On or about (MONTH) 29,2008 while employed with a hospital as a Registered Nurse in Webster, Texas, Respondent Misappropriated [MEDICATION NAME] and [MEDICATION NAME] belonging to the hospital and patients thereof or failed to take precautions to prevent such misappropriation. Possession of [MEDICATION NAME] or [MEDICATION NAME] without a prescription is prohibited. Respondents conduct was likely to defraud the facility and or its patients of the cost of medications On or about (MONTH) 29, 2008 the Respondent engaged in the use of [MEDICATION NAME] as his urine specimen for drug screen was positive for [MEDICATION NAME]. The use of [MEDICATION NAME] by a Registered Nurse while on duty could impair the nurses ability to recognize subtle signs or symptoms or change in condition CR #1 CR #1 was admitted to the facility with an initial date of 06/23/2015 and a readmission date of [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. He was transferred to a local hospital on [DATE]. Record review of the Annual Assessment Minimum Data Set (MDS) for CR #1 dated 04/07/2018 revealed a Brief Interview of Mental status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS further revealed that CR #1 required extensive assistance with one-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. MDS revealed CR #1 had an indwelling catheter and was frequently incontinent of bowel. Record review of Care Plans for CR #1 revealed the following care plans which read in part - History of chronic urinary tract infections [MEDICAL CONDITION] related to obstructive and reflux [MEDICAL CONDITION] initiated on 05/08/2017 with a revision date of 05/08/2017. Interventions-Encourage adequate fluid intake, monitor/document/report to physician as needed (PRN) for signs and symptoms of UTI: Malaise, nausea and vomiting, altered mental status, hematuria, cloudy urine, behavioral changes and loss of appetite. Obtain and monitor lab work as ordered. Report results to physician and follow up as indicated. - Activities of Daily Living (ADL) self-care performance related to cerebral infarct, limited mobility, impaired balance and Dementia initiated on 07/27/2015 and revised on 02/24/2018. Interventions-Requires extensive assistance with toilet use with 1 staff participation, transfer requires extensive assistance with 1 staff, bed mobility requires extensive assistance with 1 staff and dressing requires extensive assist with 1 staff participation. - Impaired cognitive function/dementia or impaired thought process related to cerebral infarct initiated on 07/27/2015 and revised on 04/20/2018. Interventions- Keep routine consistent, monitor/document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. - At risk for communication problem related to hearing deficit and slurred speech with low tone 07/27/2015 and revised on 02/24/2018. Interventions- Be conscious of resident position in groups, activities, dining rooom to promote proper communication with others. Encourage resident to continue stating thoughts even if resident is having difficulty. Ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position, avoid isolation. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Record review of CR #1's active Clinical Physician order [REDACTED]. - Indwelling catheter output every shift dated 06/19/2018 with a revision date of 06/20/2018. Record review of CR #1's Medication Review Record (MAR) dated 06/01/2018-06/30/2018 revealed the following orders: - Urine analysis/culture and sensitivity (UA/C&S) one time a day starting on the 1st and ending on the 1st every month for standing order to monitor for UTI, order date 05/01/2018. - Foley Catheter output every shift, three times a day, order date 06/19/2018. - Monitor/Record/Report to MD for any signs and symptoms of UTI: pain/discomforts, burning, blood tinged urine, cloudiness, scanty, or no urinary output, dark urine, color, high temp, chills, altered mental status, changes in behavior, changes in eating pattern, foul smelling urine. Order date of 05/20/2017. Record review of CR #1's Physician order [REDACTED]. - Monitor/Record/report to MD for any signs and symptoms of urinary tract infection [MEDICAL CONDITION]: Pain/Discomforts, burning, blood tinged urine, cloudiness, scanty or no urinary output, dark urine color, high temperature, chills, altered mental status, changes in behavior, changes in eating pattern, foul smelling urine. Date order initiated 05/20/2017. - UA/C&S one time a day starting the first and ending on the first every month for standing order to monitor for UTI. Date order initiated 05/01/2018 with a start date of 06/01/2018. Record review of CR #1's Medication Administration Record [REDACTED] - UA/C&S one time a day starting on the 1st and ending on the 1st every month for standing order to monitor for UTI. Order date 05/01/2018. - Foley catheter output every shift three times a day. Order date 06/19/2018. Record review of documentation labeled Investigation Into Events on 07/04/2018 with LVN A and CR#1 dated 07/05/2018 provided by DON read in part . Documentation revealed that resident pulled on his catheter at dinner time 07/04/2018 and blood was noted to be draining from his cath tube. No change of condition completed, no notifications made, not reported to oncoming nurse. Assistant Director of Nurses (ADON) arrived to facility and Nurse Educator made ADON aware of blood in cath bag. ADON promptly notified the provider and received orders to send out. ADON attempted to call spouse multiple times, spouse returned call and was made aware of situation. ADON assisted Emergency Medical System (EMS) out of the building at 8:03AM. DON spoke with spouse and spouse relayed information that resident had lost lots of blood and was also septic. Provider had concern that resident lost copious amounts of blood with the delay in care. Resident is in the Intensive Care Unit (ICU) with fair outlook. DON and Executive Director (ED) discussed findings from investigation completed by DON regarding LVN A and the shift she worked on 07/03/2018-07/04/2018. Investigation into CR #1 revealed gross negligence on LVN A as she noted that resident had pulled his catheter which resulted in frank blood to drain from his catheter. LVN A failed to follow the facility policy on Change of Condition to alert other staff to this significant change and initiate follow-up. LVN A also failed to notify family nor provider of the trauma and did not chart on him for the rest of the night, indicating she was not monitoring the resident. LVN A's actions caused the resident to endure suffering and required the day nurse to send him out via ambulance to the emergency room (ER). CR #1 is now in ICU with a fair probability of survival. Had LVN A followed the policy for a change of condition, CR #1 would not have experienced these events. Executive Director and DON determined LVN A is a threat to the other residents in this facility and is termed for gross negligence. Record review of nursing note for CR#1 written by LVN A on 07/05/2018 at 5:39AM read: During dinner Resident yanked on his foley catheter. Resident is urinating dark red blood. Urinary bag changed. Bag intact and urine is flowing. Resident had one episode of vomiting and diarrhea on this shift. Will continue to monitor. Record review of CR #1's nurse note written by ADON B on 7/5/2018 at 7:20AM read in part . Called to resident's room, noted certified nurse aides (CNA)x 2 providing care. Noted dark red blood in catheter tubing, and drainage bag. resident complained of needing to have a BM, no visible feces noted at rectum. Complained of needing to urinate. No abdominal distention noted. Vital Signs: Blood Pressure (BP) 80/40, Respirations (R) 20, Apical Pulse (AP) 64, Peripheral Capillary Oxygen Saturation (SPO2) 92% on Room Air (RA). Notified Physician, Verbal Order to Send to emergency room (E.R) via 911. Called 911, information provided to operator. DON and Administrator/Executive Director notified. Record review of hospital medical records for CR#1 revealed the following records which read in part: emergency room physician notes dated 07/05/2018 at 9:03AM- Chief Complaint- Blood in urine Onset occurred-Today Severity: Onset-Moderate Severity: Current-Moderate Associated Other: [MEDICAL CONDITION] Clinical Impression: Primary- Hematuria (blood in the urine) Secondary Impressions- [MEDICAL CONDITION], Leukocytosis,[MEDICAL CONDITION] (Bacteria that has entered into the bloodstream and/or tissues) Record review of hospital physician notes dated 07/05/2018 by hospital internist read in part . Indwelling catheter present with sediment as hematuria. Upper urine is clear now. He had hematuria yesterday. He has dried blood in the perineal and groin area without active bleeding. Assessment and Plan: 1. Septic shock status [REDACTED]. 2. Urinary tract infection complicated in a patient with chronic indwelling catheter. The indwelling catheter has been changed. The patient was given [MEDICATION NAME] and [MEDICATION NAME] yesterday and started on [MEDICATION NAME] and [MEDICATION NAME], which will be continued. 3. Acute kidney injury. Renal consult obtained. The patient has non-anion gap metabolic acidosis likely from [MEDICAL CONDITION]. Hold nephrotoxics and continue to monitor urine output. Continue to follow on IV fluids. Record review of physician notes by ICU physician dated 07/05/2018 at 3:59PM read in part . Labs were significant for a markedly leukocytosis as well as elevated blood urea nitrogen (BUN) and creatinine. Urinalysis suggests a urinary tract infection with numerous white blood cells. Lactic acid was elevated as well. Patient was administered fluids and brought to the ICU as he was noted to be mildly hypotensive. Diagnoses, Assessment & Plan: 1.[MEDICAL CONDITION] with impending shock [MEDICAL CONDITION] noted Related to urinary tract infection 2. Altered mental Status Underlying dementia Likely [MEDICAL CONDITION] as well We will continue to monitor 3. Acute Kidney injury Underlying [MEDICAL CONDITION] Continue to follow Metabolic acidosis noted Chronic urinary obstruction with chronic foley Observation and interview with CR#1 on 07/06/2018 at 2:40PM at the hospital revealed CR#1 to have intravenous line (IV) of [MEDICATION NAME] hanging along with IV antibiotics. Interview attempted at same time and CR#1 was not able to carry on a conversation and was not able to be redirected. CR#1 was talking to himself and not making any sense. Interview with CR #1's Responsible Party (RP) on 07/06/2018 at 2:30PM at the hospital, she said that CR#1 was in fair condition with acute [MEDICAL CONDITION] per the nephrologist and was in the Intensive Care Unit (ICU). RP said that the facility failed to do anything about CR#1's blood in his catheter and said that it had went on for about 12 hours before he was transferred to the hospital. RP said that she was told by staff that CR#1 had pulled his indwelling catheter at dinner time on 07/04/2018 and there was bleeding in the tubing and catheter bag but they did not do anything or transfer him to the hospital until 07/05/2018 in the morning when the day nurse came on. RP said she does not think CR#1 will recover from the delay in his care and was worried he lost to much blood. RP said that CR#1 was not communicating well and talks to himself. RP said that CR#1 had a serious infection and the hospital was having a hard time keeping his blood pressure up, so he was receiving antibiotics and an intravenous medication to assist his blood pressure. Interview with Administrator on 07/06/2018 at 2:00PM, he said that CR #1 was in the hospital due to a change of condition. Administrator said that CR #1 was sent to the hospital for blood in his indwelling catheter bag. Administrator said LVN A did not appropriately assess CR #1 after identification of blood in the catheter bag. Administrator said that LVN A was working the night shift on 07/04/2018-07/05/2018 and CR #1 had a change of condition and the physician was not notified. Record review of report dated 07/06/2018, no time noted on document provided by DON on 07/13/2018 labeled Interview conducted via phone with LVN A regarding events on the night of 07/04/2018 and 07/05/2018 read in part . LVN A made aware that she is on speaker phone and the following are present: DON Administrator/Executive Director Regional Nurse What happened the night of 07/04/2018 with CR #1? -I was told he tugged on his catheter at dinner -I went into his room and checked on him a few times Did you get vital signs? -I did when I gave him his medication cause it was required (blood pressure) Did you get any other sets of vitals? -No, I didn't What did you do when you noticed the blood? -I changed his bag and he had urine flowing -He was assisted to bed Did you go and check on him during the night? -Yes I did a few times Did you notify MD? RP? -No I didn't, they won't answer at night What about family? -I didn't call them Anything else to add? -No, not really. I should have called them. Interview with ADON B on 07/09/2018 at 5:45PM, she said that she arrived to work about 7:15AM on 7/5/2018 and the Nurse Educator said, come here and ADON B said she followed her down the hall. ADON B said there was blood in CR #1's indwelling catheter tubing and in the catheter bag. ADON B said the catheter bag was all blood and so was the tubing. ADON B said she asked the Nurse Educator to get a set of vital signs. ADON B said she then called the doctor and CR #1 was sent out via Emergency Medical Services (EMS). ADON B said CR #1's blood pressure was 80/40 when the Nurse Educator checked it. ADON B said that LVN A (night shift nurse) was gone by the time she (ADON B) arrived to work at 7:15AM. ADON B said LVN A did not mention the blood in the catheter tubing or bag in the 24-hour report and did not mention it to the oncoming nurse (ADON B). ADON B said LVN A was gone from the facility when she arrived In an interview with DON on 07/09/2018 at 5:48PM, she said that she was notified by ADON B that CR #1's catheter bag had blood in it and was hypotensive. DON was asked why did she think that LVN A did not report Resident #1's bleeding and she said that LVN A told her the provider wouldn't answer anyway. DON was asked if she knew that LVN A had been working as a Charge Nurse and she said that she was aware and that LVN A was not being supervised during shifts. DON said LVN A should not have been a Charge Nurse. Interview with ADON B on 07/12/2018 at 3:00PM she was asked by surveyor where were the monthly urinalysis and culture and sensitivity lab results for CR #1. ADON B said she would look for them and get back to surveyor. Interview via phone with LVN A on 07/12/2018 at 3:25PM, she said that after dinner and around 6:30PM on 07/03/2018, Certified Nurse Aide (CNA) D was assisting CR #1 to bed and noticed blood in the indwelling catheter. LVN A said that CNA D told LVN G about the blood in the indwelling catheter and LVN G said that it happens sometimes and to just give CR #1 some water. LVN A said she gave him a little water after 6:30PM and there was approximately <5 cubic centimeters (cc) of blood in the catheter bag. LVN A said CR #1 was alert and oriented at the time. LVN A said around 11PM that she went into CR #1's room to give him some more water and that there was only urine in the catheter tubing and no blood. LVN A said she didn't stay in the room long because CR #2 coded and she had to go deal with that. LVN A said she then went in CR #1's room at 2:30 AM on the morning of 07/04/2018 and CR #1 was sleeping, and she woke him and offered him water at that time. LVN A then said that there was no more than 20 cc's of blood in the catheter bag and CR #1 had an episode of diarrhea and he had to be changed. LVN A said she last checked on CR #1 at 5:30AM on 07/04/2018 before leaving at 6:00AM. LVN A said she did not give report to incoming nurse because she left at her scheduled time and before incoming nurse arrived and LVN G knew about the blood in CR #1's indwelling catheter bag and tubing and she was to report it to the incoming nurse and document it on the 24-hour nursing report. Record review of 24-hour nursing report for the night shift on 07/04/2018-07/05/2018 revealed that there was no documention by LVN A or any other nurse during the night shift for CR#1 regarding his indwelling catheter, blood in drainage bag or any other issues. Attempted to interview LVN G via phone and left messages on multiple occasions without success. Interview with ADON B on 07/12/2018 at 3:40PM, she said that she was able to obtain urinalysis from his urologist that had been collected on 03/06/2018 AND 04/10/2018 but could not find any results for 06/2018 or 07/2018 that should have been collected by the facility. ADON said she would continue to look. Interview with CNA D on 07/13/2018 at 2:15PM via phone, she said the shift started horrible. CNA D said she worked the night shift with LVN A. CNA D said that when she checked on CR#1 at the start of her shift his catheter bag had been emptied and there was no urine or blood. CNA D said that she was notified by LVN A at 5:30AM that CR#1 had diarrhea and that there was blood in the indwelling catheter bag. CNA D said that LVN A assisted her (CNA D) with changing CR #1's brief. CNA D said that when she and LVN A rolled Resident over to change his brief that there was vomit on his bed and CNA D said it smelled like feces and CR#1 appeared to be jaundice. CNA D said she told LVN A that CR#1 didn't look right, and he needed to be sent to the hospital but is unsure what LVN A did for CR#1 or if he was even assessed. CNA D stated that she saw LVN A empty the indwelling catheter bag which contained blood, but she could not recall how much blood. CNA D said that when CR#1's brief was changed that she noticed a scant amount of blood on the interior of the brief. Interview with CNA E on 07/13/2018 at 2:01PM, she said that she worked the day shift on 07/04/2018 and arrived to work around 6:00AM. CNA E said when she arrived she went to do her rounds and check on all the residents. CNA E said when she got to CR #1's room it was dark in the room but CR #1 was awake and she turned on the shower, so it would get hot while she went around and checked on her other residents and got them ready for breakfast. CNA E said CR #1 seemed normal and he even said to make sure the shower was hot when she came back to shower him. CNA E said that when she returned at about 6:30AM to give CR #1 his shower he was confused and not right. CNA E said that she looked at the indwelling catheter bag and noticed a lot of blood in the bag. CNA E said it was approximately 150cc's of blood in the catheter bag and said it appeared to be all blood without any urine. CNA E said she asked CNA F to get the nurse as she did not want to leave CR #1. CNA E said CR #1 has pulled on his indwelling catheter in the past and it usually causes some blood in the brief and this time there was no blood in CR #1's brief when she and CNA F checked, just in the catheter tubing and bag. CNA E said when Nurse Educator arrived at the room she assessed CR #1 and he was sent to the hospital. CNA E said that it was not reported to her from night shift CNA D that there had been blood in CR #1's catheter bag. Interview with CNA F on 07/13/2018 at 2:18PM, she said that when she went to assist CNA E on the morning of 07/04/2018 with CR #1 that she saw blood in his catheter bag and it was blood shot red. CNA E said that CR #1 has pulled on his catheter in the past and there is always blood in his brief and small amounts of blood in the catheter tubing if he pulls on it. CNA E said that when she assisted CNA F in the removal of his brief there was no blood on the brief. CNA E said that there was approximately 250cc-300cc's of blood in the indwelling catheter bag. CNA F said it looked like it was all blood and no urine in CR #1's indwelling catheter bag. CNA F said that CNA D worked the night shift and she did not report to her (CNA F or CNA E) that CR #1 had blood in his indwelling catheter bag. CR #2 Record review of face sheet for CR#2 revealed that he was initially admitted to the facility on [DATE]. CR#2 was a [AGE] year-old male with [DIAGNOSES REDACTED].

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 for two (CR#1 and CR#2) of 19 residents reviewed for quality of care. LVN A failed to assess CR#1 when he was found to have blood in his indwelling catheter bag LVN A failed to consult the physician when CR #1 had a change in condition, which contributed to delay in care and treatment. He was admitted to a local hospital and placed in ICU with [DIAGNOSES REDACTED]. LVN A failed to report to oncoming nursing staff the change in CR#1's condition LVN A failed to appropriately assess CR#2 when he had slurred speech and shortness of breath LVN A failed to consult the physician when CR #2 had a change in condition when he exhibited slurred speech and shortness of breath, which led to a delay in care. CR #2 was admitted to the hospital with [REDACTED]. 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 pattern due to needing to train staff and monitor their implementation of the Plan to Lower the Immediate Jeopardy. These failures affected 2 residents and could affect 19 residents who reside on the 3rd floor and were cared for by LVN A, placing them at risk for lack of care, decline in health, hospitalization s and diminished quality of life. Findings Included: CR #1 CR #1 was admitted to the facility with an initial date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. He was transferred to a local hospital on [DATE]. Record review of the Annual Assessment Minimum Data Set (MDS) for CR #1 dated [DATE] revealed a Brief Interview of Mental status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS further revealed that CR #1 required extensive assistance with one-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. MDS revealed CR #1 had an indwelling catheter and was frequently incontinent of bowel. Record review of Care Plans for CR #1 revealed the following care plans which read in part - History of chronic urinary tract infections [MEDICAL CONDITION] related to obstructive and reflux [MEDICAL CONDITION] initiated on [DATE] with a revision date of [DATE]. Interventions-Encourage adequate fluid intake, monitor/document/report to physician as needed (PRN) for signs and symptoms of UTI: Malaise, nausea and vomiting, altered mental status, hematuria, cloudy urine, behavioral changes and loss of appetite. Obtain and monitor lab work as ordered. Report results to physician and follow up as indicated. - Activities of Daily Living (ADL) self-care performance related to cerebral infarct, limited mobility, impaired balance and Dementia initiated on [DATE] and revised on [DATE]. Interventions-Requires extensive assistance with toilet use with 1 staff participation, transfer requires extensive assistance with 1 staff, bed mobility requires extensive assistance with 1 staff and dressing requires extensive assist with 1 staff participation. - Impaired cognitive function/dementia or impaired thought process related to cerebral infarct initiated on [DATE] and revised on [DATE]. Interventions- Keep routine consistent, monitor/document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. - At risk for communication problem related to hearing deficit and slurred speech with low tone [DATE] and revised on [DATE]. Interventions- Be conscious of resident position in groups, activities, dining rooom to promote proper communication with others. Encourage resident to continue stating thoughts even if resident is having difficulty. Ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position, avoid isolation. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Record review of CR #1's active Clinical Physician order [REDACTED]. - Indwelling catheter output every shift dated [DATE] with a revision date of [DATE]. Record review of CR #1's Medication Review Record (MAR) dated [DATE]-[DATE] revealed the following orders: - Urine analysis/culture and sensitivity (UA/C&S) one time a day starting on the 1st and ending on the 1st every month for standing order to monitor for UTI, order date [DATE]. - Foley Catheter output every shift, three times a day, order date [DATE]. - Monitor/Record/Report to MD for any signs and symptoms of UTI: pain/discomforts, burning, blood tinged urine, cloudiness, scanty, or no urinary output, dark urine, color, high temp, chills, altered mental status, changes in behavior, changes in eating pattern, foul smelling urine. Order date of [DATE]. Record review of CR #1's Physician order [REDACTED]. - Monitor/Record/report to MD for any signs and symptoms of urinary tract infection [MEDICAL CONDITION]: Pain/Discomforts, burning, blood tinged urine, cloudiness, scanty or no urinary output, dark urine color, high temperature, chills, altered mental status, changes in behavior, changes in eating pattern, foul smelling urine. Date order initiated [DATE]. - UA/C&S one time a day starting the first and ending on the first every month for standing order to monitor for UTI. Date order initiated [DATE] with a start date of [DATE]. Record review of CR #1's Medication Administration Record [REDACTED] - UA/C&S one time a day starting on the 1st and ending on the 1st every month for standing order to monitor for UTI. Order date [DATE]. - Foley catheter output every shift three times a day. Order date [DATE]. Record review of documentation labeled Investigation Into Events on [DATE] with LVN A and CR#1 dated [DATE] provided by DON read in part . Documentation revealed that resident pulled on his catheter at dinner time [DATE] and blood was noted to be draining from his cath tube. No change of condition completed, no notifications made, not reported to oncoming nurse. Assistant Director of Nurses (ADON) arrived to facility and Nurse Educator made ADON aware of blood in cath bag. ADON promptly notified the provider and received orders to send out. ADON attempted to call spouse multiple times, spouse returned call and was made aware of situation. ADON assisted Emergency Medical System (EMS) out of the building at 8:03AM. DON spoke with spouse and spouse relayed information that resident had lost lots of blood and was also septic. Provider had concern that resident lost copious amounts of blood with the delay in care. Resident is in the Intensive Care Unit (ICU) with fair outlook. DON and Executive Director (ED) discussed findings from investigation completed by DON regarding LVN A and the shift she worked on [DATE]-[DATE]. Investigation into CR #1 revealed gross negligence on LVN A as she noted that resident had pulled his catheter which resulted in frank blood to drain from his catheter. LVN A failed to follow the facility policy on Change of Condition to alert other staff to this significant change and initiate follow-up. LVN A also failed to notify family nor provider of the trauma and did not chart on him for the rest of the night, indicating she was not monitoring the resident. LVN A's actions caused the resident to endure suffering and required the day nurse to send him out via ambulance to the emergency room (ER). CR #1 is now in ICU with a fair probability of survival. Had LVN A followed the policy for a change of condition, CR #1 would not have experienced these events. Executive Director and DON determined LVN A is a threat to the other residents in this facility and is termed for gross negligence. Record review of nursing note for CR#1 written by LVN A on [DATE] at 5:39AM read: During dinner Resident yanked on his foley catheter. Resident is urinating dark red blood. Urinary bag changed. Bag intact and urine is flowing. Resident had one episode of vomiting and diarrhea on this shift. Will continue to monitor. Record review of CR #1's nurse note written by ADON B on [DATE] at 7:20AM read in part . Called to resident's room, noted certified nurse aides (CNA)x 2 providing care. Noted dark red blood in catheter tubing, and drainage bag. resident complained of needing to have a BM, no visible feces noted at rectum. Complained of needing to urinate. No abdominal distention noted. Vital Signs: Blood Pressure (BP) ,[DATE], Respirations (R) 20, Apical Pulse (AP) 64, Peripheral Capillary Oxygen Saturation (SPO2) 92% on Room Air (RA). Notified Physician, Verbal Order to Send to emergency room (E.R) via 911. Called 911, information provided to operator. DON and Administrator/Executive Director notified. Record review of hospital medical records for CR#1 revealed the following records which read in part: emergency room physician notes dated [DATE] at 9:03AM- Chief Complaint- Blood in urine Onset occurred-Today Severity: Onset-Moderate Severity: Current-Moderate Associated Other: [MEDICAL CONDITION] Clinical Impression: Primary- Hematuria (blood in the urine) Secondary Impressions- [MEDICAL CONDITION], Leukocytosis,[MEDICAL CONDITION] (Bacteria that has entered into the bloodstream and/or tissues) Record review of hospital physician notes dated [DATE] by hospital internist read in part . Indwelling catheter present with sediment as hematuria. Upper urine is clear now. He had hematuria yesterday. He has dried blood in the perineal and groin area without active bleeding. Assessment and Plan: 1. Septic shock status [REDACTED]. 2. Urinary tract infection complicated in a patient with chronic indwelling catheter. The indwelling catheter has been changed. The patient was given [MEDICATION NAME] and [MEDICATION NAME] yesterday and started on [MEDICATION NAME] and [MEDICATION NAME], which will be continued. 3. Acute kidney injury. Renal consult obtained. The patient has non-anion gap metabolic acidosis likely from [MEDICAL CONDITION]. Hold nephrotoxics and continue to monitor urine output. Continue to follow on IV fluids. Record review of physician notes by ICU physician dated [DATE] at 3:59PM read in part . Labs were significant for a markedly leukocytosis as well as elevated blood urea nitrogen (BUN) and creatinine. Urinalysis suggests a urinary tract infection with numerous white blood cells. Lactic acid was elevated as well. Patient was administered fluids and brought to the ICU as he was noted to be mildly hypotensive. Diagnoses, Assessment & Plan: 1.[MEDICAL CONDITION] with impending shock [MEDICAL CONDITION] noted Related to urinary tract infection 2. Altered mental Status Underlying dementia Likely [MEDICAL CONDITION] as well We will continue to monitor 3. Acute Kidney injury Underlying [MEDICAL CONDITION] Continue to follow Metabolic acidosis noted Chronic urinary obstruction with chronic foley Observation and interview with CR#1 on [DATE] at 2:40PM at the hospital revealed CR#1 to have intravenous line (IV) of [MEDICATION NAME] hanging along with IV antibiotics. Interview attempted at same time and CR#1 was not able to carry on a conversation and was not able to be redirected. CR#1 was talking to himself and not making any sense. Interview with CR #1's Responsible Party (RP) on [DATE] at 2:30PM at the hospital, she said that CR#1 was in fair condition with acute [MEDICAL CONDITION] per the nephrologist and was in the Intensive Care Unit (ICU). RP said that the facility failed to do anything about CR#1's blood in his catheter and said that it had went on for about 12 hours before he was transferred to the hospital. RP said that she was told by staff that CR#1 had pulled his indwelling catheter at dinner time on [DATE] and there was bleeding in the tubing and catheter bag but they did not do anything or transfer him to the hospital until [DATE] in the morning when the day nurse came on. RP said she does not think CR#1 will recover from the delay in his care and was worried he lost to much blood. RP said that CR#1 was not communicating well and talks to himself. RP said that CR#1 had a serious infection and the hospital was having a hard time keeping his blood pressure up, so he was receiving antibiotics and an intravenous medication to assist his blood pressure. Interview with Administrator on [DATE] at 2:00PM, he said that CR #1 was in the hospital due to a change of condition. Administrator said that CR #1 was sent to the hospital for blood in his indwelling catheter bag. Administrator said LVN A did not appropriately assess CR #1 after identification of blood in the catheter bag. Administrator said that LVN A was working the night shift on [DATE]-[DATE] and CR #1 had a change of condition and the physician was not notified. Record review of report dated [DATE], no time noted on document provided by DON on [DATE] labeled Interview conducted via phone with LVN A regarding events on the night of [DATE] and [DATE] read in part . LVN A made aware that she is on speaker phone and the following are present: DON Administrator/Executive Director Regional Nurse What happened the night of [DATE] with CR #1? -I was told he tugged on his catheter at dinner -I went into his room and checked on him a few times Did you get vital signs? -I did when I gave him his medication cause it was required (blood pressure) Did you get any other sets of vitals? -No, I didn't What did you do when you noticed the blood? -I changed his bag and he had urine flowing -He was assisted to bed Did you go and check on him during the night? -Yes I did a few times Did you notify MD? RP? -No I didn't, they won't answer at night What about family? -I didn't call them Anything else to add? -No, not really. I should have called them. Interview with ADON B on [DATE] at 5:45PM, she said that she arrived to work about 7:15AM on [DATE] and the Nurse Educator said, come here and ADON B said she followed her down the hall. ADON B said there was blood in CR #1's indwelling catheter tubing and in the catheter bag. ADON B said the catheter bag was all blood and so was the tubing. ADON B said she asked the Nurse Educator to get a set of vital signs. ADON B said she then called the doctor and CR #1 was sent out via Emergency Medical Services (EMS). ADON B said CR #1's blood pressure was ,[DATE] when the Nurse Educator checked it. ADON B said that LVN A (night shift nurse) was gone by the time she (ADON B) arrived to work at 7:15AM. ADON B said LVN A did not mention the blood in the catheter tubing or bag in the 24-hour report and did not mention it to the oncoming nurse (ADON B). ADON B said LVN A was gone from the facility when she arrived In an interview with DON on [DATE] at 5:48PM, she said that she was notified by ADON B that CR #1's catheter bag had blood in it and was hypotensive. DON was asked why did she think that LVN A did not report Resident #1's bleeding and she said that LVN A told her the provider wouldn't answer anyway. DON was asked if she knew that LVN A had been working as a Charge Nurse and she said that she was aware and that LVN A was not being supervised during shifts. DON said LVN A should not have been a Charge Nurse. Interview with ADON B on [DATE] at 3:00PM she was asked by surveyor where were the monthly urinalysis and culture and sensitivity lab results for CR #1. ADON B said she would look for them and get back to surveyor. Interview via phone with LVN A on [DATE] at 3:25PM, she said that after dinner and around 6:30PM on [DATE], Certified Nurse Aide (CNA) D was assisting CR #1 to bed and noticed blood in the indwelling catheter. LVN A said that CNA D told LVN G about the blood in the indwelling catheter and LVN G said that it happens sometimes and to just give CR #1 some water. LVN A said she gave him a little water after 6:30PM and there was approximately <5 cubic centimeters (cc) of blood in the catheter bag. LVN A said CR #1 was alert and oriented at the time. LVN A said around 11PM that she went into CR #1's room to give him some more water and that there was only urine in the catheter tubing and no blood. LVN A said she didn't stay in the room long because CR #2 coded and she had to go deal with that. LVN A said she then went in CR #1's room at 2:30 AM on the morning of [DATE] and CR #1 was sleeping, and she woke him and offered him water at that time. LVN A then said that there was no more than 20 cc's of blood in the catheter bag and CR #1 had an episode of diarrhea and he had to be changed. LVN A said she last checked on CR #1 at 5:30AM on [DATE] before leaving at 6:00AM. LVN A said she did not give report to incoming nurse because she left at her scheduled time and before incoming nurse arrived and LVN G knew about the blood in CR #1's indwelling catheter bag and tubing and she was to report it to the incoming nurse and document it on the 24-hour nursing report. Record review of 24-hour nursing report for the night shift on [DATE]-[DATE] revealed that there was no documention by LVN A or any other nurse during the night shift for CR#1 regarding his indwelling catheter, blood in drainage bag or any other issues. Attempted to interview LVN G via phone and left messages on multiple occasions without success. Interview with ADON B on [DATE] at 3:40PM, she said that she was able to obtain urinalysis from his urologist that had been collected on [DATE] AND [DATE] but could not find any results for ,[DATE] or ,[DATE] that should have been collected by the facility. ADON said she would continue to look. Interview with CNA D on [DATE] at 2:15PM via phone, she said the shift started horrible. CNA D said she worked the night shift with LVN A. CNA D said that when she checked on CR#1 at the start of her shift his catheter bag had been emptied and there was no urine or blood. CNA D said that she was notified by LVN A at 5:30AM that CR#1 had diarrhea and that there was blood in the indwelling catheter bag. CNA D said that LVN A assisted her (CNA D) with changing CR #1's brief. CNA D said that when she and LVN A rolled Resident over to change his brief that there was vomit on his bed and CNA D said it smelled like feces and CR#1 appeared to be jaundice. CNA D said she told LVN A that CR#1 didn't look right, and he needed to be sent to the hospital but is unsure what LVN A did for CR#1 or if he was even assessed. CNA D stated that she saw LVN A empty the indwelling catheter bag which contained blood, but she could not recall how much blood. CNA D said that when CR#1's brief was changed that she noticed a scant amount of blood on the interior of the brief. Interview with CNA E on [DATE] at 2:01PM, she said that she worked the day shift on [DATE] and arrived to work around 6:00AM. CNA E said when she arrived she went to do her rounds and check on all the residents. CNA E said when she got to CR #1's room it was dark in the room but CR #1 was awake and she turned on the shower, so it would get hot while she went around and checked on her other residents and got them ready for breakfast. CNA E said CR #1 seemed normal and he even said to make sure the shower was hot when she came back to shower him. CNA E said that when she returned at about 6:30AM to give CR #1 his shower he was confused and not right. CNA E said that she looked at the indwelling catheter bag and noticed a lot of blood in the bag. CNA E said it was approximately 150cc's of blood in the catheter bag and said it appeared to be all blood without any urine. CNA E said she asked CNA F to get the nurse as she did not want to leave CR #1. CNA E said CR #1 has pulled on his indwelling catheter in the past and it usually causes some blood in the brief and this time there was no blood in CR #1's brief when she and CNA F checked, just in the catheter tubing and bag. CNA E said when Nurse Educator arrived at the room she assessed CR #1 and he was sent to the hospital. CNA E said that it was not reported to her from night shift CNA D that there had been blood in CR #1's catheter bag. Interview with CNA F on [DATE] at 2:18PM, she said that when she went to assist CNA E on the morning of [DATE] with CR #1 that she saw blood in his catheter bag and it was blood shot red. CNA E said that CR #1 has pulled on his catheter in the past and there is always blood in his brief and small amounts of blood in the catheter tubing if he pulls on it. CNA E said that when she assisted CNA F in the removal of his brief there was no blood on the brief. CNA E said that there was approximately 250cc-300cc's of blood in the indwelling catheter bag. CNA F said it looked like it was all blood and no urine in CR #1's indwelling catheter bag. CNA F said that CNA D worked the night shift and she did not report to her (CNA F or CNA E) that CR #1 had blood in his indwelling catheter bag. CR #2 Record review of face sheet for CR#2 revealed that he was initially admitted to the facility on [DATE]. CR#2 was a [AGE] year-old male with [DIAGNOSES REDACTED]. Record review of Quarterly Minimum Data Set (MDS) for CR#2 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. MDS further revealed that CR#2 required extensive assistance for dressing, toilet use and personal hygiene. Record review of Care Plans for CR#2 read in part - Has altered respiratory status/difficulty breathing related to [DIAGNOSES REDACTED]. Interventions: Administer medications/puffers as ordered. Monitor for effectiveness and side effects. Elevate head of bed 30 to 45-degree angle. Monitor/document changes in orientation, increased heart rate, restlessness, anxiety, and air hunger. Monitor for signs and symptoms of respiratory distress and report to physician as needed: Increased respirations, decreased pulse oximetry, increased heart rate, diaphoresis, headaches, lethargy, confusion, skin color changes. Monitor/Document/Report abnormal breathing patterns to physician: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. - Has shortness of breath related to anxiety, decreased energy and fatigue, [MEDICAL CONDITION], neuromuscular impairment, pain initiated on [DATE]. Interventions: Monitor/Document/Report breathing abnormalities to physician; bradypnea, tachypnea, hyperventilation, kussmaul's (deep and labored breathing pattern) respirations, ataxic patterns. Monitor/document changes in orientation, increased restlessness, anxiety and air hunger. Interview on [DATE] at 4:45 PM with DON regarding CR#2, she said that CR#2 coded on [DATE] and LVN A found him unresponsive. DON said that she looked at CR#2's records and investigated because his change in condition happened on the same night and shift with LVN A. DON said LVN A was responsible for both residents (CR #1 and CR#2). DON said per her investigation it looks like she did what she was supposed to. DON said, I feel she followed up on that well, in regard to CR#2 and his change in condition. DON said CR#2 was at the hospital and she was not sure of his status. Record review of Medication Review Report/Physician order [REDACTED].#2 revealed the following orders: - [MEDICATION NAME] Nebulizer Solution 15 micrograms (MCG)/2 milliliters (ML)- 1 applicatorful inhale orally via nebulizer every 12 hours related [MEDICAL CONDITION] with exacerbation. - [MEDICATION NAME] Suspension 0.25 MG/2ML-1 applicatorful inhale orally every 12 hours related to shortness in breath. - [MEDICATION NAME]-[MEDICATION NAME] Solution 0.52.5(3) MG/3ML- 1 vial inhale orally via nebulizer every 6 hours for [MEDICAL CONDITION]. - Resident in Isolation for shingles. - Full Code: Use Automated External Defibrillator with Cardio-pulmonary resuscitation for [MEDICAL CONDITION]. - Check and Record oxygen saturation every shift. - [MEDICATION NAME] HFA Aerosol Solution- 1 puff inhale orally every 4 hours as needed for dyspnea. Record review of Medication Administration Record [REDACTED] - [MEDICATION NAME] Nebulizer Solution 15 micrograms (MCG)/2 milliliters (ML)- 1 applicatorful inhale orally via nebulizer every 12 hours related to shortness of breath. Start date of [DATE] - [MEDICATION NAME] Suspension 0.25 MG/2ML-1 applicatorful inhale orally every 12 hours related to shortness in breath. Start date of [DATE] - Check and Record oxygen saturation every shift. Start date of [DATE] - [MEDICATION NAME]-[MEDICATION NAME] Solution 0.52.5(3) MG/3ML- 1 vial inhale orally via nebulizer every 6 hours for [MEDICAL CONDITION]. Start date of [DATE] - [MEDICATION NAME] HFA aerosol solution-1 puff inhale orally every 4 hours as needed for dyspnea. Start date of [DATE] Record review of Medication Record for CR#2 dated [DATE]-[DATE] revealed [MEDICATION NAME] HFA aerosol solution had not been given for the day of [DATE]. Record review of document labeled Investigation Into Events on [DATE] with LVN A and CR#2 dated [DATE] provided by DON read in part . Resident coded during the same shift. Nurse administered scheduled breathing treatment at approximately 11:00PM. Same nurse passed his room at 11:33PM and noted he was slumped backwards, skin flush and no pulse. Nurse initiated CPR and summoned EMT (Emergency Medical Technician). EMT arrived at 11:44PM and took over Cardio-pulmonary-resuscitation (CPR). Resident was unresponsive even as he left the building and was tachy (178). Resident is in Intensive Care Unit (ICU) at the time of this writing, writer not able to interview resident to determine if his call light was on, if nurse responded and she documented or any other factors in this situation. Interview with LVN A via phone on [DATE] at 2:16PM she said on [DATE], CR#2 was acting weird and he kept coming out of his room at the start of her shift at 6:00PM and during the shift, which he did not do normally because he had been recently put on isolation for shingles. LVN A said she would redirect him to his room every time he came out of his isolation room. LVN A said that at 11:00PM on [DATE] CR#2 asked for a breathing treatment, and said he was talking low and short of breath but he was always short of breath. LVN A was asked to describe how CR#2 asked for the nebulizer treatment and LVN spoke slowly, softly and gasped for air over the phone to demonstrate. LVN A said she administered the nebulizer treatment but did not assess him prior to administration of nebulizer treatment and she did not assess CR#2 when he was acting weird. LVN A said she gave CR#2 his nebulizer treatment and did not go back to the room following treatment to assess CR#2. LVN A said when she was passing by CR#2's room at 11:33PM, she noticed that the nebulizer was still running, and she thought that was unusual as he normally turns off the nebulizer himself when the treatment is done. LVN A said she went into CR#2's room and found him slumped backwards and CR#2 did not have a pulse. LVN A said she left the room and went to get LVN G and CNA D. LVN A said CNA H started CPR and 911 was called. LVN A said EMS arrived at 11:44PM and took over care and they left with CR#2 around midnight to take him to the hospital. LVN A was asked if she called the doctor when CR#2 exhibited weird behavior or when he was short of breath and LVN A said No because she did not think the physician needed to be called as CR#2 was always asking for nebulizer treatments and was short of breath. Attempted to interview LVN G via phone on multiple occasions without success. Interview with CNA D on [DATE] at 2:45PM she said that she worked with LVN A on [DATE]-[DATE]. CNA D said that she notified LVN A CR #2 did not look right and that his color was off throughout the shift and she did not see LVN A assess CR#2. CNA D said she found CR#2 at 11:25PM and he was not responsive, and she told LVN A and LVN A went down to the room to check on CR#2 and then 911 was called and CPR was started. CNA D did not say who initiated CPR. Record review of Emergency Medical Services (EMS) notes for CR#2 dated [DATE] at 11:46PM read in part - Patients nurse states the patient is normally alert and oriented x 3, but when she made rounds at 6:00PM he was slurring his speech heavily, and when she rounded on him at 11:15PM, he was suffering from severe dyspnea. Patient stated to her I can't breathe. Nurse set up a nebulizer for him and continued on her rounds. When she returned around 11:30PM, he was unconscious and unresponsive. Nurse called 911 at this time and started CPR with an AED. - [AGE] year-old Hispanic male, laying supine on floor in his room at facility. Patient is unconscious, unresponsive and has Automated External Defibrillator (AED) pads attached to his chest. Nurses advise that they have performed CPR and no shocks were delivered. At this time my partner initiates CPR while I place combo pads. Patient is in asystole. Patient was intubated. Lung sounds are diminished. Patient was administered [MEDICATION NAME]. 3 and 12 lead electrocardiogram (EKG) shows [MEDICAL CONDITION]. Patient is known to suffer from [MEDICAL CONDITIONS] and did not complete his nebulizer treatment. Bolus of Normal Saline administered wide open. Patient remains hypotensive. Patient delivered to emergency room . Record review of [MEDICAL CONDITION] consultation report from the hospital for CR#2 dated [DATE] at 9:16AM read in part . - Apparently, the patient presents from the nursing home after [MEDICAL CONDITION]. History difficult to obtain as the patient is currently intubated. Prior records he was at nursing home, suffered [MEDICAL CONDITION]. He had some slurring of the speech and was short of breath. A nebulizer treatment was being administered and the patient became pulseless. EMS was alerted, and initial rhythm was noted to be asystole. CPR was initiated with return of spontaneous circulation and route following [MEDICATION NAME] administration x2. - A chest x-ray was obtained which showed multiple airspace consolidation suggested pneumonia. Endotracheal tube was noted to be in place. Record review of hospital cardiologist consultation report for CR#2 dated [DATE] read in part . - Diagnosis, Assessment & Plan - Cardiopulmonary arrest. Initiating event appears to be respiratory arrest. Continue Mechanical Ventilation. We will continue to monitor. We will continue mechanical ventilation as per [MEDICAL CONDITION] service. - The (TRUNCATED)

Based on observations, interviews and record review the facility failed to ensure 1 of 7 residents (Resident #5) 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 #5 was in severe pain and did not have any pain medication at the facility. He had not receive his pain medication in four days due to it not being refilled in a timely manner. These failures affected one residents and placed 24 other residenets on pain management at risk for not recieving their paiu medications and having their pain controlled which could lead to a decrease in life and health status. Intake # 2 Findings Include: Resident #5 Record review of Resident #5 ' s face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #5's Minimum (MDS) data set [DATE] assessed him as having a BIMS score of 14, which indicated he was cognitively intact. Record review of Resident #5 ' s Care Plan dated 03/06/13 revealed . Focus: Chronic pain r/t Arthritis, [MEDICAL CONDITION], Neuropathies, Cancer, ineffective individual coping r/t pain .Goal: demonstrate pain relief through proper administration of [MEDICATION NAME] daily .will demonstrate effective coping strategies daily, will not experience any adverse side effects from medication daily .Interventions: allow resident to vent concerns about living with chronic pain which includes anger, denial, sadness .Evaluate residents verbal and nonverbal cues to assess the degree and severity of pain .Assess ability to concentrate by observation .encourage resident to use diversional activities of his/her choice, provide with opportunities for rest and sleep, administer [MEDICATION NAME] timely as ordered, observe resident for side effects form medications Record review of Resident #5 ' s Order Summary Report dated 03/23/16 revealed, Monitor & Assess level of pain every shift using the following scale: 0=NO Pain, 1-3=Mild Pain, 4-6=Moderate Pain, 7-10=Severe Pain Order date 12/18/14 .Order Status Active Record review of Resident #5 ' s Order Summary Report dated 03/23/16 revealed, .[MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 4 hours for pain related to OTHER CHRONIC PAIN [MEDICAL CONDITION] OF LIVER WITHOUT MENTION OF ALCOHOL . Order date 12/18/2012 Record review of Resident #5 ' s Medication Administration Record [REDACTED]. Order date 12/18/2012 . Monitor & Assess level of pain every shift using the following scale: 0=NO Pain, 1-3=Mild Pain, 4-6=Moderate Pain, 7-10=Severe Pain every shift Order date 12/18/14 . Record review of Resident #5 ' s Medication Administration Record [REDACTED] 3/1 and 3/11 at 9:00pm- there was no documentation of pain medication ([MEDICATION NAME]) was administered or the reason why it was not given. 3/12 and 3/19 at 5:00am- there was no documentation that pain medication ([MEDICATION NAME]) was administered.or the reason why it was not given. 3/19 at 5:00am- there was no documentation that the pain medication ([MEDICATION NAME]) was given or why it was not given. 03/21 at 1:00am, 5:00am, 9:00am, and 1:00pm- it was documented that the pain medication ([MEDICATION NAME]) was administered. On 03/22 at 5:00pm and 9:00pm it was documented that the pain medication ([MEDICATION NAME]) was administered. There was no documentation that pain assessments were completed for Resident #5 every shift per physician's order [REDACTED].>Record review of Resident #5 ' s Progress Notes dated 03/20/16 at 21:40pm revealed that the facility was waiting on medication delivery for Resident #5's pain medication, [MEDICATION NAME]. In an interview on 03/23/16 at 12:30 PM Resident #5 stated he had not been administered his pain medication for 4 days and he was in pain at the time of interview as well as the four days he had not received his medication. The facility attempted to give him Tylenol but that did not work to control his pain. In an interview on 03/23/16 at 12:40 PM Licensed Vocational Nurse (LVN) B stated the facility called the physician this morning for the Resident #5's pain medication. The pharmacy needed the physician to triplicate the order. The physician did not put the script in on time. In an interview on 03/23/16 at 2:58 PM the Director of Nursing (DON) stated LVN B contacted the physician on 03/20/16 when she discovered the resident only had 10 pills of [MEDICATION NAME] left. The physican did not contact the pharmacy. The DON and Administrator contacted the physician today about the order. The facility staff should have contacted me once they discovered that Resident #5 did not have any pain medications. None of the staff contacted me. The DON did not find out the resident did not have any medications until this morning. Even if the physician did not call in the order we could have got our medical director to call in the order that was no excuse. We are having issues with the physician now the company was pulling the contract of all the physicians in this area at the nursing homes. She said she was not sure why the staff documented (on 3/21 and 3/22) that the medication was administered if we did not have any on hand or why there was missing documentation on the MAR. The DON was not sure why the MAR indicated [REDACTED]. In an interview on 03/23/16 at 3:39 PM LVN S stated she had made an error in charting on Resident #5's MAR. She was supposed to put the medication on hold if not available at the time of administration. MA D told her they needed to have the order triplicated, it ' s been hard to get in contact with the physicians. When LVN S found out the Resident #5 did not have any medications she said she did not contact the physician but she should have contacted him. LVN S did not contact the DON. The facility did not have any emergency medications. In an interview on 03/23/16 at 3:42 PM MA E stated she charted the administration of the medication wrong. She charted before she gave the medication. The facility policy was to administer the medication before you chart that it was given. She thought the facility had the medication on the E-cart. She said she should I should have gone back and changed the record. On Sunday (03/20/16) MA E told the LVN B about the medication issue. On Monday (03/21/16) MA E also told another nurse about the issue. On Tuesday MA E stated she charted right on Resident #5 ' s Medication Administration Record. The nurses stated they were going to follow up on the issues. Every day the resident was asking for his pain medications. MA E said the facility did not do pain assessments on Resident #5 but she said she thought it would be a 4 or a 5 on a scale of 1-10. In an interview on 03/23/16 at 4:09 PM Resident #5 stated his pain was a 10 on a scale of 1-10 during the period in time he did not have his medications and at the time of this interview. In an interview on 03/23/16 at 4:11 PM Licensed Vocational Nurse (LVN) W said Resident #5 did not have a pain assessment that was completed daily. If the resident complained of breakthrough pain then the MA would tell them so they could do an assessment. Resident #5 had scheduled pain medications and was not PRN (as needed) so he did not need a pain assessment. In an interview on 03/23/15 at 4:15 PM MA Y stated Resident #5 did not have a level of pain schedule. If Resident #5 needed a pain assessment daily a heart would show up on the computer screen there next to his record to notify the person giving the medication to check for pain and document assessment. There was not a heart next to his record. According to CMS Form 672 dated 03/17/16 there were 25 residents on pain management.

Based on observation, interview and record review the facility failed to develop and implement their policy that prohibited mistreatment and neglect of one of five residents (Resident #1) reviewed for care provided. Weekly skin assessments were not being conducted by licensed staff on all residents to identify skin issues. On 5/1/15, a necrotic area with slough was identified on Resident #1's left shin. Resident #1 was transferred to the hospital where several open areas were identified on his buttocks. Resident #1's last skin asssessment dated 4/28/15 did not identify either of the areas and the facility staff were not treating these areas. LVN #1 did not use aseptic technique when providing wound care to the recent [MEDICAL CONDITION] incision of Resident #1 who had a compromised medical condition of [MEDICAL CONDITION]. An IJ was identified on 5/18/2015. While the IJ was removed on 5/20/2015 the facility remained out of compliance at a scope of isolated and a severity level of actual harm. This failure affected one resident who required an emergency leg [MEDICAL CONDITION] and placed eight residents with wounds at risk of wounds deteriorating due to poor wound care or new wounds not being treated due to inadequate or lack of skin assessments. These failures could cause the residents to have a rapid decline in health due to a serious infection. Findings include: Intake # 8 Record review of Resident #1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #1 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of Resident #1's MDS dated [DATE] revealed the resident was moderately impaired for cognition and was at risk of developing pressure ulcers, required supervision for personal hygiene and was occasionally incontinent of bladder. The MDS identified Resident #1 as using a wheelchair for mobility. Record review of Resident #1's care plan dated 4/14/14 revealed Resident #1 was at risk for an ADL self-deficit related to dementia. Goal was to maintain current level of function, grooming and personal hygiene, approaches includes: 1-2 staff for bathing, is able to turn and reposition in bed,, allow sufficient time for dressing and undressing, able to hold cup, feed self, eat finger foods independently, able to bear weight , pivot, use arms to support, and take two steps for transfers . Further record review of Resident #1's care plan dated 9/18/14 revealed Resident #1 was resistive to care related to dementia. Goal was the resident will co-operate with care through the next review date of 7/20/15. Record review of Resident #1's care plan dated 1/19/15 revealed Resident #1 had a diabetic ulcer to his left lateral ankle measuring 6.4cm by 3.0 cm by 0.2 cm with no maceration related to vascular insufficiency. Goal was ulcer will improve by 7/20/15. Approaches outlined included: wound care consult, document progress of healing on an on-going basis, notify MD as indicated, monitor/document /report to MD any signs of infection, green drainage, foul odor and treat wound daily. Record review of Resident #1's TAR dated May 2015 revealed: cleanse left lateral foot with normal saline, pat dry, apply santyl ointment and silver alginate daily. The order was dated 4/21/15. Record review of Resident #1's last weekly skin assessment dated [DATE] revealed Resident #1 had a left lateral ankle venous ulcer only. No other areas were noted on the assessment. Record review of Resident #1 nurses' notes dated 5/1/15 at 11:16 a.m., revealed documentation by the treatment nurse that during wound care this am, noted patient to have new area to left shin, 100 % slough noted. Called DON to assess. During assessment DON noted purulent drainage and very foul odor. Call placed to MD to notify of transfer to ER. Record review of Resident #1's nurses' notes revealed late entry documentation by DON dated 5/3/15 at 1:39 p.m., treatment nurse notified DON of open area to left shin. Upon assessment noted area approximately 12.7 cm by 13.5 cm with slough in the center approximately 12.0 cm by 13.1 cm. Copious amount of purulent drainage with foul odor. Not able to palpate femoral, popliteal or pedal pulse. Resident denied pain. 2+ [MEDICAL CONDITION] to left lower extremity. Notified MD with orders received to send resident to ER. Record review of Resident #1's hospital physical examination dated 5/1/15 revealed, a [AGE] year old male with history of [MEDICAL CONDITION], presents to ER today [MEDICAL CONDITION] and wet Gangrene of the left lower extremity of unknown etiology. Review also revealed Resident #1 had multiple white plaques on shaft of penis, and multiple small area of skin breakdown on posterior buttocks. The hospital documents revealed the resident did not know how long the wound on the left shin had been there and the resident was unkempt and appeared not to have had personal care for a period of time. Further review of the record revealed a plan of an emergent below knee amputation due [MEDICAL CONDITION]. Observation on 5/2/15 at 1:00 p.m., Resident #1 at the hospital revealed he was alert and oriented, and responded to asked questions appropriately. Left below knee amputation was noted with stomp wrapped. Resident #1 had long and dirty fingernails with a buildup of a black substance underneath the nails. He had a grown and untrimmed beard. His skin was dry and appeared unkempt. The resident was in the intensive care unit for continuous observation. Interview on 5/2/15 at 1:00 p.m., Resident #1 said he was transferred to the hospital yesterday and the doctors removed his left lower leg due to some infection and poor circulation. He said he received wound care to his left lateral ankle daily at the facility. Interview on 5/3/15 at 1:40 p.m., the DON said the treatment nurse performed daily dressing change to the venous ulcer on Resident #1's left lateral ankle. She explained the area found on 5/1/15 was new according to the treatment nurse. The DON said she interviewed the treatment nurse who reported it was the first time she saw the area despite new necrotic area was on Resident #1's left shin with a foul odor. The DON said the facility, after this discovery, had performed skin assessments on all at risk residents and staff training was initiated immediately to ensure prompt reports and notifications of skin issues. The DON reported inconsistencies were identified with written documentation of wound measurements, and locations . The facility treatment Nurse resigned immediately after the discrepancies were identified. Attempts made to interview the treatment nurse on 5/2/2015 and 5/3/2015 were not successful. She did not answer the phone when called and did not return calls when message left. Interview on 5/3/15 at 3:00 p.m., the facility Corporate Nurse said the treatment nurse was hired a couple of weeks prior to the above incident and was given adequate training prior to her duty resumption. She expressed the treatment nurse had resources available for her if she was in doubt or unsure of her findings. she explained the previous DON was responsible for monitoring and evaluating the treatment Nurse's performance and wound management . The Corporate nurse explained the current DON had been in the facility for just a few days and would be responsible for the monitoring or over seeing the wound care, nurse's training and competence of skills verifications. Record review of an in-service attendance record dated 5/3/15 by the DON revealed in part the following program content which included instruction that weekly skin assessments were to be completed by the charge nurse and documented in the computer. The CNA ' s were to utilize the shower sheets to identify all open areas, sign the shower sheet, notify the charge nurse immediately, and turn the shower sheet into the DON. The nurse was to review the shower sheets, follow-up with documentation/communication the CNA has informed you of. Once the shower sheet had been evaluated by the nurse it was to be signed and submitted to the DON. Interview on 5/14/15 at 9:40 A.M. the DON stated she had two ADON ' s and they were to complete the weekly head to toe skin assessments on all residents not identified as having skin issues. She said she had recently hired a new treatment nurse who started today (5/14/15) and she would be responsible for the skin assessments on those residents with identified wounds. Observation of wound care for Resident #1 on 5/14/15 at 10:10 A.M. revealed LVN #1 gloved without hand hygiene prior to starting wound care. LVN #1 had her clean supplies on wax paper and she placed them on the resident ' s bed. She removed and discarded the old dressing from the resident ' s left lower extremity surgical wound site and the dressing was soiled with drainage. In removing one dressing it was somewhat adhered to the resident ' s skin and LVN #1 picked up a clean gauze from the supplies on the resident ' s bed and placed the gauze under the wound and poured a small amount of normal saline over the old gauze to loosen it so it could be removed without pulling on the resident ' s skin. She then used the gauze that was under the wound to cleanse around the resident ' s wound. LVN #1 picked up another gauze, moistened it with normal saline and cleansed the wound several times with the same gauze. She repeated this two more times. LVN #1 changed gloves without performing hand hygiene in between glove changes and picked up and placed clean dressing over the incision. She retrieved a package of soft (kling) gauze from her pocket, opened it and wrapped the dressing to the hold it in place. She did this twice. LVN #1 then gathered the dirty dressings in a red plastic bag as well as the remaining clean supplies and took them out of the room. She did not wash her hands until prompted by the treatment nurse. She took the bottle of normal saline out of the resident ' s room and replaced it in her medication cart. In an interview with LVN #1 immediately after the treatment she stated she had worked in Hospice services for a number of years prior to working at the facility and had not had to perform wound care in a number of years. She was unable to identify any issues with the way the treatment was performed. She said she had no wound care training and no in-services on wound care, performing treatments or performing skin assessments in the past two weeks. Interview on 5/14/15 at 10:50 A.M. ADON #1 stated she had not received any instruction on a plan for the ADON ' s to complete weekly head-to-toe skin assessments and she had not completed any. Interview on 5/14/15 at 2:30 P.M. the DON stated she had spoken to the wound care physician who was in the facility at the time and he was going to observe the treatment nurse perform wound care and he would evaluate her performance. She said the wound care physician also stated he would conduct an in-service for the nursing staff on wound care and the DON would need to contact his office to schedule a date. The DON stated she was not aware of any competencies for nursing staff for wound and skin treatments. She also stated LVN #1 would not be doing any more treatments until she had been checked off by her or one of the corporate wound care nurses. The DON stated she would have all of the skin assessments done on everyone by 5/16/15. Record review on 5/18/2015 revealed there were 32 residents on the 3rd floor. There were 9 residents identified with wounds/skin issues. Continued review with the DON revealed there were 23 residents who had not received a head to toe skin assessment the week of 5/3-5/9 and the week of 5/10-5/16/15. There were 3 residents documented as a refusal for skin assessment and 4 residents with no skin assessment documented for May 2015. Interview with the DON on 5/18/15 at 10:00 A.M. the DON did not have a response as to why skin assessments had not been consistently done on residents for the past two weeks. She stated she was aware every resident in the facility was to have a skin assessment done after the incident with Resident #1 and she thought the ADON ' s were doing them. She stated she should have followed up to make sure all of the assessments were done. The DON said the corporate nurse would be doing in-servicing and competencies for all nursing staff. She said the corporate nurse was wound care certified. Record review of facility's policy on Resident Rights dated 5/2007 revealed that the employees of the facility would take action to protect and prevent neglect from occurring by having knowledge of the individual resident's care needs. An IJ was identified and the Administrator was notified on 5/18/2015 at 12:10 P.M. A Plan of Removal (POR) was submitted and accepted on 5/19/2015. The IJ was removed on 5/20/2015. The POR included: Systemic Change to Prevent Re-Occurrence 1. A full skin assessment on 100% of the residents was initiated on 5/18/15 at 1:00 pm to identify any resident with wounds that facility was not previously aware of. DON, ADONs, treatment nurse and RN resource nurse are participating in the skin assessment. At conclusion of skin assessment, any new wound issues will be reported to resident ' s attending physician by treatment nurse, DON or ADONs. Care plans for new wounds will be updated immediately to reflect current skin status and interventions. 2. All licensed nurses will be in-serviced by RN Resource (corporate consultant nurses) and LVN WCC (Wound Care Certified) on wound care assessment, treatment and policy by 5-19-15. No nurse will be allowed to assess or do a treatment until in-service and treatment competency checklist is completed. In-service will include the guidelines from the NPUAP (National Pressure Ulcer Advisory Panel) as referenced in F314 in the SOM, support surfaces, and turning and repositioning based on assessment. 3. A competency check to be completed on Treatment Nurse, weekend Treatment Nurse, DON, ADONs, day and evening nurses by 5:00p 5/18/15. All other licensed nurses to be completed by 12 noon on 5-19-15. Competency check will be conducted by a LVN from sister facility who is Wound Care Certified. Nurses who do not pass competency check will be retrained, then competency rechecked. Nurses who cannot pass competency checks will not be allowed to assess skin or do wound treatment. 4. As of 5/18/2015, upon admission, each resident will have skin assessment conducted by facility designated treatment nurse. The LVN WCC (Wound Care Certified) from sister facility will in-service treatment nurse to conduct skin assessment upon admission. 5. As of 5/18/2015, for residents identified with current wounds; weekly measurement and observation/assessment will be completed by the Treatment Nurse rounding with Wound Physician. Attending physicians will be contacted for residents ' wounds that are not showing progress toward healing. 6. As of 5/18/2015, weekly head to toe skin assessment will be conducted on all residents by the treatment nurse. For any resident identified with a new wound issue, physician and family will be notified. 7. As of 5/18/2015, CNAs will observe any skin issues observed during resident showers. A resident shower sheet will be completed by CNAs and given to charge nurses to initiate wound assessment. CNAs will be in-serviced by DON and ADONs on skin shower observations to be completed by 5-19-15. Residents who refuse shower will be offered bed bath by CNA, at which time skin assessment with licensed nurse will be completed. If a resident consistently refuses to shower and bathe in bed, nursing administration, their physician and their RP will be notified. Their Care Plan will be updated to reflect their refusal. The social worker will be notified to setup a care plan meeting with the RP. 8. As of 5/18/2015 and ongoing, DON and/or ADON will ensure daily treatments are occurring per order by direct observation of all wound treatments/and or dressing until compliance with facility treatment procedure. TARs will be printed and placed in QA binder for DON and/or ADON to initial after monitoring observation has occurred. Weekend Treatments observation/monitoring will be assigned and rotated with DON, and ADONs, until compliance with facility treatment procedures is achieved. 9. As of 5/18/2015 and ongoing, DON and/or ADON will review new Admissions with 24 hours of admission to ensure wound assessment completed per policy. 10. As of 5/18/2015, Treatment nurse will prepare weekly skin report with list of all residents with current wounds by site/stage. The report will go to the DON for review Monitoring of the POR: Record review of the facility ' s skin assessment, shower/bathing observations, completing/documentation on shower sheets, wound care and staff competency checks in-services dated 5/19/15 through 5/20/15 revealed about 95 % of facility nursing staff including CNAs, MAs, LVNs, RNs, and Weekend Supervisors on three of three shifts were in-serviced. LVNs and RNs had received competency checks from wound care certified nurse. Interviews on 5/20/15 revealed 25 nursing staffs on two of three shifts were interviewed on shower/bathing observations, completing shower/bathing sheets, notifying charge nurse/DON of care refusal, skin assessment and documentation, and wound care/documentation of treatment. All staff members interviewed had been in-serviced and were able to identify the protocols implemented. Record review of Resident #1's skin assessment was updated as well as skin assessment for all residents on both 200 and 300 halls this was completed on 5/19/15 and 5/20/15. Record review of Resident #1's care plan as well as all residents with wounds and skin issues were updated on 5/19/15 through 5/20/15. Observations on 5/20/15 at 8:30AM revealed Resident #1 was in his room eating breakfast; left below knee stomp was wrapped. Resident #1 had follow -up appointment on 5/21/15. Resident #1 expressed no negative concerns. Record review of the facility's policy on skin assessment not dated revealed the facility will assess all residents upon admission, when a comprehensive assessment is required , quarterly thereafter to identify risk of skin breakdown. All resident will be assessed for skin risk using a pressure ulcer risk assessment form (Braden, Norton or facility specific) within 24 hours of the time of admission by a licensed nurse. Residents will be re-assessed for skin when a comprehensive assessment is requires and quarterly and thereafter. Nursing and dietary will monitor dietary intake and weight patterns on an ongoing basis to identify residents at risk for malnutrition and skin breakdown. The care plan will be updated and implemented based on the needs identified by the comprehensive assessments the and score on the pressure ulcer risk assessment form. Record review of the facility's policy on skin inspection ,shower day not dated revealed this facility will identify any pertinent skin issues with residents during routine inspection of residents at shower/bath times. CNAs will document all skin issues that he/she observes on the resident as the resident ' s shower, tub or bed bath is given. CNAs will document these issues using the skin assessment -shower form. DON signs off on the form. Record review on 5/20/2015 of 100% of the resident's records revealed all had skin assessments conducted between 5/18/2015 and 5/20/2015. Observations on 5/20/2015 of sampled residents on both floors revealed accurate skin assessments documented. Observation of wound care on 5/ 5 by new treatment nurse revealed good infection control technique. The Administrator was informed on 5/20/2015 at 11:57 A.M. that the IJ was lowered after verification of the POR implementation had occurred. While the IJ was lowered on 5/20/2015, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. The facility was continuing to monitor and train staff on skin assessments and wound care. The DON reported there were eight residents with wounds .

Based on observation, interview and record review the facility failed to provide care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of five residents (Resident #1) reviewed for care provided. Weekly skin assessments were not being conducted by licensed staff on all resident to identify skin issues. On 5/1/15, a necrotic area with slough was identified on Resident #1's left shin. Resident #1 was transferred to the hospital where several open areas were identified on his buttocks. Resident #1's last skin assessment dated [DATE] did not identify either of the areas and the facility staff were not treating these areas. LVN #1 did not use aseptic technique when providing wound care to the recent [MEDICAL CONDITION] incision of Resident #1 who had a compromised medical condition of [MEDICAL CONDITION]. An IJ was identified on 5/18/2015. While the IJ was removed on 5/20/2015 the facility remained out of compliance at a scope of isolated and a severity level of actual harm. This failure affected one resident who required an emergency leg [MEDICAL CONDITION] and placed eight residents with wounds at risk of wounds deteriorating due to poor wound care or new wounds not being treated due to inadequate or lack of skin assessments. These failures could cause the residents to have a rapid decline in health due to a serious infection. Findings include: Intake # 8 Record review of Resident #1 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #1 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of Resident #1's MDS dated [DATE] revealed the resident was moderately impaired for cognition and was at risk of developing pressure ulcers, required supervision for personal hygiene and was occasionally incontinent of bladder. The MDS identified Resident #1 as using a wheelchair for mobility. Record review of Resident #1's care plan dated 4/14/14 revealed Resident #1 was at risk for an ADL self-deficit related to dementia. Goal was to maintain current level of function, grooming and personal hygiene, approaches includes: 1-2 staff for bathing, is able to turn and reposition in bed,, allow sufficient time for dressing and undressing, able to hold cup, feed self, eat finger foods independently, able to bear weight , pivot, use arms to support, and take two steps for transfers . Further record review of Resident #1's care plan dated 9/18/14 revealed Resident #1 was resistive to care related to dementia. Goal was the resident will co-operate with care through the next review date of 7/20/15. Record review of Resident #1's care plan dated 1/19/15 revealed Resident #1 had a diabetic ulcer to his left lateral ankle measuring 6.4cm by 3.0 cm by 0.2 cm with no maceration related to vascular insufficiency. Goal was ulcer will improve by 7/20/15. Approaches outlined included: wound care consult, document progress of healing on an on-going basis, notify MD as indicated, monitor/document /report to MD any signs of infection, green drainage, foul odor and treat wound daily. Record review of Resident #1 ' s Physician order [REDACTED]. Record review of Resident #1's TAR dated May 2015 revealed: cleanse left lateral foot with normal saline, pat dry, apply santyl ointment and silver alginate daily. The order was dated 4/21/15. Record review of Resident #1 ' s last weekly skin assessment dated [DATE] revealed Resident #1 had a left lateral ankle venous ulcer only. No other open skin areas were noted on the assessment. Record review of Resident #1's nurses' notes dated 5/1/15 at 11:16 a.m., revealed documentation by the treatment nurse that during wound care this am, noted patient to have new area to left shin, 100 % slough noted. Called DON to assess. During assessment DON noted purulent drainage and very foul odor. Call placed to MD to notify of transfer to ER. Record review of Resident #1's nurses' notes revealed late entry documentation by DON dated 5/3/15 at 1:39 p.m., treatment nurse notified DON of open area to left shin. Upon assessment noted area approximately 12.7 cm by 13.5 cm with slough in the center approximately 12.0 cm by 13.1 cm. Copious amount of purulent drainage with foul odor. Not able to palpate femoral, popliteal or pedal pulse. Resident denied pain. 2+ [MEDICAL CONDITION] to left lower extremity. Notified MD with orders received to send resident to ER. Record review of Resident #1's hospital physical examination dated 5/1/15 revealed, a [AGE] year old male with history of [MEDICAL CONDITION], presents to ER today [MEDICAL CONDITION] and wet Gangrene of the left lower extremity of unknown etiology. Review also revealed Resident #1 had multiple white plaques on shaft of penis, and multiple small area of skin breakdown on posterior buttocks. The hospital documents revealed the resident did not know how long the wound on the left shin had been there and the resident was unkempt and appeared not to have had personal care for a period of time. Further review of the record revealed a plan of an emergent [MEDICAL CONDITION] due [MEDICAL CONDITION]. Observation on 5/2/15 at 1:00 p.m., Resident #1 at the hospital revealed he was alert and oriented, and responded to asked questions appropriately. Left below knee amputation was noted with stomp wrapped. Resident #1 had long and dirty fingernails with a buildup of a black substance underneath the nails. He had a grown and untrimmed beard. His skin was dry and appeared unkempt. The resident was in the intensive care unit for continuous observation. Interview on 5/2/15 at 1:00 p.m., Resident #1 said he was transferred to the hospital yesterday and the doctors removed his left lower leg due to some infection and poor circulation. He said he received wound care to his left lateral ankle daily at the facility. Interview on 5/3/15 at 1:40 p.m., the DON said the treatment nurse performed daily dressing change to the venous ulcer on Resident #1's left lateral ankle. She explained the area found on 5/1/15 was new according to the treatment nurse. The DON said she interviewed the treatment nurse who reported it was the first time she saw the area despite new necrotic area was on Resident #1's left shin with a foul odor. The DON said the facility, after this discovery, had performed skin assessments on all at risk residents and staff training was initiated immediately to ensure prompt reports and notifications of skin issues. The DON reported inconsistencies were identified with the Treatment Nurse ' s written documentation of the left foot ' s wound measurements and even the location. The facility Treatment Nurse resigned immediately after the discrepancies were identified. Attempts made to interview the treatment nurse on 5/2/2015 and 5/3/2015 were not successful. She did not answer the phone when called and did not return calls when message left. Interview on 5/3/15 at 3:00 p.m., the facility Corporate Nurse said the treatment nurse was hired a couple of weeks prior to the above incident and was given adequate training prior to her duty resumption. She expressed the treatment nurse had resources available for her if she was in doubt or unsure of her findings. she explained the previous DON was responsible for monitoring and evaluating the treatment Nurse's performance and wound management. The Corporate nurse explained the current DON had been in the facility for just a few days and would be responsible for the monitoring or over seeing the wound care, nurse's training and competence of skills verifications. Record review of an in-service attendance record dated 5/3/15 by the DON revealed in part the following program content which included instruction that weekly skin assessments were to be completed by the charge nurse and documented in the computer. The CNA ' s were to utilize the shower sheets to identify all open areas, sign the shower sheet, notify the charge nurse immediately, and turn the shower sheet into the DON. The nurse was to review the shower sheets, follow-up with documentation/communication the CNA has informed you of. Once the shower sheet had been evaluated by the nurse it was to be signed and submitted to the DON. Interview on 5/14/15 at 9:40 A.M. the DON stated she had two ADON ' s and they were to complete the weekly head to toe skin assessments on all residents not identified as having skin issues. She said she had recently hired a new treatment nurse who started today (5/14/15) and she would be responsible for the skin assessments on those residents with identified wounds. She stated Resident #1 returned to the facility on [DATE]. Observation of wound care to the stump for Resident #1 on 5/14/15 at 10:10 A.M. revealed LVN #1 gloved without hand hygiene prior to starting the wound care. LVN #1 had her clean supplies on wax paper and she placed them on the resident ' s bed. She removed and discarded the old dressing from the resident ' s left lower extremity surgical wound site and the dressing was soiled with drainage. In removing one dressing it was somewhat adhered to the resident ' s skin and LVN #1 picked up a clean gauze from the supplies on the resident ' s bed and placed the gauze under the wound and poured a small amount of normal saline over the old gauze to loosen it so it could be removed without pulling on the resident ' s skin. She then used the gauze that was under the wound to cleanse around the resident ' s wound. LVN #1 picked up another gauze, moistened it with normal saline and cleansed the wound several times with the same gauze. She repeated this two more times. LVN #1 changed gloves without performing hand hygiene in between glove changes and picked up and placed clean dressing over the incision. She retrieved a package of soft (kling) gauze from her pocket, opened it and wrapped the dressing to the hold it in place. She did this twice. LVN #1 then gathered the dirty dressings in a red plastic bag as well as the remaining clean supplies and took them out of the room. She did not wash her hands until prompted by the treatment nurse. She took the bottle of normal saline out of the resident ' s room and replaced it in her medication cart. In an interview with LVN #1 immediately after the treatment she stated she had worked in Hospice services for a number of years prior to working at the facility and had not had to perform wound care in a number of years. She was unable to identify any issues with the way the treatment was performed. She said she had no wound care training and no in-services on wound care, performing treatments or performing skin assessments in the past two weeks. Interview on 5/14/15 at 10:50 A.M. ADON #1 stated she had not received any instruction on a plan for the ADON ' s to complete weekly head-to-toe skin assessments and she had not completed any. Interview on 5/14/15 at 2:30 P.M. the DON stated she had spoken to the wound care physician who was in the facility at the time and he was going to observe the treatment nurse perform wound care and he would evaluate her performance. She said the wound care physician also stated he would conduct an in-service for the nursing staff on wound care and the DON would need to contact his office to schedule a date. The DON stated she was not aware of any competencies for nursing staff for wound and skin treatments. She also stated LVN #1 would not be doing any more treatments until she had been checked off by her or one of the corporate wound care nurses. The DON stated she would have all of the skin assessments done on everyone by 5/16/15. Record review on 5/18/2015 revealed there were 32 residents on the 3rd floor. There were 9 residents identified with wounds/skin issues. Continued review with the DON revealed there were 23 residents who had not received a head to toe skin assessment the week of 5/3-5/9 and the week of 5/10-5/16/15. There were 3 residents documented as a refusal for skin assessment and 4 residents with no skin assessment documented for both of the two weeks in May. Interview with the DON on 5/18/15 at 10:00 A.M. the DON did not have a response as to why skin assessments had not been consistently done on residents for the past two weeks. She stated she was aware every resident in the facility was to have a skin assessment done after the incident with Resident #1 and she thought the ADON ' s were doing them. She stated she should have followed up to make sure all of the assessments were done. The DON said the corporate nurse would be doing in-servicing and competencies for all nursing staff. She said the corporate nurse was wound care certified. Record review of facility's policy on Resident Rights dated 5/2007 revealed that the employees of the facility would take action to protect and prevent neglect from occurring by having knowledge of the individual resident's care needs. An IJ was identified and the Administrator was notified on 5/18/2015 at 12:10 P.M. A Plan of Removal (POR) was submitted and accepted on 5/19/2015. The IJ was removed on 5/20/2015. The POR included: Systemic Change to Prevent Re-Occurrence 1. A full skin assessment on 100% of the residents was initiated on 5/18/15 at 1:00 pm to identify any resident with wounds that facility was not previously aware of. DON, ADONs, treatment nurse and RN resource nurse are participating in the skin assessment. At conclusion of skin assessment, any new wound issues will be reported to resident ' s attending physician by treatment nurse, DON or ADONs. Care plans for new wounds will be updated immediately to reflect current skin status and interventions. 2. All licensed nurses will be in-serviced by RN Resource (corporate consultant nurses) and LVN WCC (Wound Care Certified) on wound care assessment, treatment and policy by 5-19-15. No nurse will be allowed to assess or do a treatment until in-service and treatment competency checklist is completed. In-service will include the guidelines from the NPUAP (National Pressure Ulcer Advisory Panel) as referenced in F314 in the SOM, support surfaces, and turning and repositioning based on assessment. 3. A competency check to be completed on Treatment Nurse, weekend Treatment Nurse, DON, ADONs, day and evening nurses by 5:00p 5/18/15. All other licensed nurses to be completed by 12 noon on 5-19-15. Competency check will be conducted by a LVN from sister facility who is Wound Care Certified. Nurses who do not pass competency check will be retrained, then competency rechecked. Nurses who cannot pass competency checks will not be allowed to assess skin or do wound treatment. 4. As of 5/18/2015, upon admission, each resident will have skin assessment conducted by facility designated treatment nurse. The LVN WCC (Wound Care Certified) from sister facility will in-service treatment nurse to conduct skin assessment upon admission. 5. As of 5/18/2015, for residents identified with current wounds; weekly measurement and observation/assessment will be completed by the Treatment Nurse rounding with Wound Physician. Attending physicians will be contacted for residents ' wounds that are not showing progress toward healing. 6. As of 5/18/2015, weekly head to toe skin assessment will be conducted on all residents by the treatment nurse. For any resident identified with a new wound issue, physician and family will be notified. 7. As of 5/18/2015, CNAs will observe any skin issues observed during resident showers. A resident shower sheet will be completed by CNAs and given to charge nurses to initiate wound assessment. CNAs will be in-serviced by DON and ADONs on skin shower observations to be completed by 5-19-15. Residents who refuse shower will be offered bed bath by CNA, at which time skin assessment with licensed nurse will be completed. If a resident consistently refuses to shower and bathe in bed, nursing administration, their physician and their RP will be notified. Their Care Plan will be updated to reflect their refusal. The social worker will be notified to setup a care plan meeting with the RP. 8. As of 5/18/2015 and ongoing, DON and/or ADON will ensure daily treatments are occurring per order by direct observation of all wound treatments/and or dressing until compliance with facility treatment procedure. TARs will be printed and placed in QA binder for DON and/or ADON to initial after monitoring observation has occurred. Weekend Treatments observation/monitoring will be assigned and rotated with DON, and ADONs, until compliance with facility treatment procedures is achieved. 9. As of 5/18/2015 and ongoing, DON and/or ADON will review new Admissions with 24 hours of admission to ensure wound assessment completed per policy. 10. As of 5/18/2015, Treatment nurse will prepare weekly skin report with list of all residents with current wounds by site/stage. The report will go to the DON for review Monitoring of the POR: Record review of the facility ' s skin assessment, shower/bathing observations, completing/documentation on shower sheets, wound care and staff competency checks in-services dated 5/19/15 through 5/20/15 revealed about 95 % of facility nursing staff including CNAs, MAs, LVNs, RNs, and Weekend Supervisors on three of three shifts were in-serviced. LVNs and RNs had received competency checks from wound care certified nurse. Interviews on 5/20/15 revealed 25 nursing staffs on two of three shifts were interviewed on shower/bathing observations, completing shower/bathing sheets, notifying charge nurse/DON of care refusal, skin assessment and documentation, and wound care/documentation of treatment. All staff members interviewed had been in-serviced and were able to identify the protocols implemented. Record review of Resident #1' s skin assessment was updated as well as skin assessment for all residents on both 200 and 300 halls this was completed on 5/19/15 and 5/20/15. Record review of Resident #1' s care plan as well as all residents with wounds and skin issues were updated on 5/19/15 through 5/20/15. Observations on 5/20/15 at 8:30AM revealed Resident #1 was in his room eating breakfast; left below knee stomp was wrapped. Resident #1 had follow -up appointment on 5/21/15. Resident #1 expressed no negative concerns. Record review of the facility's policy on skin assessment not dated revealed the facility will assess all residents upon admission, when a comprehensive assessment is required , quarterly thereafter to identify risk of skin breakdown. All resident will be assessed for skin risk using a pressure ulcer risk assessment form (Braden, Norton or facility specific) within 24 hours of the time of admission by a licensed nurse. Residents will be re-assessed for skin when a comprehensive assessment is requires and quarterly and thereafter. Nursing and dietary will monitor dietary intake and weight patterns on an ongoing basis to identify residents at risk for malnutrition and skin breakdown. The care plan will be updated and implemented based on the needs identified by the comprehensive assessments the and score on the pressure ulcer risk assessment form. Record review of the facility's policy on skin inspection ,shower day not dated revealed this facility will identify any pertinent skin issues with residents during routine inspection of residents at shower/bath times. CNAs will document all skin issues that he/she observes on the resident as the resident ' s shower, tub or bed bath is given. CNAs will document these issues using the skin assessment -shower form. DON signs off on the form. Record review on 5/20/2015 of 100% of the resident's records revealed all had skin assessments conducted between 5/18/2015 and 5/20/2015. Observations on 5/20/2015 of sampled residents on both floors revealed accurate skin assessments documented. Observation of wound care on 5/ 5 by new treatment nurse revealed good infection control technique. The Administrator was informed on 5/20/2015 at 11:57 A.M. that the IJ was lowered after verification of the POR implementation had occurred. While the IJ was lowered on 5/20/2015, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. The facility was continuing to monitor and train staff on skin assessments and wound care. The DON reported there were eight residents with wounds.

Based on observations, record review and interviews the administration failed to manage the facility in a manner that enabled it to use the facility ' s resources effectively to maintain the highest practicable physical well-being of 1 of 32 residents (Resident #1) who were reviewed for having the highest physical and mental well-being because of the effective management of the facility. The Administrator failed to supervise the DON and assist with the development and implementation of effective policies and procedures on identifying skin issues for all residents. The Administrator failed to supervise the DON on ensuring staff were trained on performing accurate weekly skin assessments, the correct and timely identification of skin issues, performing wound care and procedures to follow when a resident refused care. The DON failed to verify all staff were competent in performing skin assessments and wound care. The DON failed to train staff on what steps to take when a resident refused care. An IJ was identified on 5/18/2015. While the IJ was removed on 5/20/2015 the facility remained out of compliance at a scope of isolated and a severity level of actual harm. This failure affected one resident who required an emergency leg [MEDICAL CONDITION] and placed eight residents with wounds at risk of wounds deteriorating due to poor wound care or new wounds not being treated due to inadequate or lack of skin assessments. These failures could cause the residents to have a rapid decline in health due to a serious infection. Findings include: Intake # 8 Record review of Resident #1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #1 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. On 5/1/15, a necrotic area approximately 12.7 cm by 13.5 cm with 100 % slough was identified on Resident #1's left shin. Resident #1 also developed multiple open areas on his buttocks which the facility were not treating. The area had purulent drainage with a foul odor. Resident #1 was transferred to the hospital where an emergency [MEDICAL CONDITION] was performed on the left lower leg. Interview on 5/19/15 at 9:50 A.M. the Administrator stated he was not aware there were issues with skin assessments not being conducted on residents. He stated he found out about the incident with Resident #1 after the resident went to the hospital. He stated that was when he also found out the treatment nurse was not doing her job. He said this had not been identified as a problem prior to the issue with Resident #1 and therefore was not part of QA. He stated he trusted the DON to ensure staff were working within their job descriptions and performing their duties as expected. He said when he was told by the DON on 5/15/15 by e-mail all the assessments were completed he did not follow-up to ensure they had been done. He said he did not want to micro-manage the staff. He also said he would make sure to be more involved in holding managers accountable by asking more questions, following up with department heads on issues discussed at morning meetings and make more frequent rounds to discuss issues with staff on the units. Interview on 5/3/15 at 1:40 p.m., the DON said the treatment nurse performed daily dressing change to the venous ulcer on Resident #1's left lateral ankle. She explained the area found on 5/1/15 was new according to the treatment nurse. The DON said she interviewed the treatment nurse who reported it was the first time she saw the area despite new necrotic area was on Resident #1's left shin with a foul odor. The DON said the facility, after this discovery, had performed skin assessments on all at risk residents and staff training was initiated immediately to ensure prompt reports and notifications of skin issues. The DON reported inconsistencies were identified with written documentation of wound measurements, and locations . The facility treatment Nurse resigned immediately after the discrepancies were identified. Record review of an in-service attendance record dated 5/3/15 by the DON revealed in part the following program content which included instruction that weekly skin assessments were to be completed by the charge nurse and documented in the computer. The CNA ' s are to utilize the shower sheets to identify all open areas, sign the shower sheet, notify the charge nurse immediately, and turn the shower sheet into the DON. The nurse is to review the shower sheets, follow-up with documentation/communication the CNA has informed you of. Once the shower sheet had been evaluated by the nurse it was to be signed and submitted to the DON. Interview on 5/14/15 at 9:40 A.M. the DON stated she had two ADON ' s and they were to complete the weekly head to toe skin assessments on all residents not identified as having skin issues. She said she had recently hired a new treatment nurse who started today (5/14/15) and she would be responsible for the skin assessments on those residents with identified wounds. Interview on 5/14/15 at 10:50 A.M. ADON #1 stated she had not received any instruction on a plan for the ADON ' s to complete weekly head-to-toe skin assessments and she had not completed any. Interview on 5/14/15 at 2:30 P.M. the DON stated she had spoken to the wound care physician who was in the facility at the time and he was going to observe the treatment nurse perform wound care and he would evaluate her performance. She said the wound care physician also stated he would conduct an in-service for the nursing staff on wound care and the DON would need to contact his office to schedule a date. The DON stated she was not aware of any competencies for nursing staff for wound and skin treatments. The DON stated she would have all of the skin assessments done on everyone by 5/16/15. Record review on 5/18/2015 revealed there were 32 residents on the 3rd floor. There were nine residents identified with wounds/skin issues. Continued review with the DON revealed there were 23 residents who had not received a head to toe skin assessment the week of 5/3-5/9 and the week of 5/10-5/16/15. There were three residents documented as a refusal for skin assessment and 4 residents with no skin assessment documented for May 2015. Interview with the DON on 5/18/15 at 10:00 A.M. the DON did not have a response as to why skin assessments had not been consistently done on residents for the past two weeks. She stated she was aware every resident in the facility was to have a skin assessment done after the incident with Resident #1 and she thought the ADON ' s were doing them. She stated she should have followed up to make sure all of the assessments were done. The DON said the corporate nurse would be doing in-servicing and competencies for all nursing staff. She said the corporate nurse was wound care certified. Interview on 5/18/15 at 10:30 A.M. the Administrator stated he did not know there was a problem with the skin assessments. He stated he was aware of the issues surrounding Resident #1 and all residents were to have a head-to-toe skin assessment and he was informed by the DON that it had all been taken care of. He further stated the company had plenty of resources to assist Administration and nursing. Interview on 5/19/15 at 10:40 A.M. the DON stated she had directed the ADON ' s to complete the head-to toe assessments for residents on the second and third floor but she did not follow-up to make sure it was completed. She further stated she did not have a specified plan or timeline on which residents to assess and assumed the task would be completed. The DON stated she should have made sure the skin assessments were done as well as competencies to ensure staff were able to perform the tasks. She further stated there were resources available sure as regional resources, staff at sister facilities to ask for ideas and suggestions, physicians and the medical director. An IJ was identified and the Administrator was notified on 5/18/2015 at 12:10 P.M. A Plan of Removal (POR) was submitted and accepted on 5/19/2015. The IJ was removed on 5/20/2015. The POR included: Systemic Change to Prevent Re-Occurrence 1. A full skin assessment on 100% of the residents was initiated on 5/18/15 at 1:00pm to identify any resident with wounds that facility was not previously aware of. DON, ADONs, treatment nurse and RN resource nurse are participating in the skin assessment. At conclusion of skin assessment, any new wound issues will be reported to resident ' s attending physician by treatment nurse, DON or ADONs. Care plans for new wounds will be updated immediately to reflect current skin status and interventions. 2. All licensed nurses will be in-serviced by RN Resource (corporate consultant nurses) and LVN WCC (Wound Care Certified) on wound care assessment, treatment and policy by 5-19-15. No nurse will be allowed to assess or do a treatment until in-service and treatment competency checklist is completed. In-service will include the guidelines from the NPUAP (National Pressure Ulcer Advisory Panel) as referenced in F314 in the SOM, support surfaces, and turning and repositioning based on assessment. 3. A competency check to be completed on Treatment Nurse, weekend Treatment Nurse, DON, ADONs, day and evening nurses by 5:00p 5/18/15. All other licensed nurses to be completed by 12 noon on 5-19-15. Competency check will be conducted by a LVN from sister facility who is Wound Care Certified. Nurses who do not pass competency check will be retrained, then competency rechecked. Nurses who cannot pass competency checks will not be allowed to assess skin or do wound treatment. 4. As of 5/18/2015, upon admission, each resident will have skin assessment conducted by facility designated treatment nurse. The LVN WCC (Wound Care Certified) from sister facility will in-service treatment nurse to conduct skin assessment upon admission. 5. As of 5/18/2015, for residents identified with current wounds; weekly measurement and observation/assessment will be completed by the Treatment Nurse rounding with Wound Physician. Attending physicians will be contacted for residents ' wounds that are not showing progress toward healing. 6. As of 5/18/2015, weekly head to toe skin assessment will be conducted on all residents by the treatment nurse. For any resident identified with a new wound issue, physician and family will be notified. 7. As of 5/18/2015, CNAs will observe any skin issues observed during resident showers. A resident shower sheet will be completed by CNAs and given to charge nurses to initiate wound assessment. CNAs will be in-serviced by DON and ADONs on skin shower observations to be completed by 5-19-15. Residents who refuse shower will be offered bed bath by CNA, at which time skin assessment with licensed nurse will be completed. If a resident consistently refuses to shower and bathe in bed, nursing administration, their physician and their RP will be notified. Their Care Plan will be updated to reflect their refusal. The social worker will be notified to setup a care plan meeting with the RP. 8. As of 5/18/2015 and ongoing, DON and/or ADON will ensure daily treatments are occurring per order by direct observation of all wound treatments/and or dressing until compliance with facility treatment procedure. TARs will be printed and placed in QA binder for DON and/or ADON to initial after monitoring observation has occurred. Weekend Treatments observation/monitoring will be assigned and rotated with DON, and ADONs, until compliance with facility treatment procedures is achieved. 9. As of 5/18/2015 and ongoing, DON and/or ADON will review new Admissions with 24 hours of admission to ensure wound assessment completed per policy. 10. As of 5/18/2015, Treatment nurse will prepare weekly skin report with list of all residents with current wounds by site/stage. The report will go to the DON for review Monitoring of the POR: Record review of the facility ' s skin assessment, shower/bathing observations, completing/documentation on shower sheets, wound care and staff competency checks in-services dated 5/19/15 through 5/20/15 revealed about 95 % of facility nursing staff including CNAs, MAs, LVNs, RNs, and Weekend Supervisors on three of three shifts were in-serviced. LVNs and RNs had received competency checks from wound care certified nurse. Interviews on 5/20/15 revealed 25 nursing staffs on two of three shifts were interviewed on shower/bathing observations, completing shower/bathing sheets, notifying charge nurse/DON of care refusal, skin assessment and documentation, and wound care/documentation of treatment. All staff members interviewed had been in-serviced and were able to identify the protocols implemented. Record review of Resident #1 ' s skin assessment was updated as well as skin assessment for all residents on both 200 and 300 halls this was completed on 5/19/15 and 5/20/15. Record review of Resident #1 ' s care plan as well as all residents with wounds and skin issues were updated on 5/19/15 through 5/20/15. Observations on 5/20/15 at 8:30AM revealed Resident #1 was in his room eating breakfast; left below knee stomp was wrapped. Resident #1 had follow -up appointment on 5/21/15. Resident #1 expressed no negative concerns. Record review of the facility's policy on skin assessment not dated revealed the facility will assess all residents upon admission, when a comprehensive assessment is required , quarterly thereafter to identify risk of skin breakdown. All resident will be assessed for skin risk using a pressure ulcer risk assessment form (Braden, Norton or facility specific) within 24 hours of the time of admission by a licensed nurse. Residents will be re-assessed for skin when a comprehensive assessment is requires and quarterly and thereafter. Nursing and dietary will monitor dietary intake and weight patterns on an ongoing basis to identify residents at risk for malnutrition and skin breakdown. The care plan will be updated and implemented based on the needs identified by the comprehensive assessments the and score on the pressure ulcer risk assessment form. Record review of the facility's policy on skin inspection ,shower day not dated revealed this facility will identify any pertinent skin issues with residents during routine inspection of residents at shower/bath times. CNAs will document all skin issues that he/she observes on the resident as the resident ' s shower, tub or bed bath is given. CNAs will document these issues using the skin assessment -shower form. DON signs off on the form. Record review of 100% of the residents records revealed all had skin assessment completed between 5/18/2015 and 5/20/2015 Observation of sampled residents on both floors revealed accurate skin assessments documented. Observation of wound care by the new treatment nurse on 5/20/2015 revealed good infection control technique. The Administrator was informed on 5/20/2015 at 11:57 A.M. that the IJ was lowered after verification of the POR implementation had occurred. While the IJ was lowered on 5/20/2015, the facility remained out of compliance at a scope of isolated and a severity level of actual harm. The facility was continuing to monitor and train staff on skin assessments and wound care. Refer to F224 and F30 for additional evidence. The DON reported there were eight residents with wounds.

Based on interview, and record review the facility failed to consult with the physician regarding anticoagulant and antiplatelet use when Resident #17 had a fall with injury on [DATE], and when Resident #17 had a change in condition on [DATE] at 8:45 a.m.; for 1 of 18 residents (#17). --Resident #17 sustained a fall with injury on [DATE]. The resident was on [MEDICATION NAME] (prevents the blood from clotting) which was on hold due to a high PT/INR. Resident #17 exhibited changes in condition on [DATE] at 8:45 a.m. and 12:45 p.m. and LVN R failed to notify his physician of the change. He was sent to the hospital on [DATE] when he became unresponsive at 3:51 p.m. He died on [DATE] with a primary cause of death being [MEDICAL CONDITION] subdural hematoma. --LVN B failed to review all medications with the doctor after the fall to determine if Resident #17's antiplatelet therapy, [MEDICATION NAME] (prevents platelet aggregation) should be held. --Staff failed to revise and update Resident #17's plan of care interventions after previous falls on [DATE] and [DATE]. Staff documented having a bed alarm in place when one was not in place. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:39 p.m. While the IJ was removed on [DATE] at 7:12 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. This failure affected 1 resident and placed 3 residents receiving anticoagulants at risk of injury, hospitalization , delayed treatment, and death. Intake # 8 Findings Include: Record review of Resident #17's closed record admission sheet revealed he was an [AGE] year old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed he required the extensive assistance of one staff for bed mobility and walking in his room. He required the extensive assistance of two staff for transfers. He had bilateral lower extremity impairments. He used a wheelchair for mobility. He was not steady, only able to stabilize with staff assistance when moving from a seated to standing position. He had no restraints. During a telephone interview on [DATE] at 11:56 a.m. the complainant said Resident #17 fell and hit his head. The complainant said the facility did not call 911. During additional telephone interview on [DATE] at 1:00 p.m. with the complainant, the complainant said the death certificate had been received. The complainant said Resident #17 expired on [DATE] with a primary cause of death of [MEDICAL CONDITION] subdural hematoma and a secondary cause of death of coagulopathy related to [MEDICATION NAME]. The complainant said she did not have access to a fax machine and was mailing the Death Certificate to the Texas Department of Aging and Disability Services. During an interview on [DATE] at 2:16 p.m., with LVN B when asked about Resident #17's fall on [DATE] she said, he had a fall. She said she and 3 aides performed his transfer back to bed. She said he was talking and denied pain. She said he had a cut on his eyebrow approximately 1 cm. She said she assessed him again after the transfer. She said she reported the fall to NP A and did not receive an order to send him out. She said she and NP A knew he was on [MEDICATION NAME]. She said they had been having trouble controlling his INR level. When asked if she thought it was odd that he was not sent out she said yes but that his neurological vital signs were normal. She said NP A told her to call back if he had any change in his neurological vital signs. When asked if she called the DON to ask about not receiving an order to send the resident out, she said no because she did not think she would get an answer. Record review of Resident #17's print out of computer physician orders [REDACTED]. Record review of Resident #17's incident/accident report dated [DATE] revealed, "...Upon entering residents room this writer (LVN B) observed resident laying on the floor on the side of bed on right side of bed on right side approx. (approximately) 60 cc (cubic centimeters) of dark red fluid noted on floor. V/S ,[DATE] (blood pressure) 95 (heart rate) 20 (respiratory rate) SpO2 (oxygen saturation) 97% in (sic) room air 97.2 AX (axillary temperature) Resident S/T (skin tear) 1 cm (centimeter) W (wide) by 1 cm (L) (length) by 1 cm (D) (depth) noted above right eyebrow resident denies pain cleansed dried TAO (triple antibiotic ointment) and bordered dressing applied Neuro (neurological) checks in progress resident resting stable DPOA (Durable Power of Attorney) (name) notified ' "I was trying to get up." '... "...S/T treated new orders noted MD (Medical Doctor) and RP (Responsible Party) notified ..." There was no documentation of whether his bed alarm was in place. During an interview on [DATE] at 2:52 p.m. with the DON she said Resident #17 was not sent to the hospital due to his neurological vital signs were normal and he was responsive. She said since the incident they had changed their policy. She said the new policy was that if a resident on [MEDICATION NAME] had a fall they were to be sent out to the hospital. When asked if they had a protocol for nurses for when they receive orders they disagree with she said they do. She said if a staff member disagrees with an order received, they are to call her and she can override a decision such as whether to send a resident out. When asked if LVN B called her the evening Resident #17 had the fall, she said no. Record review of Resident #17's Neurological Flow Sheet dated [DATE] revealed neurological checks had been initiated on [DATE] at 7:00 p.m. and checked again at 7:15 p.m., 7:30 p.m., 7:45 p.m., 8:15 p.m., 8:45 p.m., 9:15 p.m., 9:45 p.m., 10:45 p.m., 11:45 p.m., 12:45 a.m. ([DATE]), 4:45 a.m., 8:45 a.m. and at 12:45 p.m. Staff failed to change the date from [DATE] to [DATE] after passing midnight on [DATE]. Continued review of Resident #17's Neurological Flow Sheet dated [DATE] revealed Resident #17's pupil size in both eyes was documented as being a consistent 3 mm (millimeters) from 7:00 p.m. on [DATE] through 4:45 a.m. on [DATE]. At 8:45 a.m. and 12:45 p.m. on [DATE] his pupil size changed to 4 mm. The Neurological Flow Sheet contained instructions to staff to, "...Notify MD IMMEDIATELY of signs and symptoms of intracranial Pressure!!!..." The documentation reflected a change in the resident's condition on [DATE] at 8:45 a.m. There was no documentation of physician notification until [DATE] at 3:51 p.m. Record review of http://medical-dictionary.thefreedictionary.com for intracranial pressure revealed, "...Changes in pupil size, equality, and reaction to light, and extraocular movements are indicative of compression of the third, fourth, and sixth cranial nerves. Assessment of these changes should be as accurate and objective as possible. Unilateral and bilateral evaluations are important and usally are recorded by a drawing of the actual size of each pupil or by precise measurements using a small metric ruler. ... During an interview on [DATE] at 10:02 a.m. with the DON when asked if a change in pupil size from 3 mm to 4 mm should have been called to the doctor she said yes. When asked if anyone had asked the doctor about also holding Resident #17's [MEDICATION NAME] she said, "I don't think so." A voice mail message was left for LVN R on [DATE] at 10:30 a.m. LVN R left a return message and was called for a telephone interview on [DATE] at 1:19 p.m. LVN R said she should have corrected the date on her neuro vital signs monitoring sheet to [DATE] since it was [DATE]. When asked if she reported the change in pupil size from 3 mm to 4 mm to Resident #17's doctor she said no. She said she did not call the doctor to report the change. When asked if she had been interviewed during the facility's investigation of the incident she said no. She said she cared for Resident #17 for 7 hours on [DATE] and that he had not had any additional falls. She said she went into the room to help the aide clean him up and he was gurgling and threw up. She said he had not wanted to eat that day. She said he had voiced no complaints of pain or nausea. When asked again if she reported the change in his pupil size to the doctor she again said she did not call the doctor. During a telephone interview on [DATE] at 10:37 a.m. with Physician A, who is also the Medical Director, he said if a resident hit their head and had a high INR he should have been sent out. He said, "That's the standard." When asked if he was consulted about if the [MEDICATION NAME] should be held and whether he was informed of Resident #17's change in condition on [DATE] at 8:45 a.m. when Resident #17's pupil size changed, he said he would call back on Monday, [DATE]. Physician A did not call back as of 5:00 p.m. on [DATE]. Record review of the Provider Investigation Report dated [DATE] revealed on [DATE] at 7:00 p.m. Resident #17 had an unwitnessed fall. A description of the Allegation included that on [DATE], (Resident #17) was observed lying on his right side on the floor by his bed by Nurse (LVN B). On [DATE] @ 3:51 p.m. (Resident #17) was noted to be unresponsive to physical stimuli. (Resident #17) was gurgling when repositioned on his right side (Resident #17) vomited a large amount of brown fluid with 2 small blood clots. The physician was then notified and the resident was sent out via 911. Record review of Resident #17's Nursing Progress Notes dated [DATE] revealed there was no documentation of Resident #17's medications being reviewed with his physician or nurse practitioner after his fall with injury on [DATE]. Record review of Resident #17's Nursing Progress notes revealed there was no documentation of Resident #17's change in condition (pupil size) being reported to the doctor. A note dated [DATE] 08:41 read, "...Resident in the bed s/p (status [REDACTED]. neuro (neurological) checks in progress and wnl (within normal limits). will cont (continue to monitor. ..." Record review of Resident #17's Nursing Progress notes dated [DATE] 15:51 (3:51 p.m.) revealed, "...resident in room unresponsive attempted the sternum rub, no respond (sic) v/s ,[DATE] (blood pressure) 109 (unclear if heart rate) 98 (unclear if temperature) O2 room air 94% BS (blood sugar) 131 noted that resident was (sic) gurgling (sic) turned resident on to his rt (right) side resident started to vomit excessive amount brown fluids with two small red clots notified Dr (Physician A) Spoke to (NP B) NP send resident out 911. stretcher with EMS (emergency medical services) in stable condition. Notified (family member) she stated ok. Notified (name of DON) DON she stated ok. ... " Record review of the facility's policy and procedure for Falls revised ,[DATE] revealed there was no directive for a resident on anticoagulants having a fall. Record review of the facility's policy and procedure for Post Fall Assessment revised ,[DATE] revealed, "...An incident Report and a Fall Investigation, Post Form will be completed by a Licensed Nurse on the shift that the fall occurred The Licensed Nurse will complete the form as follows: ...6. Identify an action plan or approaches to be taken in an attempt to prevent further falls based on newly identified facts or risk factors. ...7. Document on the post fall assessment form that the care plan was updated to reflect new action plan or approaches for prevention of falls. ...ignificant (sic) information obtained as a result of the post fall assessment should be reported to the physician, and documented in the edical (sic) Records. ..." Record review of the facility's policy and procedure for Neurological Evaluation revised ,[DATE] revealed, "...All incidents involving trauma to the head will result in a comprehensive neurological assessment for a minimum of seventy-two (72) hours. ...7. Pupil Signs A. Look at pupils and compare size and equality. b. sing (sic) an overhead light, simultaneously compare the size of the pupils and their reaction to light. C. If flashlight is used, shine directly into eye being examined while other eye is covered. ..." The policy and procedure did not address consulting the doctor about changes. Record review of the facility's policy and procedure for Monitoring for Significant Change in Condition revised ,[DATE] revealed, "...8. Physician, resident, and responsible party will be notified of the significant change. ..." An IJ was identified on [DATE] at 4:39 p.m. and the Administrator, Regional Clinical Nurse A, Regional Clinical Nurse B, DON, Operations Manager, and Executive Director B were informed at that time. During an interview with them at that time, they all said they did not know why the night shift had not received the in-service. A Plan of Removal (PoR) for the IJ was submitted [DATE] and after revisions was accepted on [DATE] at 2:15 p.m. The PoR included: D. Revised the Policy and Procedure on Falls with residents on anticoagulants on [DATE] at 5:00 p.m.. E. The nurse will notify the DON and the resident physician if the resident neuro vital signs or his/her condition change immediately. F. Post Fall Procedure will include a review and update of resident care plans and medication and appropriate interventions will be put in place. 3.) Training A. License nurses will be In-serviced on Fall precautions, Change of condition, treatment of [REDACTED]. In- service started on [DATE] and will be completed by 11:00 p.m. on [DATE]. Training will be provided by Director of Nursing or designee. During an interview on [DATE] at 3:56 p.m. with Regional Clinical Nurse A she said she was now the acting DON for the weekend and a new DON would be starting on Monday, [DATE]. She said all nurses had been in-serviced except for one who would not be allowed to return to work until being in-serviced. She said none of the 3 current residents on anticoagulants had any falls. She said she had reviewed anti-coagulant monitoring. She said the QAA committee met last night, [DATE], including the Medical Director, Physician A, via telephone. She said Physician A agreed any resident on an anti-coagulant who had a fall was to be sent out to the emergency room . During an interview on [DATE] at 4:59 p.m. with LVN H she said she had received in-service training about residents with falls on anticoagulants. She was able to describe the training and what to do. During an interview on [DATE] at 5:13 p.m. with LVN E she said she was in-serviced yesterday, [DATE]. She was able to describe the training and the facility s policy on residents who had a fall and were on an anticoagulant. During an interview on [DATE] at 5:25 p.m. with LVN M she said she had received in-service training yesterday, [DATE]. She was able to describe the training and the facility's policy on residents who had a fall and were on an anticoagulant. During an interview on [DATE] at 5:38 p.m. with the Administrator, when asked what type of procedure is there to make sure the nursing needs of residents' are being met, he said they have interdisciplinary team meetings. He said in those meetings they discuss the needs of the residents and standards of care. He said they have daily stand-up meetings and discuss any changes. He said they make daily rounds and interview residents. When asked how he monitors staff, such as the DON, to ensure the systems they monitor are being done sufficiently he said there had been a problem in the facility with monitoring. He said when they realized there were problems they made changes in the nursing team. He said they had been having the Clinical Resources (Regional Clinical Nurses) in the building more. He said they have weekly meetings with department heads. He said to ensure competency of staff they make rounds. He said the Clinical Resources (Regional Clinical Nurses) review matrixes they review such as pressure ulcers, restraints, and falls tracking. He said they also have annual evaluation practices and they set standards. When asked how they evaluate their policy and procedures he said they do that in the Quality Assurance committee and standard care meetings. He said if they have a poor outcome, policies are reviewed in the Quality Assurance committee, including the Medical Director. When asked how they assure the effectiveness of facility processes he said they do it by reviewing results, reevaluate, and make any changes to get the outcomes they hope to achieve. When asked how he thought this immediate jeopardy/substandard quality of care came about he said, "...perhaps we had the wrong leadership in place before and that's why we've made some changes." He said new leadership was now in place. He said a new DON was starting Monday. He said they had a new ADON and a new MDS nurse. When asked if he was aware of the situation he said yes. He said he was informed on Monday, [DATE] that Resident #17 had fallen and of what had been done, for example, calls to the doctor and neurological checks. He said he was concerned. He said he called the hospital Resident #17 had been sent to and was informed Resident #17 had been transferred to another hospital. He said he called the other hospital and was told Resident #17 was not doing well. He said they started their investigation and based on findings, determined they could have done some things differently. He said, "You know, I think, of course, looking in retrospect." He said perhaps reviewing the policy and procedures in place at the time, how situations were handled in the past, and handling patients on anticoagulants. When asked if anyone had questioned the continued administration of [MEDICATION NAME] to Resident #17 he said, to his knowledge, he was not aware of the [MEDICATION NAME] administration being questioned. When asked if he knew if it was questioned during the investigation why the doctor was not notified of the change in Resident #17's pupil size from 3 mm to 4 mm he said he did not know. During an interview on [DATE] at 5:50 p.m. with LVN G she said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she had received in-services on [DATE] over the concerns. She was able to describe the training and new policy. When asked if she were caring for a resident on [MEDICATION NAME] who had a fall, would she review the resident's medications and include that information in a call to the doctor, she said yes. She said, "That's usually one of the first things they ask is are they on any medications other than [MEDICATION NAME]." When asked if a change in the size of pupils from 3 mm to 4 mm is a reportable change in condition she said yes. She said it could indicate an head injury or bleed. During an interview on [DATE] at 6:23 p.m. with LVN B she said she had received in-services on [DATE]. She described the training. She said if a resident is on an anticoagulant and has a fall, you assess the resident, call the doctor and send the resident to the hospital. She said the care plan and medications are to be reviewed. When asked if she would report a change in pupil size from 3 mm to 4 mm when monitoring neurological vital signs she said, "Definitely." She said it could indicate a brain bleed or injury. During an interview on [DATE] at 6:31 p.m. with LVN L she said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she had received the in-services. She was able to describe the training and policy changes. When asked if it would be important to let the doctor know the resident was also taking [MEDICATION NAME], she said, "Of course." When asked about a change in pupil size, she said yes, a change from 3 mm to 4 mm is reportable to the doctor. She said any change of condition is reportable. She said a change in pupil size from 3 mm to 4 mm could indicate a head injury or internal bleeding. The DON was no longer working at the facility. An interview was conducted with Regional Clinical Nurse A on [DATE] at 7:01 p.m. due to she was serving as the interim DON for the weekend. When asked what training was ensured the nurses had in order to care for residents on anticoagulants she said after the incident, she trained staff on anticoagulants, change in condition, change in neurological vital signs, anticoagulants and falls, assessments, and sending a resident to the hospital immediately even if it ' s minor. She said the policy and procedure had been updated and reviewed and approved by the quality assurance committee and the Medical Director, Physician A. She said a previous in-service on anticoagulants had been done at some point but was not tied to falls. She said she also had the nurses identify which residents were on anticoagulants. When asked how she ensured the nurses were competent in their skills for caring for a resident on anticoagulants she said she did a verbal discussion with them and had feedback with them. She said she had them describe what to do if they have a fall; discussed the monitoring log for residents on anticoagulants; discussed what to say to the doctor; and that they needed to reinforce what medications a resident was on and reiterated they needed to ensure awareness of all medications a resident was receiving. When asked what type of plan was in place for residents on anticoagulants she said prior to the incident, they had an anticoagulant policy and procedure and a fall policy and procedure but they did not have them interacting together. When asked had there been any types of in-services on residents on anticoagulants prior to accepting residents on anticoagulants she said there were some in-services done but not on a quarterly basis or a schedule. She did not say when the most recent in-service prior to the incident had been. When asked how she thought the immediate jeopardy/substandard quality of care came about she said, "I think that our policy and procedures were not specific to the fall with anticoagulants," but felt now everyone was more knowledgeable. When asked if any nursing judgment came into play she said, "Yes, following generic protocols." When asked if the doctor should have been notified that Resident #17 was also on [MEDICATION NAME] she said, "I think, as a nurse, doing multiple things probably thought he already knew instead of re-informing him. When asked if a change in the size of pupils from 3 mm to 4 mm should have been called to the doctor she said she would consider the baseline. She said considering and looking at everything in general, "...it probably should have been called." Record review of in-services dated [DATE] and comparison to the active staff nursing roster confirmed training of staff on the new policy with the exception of one as needed staff member. Record review of monitoring logs for anticoagulants confirmed a log for each of the three residents on anticoagulants. Record review of the facility's policy and procedure for Falls revised [DATE] revealed the addition of, "9. If patient is on anticoagulant therapy MD must be notified immediately to consult for emergency room evaluation. ... " The Administrator, Regional Clinical Nurse A, Operations Manager, and Executive Director B were informed on [DATE] at 2:43 p.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. Record review of a list of residents on anticoagulants revealed 3 residents were receiving anticoagulants.

Based on interview, and record review the facility failed to ensure staff consulted with the physician, for 1 of 18 residents (Resident #17), after a fall by failing to review medications with the physician and failed to notify and consult with the physician when a change in condition occurred. --Resident #17 sustained a fall with injury on [DATE]. The resident was on [MEDICATION NAME] (prevents the blood from clotting) which was on hold due to a high PT/INR. Resident #17 had a change in condition on [DATE] at 8:45 a.m. and 12:45 p.m. and LVN R failed to notify his physician of the change. He was sent to the hospital on [DATE] when he became unresponsive at 3:51 p.m. He died on [DATE] with a primary cause of death being [MEDICAL CONDITION] subdural hematoma. --LVN B failed to ask about Resident #17's [MEDICATION NAME] and review all medications with the doctor after the fall to determine if Resident #17's antiplatelet therapy, [MEDICATION NAME] (prevents platelet aggregation) should be held. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:39 p.m. While the IJ was removed on [DATE] at 7:12 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. This failure affected 1 resident and placed 3 residents receiving anticoagulants at risk of injury, hospitalization , delayed treatment, and death. Intake # 8 Findings Include: Record review of Texas Administrative Code Title 22, Part 11, Chapter 217 regarding the Standards of Nursing Practice revealed: Nurses are required to meet the following standards of practice: "... even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; ... (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; ..." Record review of Resident #17's closed record admission sheet revealed he was an [AGE] year old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed he required the extensive assistance of one staff for bed mobility and walking in his room. He required the extensive assistance of two staff for transfers. He had bilateral lower extremity impairments. He used a wheelchair for mobility. He was not steady, only able to stabilize with staff assistance when moving from a seated to standing position. He had no restraints. During a telephone interview on [DATE] at 11:56 a.m. the complainant said Resident #17 fell and hit his head. The complainant said the facility did not call 911. During additional telephone interview on [DATE] at 1:00 p.m. with the complainant, the complainant said the death certificate had been received. The complainant said Resident #17 expired on [DATE] with a primary cause of death of [MEDICAL CONDITION] subdural hematoma and a secondary cause of death of coagulopathy related to [MEDICATION NAME]. The complainant said he/she did not have access to a fax machine and was mailing the Death Certificate to the Texas Department of Aging and Disability Services. During an interview on [DATE] at 2:16 p.m., with LVN B when asked about Resident #17's fall with injury on [DATE] she said, he had a fall. She said she and 3 aides performed his transfer back to bed. She said he was talking and denied pain. She said he had a cut on his eyebrow approximately 1 cm. She said she assessed him again after the transfer. She said she reported the fall to NP A and did not receive an order to send him out. She said she and NP A knew he was on [MEDICATION NAME]. She said they had been having trouble controlling his INR level. When asked if she thought it was odd that he was not sent out she said yes but that his neurological vital signs were normal. She said NP A told her to call back if he had any change in his neurological vital signs. When asked if she called the DON to ask about not receiving an order to send the resident out, she said no because she did not think she would get an answer. Record review of Resident #17's print out of computer physician orders [REDACTED]. to [MEDICAL CONDITION], and [MEDICATION NAME] 75 mg by mouth once daily. Additionally, there were orders for a floor mat at bedside with an order date of [DATE] and bed alarm to alert staff that patient needs assist with transfers dated [DATE]. Record review of the Provider Investigation Report dated [DATE] revealed on [DATE] at 7:00 p.m. Resident #17 had an unwitnessed fall. A description of the Allegation included that on [DATE], (Resident #17) was observed lying on his right side on the floor by his bed by Nurse (LVN B). On [DATE] @ 3:51 p.m. (Resident #17) was noted to be unresponsive to physical stimuli. (Resident #17) was gurgling when repositioned on his right side (Resident #17) vomited a large amount of brown fluid with 2 small blood clots. The physician was then notified and the resident was sent out via 911. During an interview on [DATE] at 2:52 p.m. with the DON she said Resident #17 was not sent to the hospital due to his neurological vital signs were normal and he was responsive. She said since the incident they had changed their policy. She said the new policy was that if a resident on [MEDICATION NAME] had a fall they were to be sent out to the hospital. When asked if they had a protocol for nurses for when they receive orders they disagree with she said they do. She said if a staff member disagrees with an order received, they are to call her and she can override a decision such as whether to send a resident out. When asked if LVN B called her the evening Resident #17 had the fall, she said no. Record review of Resident #17's Neurological Flow Sheet dated [DATE] revealed neurological checks had been initiated on [DATE] at 7:00 p.m. and checked again at 7:15 p.m., 7:30 p.m., 7:45 p.m., 8:15 p.m., 8:45 p.m., 9:15 p.m., 9:45 p.m., 10:45 p.m., 11:45 p.m., 12:45 a.m. ([DATE]), 4:45 a.m., 8:45 a.m. and at 12:45 p.m. Staff failed to change the date from [DATE] to [DATE] after passing midnight on [DATE]. Continued review of Resident #17's Neurological Flow Sheet dated [DATE] revealed Resident #17's pupil size in both eyes was documented as being a consistent 3 mm (millimeters) from 7:00 p.m. on [DATE] through 4:45 a.m. on [DATE]. At 8:45 a.m. and 12:45 p.m. on [DATE] his pupil size changed to 4 mm. The Neurological Flow Sheet contained instructions to staff to, "...Notify MD IMMEDIATELY of signs and symptoms of intracranial Pressure!!!..." Record review of http://medical-dictionary.thefreedictionary.com for intracranial pressure revealed, "...Changes in pupil size, equality, and reaction to light, and extraocular movements are indicative of compression of the third, fourth, and sixth cranial nerves. Assessment of these changes should be as accurate and objective as possible. Unilateral and bilateral evaluations are important and usally are recorded by a drawing of the actual size of each pupil or by precise measurements using a small metric ruler. ... Record review of Resident #17's incident/accident report dated [DATE] revealed, "...Upon entering residents room this writer (LVN B) observed resident laying on the floor on the side of bed on right side of bed on right side approx. (approximately) 60 cc (cubic centimeters) of dark red fluid noted on floor. V/S ,[DATE] (blood pressure) 95 (heart rate) 20 (respiratory rate) SpO2 (oxygen saturation) 97% in (sic) room air 97.2 AX (axillary temperature) Resident S/T (skin tear) 1 cm (centimeter) W (wide) by 1 cm (L) (length) by 1 cm (D) (depth) noted above right eyebrow resident denies pain cleansed dried TAO (triple antibiotic ointment) and bordered dressing applied Neuro (neurological) checks in progress resident resting stable DPOA (Durable Power of Attorney) (name) notified ' "I was trying to get up." '... "...S/T treated new orders noted MD (Medical Doctor) and RP (Responsible Party) notified ..." There was no documentation of whether his bed alarm was in place. During an interview on [DATE] at 10:02 a.m. with the DON Resident #17's bed alarm order was discussed. She said the bed alarm had already been in his physician orders. She said no one had mentioned if his bed alarm had sounded. When asked why there were no intervention changes after his previous falls on [DATE] and [DATE] she said they tried to keep Resident #17 in the common areas and encourage him to stay out and watch television. When asked about the date on Resident #17's [DATE] neurological vital signs check documentation sheet not changing to ,[DATE] after midnight she said the date should have been changed to ,[DATE]. When asked how often LVN R, the nurse with Resident #17 when his pupil size changed, worked, she said LVN R is an as needed nurse and had not been very active on the schedule. When asked if a change in pupil size from 3 mm to 4 mm should have been called to the doctor she said yes. When asked if anyone had asked the doctor about also holding Resident #17's [MEDICATION NAME] she said, "I don't think so." A voice mail message was left for LVN R on [DATE] at 10:30 a.m. LVN R left a return message and was called for a telephone interview on [DATE] at 1:19 p.m. LVN R said she should have corrected the date on her neuro vital signs monitoring sheet to [DATE] since it was [DATE]. When asked if she reported the change in pupil size from 3 mm to 4 mm to Resident #17's doctor she said no. She said she did not call the doctor to report the change. When asked if she had been interviewed during the facility's investigation of the incident she said no. She said she cared for Resident #17 for 7 hours on [DATE] and that he had not had any additional falls. She said she went into the room to help the aide clean him up and he was gurgling and threw up. She said he had not wanted to eat that day. She said he had voiced no complaints of pain or nausea. When asked again if she reported the change in his pupil size to the doctor she again said she did not call the doctor. During a telephone interview on [DATE] at 10:37 a.m. with Physician A, who is also the Medical Director, he said if a resident hit their head and had a high INR he should have been sent out. He said, "That's the standard." When asked if he was consulted about if the [MEDICATION NAME] should be held and whether he was informed of Resident #17's change in condition on [DATE] at 8:45 a.m. when Resident #17's pupil size changed, he said he would call back on Monday, [DATE]. Physician A did not call back as of 5:00 p.m. on [DATE]. Record review of the Provider Investigation Report dated [DATE] revealed on [DATE] at 7:00 p.m. Resident #17 had an unwitnessed fall. A description of the Allegation included that on [DATE], (Resident #17) was observed lying on his right side on the floor by his bed by Nurse (LVN B). On [DATE] @ 3:51 p.m. (Resident #17) was noted to be unresponsive to physical stimuli. (Resident #17) was gurgling when repositioned on his right side (Resident #17) vomited a large amount of brown fluid with 2 small blood clots. The physician was then notified and the resident was sent out via 911. Record review of Resident #17's PT/INR results dated [DATE] revealed his INR was 5.30 out of a therapeutic range of 2XXX,[DATE].0. Record review of Resident #17's PT/INR results dated [DATE] revealed his INR had increased and was 6.45 out of a therapeutic range of 2XXX,[DATE].0. Record review of Resident #17's physician order [REDACTED]. There was no documentation of a result for [DATE]. Record review of Resident #17's [DATE] medication administration records revealed documentation of his [MEDICATION NAME] being held [DATE] through [DATE]. His [MEDICATION NAME] 75 mg continued to be administered daily at 9:00 a.m. through [DATE]. Record review of Resident #17's Nursing Progress Notes dated [DATE] revealed there was no documentation of Resident #17's medications being reviewed with his physician or nurse practitioner after his fall with injury on [DATE]. Record review of Resident #17's Nursing Progress notes revealed there was no documentation of Resident #17's change in condition (pupil size) being reported to the doctor. A note dated [DATE] 08:41 read, "...Resident in the bed s/p (status [REDACTED]. neuro (neurological) checks in progress and wnl (within normal limits). will cont (continue to monitor. ..." Record review of Resident #17's Nursing Progress notes dated [DATE] 15:51 (3:51 p.m.) revealed, "...resident in room unresponsive attempted the sternum rub, no respond (sic) v/s ,[DATE] (blood pressure) 109 (unclear if heart rate) 98 (unclear if temperature) O2 room air 94% BS (blood sugar) 131 noted that resident was (sic) gurgling (sic) turned resident on to his rt (right) side resident started to vomit excessive amount brown fluids with two small red clots notified Dr (Physician A) Spoke to (NP B) NP send resident out 911. stretcher with EMS (emergency medical services) in stable condition. Notified (family member) she stated ok. Notified (name of DON) DON she stated ok. ... " Record review of Resident #17's plan of care for Anticoagulant therapy dated as initiated on [DATE] revealed an intervention of , "...Monitor lab reports, and notify physician promptly of results ..." Record review of Resident #17's most recent plan of care for, "...Has had an actual fall with (No Injury, Unsteady gait, Poor Balance ..." dated as initiated on [DATE] revealed the next target dated was [DATE] to meet goals. There was no documentation of when the actual fall(s) occurred or the use of a bed/chair alarm. The care plan conference date was requested from the Administrator and Regional Clinical Nurse A on [DATE] at 3:56 p.m. The date was not provided prior to exit on [DATE]. Record review of Resident #17's plan of care for, "At risk for falls," dated as initiated on [DATE] revealed one intervention of floor mat at bedside. There was no documentation of the use of a bed/chair alarm as an intervention. Record review of a list provided by the facility revealed three residents on anticoagulants During an interview on [DATE] at 11:17 a.m. with LVN Q when asked what the facility's policy was for when a resident on an anticoagulant had a fall, she said, "Our policy is to send them out 911." She said this was a new policy that had been in effect for approximately 2 months. She said she had been in-serviced on the policy about 2 months ago and signs had been posted at the nurses' stations. Observation on [DATE] at 11:20 a.m. of the 3 West Nurses' station revealed a posting which read, "...ATTENTION NURSES! IF a resident is on any type of anticoagulant therapy including aspirin and the resident falls please send to the E.R. for evaluation. ..XXX[DATE]" The posting was signed by the DON. During an interview on [DATE] at 11:26 a.m. with LVN O she was asked about the facility's policy for if a resident on an anticoagulant had a fall. She said if they fall and are on an anti-coagulant the policy is to send them out to the hospital, and notify the doctor and family. She said as a long-term nurse, you know if they fall and are on [MEDICATION NAME], you send them out. She said the facility posted the policy last month. She said she was not at the in-service. During an interview on [DATE] at 4:05 p.m. with Regional Clinical Nurse A, the Administrator, and the Operations Manager they said they had identified the problem of falls for those on [MEDICATION NAME] in the Quality Assurance meeting. Evidence of a plan of action and monitoring was requested at that time. No Quality Assurance plan was received before exit. Record review of an in-service provided by Regional Clinical Nurse A revealed all staff listed on the in-service documented their work shift as the 6:00 a.m. to 6:00 p.m. shift. There was no documentation of night shift staff being trained on the new policy. During an interview on [DATE] at 4:35 p.m. with Regional Clinical Nurse A she said they did not have documentation of a plan of action or monitoring. When asked why the night shift staff did not receive the in-service, she said, "I don't know." Record review of the facility's policy and procedure for Falls revised ,[DATE] revealed there was no directive for a resident on anticoagulants having a fall. Record review of the facility's policy and procedure for Post Fall Assessment revised ,[DATE] revealed, "...An incident Report and a Fall Investigation, Post Form will be completed by a Licensed Nurse on the shift that the fall occurred The Licensed Nurse will complete the form as follows: ...6. Identify an action plan or approaches to be taken in an attempt to prevent further falls based on newly identified facts or risk factors. ...7. Document on the post fall assessment form that the care plan was updated to reflect new action plan or approaches for prevention of falls. ...ignificant (sic) information obtained as a result of the post fall assessment should be reported to the physician, and documented in the edical (sic) Records. ..." Record review of the facility's policy and procedure for Neurological Evaluation revised ,[DATE] revealed, "...All incidents involving trauma to the head will result in a comprehensive neurological assessment for a minimum of seventy-two (72) hours. ...7. Pupil Signs A. Look at pupils and compare size and equality. b. sing (sic) an overhead light, simultaneously compare the size of the pupils and their reaction to light. C. If flashlight is used, shine directly into eye being examined while other eye is covered. ..." The policy and procedure did not address notifying the doctor of changes. Record review of the facility's policy and procedure for Monitoring for Significant Change in Condition revised ,[DATE] revealed, "...8. Physician, resident, and responsible party will be notified of the significant change. ..." An IJ was identified on [DATE] at 4:39 p.m. and the Administrator, Regional Clinical Nurse A, Regional Clinical Nurse B, DON, Operations Manager, and Executive Director B were informed at that time. During an interview with them at that time, they all said they did not know why the night shift had not received the in-service. A Plan of Removal (PoR) for the IJ was submitted [DATE] and after revisions was accepted on [DATE] at 2:15 p.m. The PoR included: 1.) Problem Ensuring facility evaluates extent of injury after fall and prevents complications with residents on Anticoagulant therapy. Education on policy for assessment post fall of residents on anticoagulant therapy not completed with all licensed nurses. 2.) Immediate Actions: A. Criteria used to identify residents on [MEDICATION NAME]: Director of Nursing and Clinical Resource Nurses reviewed the orders completed 100% review on all residents on anticoagulant therapy identified on [DATE] at 5:00 p.m.. B. All residents identified on Anticoagulants had their care plans reviewed and updated [DATE] at 6: 00 p.m.. C. Anticoagulant Order and Administration Record Sheet created [DATE] at 5:00 p.m. to be monitored daily by Director of Nursing or designee. Any discrepancies to be addressed immediately and discussed in QAA. D. Revised the Policy and Procedure on Falls with residents on anticoagulants on [DATE] at 5:00 p.m.. E. The nurse will notify the DON and the resident physician if the resident neuro vital signs or his/her condition change immediately. F. Post Fall Procedure will include a review and update of resident care plans and medication and appropriate interventions will be put in place. 3.) Training A. License nurses will be In-serviced on Fall precautions, Change of condition, treatment of [REDACTED]. In- service started on [DATE] and will be completed by 11:00 p.m. on [DATE]. Training will be provided by Director of Nursing or designee. B. All license nurses not available for live in-services will be contacted by phone and receive training by [DATE] by 11:00 p.m.. C. All nursing staff not available on live or phone in-service will not be permitted to work until in-service is completed. During an interview on [DATE] at 3:56 p.m. with Regional Clinical Nurse A she said she was now the acting DON for the weekend and a new DON would be starting on Monday, [DATE]. She said all nurses had been in-serviced except for one who would not be allowed to return to work until being in-serviced. She said none of the 3 residents on anticoagulants had any falls. She said she had reviewed anti-coagulant monitoring. She said the QAA committee met last night, [DATE], including the Medical Director, Physician A, via telephone. She said Physician A agreed any resident on an anti-coagulant who had a fall was to be sent out to the emergency room . During a telephone interview on [DATE] at 4:41 p.m. with LVN B when asked if Resident #17's bed alarm had been in place when he fell on [DATE] she said he had no bed alarm at that time. She said that was why she got an order for [REDACTED]. Record review of Resident #17's [DATE] medication administration sheets revealed staff were documenting the presence of a bed/chair alarm each shift, including on [DATE] during the evening shift when the fall occurred. During an interview on [DATE] at 4:59 p.m. with LVN H she said she had received in-service training about residents with falls on anticoagulants. She was able to describe the training and what to do. When asked where a nurse documents monitoring a bed alarm she said on the nurses' medication administration record. During an interview on [DATE] at 5:13 p.m. with LVN E she said she was in-serviced yesterday, [DATE]. She was able to describe the training and the facility ' s policy on residents who had a fall and were on an anticoagulant. During an interview on [DATE] at 5:25 p.m. with LVN M she said she had received in-service training yesterday, [DATE]. She was able to describe the training and the facility ' s policy on residents who had a fall and were on an anticoagulant. During an interview on [DATE] at 5:38 p.m. with the Administrator, when asked what type of procedure is there to make sure the nursing needs of residents' are being met, he said they have interdisciplinary team meetings. He said in those meetings they discuss the needs of the residents and standards of care. He said they have daily stand-up meetings and discuss any changes. He said they make daily rounds and interview residents. When asked how he monitors staff, such as the DON, to ensure the systems they monitor are being done sufficiently he said there had been a problem in the facility with monitoring. He said he had been at the facility since the end of [DATE]. He said when they realized there were problems they made changes in the nursing team. He said they had been having the Clinical Resources (Regional Clinical Nurses) in the building more. He said they have weekly meetings with department heads. He said to ensure competency of staff they make rounds. He said the Clinical Resources (Regional Clinical Nurses) review matrixes they review such as pressure ulcers, restraints, and falls tracking. He said they also have annual evaluation practices and they set standards. When asked how they evaluate their policy and procedures he said they do that in the Quality Assurance committee and standard care meetings. He said if they have a poor outcome, policies are reviewed in the Quality Assurance committee, including the Medical Director. When asked how they assure the effectiveness of facility processes he said they do it by reviewing results, reevaluate, and make any changes to get the outcomes they hope to achieve. When asked how he thought this immediate jeopardy/substandard quality of care came about he said, "...perhaps we had the wrong leadership in place before and that's why we've made some changes." He said new leadership was now in place. He said a new DON was starting Monday. He said they had a new ADON and a new MDS nurse. When asked if he was aware of the situation he said yes. He said he was informed on Monday, [DATE] that Resident #17 had fallen and of what had been done, for example, calls to the doctor and neuro checks. He said he was concerned. He said he called the hospital Resident #17 had been sent to and was informed Resident #17 had been transferred to another hospital. He said he called the other hospital and was told Resident #17 was not doing well. He said they started their investigation and based on findings, determined they could have done some things differently. He said, "You know, I think, of course, looking in retrospect." He said perhaps reviewing the policy and procedures in place at the time, how situations were handled in the past, and handling patients on anticoagulants. When asked if anyone had questioned the continued administration of [MEDICATION NAME] to Resident #17 he said, to his knowledge, he was not aware of the [MEDICATION NAME] administration being questioned. When asked if he knew if it was questioned during the investigation why the doctor was not notified of the change in Resident #17's pupil size from 3 mm to 4 mm he said he did not know. When asked what resources were available to him and his staff he said policy and procedures, Corporate staff, sister facilities, and a medical director. He said he also tries to reach out to the Texas Department of Aging program managers, if needed, and the Ombudsman. During an interview on [DATE] at 5:50 p.m. with LVN G she said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she had received in-services on [DATE] over the concerns. She was able to describe the training and new policy. When asked if she were caring for a resident on [MEDICATION NAME] who had a fall, would she review the resident's medications and include that information in a call to the doctor, she said yes. She said, "That's usually one of the first things they ask is are they on any medications other than [MEDICATION NAME]." When asked how they ensure ordered interventions such as a bed alarm or floor mat were in place, she said she makes rounds and observes these items. She said they document on the nurses' medication or treatment administration records. When asked if a change in the size of pupils from 3 mm to 4 mm is a reportable change in condition she said yes. She said it could indicate an head injury or bleed. During an interview on [DATE] at 6:23 p.m. with LVN B she said she had received in-services on [DATE]. She described the training. She said if a resident is on an anticoagulant and has a fall, you assess the resident, call the doctor and send the resident to the hospital. She said the care plan and medications are to be reviewed. When asked if she would report a change in pupil size from 3 mm to 4 mm when monitoring neurological vital signs she said, "Definitely." She said it could indicate a brain bleed or injury. During an interview on [DATE] at 6:31 p.m. with LVN L she said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she had received the in-services. She was able to describe the training and policy changes. When asked if it would be important to let the doctor know the resident was also taking [MEDICATION NAME], she said, "Of course." When asked about a change in pupil size, she said yes, a change from 3 mm to 4 mm is reportable to the doctor. She said any change of condition is reportable. She said a change in pupil size from 3 mm to 4 mm could indicate a head injury or internal bleeding. The DON was no longer working at the facility as of [DATE]. An interview was conducted with Regional Clinical Nurse A on [DATE] at 7:01 p.m. due to she was serving as the interim DON for the weekend. When asked what training was ensured the nurses had in order to care for residents on anticoagulants she said after the incident, she trained staff on anticoagulants, change in condition, change in neuro vital signs, anticoagulants and falls, assessments, and sending a resident to the hospital immediately even if it ' s minor. She said the policy and procedure had been updated and reviewed and approved by the quality assurance committee and the Medical Director (Physician A). She said a previous in-service on anticoagulants had been done at some point but was not tied to falls. She said she also had the nurses identify which residents were on anticoagulants. When asked how she ensured the nurses were competent in their skills for caring for a resident on anticoagulants she said she did a verbal discussion with them and had feedback with them. She said she had them describe what to do if they have a fall; discussed the monitoring log for residents on anticoagulants; discussed what to say to the doctor; and that they needed to reinforce what medications a resident was on and reiterated they needed to ensure awareness of all medications a resident was receiving. When asked what type of plan was in place for residents on anticoagulants she said prior to the incident, they had an anticoagulant policy and procedure and a fall policy and procedure but they did not have them interacting together. When asked had there been any types of in-services on residents on anticoagulants prior to accepting residents on anticoagulants she said there were some in-services done but not on a quarterly basis or a schedule. She did not say when the most recent in-service prior to the incident had been. When asked how she thought the immediate jeopardy/substandard quality of care came about she said, "I think that our policy and procedures were not specific to the fall with anticoagulants," but felt now everyone was more knowledgeable. When asked if any nursing judgment came into play she said, "Yes, following generic protocols." When asked if the doctor should have been notified that Resident #17 was also on [MEDICATION NAME] she said, "I think, as a nurse, doing multiple things probably thought he already knew instead of re-informing him. When asked if a change in the size of pupils from 3 mm to 4 mm should have been called to the doctor she said she would consider the baseline. She said considering and looking at everything in general, "...it probably should have been called." When asked what resources are available to her and the staff she said policy and procedures, consultant nurses, consultant dietician, and pharmacy. She said they also had sister facilities and a medical director. She said there was one nurse, LVN Z, who is an as needed nurse, who still needed the training. She said the training would be done prior to that nurse being allowed to work. Record review of in-services dated [DATE] and comparison to the active staff nursing roster confirmed training of staff on the new policy with the exception of one as needed staff member. Record review of monitoring logs for anticoagulants confirmed a log for

Based on observation, interview, and record review the facility failed to ensure 1 of 18 residents (Resident #17) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. --Resident #17 sustained a fall on [DATE]. The resident was on [MEDICATION NAME] (prevents the blood from clotting) which was on hold due to a high PT/INR. LVN R failed to notify the physician immediately when a change of condition was assessed and documented during two separate assessments at 8:45 a.m. and 12:45 p.m. on [DATE] prior to the resident becoming unresponsive at 3:51 p.m. and sent to the emergency roiagnom on [DATE]. He died on [DATE] with a primary cause of death of [MEDICAL CONDITION] subdural hematoma. --LVN B failed to review all medications with the doctor after the fall to determine if Resident #17's antiplatelet therapy, [MEDICATION NAME] (prevents platelet aggregation) should be held. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:39 p.m. While the IJ was removed on [DATE] at 7:12 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. This failure affected 1 resident and placed 3 residents receiving anticoagulants at risk of injury, hospitalization , delayed treatment, and death. Intake # 8 Record review of Resident #17's closed record admission sheet revealed he was an [AGE] year old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. state, and [MEDICAL CONDITION]. Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed he required the extensive assistance of one staff for bed mobility and walking in his room. He required the extensive assistance of two staff for transfers. He had bilateral lower extremity impairments. He used a wheelchair for mobility. He was not steady, only able to stabilize with staff assistance when moving from a seated to standing position. He had no restraints. Record review of Resident #17's plan of care for Anticoagulant therapy dated as initiated on [DATE] revealed an intervention of , "...Monitor lab reports, and notify physician promptly of results ..." Record review of Resident #17's most recent plan of care for, "...Has had an actual fall with (No Injury, Unsteady gait, Poor Balance ..." dated as initiated on [DATE] revealed the next target dated was [DATE] to meet goals. There was no documentation of when the actual fall(s) occurred or the use of a bed/chair alarm. The care plan conference date was requested from the Administrator and Regional Clinical Nurse A on [DATE] at 3:56 p.m. The date was not provided prior to exit on [DATE]. Record review of Resident #17's plan of care for, "At risk for falls," dated as initiated on [DATE] revealed one intervention of floor mat at bedside. There was no documentation of the use of a bed/chair alarm as an intervention. During a telephone interview on [DATE] at 11:56 a.m. the complainant said Resident #17 fell and hit his head. The complainant said the facility did not call 911. During additional telephone interview on [DATE] at 1:00 p.m. with the complainant, the complainant said the death certificate had been received. The complainant said Resident #17 expired on [DATE] with a primary cause of death of [MEDICAL CONDITION] subdural hematoma and a secondary cause of death of coagulopathy related to [MEDICATION NAME]. The complainant said she did not have access to a fax machine and was mailing the Death Certificate to the Texas Department of Aging and Disability Services. During an interview on [DATE] at 2:16 p.m. with LVN B when asked about Resident #17's fall on [DATE] she said, he had a fall. She said she and 3 aides performed his transfer back to bed. She said he was talking an denied pain. She said he had a cut on his eyebrow approximately 1 cm. She said she assessed him again after the transfer. She said she reported the fall to NP A and did not receive an order to send him out. She said she and NP A knew he was on [MEDICATION NAME]. She said they had been having trouble controlling his INR level. When asked if she thought it was odd that he was not sent out she said yes but that his neurological vital signs were normal. She said NP A told her to call back if he had any change in his neurological vital signs. When asked if she called the DON to ask about not receiving an order to send the resident out, she said no because she did not think she would get an answer. Record review of Resident #17's print out of computer physician orders [REDACTED]. to [MEDICAL CONDITION], and [MEDICATION NAME] 75 mg by mouth once daily. Additionally, there were orders for a floor mat at bedside with an order date of [DATE] and bed alarm to alert staff that patient needs assist with transfers dated [DATE]. Record review of Resident #17's incident/accident reports revealed he was found on the floor of his room sitting with his back against his bed on [DATE] and had a fall during a transfer on [DATE]. There was no documentation of whether Resident #17's bed alarm was in place when he fell on [DATE]. Record review of the Provider Investigation Report dated [DATE] revealed on [DATE] at 7:00 p.m. Resident #17 had an unwitnessed fall. A description of the Allegation included that on [DATE], (Resident #17) was observed lying on his right side on the floor by his bed by Nurse (LVN B). On [DATE] @ 3:51 p.m. (Resident #17) was noted to be unresponsive to physical stimuli. (Resident #17) was gurgling when repositioned on his right side (Resident #17) vomited a large amount of brown fluid with 2 small blood clots. The physician was then notified and the resident was sent out via 911. Record review of Resident #17's incident/accident report dated [DATE] revealed, "...Upon entering residents room this writer (LVN B) observed resident laying on the floor on the side of bed on right side of bed on right side approx. (approximately) 60 cc (cubic centimeters) of dark red fluid noted on floor. V/S ,[DATE] (blood pressure) 95 (heart rate) 20 (respiratory rate) SpO2 (oxygen saturation) 97% in (sic) room air 97.2 AX (axillary temperature) Resident S/T (skin tear) 1 cm (centimeter) W (wide) by 1 cm (L) (length) by 1 cm (D) (depth) noted above right eyebrow resident denies pain cleansed dried TAO (triple antibiotic ointment) and bordered dressing applied Neuro (neurological) checks in progress resident resting stable DPOA (Durable Power of Attorney) (name) notified ' "I was trying to get up." '... "...S/T treated new orders noted MD (Medical Doctor) and RP (Responsible Party) notified ..." There was no documentation of whether his bed alarm was in place. During an interview on [DATE] at 2:52 p.m. with the DON she said Resident #17 was not sent to the hospital due to his neurological vital signs were normal and he was responsive. She said since the incident they had changed their policy. She said the new policy was that if a resident on [MEDICATION NAME] had a fall they were to be sent out to the hospital. When asked if they had a protocol for nurses for when they receive orders they disagree with she said they do. She said if a staff member disagrees with an order received, they are to call her and she can override a decision such as whether to send a resident out. When asked if LVN B called her the evening Resident #17 had the fall, she said no. During an interview on [DATE] at 10:02 a.m. with the DON Resident #17's bed alarm order was discussed. She said the bed alarm had already been in his physician orders. She said no one had mentioned if his bed alarm had sounded. When asked why there were no intervention changes after his previous falls on [DATE] and [DATE] she said they tried to keep Resident #17 in the common areas and encourage him to stay out and watch television. When asked about the date on Resident #17's [DATE] neurological vital signs check documentation sheet not changing to ,[DATE] after midnight she said the date should have been changed to ,[DATE]. When asked how often LVN R, the nurse with Resident #17 when his pupil size changed, worked, she said LVN R is an as needed nurse and had not been very active on the schedule. When asked if a change in pupil size from 3 mm to 4 mm should have been called to the doctor she said yes. When asked if anyone had asked the doctor about also holding Resident #17's [MEDICATION NAME] she said, "I don't think so." Record review of Resident #17's Neurological Flow Sheet dated [DATE] revealed neurological checks had been initiated on [DATE] at 7:00 p.m. and checked again at 7:15 p.m., 7:30 p.m., 7:45 p.m., 8:15 p.m., 8:45 p.m., 9:15 p.m., 9:45 p.m., 10:45 p.m., 11:45 p.m., 12:45 a.m. ([DATE]), 4:45 a.m., 8:45 a.m. and at 12:45 p.m. Staff failed to change the date from [DATE] to [DATE] after passing midnight on [DATE]. Continued review of Resident #17's Neurological Flow Sheet dated [DATE] revealed Resident #17's pupil size in both eyes was documented as being a consistent 3 mm (millimeters) from 7:00 p.m. on [DATE] through 4:45 a.m. on [DATE]. At 8:45 a.m. and 12:45 p.m. on [DATE] his pupil size changed to 4 mm. The Neurological Flow Sheet contained instructions to staff to, "...Notify MD IMMEDIATELY of signs and symptoms of intracranial Pressure!!!..." Record review of http://medical-dictionary.thefreedictionary.com for intracranial pressure revealed, "...Changes in pupil size, equality, and reaction to light, and extraocular movements are indicative of compression of the third, fourth, and sixth cranial nerves. Assessment of these changes should be as accurate and objective as possible. Unilateral and bilateral evaluations are important and usally are recorded by a drawing of the actual size of each pupil or by precise measurements using a small metric ruler. ... A voice mail message was left for LVN R on [DATE] at 10:30 a.m. LVN R left a return message and was called for a telephone interview on [DATE] at 1:19 p.m. LVN R said she should have corrected the date on her neuro vital signs monitoring sheet to [DATE] since it was [DATE]. When asked if she reported the change in pupil size from 3 mm to 4 mm to Resident #17's doctor she said no. She said she did not call the doctor to report the change. When asked if she had been interviewed during the facility's investigation of the incident she said no. She said she cared for Resident #17 for 7 hours on [DATE] and that he had not had any additional falls. She said she went into the room to help the aide clean him up and he was gurgling and threw up. She said he had not wanted to eat that day. She said he had voiced no complaints of pain or nausea. When asked again if she reported the change in his pupil size to the doctor she again said she did not call the doctor. During a telephone interview on [DATE] at 10:37 a.m. with Physician A, who is also the Medical Director, he said if a resident hit their head and had a high INR he should have been sent out. He said, "That's the standard." When asked if he was consulted about if the [MEDICATION NAME] should be held and whether he was informed of Resident #17's change in condition on [DATE] at 8:45 a.m. when Resident #17's pupil size changed, he said he would call back on Monday, [DATE]. Physician A did not call back as of 5:00 p.m. on [DATE]. Record review of Resident #17's physician order [REDACTED]. Record review of Resident #17's PT/INR results dated [DATE] revealed his INR was 5.30 out of a therapeutic range of 2XXX,[DATE].0. Record review of Resident #17's physician order [REDACTED]. Record review of Resident #17's PT/INR results dated [DATE] revealed his INR had increased and was 6.45 out of a therapeutic range of 2XXX,[DATE].0. Record review of Resident #17's physician order [REDACTED]. There was no documentation of a result for [DATE]. Record review of Resident #17's [DATE] medication administration records revealed documentation of his [MEDICATION NAME] being held [DATE] through [DATE]. His [MEDICATION NAME] 75 mg continued to be administered daily at 9:00 a.m. through [DATE]. Record review of Resident #17's Nursing Progress Notes dated [DATE] revealed there was no documentation of Resident #17's medications being reviewed with his physician or nurse practitioner after his fall with injury on [DATE]. Record review of Resident #17's Nursing Progress notes revealed there was no documentation of Resident #17's change in condition (pupil size) being reported to the doctor. A note dated [DATE] 08:41 read, "...Resident in the bed s/p (status [REDACTED]. neuro (neurological) checks in progress and wnl (within normal limits). will cont (continue to monitor. ..." Record review of Resident #17's Nursing Progress notes dated [DATE] 15:51 (3:51 p.m.) revealed, "...resident in room unresponsive attempted the sternum rub, no respond (sic) v/s ,[DATE] (blood pressure) 109 (unclear if heart rate) 98 (unclear if temperature) O2 room air 94% BS (blood sugar) 131 noted that resident was (sic) gurgling (sic) turned resident on to his rt (right) side resident started to vomit excessive amount brown fluids with two small red clots notified Dr (Physician A) Spoke to (NP B) NP send resident out 911. stretcher with EMS (emergency medical services) in stable condition. Notified (family member) she stated ok. Notified (name of DON) DON she stated ok. ... " Record review of a list provided by the facility revealed three residents on anticoagulants During an interview on [DATE] at 11:17 a.m. with LVN Q when asked what the facility's policy was for when a resident on an anticoagulant had a fall, she said, "Our policy is to send them out 911." She said this was a new policy that had been in effect for approximately 2 months. She said she had been in-serviced on the policy about 2 months ago and signs had been posted at the nurses' stations. Observation on [DATE] at 11:20 a.m. of the 3 West Nurses' station revealed a posting which read, "...ATTENTION NURSES! IF a resident is on any type of anticoagulant therapy including aspirin and the resident falls please send to the E.R. for evaluation. ..XXX[DATE]" The posting was signed by the DON. During an interview on [DATE] at 11:26 a.m. with LVN O she was asked about the facility's policy for if a resident on an anticoagulant had a fall. She said if they fall and are on an anti-coagulant the policy is to send them out to the hospital, and notify the doctor and family. She said as a long-term nurse, you know if they fall and are on [MEDICATION NAME], you send them out. She said the facility posted the policy last month. She said she was not at the in-service. During an interview on [DATE] at 4:05 p.m. with Regional Clinical Nurse A, the Administrator, and the Operations Manager they said they had identified the problem of falls for those on [MEDICATION NAME] in the Quality Assurance meeting. Evidence of a plan of action and monitoring was requested at that time. No Quality Assurance plan was received before the time of exit. Record review of an in-service provided by Regional Clinical Nurse A revealed all staff listed on the in-service documented their work shift as the 6:00 a.m. to 6:00 p.m. shift. There was no documentation of night shift staff being trained on the new policy. During an interview on [DATE] at 4:35 p.m. with Regional Clinical Nurse A she said they did not have documentation of a plan of action or monitoring. When asked why the night shift staff did not receive the in-service, she said, "I don't know." Record review of the facility's policy and procedure for Falls revised ,[DATE] revealed there was no directive for a resident on anticoagulants having a fall. Record review of the facility's policy and procedure for Post Fall Assessment revised ,[DATE] revealed, "...An incident Report and a Fall Investigation, Post Form will be completed by a Licensed Nurse on the shift that the fall occurred The Licensed Nurse will complete the form as follows: ...6. Identify an action plan or approaches to be taken in an attempt to prevent further falls based on newly identified facts or risk factors. ...7. Document on the post fall assessment form that the care plan was updated to reflect new action plan or approaches for prevention of falls. ...ignificant (sic) information obtained as a result of the post fall assessment should be reported to the physician, and documented in the edical (sic) Records. ..." Record review of the facility's policy and procedure for Neurological Evaluation revised ,[DATE] revealed, "...All incidents involving trauma to the head will result in a comprehensive neurological assessment for a minimum of seventy-two (72) hours. ...7. Pupil Signs A. Look at pupils and compare size and equality. b. sing (sic) an overhead light, simultaneously compare the size of the pupils and their reaction to light. C. If flashlight is used, shine directly into eye being examined while other eye is covered. ..." The policy and procedure did not address notifying the doctor of changes. Record review of the facility's policy and procedure for Monitoring for Significant Change in Condition revised ,[DATE] revealed, "...8. Physician, resident, and responsible party will be notified of the significant change. ..." An IJ was identified on [DATE] at 4:39 p.m. and the Administrator, Regional Clinical Nurse A, Regional Clinical Nurse B, DON, Operations Manager, and Executive Director B were informed at that time. During an interview with them at that time, they all said they did not know why the night shift had not received the in-service. A Plan of Removal (PoR) for the IJ was submitted [DATE] and after revisions was accepted on [DATE] at 2:15 p.m. The PoR included: 1.) Problem Ensuring facility evaluates extent of injury after fall and prevents complications with residents on Anticoagulant therapy. Education on policy for assessment post fall of residents on anticoagulant therapy not completed with all licensed nurses. 2.) Immediate Actions: A. Criteria used to identify residents on [MEDICATION NAME]: Director of Nursing and Clinical Resource Nurses reviewed the orders completed 100% review on all residents on anticoagulant therapy identified on [DATE] at 5:00 p.m.. B. All residents identified on Anticoagulants had their care plans reviewed and updated [DATE] at 6: 00 p.m.. C. Anticoagulant Order and Administration Record Sheet created [DATE] at 5:00 p.m. to be monitored daily by Director of Nursing or designee. Any discrepancies to be addressed immediately and discussed in QAA. D. Revised the Policy and Procedure on Falls with residents on anticoagulants on [DATE] at 5:00 p.m.. E. The nurse will notify the DON and the resident physician if the resident neuro vital signs or his/her condition change immediately. F. Post Fall Procedure will include a review and update of resident care plans and medication and appropriate interventions will be put in place. 3.) Training A. License nurses will be In-serviced on Fall precautions, Change of condition, treatment of [REDACTED]. In- service started on [DATE] and will be completed by 11:00 p.m. on [DATE]. Training will be provided by Director of Nursing or designee. B. All license nurses not available for live in-services will be contacted by phone and receive training by [DATE] by 11:00 p.m.. C. All nursing staff not available on live or phone in-service will not be permitted to work until in-service is completed. During an interview on [DATE] at 3:56 p.m. with Regional Clinical Nurse A she said she was now the acting DON for the weekend and a new DON would be starting on Monday, [DATE]. She said all nurses had been in-serviced except for one who would not be allowed to return to work until being in-serviced. She said none of the 3 residents on anticoagulants had any falls. She said she had reviewed anti-coagulant monitoring. She said the QAA committee met last night, [DATE], including the Medical Director, Physician A, via telephone. She said Physician A agreed any resident on an anti-coagulant who had a fall was to be sent out to the emergency room . During an interview on [DATE] at 4:59 p.m. with LVN H she said she had received in-service training about residents with falls on anticoagulants. She was able to describe the training and what to do. When asked where a nurse documents monitoring a bed alarm she said on the nurses' medication administration record. During an interview on [DATE] at 5:13 p.m. with LVN E she said she was in-serviced yesterday, [DATE]. She was able to describe the training and the facility ' s policy on residents who had a fall and were on an anticoagulant. During an interview on [DATE] at 5:25 p.m. with LVN M she said she had received in-service training yesterday, [DATE]. She was able to describe the training and the facility ' s policy on residents who had a fall and were on an anticoagulant. During an interview on [DATE] at 5:38 p.m. with the Administrator, when asked what type of procedure is there to make sure the nursing needs of residents' are being met, he said they have interdisciplinary team meetings. He said in those meetings they discuss the needs of the residents and standards of care. He said they have daily stand-up meetings and discuss any changes. He said they make daily rounds and interview residents. When asked how he monitors staff, such as the DON, to ensure the systems they monitor are being done sufficiently he said there had been a problem in the facility with monitoring. He said he had been at the facility since the end of [DATE]. He said when they realized there were problems they made changes in the nursing team. He said they had been having the Clinical Resources (Regional Clinical Nurses) in the building more. He said they have weekly meetings with department heads. He said to ensure competency of staff they make rounds. He said the Clinical Resources (Regional Clinical Nurses) review matrixes they review such as pressure ulcers, restraints, and falls tracking. He said they also have annual evaluation practices and they set standards. When asked how they evaluate their policy and procedures he said they do that in the Quality Assurance committee and standard care meetings. He said if they have a poor outcome, policies are reviewed in the Quality Assurance committee, including the Medical Director. When asked how they assure the effectiveness of facility processes he said they do it by reviewing results, reevaluate, and make any changes to get the outcomes they hope to achieve. When asked how he thought this immediate jeopardy/substandard quality of care came about he said, "...perhaps we had the wrong leadership in place before and that's why we've made some changes." He said new leadership was now in place. He said a new DON was starting Monday. He said they had a new ADON and a new MDS nurse. When asked if he was aware of the situation he said yes. He said he was informed on Monday, [DATE] that Resident #17 had fallen and of what had been done, for example, calls to the doctor and neuro checks. He said he was concerned. He said he called the hospital Resident #17 had been sent to and was informed Resident #17 had been transferred to another hospital. He said he called the other hospital and was told Resident #17 was not doing well. He said they started their investigation and based on findings, determined they could have done some things differently. He said, "You know, I think, of course, looking in retrospect." He said perhaps reviewing the policy and procedures in place at the time, how situations were handled in the past, and handling patients on anticoagulants. When asked if anyone had questioned the continued administration of [MEDICATION NAME] to Resident #17 he said, to his knowledge, he was not aware of the [MEDICATION NAME] administration being questioned. When asked if he knew if it was questioned during the investigation why the doctor was not notified of the change in Resident #17's pupil size from 3 mm to 4 mm he said he did not know. When asked what resources were available to him and his staff he said policy and procedures, Corporate staff, sister facilities, and a medical director. He said he also tries to reach out to the Texas Department of Aging program managers, if needed, and the Ombudsman. During an interview on [DATE] at 5:50 p.m. with LVN G she said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she had received in-services on [DATE] over the concerns. She was able to describe the training and new policy. When asked if she were caring for a resident on [MEDICATION NAME] who had a fall, would she review the resident's medications and include that information in a call to the doctor, she said yes. She said, "That's usually one of the first things they ask is are they on any medications other than [MEDICATION NAME]." When asked how they ensure ordered interventions such as a bed alarm or floor mat were in place, she said she makes rounds and observes these items. She said they document on the nurses' medication or treatment administration records. When asked if a change in the size of pupils from 3 mm to 4 mm is a reportable change in condition she said yes. She said it could indicate an head injury or bleed. During an interview on [DATE] at 6:23 p.m. with LVN B she said she had received in-services on [DATE]. She described the training. She said if a resident is on an anticoagulant and has a fall, you assess the resident, call the doctor and send the resident to the hospital. She said the care plan and medications are to be reviewed. When asked if she would report a change in pupil size from 3 mm to 4 mm when monitoring neuros she said, "Definitely." She said it could indicate a brain bleed or injury. During an interview on [DATE] at 6:31 p.m. with LVN L she said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she had received the in-services. She was able to describe the training and policy changes. When asked if it would be important to let the doctor know the resident was also taking [MEDICATION NAME], she said, "Of course." When asked about a change in pupil size, she said yes, a change from 3 mm to 4 mm is reportable to the doctor. She said any change of condition is reportable. She said a change in pupil size from 3 mm to 4 mm could indicate a head injury or internal bleeding. The DON was no longer working at the facility as of [DATE]. An interview was conducted with Regional Clinical Nurse A on [DATE] at 7:01 p.m. due to she was serving as the interim DON for the weekend. When asked what training was ensured the nurses had in order to care for residents on anticoagulants she said after the incident, she trained staff on anticoagulants, change in condition, change in neuro vital signs, anticoagulants and falls, assessments, and sending a resident to the hospital immediately even if it ' s minor. She said the policy and procedure had been updated and reviewed and approved by the quality assurance committee and the Medical Director, Physician A. She said a previous in-service on anticoagulants had been done at some point but was not tied to falls. She said she also had the nurses identify which residents were on anticoagulants. When asked how she ensured the nurses were competent in their skills for caring for a resident on anticoagulants she said she did a verbal discussion with them and had feedback with them. She said she had them describe what to do if they have a fall; discussed the monitoring log for residents on anticoagulants; discussed what to say to the doctor; and that they needed to reinforce what medications a resident was on and reiterated they needed to ensure awareness of all medications a resident was receiving. When asked what type of plan was in place for residents on anticoagulants she said prior to the incident, they had an anticoagulant policy and procedure and a fall policy and procedure but they did not have them interacting together. When asked had there been any types of in-services on residents on anticoagulants prior to accepting residents on anticoagulants she said there were some in-services done but not on a quarterly basis or a schedule. She did not say when the most recent in-service prior to the incident had been. When asked how she thought the immediate jeopardy/substandard quality of care came about she said, "I think that our policy and procedures were not specific to the fall with anticoagulants," but felt now everyone was more knowledgeable. When asked if any nursing judgment came into play she said, "Yes, following generic protocols." When asked if the doctor should have been notified that Resident #17 was also on [MEDICATION NAME] she said, "I think, as a nurse, doing multiple things probably thought he already knew instead of re-informing him. When asked if a change in the size of pupils from 3 mm to 4 mm should have been called to the doctor she said she would consider the baseline. She said considering and looking at everything in general, "...it probably should have been called." When asked what resources are available to her and the staff she said policy and procedures, consultant nurses, consultant dietician, and pharmacy. She said they also had sister facilities and a medical director. She said there was one nurse, LVN Z, who is an as needed nurse, who still needed the training. She said the training would be done prior to that nurse being allowed to work. Record review of in-services dated [DATE] and comparison to the active staff nursing roster confirmed training of staff on the new policy with the exception of one as needed staff member. Record review of monitoring logs for anticoagulants confirmed a log for each of the three residents on anticoagulants. Record review of the facility's policy and procedure for Falls revised [DATE] revealed the addition of, "9. If patient is on anticoagulant therapy MD must be notified immediately to consult for emergency room evaluation. ... " The Administrator, Regional Clinical Nurse A, Operations Manager, and Executive Director B were informed on [DATE] at 2:43 p.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. Record review of a list of residents on anticoagulants revealed 3 residents were receiving anticoagulants.

Based on interview and record review the Administrator failed to supervise the DON and DON failed to supervise, monitor, and train staff to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in that: --The Administrator and DON were unable to say based on their investigation whether staff consulted Resident #17's Physician on whether to hold his [MEDICATION NAME] administration and did not include the failure of LVN R to report a change of condition that occurred approximately 7 hours prior to the resident vomiting blood and becoming unresponsive during their investigation. --The Administrator and DON failed to ensure nursing staff on the 6:00 p.m. to 6:00 a.m. shift were trained on a new policy implemented after Resident #17's fall at 7:00 p.m. on [DATE]. They failed to ensure Resident #17's plan of care was updated after falls occurring on [DATE] and [DATE]. --The DON and Administrator failed to ensure staff put in place a physician ordered bed alarm for Resident #17. --Resident #17 sustained a fall with injury on [DATE]. The resident was on [MEDICATION NAME] (prevents the blood from clotting) which was on hold due to a high PT/INR. Resident #17 had a change in condition on [DATE] at 8:45 a.m. and 12:45 p.m. and LVN R failed to notify his physician of the change. He was sent to the hospital on [DATE] when he became unresponsive at 3:51 p.m. He died on [DATE] with a primary cause of death being [MEDICAL CONDITION] subdural hematoma. --LVN B failed to review all medications after the fall to determine with the doctor if Resident #17's antiplatelet therapy, [MEDICATION NAME] (prevents platelet aggregation) should be held. --Staff failed to revise and update Resident #17's plan of care interventions after previous falls on [DATE] and [DATE]. Staff documented having a bed alarm in place when one was not in place. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:39 p.m. While the IJ was removed on [DATE] at 7:12 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. This failure affected 1 resident and placed 3 residents receiving anticoagulants at risk of injury, hospitalization , delayed treatment, and death and of staff being untrained in facility policy and procedures. Intake # 8 Findings Include: Record review of Resident #17's closed record admission sheet revealed he was an [AGE] year old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed he required the extensive assistance of one staff for bed mobility and walking in his room.He required the extensive assistance of two staff for transfers. He had bilateral lower extremity impairments. He used a wheelchair for mobility. He was not steady, only able to stabilize with staff assistance when moving from a seated to standing position. He had no restraints. Record review of Resident #17's plan of care for Anticoagulant therapy dated as initiated on [DATE] revealed an intervention of , "...Monitor lab reports, and notify physician promptly of results ..." Record review of Resident #17's most recent plan of care for, "...Has had an actual fall with (No Injury, Unsteady gait, Poor Balance ..." dated as initiated on [DATE] revealed the next target dated was [DATE] to meet goals. There was no documentation of when the actual fall(s) occurred or the use of a bed/chair alarm. The care plan conference date was requested from the Administrator and Regional Clinical Nurse A on [DATE] at 3:56 p.m. The date was not provided prior to exit on [DATE]. Record review of Resident #17's plan of care for, "At risk for falls," dated as initiated on [DATE] revealed one intervention of floor mat at bedside. There was no documentation of the use of a bed/chair alarm as an intervention. During a telephone interview on [DATE] at 11:56 a.m. the complainant said Resident #17 fell and hit his head. The complainant said the facility did not call 911. During additional telephone interview on [DATE] at 1:00 p.m. with the complainant, the complainant said the death certificate had been received. The complainant said Resident #17 expired on [DATE] with a primary cause of death of [MEDICAL CONDITION] subdural hematoma and a secondary cause of death of coagulopathy related to [MEDICATION NAME]. The complainant said he/she did not have access to a fax machine and was mailing the Death Certificate to the Texas Department of Aging and Disability Services. Record review of the Provider Investigation Report dated [DATE] revealed on [DATE] at 7:00 p.m. Resident #17 had an unwitnessed fall. A description of the Allegation included that on [DATE], (Resident #17) was observed lying on his right side on the floor by his bed by Nurse (LVN B). On [DATE] @ 3:51 p.m. (Resident #17) was noted to be unresponsive to physical stimuli. (Resident #17) was gurgling when repositioned on his right side (Resident #17) vomited a large amount of brown fluid with 2 small blood clots. The physician was then notified and the resident was sent out via 911. During an interview on [DATE] at 2:16 p.m., with LVN B when asked about Resident #17's fall on [DATE] she said, he had a fall. She said she and 3 aides performed his transfer back to bed. She said he was talking and denied pain. She said he had a cut on his eyebrow approximately 1 cm. She said she assessed him again after the transfer. She said she reported the fall to NP A and did not receive an order to send him out. She said she and NP A knew he was on [MEDICATION NAME]. She said they had been having trouble controlling his INR level. When asked if she thought it was odd that he was not sent out she said yes but that his neurological vital signs were normal. She said NP A told her to call back if he had any change in his neurological vital signs. When asked if she called the DON to ask about not receiving an order to send the resident out, she said no because she did not think she would get an answer. Record review of Resident #17's print out of computer physician orders [REDACTED]. Record review of Resident #17's incident/accident reports revealed he was found on the floor of his room sitting with his back against his bed on [DATE] and had a fall during a transfer on [DATE]. There was no documentation of whether Resident #17's bed alarm was in place when he fell on [DATE]. During an interview on [DATE] at 2:52 p.m. with the DON she said Resident #17 was not sent to the hospital due to his neurological vital signs were normal and he was responsive. She said since the incident they had changed their policy. She said the new policy was that if a resident on [MEDICATION NAME] had a fall they were to be sent out to the hospital. When asked if they had a protocol for nurses for when they receive orders they disagree with she said they do. She said if a staff member disagrees with an order received, they are to call her and she can override a decision such as whether to send a resident out. When asked if LVN B called her the evening Resident #17 had the fall, she said no. Record review of Resident #17's incident/accident report dated [DATE] revealed, "...Upon entering residents room this writer (LVN B) observed resident laying on the floor on the side of bed on right side of bed on right side approx. (approximately) 60 cc (cubic centimeters) of dark red fluid noted on floor. V/S ,[DATE] (blood pressure) 95 (heart rate) 20 (respiratory rate) SpO2 (oxygen saturation) 97% in (sic) room air 97.2 AX (axillary temperature) Resident S/T (skin tear) 1 cm (centimeter) W (wide) by 1 cm (L) (length) by 1 cm (D) (depth) noted above right eyebrow resident denies pain cleansed dried TAO (triple antibiotic ointment) and bordered dressing applied Neuro (neurological) checks in progress resident resting stable DPOA (Durable Power of Attorney) (name) notified ' "I was trying to get up." '... "...S/T treated new orders noted MD (Medical Doctor) and RP (Responsible Party) notified ..." There was no documentation of whether his bed alarm was in place. There was no documentation of asking about the [MEDICATION NAME]. Record review of Resident #17's Neurological Flow Sheet dated [DATE] revealed neurological checks had been initiated on [DATE] at 7:00 p.m. and checked again at 7:15 p.m., 7:30 p.m., 7:45 p.m., 8:15 p.m., 8:45 p.m., 9:15 p.m., 9:45 p.m., 10:45 p.m., 11:45 p.m., 12:45 a.m. ([DATE]), 4:45 a.m., 8:45 a.m. and at 12:45 p.m. Staff failed to change the date from [DATE] to [DATE] after passing midnight on [DATE]. Continued review of Resident #17's Neurological Flow Sheet dated [DATE] revealed Resident #17's pupil size in both eyes was documented as being a consistent 3 mm (millimeters) from 7:00 p.m. on [DATE] through 4:45 a.m. on [DATE]. At 8:45 a.m. and 12:45 p.m. on [DATE] his pupil size changed to 4 mm. The Neurological Flow Sheet contained instructions to staff to, "...Notify MD IMMEDIATELY of signs and symptoms of intracranial Pressure!!!..." Record review of http://medical-dictionary.thefreedictionary.com for intracranial pressure revealed, "...Changes in pupil size, equality, and reaction to light, and extraocular movements are indicative of compression of the third, fourth, and sixth cranial nerves. Assessment of these changes should be as accurate and objective as possible. Unilateral and bilateral evaluations are important and usally are recorded by a drawing of the actual size of each pupil or by precise measurements using a small metric ruler. ... During an interview on [DATE] at 10:02 a.m. with the DON Resident #17's bed alarm order was discussed. She said the bed alarm had already been in his physician orders. She said no one had mentioned if his bed alarm had sounded. When asked why there were no intervention changes after his previous falls on [DATE] and [DATE] she said they tried to keep Resident #17 in the common areas and encourage him to stay out and watch television. When asked about the date on Resident #17's [DATE] neurological vital signs check documentation sheet not changing to ,[DATE] after midnight she said the date should have been changed to ,[DATE]. When asked how often LVN R, the nurse with Resident #17 when his pupil size changed, worked, she said LVN R is an as needed nurse and had not been very active on the schedule. When asked if a change in pupil size from 3 mm to 4 mm should have been called to the doctor she said yes. When asked if anyone had asked the doctor about also holding Resident #17's [MEDICATION NAME] she said, "I don't think so." A voice mail message was left for LVN R on [DATE] at 10:30 a.m. LVN R left a return message and was called for a telephone interview on [DATE] at 1:19 p.m. LVN R said she should have corrected the date on her neuro vital signs monitoring sheet to [DATE] since it was [DATE]. When asked if she reported the change in pupil size from 3 mm to 4 mm to Resident #17's doctor she said no. She said she did not call the doctor to report the change. When asked if she had been interviewed during the facility's investigation of the incident she said no. She said she cared for Resident #17 for 7 hours on [DATE] and that he had not had any additional falls. She said she went into the room to help the aide clean him up and he was gurgling and threw up. She said he had not wanted to eat that day. She said he had voiced no complaints of pain or nausea. When asked again if she reported the change in his pupil size to the doctor she again said she did not call the doctor. During a telephone interview on [DATE] at 10:37 a.m. with Physician A, who is also the Medical Director, he said if a resident hit their head and had a high INR he should have been sent out. He said, "That's the standard." When asked if he was consulted about if the [MEDICATION NAME] should be held and whether he was informed of Resident #17's change in condition on [DATE] at 8:45 a.m. when Resident #17's pupil size changed, he said he would call back on Monday, [DATE]. Physician A did not call back as of 5:00 p.m. on [DATE]. Record review of Resident #17's physician order [REDACTED]. On [DATE] his [MEDICATION NAME] was placed on hold for two days. His PT/INR was to be repeated on [DATE] with resutls to be called to the doctor. A physician order [REDACTED]. There was no documentation of a result for [DATE]. Record review of Resident #17's PT/INR results dated [DATE] revealed his INR was 5.30 out of a therapeutic range of 2XXX,[DATE].0. Results dated [DATE] revealed his INR had increased and was 6.45. Record review of Resident #17's [DATE] medication administration records revealed documentation of his [MEDICATION NAME] being held [DATE] through [DATE]. His [MEDICATION NAME] 75 mg continued to be administered daily at 9:00 a.m. through [DATE]. Record review of Resident #17's Nursing Progress Notes dated [DATE] revealed there was no documentation of Resident #17's medications being reviewed with his physician or nurse practitioner after his fall with injury on [DATE]. Record review of Resident #17's Nursing Progress notes revealed there was no documentation of Resident #17's change in condition (pupil size) being reported to the doctor. A note dated [DATE] 08:41 read, "...Resident in the bed s/p (status [REDACTED]. neuro (neurological) checks in progress and wnl (within normal limits). will cont (continue to monitor. ..." Record review of Resident #17's Nursing Progress notes dated [DATE] 15:51 (3:51 p.m.) revealed, "...resident in room unresponsive attempted the sternum rub, no respond (sic) v/s ,[DATE] (blood pressure) 109 (unclear if heart rate) 98 (unclear if temperature) O2 room air 94% BS (blood sugar) 131 noted that resident was (sic) gurgling (sic) turned resident on to his rt (right) side resident started to vomit excessive amount brown fluids with two small red clots notified Dr (Physician A) Spoke to (NP B) NP send resident out 911. stretcher with EMS (emergency medical services) in stable condition. Notified (family member) she stated ok. Notified (name of DON) DON she stated ok. ... " Observation on [DATE] at 11:20 a.m. of the 3 West Nurses' station revealed a posting which read, "...ATTENTION NURSES! IF a resident is on any type of anticoagulant therapy including aspirin and the resident falls please send to the E.R. for evaluation. ..XXX[DATE]" The posting was signed by the DON. During an interview on [DATE] at 4:05 p.m. with Regional Clinical Nurse A, the Administrator, and the Operations Manager they said they had identified the problem of falls for those on [MEDICATION NAME] in the Quality Assurance meeting. Evidence of a plan of action and monitoring was requested at that time but was not provided. Record review of an in-service provided by Regional Clinical Nurse A revealed all staff listed on the in-service documented their work shift as the 6:00 a.m. to 6:00 p.m. shift. There was no documentation of night shift staff being trained on the new policy. During an interview on [DATE] at 4:35 p.m. with Regional Clinical Nurse A she said they did not have documentation of a plan of action or monitoring. When asked why the night shift staff did not receive the in-service, she said, "I don't know." Record review of the facility's policy and procedure for Falls revised ,[DATE] revealed there was no directive for a resident on anticoagulants having a fall. Record review of the facility's policy and procedure for Post Fall Assessment revised ,[DATE] revealed, "...An incident Report and a Fall Investigation, Post Form will be completed by a Licensed Nurse on the shift that the fall occurred The Licensed Nurse will complete the form as follows: ...6. Identify an action plan or approaches to be taken in an attempt to prevent further falls based on newly identified facts or risk factors. ...7. Document on the post fall assessment form that the care plan was updated to reflect new action plan or approaches for prevention of falls. ...ignificant (sic) information obtained as a result of the post fall assessment should be reported to the physician, and documented in the edical (sic) Records. ..." Record review of the facility's policy and procedure for Neurological Evaluation revised ,[DATE] revealed, "...All incidents involving trauma to the head will result in a comprehensive neurological assessment for a minimum of seventy-two (72) hours. ...7. Pupil Signs A. Look at pupils and compare size and equality. b. sing (sic) an overhead light, simultaneously compare the size of the pupils and their reaction to light. C. If flashlight is used, shine directly into eye being examined while other eye is covered. ..." The policy and procedure did not address notifying the doctor of changes. Record review of the facility's policy and procedure for Monitoring for Significant Change in Condition revised ,[DATE] revealed, "...8. Physician, resident, and responsible party will be notified of the significant change. ..." An IJ was identified on [DATE] at 4:39 p.m. and the Administrator, Regional Clinical Nurse A, Regional Clinical Nurse B, DON, Operations Manager, and Executive Director B were informed at that time. During an interview with them at that time, they all said they did not know why the night shift had not received the in-service. A Plan of Removal (PoR) for the IJ was submitted [DATE] and after revisions was accepted on [DATE] at 2:15 p.m. The PoR included: 1.) Problem Ensuring facility evaluates extent of injury after fall and prevents complications with residents on Anticoagulant therapy. Education on policy for assessment post fall of residents on anticoagulant therapy not completed with all licensed nurses. 2.) Immediate Actions: A. Criteria used to identify residents on [MEDICATION NAME]: Director of Nursing and Clinical Resource Nurses reviewed the orders completed 100% review on all residents on anticoagulant therapy identified on [DATE] at 5:00 p.m.. B. All residents identified on Anticoagulants had their care plans reviewed and updated [DATE] at 6: 00 p.m.. C. Anticoagulant Order and Administration Record Sheet created [DATE] at 5:00 p.m. to be monitored daily by Director of Nursing or designee. Any discrepancies to be addressed immediately and discussed in QAA. D. Revised the Policy and Procedure on Falls with residents on anticoagulants on [DATE] at 5:00 p.m.. E. The nurse will notify the DON and the resident physician if the resident neuro vital signs or his/her condition change immediately. F. Post Fall Procedure will include a review and update of resident care plans and medication and appropriate interventions will be put in place. 3.) Training A. License nurses will be In-serviced on Fall precautions, Change of condition, treatment of [REDACTED]. In- service started on [DATE] and will be completed by 11:00 p.m. on [DATE]. Training will be provided by Director of Nursing or designee. During an interview on [DATE] at 3:56 p.m. with Regional Clinical Nurse A she said she was now the acting DON for the weekend and a new DON would be starting on Monday, [DATE]. She said all nurses had been in-serviced except for one who would not be allowed to return to work until being in-serviced. She said none of the 3 residents on anticoagulants had any falls. She said she had reviewed anti-coagulant monitoring. She said the QAA committee met last night, [DATE], including the Medical Director (Physician A) via telephone. She said Physician A agreed any resident on an anti-coagulant who had a fall was to be sent out to the emergency room . During a telephone interview on [DATE] at 4:41 p.m. with LVN B when asked if Resident #17's bed alarm had been in place when he fell on [DATE] she said he had no bed alarm at that time. She said that was why she got an order for [REDACTED]. Record review of Resident #17's [DATE] medication administration sheets revealed staff were documenting the presence of a bed/chair alarm each shift, including on [DATE] during the evening shift when the fall occurred. During an interview on [DATE] at 4:59 p.m. with LVN H she said she had received in-service training about residents with falls on anticoagulants. She was able to describe the training and what to do. When asked where a nurse documents monitoring a bed alarm she said on the nurses' medication administration record. During an interview on [DATE] at 5:13 p.m. with LVN E she said she was in-serviced yesterday, [DATE]. She was able to describe the training and the facility's policy on residents who had a fall and were on an anticoagulant. During an interview on [DATE] at 5:25 p.m. with LVN M she said she had received in-service training yesterday, [DATE]. She was able to describe the training and the facility's policy on residents who had a fall and were on an anticoagulant. During an interview on [DATE] at 5:38 p.m. with the Administrator, when asked what type of procedure is there to make sure the nursing needs of residents' are being met, he said they have interdisciplinary team meetings. He said in those meetings they discuss the needs of the residents and standards of care. He said they have daily stand-up meetings and discuss any changes. He said they make daily rounds and interview residents. When asked how he monitors staff, such as the DON, to ensure the systems they monitor are being done sufficiently he said there had been a problem in the facility with monitoring. He said when they realized there were problems they made changes in the nursing team. He said they had been having the Clinical Resources (Regional Clinical Nurses) in the building more. He said they have weekly meetings with department heads. He said to ensure competency of staff they make rounds. He said the Clinical Resources (Regional Clinical Nurses) review matrixes they review such as pressure ulcers, restraints, and falls tracking. He said they also have annual evaluation practices and they set standards. When asked how they evaluate their policy and procedures he said they do that in the Quality Assurance committee and standard care meetings. He said if they have a poor outcome, policies are reviewed in the Quality Assurance committee, including the Medical Director. When asked how they assure the effectiveness of facility processes he said they do it by reviewing results, reevaluate, and make any changes to get the outcomes they hope to achieve. When asked how he thought this immediate jeopardy/substandard quality of care came about he said, "...perhaps we had the wrong leadership in place before and that's why we've made some changes." He said new leadership was now in place. He said a new DON was starting Monday. He said they had a new ADON and a new MDS nurse. When asked if he was aware of the situation he said yes. He said he was informed on Monday, [DATE] that Resident #17 had fallen and of what had been done, for example, calls to the doctor and neuro checks. He said he was concerned. He said he called the hospital Resident #17 had been sent to and was informed Resident #17 had been transferred to another hospital. He said he called the other hospital and was told Resident #17 was not doing well. He said they started their investigation and based on findings, determined they could have done some things differently. He said, "You know, I think, of course, looking in retrospect." He said perhaps reviewing the policy and procedures in place at the time, how situations were handled in the past, and handling patients on anticoagulants. When asked if anyone had questioned the continued administration of [MEDICATION NAME] to Resident #17 he said, to his knowledge, he was not aware of the [MEDICATION NAME] administration being questioned. When asked if he knew if it was questioned during the investigation why the doctor was not notified of the change in Resident #17's pupil size from 3 mm to 4 mm he said he did not know. When asked what resources were available to him and his staff he said policy and procedures, Corporate staff, sister facilities, and a medical director. He said he also tries to reach out to the Texas Department of Aging program managers, if needed, and the Ombudsman. During an interview on [DATE] at 5:50 p.m. with LVN G she said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she had received in-services on [DATE] over the concerns. She was able to describe the training and new policy. When asked if she were caring for a resident on [MEDICATION NAME] who had a fall, would she review the resident's medications and include that information in a call to the doctor, she said yes. She said, "That's usually one of the first things they ask is are they on any medications other than [MEDICATION NAME]." When asked how they ensure ordered interventions such as a bed alarm or floor mat were in place, she said she makes rounds and observes these items. She said they document on the nurses' medication or treatment administration records. When asked if a change in the size of pupils from 3 mm to 4 mm is a reportable change in condition she said yes. She said it could indicate an head injury or bleed. During an interview on [DATE] at 6:23 p.m. with LVN B she said she had received in-services on [DATE]. She described the training. She said if a resident is on an anticoagulant and has a fall, you assess the resident, call the doctor and send the resident to the hospital. She said the care plan and medications are to be reviewed. When asked if she would report a change in pupil size from 3 mm to 4 mm when monitoring neurological vital signs she said, "Definitely." She said it could indicate a brain bleed or injury. During an interview on [DATE] at 6:31 p.m. with LVN L she said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she had received the in-services. She was able to describe the training and policy changes. When asked if it would be important to let the doctor know the resident was also taking [MEDICATION NAME], she said, "Of course." When asked about a change in pupil size, she said yes, a change from 3 mm to 4 mm is reportable to the doctor. She said any change of condition is reportable. She said a change in pupil size from 3 mm to 4 mm could indicate a head injury or internal bleeding. The DON was no longer working at the facility. An interview was conducted with Regional Clinical Nurse A on [DATE] at 7:01 p.m. due to she was serving as the interim DON for the weekend. When asked what training was ensured the nurses had in order to care for residents on anticoagulants she said after the incident, she trained staff on anticoagulants, change in condition, change in neuro vital signs, anticoagulants and falls, assessments, and sending a resident to the hospital immediately even if it's minor. She said the policy and procedure had been updated and reviewed and approved by the quality assurance committee and the Medical Director, Physician A. She said a previous in-service on anticoagulants had been done at some point but was not tied to falls. She said she also had the nurses identify which residents were on anticoagulants. When asked how she ensured the nurses were competent in their skills for caring for a resident on anticoagulants she said she did a verbal discussion with them and had feedback with them. She said she had them describe what to do if they have a fall; discussed the monitoring log for residents on anticoagulants; discussed what to say to the doctor; and that they needed to reinforce what medications a resident was on and reiterated they needed to ensure awareness of all medications a resident was receiving. When asked what type of plan was in place for residents on anticoagulants she said prior to the incident, they had an anticoagulant policy and procedure and a fall policy and procedure but they did not have them interacting together. When asked had there been any types of in-services on residents on anticoagulants prior to accepting residents on anticoagulants she said there were some in-services done but not on a quarterly basis or a schedule. She did not say when the most recent in-service prior to the incident had been. When asked how she thought the immediate jeopardy/substandard quality of care came about she said, "I think that our policy and procedures were not specific to the fall with anticoagulants," but felt now everyone was more knowledgeable. When asked if any nursing judgment came into play she said, "Yes, following generic protocols." When asked if the doctor should have been notified that Resident #17 was also on [MEDICATION NAME] she said, "I think, as a nurse, doing multiple things probably thought he already knew instead of re-informing him. When asked if a change in the size of pupils from 3 mm to 4 mm should have been called to the doctor she said she would consider the baseline. She said considering and looking at everything in general, "...it probably should have been called." When asked what resources are available to her and the staff she said policy and procedures, consultant nurses, consultant dietician, and pharmacy. She said they also had sister facilities and a medical director. She said there was one nurse, LVN Z, who is an as needed nurse, who still needed the training. She said the training would be done prior to that nurse being allowed to work. Record review of in-services dated [DATE] and comparison to the active staff nursing roster confirmed training of staff on the new policy with the exception of one as needed staff member. Record review of monitoring logs for anticoagulants confirmed a log for each of the three residents on anticoagulants. Record review of the facility's policy and procedure for Falls revised [DATE] revealed the addition of, "9. If patient is on anticoagulant therapy MD must be notified immediately to consult for emergency room evaluation. ... " The Administrator, Regional Clinical Nurse A, Operations Manager, and Executive Director B were informed on [DATE] at 2:43 p.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. Record review of a list of residents on anticoagulants revealed 3 residents were receiving anticoagulants.