Every finding on record at The Plaza at Lubbock

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff, and the public, for 2 of 4 shower rooms (Hall 200 and Hall 400) and 1 of 1 public toilet, reviewed for physical environment.The facility failed to ensure:The shower room on hall 200 had loose and missing tiles in numerous areas of the showerThe shower room on hall 400 had loose and missing tiles in numerous areas of the shower.The door to the shower room on hall 200 was broken. The vanity in shower room [ROOM NUMBER] contained water damage. The hand sink in shower room [ROOM NUMBER] contained corrosion and calcium build up under the sink faucet. The toilet seat in the public bathroom near the nurse's station was loose. This failure could lead to residents falls, injuries, and experiencing a diminished quality of life. Findings include:During an observation on 01/06/2026 at 02:10 PM, the public bathroom near the nurse's station was observed to have a broken toilet seat. The toilet seat was not secure and moved from side to side, 3 to 4 inches. During a confidential interview held on 01/07/2025 at 2:00 PM, 2 confidential residents stated there were numerous repairs that needed to be completed throughout the facility. The confidential residents did not want to specify what repairs were needed but stated the shower rooms should be checked. During an observation and interview on 01/07/2026 at 11:57 AM, the shower room on hall 200 was observed to have two large areas of red tape, approximately 12 by 12 inches, covering missing tiles in the shower. CNA E stated the tape had been on the shower wall since he had been employed at the facility for approximately one year. CNA E stated the MS was aware of the missing tiles, and a work order had been requested for the repair. The door to the shower room was observed to be broken at the top half of the door, with the wood separating down the side of the door. The separation was approximately 12 inches in length. CNA E stated the MS was aware of the broken door, and a work order had been requested for the door as well. During an observation on 01/07/2026 at 12:10 PM, the shower room on hall 400 was observed to have numerous areas of loose and missing tiles from the shower. The vanity was observed to have water damage and deteriorated particle board at the bottom right side of the cabinet. The sink was observed to have a thick build up of corrosion and calcium under the faucet. During an interview on 1/08/2026 at 12:35 PM, the MS stated he had worked at the facility for approximately ten years. The MS stated he was aware there was tape covering missing tiles in the shower in the shower room on hall 200, as well as loose tiles throughout the shower. The MS stated he was aware of the water damage to the vanity in the shower room on hall 200. The MS stated he was aware of the broken door in the shower room on hall 200, and he stated he needed to order a new door. The MS stated he was aware of the broken toilet seat in the public bathroom near the nurse's station. The MS stated he was aware of the corrosion and build-up under the faucet in the hand sink in the shower room on hall 400. The MS stated he was responsible for responding to all maintenance requested for the facility. The MS stated maintenance requests were communicated in a binder at the nurse's station. The MS stated any of their staff could have submitted a maintenance request for repairs needed. The MS stated some maintenance requests were communicated to him verbally, and he was responsible for ensuring they were followed up on. The MS stated he was working on the tile in the shower rooms on hall 200 and 400, but he stated he was having a hard time matching the tile to replace them. The MS stated he would submit a bid as soon as he could to obtain approval to fix both shower rooms. The MS stated this had not been done yet. The MS stated he would make this a priority in his upcoming tasks. The MS stated he checked the maintenance request book daily, and he prioritized his work based on importance in regard to resident safety and resident need. The MS stated he would check on the broken toilet seat as soon as possible, as he felt this was a priority. The MS stated the uncompleted repairs could cause concern to the residents, and he planned to have the repairs completed within the upcoming month. During an interview on 01/08/2026 at 02:15 PM, the ADM stated she was not aware of the repairs needed in the shower rooms on halls 200 and 400, nor the broken toilet seat in the public bathroom. The ADM stated the MS was responsible for all maintenance requests for the facility. The ADM stated any staff could report a maintenance request, and it was recorded in a book at the nurse's station. The ADM stated the MS was responsible for checking the book daily and prioritizing his work order requests based on resident safety and resident need. The ADM stated the MS also did a daily walk-through of the facility and should have noted any needed repairs during that time as well. The ADM stated some work orders were reported during their morning meetings held with all department heads. The ADM stated it was her expectation for maintenance requests to be completed as quickly as possible to ensure a safe environment for the residents. The ADM stated uncompleted repairs could pose a safety concern for residents, could create hazards for residents, and potentially attract rodents into the facility/. Record review of the policy titled, Maintenance Service, undated, included the following: Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation:I. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. The following functions are performed by maintenance, but are not limited to:a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. Maintaining the building in good repair and free from hazards.f. Establishing priorities in providing repair service.i. Providing routinely scheduled maintenance service to all areas.j. Others that may become necessary or appropriate.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable, attractive and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 (Lunch) meal reviewed for palatability. 1) The facility failed to provide food that was palatable for the lunch meal on 01/07/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 3 of 15 residents voiced concerns related to food palatability. One resident stated the food was not good and lacked flavor. One resident stated the food lacked seasoning and tasted like nothing. One resident stated the food was very bland and had little taste. Observation on 01/07/26 at 12:38 PM the test trays arrived at the family dining room and were sampled by three surveyors at 12:40 PM with the following results:Regular Meal - Regular TextureBaked Ham - blandMashed Potatoes - blandSpinach Bake - no issuesCorn Bread - no issues Regular Meal - Mechanical Soft TextureBaked Ham - had a processed/plastic taste, lacked flavorMashed Potatoes - blandSpinach Bake - no issuesCorn Bread - no issues Regular Meal - PureeBaked Ham - had a processed/plastic taste, lacked flavor, very chunky and required chewingMashed Potatoes - blandSpinach Bake - did not taste like the regular spinach bake, bad taste, very thick consistencyBread - bad taste Regular Meal - Substitution offeredTomato Soup - strong acidic taste, bad taste During an interview on 01/07/26 at 12:50 PM, the ADM was asked to try the test tray and stated the puree spinach bake and the regular spinach did not have the same taste. During an interview on 01/08/26 at 9:31 AM, [NAME] A stated sometimes he tasted the food before serving it to the residents, but not all the time. [NAME] A stated he added breadcrumbs to the puree spinach bake yesterday, and that was probably what changed the taste. [NAME] A stated the mechanical soft ham was delivered to the facility already chopped up like that. [NAME] A stated the puree form ham was made from the mechanical soft form ham. [NAME] A stated the ham had a different texture than the regular ham, but he did not know why because it was delivered that way. [NAME] A stated he tasted the puree ham from yesterday's lunch, and it did have a gritty taste to it. [NAME] A stated the residents had complained to him about the tomato soup not tasting good, but he had not changed anything yet. [NAME] A stated he had been trained in food palatability when he first started working at the facility. [NAME] A stated a potential negative outcome to the residents was choking on the food. During an interview on 01/08/26 at 11:00 AM, the DM stated [NAME] A had been trained in food palatability and proper puree form, but she could not give an exact date. The DM stated none of the residents or their families had complained to her about the taste of the food. The DM stated a potential negative outcome to the residents was that they would not want to eat and could lose weight if the food did not taste good. During an interview on 01/08/26 at 11:14 AM, the ADM stated the DM was responsible for food palatability. The ADM stated the dietary staff had been trained in food palatability. The ADM stated the residents had not complained to her recently about the food and she was not aware of the resident's making complaints about the tomato soup specifically. The ADM stated a potential negative outcome to the residents with the food not tasting good was they could not eat enough and have weight loss. Interview on 01/08/26 at 4:01 PM, the ADM stated the policy provided for food palatability was the most relevant policy she could find. Record review of the facility's grievance log from July 2025 to January 2026 revealed four complaints regarding food concerns. Record review of the facility's document titled, Resident Council Meeting Form, dated 08/25/25 revealed a dietary concern, Residents state food on the halls can sometimes be cold and flavorless. Record review of the facility's document titled, Resident Council Meeting Form, dated 10/27/25 revealed a dietary concern, Resident on Hall 1 stated that food on the hall trays are not always hot. Some residents stated they are inconsistent with seasoning. Record review of the facility's policy and procedure titled, Use of Recipes, with a revised date of 02/06/24, reflected the following: Policy: Recipes will be used when preparing menu items.Procedure: Recipes (in appropriate portion sizes) for each menu cycle are available and maintained in the facility.Recipes will be printed to scale according to information derived from resident tray tickets and current census.Nutrition Services employees are expected to use and follow the recipes provided.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to store bowls and plates upside down, ensure the deep fryer was cleaned, ensure no expired food items were in the kitchen, ensure all food items in the refrigerator were properly labeled or stored in airtight containers, ensure all food items in the dry storage area were properly sealed, and ensure the oven door was clean. These failures could place residents at risk for food contamination and foodborne illness. The findings include: Observations during the initial tour on 01/06/26 at 9:45 AM revealed 5 stack of bowls (each stack of bowls contained 10 - 15 each), 2 stacks of small plates (each stack of plates contained about 20 each), 3 stacks of medium bowls (each stack bowls contained 2 - 9 each), and 1 stack of small bowls (7 bowls contained) on metal shelves and all of the items were stored right side up, meaning the inside of the bowls and plates were exposed. The deep fryer had small brown food crumbs along the inside and the food baskets, the oil in the fryer was a dark brown color and there were food crumbs and grease splatter along the insides of the fryer. The oven door had 7 lines of brown grease dripping from the top of the oven down to the bottom of the oven. In the refrigerator, there were 5 sandwiches that were unlabeled and undated, 1 block of yellow cheese that was undated and unlabeled, 1 pitcher of dark red juice that was undated and unlabeled, 1 pitcher of yellow/brown juice that was undated and unlabeled, and 1 pitcher of orange juice that was undated and unlabeled. The dry storage area contained a large container labeled salt that was not fully sealed and undated, 1 box of potato pearls that was not fully sealed and dated 01/04/26 and 1 box of baking soda that was not fully sealed and undated. The walk-in freezer contained 1 large container of hard-boiled eggs with a best use by date of 01/01/26. During an interview on 01/06/26 at 9:55 AM, the DM stated the prior shift had placed the items in the refrigerator and they had been trained that only a date was needed for the food items. During an interview on 01/06/26 at 9:57 AM, [NAME] A stated he had cleaned out the grease trap on the oven earlier that day and had forgotten to go back and clean up the grease mess on the oven door. During an interview on 01/08/26 at 9:31 AM, [NAME] A stated the kitchen staff were trained to clean as they went. [NAME] A stated sometimes they get busy and cannot clean up as they go. [NAME] A stated that was why the deep fryer was dirty, because he had not had a chance to clean it in a little over a week now. [NAME] A stated they were trained to clean the deep fryer once a week. [NAME] A stated he was last trained a couple months ago about labeling and dating all items in the refrigerator. [NAME] A stated the items were not labeled or dated probably due to laziness, but it was unknown why. [NAME] A stated a potential negative outcome to the residents was cross-contamination and some food items may not be fresh if there was no date on it. During an interview on 01/08/26 at 11:00 AM, the DM stated all the kitchen staff were responsible for labeling and dating all food items and keeping the kitchen cleaned. The DM stated she expected the staff to follow the cleaning schedule and deep clean the deep fryer every Friday. The DM stated the deep fryer was cleaned last Friday and had not been used again, so she was not sure why it was dirty. The DM stated she was confused on the labeling of the food items, but she was told all food items need to be labeled with what it is and the date. The DM stated she had instructed her staff to follow what corporate said to do regarding food storage. The DM stated the stacks of bowls and plates should have been stored upside down and she did not know why they were not stored that way. The DM stated she did not know the expiration date on the boiled eggs and thought they were ok because the container was new. The DM stated the risk to the residents was they could get sick or food poisoning. During an interview on 01/08/26 at 11:14 AM, the ADM stated she expected food items in the kitchen to be labeled or dated if they were not in their original containers. The ADM stated she expected there to be a safe, clean environment in the kitchen at all times. The ADM stated she expected food items like bowls and plates to be stored appropriately. The ADM stated the DM or an appointed designee were responsible for ensuring the kitchen was cleaned and all food items were properly labeled and stored. The ADM stated there was a risk for food borne illness or cross contamination. Record review of the facility policy titled, Food Storage, with a revised date of 04/08/25 reflected the following: Policy: .Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination.Procedure:Storeroom: .Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened.Refrigerator: .All foods are covered, labeled, and dated.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 9 residents observed for infection control (Resident #33, #98, #94, and #8) .LVN A failed to utilize enhanced barrier precautions (EBP) during medication administration for Resident #98.The facility failed to ensure Resident #94 had an EBP sign on her door and a personal protective equipment (PPE) box available.CNA B failed to remove the dirty pad from the bed during incontinence care for Resident #33.CNA C failed to change his gloves during incontinence care for Resident #8.CNA D failed to utilize hand hygiene between glove changes during incontinence care for Resident #8. These failures could place residents at risk for cross contamination and infection.The findings include:Resident #98Record review of Resident #98's face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #98 had a medical history of gastrostomy (a surgical procedure creating a direct opening from the abdomen into the stomach for a feeding tube to deliver nutrition), tracheostomy (a surgically created opening in the neck into the windpipe to provide an airway), and dysphagia (difficulty swallowing).Record review of Resident #98's physician orders revealed an order for Enhanced Barrier Precautions (EBP) .Trach, Peg Tube & implanted port with a start date of 1/07/2026.Record review of Resident #98's admission MDS Section C- Cognitive Patterns dated 10/03/2025 revealed a BIMS score of 13 which indicated Resident #98 was cognitively intact.Record review of Resident #98's care plan revealed an intervention of Resident on ENHANCED BARRIER PRECAUTIONS related to trach. Protective personal equipment to be worn provided in cart in resident's room dated 10/21/2025.During an observation of medication administration on 01/07/26 at 7:14 AM, LVN A provided medication administration via g-tube (feeding tube) to Resident #98, LVN A did not wear a PPE gown. A blue name tag was observed on the name plate next to the door behind Resident #98's name.During an interview on 01/07/26 at 7:38 AM, LVN A stated residents who were on EBP (infection control measures, primarily for nursing homes, requiring gowns and gloves for healthcare personnel during high-contact care for residents with multidrug-resistant organisms (MDROs), wounds, or devices, bridging standard precautions and contact precautions to prevent spread when standard methods aren't enough) have a blue tag behind their name. LVN A stated she was taught that if a resident had a blue tag behind their name, the staff needed to wear a gown and gloves when providing direct care. LVN A stated she did not notice if Resident #98 had a blue tag behind his name. LVN A stated she must have missed seeing the blue tag behind Resident #98's name to note that he was on EBP. LVN A stated the PPE box was usually kept right inside the room and the PPE box for Resident #98 had been placed in the bathroom and that was why she forgot to put a gown on to provide him with medications via g-tube. LVN A stated she had been trained last month on EBP in the facility, but she did not remember an exact date. LVN A stated the residents had an increased risk for infection with staff not wearing the proper PPE for EBP. LVN A stated EBP for the residents was to help protect the residents from infections.Resident #94Record review of Resident #94's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #94 had a medical history of cerebral palsy (a permanent group of neurological disorders affecting movement, balance, and posture, caused by non-progressive damage to the developing brain), pressure ulcer of sacral region, unstageable, and hypertension (high blood pressure).Record review of Resident #94's quarterly MDS Section C- Cognitive Patterns dated 12/05/2025 revealed a BIMS score of 07 which indicated Resident #94 had a severe cognitive deficit. Record review of Resident #94's care plan revealed Resident (#94) has a stage 4 ulcer to her sacrum dated 1/07/2026. The Care plan revealed Resident (#94) on ENHANCED BARRIER PRECAUTIONS (EBP) related to wounds.Protective personal equipment to be worn provided in cart in resident's room.Post signs at resident`s door informing visitors to check in with licensed staff with questions regarding EBP. dated 1/08/2026.Record review of Resident #94's physician orders revealed an order for Enhanced Barrier Precautions (EBP) . wound dated 1/06/2026. The Physician orders revealed an order for Wound Care To Coccyx/Sacrum. dated 12/19/2025.During an observation on 1/7/2025 at 8:26AM, Resident #94's room did not have a PPE box or an EBP sign on her door. Resident #33Record review of Resident #33's face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #33 had a medical history of Parkinson's disease (a progressive neurological disorder affecting movement), type 2 diabetes, muscle wasting and muscle weakness.Record review of Resident #33's admission data dated 12/29/2025 revealed a BIMS score of 14, which indicated Resident #33 was cognitively intact. The Bladder review section of the assessment data revealed Resident #3 was incontinent of bladder.Record review of Resident #33's care plan revealed a problem of bowel and bladder. Check and change, keep clean and dry dated 12/29/2025.During an incontinence care observation on 1/07/2026 at 10:00 AM, CNA B removed Resident #33's dirty brief and laid resident onto her back on a bed pad. CNA B turned Resident #33 onto her right side and cleaned Resident #33's bottom. CNA B laid Resident #33 onto her back and on the dirty bed pad. CNA B turned Resident #33 again on right side and placed a clean brief under Resident #33. CNA B did not remove the dirty pad before placing a clean brief on Resident #33.Resident #8Record review of Resident #8's face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #8 had a medical history of chronic obstructive pulmonary disorder (a progressive lung condition causing airflow blockage and breathing problem), type 2 diabetes, alcohol dependence, unspecified cirrhosis of liver (scarring of the liver), and abnormal posture.Record review of Resident #8's quarterly MDS Section C- Cognitive Patterns dated 8/2/2025 revealed a BIMS score of 12 which indicated Resident #8 had moderate cognitive impairment.Record review of Resident #8's care plan revealed Urinary catheter. Resident will be free of complications of indwelling catheter. Care/changing of urinary catheter as ordered dated 8/05/2025.During a foley care observation on 1/07/2025 at 10:13 AM, CNA C cleaned Resident #8's foley and turned Resident #8 onto his right side. CNA C did not change gloves or utilize hand hygiene. CNA D assisted Resident #8 to turn onto his right side and provided CNA C with clean wipes as CNA C cleaned Resident #8's bottom. CNA D changed her gloves after finishing handing wipes to CNA C. No ABHS or hand hygiene was utilized during the glove change by CNA D. CNA C cleaned Resident #8's bottom and removed the dirty brief. CNA C did not utilize hand hygiene or change gloves. CNA C placed a new clean brief on Resident #8 with dirty gloves.During an interview on 1/08/2026 at 11:20 a.m., CNA B stated she had been trained on infection control. She stated had been trained on incontinence care on 1/7/2026 with a mannequin but had no training prior to that at this facility. She stated she was not sure why she did not change the pad out from Resident #33 after it became dirty but she was aware she should have done so. She stated the pad would be considered dirty after she removed the dirty brief from the resident and laid Resident #33 down on the bed pad. She stated the potential negative outcome of not changing the dirty pad during incontinence care would be spreading infection.During an interview on 1/08/2026 at 11:28 a.m., CNA C stated he had been trained on infection control and incontinence care. He stated his last training was in November 2025. He stated he had been trained to change his gloves when going from dirty to clean and to use hand hygiene in between glove changes. He stated he did not change his gloves because he was nervous at the time of the incontinence care and forgot to change them. He stated the potential negative outcome of not changing gloves or using hand hygiene during incontinence care could be spreading germs to other staff and to residents. He stated he would be reviewing the incontinence care steps more and making sure he is not missing any steps.During an interview on 1/08/2026 at 11:33 a.m., CNA D stated she had been trained on infection control and hand hygiene between glove changes. She stated her last training was in December 2025. CNA D stated she did not use hand hygiene between glove changes because she did not see the hand sanitizer on the table. She stated a potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection and bacteria. She stated she would be carrying a bottle of hand sanitizer with her at all times and using it during glove changes.During an interview on 1/08/2026 at 11:48 a.m., the DON stated she was the infection preventionist. She stated staff had been trained on infection control, EBP, incontinence care and hand hygiene and the last training was 1/6/2026. She stated EBP was used as an intervention for infection control and to protect residents and staff from spreading infection. She stated she monitors compliance by going through the halls and would observe staff utilize EBP during direct patient care. She stated EBP was identified by the blue tags on the resident's doors. She stated EBP was used for residents who had a history of MDRO or who may have a catheter, IV, wound, or gastric tubes. She stated audits were done weekly and wound reports were looked at to ensure all the appropriate orders were in place as well as the PPE and EBP signs. She stated CMA F was responsible for ensuring the blue signs and PPE boxes were placed in the residents' rooms. She stated if a residents room had a blue sign on the door, and the staff were providing direct resident care such as toileting, EBP should be utilized. The DON stated the nursing staff are trained to identify the need for EBP even if there was no blue signs or PPE boxes in the room. She stated a G-tube would indicate to staff the need for EBP. She stated she was not sure why LVN A would not have worn EBP, there was no reason for LVN A to not have utilized EBP. The DON stated a potential negative outcome of staff not utilizing EBP or not having EBP signs on the doors could be an infection transmission risk to other residents. The DON stated staff are trained to use hand hygiene between glove changes and when going from a dirty area to a clean area. She stated she was not aware of staff not changing gloves during incontinence care or using hand hygiene between glove changes. She stated a potential negative outcome of not using hand hygiene or changing gloves could be spreading infection. The DON stated she would consider a pad dirty if a resident was laid down on the pad before they had been cleaned and the pad should have to be changed. She stated a potential negative outcome of not changing a dirty pad during incontinence care could be skin breakdown, the resident not being clean and infection concerns. She stated she was not aware of the dirty pads not being changed during incontinence care.During an interview on 1/08/2026 at 2:31 p.m., CMA F stated EBP can be initiated anytime a resident may have a wound or an invasive tube such as a catheter. She stated the nurse who identified the need for the EBP would be responsible for ensuring they get an order from the physician and notify her of the new order. She stated she would then put a blue sign on the door and a PPE box in the room. She stated Resident #94 had a wound on her coccyx that had healed in December of 2025 and the EBP had been removed. She stated over the last few days, the wound re-opened and she had not been made aware therefore the EBP signs and PPE box had not been placed in her room. She stated a potential negative outcome of not having the EBP signs on the door could be spreading infection. She stated compliance was monitored by reviewing the wound logs and invasive devices log and ensuring the EBP policy is implemented. She stated monitoring was done 2-3 times a week. She stated EBP should be implemented immediately once the need for it is identified.During an interview on 1/08/2026 at 3:03 p.m., the ADM stated staff had been trained on infection control and the last training was in December of 2025. She stated staff had been trained on EBP. She stated the EBP was identified through blue tags on resident doors and staff was trained to know they would need to use PPE when providing direct resident care. She stated residents with wounds or a history of MDRO require EBP. She stated EBP is used to protect the resident and staff from spreading infection to themselves and to others. She stated the nurses are responsible for obtaining the EBP order and implementing those orders but the DON would ultimately be responsible. She stated staff are trained to recognize when the use of EBP is needed and if a resident did not have a current sign or PPE box they would need to follow up and make sure it was put into place. She stated she was not sure why LVN A did not utilize EBP but she had been trained to recognize when residents need the EBP and should have worn the PPE. She stated a potential negative outcome of not using EBP or having the EBP signs on the doors could be spreading infection to other residents. The DON stated staff are trained to change their gloves during incontinence care. She stated staff are trained to utilize hand hygiene between glove changes. She stated glove changes should be done when going from dirty to clean and hand hygiene in between. She stated she was not aware that staff were not utilizing hand hygiene and glove changes during incontinence care. She stated a potential negative outcome of not using hand hygiene or glove changes could be spreading infection. The DON stated she would consider a bed pad dirty if a resident was laid on it before being cleaned. She stated she expected staff to change the dirty pad before placing a clean brief on the residents. She stated the potential negative outcome of not changing a dirty bed pad during incontinence care could be spreading infection, dignity concerns and dirtying what had been cleaned.Record review of facility policy titled Enhanced Barrier Precautions last revised April 1, 2024, revealed; Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug-resistant organisms (MDROs). This facility utilizes Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply.A. Indications.Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO.3. High Contact Resident Care Activities: .g. Device care or use: Central line, Urinary catheter, feeding tube, tracheostomy, h. Wound Care: any skin opening requiring a dressing.Communication.1. Indicate the residents who are on EBP by subtle means, such as an alternate color of the resident's name badge on door, to maintain a home-like environment.Record review of facility policy titled Hand Hygiene for Staff and Residents last revised July 2018 revealed; Policy: Proper hand hygiene technique is completed whenever hand hygiene is indicated.Procedures: Hand hygiene is done after. H. removal of medical surgical or utility gloves.Wash hands at end of procedures where glove changes are not required. For procedures in which change of gloves. indicated follow the specific standard of practice. If glove hands become contaminated as gloves are changed hands can be washed.Record review of facility policy titled Perineal Care last revised April 10, 2023 revealed; Procedure: Staff will provide perineal care in accordance with the standards of practice to prevent skin breakdown and infection.Procedure:.8. Turn resident to clean all areas of buttocks with new wipe or section of washcloth wiping front to back to remove feces present ., 9. Dispose of gloves and used supplies and perform hand hygiene, 10. Apply new gloves and place new brief and change linens as needed.

Based on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I assessments accurately reflected the resident's status for 2 of 24 residents (Residents #16 and #5) reviewed for PASRR screening, in that:The facility failed to ensure:Residents #5 and #16's PASRR Level 1 assessment did not indicate a diagnosis of mental illness. These failures could place residents who had a mental illness at risk for not receiving care and services to meet their needs.The findings were as follows:Resident #5Record review of Resident #5's face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #5 had a primary diagnosis of syringomyelia and syringobulbia (a spinal disorder with a fluid-filled cyst (syrinx) in the spinal cord, while syringobulbia is when that syrinx extends into the brainstem) and a medical history of bipolar II (a mood condition marked by significant depressive episodes and less intense up periods called hypomania, without full-blown mania), multiple sclerosis (a chronic autoimmune disease where the immune system mistakenly attacks myelin) and type 2 diabetes.Record review of Resident #5's admission MDS assessment dated [DATE] revealed Section C- Cognitive Patterns, a BIMS score of 12 indicated the resident was moderately, cognitively impaired. Section I- Active Diagnosis revealed resident had a psychiatric/Mood disorder of bipolar disorder.Record review of Resident #5's care plan revealed Medication: Potential for discomfort and side effects related to the use of antipsychotic medication. Administer medication as ordered Physician to review medication Report pertinent lab results to physician, Monitor for Adverse Consequences possible side effects every shift via concurrent review dated 12/31/2025.Record review of Resident #5's physician orders revealed and order for Aripiprazole (an antipsychotic medication used to treat schizophrenia, bipolar disorder, major depressive disorder) 15mg tablet once a day, dated 9/25/2025.Record review of Resident #5's PL1 form dated 9/24/2025 revealed under section C0100 Mental Illness an answer of NO, indicated the resident did not have a mental illness.Resident #16Record review of Resident #16's face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #16 had a primary diagnoses of lack of coordination and a medical history of bipolar II, type 2 diabetes, muscle weakness, and dementia.Record review of Resident #16's quarterly MDS assessment dated [DATE] revealed Section C- Cognitive Patterns, a BIMS score of 0 indicating the resident was unable to complete the interview. Section I- Active Diagnosis revealed resident had a psychiatric/Mood disorder of bipolar disorder and depression.Record review of Resident #16's care plan revealed Medication: Potential for discomfort and side effects related to the use of anticonvulsant medication. Administer medication as ordered, Physician to review medication, report pertinent lab results to physician Monitor for Adverse Consequences possible side effects every shift via concurrent review dated 07/28/2025.Record review of Resident #16's physician orders revealed and order for Divalproex Sodium (an anticonvulsant medication, FDA-approved treatment for the manic and mixed episodes associated with bipolar disorder), 500mg tablet, twice a day, dated 6/25/2025.Record review of Resident #16's PL1 form dated 4/08/2024 revealed under section C0100 Mental Illness an answer of NO, which indicated the resident did not have a mental illness. Section C0090 revealed an answer of yes, which indicated the resident had a primary diagnosis of dementia.During an interview on 1/08/2026 at 11:43AM, with the MDS Nurse, she stated she was responsible for obtaining the PASRR from the admissions coordinator and reviewing them for accuracy. She stated when she reviewed the PASRR she looked at the residents diagnosis and social security to make sure they are accurate. She stated if the PASRR was incorrect they would request the facility that was transferring the resident, to do another screening but if the resident was in the facility, they would correct it via their online system SIMPLE (a healthcare software company designed to streamline workflows for providers .especially concerning long-term care and Preadmission Screening and Resident Review (PASRR) processes). The MDS Nurse stated Resident #16 did not have a primary diagnosis of dementia but did have a current diagnosis of dementia. She stated Resident #16's primary diagnosis was lack of coordination. She stated Resident #5 had a primary diagnosis of syringomyelia and syringobulbia. She stated both Resident #5 and #16 had a diagnosis of Bipolar II. She stated Bipolar II is classified as a mental illness. She stated she considered Resident #5 and Resident #16's PASRR to be accurate. She stated Resident #5 would need to have a re-evaluation by the local authority to correct the PASRRs but Resident #16 could have his dementia as his primary diagnosis. She stated PASRRs are reviewed for accuracy every three months and anytime there are changes to residents' diagnosis. She stated the potential negative outcome of not having an accurate PASRRs could be residents missing out on services that they may qualify for. During an interview on 1/08/2025 at 3:03 PM with the ADM, she stated the admission coordinator receives the PASRRs from the transferring facility and gives it to the MDS Nurse for review. She stated the MDS Nurse was responsible for requesting any changes or updates on the PASRRs. She stated she did not believe Resident #16 had a primary diagnosis of dementia and Resident #5 did not have a primary diagnosis of dementia. She stated Resident #5 and Resident #16 had a diagnosis of Bipolar II. She stated Bipolar II is classified as a mental illness. She stated she did not believe PASRRs to be accurate for Resident #5 and Resident #16. She stated she expected the MDS Nurse to send a request for a new PASRR screening for both Resident #5 and #16 to the local authority. She stated she believed the PASRRs are reviewed quarterly for accuracy and any changes. She stated the potential negative outcome of not having an accurate PASRR could be residents not receiving the services they may need or qualify for.Facility policy for PASRR requested. On 1/14/2025 at 5:05 p.m., the ADM stated the facility followed the state process and did not have a separate policy for PASRR.

Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 1 noon meals observed for puree texture. The facility failed to ensure puree meat, and spinach bake were prepared to a smooth uniform texture on 01/07/26. This failure could place residents at risk of decreased food intake, choking and aspiration.The findings included: During an observation on 01/07/26 at 12:40 PM [NAME] A prepared puree ham, bread, spinach bake, and potatoes and provided a sample tray to the surveyors. The surveyors tasted the puree ham, and it had small chunks of meat and required chewing. The spinach bake had a very thick consistency and required a small amount of chewing. During an interview on 01/08/26 at 9:31 AM [NAME] A stated he was last trained on food form when he started working at the facility. [NAME] A stated puree should be a pudding-like texture and be smooth when your tongue touches the food to the top of your mouth. [NAME] A stated he tasted the puree ham from yesterday and tasted a gritty texture. [NAME] A stated a potential negative outcome to the residents was they could choke on his food. During an interview on 01/08/26 at 11:00 AM, the DM stated [NAME] A was trained on puree texture. The DM stated she did not know why the puree ham and the puree spinach was not the proper texture for puree form. The DM stated she would work with [NAME] A more on food form. The DM stated a potential negative outcome to the residents was they could choke and not be able to swallow the food. During an interview on 01/08/26 at 11:14 AM the ADM stated she expected the puree foods to be smooth in texture and not require chewing. The ADM stated the kitchen staff were trained in proper food forms, but she did not remember the last time prior to 01/07/26 they had been trained. The ADM stated a potential negative outcome to the residents was possible issues with swallowing, choking or pocketing food. During an interview on 01/08/26 at 4:01 PM, the ADM stated the policy provided for food form was the most relevant policy she could find. Record review of the facility's policy and procedure titled, Use of Recipes, with a revised date of 02/06/24, reflected the following: Policy: Recipes will be used when preparing menu items.Procedure: 1. Recipes (in appropriate portion sizes) for each menu cycle are available and maintained in the facility.2. Recipes will be printed to scale according to information derived from resident tray tickets and current census.3. Nutrition Services employees are expected to use and follow the recipes provided.

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 of 7 residents reviewed for advanced directives. (Resident #1, #2, #3, #4, #5, #6, and #7). The RN A did not initiate CPR for Resident #1 when Resident #1 was found with no pulse or respirations. Resident #1 was listed as Full Code (all resuscitation procedures are provided to keep a person alive during a medical emergency). This failure could place all residents in the facility who requested a full code status at risk of death. An Immediate Jeopardy situation was identified on [DATE] at 3:20 PM. The Immediate Jeopardy was removed on [DATE] at 3:24 PM The facility remained out of compliance at a scope of isolated incident of and a severity level of potential actual harm due to the facility's need to complete in service training and evaluate the effectiveness of the corrective systems. This failure could place all residents in the facility who requested a full code status (everything is done to keep a person alive) at risk of death. Findings included: Resident #1: Record review of an Admission Record dated for Resident #1 showed a [AGE] year old male with an admitted [DATE] with diagnoses of Secondary malignant neoplasm (a cancer that forms in the cells of the breasts) of other parts of nervous system, Gastro esophageal reflux disease without esophagitis (acid reflux), Constipation, Hyperkalemia (high potassium), Benign prostatic hyperplasia (age associated prostate gland enlargement that can cause urinary difficulty) with lower urinary tract symptoms, Generalized anxiety disorder, Muscle weakness (generalized), Malignant neoplasm of unspecified site of unspecified male breast, History of falling. Admission record did not specify Resident #1's code status. Record review of an Entry MDS (Minimum Data Set) assessment dated [DATE] for Resident #1 listed no BIMs (Brief interview for Mental Status). The most recent MDS dated [DATE] did not address advance directives or code status for Resident #1. Record review of Resident #1's care plan for Advance Directives, dated [DATE] revealed Social worker has discussed advanced directives and code status with resident and/or resident representative. The interventions were listed as: The facility staff will assure my advanced directives are discussed and appropriate paperwork is provided to me and placed in my medical record when returned to facility, Assure Advanced directives are discussed, and appropriate paperwork is obtained. No code status listed in orders. The care plan dated [DATE] for Resident #1 did not address code status. Record review of facility provided the code status for Resident #1, titled, Order Group Report (Advance Directive), dated from [DATE] to [DATE], stated: under order name: D/C Code STATUS FULL CODE may use AED, Dx: Secondary malignant neoplasm of other parts of nervous system. D/C date: [DATE] A Cardiopulmonary Resuscitation Advanced Directives Policy dated [DATE]. Indicated, .When a patient is found to be without heartbeat or respirations by any staff member the patient's medical record must be checked to ensure that the patient's wishes are followed. If there are no advanced directives or a Full Code status the licensed staff will start CPR . Record review of Resident #1's nurse notes, dated [DATE] at 5:34 AM, stated: revealed Resident declined to take any prn pain medication thru the night. Signed and dated by Medication Aide. Record review of Resident #1's nurse notes, dated [DATE] at 8:23 AM, stated revealed: went into patient's room at 0653 to find him pale, not breathing, no pulse was present, no lung or heart sounds were present. Called DON,911, wife and the physician shortly after finding. Signed and dated by RN A Record review of Resident #1's nurse notes, dated [DATE] at 8:50 AM, stated: Med aid went to patients' room and noticed patient was not responding, left room to call RN. RN went in room at 0653, assessed patient. RN checked for a pulse near carotid and brachial, listened for lung and heart sounds. RN found no pulse or sounds. Called DON at 0707 to inform of patient's current status, was ordered to call 911. called 911 at 0715, EMS arrived at 0724. called physician at 0716, no answer. RN left a message for the physician to inform him of patient's status. RN called wife at 0717 to inform of patient's current status. Wife said she can arrive in an hour and a half because she lives out of town. Signed and dated by RN A. Record review of Resident #1's nurse notes, dated [DATE] at 8:23 AM, stated: went into patient's room at 0653 to find him pale, not breathing, no pulse was present, no lung or heart sounds were present. Called DON,911, wife and the physician shortly after finding. Signed and dated by RN A Record review of Resident #1's nurse notes, dated [DATE] at 5:34 AM, stated: Resident declined to take any prn pain medication thru the night. Signed and dated by Medication Aide. Record review of facility provided code status for Resident #1, titled, Order Group Report (Advance Directive), dated from [DATE] to [DATE], stated: under order name: D/C Code STATUS FULL CODE may use AED, Dx: Secondary malignant neoplasm of other parts of nervous system. D/C date: [DATE] Record review of EMS report, titled, Pre hospital Care Report Summary, for Resident #1, dated [DATE], revealed: Record revealed that the call came in at 07:18:12, dispatched at 07:18:26, En Route at 07:18:28, On Scene at 07:21:37, Patient Contact at 07:23:00 Billing Disposition stated: Dead after arrival, patient dead at scene resuscitation attempted (without transport) deceased Patient: Dead After Arrival Assessments: Airway Breathing Rate; Apneic (is a temporary cessation of breathing, where the muscles used for inhalation stop moving). Skin Color: Cyanotic, pale Skin temperature: Cool Skin condition: Normal Comments: Resident is apneic and pulseless Type of CPR Provided: Compressions Manual Ventilation Passive Ventilation with Oxygen ([DATE] 07:51) Reason CPR/Resuscitation Discontinued: Protocol/Policy Requirements Completed. First Arrest Rhythm of the Patient; Asystole (flatline, is a cardiac arrest rhythm where the heart's electrical and mechanical activity stops completely). Who first initiated CPR: EMS Responder (transport EMS) Arrest Witnessed: unwitnessed. Narrative History Text: 9742 responded to facility for cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness). Upon arrival at bedside, two caregivers were noted and stated that they just cleaned and changed the patient. The patient was noted to be unresponsive, pulseless, and apneic (is a temporary cessation of breathing, where the muscles used for inhalation stop moving). The patient did not present with rigor (a postmortem change resulting in the stiffening of the body muscles due to chemical changes in the myofibrils). The patient was moved to the floor and CPR initiated CPR (cardiopulmonary resuscitation) initiated. OPA (oropharyngeal airway insertion) and NRB (non rebreather mask) were placed for passive airway and IO (intraosseous vascular) access obtained. Cardiac monitor with stat pads were placed. The initial rhythm of the patient was noted to be asystole. Staff then relayed to EMS (emergency medical services) that the patient was found unresponsive and pulseless at 0658, and that resuscitation (the action or process of reviving someone from unconsciousness or apparent death) was not attempted. The staff reported that the patient is full code. Cardiac arrest medications were administered, and the patient was successfully intubated with end tidal co2 monitoring used to confirm placement, lung sounds auscultated (examine a patient by listening to sounds from the heart, lungs, or other organs). The patient was noted to remain in asystole (flatline, is a cardiac arrest rhythm where the heart's electrical and mechanical activity stops completely) throughout. Signal 28 was called at 0751. Information was given to LPD (police department). EMS (emergency medical services) cleared the scene. During an interview with the Administrator on [DATE] at 11:28 AM,. The Administrator stated that the policy for code status stated was that CPR should be initiated to for a full code resident unless the seven signs of death are present. The Administrator stated that the RN A did not initiate CPR because all seven signs of death were present. The Administrator did not specify the seven signs of death. The Administrator stated that the documentation that the RN A made is incomplete and not finished. The Administrator did not give a reason the RN A had unfinished documentation. The Administrator stated that if the resident was not showing all seven signs of death, then she should have initiated CPR. The Administrator stated that education was provided to the RN immediately. The education that had been provided was through in services on [DATE] for Active Signs of Death, BON guidance positions for nurses (LVN & RN) position statement 15.2 & 15.20, CN are to print code statuses at beginning of every shift and keep on them at all times during shift. During an interview with EMS Staff on [DATE] at 2:37 PM, The EMS Staff member stated that when the team had gotten on scene, that there were two staff members that had already cleaned the resident. The EMS staff member had stated that Resident #1 appeared deceased , no pulse, no respirations, slightly cool to touch, jaw was loose, and did not have any darkening of the skin. The EMS Staff member stated that they had to get the RN to ask what the resident's code status was. The EMS staff member stated that the RN should have initiated CPR immediately when she had found the resident and continued CPR until EMS arrived. The EMS staff member stated that the RN stated that Resident #1 was a full code. The EMS Staff member stated that there was no reason the RN should not have initiated CPR. EMS staff member,, She stated that the body of Resident #1 was not in rigor mortis. During an interview with RN A on [DATE] at 5:00 PM., RN A stated that she arrived on shift at 6 am and received report from LVN. RN stated that during report, Resident #1 was stable, and he had refused his pain medication. RN A stated that CMA E went to give Resident #1's medication before 7 am and that was when she realized he was unresponsive and not breathing. RN A stated that is when the CMA E came to get her, and RN A went to Resident #1's room to assess him. RN A stated that his skin was cold to touch and no movement. RN A stated that Resident #1 was cyanotic (blue) and had rigor mortis. RN A stated that she immediately contacted the DON and was instructed to call 911. RN A then contacted the Physician and he said, Thank you for letting me know. RN A stated that she contacted the wife after the physician. RN A stated that on the computer Resident #1 was DNR, so she did not initiate CPR. RN A stated that a few days ago when he was admitted his vitals were stable, he was cognitive, and no issues other than his cancer. RN A stated, This was unexpected. RN A stated, How long will you be investigating this. During an interview with CNA G on [DATE] at 5:36 PM. CNA G stated that she had worked the evening shift of [DATE] and had gotten off shift the morning of [DATE]. CNA G stated that she had been the only CNA G on shift for three hundred hall and she had one nurse on shift. CNA G stated that Resident #1 had expired later that afternoon because a co worker had called and told her. CNA G stated that she had done her rounds at 4:45 4:50 AM with Resident #1. CNA G stated that Resident #1 was sleeping and had visible respirations when she had gone in Resident #1'shis room to change his foley bag. CNA G stated that Resident #1 had moved a little (changed positions in bed) and she was trying to be quiet and not wake him. CNA G stated that she normally makes made her rounds at 12 am, 2 am, and 4 am. CNA G stated that she will normally walk around and do checks on the residents in between making her rounds. CNA G stated that she was supposed to leave at 6 am that morning and supposed to do report with the on coming CNA G but the oncoming CNA G was late, so she just left. CNA G stated that the resident was breathing and asleep at 4:45 AM and did not show and signs of distress through the night. During an interview with LVN C on [DATE] at 8:46 PM. LVN C stated that she worked the evening of [DATE] and had gotten off the morning of [DATE]. LVN C stated that she had given report to RN A the morning of [DATE]. LVN C stated that she had given report with the RN A at the desk and then they had gone and did the narcotics count. LVN C stated that the nurse would normally check residents when coming onto shift. LVN stated that she would usually check on her resident's every 2 3 hours throughout the night. LVN C stated that she had last seen Resident #1 around 5:30 AM on [DATE] and he was awake and talking to her. LVN C stated that Resident #1he had denied his pain medication and had had told her that he was not in any pain and did not want anything for pain. LVN C stated that she was not surprised because the night before Resident #1 had been in a lot of pain, and Resident #1he had new Fentanyl patches put on earlier that day and had not been in pain since then. During an interview with the DON on [DATE] at 11:39 AM. The DON stated that she was notified by RN A at 707 AM on [DATE] of the unresponsive resident. The DON stated that the RN A had notified her that Resident #1 had no pupil response, no pulse, cold to the touch, and no signs of life. The DON stated that the RN A had not initiated CPR because she told DON that based on her assessment that she had done, he showed signs of death, and it would not have be appropriate to perform CPR. The DON stated that rigor mortis is the settling of blood and starts in face, pale, cyanotic (blue), will turn into blood settling and stiffness. The DON stated that RN A did not complete her notes. The DON did not specify why RN A did not finish her notes. The DON stated that on the nurse notes it stated that resident was cold to touch, pale, but did not state rigor mortis. The DON stated that while she was coming into the facility, the EMS was leaving the building, and they had stopped her and asked her why CPR was not initiated. The DON stated that she had not been here and could not determine what should have been done because she had not done the assessment. The DON stated that RN A stated to her that the resident was, Dead, Dead, The DON stated that per her education from TBON (Texas Board of Nursing), that RN's can make the decision if CPR is appropriate or not upon assessment. The DON stated that she can cannot question another nurse's judgement as a nurse. The DON stated that if a nurse were wrong, she would educate that nurse, but since the DON was not in the facility to do her own assessment, she could not judge the RN's assessment. The DON stated that she immediately started in services for active signs of death, BON guidance positions for nurse's (LVN & RN) position statement 15.2 & 15.20, CN are to print code statuses at beginning of every shift and keep on them at all times during shift. signs of impeding death and code status. During an interview with CMA E on [DATE] at 1: 37 PM. CMA E stated that she was the person that had found the Resident #1 unresponsive in his room the morning of ,d+[DATE]/.2025. CMA E stated that she was on shift the morning of [DATE], her shift had been from 6 am 2pm. CMA E stated that she had found Resident #1 unresponsive around 6:35 am 6:40 am. CMA E stated that she had gone to Resident #1's room and the door was slightly cracked open, and she had knocked and called out his name. CMA E stated that she did not hear any response from Resident #1, so she had knocked again and called out his name. CMA E stated that she still did not hear anything and then she had opened the door and walked in to check on him. CMA E stated that she had thought it was strange that Resident #1 did not answer because she did not notice any breathing or respirations. CMA E stated that she had shaken Resident #1'shis shoulder and had called his name. CMA E stated that Resident #1's eyes were closed, and he was laying back but to the side a little and his mouth was open, and the head of his bed was slightly elevated. CMA E stated that Resident #1 was not stiff because when she shook him, he was very loose when she had shaken him;, and he wasn't firm or stiff. CMA E stated that she had not seen any different coloration of his ( Resident #1's) face or lips and no blotchiness. CMA E stated that she had immediately left Resident #1's room and went down the hall to get RN A. CMA stated that she and the RN had went back to Resident #1's room and RN A had taken took the pulse by wrist on Resident #1. CMA E stated that when RN A had taken Resident #1's pulse by his wrist, his wrist was loose. CMA E stated that the RN A stated that she did not feel a pulse. CMA E stated that her and RN A had then went to the nurse's station, and the RN A had gotten on the computer to look up a phone number and had then she contacted the DON. CMA E stated that the DON had then instructed RN A to call 911. CMA E stated that she had left the nurse's station after that because she had to administer the medications to other residents. CMA E stated that she did not witness RN A performing any CPR at all. CMA E stated that she would know what the code status of a resident is was because all the nurse's would pull a code status at the beginning of the shift, and they carry that in their pocket to check every resident. CMA E stated that Resident #1 was listed as a full code. During an interview with CNA H on [DATE] at 2:16 PM. CNA H stated that she was on shift the morning that Resident #1 was found unresponsive. CNA H stated that her shift was 6 am 2pm on [DATE]. CNA H stated that she clocked in at 6:37 AM. CNA H stated that when she came in, she went room to room to write down all resident's names down so that she would know who needed showers. CNA H stated that she went to talk to RN A about shower sheets. CNA H stated that while she was talking with RN A about shower sheets, the CMA E came in and stated that a resident is was unresponsive. CNA H stated that when she saw Resident #1, he was pale and foaming out of the mouth. CNA H stated that she did not see RN A initiate CPR. CNA H stated that they had found Resident #1 at 6:42 AM. CNA H stated that RN A thought that Resident #1 was a DNR because RN A stated that Resident #1 was a DNR to her. CNA H stated that Resident #1 was not stiff, and he did not have any discoloration of the skin. CNA H stated that she knew this that because she helped to clean up the body before EMS got to the facility. CNA H stated that Resident #1 was in bed and was turned to the side with his eyes closed. CNA H stated that they usually just ask the nurse of the code status of the residents. Record review of a report provided by the facility on [DATE] at 4:36 PM, between the dates of [DATE] to [DATE]., indicated there were 50 of 93 residents with a full code status. A Cardiopulmonary Resuscitation Advanced Directives Policy dated [DATE] .Indicated, .When a patient is found to be without heartbeat or respirations by any staff member the patient's medical record must be checked to ensure that the patient's wishes are followed. If there are no advanced directives or a Full Code status the licensed staff will start CPR . Record review of facility provided policy, titled, Cardiopulmonary Resuscitation (CPR): Basic Life Support (BLS)/ Hands Only CPR, date revised on February 12, 2020; stated: Policy: CPR (BLS and/or Hands Only) will be initiated for residents that experience a witnessed or unwitnessed cardiopulmonary arrest while in the community. CPR will not be initiated (or continued) for any resident that: a. Has a DNR order on record. b. Shows American Heart Association (AHA) signs of clinical death as defined in the AHA Guidelines. Procedure: Preparations: 1. Licensed clinical staff involved in resuscitative efforts will obtain and/or maintain certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR). 2. Unlicensed personnel will receive hands on training annually (at minimum) by DON or designee. 3. DON or designee will conduct a Mock Code (educational simulation of actual arrest) annually at minimum for training purposes. 4. Emergency equipment and supplies necessary for CPR/BLS will be maintained in the community. 5. Information will be provided upon admission on CPR/BLS policies and advance directive to each resident/ representative. General Guidelines; 1. The goal of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 2. If an individual is found unresponsive by an employee of the community the employee will initiate CPR unless: a). It is known that a Do Not Resuscitate order exists for the resident; or b). In the event of an unwitnessed cardiac event an RN may determine that CPR would be futile and an inappropriate intervention if all signs of death are present: i. The resident is unresponsive. ii. The resident has no respiration. iii. The resident has no pulse. iv. Resident's pupils are fixed and dilated. v. The resident's body temperature indicated hypothermia: skin is cold relative to the resident's baseline skin temperature. vi. The resident has generalized cyanosis, and vii. There is presence of livor mortis (venous pooling of blood in dependent body parts). 3. RN must document description of discovery for example: treatment undertaken; findings of assessment; individual notified, result of communication and presence or absence of witness. Equipment and Supplies: 1. Personal Protective equipment including: gloves, masks, gowns, and eyewear as appropriate. 2. Airway delivery device such as: pocket face mask, Ambu bag and/or mouth shields. Heart Association's Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or community BLS training material. Bystander/Unlicensed Staff: 1. Summon for help 2. Request AED 3. Check for Responsiveness (for example shaking, tap shoulder and shout are you okay etc.) 4. While awaiting AED, if unresponsive begin performing chest compressions (unless known code status is DNR). Continue until licensed staff arrive. 5. If responsive stay with resident until help arrives. CPR Certified Staff: 1. Determine unresponsiveness; if no response 2. Request AED and summon for help 3. Check for no breathing or no normal breathing 4. Check for pulse (no more than 10 seconds) 5. Initiate community emergency response 6. Start CPR as trained Documentation: 1. Document events of episode in residents medical record (if victim is a resident) a. Approximate time and condition in which the resident was found, or the event was witnessed. b. The sequence of resuscitation efforts, including approximate times and AED shock was delivered (if applicable). c. The resident's response to resuscitation efforts. d. Approximate time that EMS team took over. e. Notification of physician and resident family. f. Time resident was transported or time of death. Reporting: Follow community policy regarding reporting. References: American Heart Association. Retrieved from http://www.heart.org/HEARTORG/ on [DATE] Definitions: Cardiopulmonary Resuscitation (CPR) is a group of emergency treatments that are executed when someone's breathing, or heartbeat has stopped. The treatments consist of rescue breathing and chest compressions. CPR allows oxygenated blood to circulate to vital organs such as the brain and heart. Hands only CPR is CPR without rescue breathing. AHA has recommended it for use by untrained layperson/bystander (non licensed) on teens or adults who collapse (observed and unobserved). This involves calling 911 or sending someone to call and pushing hard and fast in the center of the chest. Record review of website viewed for American Heart Association at, date retrieved on [DATE], stated: The American Heart Association (AHA) considers a person clinically dead if they have obvious signs of irreversible death, such as rigor mortis, decapitation, or decomposition. The AHA also considers a person clinically dead if they have a valid advance directive or DNAR order that states they do not want resuscitation. Signs of irreversible death rigor mortis, dependent lividity, decapitation, transection, and decomposition. Advance directives A valid, signed, and dated advance directive that states the person does not want resuscitation. A valid, signed, and dated DNAR order Signs of irreversible death Rigor mortis, which is when the body stiffens after death. Dependent lividity Decapitation Transection Decomposition Advance directives A valid Do Not Resuscitate (DNR) order. A valid, signed, and dated advance directive that states the person does not want resuscitation. A living will, which is a written direction to physicians about the patient's wishes for end of life care. The AHA recommends that rescuers initiate CPR unless they see obvious signs of irreversible death, have a valid DNR order, or could be injured. Record review of facility provided in services, dated [DATE], titled, Active Signs of Death, with forty seven staff signatures including RN A, stated: Signs that someone is near death: 1. Shortness of breath 2. Isolation and drifting away 3. Decreased appetite and thirst 4. Nausea and vomiting 5. Anxiety 6. Constipation 7. Fatigue 8. Incontinence 9. Skin Conditions 10. Delirium 11. The death rattle 12. Pain Record review of facility provided in services, dated [DATE], titled, BON Guidance Positions for Nurses, with seventeen staff signatures including RN A, stated: The Registered Nurse Scope of Practice: The RN takes the responsibility and accepts accountability for practicing within the legal scope of practice and is prepared to work in all health care settings and may engage in independent nursing practice without supervision by another health care provider. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs. Record review of facility provided in services, dated [DATE], titled, print code statuses at beginning of every shift and keep on them at all times during shift, with eighteen staff signatures including RN A, stated: How to print Code Statuses: 1. Go to reports in system 2. Select order group report 3. Enter room numbers for your hall 4. Select Active order under order status 5. Search by order group Advanced Directives The Administrator was notified on [DATE] at 3:20 PM., that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was emailed to the Administrator on [DATE] at 3:43 PM. The facility's Plan of Removal was accepted on [DATE] at 8:12 A.M., and included: Summary of Details which lead to outcomes: On [DATE], during a complaint survey initiated at the facility a surveyor. provided an IJ Template notification that the Survey Agency has determined that the conditions. at the center constitute immediate jeopardy to resident health. F678 The notification of the alleged immediate jeopardy states as follows: F678 The resident was a 65 y/o male, admitted on [DATE] with a diagnosis of malignant neoplasm of the breast with secondary malignant neoplasm of other parts of the nervous system. The facility allegedly failed to provide basic life support, including CPR, prior to the arrival of emergency. medical personnel for 1 (Resident #1) of 1 resident. Resident #1's code status was listed as full code. How other residents with the potential to be affected by the same deficient practice. will be identified. Any resident with full code status have potential to be affected by the alleged. deficient practice What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur. DON (Director of Nursing) or designated nurse will in service all licensed nurses on policy and procedure for identifying code status on residents by 10:00 pm on [DATE]. No nurses will be allowed to work until training has been completed. Any nurses who did not receive training before 10:00 P.M. on [DATE] will receive training prior to the start of their next shift. This education was initiated on [DATE]. DON or designee will educate all staff on emergency policy and procedures when residents. are found to be unresponsive by 10:00 pm on [DATE]. No nurses will be allowed to work. until training has been completed. Any nurses who did not receive training before 10:00 P.M. on [DATE] will receive training prior to the start of their next shift. This education was initiated on [DATE]. DON or designee will monitor 10 staff members per week for 4 weeks on competency of 7 signs of death/ active signs of death, competency of nurses printing code statuses from EMR and on person, and CNA competency on code status on POC. This monitoring was initiated. on [DATE]. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes); and Proof of the education will be submitted to QA committee Involvement of Medical Director Medical Director was notified and met with interdisciplinary team on [DATE]. Involvement of QA An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Administrator will forward results of audits monthly to the QAPI Committee for review and/or action and be reviewed monthly x 90 days. Who is responsible for implementation of process? The Director of Nursing/designee will be responsible for implementation of New Process. The New Process/ system will be started on [DATE] and no employee be able to return to work until they complete the Inservice. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on [DATE]. Interviews for POR: Interviews with 1 RN, 1 LVN, 4 CNAs and 2 CMAs regarding the training they had received on signs of impeding death, and code status of a resident on [DATE] by 2:30 PM, showed that the staff had an understanding of the education provided. During an interview with CMA E for training for POR on [DATE] at 11:34 AM. CMA E stated that she had received an in service training by the DON. CMA E stated that the training was about how to locate the code status of a resident. CMA E stated that the nurses are supposed to carry a printout paper of all resident's code status. CMA E stated that for CNA's can find the code status of a resident by getting into the POC and clicking on the resident's name and that will pull up the code status. CMA E stated that the CMA's are not required to print out the code status. CMA E stated that the other training that they received was for the signs of death which are pain, sleeping a lot, not able to eat or drink, not able to get out of bed. You would report these signs through chain of command. CMA E stated that she would then step out in the hall and keep her eyes on the resident and yell for help if she noticed t [TRUNCATED]

Based on interviews and record review, the facility failed to notify the residents physician and representative regarding a change in the resident's condition, for 1 of 2 residents (Resident #1) reviewed for changes in condition. 1. RN C failed to notify Resident #1's family and physician when RN C administered Resident #2's lorazepam to Resident #1 on 11/21/2024. This failure could place residents at risk of not having their family and physicians notified of changes resulting in a delay in decision making for medical interventions. Findings: Resident #1 Record review of Resident #1's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a medical history of urinary tract infection, obstructive sleep apnea (the most common sleep-related breathing disorder), and muscle weakness. Record review of Resident #1's admission MDS Section- C Cognitive Patterns revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's physician orders did not reveal an order for lorazepam 1mg (a sedative that can treat seizure disorders, such as epilepsy. It can also be used before surgery and medical procedures to relieve anxiety ). Record review of physician orders did not reveal any new orders regarding the medication error. Record review of Resident #1's medication Error Report revealed: Date/Time Error(s) discovered- 11/21/2024 9:36PM. Errors Discovered by/ Title- RN C. Person Responsible for error- RN C. Date of error(s) 11/21/2024. Time of error(s) 09:30 PM. Medication Ordered- Resident #1 doesn't have order for Ativan Type of Error- Drug Administered without a MD Order, Wrong resident Description of error- Misread , - Wrong Patient Statement of person responsible for error- I had a new patient with 7 new cards and a patient Resident #2 with the wrong first name was in the pile of medications, and I gave the wrong med because I did not read the first name correctly it was another Resident #2 in the pile of new meds. The FM told me to give her, her pain meds as soon as they get here because she was in pain. I tried to accommodate the Resident #1's request as soon as I could. This was a mistake. I tried to hurry up and help a patient and as a result the wrong patients med with the wrong first name was given. Physician notified? -yes. By Whom? -RN C Date/Time- 11/22/2024, 03:35 PM Family notified? - Yes 11/22/2024, 04:01 PM . .Classify errors according to the Medication Error Index as adopted by the National Coordinating Council for Medication Error Reporting and Prevention: Category C An error occurred that reached the patient but did not cause patient harm. Record review of Resident #1's Observation Data sheet revealed vitals signs taken on 11/21/2024 at 9:36pm with reason for observation - follow up incident/fall. BP: 122,65. Heart rate 73, Respiratory rate 18, Temp 97.5, and Pulse Oximetry 98. Document signed by RN C. Resident #2 Record review of Resident #2's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had a medical history of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks), panic disorder with episodic paroxysmal anxiety (a term used to describe the recurrent, severe, and unpredictable panic attacks that are a primary feature of panic disorder), and muscle weakness. Record review of Resident #2's physician orders revealed an order for lorazepam 1mg tablet, give 1 tablet by mouth four times daily. Record review of Resident #2's Controlled Drug Record for Lorazepam 1mg revealed RN C receiving from the pharmacy 48 tablets of Lorazepam and administering 1 lorazepam tablet at 2100 (9pm) on 11/21/2024 with a note written beside stating administered to wrong resident. During an interview with Resident #1's family on 12/03/2024 at 09:30AM, she stated on 11/21/2024 at around 9pm, Resident #1 had been given a tramadol and Ativan (lorazepam) by RN C. She stated RN C clocked out of work around 10pm. She stated nothing was mentioned to her that night regarding a medication error, but the next morning Resident #1 was difficult to arouse from sleep. She stated later in the day on 11/22/2024, RN C did tell her he had made a medication error, but she felt he had treated it like it was nothing. She stated she had talked to Med Aid D about the medication that had made her mother very hard to wake up, and she did not want her taking that medication again. She stated Med Aid D explained that Resident #1 did not have any sleeping medication in her chart. She stated she spoke to the ADM and DON, but she did not know what had been done about RN C. She stated she felt that although mistakes can happen and Resident #1 was okay, she felt that Resident #1's situation was not addressed with importance and a simple apology would have made a difference. She stated RN C knew he had made the error that night on 11/21/2024 and did not notify the physician, the family, or the DON. She stated Med Aid D had notified the DON, but she is not sure why the DON did not address it until the next day instead of that night . During an observation and interview with Resident #1 on 12/03/2024 at 9:30AM, she did not remember any information regarding the incident . Resident appeared clean and comfortable sitting in a wheelchair. Resident was watching television and had finished breakfast. During an interview with LVN A on 12/03/2024 at 11:15AM, she stated she had taken care of Resident #1 on 11/22/24 in the morning. She stated she had not been made aware (that morning) of the medication error that had occurred. She stated if she had, she would have initiated closer observation of Resident #1 even if she had to sit by her door. She stated she received report from LVN B, and the medication error was not reported. LVN A stated she had been trained on medication administration and the five rights of medication administration were right patient, right medication, right dose, right time, and right route. She stated when a medication error occurred, the person who committed the errors needed to notify the physician, the DON, and the family as soon as possible and assess the resident. She stated the possible negative outcomes of medication errors could be harm to the patient. During an interview with Med Aid D on 12/03/2024 at 1:02pm, she stated she had been working on 11/21/2024, in medical records. She stated at approximately 9:15pm the pharmacy had dropped off some medications. She stated she was at her medication cart when RN C came up to her to sign off the Ativan in the resident's electronic medical record. She stated when they checked the order on her chart, there was no order for Ativan for Resident #1. She stated she looked at the medication card with the pills and noticed the medication card was for Resident #2. She stated she then asked him please don't tell me you gave this to Resident #1?. She stated he replied, yes I did, I thought it was for Resident #1. She stated RN C went back down hall 300 and she returned to medical records. Med Aid D stated before leaving around 10pm that night she had asked the oncoming night nurse if he had been notified of the medication error on Resident #1. She stated LVN B denied being informed of the medication error. She stated she texted the DON at 10:27pm asking if she had been notified of RN C's medication error. She stated she did not get a response back that night but did get a response saying nope at around 11:25 AM on 11/22/2024. She stated she told the DON she would come talk to her when she got there. She stated the DON asked if the medication error was on a different resident, and she stated it was someone else. The Med Aid stated when she did come in on 11/22/2024, she informed the ADM and the DON of the medication error that RN C had caused. She stated because RN C did not notify anyone, Resident #1 did not have increased monitoring or assessment and the physician had not been notified. She stated the DON did talk to RN C on 11/22/2024 but she did not know about what. The Med Aid stated she had been trained on medication administration and she would report any medication errors to the physician, the family, the DON, and the ADM. She stated the possible negative outcomes of medication errors could be any adverse effect, or an allergic reaction and residents could be harmed. She stated she felt that RN C did not look at the entire name on the medication card and only saw the last name as Resident #1 and Resident #2 had the same last name. During an interview with RN C on 12/03/2024 at 2:30pm, he stated Resident #1 was a new resident to the facility. He stated on 11/21/2024 he had received about 8 medication cards and all the information had not been put into the computer. He stated all the cards had the same last name. He stated Resident #1's family had requested the resident receive her pain medication as soon as it was delivered. He stated as soon as the medications came in, he popped the tramadol and the lorazepam, and administered the medication to Resident #1. He stated he had made the mistake trying to make the family happy. He stated he had rushed and did not go through the five rights of administration. RN C stated he knew he made the error right away because the Med Aid D had informed him. He stated the Med Aid D had notified the DON. He stated he did notify the FNP. She asked if there had been any adverse reactions, or allergic reactions, and he told her no, and the FNP told him to document the error. He stated at that time, 11/22/2024 the resident was alert but in the morning she had been groggy. He stated he had informed Resident #1 FM of what medication he was giving the resident and the family never said anything about that, they only wanted to know why tramadol and not hydrocodone. RN C stated he notified the FNP on 11/22/2024 at 3:30pm. He stated he did not call the night the mistake was made because he thought Med Aid D would take care of it and notify everyone. He stated the medication error report was usually done on paper and given to the DON. RN C stated he did not follow up with Med Aid D after because he had been busy with other residents. He stated they did not have a charge nurse. RN C stated he had been trained on medication administration, but it had been a while. He stated the five rights of medication administration were right patient, right name, right dose, right time, and right order. He stated the potential negative outcomes of a medication error could be an allergic reaction, loss of balance, and possibly overdose. RN C stated he did not remember mentioning the medication error when he gave report to the night nurse. He stated he did not initiate any increased monitoring or observation on Resident #1. He stated, this often happens when you try to do too much, and mistakes happen. RN C stated he did one set of vital signs but nothing after. He stated, Now that I think about it, I should have initiated more observation. During an interview with the DON on 12/03/2024 at 2:51pm, she stated she was not present at the time of the medication error. She stated she received a text message on 11/22/2024 from Med Aid D asking if RN C had notified her of what had happened the previous night. She stated she was not aware of the events that occurred the previous night and the Med Aid D told her she would talk to her at 2pm. She stated Resident #2's narcotic count appeared off in the computer system due to the medication error. She stated she worked with a med aid to resolve the issue and when RN C arrived at the facility, she had him do the medication error report, notify the physician, and notify the family. She stated the facility did have charge nurses and RN C was the charge nurse on night shift. She stated she did speak to Resident #1's family member on 11/26/2024 after learning the family was very upset about the medication error. The DON stated she was unable to share details of RN C's disciplinary actions but that she had taken the incident seriously. She stated the FNP had a conversation with Resident #1's family and the FNP was willing to send Resident #1 to the ER but at that point the medication was mostly metabolized. She stated, Resident #1 was okay, but if Resident #1's family still wanted her to go to the ER, the FNP would send her. Resident #1 did not go to the ER after that conversation . The DON stated the person who makes the medication errors is to report it to the physician, DON, family and make the medication error report. She stated she was unsure why RN C did not initiate those steps. During an interview with LVN B on 12/03/2024 at 4:01pm, he stated he was working that night, 11/21/2024, and remembered someone telling him there had been a medication error with Resident #1. He stated he did not remember who told him that information. He stated he did go and check on her through the night and he did not observe any adverse events or adverse effects. He stated he did not know if the physician had been notified of the medication error. He stated Resident #1 rested through the night. LVN B stated he had been trained on medication administration and medication errors are to be reported immediately to the DON, physician, and family. He stated that the possible negative outcomes could have been an allergic reaction, and abnormal vital signs. During an interview with FNP on 12/04/2024 at 9:26AM, she stated she had not been notified of the medication error with Resident #1 until the following day. She stated she expected to be notified of medication errors when they occurred or within four hours of the medication error. She stated when she was called, Resident #1 was alert and stable and she had no concerns for long lasting negative effects. She stated lorazepam was a medication given for mild sedation or to calm someone down. She stated after the medication was administered, Resident #1 would have experienced some sedation. The FNP stated she talked to Resident #1's family and explained at that time Resident #1 was awake, alert, and stable and did not see a need to send her to the ER. She stated she would expect to be notified sooner of medication errors and implement any needed interventions or orders. Record review of facility policy titled Change of Conditions, last revised on February 13,2023 revealed: The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the community's staff and practitioners must recognize an ACOC and identify its nature, severity, and cause(s) . Changes in condition of the patient are determined by current and past medical conditions, medical orders, patient safety factors, and/or by assessments . .4 . The nurse notifies the responsible physician or advanced practice nurse (APRN) utilizing appropriate channels and chain of command. 5.Document in the medical record the date, time, and name of each physician notified, actions taken and/or patient's response to treatment. Documentation should also include all nursing assessments and findings, nursing actions, and notification of charge nurse/nurse supervisor. All entries in the EHR will be automatically dated, timed, and signed according to community policy. 6. Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in a patient's condition or health status . Definitions: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Record review of facility policy titled Medication Error: Reporting & Management, last revised on January 10, 2023, revealed: Purpose: To describe the procedure for reporting a medication error and the mechanism for review to allow appropriate follow-up and possible implementation of change to decrease the causes and incidences of medication errors . 4. Administration Error - Wrong: a. Patient . Medication Error Review-Upon discovery of an unusual incident regarding a medication, the staff member should immediately evaluate the patient, notify the physician (or designee), and nurse manager. The staff member will report the incident immediately by completing a Medication Error Report in the EHR. EMR>QAPl>Medication Error Report. The error will be classified according to the Medication Error Index, as adopted by the NCC MERP . Guidelines: 1. The staff member that identifies the error will complete the Medication Error Report 2. Notification to the Director of Nursing

Based on interviews and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 3 residents (Resident #1), reviewed for pharmacy services. 1. The facility failed to ensure Resident #1 was free of significant medication errors when a dose of lorazepam 1 mg was administered on 11/21/2024 by RN C. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician. Findings: Resident #1 Record review of Resident #1's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a medical history of urinary tract infection, obstructive sleep apnea (the most common sleep-related breathing disorder), and muscle weakness. Record review of Resident #1's admission MDS Section- C Cognitive Patterns revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's physician orders did not reveal an order for lorazepam 1mg (a sedative that can treat seizure disorders, such as epilepsy. It can also be used before surgery and medical procedures to relieve anxiety ). Record review of physician orders did not reveal any new orders regarding the medication error. Record review of Resident #1's medication Error Report revealed: Date/Time Error(s) discovered- 11/21/2024 9:36PM. Errors Discovered by/ Title- RN C. Person Responsible for error- RN C. Date of error(s) 11/21/2024. Time of error(s) 09:30 PM. Medication Ordered- Resident #1 doesn't have order for Ativan Type of Error- Drug Administered without a MD Order, Wrong resident Description of error- Misread , - Wrong Patient Statement of person responsible for error- I had a new patient with 7 new cards and a patient Resident #2 with the wrong first name was in the pile of medications, and I gave the wrong med because I did not read the first name correctly it was another Resident #2 in the pile of new meds. The daughter told me to give her, her pain meds as soon as they get here because she was in pain. I tried to accommodate the Resident #1's daughters request as soon as I could. This was a mistake. I tried to hurry up and help a patient and as a result the wrong patients med with the wrong first name was given. Physician notified? -yes. By Whom? -RN C Date/Time- 11/22/2024, 03:35 PM Family notified? - Yes 11/22/2024, 04:01 PM . .Classify errors according to the Medication Error Index as adopted by the National Coordinating Council for Medication Error Reporting and Prevention: Category C An error occurred that reached the patient but did not cause patient harm. Record review of Resident #1's Observation Data sheet revealed vital signs taken on 11/21/2024 at 9:36pm with reason for observation - follow up incident/fall. BP: 122,65. Heart rate 73, Respiratory rate 18, Temp 97.5, and Pulse Oximetry 98. Document signed by RN C. Vital signs dated 11/22/2024 at 7:54pm revealed a BP of 109/85, and a HR of 65. Vital signs at 9:03 AM 11/22/2024 revealed a respiration rate of 18 and oxygen saturation of 95%. Resident #2 Record review of Resident #2's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had a medical history of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks), panic disorder with episodic paroxysmal anxiety (a term used to describe the recurrent, severe, and unpredictable panic attacks that are a primary feature of panic disorder), and muscle weakness. Record review of Resident #2's physician orders revealed an order for lorazepam 1mg tablet, give 1 tablet by mouth four times daily. Record review of Resident #2's Controlled Drug Record for Lorazepam 1mg revealed RN C receiving from the pharmacy 48 tablets of Lorazepam and administering 1 lorazepam tablet at 2100 (9pm) on 11/21/2024 with a note written beside stating administered to wrong resident. During an interview with Resident #1's family on 12/03/2024 at 09:30AM, she stated on 11/21/2024 at around 9pm, Resident #1 had been given a tramadol and Ativan (lorazepam) by RN C. She stated RN C clocked out of work around 10pm. She stated nothing was mentioned to her that night regarding a medication error, but the next morning Resident #1 was difficult to arouse from sleep. She stated later in the day on 11/22/2024, RN C did tell her he had made a medication error, but she felt he had treated it like it was nothing. She stated she had talked to Med Aid D about the medication that had made her mother very hard to wake up, and she did not want her taking that medication again. She stated Med Aid D explained that Resident #1 did not have any sleeping medication in her chart. She stated she spoke to the ADM and DON, but she did not know what had been done about RN C. She stated she felt that although mistakes can happen and Resident #1 was okay, she felt that Resident #1's situation was not addressed with importance and a simple apology would have made a difference. She stated RN C knew he had made the error that night on 11/21/2024 and did not notify the physician, the family, or the DON. She stated Med Aid D had notified the DON, but she is not sure why the DON did not address it until the next day instead of that night . During an observation and interview with Resident #1 on 12/03/2024 at 9:30AM, she did not remember any information regarding the incident . Resident appeared clean and comfortable sitting in a wheelchair. Resident was watching television and had finished breakfast. During an interview with Med Aid D on 12/03/2024 at 1:02pm, she stated she had been working on 11/21/2024, in medical records. She stated at approximately 9:15pm the pharmacy had dropped off some medications. She stated she was at her medication cart when RN C came up to her to sign off the Ativan in the resident's electronic medical record. She stated when they checked the order on her chart, there was no order for Ativan for Resident #1. She stated she looked at the medication card with the pills and noticed the medication card was for Resident #2. She stated she then asked him please don't tell me you gave this to Resident #1?. She stated he replied, yes I did, I thought it was for Resident #1. She stated RN C went back down hall 300 and she returned to medical records. Med Aid D stated before leaving around 10pm that night she had asked the oncoming night nurse if he had been notified of the medication error on Resident #1. She stated LVN B denied being informed of the medication error. She stated she texted the DON at 10:27pm asking if she had been notified of RN C's medication error. She stated she did not get a response back that night but did get a response saying nope at around 11:25 AM on 11/22/2024. She stated she told the DON she would come talk to her when she got there. She stated the DON asked if the medication error was on a different resident, and she stated it was someone else. The Med Aid stated when she did come in on 11/22/2024, she informed the ADM and the DON of the medication error that RN C had caused. She stated because RN C did not notify anyone, Resident #1 did not have increased monitoring or assessment and the physician had not been notified. She stated the DON did talk to RN C on 11/22/2024 but she did not know about what. The Med Aid stated she had been trained on medication administration and she would report any medication errors to the physician, the family, the DON, and the ADM. She stated the possible negative outcomes of medication errors could be any adverse effect, or an allergic reaction and residents could be harmed. She stated she felt that RN C did not look at the entire name on the medication card and only saw the last name as Resident #1 and Resident #2 had the same last name. During an interview with RN C on 12/03/2024 at 2:30pm, he stated Resident #1 was a new resident to the facility. He stated on 11/21/2024 he had received about 8 medication cards and all the information had not been put into the computer. He stated all the cards had the same last name. He stated Resident #1's family had requested the resident receive her pain medication as soon as it was delivered. He stated as soon as the medications came in, he popped the tramadol and the lorazepam and administered the medication to Resident #1. He stated he had made the mistake trying to make the family happy. He stated he had rushed and did not go through the five rights of administration. RN C stated he knew he made the error right away because the Med Aid D had informed him. He stated the Med Aid D had notified the DON. He stated he did notify the FNP and she had asked if there had been any adverse reactions, or allergic reactions and he told her no, and the FNP told him to document the error. He stated at that time, 11/22/2024 the resident was alert but in the morning she had been groggy. He stated he had informed Resident #1's FM of what medication he was giving the resident and the family never said anything about that, they only wanted to know why tramadol and not hydrocodone. He stated the medication error report is usually done on paper and given to the DON. RN C stated he had been trained on medication administration, but it had been a while. He stated the five rights of medication administration was right patient, right name, right dose, right time and right order. He stated the potential negative outcomes of a medication error could be an allergic reaction, loss of balance, and possibly overdose. During an interview with the DON on 12/03/2024 at 2:51pm, she stated she was not present at the time of the medication error. She stated she received a text message on 11/22/2024 from Med Aid D asking if RN C had notified her of what had happened the previous night. She stated she was not aware of the events that occurred the previous night and the Med Aid D told her she would talk to her at 2pm. She stated Resident #2's narcotic count appeared off in the computer system due to the medication error. She stated she worked with a med aid to resolve the issue and when RN C arrived at the facility, she had him do the medication error report, notify the physician, and notify the family. She stated the facility did have charge nurses and RN C was the charge nurse on night shift. She stated she did speak to Resident #1's family member on 11/26/2024 after learning the family was very upset about the medication error. The DON stated she was unable to share details of RN C's disciplinary actions but that she had taken the incident seriously. She stated the FNP had a conversation with Resident #1's family and the FNP was willing to send Resident #1 to the ER but at that point the medication was mostly metabolized. She stated, Resident #1 was okay, but if Resident #1's family still wanted her to go to the ER, the FNP would send her. Resident #1 did not go to the ER after that conversation . The DON stated the person who makes the medication errors is to report it to the physician, DON, family and make the medication error report. She stated she was unsure why RN C did not initiate those steps. During an interview with FNP on 12/04/2024 at 9:26AM, she stated she had not been notified of the medication error with Resident #1 until the following day. She stated she expects to be notified of medication errors when they occur or within four hours of the medication error. She stated after the medication was administered Resident #1 would have experienced some sedation. The FNP stated she talked to Resident #1's family and explained at that time Resident #1 was awake, alert, and stable and did not see a need to send her to the ER. She stated she would expect to be notified sooner of medication errors and implement any needed interventions or orders. Record review of facility policy titled Medication Error: Reporting & Management, last revised on January 10, 2023 revealed: Purpose: To describe the procedure for reporting a medication error and the mechanism for review to allow appropriate follow-up and possible implementation of change to decrease the causes and incidences of medication errors . 4. Administration Error - Wrong: a. Patient . Medication Error Review-Upon discovery of an unusual incident regarding a medication, the staff member should Immediately evaluate the patient, notify the physician (or designee) and nurse manager. The staff member will report the incident immediately by completing a Medication Error Report in the EHR. EMR>QAPl>Medicatlon Error Report. The error will be classified according to the Medication Error Index, as adopted by the NCC MERP . Guidelines: 1. The staff member that identifies the error will complete the Medication Error Report 2. Notification the Director of Nursing

Based on interviews, and record reviews the facility failed to ensure residents the right to be free from abuse and/or neglect for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for abuse and/or neglect. 1. The facility failed to keep RN A made inappropriate sexual comments to Resident #1 resulting in Resident #1 feeling ashamed and embarrassed. 2. The facility failed to ensure that CNA B did not refuse to change Resident #2 when Resident #2's brief was saturated. 3. The facility failed to ensure that CNA B did not make verbally abusive comments to Resident #2 when Resident #2 was talking to CNA B 4. The facility failed to ensure that CNA B was not excessively rough when transferring Resident #3 from wheelchair to the commode. These failures could affect residents resulting in physical or emotional harm resulting in in deterioration in their health condition, need for medical treatment, physical impairment, exacerbation of their condition, serious bodily harm, emotional distress, and feelings of isolation. Findings included: Resident #1: Record Review of Resident #1 face sheet, dated 10/17/2024, revealed that Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with, but not limited to the following diagnoses: Spinal stenosis (a chronic condition that occurs when the spinal canal narrows, putting pressure on the spinal cord and nerves), lumbar region with neurogenic claudication (a condition that occurs when the spinal canal narrows in the lower back, compressing the spinal nerves), Injury of peroneal nerve(a major nerve in the lower leg that controls movement and sensation in the foot, toes, and lower leg) at lower leg level, right leg, acute kidney failure, unspecified, low back pain, unspecified, other abnormalities of gait and mobility, muscle weakness (generalized), Pain, unspecified, cognitive communication deficit, urinary tract infection, site not specified. Record Review of Resident #1's MDS, dated [DATE], revealed Resident #1 had a BIMS score of 15 and a functional capacity of being independent. Interview on 10/17/2024 at 6:39am LVN D stated that Resident #1 confided in her about things RN A had said to her. LVN D stated that RN A said, If you feel a warm body in bed with you, it is me crawling in next to you. LVN D could not give a date on which this was said. LVN D stated that Resident #1 told her that she did not feel comfortable around RN A and did not allow RN A to perform wound care on a wound that was located in between Resident #1's thighs. RN A then confronted Resident #1 and asked why she allowed another male nurse to perform wound care for that particular wound. LVN D stated she was unsure what was Resident #1's response to RN A. LVN D immediately reported this to the abuse coordinator for the facility. Interview on 10/17/2024 at 7:49am with Resident #1 stated that she was in the facility for just a few days when RN A came into her room and stated Wow, you are beautiful. Resident #1 stated that she thought that was weird, that some random man came into my room and gave me a compliment. Resident #1 stated that she did not learn RN A's name for quite some time and every time he would leave Resident #1's room RN A would I love you. Resident #1 stated, It was just too much, so I just blocked it out. Resident #1 stated that one day RN A came to perform wound care for my legs and feet. I apologized for my legs being swollen and RN A said Well, I would still lick and kiss them. I do have a wound in between my legs close to my groin area, I would not allow him to change the bandage. The next day RN A came into my room and said to me I thought you didn't want your bandage changed? I told RN A well I did, RN A stated, Well LVN D did it! I said to him yes he did. Resident #1 stated that there was one night she was up, and RN A came into her room. Resident #1 stated that she should have gotten in bed before the start of his shift and then maybe he wouldn't have come in. Resident #1 stated that she told RN A that she was getting ready for bed and that she didn't need anything. RN A then stated to Resident #1 Well if you feel a hot body behind you in bed, it is me getting in. Resident #1 stated she didn't know how to respond to him, and severe nervousness took over. On a different occasion RN A came into my room stating that there were 2 sisters that lived in the facility and that they fought over him every time that he went into their room. RN A stated that the sisters will say things like He is mine!. Resident #1 stated one day when LVN D came into perform wound care I told her that I was happy that she could get to my wound care because I didn't want RN A to have to do it. LVN D stated that RN A no longer worked here. Once LVN D said that to me I knew I could tell her everything, so I opened up to her, before that I felt so ashamed and embarrassed, I just didn't want any problems. Interview on 10/17/2024 at 8:59am with ADM revealed that during the facilities full book survey RN A was being interviewed by SS and an inappropriate comment was said to SS about being a red head. SS felt uncomfortable enough to report it to the ADM of the facility and stated that the comment was just a little off. Interview on 10/17/2024 at 10:11am with ADM revealed that the in-service that was performed for staff regarding the abuse allegation by RN A was a review of the Abuse policy along with interviews of the residents. ADM stated that there no concerns from residents. Interview on 10/17/2024 at 11:58am-when a call was attempted to reach RN A to interview him, however his phone has been disconnected. Interview on 10/17/2024 at 12:30pm with DON stated that when she went to go and speak to Resident #1 about the allegation of abuse by RN A. Resident #1 stated to DON that it was safe to say something because RN A was no longer employed in the facility. DON was asked what a negative outcome was for having staff that were verbally abuse towards residents. DON responded with Residents will feel like they cannot talk to anyone, and it can take a huge toll on their overall health. Interview on 10/17/2024 at 3:55pm with ADM stated that a negative outcome of having staff who are abusive towards residents could lead to residents isolating, not wanting to come out of their rooms, this could lead to an increase in depression and weight loss. Resident #2: Record review of Resident #2's face sheet, dated 10/17/2024 revealed that Resident #2 is a [AGE] year-old male who was admitted to the facility on [DATE] with, but not limited to the following diagnoses: Parkinsonism, unspecified, chronic systolic (congestive) heart failure, unspecified atrial fibrillation, unspecified kidney failure, transient cerebral ischemic attack, unspecified, malignant neoplasm of prostate, obstructive sleep apnea (adult) (pediatric), muscle weakness (generalized), other lack of coordination, cognitive communication deficit. Record Review of Resident #2's MDS, dated [DATE], revealed that Resident #2 had a BIMS score of 15 and functional capacity of maximal assistance. Record review of Resident #2's care plan dated, 10/11/2024, revealed nothing related to deficiency. Interview on 10/17/2024 at 7:14am with Resident #2 revealed that CNA B had yelled at Resident #2 after I accidentally called her 'sir'. She then got angry with me yelled at me I am not a sir! My name is [CNA B]! Resident #2 stated This was not the only time she has snapped at me. I said 'Hi, how are you?', CNA B responded by saying, 'My name is [CNA B]!'. On a different occasion, unsure of when exactly it happened, I pushed my call light because my brief was wet and needed to be changed. My call light was going off, CNA B came into the room very flamboyantly walked over to the call light and turned it off. CNA B then looked at me and said, What do you want?!. I let her know that I was wet and that my sweats were even wet now. CNA B told me that she was going to go and get someone, I never saw her again, and I had to call again. Interview on 10/17/2024 at 11:02am with CNA B revealed that the CNA B could not recall any instances of abuse or neglect towards residents. CNA B stated, I could never jeopardize myself after investing 2 years of energy into getting my CNA. It is very difficult to stay positive and have a good attitude when so many residents on that hall have a flirtations attitude. I have very thick skin when it comes to things like this, however it is a very difficult environment to work in. The residents are being very needy, I tried to get to the lights as soon as I could. Resident #3: Record review of Resident #3's face sheet, dated 10/17/2024, revealed that Resident #3 is a 70+ year-old male who was admitted to the facility on [DATE] with, but not limited to the following diagnoses: Heart failure, unspecified, muscle wasting and atrophy, not elsewhere classified, unspecified site, muscle weakness (generalized), Pain, unspecified, other reduced mobility, other lack of coordination, nasal congestion, other hemorrhoids, edema, unspecified, iron deficiency anemia, unspecified. Record review of Resident #3's MDS, dated [DATE], revealed that Resident #2 has a BIMS score of 14 and a functional capacity of limited assistance. Interview on 10/17/2024 at 3:52am with Resident #3 stated that there was one CNA who was very rough with me when she transferred me to the commode from my wheelchair. Resident #3 stated that he did not know the CNA's name. She was just a tall black girl who worked in the afternoon during the daytime. Interview on 10/17/2024 at 6:08am with LVN C stated that there was a CNA that matched the description given by Resident #3. LVN C stated that it would be CNA B. LVN C did state that CNA B can be very rough with residents and loud. LVN C was asked if this type of behavior was reported, LVN C stated that it had been. Interview on 10/17/2024 At 6:17am with ADON stated that there was a CNA that matched the description given by Resident #3. ADON stated that there was a CNA that worked in the afternoon that matched that description and named CNA B. ADON stated that CNA B did not have the best personality for this type of work but was not aware of any abuse or neglect by CNA B towards residents. Record review of facility provided policy titled, ABUSE, NEGLECT AND EXPLOITATION AND MISAPPROPRIATION OF RESIDENT PROPERTY, reviewed on February 12, 2020, revealed the following: Purpose The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, .Verbal abuse: the use of oral, written or gestured language that willfully includes disparaging terms to residents or their families, or within their hearing distance, regardless of their age, inability to comprehend, or disability. Sexual abuse: includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. .Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interviews and record reviews the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of (Resident #4) 10 residents reviewed for misappropriation of property. The facility did not prevent CNA F from taking a bag of chips from Resident #4. This failure could place residents at risk of continued misappropriation of property. Findings included: Record review of face sheet, dated 10/17/2024 revealed that Resident #4 was a [AGE] year-old female who was admitted to the facility on [DATE] with, but not limited to the following diagnoses: chronic kidney disease, unspecified, primary osteoarthritis, unspecified site, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, unspecified, gastro-esophageal reflux disease without esophagitis, essential (primary) hypertension, cognitive communication deficit, other lack of coordination, difficulty in walking, not elsewhere classified, muscle weakness (generalized) Record review of Resident #4's MDS, dated [DATE], revealed Resident #4 had a BIMS score of 00 and a functional capacity of supervision. Observation on 10/17/2024 at 4:41am revealed Resident #4's room where there was basket of food products on a small table next to Resident #4's dresser. Resident was sleeping at this time and investigator did not disturb her for an interview. Observation on 10/17/2024 at 5:36am of a text message, dated 10/17/2024 at 5:36am from ADM with the video evidence revealing CNA F taking a bag of chips from the snack basket in Resident #4's room. Observation on 10/17/2024 at 7:14am revealed Resident #4 up and dressed and ready for breakfast. Interview was attempted, Resident #4 was unable to answer questions and only mumbled answers. Interview on 10/17/2024 at 10:11am ADM stated that an in-service was being completed regarding the allegations of misappropriation of property for Resident #4. ADM stated that CNA F was suspended until the investigation was completed. Interview 10/17/2024 at 12:10pm CNA F stated A lot of residents give me stuff and I didn't know that food was considered a gift. Resident #4 pointed over to the bag of chips and pointed and said, 'Here Momma'. I didn't have time to get them at that time and so I just went and got them later. I was then pulled into the office and the ADM said, 'I caught you on camera'. I really wasn't sure what she was even talking about. I honest to God didn't know that taking a snack from a resident was something that I didn't know I could do. CNA F was asked what misappropriation of property was, CNA F stated, taking a resident's belongings. Interview on 10/17/2024 at 12:10pm DON stated that a negative outcome for having a staff member take a resident's personal belongings. DON stated, That snack could be the only thing that the resident eats all day, because she has dementia so badly that maybe she takes a couple of bites of her food and then gets up to leave the dining room. Interview on 10/17/2024 at 3:55pm ADM stated that a negative outcome for having a staff member take a resident's personal belongings. ADM stated, the resident could be without something they purchased and could lead to them not leaving their rooms for fear of having something else taken. Record review of facility provided section of employee handbook, titled Gratuities and Other Gifts, dated 06/01/2023, revealed the following: accepting gifts or gratuities for services rendered to residents or patients, or for the granting of business contracts to vendors or contractors is unethical, unprofessional, and strictly prohibited by the Compliance Program. Soliciting or accepting gratuities, tips or gifts of any kind from residents, clients, family members, vendors or contractors may result in corrective action up to and including discharge from employment. Record review of facility provided policy titled, ABUSE, NEGLECT AND EXPLOITATION AND MISAPPROPRIATION OF RESIDENT PROPERTY, reviewed on February 12, 2020, revealed the following: Purpose The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation, and misappropriation of resident property .Misappropriation: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on observations, interviews, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 7 of 18 confidential residents. The facility failed to ensure 7 of 18 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, were provided access to the Grievance form, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews during confidential interviews on, 10/10/2024 at 2:00pm, attendees 7 of 18 confidential residents, stated they did not know the grievance process, they did not know where to obtain or submit a grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in confidential interviews, and they had not observed a posting of the Grievance procedure in prominent locations. The Residents attending the confidential interview did not know how to file a grievance. The Residents did not know where to acquire a grievance form, who to turn the form into, and what happened once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Seven Residents attended the meeting, the seven Residents in attendance had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy on 10/11/2024 at 10:05am revealed a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observed prominent postings on 10/11/2024 at 10:30am; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available to Residents and there was no access to submit a Grievance anonymously. Interview with the ADM on 10/11/2024 at 11:05am; the ADM stated she was the Grievance Officer for the facility. The ADM stated the Grievance form was kept in the facilities' electronic record system. The ADM stated there was not a written Grievance form accessible to the residents. The ADM stated she completed all Grievances as there was not currently a Social Worker on her team. The Grievances were completed when a Resident came to her or another staff member with a complaint, and/or if complaints were voiced in the Resident Council meeting. The ADM stated the Grievance Procedure was not posted for Residents. The ADM stated the Residents cannot file a Grievance anonymously due to the Residents not having access to the Grievance form and having no means of submitting a Grievance form anonymously. The ADM stated she was responsible for assigning a Grievance to a staff member to address. She stated her expectation was Grievances were to be resolved in 24 hours. The ADM stated Residents who voice a complaint were interviewed by the staff member assigned to resolve the Grievance; she stated this was the first step in resolving the Grievance. These interviews were documented on the electronic Grievance form. The ADM stated the resolutions to the Grievances were documented on the electronic Grievance form. The ADM stated the resolutions to Grievances were discussed with Residents face to face. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance. The ADM stated she would meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in the Resident Council meetings . The ADM stated the potential negative outcome to residents could be increased depression, increased behaviors and isolation. Grievance Policy Record Review of the Grievance Policy last updated in 2020. Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or their representative. Residents have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. The resident has the right to file a complaint/concern and the facility must make prompt efforts to resolve grievances the resident may have. Policy Interpretation and Implementation: 1. Any resident, family member, or representative may file a grievance or complaint. 2. Residents, family, and representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances from resident or family concerning issues of residents' care in the facility will be considered. Actions will be responded to in writing. 4. Upon admission residents are provided with written information on how to file a grievance. 5. Grievances may be submitted orally or in writing and may be filed anonymously. 6. The contact information for the individual with whom a grievance may be filed is provided to the resident or representative upon admission . 12. The resident or person filing the grievance on behalf of the resident, will be informed (verbally or in writing) of the findings of the investigation and actions will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident and a copy will be filed in the business office. 13. If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance and report the findings. 14. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. 15. This policy will be provided to the resident or the resident's representative upon request.

Based on observations, interviews, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group, individual activities, and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 7 of 18 residents (confidential residents) reviewed for quality of life. The facility: 1. Failed to engage in activities at scheduled times. 2. Failed to offer engaging activity replacement for scheduled activities that were cancelled or not completed. This failure could affect Residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: Observation and an interview of the dining room and the common area on 10/09/24 beginning at 10:10am, revealed the scheduled activity at 10:00am was Washer Toss. There were four confidential residents sitting in the common area and three confidential residents sitting in the dining area, the AD was not present. The residents in the common area informed the state surveyor they were waiting for Washer Toss to start; two of the confidential residents stated the activities never start on time. The residents in the dining room also stated they were waiting for Washer Toss to start; all seven residents informed the state surveyor they had not seen the AD. Continued observation of the dining room and common area at 10:23am revealed the four residents in the dining room remained in the dining room. The three residents in the common area remained in the common area and stated they assumed the activity was not going to happen, they had not seen the AD. Observation and an interview of the dining room and the common area on 10/09/24 at 3:10pm, revealed the scheduled activity was an Outdoor Lemonade Social, there were five confidential residents in the dining room who informed this state surveyor they were waiting for the activity. The residents informed the state surveyor they had not seen the AD; however, the AD told them after lunch to wait in the dining room for the outdoor activity. Continued observation of the dining room and the courtyard at 3:25pm revealed the same five residents waiting for the activity. The residents informed this state surveyor they had not seen the AD and nothing was set up for the activity. Last observation completed at 3:55pm, the residents stated the activity did not occur. Observation and an interview of the dining room on 10/10/24 at 3:35pm, revealed the scheduled activity was Music Works, Name that Tune, there was nothing set up for the activity, there were five confidential residents who stated they were waiting for the activity. Continued observation of the dining room at 3:45pm revealed the same residents waiting for the activity. One confidential resident stated the activities rarely happened as scheduled; therefore, they choose to stay in the dining room together and socialize. Observation at 4:05pm revealed the same five residents in the dining room, one of the confidential residents stated they had not seen the AD and the activity did not occur. Observation and an interview of the dining room and the common area on 10/11/2024 at 10:10am revealed the scheduled activity of Bible Study with was not occurring in either area. Observation of the dining room revealed the dining room displayed a sign stating it was closed for cleaning. Interview with six confidential residents waiting in the common area stated they were waiting for the 10:00am activity. Observation of the AD's office revealed the AD sitting in her office at her desk. Observation at 10:25am revealed a confidential resident asking the AD where he could join the Bible activity; the AD informed the resident the activity would not begin until the dining room was clean. The AD told the resident he would need to check back because she did not know what time the dining room would be clean. Observation of the dining room at 10:45am revealed 8 confidential residents sitting at a table; one of the residents stated they were waiting for the Bible Study activity. Observation of the same eight residents at 10:50am revealed the AD was at the table with the residents beginning the activity. Interview on 10/11/2024 at 10:51am, ADM stated her expectation was for the AD to follow the activities on the calendar as scheduled, ask for resident preferences for activities, for activities to begin on time, and to inform residents of any changes to the calendar. The ADM stated if the AD was not able to attend a scheduled activity the AD has an AD assistant and other department heads can assist with activities as needed. The ADM stated her expectation if no residents were present for an activity was for the AD to go to the rooms of the residents and invite them to the activity. In addition, the ADM stated if there was no interest in the activity the ADM expected the AD to change the activity to activity of interest to the residents. The ADM stated if an activity was scheduled in the dining room, however, the dining room was closed, her expectation was for the activity to be held in another location. The ADM stated the activity should not be cancelled or started late due to the dining room being closed. The ADM stated the potential negative outcome of residents not having activities was increased depression, social isolation, and residents' needs were not being met. Interview on 10/11/2024 at 11:20am with the AD, the AD stated she has been employed by the facility for 3 years. The AD stated she walked to every resident's rooms if an activity was cancelled or was going to begin later than scheduled. The AD stated she has fell ow employees and volunteers she can lean on if she was unable to lead an activity. The AD stated if no residents attend an activity, she goes room to room to invite residents. The AD stated she asked residents for their choices regarding activities in resident council monthly. The AD stated the scheduled activities this state surveyor observed that did not occur or began late were all due to the dining room not being available. The AD stated she could have moved the activity to another area in the facility, however, she chose not to move the activity. The AD stated residents do not have any emotions when activities do not occur because all the scheduled activities were occurring as scheduled; she had no concerns with activities not occurring as scheduled. The AD stated the potential negative outcome for residents if activities' calendar was not followed was increased depression, boredom, increased behaviors, falls, and possible issue with hydration. Record Review of facility's undated activity policy reflected the following: The facility provides an ongoing program providing a variety of activity functions through the Resident Wellness and Activities Program. The program is designed to include attractions to meet the interests and physical, mental, and psychological well-being of each resident in accordance with the resident's comprehensive assessment. The facility provides group and individual opportunities for all residents who are able to participate. Resident Council meetings are encouraged if desired. All residents, particularly bedfast and those residents unable to participate in group functions will be visited by the Wellness and Life Enrichment Director and/or a volunteer. A monthly calendar of events is posted at the beginning of each month in an area that is accessible and frequented by the residents. A balance of recreational functions including physical, social, religious, arts and crafts, diversional, and intellectual, will be scheduled.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1of 2 treatment carts observed for pharmacy services. The facility failed to ensure 1 tube of Medih [NAME] Gel and 1 tube of zinc oxide ointment were dated when opened. The facility failed to ensure that all medical supplies in the treatment cart were not past their expiration date. The facility failed to ensure single use open collagen packets were not stored in the treatment cart after being opened. This failure could result in harm due to resident received expired medical supplies, such as wound dressings, as well as those supplies not being maintained at their best therapeutic level. The findings were: During an observation on [DATE] at 11:00 AM during treatment cart inspection observed 1 tube of Med Honey gel and 1 tube of zinc oxide ointment with no open date. Observed 1 package of single use collagen powder packet open with no date or resident information. Observed 1 package of hydrofera blue wound dressing with expiration date [DATE]. During an interview on [DATE] at 11:10 AM with LVN A, she stated med honey gel and zinc oxide ointment should have been dated when opened. She stated the open packet of collagen powder was a onetime use and should have been discarded. She stated the collagen powder was no longer sterile because it was opened. She stated hydrofera blue should have been thrown away because it had expired on [DATE]. She stated using an expired dressing was not as effective and could loss sterility. She stated the collagen package was meant to be single use as it could become contaminated with bacteria since it was no longer sealed. She stated all nurses were responsible for checking treatment carts for expired and undated supplies. She stated treatment carts were checked weekly. She stated the undated zinc oxide ointment and med honey gel not being dated, the open collagen packet, and expired hydrofera blue was an over site. She stated the potential negative outcome of not dating open multiuse supplies was it can become contaminated with bacteria and multiuse supplies should be discarded 30 days after opening. During an interview on [DATE] at 12:20 PM with the DON, she stated the med honey gel and zinc oxide ointment should have been dated when opened. She stated the collagen packets were single use and should have been discarded. She stated the supply coordinator, wound care nurse, the ADON, and the DON were responsible for checking the treatment carts. She stated the treatment carts were checked every ,d+[DATE] weeks. She stated the potential negative outcome could be the supplies not having the same effectiveness as it would if not expired. She stated expired supplies could make wounds worse. She stated reusing single use collagen packets could cross contaminate. She stated all staff have been trained on checking the treatment carts. During an interview on [DATE] at 01:02 PM with the ADM, she stated the expired dressing, and the single use collagen powder should have been discarded. She stated the med honey gel and zinc oxide ointment should have been dated when opened. The stated the expired hydrofera blue dressing should have been discarded. She stated the potential negative outcome could be a decrease in effectiveness of the dressing and decrease the healing of the wound. She stated supplies undated staff would not be able to know when to discard supplies. She stated the nurses and nurse manager were responsible for checking treatment carts. She stated all staff have been trained. She stated all staff should check all supplies and medications before use. Record review of facility policy titled Medication Ordering and Receiving from Pharmacy Provider - Medications and Medication Labels dated ,d+[DATE] reflected the following: Policy: The pharmacy will use sound professional judgement and acceptable industry practices for establishing pharmacy's formulary. Medications were labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws. Only the dispensing pharmacy can modify or change prescription labels . 5. Non-prescription medications not labeled by the pharmacy were kept in the manufacturer's original container. Nursing care center personnel may write the resident's name on the container or label as long as the required information is not covered, if applicable by state regulations.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food was accurately dated and labeled. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made during a kitchen tour on 10/9/24 that began at 10:00 AM and concluded at 11:40 AM: Observation on 10/9/2024 at 10:12 AM revealed the following unlabeled and undated items: Ziplock bag of 2 ounce mayonnaise and mustard cups, tray of approximately 15 sandwich halves, glass of white substance that was later identified by the KMGR as milk, stainless steel container of yellow substance that was later identified by the KMGR as egg salad, four 2 ounce cups of a red substance that was later identified as salsa, 8 serving flutes of juice, and a Ziplock bag of 2 ounce cups of a white substance later identified by the KMGR as tartar sauce. The following observations were made during a kitchen tour on 10/10/2024 that began at 11:50 AM and concluded at 12:05 PM: Observation on 10/10/2024 at 11:55 AM revealed the following: a Ziplock bag of mayonnaise and mustard containers were dated 10/8; a Ziplock bag of tartar sauce contained a date of 10/8; juice flutes were dated dates from 10/8-10/10, the milk glass, salsa, sandwiches, and egg salad were no longer observed in the refrigerator. The following observations were made during a kitchen tour on 10/11/24 that began at 10:55 AM and concluded at 11:05 AM: Observation on 10/11/2024 at 10:57 AM revealed the following: approximately 11 juice flutes were undated and unlabeled and approximately 6 pitchers of liquids were unlabeled and undated. On 10/11/2024 at 1:30 PM an interview was conducted with the KMGR regarding concerns observed in the kitchen and dining areas. The KMGR stated she was aware of the unlabeled and undated items observed in the kitchen refrigerator and stated she also saw these items. The KMGR stated dates were placed on the items after they were observed, based on her knowledge of when the items were prepared. The KMGR stated it was the facility's policy to label and date all items in the kitchen as they were opened. The KMGR stated it was the facility's policy to throw items in the refrigerator, that were opened, away within 3 days. The KMGR stated all kitchen staff were responsible for ensuring items were labeled and dated when stored in the refrigerator. The KMGR stated she was responsible for double checking to ensure this was done by staff. The KMGR stated it was important for items in the refrigerator to be labeled and dated so residents did not get sick from food poisoning and to make sure food didn't spoil. The KMGR stated she was trained in food service and had a food handler's certification, and she referred to the copy hanging on her office wall. The KMGR stated all kitchen staff received training on food safety and had a food handler's certification. The KMGR stated all staff that serve food should have washed or sanitized their hands before serving each resident's plate and as necessary when they touched anything contaminated. The KMGR stated all staff were trained on hand hygiene. The KMGR stated the potential negative outcome for the residents when food was not stored properly was the potential for residents getting sick or getting food poisoning. The KMGR stated the potential negative outcome for residents when staff did not wash or sanitize their hands properly could be passing germs to residents and residents and/or staff could get sick. On 10/11/2024 at 1:47 PM an interview was conducted with the ADM regarding concerns observed in the kitchen and dining areas. The ADM stated the facility's policy on storing items in the refrigerator stated all items in the refrigerator should be dated when they were made. The ADM stated sauces and other items opened should have been dated when they were opened. The ADM stated items should never be backdated and if staff were not sure of the date of the items, they should have been thrown away to ensure resident's safety. The ADM stated the person who prepared the food or opened the item was responsible for dating and labeling the items stored in the refrigerator. The ADM stated the kitchen manager should have checked to ensure items were dated and labeled properly in the refrigerator. The ADM stated labeling and dating items in the refrigerator were important to prevent food born illnesses. The ADM stated sandwiches, to her knowledge, should have only been kept for one day and milk should not have been stored in the refrigerator in a glass since the expiration date was on the milk container and not the glass. The ADM stated the KMGR, and all kitchen staff have received food storage training and completed a food handler's certification. The ADM stated on-going training was conducted with the KMGR. The ADM stated staff should have practiced good hand hygiene between each task, such as serving plates, touching the handles of a wheelchair, and touching anything soiled. The ADM stated the potential negative outcome for a resident if items were not stored properly in the refrigerator could result in the resident getting sick, losing weight, and the resident not being comfortable eating food that could make them sick. The ADM stated staff not practicing good hand hygiene could result in residents getting sick. Record review of the facility policy titled Food Storage for the Nutritional Services Department, dated 8/1/2018 and revised on 2/6/2024, revealed the following documentation: Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Refrigerator: o Opened containers of thickened liquids are stored in the refrigerator with both open and discard dates. o All foods are covered, labeled, and dated. Record review of the facility policy titled Hand Hygiene for Staff and Residents for the Infection Control Department, effective 8/2018, revised on 8/2018, and reviewed 1/2022, revealed the following documentation: Purpose: To reduce the spread of infection with proper hand hygiene Policy: Proper hand hygiene technique is completed whenever hand hygiene is indicated. NOTE: Hand Hygiene is the most important component for preventing the spread of infection. Maintaining clean hands is important for residents/visitors as well as staff. Procedures: 1. Hand hygiene is done: Before: A. resident contact. B. eating or handling food. After: A. contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. resident contact. Record review of the FDA Food Code titled On-premises preparation; Prepare and hold cold: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking (Chapter 3) effective for 2022, revealed the following: On-premises preparation Prepare and hold cold 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 4 Residents and 5 of 5 staff members (LVN A, CNA A, CNA C, CNA E and CNA F) observed for infection control practices (Resident #7, #15, #87, and #257). in that: 1. CNA A failed to use proper hand hygiene before or after assisting with incontinent care for Resident #7. 2. CNA C failed to use proper hand hygiene before or after assisting with wound care for Resident #15. 3. LVN A failed to use proper wound care techniques and CNA D did not use proper hand hygiene before or after assisting with wound care for Resident #87 4. LVN A failed to use proper wound care techniques and CNA D did not wash hands before or after assisting with wound care for Resident #257. 5. CNA F failed to ensure using good hygienic practices while assisting with passing food trays. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Resident #7: Record Review of Resident #7's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE] with a primary diagnoseis of: Parkinsonism (is caused by one or more strokes, it refers to brain conditions that caused slowed movements), Tourette's disorder (a nervous system disorder involving repetitive movements or unwanted sounds), muscle wasting and atrophy, unsteadiness on feet, dependence on renal dialysis, hyperkalemia (a high level of potassium in the blood), and acidosis (a buildup of acid in the bloodstream). Record Review of Resident #7's Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of 14 indicating that Resident #7 was cognitively intact. During An observation was completed of CNA E aiding for CNA F with incontinent care for Resident #7 on 10/10/2024 at 12:01 PM. CNA E washed hands prior to assisting CNA F with incontinent care by the following steps: CNA E turned on the water and put two squirts of soap in her hands. CNA E immediately washed her hands under the water by rubbing her hands together. CNA E grabbed two clean paper towels and dried her hands and turned off the faucet with the same paper towel that she dried her hands with and disposed of the paper towel. After assisting with incontinent care for Resident #7, she turned on the water and quickly rinsed her hands and did not use any soap. CNA E grabbed two clean paper towels and dried her hands and turned off the faucet with the same paper towel that she dried her hands with and then disposed of the paper towel. During an interview with CNA E on 10/10/2024 at 2:13 PM, CNA E stated that she had been trained in hand washing and infection control practices once a month by in-services or verbal education. CNA E stated that the DON and the ADON was responsible for holding these trainings. CNA E stated that they do have skills checks monthly. CNA E stated that she did not provide proper hand washing techniques because she was nervous. CNA E stated that the negative potential outcome was the spread of infections and germs. Resident #15: Record Review of Resident #15's face sheet revealed an [AGE] year-old female, who was admitted to the facility on [DATE] with a primary diagnosis of: Senile degeneration of brain, atherosclerotic heart disease (a build-up of fats in and on the artery walls), muscle weakness, dementia (a group of thinking and social symptoms that interferes with daily functioning), psychotic disturbance, mood disturbance, and anxiety, pressure ulcer of sacral region, stage 2, cortical age related cataract (begins as white, wedge-shaped spots or streaks on the outer edge of the lens cortex), and age-related nuclear cataract (age-related change in the density of the crystalline lens nucleus). Record Review of Resident #15's Admission MDS dated [DATE] revealed Resident #15 had a BIMS score of 9 indicating that Resident #15 was cognitively moderately impaired. During an observation of CNA C on 10/10/2024 at 9:30 AM, CNA C did not wash hands prior to gathering supplies to perform incontinent care for Resident #15. CNA C grabbed a clear trash bag and put the following supplies in the bag with her bare hands: hand sanitizer, towel, gloves, sheet, and couple of clear trash bags. CNA C knocked on the door and explained the procedure to Resident #15. CNA C shut the resident's door. CNA C put the supplies on the bedside table but did not clean the bedside table. CNA C went into the resident's bathroom to wash hands by performing the following steps: CNA C put two squirts of soap in her hands and then turned on the water faucet. CNA C immediately rinsed her hands under the water without lathering the soap for four seconds. CNA C grabbed two clean paper towels and dried her hands and disposed of the paper towel. CNA C turned off the water faucet with her bare hands. CNA C put the gait belt around Resident #15 and transferred from the wheelchair into the bed. CNA C removed the gait belt. CNA C put on a pair of clean gloves. CNA C raised the bed. CNA C grabbed a clean brief out of the dresser. CNA C disposed of gloves in the trash. CNA C put on hand sanitizer and put on pair of clean gloves. CNA C removed pants from off Resident #15 and removed the front of the old brief and stuffed it between the resident's legs. CNA C removed gloves and discarded in the trash. CNA C put on pair of clean gloves. CNA C took a wipe and began incontinent care by cleaning using the one wipe per swipe method starting on the center of groin area and wiping twice. CNA C asked Resident #15 to turn to the left side and she removed the backside of the old brief and discarded. CNA C removed gloves and discarded. CNA C put on hand sanitizer and put on pair of clean gloves. CNA C wiped the backside of Resident #15 using the one wipe per swipe method starting from the center and then going to the left and the right buttocks. CNA C placed a clean brief under the resident. CNA C asked resident to lay back and fastened the front of the brief. CNA C put on Resident #15's pants. CNA C removed gloves and put on a new pair of gloves. CNA C placed a gait belt around the resident and transferred back into the wheelchair. CNA C removed the gait belt off Resident #15. CNA C removed gloves and discarded in the trash. CNA C removed all trash and left Resident #15's room without washing hands. During an interview with CNA C on 10/10/2024 at 9:51 AM, CNA C stated that she had been trained in infection control practices and hand washing, every three months. CNA C stated that training included on-line training every three months, skills check every two months, and that the DON and the ADON were responsible for providing these trainings. CNA C stated that she should have washed her hands prior to gathering incontinent care supplies. CNA C stated that she should have washed her hands by lathering for twenty seconds instead of immediately rinsing hands and not lathering. CNA C stated that she should have cleaned the bedside table before and after incontinent care. CNA C stated that she should have washed her hands after incontinent care and does not know why she did not wash her hands. CNA C stated that she was so nervous that she could not think of what steps to take. CNA C stated that the negative potential outcome of not providing infection control practices is the spread of diseases, frequent UTI's, and sicknesses. Resident #87: Record Review of Resident #87's face sheet revealed a [AGE] year-old male, who was admitted to the facility on [DATE] with a primary diagnosis of fracture of unspecified part of neck of right femur, senile degeneration of brain (loss of intellectual ability), Guillain-Barre syndrome (condition in which the immune system attacks the nerves), acute cerebrovascular insufficiency (a number of rare conditions that result in obstruction of one or more arteries that supply blood to the brain), pain in right hip, muscle weakness, and dependence on wheelchair. Record Review of Resident #87's Admission MDS dated [DATE] revealed Resident #87 had a BIMS score of 12 indicating that Resident #87 was cognitively moderately impaired. MDS indicated under skin conditions indicated that Resident #87 had Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, under risk of pressure ulcer indicated that Resident #87 was at risk for pressure ulcers, under unhealed pressure ulcers/injuries were left blank and incomplete, under current number of unhealed pressure ulcers/injuries at each stage listed as 1, under current number of unhealed pressure ulcers/injuries at each stage were listed at 0 and 2 listed as a stage 4, under number of venous & arterial ulcers were listed as 0, under other ulcers, wounds, and skin conditions were listed as none, and under skin and ulcer/injury treatments were listed as pressure ulcer/injury care and pressure reducing device for bed. Record Review of Resident #87's Care Plan dated 10/02/2024 revealed Resident #87 had a skin tear on left hand dated 04/23/24, stage 4 pressure ulcer dated 06/07/2024, history of bruising and skin tears dated 11/08/2023, and history of pressure injury dated 06/20/2024. Record Review of Resident #87's Physician Orders dated 09/02/2024 revealed: pressure relieving mattress every shift. Record Review of Resident #87's Physician Orders dated 09/03/2024 revealed: non weight bearing to right lower extremity until seen by ortho. Record Review of Resident #87's Physician Orders dated 09/13/2024 revealed: Enhanced barrier precautions every shift due to current wounds needing treatment. Record Review of Resident #87's Physician Orders dated 09/19/2024 revealed: cleanse wound every am shift (6am-2pm). Cleanse the right heel with wound cleanser or normal saline, pat dry, apply calcium alginate cut to wound size and cover with silicone foam dressing. During an observation of LVN A providing wound care for Resident #87 on 10/10/2024 at 10:53 AM, LVN A provided hand washing and put on clean gloves. CNA D provided hand washing and put on clean gloves. CNA D removed resident sock on right foot and held Resident #87's foot up for LVN A to provide wound care. LVN A removed the old bandage dated 10/07/2024 and discarded in the trash. LVN A put on hand sanitizer and put on clean gloves. LVN A put wound cleanser on one gauze pad and placed it in the center wound, consistently using circular motion three times. LVN A lifted the gauze pad off the skin and used the same gauze pad using circular motion in the center of the wound, another three times. LVN A discarded gauze in the trash. LVN A used a dry gauze to pad dry in the center wound by touching the wound with the gauze, lifting, and touching the wound with the same side of the gauze five times. LVN A covered wound with bandage with initial and date. LVN A removed gloves and discarded. CNA D replaced Resident #87's sock on the right foot. During an observation on 10/9/2024 at 1:00 PM CNA F was seen entering the serving line after delivering a meal to a resident in the dining room. CNA F did not wash or sanitize her hands before obtaining another resident's meal to serve. During an observation on 10/9/2024 at 1:02 PM CNA F was seen entering the serving line after delivering a meal to another resident in the dining room. CNA F did not wash or sanitize her hands before obtaining another resident's meal to serve. CNA F was observed preparing the resident's meal by opening the silverware and cutting up food on the plate. During an observation on 10/9/2024 at 1:05 PM CNA F was seen entering the serving line after delivering a meal to another resident in the dining room. CNA F did not wash or sanitize her hands before obtaining another resident's plate to serve. During an observation on 10/9/2024 at 1:06 PM CNA F was seen entering the serving line after delivering a meal to another resident in the dining room. CNA F did not wash or sanitize her hands before obtaining another resident's plate to serve. CNA F was observed opening silverware and aligning the plate for the resident. During an observation on 10/9/2024 at 1:13 PM CNA F was seen entering the serving line after delivering a meal to another resident in the dining room. CNA F did not wash or sanitize her hands before obtaining another resident's plate to serve. During an observation on 10/9/2024 at 1:14 PM CNA F was seen entering the serving line after delivering a meal to another resident in the dining room. CNA F did not wash or sanitize her hands before obtaining another resident's plate to serve. CNA F was observed opening the silverware for the resident. CNA F was observed speaking with the residents at the dining while standing behind a resident's wheelchair and her hands were observed to be resting on the handles of the resident's wheelchair. CNA F did not wash or sanitize her hands after touching the handles of the resident's wheelchair. During an observation on 10/9/2024 at 1:16 PM CNA F was seen entering the serving line after delivering a meal to another resident in the dining room. CNA F did not wash or sanitize her hands before obtaining another resident's plate to serve. CNA F was observed exiting the serving line with three plates in her hands, and one plate was touching her scrub top as she was carrying it next to her body. During an observation on 10/9/2024 at 1:17 PM CNA F was seen obtaining a glass of milk and serving it to a different resident. CNA F did not wash or sanitize her hands before obtaining the glass of milk. During an interview with LVN A on 10/10/2024 at 2:18 PM, LVN A stated that it was best that once you lifted off the skin with the gauze to not retouch the skin. LVN A stated that she should have cleaned the skin with one gauze and once she lifted off the skin to discard of the gauze and get a new one. LVN A stated that she should have cleaned in a circular motion from inside the wound to outward. LVN A stated that she was nervous and was not used to being watched. LVN A stated that she had been trained by the wound care education center that the facility used, and she was trained in April 2024. LVN A stated that it was a hands-on training, and it was provided once a year. LVN A stated that the negative potential outcome for not cleaning wounds with the correct technique would be dispersing bacteria from inside the wound to another area of the skin. During an observation of CNA D aiding with wound care with LVN A for Resident #87 on 10/10/2024 at 10:53 AM. CNA D aided with wound care by removing the sock and holding up Resident #87's foot during wound care. Prior to assisting with the wound care, CNA D washed her hands by the following steps: CNA D turned on faucet with her hands. CNA D put one squirt of soap in her hands and rubbed hands immediately under water without allowing the soap to lather. CNA D used a clean paper towel to dry her hands. CNA D used her elbow to turn off the faucet. After wound care CNA D placed Resident #87's sock back on, removed her gloves, and discarded in the trash. CNA D provided hand washing after assisting by the following steps: CNA D turned on the faucet. CNA D put two squirts of soap in her hands, rubbing her hands together for nine seconds and then rinsing her hands. CNA D grabbed two clean paper towels to dry her hands and discarded them in the trash. CNA D used her bare hands to turn off the faucet. During an interview with CNA D on 10/10/2024 at 2:30 PM, The CNA D stated that she should wash her hands longer and not use her elbow or bare hands to turn off the faucet. CNA D stated that she just sang the Happy Birthday song, too fast. CNA D stated that she should have lathered her hands instead of rinsing immediately. CNA D stated that she had been trained in infection control and hand washing by in-services and competency checks, monthly. CNA D stated that the negative potential outcome for not using proper handwashing techniques was transferring germs. Resident #257: Record Review of Resident #257's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE] with a primary diagnosis of spinal stenosis lumbar region (narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), urinary tract infection, type 2 diabetes mellitus with diabetic nephropathy, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), major depressive disorder, and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Record Review of Resident #257's Admission MDS dated [DATE] revealed Resident #257 with the BIMS left blank and incomplete. MDS indicated under skin conditions were left blank and incomplete, under risk of pressure ulcer were left blank and incomplete, under unhealed pressure ulcers/injuries were left blank and incomplete, under current number of unhealed pressure ulcers/injuries at each stage were left blank and incomplete, under current number of unhealed pressure ulcers/injuries at each stage were left blank and incomplete, and under number of venous & arterial ulcers were left blank and incomplete. Record Review of Resident #257's Care Plan dated 10/02/2024 revealed Resident #257 had Skin Breakdown: Pressure Ulcer, cleanse wound every am shift (6am-2pm), wound (pressure, diabetic, or stasis). Interventions of dietitian referral, inspect skin complete body head to toe every week and document, inspect skin daily with care and bathing, and report any changes to charge nurse, monitor nutritional intake, weight, lab values, report significant changes to MD, off load heels, position resident properly, use pressure-reducing or pressure-relieving devices, treatments, and dressings as ordered per physician. Record Review of Resident #257's Physician Orders dated 10/09/2024 revealed: Cleanse wound every am shift (6am-2pm). Cleanse right groin wound with wound cleanser or NS, pack with iodoform 1/2 inches packing strip, and cover with a silicone foam dressing. Record Review of Resident #257's Physician Orders dated 10/09/2024 revealed: Cleanse wound every am shift (6am-2pm), cleanse right foot wound with wound cleanser or normal saline, pat dry, apply calcium alginate, cover with a border gauze. Record Review of Resident #257's Physician Orders dated 10/09/2024 revealed: Cleanse wound every am shift (6am-2pm), cleanse right calf wound with wound cleanser or normal saline, pat dry, apply calcium alginate, cover with a border gauze. Record Review of Resident #257's Physician Orders dated 10/09/2024 revealed: Cleanse wound every am shift (6am-2pm), cleanse left foot wound with wound cleanser or normal saline, pat dry, apply calcium alginate, cover with a border gauze. During an observation of LVN A providing wound care for Resident #257 on 10/10/2024 at 1:43 PM, LVN A provided hand washing and put on clean gloves. LVN A checked Resident #257's wounds on right groin area. LVN A removed gloves and discarded in trash. LVN A used hand sanitizer and put on clean gloves. LVN A used a gauze pad with wound wash on it to blot the center of the wound and picked up the gauze off the skin and placed it back on the skin on same gauze, seven times. LVN A placed calcium alginate in the wound. LVN A removed dirty gloves and discarded in the trash. LVN A used hand sanitizer and put on clean gloves. LVN A used a clean gauze pad to pat dry the wound on the right groin area by blotting with the same gauze five times. LVN A removed gloves and discarded in trash. LVN A used hand sanitizer and put on clean gloves. LVN A used wound cleanser on a gauze pad to clean the wound on Resident #257's right foot using the blotting method, four times, using the same gauze pad. LVN A used a clean gauze pad and pat dry six times using the same gauze pad. LVN A removed gloves and discarded in the trash. LVN A used hand sanitizer and put on clean gloves. LVN A used wound wash on a clean gauze pad to clean wound on right calf by going in horizontal direction back and forth over the wound without lifting the gauze pad, nine times. LVN A used a dry clean gauze to pat dry, five times, using the same gauze pad. LVN A applied calcium alginate to the top of the foot and covered with bandage with date and initials. LVN A placed calcium alginate on wound on the right calf and covered with a bandage with date and initials. LVN A removed gloves and discarded in the trash. LVN A used hand sanitizer and put on clean gloves. LVN A used clean gauze pad with wound wash to clean the closed wound on the bottom of the right foot, going in a horizontal direction, back and forth, six times using the same gauze. LVN A discarded the gauze pad in the trash. LVN A used a dry clean gauze pad to pat dry the right bottom foot by blotting, five times. LVN A discarded the used gauze in the trash. LVN A covered the wound on the bottom of the foot with a bandage with date and initials. LVN A discarded gloves in the trash. During an observation of CNA D aiding with wound care with LVN A for Resident #257 on 10/10/2024 at 1:43 PM. CNA D did not wash hands before or after aiding with wound care for Resident #257. CNA D put on one pair of clean gloves throughout the process of assisting with holding of Resident #257's leg, removing clothing, and disposing of trash. During an interview with LVN A on 10/10/2024 at 2:18 PM. LVN A stated that it was best that once you lifted off the skin with the gauze to not retouch the skin. LVN A stated that she should have cleaned the skin with one gauze and once she lifted off the skin to discard of the gauze and get a new one. LVN A stated that she should have cleaned in a circular motion from inside the wound to outward. LVN A stated that she was nervous and was not used to being watched. LVN A stated that she had been trained by the wound care education center that the facility uses, and she was trained in April 2024. LVN A stated that it was a hands-on training, and it was provided once a year. LVN A stated that the negative potential outcome for not cleaning wounds with correct technique would be dispersing bacteria from inside the wound to another area of the skin. During an interview with the KMGR on 10/11/2024 at 1:30 PM an interview had been conducted regarding concerns observed in the dining areas. The KMGR stated all staff that serve food should have washed or sanitized their hands before serving each resident's plate and as necessary when they touched anything contaminated. The KMGR stated all staff were trained on hand hygiene. The KMGR stated the potential negative outcome for residents when staff did not wash or sanitize their hands properly could be passing germs to residents and residents and/or staff could get sick. During an interview with the Administrator on 10/11/2024 at 1:47 PM an interview was conducted regarding concerns observed in the dining areas. The Administrator stated staff should have practiced good hand hygiene between each task, such as serving plates, touching the handles of a wheelchair, and touching anything soiled. The ADMIN stated staff not practicing good hand hygiene could result in residents getting sick. During an interview with the Administrator on 10/11/2024 at 2:37 PM, she the Administrator stated that she expected that staff wash their hands at least twenty seconds. The Administrator stated that staff should follow the policy for hand washing and infection control practices. The Administrator stated that the staff had been trained in hand washing and infection control practices. The Administrator stated that the facility holds skills fairs annually, and competency checks upon hire and monthly. The Administrator stated that the negative potential outcome would be the spread of germs, frequent UTI's, or infected wounds. During an interview with the DON on 10/11/2024 at 2:54 PM, she the DON stated that she expected handwashing to be done properly to keep from spreading infection. The DON stated that she believed the policy stated that staff should use soap and friction for full twenty seconds before rinsing. The DON stated that she expected staff to follow the policy. The DON stated that training and competency checks were provided for staff every month and they have a skills fair annually. The DON stated that the negative potential outcome was the spread of infection and transfer of bacteria. Record review of the facility policy titled; Infection Control date Revised July 2018 revealed: Purpose: The surveillance of infections is an essential part of any infection prevention and control strategy. The main objectives of a surveillance program are: I the prevention and early detection of outbreaks to allow timely investigation and control. II the assessment of infection rates over time to determine the need for, and measure the effect of, preventative or control measures. Policy: This facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method of collecting, consolidating, and analyzing data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. I Decrease the spread of infection. II Increase knowledge of infections and how they are spread. Handwashing Surveillance Handwashing is monitored by direct surveillance of persons performing their normal job functions. It is best to complete this type of surveillance without notifying persons you are observing handwashing, to get accurate results. Monitor for short periods several times per month. Monitor as many different disciplines as possible (CNA, LVN, RN, housekeeping, therapy, and kitchen staff) ANALYZING Record review of the facility policy titled; Handwashing/ Hand Hygiene date Revised August 2018 revealed: Purpose: To reduce the spread of infection with proper hand hygiene Policy: Proper hand hygiene technique is completed whenever hand hygiene is indicated. NOTE: Hand Hygiene is the most vital component for preventing the spread of infection. Maintaining clean hands is important for residents/visitors as well as staff. Procedures: 1. Hand hygiene is done: Before: A. resident contact. B. eating or handling food. G. taking part in a medical or surgical procedure. After: A. contact with soiled or contaminated articles, such as articles that are contaminated with. body fluids. B. resident contact. C. contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds. D. toileting or assisting others with toileting, or after personal grooming. H. removal of medical/surgical or utility gloves. NOTE: Wash hands at end of procedures where glove changes are not required. For procedures in which change of gloves, e.g., clean gloves to sterile gloves, is indicated follow. the specific standard of practice. If glove hands become contaminated as gloves are changed hands can be washed. Record review of the facility policy titled Hand Hygiene for Staff and Residents for the Infection Control Department, effective 8/2018, revised on 8/2018, and reviewed 1/2022, revealed the following documentation: Purpose: To reduce the spread of infection with proper hand hygiene Policy: Proper hand hygiene technique is completed whenever hand hygiene is indicated. NOTE: Hand Hygiene is the most vital component for preventing the spread of infection. Maintaining clean hands is important for residents/visitors as well as staff. Procedures: 1. Hand hygiene is done: Before: A. resident contact. B. eating or handling food. After: A. contact with soiled or contaminated articles, such as articles that are contaminated with body fluids.

Based on observation, interview, and record review, the facility failed to ensure personal privacy was provided for 1 of 1 residents reviewed for dignity. (Resident #257) 1. CNA D and LVN A failed to pull the privacy curtain while providing wound care for Resident #257. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: Resident #257: Record Review of Resident #257's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE] with a primary diagnoses of spinal stenosis lumbar region (narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), urinary tract infection, type 2 diabetes mellitus with diabetic nephropathy, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), major depressive disorder, and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Record Review of Resident #257's Admission MDS dated [DATE] revealed Resident #257 with the BIMS left blank and incomplete. Record Review of Resident #257's Physician Orders dated 10/02/2024 revealed: Cleanse wound every am shift (6am-2pm). Cleanse right groin wound with wound cleanser or NS, pack with iodoform 1/2 inches packing strip, and cover with a silicone foam dressing. An observation was done of LVN A providing wound care with assistance from CNA D for Resident #257 on 10/10/2024 at 1:43 PM. LVN A and CNA B entered Resident #257's room to provide wound care on the right groin area. LVN A and CNA D closed Resident #257's door but failed to close the privacy curtain. Resident #257's pants had to be removed in order to provide wound care. Resident #257 had a brief on while LVN A cleaned the wound on the groin area. During an interview with LVN A on 10/10/2024 at 2:22 PM LVN A stated that she should have pulled the curtain to provide privacy for the resident but did not think of it because she was nervous. LVN A stated that by not providing a secondary form of privacy it could be a dignity issue especially where the wounds were located. LVN A stated that she had been trained in privacy and dignity upon hire in March. During an interview with CNA D on 10/10/2024 at 2:37 PM CNA D stated that she did not realize that she should had closed the curtain to provide a second form of privacy for the resident. CNA D stated that she had thought as long as the door was closed then it would of be fine to provide care. CNA D stated that she had not known that if someone walked in the door then the resident would be exposed. CNA D stated that she had been trained in privacy and resident rights by in-services, approximately monthly. CNA D stated that the negative outcome was that someone could walk in, making the resident feel embarrassed. During an interview with the DON on 10/10/2024 at 2:54 PM revealed that the DON expected staff to provide a second form of privacy when providing care to the residents. The DON stated that staff should have closed the door and pull the curtain to make sure to provide as much privacy as possible. The DON stated that staff had been trained in dignity and privacy at least once a month through in-services. The DON stated that the negative potential outcome for not providing a second form of privacy during resident care was that the resident could be exposed causing them emotional distress and embarrassment. The DON stated that privacy and dignity was a big deal. During an interview with the Administrator on 10/11/2024 at 2:37 PM revealed that the Administrator expected staff to close the door and pull the curtain completely closed when providing care for the resident, to keep the resident from being exposed. The Administrator stated that the staff had been trained through in-services, annually, and upon hire. The Administrator stated that the negative potential outcome for not providing complete privacy when providing care would be emotional distress and embarrassment if someone other than the nurse had seen them. During an Interview with the Administrator on 10/11/2024 at 2:41 PM. The Administrator stated that the facility did not have a policy on pulling privacy curtain during care.

Based on observations, interviews, and record review, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for 2 of 2 residents (Residents #87 and Resident #257) reviewed for pressure ulcer care. 1. LVN A failed to use the correct wound techniques during wound care for Resident #87 and #257. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new pressure ulcers, worsening of existing pressure ulcers, and infection. Findings included: Resident #87: Record Review of Resident #87's face sheet revealed a [AGE] year-old male, who was admitted to the facility on [DATE] with primary diagnoses of fracture of unspecified part of neck of right femur, senile degeneration of the brain (loss of intellectual ability),Guillain-Barre syndrome (condition in which the immune system attacks the nerves), acute cerebrovascular insufficiency (a number of rare conditions that result in obstruction of one or more arteries that supply blood to the brain), pain in right hip, muscle weakness, and dependence on wheelchair. Record Review of Resident #87's Admission MDS dated [DATE] revealed Resident #87 had a BIMS score of 12 indicating that Resident #87 was cognitively moderately impaired. The MDS indicated under skin conditions that Resident #87 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, under risk of pressure ulcer indicated that Resident #87 was at risk for pressure ulcers, under unhealed pressure ulcers/injuries were left blank and incomplete, under current number of unhealed pressure ulcers/injuries at each stage listed as 1, under current number of unhealed pressure ulcers/injuries at each stage were listed at 0 and 2 listed as a stage 4, under number of venous & arterial ulcers were listed as 0, under other ulcers, wounds, and skin conditions were listed as none, under skin and ulcer/injury treatments were listed as pressure ulcer/injury care and pressure reducing device for bed. Record Review of Resident #87's Care Plan dated 10/02/2024 revealed Resident #87 had a skin tear on the left hand dated 04/23/24, stage 4 pressure ulcer dated 06/07/2024, history of bruising and skin tears dated 11/08/2023, and history of pressure injury dated 06/20/2024. Record Review of Resident #87's Physician Orders dated 09/02/2024 revealed: pressure relieving mattress every shift. Record Review of Resident #87's Physician Orders dated 09/03/2024 revealed: non weight bearing to right lower extremity until seen by ortho. Record Review of Resident #87's Physician Orders dated 09/13/2024 revealed: Enhanced barrier precautions every shift due to current wounds needing treatment. Record Review of Resident #87's Physician Orders dated 09/19/2024 revealed: cleanse pressure wound every am shift (6am-2pm), cleanse right heel with wound cleanser or normal saline, pat dry, apply calcium alginate cut to wound size and cover with silicone foam dressing. During an observation of LVN A providing wound care for Resident #87 on 10/10/2024 at 10:53 AM, LVN A provided hand washing and put on clean gloves. CNA D provided hand washing and put on clean gloves. CNA D removed residents sock on right foot and held Resident #87's foot up for LVN A to provide wound care to pressure ulcer on right foot. LVN A removed the old bandage dated 10/07/2024 and discarded in the trash. LVN A put on hand sanitizer and put on clean gloves. LVN A put wound cleanser on one gauze pad and placed in center wound, consistently using circular motion three times. LVN A lifted the gauze pad off of the skin and used the same gauze pad using circular motion in the center of the wound, another three times. LVN A discarded gauze in the trash. LVN A used a dry gauze to pat dry in the center wound by touching the wound with the gauze, lifting, and touching the wound with the same side of the gauze five times. LVN A covered wound with bandage with initial and date. LVN A removed gloves and discarded. CNA D replaced Resident #87's sock on the right foot. Resident #257: Record Review of Resident #257's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE] with a primary diagnoses of spinal stenosis lumbar region (narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), urinary tract infection, type 2 diabetes mellitus with diabetic nephropathy, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), major depressive disorder, and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Record Review of Resident #257's Admission MDS dated [DATE] revealed Resident #257 with the BIMS left blank and incomplete. MDS indicated under skin conditions were left blank and incomplete, under risk of pressure ulcer were left blank and incomplete, under unhealed pressure ulcers/injuries were left blank and incomplete, under current number of unhealed pressure ulcers/injuries at each stage were left blank and incomplete, under current number of unhealed pressure ulcers/injuries at each stage were left blank and incomplete, under number of venous & arterial ulcers were left blank and incomplete. Record Review of Resident #257's Care Plan dated 10/02/2024 revealed Resident #257 had Skin Breakdown: Pressure Ulcer, cleanse wound every am shift (6am-2pm), wound (pressure, diabetic, or stasis). Interventions of dietitian referral, inspect skin complete body head to toe every week and document, inspect skin daily with care and bathing, and report any changes to charge nurse, monitor nutritional intake, weight, lab values, report significant changes to MD, off load heels, position resident properly, use pressure-reducing or pressure-relieving devices, treatments, and dressings as ordered per physician. Record Review of Resident #257's Physician Orders dated 10/09/2024 revealed: Cleanse wound every am shift (6am-2pm). Cleanse right groin wound with wound cleanser or NS, pack with iodoform 1/2 inches acking strip, and cover with a silicone foam dressing. Record Review of Resident #257's Physician Orders dated 10/09/2024 revealed: Cleanse wound every am shift (6am-2pm), cleanse right foot wound with wound cleanser or normal saline, pat dry, apply calcium alginate, cover with a border gauze. Record Review of Resident #257's Physician Orders dated 10/09/2024 revealed: Cleanse wound every am shift (6am-2pm), cleanse right calf wound with wound cleanser or normal saline, pat dry, apply calcium alginate, cover with a border gauze. Record Review of Resident #257's Physician Orders dated 10/09/2024 revealed: Cleanse wound every am shift (6am-2pm), cleanse left foot wound with wound cleanser or normal saline, pat dry, apply calcium alginate, cover with a border gauze. During an observation of LVN A providing wound care for Resident #257 on 10/10/2024 at 1:43 PM, LVN A provided hand washing and put on clean gloves. LVN A checked Resident #257's wounds on right groin area. LVN A removed gloves and discarded in trash. LVN A used hand sanitizer and put on clean gloves. LVN A used a gauze pad with wound wash on it to blot the center of wound, picking up gauze off the skin, and placing it back on the skin on same gauze, seven times. LVN A place calcium alginate in the wound. LVN A removed dirty gloves and discarded in the trash. LVN A used hand sanitizer and put on clean gloves. LVN A used a clean gauze pad to pad dry the wound on right groin area by blotting with the same gauze five times. LVN A removed gloves and discarded in the trash. LVN A used hand sanitizer and put on clean gloves. LVN A used wound cleanser on a gauze pad to clean the wound on Resident #257's right foot using the blotting method, four times, using the same gauze pad. LVN A used a clean gauze pad and pat dry six times using the same gauze pad. LVN A removed gloves and discarded in the trash. LVN A used hand sanitizer and put on clean gloves. LVN A used wound was on a clean gauze pad to clean wound on right calf by going in horizontal direction back and forth over the wound without lifting the gauze pad, nine times. LVN A used a dry clean gauze to pat dry, five times, using the same gauze pad. LVN A applied calcium alginate to the top of the foot and covered it with bandage with date and initials. LVN A placed calcium alginate on wound on right calf and covered it with bandage with date and initials. LVN A removed gloves and discarded in the trash. LVN A used hand sanitizer and put on clean gloves. LVN A used clean gauze pad with wound wash to clean closed wound on bottom of right foot, going in a horizontal direction, back and forth, six times using the same gauze. LVN A discarded the gauze pad in the trash. LVN A used a dry clean gauze pad to pat dry the right bottom foot by blotting, five times. LVN A discarded the used gauze in the trash. LVN A covered wound on bottom foot with a bandage with date and initials. LVN A discarded gloves in the trash. During an interview with LVN A on 10/10/2024 at 2:18 PM. LVN A stated that it was best that once you lifted off the skin with the gauze to not retouch the skin. LVN A stated that she should have cleaned the skin with one gauze and once she lifted off the skin to discard of the gauze and get a new one. LVN A stated that she should have cleaned in a circular motion from inside the wound to outward. LVN A stated that she was nervous and was not used to being watched. LVN A stated that she had been trained by the wound care education center that the facility used, and she was trained in April 2024. LVN A stated that it was a hands-on training, and it was provided once a year. LVN A stated that the negative potential outcome for not cleaning wounds with correct technique would be dispersing bacteria from inside wound to another area of the skin. During an interview with the DON on 10/11/2024 at 2:55 PM she stated that she expected wound care to be done per policy. The DON stated that LVN A had been trained by the wound care education that came to the facility to teach techniques as well as competency skills checks, annually. The DON stated that the negative potential outcome of not using the correct techniques for wound care would be getting the wound infected. During an interview with the Administrator on 10/11/2024 at 2:37 PM she stated that she expected staff that were cleaning wounds to use a clean gauze and not the same one. The Administrator stated that LVN A should have followed policy for technique. The Administrator stated that LVN A had been trained by a wound care education center for wound care techniques, upon hire and annually. The Administrator stated that the negative potential outcome was spread of infection and poor wound healing. Record Review of facility provided policy, labeled, An Overview of Wound Care, dated July 2018, revealed: Record review of facility policy for wounds did not address the cleaning technique to be used.

Based on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 7 (Resident #1) residents in that: The facility failed to ensure Resident #1 was treated with respect, dignity, and care when they failed to obtain clear informed consent on 8/11/2024 at approximately 3:30 AM, to perform a straight catheter procedure to collect a urine sample. An Immediate Jeopardy (IJ) situation was determined to have existed on 8/11/24. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 8/19/24 and updated 9/4/2024 prior to the beginning of the survey. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. Findings Included : Resident #1 Record review of Resident #1's undated face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of acute kidney failure (kidneys no longer work on their own), muscle weakness (lack of strength), and muscle wasting (thinning of muscle). Record review of Resident #1's MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 13 which indicated Resident #1 was cognitively intact. Section GG- Functional Abilities and goals- Admission, revealed the resident required partial/moderate assistance with toileting hygiene. Section H- Bladder and Bowel revealed Resident #1 was always continent of urinary and bowel and Resident #1 did not have any appliances (indwelling catheters, intermittent catheterization). Record review of Resident #1's care plan dated 8/15/24 revealed Resident #1 was at risk for problems with elimination. The care plan goal reflected, the resident elimination status will be maintained or improved over the next 90 days. Interventions revealed, Assist to toilet as needed. Monitor for signs and symptoms of urinary tract infection. Additionally, the care plan reflected the resident's health condition prior to admission was healthy with no major physical or mental illnesses. Record review of Resident #1's urine analysis collected on 8/9/24 at 2:55PM, revealed a culture result of three or more organisms, probable contamination. Lab result was faxed to the facility on [DATE] at 8:03pm. Lab report revealed a written note New specimen obtained 8/11 signed by LVN B. Record review of Resident #1's urine analysis collected on 8/11/24 at 11:00 AM, revealed a culture result of staphylococcus epidermidis (gram-positive bacteria) and a sensitivity to oxacillin, tetracycline, and vancomycin (medication used to treat bacteria infections). Lab result was faxed to the facility on [DATE] at 12:07pm. Record review of Resident #1's EMR physician orders provided by the DON, dated 9/4/24 revealed, there were no orders located for the straight catheter procedure that occurred on 8/10/24. Record review Resident #1 hospital records dated 8/13/24 revealed a SANE exam was not conducted as there was no indication to conduct the exam. Furthermore, the exam revealed there was mild edema around the urethral meatus (inflammation, swelling and irritation) and that there was no evidence of trauma otherwise and no vaginal tenderness. Record review of Resident #1's EMR physician orders revealed, Order/Start date: 8/13/24. vancomycin 500 mg (antibiotic) intravenous solution 500 Milligram intravenously 2 times per day 7 Days. Dx: Urinary tract infection, site not specified. Order/Start Date Order Time 08/16/24 2 times per day. Vancomycin 500 mg intravenous solution 2 times per day 7 Days Dx: Urinary tract infection, site not specified. Record review revealed Resident #1 was also receiving vancomycin medication for a dx of Unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent encounter. Record review of Resident #1 Trauma informed Observation, dated 8/12/24, revealed the assessment was completed with recommendations of resident wishes/goal, There's no reason to. Oriented to notify staff if when needs to talk and or would like therapy. Oh no I just want to get therapy, go home, see my old dog, she's 15 a [NAME], was electronically signed by [Name] Social Services Director 8/12/24 at 12:23 PM. During an interview with Resident #1 on 9/4/24 at 12:34 PM, Resident #1 stated she believed she had a UTI around 8/9/24, and she had notified the staff. The staff proceeded to test her for the UTI. She stated she was provided a urine collection hat to urinate in for the urine sample. She stated staff told her that the sample could become contaminated due to the urine collection hats not being in a clean environment. She stated for years she had urinated in a little jar for UA tests. She stated Sunday morning, 8/11/24, at approximately 3am, staff had come into her room and did a catheter ,(small, flexible tube that is used to empty urine form the bladder) when she was unconscious. She stated she was asleep and was unconscious (sleeping), and staff had not told her anything until after she had woken up . She stated on 8/11/2024, the nurse, and the aide told her they came in to do a straight catheter to get a urine sample. She stated she had not known the prior urine specimen was contaminated until after they did the straight catheter. Resident #1 stated she was not told until after the procedure had been done. She stated she had never had a catheter in her life, and she had always refused them before. She stated she would have refused and never have consented to a catheter and that she would have preferred to provide a urine sample herself in a cup. She stated staff did not request another sample; they just took it from her. She stated she did not say anything to the nurses because she felt it was not the right time. Resident #1 stated she felt very violated, and she did not think the facility cared too much about her concerns. She stated the procedure was painful and she reported it on 8/12/24 to the ADM and she was sent to the ER for further evaluation. She stated the EDO physician explained she was swollen down there (vaginal area). Resident #1 stated she was in pain and the procedure was painful. Resident #1 stated she reported the incident to the police on 8/12/2024 when the facility called the local police to the facility. Resident #1 stated she did not understand why they could not wait to ask her for the sample during the day or in the morning instead of when she was unconscious. She stated they took a sample that would not have been sent out until late because it was on a Sunday and the lab place was not open until Monday. Resident #1 stated she felt she was taken advantage of, and that the procedure wasn't handled correctly, and that the catheter procedure was unnecessary. She also stated she felt violated, as if she had been raped and was very upset over the whole incident and had continued to be bothered and upset about it since the time it happened. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed there was no documentation by RN D, for Resident #1 reporting pain and discomfort with urination and requesting to be tested for a UTI on 8/9/24 or the days prior to. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed there was no communication between staff and physician for notification of Resident #1's change in condition. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed no documentation by LVN B or RN D's communication with a physician regarding a contaminated urine analysis. Record review of Resident #1's EMR physician orders revealed there was no order for a UA repeat and method of collection on 8/10/24 or 8/11/24. Record review of physician standing orders dated 6/19/2019 for MD revealed the following, Laboratory .54. Fasting Labs Upon Admission: BMP, CBC, U/A, lipid profile. Record review of Police call sheet dated 9/5/24 revealed, Police Sequence #P240807233 as of 9/5/24 11:18:55 . Created: 8/12/24 11:24:58 Entered: 8/12/24 11:57:47 Dispatch: 8/12/24 13:11:46 Enroute: 8/12/24 13:11:49 Onscene: 8/12/24 13:13:49 Closed: 8/12/24 14:07:35 11:54:58 Location: [Facility address], Name: [Redacted], Phone: [Redacted] 11:57:47 Comment: Victim [Redacted] Against a female nurse who went into her room at night/reported advised nurse was doing a procedure to extract urine and victim felt violated. 14:07:27 Comment: I spoke with [Redacted] who advised about 2 nights ago a nurse and a nurse aide woke her up and told her they needed a urine sample. [Redacted] advised she was groggy and still sleepy but advised later they came back in and advised her they put a catheter in to get a clean urine sample. [Redacted] advised she did not authorize a catheter to be put in and she felt violated, but advised she does not remember them even putting the catheter in. I spoke with the Administrator [Redated], who advised there is documentation that the doctor ordered the catheter for [Redacted] advised the nurses chart advised they put the catheter without any complaints from [Redacted], advised the nurse and aide who put the catheter were not at time but advised she would get in contact with them later to see what happened and why [Redacted] would be complaining now. I gave [Redacted] a sequence number for their records. There is clear documentation this was a medical procedure done at the request of the doctor. No crime occurred. 14:07:34 Clear. During an interview on 9/4/24 at 1:30 PM, the DON stated she was on leave when the incident occurred, but she believed the initial urine test was done based on the standing orders the EDO had for admission lab work which includes a urine test. She stated she knew the urine test was redone because the lab said it was contaminated. She stated they always do UA's every morning because the lab staff come in the mornings to draw labs and facility staff draw the UAs in-house. She stated Resident #1's admitting labs were dated on 8/13/24, she had UA lab results dated on 8/9/24. She stated she believed they were the results from a UA test done on 8/5/24, but she was not sure. She stated the rest of the standing order labs were done on 8/14/24. She stated she did not see an order for the UA in the EMR, only for the bloodwork, which were dated 8/14/24. She stated usually when a lab is contaminated, they would send a request to the FNP for a retest and a lot of times they prefer to redo the UA by straight catheter when they come back contaminated because it is cleaner. She stated she had not located an order for the straight catheter procedure. She stated she did not locate any documentation showing that the physician was notified of the straight catheter or that there was an order for the straight catheter. She stated she was not aware of any of those issues until the next day and she had not spoken to the resident. She stated she had not spoken to the nurse about the issue until now because she was not aware of it. She stated she expected for staff to document proper steps. She stated she was not aware if staff were trained how to document properly and the proper steps to take in those situations. She stated the original lab was faxed on 8/9/24 at 4:04 PM, which showed an abnormality, the facility received the contaminated lab results on 8/9/24 at 20:03 PM (8:03 PM). She stated the evening shift (2 PM-10 PM) would have been responsible to take care of it. She stated she had not seen any documentation that the evening shift took care of it. She stated it was not typical for a staff to do a procedure like that at 3:00 AM because residents were asleep, and it was not okay to take samples at that time because residents may not be clear on what was going on because they were in a dead sleep. She stated the UA recollection should have been done close to the time the fax was received between 8:00 PM-10:00 PM. She did not know why the culture was not done during the 2PM/10PM shift. She stated a potential negative outcome could be that the resident may not completely understand what was going on which could cause them to have felt something inappropriate went on. She stated the resident was not aware of what staff were doing which could make them think something else could be going on. She stated typically staff would have explained to the resident that the doctor ordered a straight catheter as well as explain why it is needed, which is how staff typically obtain consent from residents. She stated consent for straight cath procedures were obtained verbally from the resident and a lot of the time residents say no and the physician are then notified. She stated there should have been progress notes of communication with physician and verbal orders should have been documented in the EMR. She stated she never spoke to the resident because she had already been assessed and it was the end of the situation when she returned to work. DON stated the facility did in-service staff on abuse/neglect, customer services, resident rights, and for staff to explain the procedure before they start. During an interview on 9/4/24 at 4:03 PM, the ADM stated on 8/12/2024, she was told Resident #1 wanted to speak with her. The ADM stated Resident #1 told her she wanted to speak to her about an incident she was concerned about. The ADM stated Resident #1 told her she peed in a cup and was told the test came back contaminated. She stated Resident #1 told her that staff came in to repeat the UA and that it was at night and said, I felt I was raped. The ADM stated she explained that a straight catheter went into the urethra (hollow tube that lets urine, a waste product, leave the body) and asked Resident #1 if something went into her vagina, and she said she did not know. She stated Resident #1 said she would not have wanted a straight catheter. The ADM stated she told Resident #1 she would report it. She stated she called law enforcement and reported the incident to HHS. She stated they completed a skin assessment and there were no findings. She stated Resident #1 was sent to the hospital and asked for a rape kit, but the rape kit was not done due to the information Resident #1 provided to hospital staff about the incident during that examination. She stated Resident #1 stated she understood she was not raped and just did not want a catheter done and said she would have refused it. She stated she spoke to LVN B who said she was passed on report from RN D who told her the test was contaminated and that it needed to be repeated. She stated CNA A went in with LVN B because she wanted a second person for help in case the bed needed to be changed. The ADM stated both LVN B and CNA A said Resident #1 was awake and asked questions during the procedure, and that LVN B explained the procedure. She stated she was told Resident #1 tolerated the procedure without any issue and she appeared to be awake. She stated she was told Resident #1 said ouch, but that was all. She stated she was told Resident #1 had not expressed having an issue with the procedure. She stated RN D reached out to the FNP who gave the order to repeat the UA. She stated there should be an order to do a straight catheter. She stated consent was typically obtained by a resident verbally after the procedure was explained to them. She stated she thought [LVN B] did the procedure at 3:30 AM because she was trying to get it done before her shift ended. She stated it was typical to get a straight catheter sample to prevent getting another contaminated sample. She stated it could have delayed treatment if another contaminated sample was received. She stated staff called physicians or talked to them in person when they were in the building to obtain orders and that there should have been a progress note in the record when orders were received or documented in the 24-hour report. During an interview on 9/4/24 at 5:57 PM, the EDO stated he would have been fine with a resident providing their own urine sample when they were able to but would want the urine sample to be obtained by a straight catheter for residents who were unable to provide a urine sample on their own. He stated he felt nurses would know the best way to obtain the sample. He stated he believed the FNP was contacted about the UA orders for Resident #1. He stated he was aware Resident #1 reported feeling abused and violated by the straight catheter procedure and that she was sent to the emergency room for an examination. He stated after speaking with Resident #1, she realized she was not assaulted but insisted she did not like the way it was handled. He stated he was not sure if he saw Resident #1 afterwards. He stated he was not aware staff completed the straight catheter procedure on Resident #1 at 3:30 AM. He stated he hoped staff would not do a straight catheter procedure on a resident at that time of night. During an interview on 9/4/24 at 11:38 PM, CNA A stated LVN B asked her to help her get a urine sample from Resident #1, on 8/10/2024 after she arrived for the night shift but could not recall the exact time. She stated they got supplies together to go see Resident #1. She stated Resident #1 was asleep when they entered her room. She stated the dim lights were on in the room when they entered, and they turned the big light on during the procedure. She stated she asked Resident #1 to wake up and Resident #1 hummed like she did not want to wake up. CNA A stated she stayed in the room the whole time. She stated LVN B stepped out to get a collection bag. CNA A stated she had spoken to Resident #1 because she was still kind of knocked out (drowsy, did not stay awake, continued to fall back asleep). CNA A stated she asked Resident #1 if she needed water or anything else, and she said no. She stated then LVN B reentered the room. She stated Resident #1 asked what was going on and LVN B explained she needed a clean urine sample, Resident #1 replied that she already gave one, and then LVN B explained it was not a clean sample and they needed another one. CNA A stated Resident #1 said, Well I guess., then she undid the straps on the brief, and she wiped Resident #1 front to back. CNA A stated Resident #1's brief was dry when she undid the brief straps. She stated then LVN B wiped the area with a cotton swab that had alcohol/brown liquid on it. She stated she could not recall if LVN B told Resident #1 she was going to clean her with the cotton swab, but she did recall that LVN B told Resident #1 she was going to feel some pressure. She stated LVN B inserted the catheter and got the urine sample, removed the catheter, and completed her part. She stated Resident #1's eyes were open during the procedure, and she watched what was going on. She stated Resident #1 loudly said ouch when the catheter went in, and LVN B told her she had to insert a catheter to get a sample. CNA A stated LVN B did not explain where she was going to insert the catheter to get the sample. She stated after the procedure was over Resident #1 said, I guess this was a rude awakening. and she told Resident #1 she was sorry. She stated LVN B said, Sorry but it needed to be done. She stated there were no other words said between Resident #1 and LVN B after that. CNA A stated she stayed about five minutes to clean after LVN B stepped out. CNA A stated she put a clean brief on Resident #1 and picked up trash. She stated she changed the brief because it had dye and other stuff on it. She stated Resident #1 woke up after LVN B left. She stated Resident #1 was upset afterwards and said she felt like it was rude of them to go in at that time of night. She stated she checked on Resident #1 that shift a few more times and Resident #1 expressed it was rude each time she went into her room. CNA A stated she told LVN B that Resident #1 was upset and LVN B told her she would chart what all happened. CNA A stated she could not say if doing the procedure at 3:30 AM was not a good time. CNA A stated she saw Resident #1 right before she left her shift and Resident #1 told her she was not able to go back to sleep because she was mad and said it was rude of them to go in there and get the sample and she had not slept much because they woke her up. She stated Resident #1 did not express having pain afterwards. CNA A stated during the procedure, she held a box to make sure they didn't get urine on the bed sheet, and she did not assist with the straight catheter procedure. She stated Resident #1 always wore a brief at night but was not sure if she wore one during the day, but she knew Resident #1 went to the bathroom during the day. She stated Resident #1 had about four brief changes at night. She stated sometimes Resident #1 used the call light to request her brief be changed but sometimes her brief was wet during brief checks. CNA A stated the DON told her she needed to come in and speak with her and the ADM about the incident. CNA A stated she was suspended for a day because Resident #1 made allegations of being raped. CNA A stated no one expected have a catheter inserted in the middle of night. CNA A stated she also assisted LVN B during another straight catheter procedure that night with another female resident on hall 200 that was Spanish speaking. She stated she translated information between the resident and LVN B and translated the catheter process to that resident during the procedure. CNA A stated that procedure was before the procedure with Resident #1. She stated that resident was sitting on the side of her bed when they entered the room and said she needed to pee but could not go. She stated LVN B got the UA sample, and she cleaned the resident afterwards. CNA A provided information on recent in-service received on abuse/neglect, resident rights, customer service after the incident with Resident #1, and abuse/neglect, resident rights, customer service after the incident with Resident #2. Record Review of an undated written statement provided by the facility of a statement given by CNA A revealed, [LVN B] asked me to go with her to help with the supplies while she was doing a straight catheter on [Resident #1]. [Resident #1] was asleep, and she woke her and said we have to get a sample from you. I made sure that she was awake. Resident #1 said she had already given a sample and asked why we needed another sample. [LVN B] explained it was contaminated and needed to redo it. [LVN B] prepped and completed the procedure, [LVN B] was explaining the whole time to [Resident #1] what was going on. [Resident #1] asked a few questions and was awake during the procedure. [Resident #1] said that it was painful at the time of the procedure. Throughout the night I continued to round on her, and she asked for water which I provided, she continued to thank me throughout the shift. During an interview on 9/5/24 at 12:25 AM, LVN B stated she arrived for her shift that night around 9:45 PM on 8/10/2024 and got report from RN D, who was the off-going nurse. She stated RN D told her Resident #1's urine test was contaminated, and they needed another specimen. LVN B stated she confirmed with RN D that Resident #1 was incontinent at night but could not recall if they discussed in report about doing a catheter. LVN B stated she remembered seeing the lab slip and that it said the specimen was contaminated, but she could not remember if the slip said to recollect a urine sample or if there was an order on the lab slip. LVN B stated she could not remember if RN D told her he spoke to anyone about the lab. LVN B stated she told CNA A they needed to collect a specimen and asked when she was doing care on Resident #1 so they could do the straight catheter procedure at the same time. She stated it was easier to have a CNA present to facilitate the process. She stated lab staff came every day any time after 5:00 AM to pick up specimens, so she was trying to get it done before then. LVN B stated Resident #1 was asleep when they entered her room, so they woke her up. She stated she explained to Resident #1 she was there to do the straight catheter procedure to get a urine sample and Resident #1 replied that she had already done one. She stated Resident #1 asked why she could not do it on the toilet, and she explained they needed a clean sample. LVN B stated she did not recall if Resident #1 had any other questions after that. LVN B stated she told Resident #1 that the UA was contaminated, and they needed another specimen. LVN B stated Resident #1 did not say anything to her after that, so she began the procedure. LVN B stated she explained to Resident #1 that she was going to put a tube in her. She stated Resident #1 said ouch, so she stopped and asked if she was okay, Resident #1 said yes, so she collected the specimen and completed the procedure, and then her brief was changed by CNA A. LVN B stated again she did not remember Resident #1 saying anything after she explained the procedure. She stated she felt she got informed consent from Resident #1 to complete the procedure because Resident #1 was cooperative during the procedure by spreading her legs when asked and Resident #1 allowed her to do the pre-cleaning without any issues. She stated Resident #1 also did not refuse the procedure when she told her about it, or she would not have done it. She stated she explained to Resident #1 every time she was going to do something and told her it would be uncomfortable. She stated she did the straight catheter procedure because Resident #1 was incontinent and symptomatic by complaining of not feeling well. LVN B stated Resident #1 had lab work done as well, and she believed they did the lab work when they did the first UA. She stated the facility did admission labs when residents first came in. LVN B stated she did not ask Resident #1 if she wanted to provide a urine sample by urine collection hat because she was incontinent at night and because the previous sample that was collected in that manner was contaminated and she wanted a clean specimen. LVN B stated part of the consent was verbal and part of it was demeanor. She stated Resident #1 responded to what she asked her to do and did not state she did not want to do it. She stated she did not know if residents had to say the exact words I agree, or I refuse. She stated, If they don't agree but they cooperate .I recall her saying okay and being aware of what we were doing. If she had said don't do that, then I wouldn't have done it. I believe she consented. She stated she felt Resident #1 was fully awake during the procedure because Resident #1 cooperated when she asked her to do things, such as scoot her bottom down and then spread her legs. LVN B stated she did not recall if there was any other conversation during the process. LVN B stated Resident #1 did not say anything afterwards and she left. LVN B stated later during the shift, she went to give Resident #1 some medication and Resident #1 asked LVN B why she did that to her and LVN B explained to Resident #1 that the previous test was contaminated, and they needed to get another urine sample and Resident #1 said okay. LVN B stated she did not call the FNP to get orders to perform the straight catheter procedure on Resident #1 because she was under the impression from report given to her by RN D that there was a physician's orders for the collection of the urine specimen from Resident #1, but she did not check to verify if there were orders. LVN B stated staff were supposed to have orders before doing an invasive procedure like that. She stated the order usually specified the way the urine specimen was collected, but she would clarify if that information was not written on the order. She stated she did not recall if RN D told her there was an order in the chart. She stated she was trained to verify orders before performing a procedure. LVN B stated, I don't guess I did that day. I do not remember seeing any physician orders. I don't recall if [RN D] told me he had notified the physician or if he had gotten an order. I just knew that I needed to collect a UA through the conversation with [RN D]. She stated no one told her that day that Resident #1 was upset. She stated she did not remember if the ADM or the DON spoke to her about the incident. She stated she was told Resident #1 was sent for a medical exam. She stated she did not recall if she was told the reason for the exam. She stated she was off the next day. She stated she went into the facility and explained the procedure to the ADM and the DON. She stated she did not recall if they told her the incident was reported. She stated she was suspended for one day so they could investigate things, but it was her day off, so she did not miss any scheduled work. She stated when she returned to work the nurse giving report told her Resident #1 was upset because of the procedure that had been done collecting the UA. She stated then Resident #1 confronted her again and asked why she did the procedure and asked who told her to do it. She stated she told Resident #1 she had been told they needed another sample and it needed to be recollected by a catheter. She stated Resident #1 told her she usually provided the sample in a cup and that she was upset, and she told Resident #1 that the sample was contaminated. LVN B stated she told Resident #1 she was sorry she felt that way. LVN B stated Resident #1 never told her she did not want to see her again and she continued to provide care to Resident #1 while she was at the facility. LVN B stated she was not aware of anything being inserted into the vaginal canal during the procedure. LVN B stated Resident #1 was easy to catheterize anatomically and that she wiped her with betadine. LVN B stated she believed the initial urine sample was done because it was an admission thing and because she was also having symptoms. She stated admission labs were usually done by the night shift; therefore, the initial urine test was not done timely. LVN B stated she had received training on abuse and neglect and informed consent, but she did not remember when because most of the training is done on the computer. LVN B stated they had been told that at night, not to send stuff to the FNP's if it was not critical, she would fax or send a picture to them, and then document a nurse note of what the item was and what the response was. LVN B stated she had been stressed about work and did not remember time well. LVN B stated she did not recall doing another straight catheter procedure that night. She stated she had another resident she needed to do a straight catheter procedure on, but she ran out of time and was not able to do it. LVN B provided information on recent in-service received on abuse/neglect, resident rights, customer service, explaining procedure, obtaining consent prior to a procedure after the incident with Resident #1, and abuse/neglect, resident rights, customer service after the incident with Resident #2. Record Review of an undated written statement provided by the facility of a statement given by LVN B revealed, When I came on shift there was a report on the fax machine that [Resident #1's ] UA was contaminated. In verbal report from [RN D], I knew that she needed it collected again. During the day she is continent and at night she's fully incontinent and she doesn't communicate when she is wet. So, I knew that I needed to do a straight catheter due to the fact that the first UA was contaminated and that she is incontinent at night. [CNA A] and I went in together so that she could help me. I always bring a CNA with me so that she wouldn't have to change the whole bed afterwards if I didn't get the urine into the cup. We went in and woke her up to do the procedure, she was somewhat drowsy, but she was talking to us. I explained that we needed to get a UA she said we already got one earlier and she said it came back contaminated, so we needed to do a straight cath. LVN B showed her the

Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 7 residents (Resident #1 and Resident #2) reviewed for abuse in that: 1. The facility staff failed to protect Resident #1 from abuse when staff woke up the resident at approximately 3:30 AM on 8/11/24 and performed an invasive straight catheter procedure which caused Resident #1 physical pain and mental anguish, and Resident #1 reported she felt violated, traumatized, abused, and raped. 2. The facility failed to protect Resident #2 from verbal abuse from CNA C, when CNA C continued call Resident #2 names and belittle him and made a threat to do it again (call him names), at the nurse's station after being told to stop. An Immediate Jeopardy (IJ) situation was determined to have existed on 8/11/24. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 8/29/24, updated 9/4/24 prior to beginning of the survey. These failures could place residents at risk of physical harm, mental anguish, and emotional distress. Findings Included: 1. Resident #1 Record review of Resident #1's undated face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of acute kidney failure (kidneys no longer work on their own), muscle weakness (lack of strength), and muscle wasting (thinning of muscle). Record review of Resident #1's MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 13 which indicated Resident #1 was cognitively intact. Section GG- Functional Abilities and goals- Admission, revealed the resident required partial/moderate assistance with toileting hygiene. Section H- Bladder and Bowel revealed Resident #1 was always continent of urinary and bowel and Resident #1 did not have any appliances (indwelling catheters, intermittent catheterization). Record review of Resident #1's care plan dated 8/15/24 revealed Resident #1 was at risk for problems with elimination. The care plan goal reflected, the resident elimination status will be maintained or improved over the next 90 days. Interventions revealed, Assist to toilet as needed. Monitor for signs and symptoms of urinary tract infection. Additionally, the care plan reflected the resident's health condition prior to admission was healthy with no major physical or mental illnesses. During an interview on 9/4/24 at 12:34 PM, Resident #1 stated she believed she had a UTI around 8/9/24, and she had notified the staff. The staff proceeded to test her for the UTI. She stated she was provided a urine collection hat to urinate in for the urine sample. She stated staff told her that the sample could become contaminated due to the urine collection hats not being in a clean environment. She stated for years she had urinated in a little jar for UA tests. She stated Sunday morning, 8/11/24, at approximately 3am, staff had come into her room and did a catheter ,(small, flexible tube that is used to empty urine form the bladder) when she was unconscious. She stated she was asleep and was unconscious (sleeping), and staff had not told her anything until after she had woken up . She stated on 8/11/2024, the nurse, and the aide told her they came in to do a straight catheter to get a urine sample. She stated she had not known the prior urine specimen was contaminated until after they did the straight catheter. Resident #1 stated she was not told until after the procedure had been done. She stated she had never had a catheter in her life, and she had always refused them before. She stated she would have refused and never have consented to a catheter and that she would have preferred to provide a urine sample herself in a cup. She stated staff did not request another sample; they just took it from her. She stated she did not say anything to the nurses because she felt it was not the right time. Resident #1 stated she felt very violated, and she did not think the facility cared too much about her concerns. She stated the procedure was painful and she reported it on 8/12/24 to the ADM and she was sent to the ER for further evaluation. She stated the EDO physician explained she was swollen down there (vaginal area). Resident #1 stated she was in pain and the procedure was painful. Resident #1 stated she reported the incident to the police on 8/12/2024 when the facility called the local police to the facility. Resident #1 stated she did not understand why they could not wait to ask her for the sample during the day or in the morning instead of when she was unconscious. She stated they took a sample that would not have been sent out until late because it was on a Sunday and the lab place was not open until Monday. Resident #1 stated she felt she was taken advantage of, and that the procedure wasn't handled correctly, and that the catheter procedure was unnecessary. She also stated she felt violated, as if she had been raped and was very upset over the whole incident and had continued to be bothered and upset about it since the time it happened. Record review of a police call sheet dated 9/5/24 revealed, Police Sequence #P240807233 as of 9/5/24 11:18 AM: Created: 8/12/24 11:24:58 Entered: 8/12/24 11:57:47 Dispatch: 8/12/24 13:11:46 Enroute: 8/12/24 13:11:49 On scene: 8/12/24 13:13:49 Closed: 8/12/24 14:07:35 11:54:58 Location: [Facility address], Name: [Redacted], Phone: [Redacted] 11:57:47 Comment: Victim [Redacted] Against a female nurse who went into her room at night/reported advised nurse was doing a procedure to extract urine and victim felt violated. 14:07:27 Comment: I spoke with [Redacted] who advised about 2 nights ago a nurse and a nurse aide woke her up and told her they needed a urine sample. [Redacted] advised she was groggy and still sleepy but advised later they came back in and advised her they put a catheter in to get a clean urine sample. [Redacted] advised she did not authorize a catheter to be put in and she felt violated, but advised she does not remember them even putting the catheter in. I spoke with the Administrator [Redated], who advised there is documentation that the doctor ordered the catheter for [Redacted] advised the nurses chart advised they put the catheter without any complaints from [Redacted], advised the nurse and aide who put the catheter were not at time but advised she would get in contact with them later to see what happened and why [Redacted] would be complaining now. I gave [Redacted] a sequence number for their records. There is clear documentation this was a medical procedure done at the request of the doctor. No crime occurred. 14:07:34 Clear. Record review of Resident #1's EMR physician's orders provided by the DON, dated 9/4/24 revealed, there were no orders located for the straight catheter procedure that occurred on 8/11/24. There were no orders for nighttime medications that would induce sleep. Record review of Resident #1 Trauma informed Observation, dated 8/12/24, revealed the assessment was completed with recommendations of resident wishes/goal, There's no reason to. Oriented to notify staff if or when needs to talk and or would like therapy. Oh no I just want to get therapy, go home, see my old dog, she's 15 a [NAME], was electronically signed by [Name] Social Services Director 8/12/24 at 12:23 PM. Record review Resident #1 hospital records dated 8/13/24 revealed a SANE exam was not conducted as there was no indication to conduct the exam. Furthermore, the exam revealed there was mild edema (inflammation, swelling and irritation) around the urethral meatus (opening that allows urine to exit the body) and that there was no evidence of trauma otherwise and no vaginal tenderness. During an interview on 9/4/24 at 1:30 PM, the DON stated she was on leave when the incident occurred with Resident #1 on 8/11/2024, but she believed the initial urine test was done based on the standing orders the EDO had for admission lab work which included a urine test. She stated she knew the urine test was redone because the lab said it was contaminated. She stated they always did UAs every morning because the lab staff came in the mornings to draw labs and facility staff drew the UAs in-house. She stated Resident #1's admitting labs were dated on 8/13/24, she had UA lab results dated on 8/9/24. She stated she believed they were the results from a UA test done on 8/5/24, but she was not sure. She stated the rest of the standing order labs were done on 8/14/24. She stated she did not see an order for the UA in the EMR, only for the bloodwork, which was dated 8/14/24. She stated usually when labs are contaminated, they would send a request to the FNP for a retest and a lot of times they prefer to redo the UA by straight catheter when they come back contaminated because it was cleaner. She stated she had not located an order for the straight catheter procedure. She stated she had not located any documentation showing that the physician was notified of the straight catheter or that there was an order for the straight catheter. The DON stated she was not aware of concerns Resident #1 voiced, until the next day 8/12/2024, and she had not spoken to the resident. The DON stated the ADM had spoken to Resident #1 and she was not at the facility because she had been sent to the ED. She stated she had not spoken to the nurse about the issue of the orders not received or documented, until now because she was not aware of it. She stated she expected for staff to document the proper steps. She stated she was not aware if staff were trained how to document properly and the proper steps to take in those situations (documented orders, care, consent). She stated the original lab was faxed to the facility on [DATE] at 4:04 PM, which showed an abnormality, the facility received the contaminated lab results on 8/9/24 at 20:03 PM (8:03 PM). She stated the evening shift (2 PM-10 PM) would have been responsible to take care of it. She stated she did not see any documentation that the evening shift took care of it. She stated it was not typical for a staff to do a procedure like that at 3:00 AM because residents were asleep, and it was not okay to take samples at that time because residents may not be clear on what was going on because they were in a dead sleep. She stated the UA recollection should have been done close to the time the fax was received between 8:00 PM-10:00 PM. She did not know why the culture was not done during the 2PM/10PM shift. She stated a potential negative outcome could be that the resident may not completely understand what was going on which could cause them to have felt something inappropriate went on. She stated the resident was not aware of what staff were doing which could make them think something else could be going on. She stated typically staff would have explained to the resident that the doctor ordered a straight catheter as well as explain why it is needed, which is how staff typically obtain consent from residents. She stated consent for straight cath procedures were obtained verbally from the resident and a lot of the time residents say no and the physician are then notified. She stated there should have been progress notes of communication with physician and verbal orders should also be documented in the EMR. She stated she never spoke to the resident because she had already been assessed and it was the end of the situation when she returned to work. She stated the facility started in-service with staff on abuse/neglect, resident rights, customer service, and explaining procedure before you start. During an interview on 9/4/24 at 4:03 PM, the ADM stated on 8/12/2024, she was told Resident #1 wanted to speak with her. The ADM stated when she went to speak with Resident #1, they both realized they knew each other from years ago when Resident #1's family member lived at a facility the ADM previously worked at. The ADM stated Resident #1 mentioned she was previously at another nursing home for rehabilitation services that the ADM was the ADM at, and they discussed how they did not have any contact with each other at that facility. The ADM stated Resident #1 told her she wanted to speak to her about an incident she was concerned about. The ADM stated Resident #1 told her she peed in a cup and was told the test came back contaminated. She stated Resident #1 told her that staff came in to repeat the UA and that it was at night and said, I felt I was raped. The ADM stated she explained that a straight catheter went into the urethra (hollow tube that lets urine, a waste product, leave the body) and asked Resident #1 if something went into her vagina, and she said she did not know. She stated Resident #1 said she would not have wanted a straight catheter. The ADM stated she told Resident #1 she would report it. She stated she called law enforcement and reported the incident to HHS. She stated they completed a skin assessment and there were no findings. She stated Resident #1 was sent to the hospital and asked for a rape kit, but the rape kit was not done due to the information Resident #1 provided to hospital staff about the incident during that examination. She stated Resident #1 stated she understood she was not raped and just did not want a catheter done and said she would have refused it. She stated she spoke to LVN B who said she was passed on report from RN D who told her the test was contaminated and that it needed to be repeated. She stated CNA A went in with LVN B because she wanted a second person for help in case the bed needed to be changed. The ADM stated both LVN B and CNA A said Resident #1 was awake and asked questions during the procedure, and that LVN B explained the procedure. She stated she was told Resident #1 tolerated the procedure without any issue and she appeared to be awake. She stated she was told Resident #1 said ouch, but that was all. She stated she was told Resident #1 had not expressed having an issue with the procedure. She stated RN D reached out to the FNP who gave the order to repeat the UA. She stated there should be an order to do a straight catheter. She stated consent was typically obtained by a resident verbally after the procedure was explained to them. She stated she thought [LVN B] did the procedure at 3:30 AM because she was trying to get it done before her shift ended. She stated it was typical to get a straight catheter sample to prevent getting another contaminated sample. She stated it could have delayed treatment if another contaminated sample was received. She stated staff called physicians or talked to them in person when they were in the building to obtain orders and that there should have been a progress note in the record when orders were received or documented in the 24-hour report. During an interview on 9/4/24 at 4:17pm, RN D stated he received the lab report of the contaminated urine sample for Resident #1 the evening of near the end of his shift on 8/10/2024. He stated it had been a busy shift so at the end of the shift he told the oncoming nurse, LVN B, that he had not had time to report the lab and asked her to follow up on it. He stated he asked LVN B to notify the FNP. RN D stated he never spoke to the FNP on 8/10/24 and delegated it to LVN B. He stated he believed he collected the first UA sample via urine collection hat that came back contaminated. He stated Resident #1 complained of burning and discomfort during urination, so he had notified the FNP on 8/09/2024. He stated at that same time he noticed the admitting labs had not been completed and the FNP stated okay, so he went ahead and did the UA. RN D stated Resident #1 was very modest and did not like the male nurses to assist her. He stated she was adamant that she used the urine collection hat to provide the sample as that was how they usually collected her urine. RN D stated in his experience the urine collection hat often resulted in an anomaly. He stated he told Resident #1 if the sample came back contaminated, they may have to do a straight catheter. He stated Resident #1 said okay at that time, but he didn't think too much about it. He stated he did not remember if he had put a progress note in the EMR about her having the urinary discomfort. He stated the nurse who admitted the resident was responsible for initiating the admission labs. He stated all communication should have been documented in the progress notes to protect themselves, especially if it was a new order. He stated if he had reported the contaminated lab to the FNP, they probably would have said to do a straight catheter. He stated if he could not get ahold of the FNP, he would have waited until he received an order. He stated he would not have gone outside of his scope of practice. RN D provided information on recent in-service received on abuse/neglect, resident rights, customer service, and explaining procedure before you start, after the incident with Resident #1 and Resident #2. Record review of Resident #1's urine analysis collected on 8/9/24 at 2:55PM, revealed a culture result of three or more organisms, probable contamination. The lab result was faxed to the facility on [DATE] at 8:03pm. The lab report revealed a written note New specimen obtained 8/11, signed by LVN B. Record review of Resident #1's urine analysis collected on 8/11/24 at 11:00 AM, revealed a culture result of staphylococcus epidermidis (gram-positive bacteria) and a sensitivity to oxacillin, tetracycline, and vancomycin (medications used to treat bacterial infections). The lab result was faxed to the facility on [DATE] at 12:07pm. Record review of Resident #1's EMR physician orders revealed, Order/Start date: 8/13/24. vancomycin 500 mg (antibiotic) intravenous solution 500 Milligram intravenously 2 times per day 7 Days Dx: Urinary tract infection, site not specified. Order/Start Date Order Time 08/16/24 2 times per day. Vancomycin 500 mg (antibiotic) intravenous solution 2 times per day 7 Days Dx: Urinary tract infection, site not specified. Record review revealed Resident #1 was also receiving vancomycin medication for a dx of Unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity (space in the abdomen that contains the stomach, liver and intestines) subsequent encounter. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed, there was no documentation by RN D, for Resident #1 reporting pain and discomfort with urination and requesting to be tested for a UTI on 8/9/24 or the days prior to. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed, there was no documented communication between staff and physician for notification of Resident #1's change in condition. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed no documentation by LVN B or RN D's communication with a physician regarding a contaminated urine analysis. Record review of Resident #1's EMR physician's orders revealed, there was no order for a UA repeat and method of collection on 8/10/24 or 8/11/24. Record review of the physician's standing orders dated 6/19/2019 for the MD revealed the following, Laboratory .54. Fasting Labs Upon Admission: BMP, CBC, U/A, lipid profile. During an interview on 9/4/24 at 5:57 PM, the EDO stated he would have been fine with a resident providing their own urine sample when they were able to but would want the urine sample to be obtained by a straight catheter for residents who were unable to provide a urine sample on their own. He stated he felt nurses would know the best way to obtain the sample. He stated he believed the FNP was contacted about the UA orders for Resident #1. He stated he was aware Resident #1 reported feeling abused and violated by the straight catheter procedure and that she was sent to the emergency room for an examination. He stated after speaking with Resident #1, she realized she was not assaulted but insisted she did not like the way it was handled. He stated he was not sure if he saw Resident #1 afterwards. He stated he was not aware staff completed the straight catheter procedure on Resident #1 at 3:30 AM. He stated he hoped staff would not do a straight catheter procedure on a resident at that time of night. During an interview with CNA A on 9/4/24 at 11:38 PM, CNA A stated LVN B asked her to help her get a urine sample from Resident #1, on 8/10/2024 after she arrived for the night shift but could not recall the exact time. She stated they got supplies together to go see Resident #1. She stated Resident #1 was asleep when they entered her room. She stated the dim lights were on in the room when they entered, and they turned the big light on during the procedure. She stated she asked Resident #1 to wake up and Resident #1 hummed like she did not want to wake up. CNA A stated she stayed in the room the whole time. She stated LVN B stepped out to get a collection bag. CNA A stated she had spoken to Resident #1 because she was still kind of knocked out (drowsy, did not stay awake, continued to fall back asleep). CNA A stated she asked Resident #1 if she needed water or anything else, and she said no. She stated then LVN B reentered the room. She stated Resident #1 asked what was going on and LVN B explained she needed a clean urine sample, Resident #1 replied that she already gave one, and then LVN B explained it was not a clean sample and they needed another one. CNA A stated Resident #1 said, Well I guess., then she undid the straps on the brief, and she wiped Resident #1 front to back. CNA A stated Resident #1's brief was dry when she undid the brief straps. She stated then LVN B wiped the area with a cotton swab that had alcohol/brown liquid on it. She stated she could not recall if LVN B told Resident #1 she was going to clean her with the cotton swab, but she did recall that LVN B told Resident #1 she was going to feel some pressure. She stated LVN B inserted the catheter and got the urine sample, removed the catheter, and completed her part. She stated Resident #1's eyes were open during the procedure, and she watched what was going on. She stated Resident #1 loudly said ouch when the catheter went in, and LVN B told her she had to insert a catheter to get a sample. CNA A stated LVN B did not explain where she was going to insert the catheter to get the sample. She stated after the procedure was over Resident #1 said, I guess this was a rude awakening. and she told Resident #1 she was sorry. She stated LVN B said, Sorry but it needed to be done. She stated there were no other words said between Resident #1 and LVN B after that. CNA A stated she stayed about five minutes to clean after LVN B stepped out. CNA A stated she put a clean brief on Resident #1 and picked up trash. She stated she changed the brief because it had dye and other stuff on it. She stated Resident #1 woke up after LVN B left. She stated Resident #1 was upset afterwards and said she felt like it was rude of them to go in at that time of night. She stated she checked on Resident #1 that shift a few more times and Resident #1 expressed it was rude each time she went into her room. CNA A stated she told LVN B that Resident #1 was upset and LVN B told her she would chart what all happened. CNA A stated she could not say if doing the procedure at 3:30 AM was not a good time. CNA A stated she saw Resident #1 right before she left her shift and Resident #1 told her she was not able to go back to sleep because she was mad and said it was rude of them to go in there and get the sample and she had not slept much because they woke her up. She stated Resident #1 did not express having pain afterwards. CNA A stated during the procedure, she held a box to make sure they didn't get urine on the bed sheet, and she did not assist with the straight catheter procedure. She stated Resident #1 always wore a brief at night but was not sure if she wore one during the day, but she knew Resident #1 went to the bathroom during the day. She stated Resident #1 had about four brief changes at night. She stated sometimes Resident #1 used the call light to request her brief be changed but sometimes her brief was wet during brief checks. CNA A stated the DON told her she needed to come in and speak with her and the ADM about the incident. CNA A stated she was suspended for a day because Resident #1 made allegations of being raped. CNA A stated no one expected have a catheter inserted in the middle of night. CNA A stated she also assisted LVN B during another straight catheter procedure that night with another female resident on hall 200 that was Spanish speaking. She stated she translated information between the resident and LVN B and translated the catheter process to that resident during the procedure. CNA A stated that procedure was before the procedure with Resident #1. She stated that resident was sitting on the side of her bed when they entered the room and said she needed to pee but could not go. She stated LVN B got the UA sample, and she cleaned the resident afterwards. CNA A provided information on recent in-service received on abuse/neglect, resident rights, customer service after the incident with Resident #1, and abuse/neglect, resident rights, customer service after the incident with Resident #2. Record Review of an undated written statement provided by the facility of a statement given by CNA A revealed, [LVN B] asked me to go with her to help with the supplies while she was doing a straight catheter on [Resident #1]. [Resident #1] was asleep, and she woke her and said we have to get a sample from you. I made sure that she was awake. Resident #1 said she had already given a sample and asked why we needed another sample. [LVN B] explained it was contaminated and needed to redo it. [LVN B] prepped and completed the procedure, [LVN B] was explaining the whole time to [Resident #1] what was going on. [Resident #1] asked a few questions and was awake during the procedure. [Resident #1] said that it was painful at the time of the procedure. Throughout the night I continued to round on her, and she asked for water which I provided, she continued to thank me throughout the shift. During an interview on 9/5/24 at 12:25 AM, LVN B stated she arrived for her shift that night around 9:45 PM on 8/10/2024 and got report from RN D, who was the off-going nurse. She stated RN D told her Resident #1's urine test was contaminated, and they needed another specimen. LVN B stated she confirmed with RN D that Resident #1 was incontinent at night but could not recall if they discussed in report about doing a catheter. LVN B stated she remembered seeing the lab slip and that it said the specimen was contaminated, but she could not remember if the slip said to recollect a urine sample or if there was an order on the lab slip. LVN B stated she could not remember if RN D told her he spoke to anyone about the lab. LVN B stated she told CNA A they needed to collect a specimen and asked when she was doing care on Resident #1 so they could do the straight catheter procedure at the same time. She stated it was easier to have a CNA present to facilitate the process. She stated lab staff came every day any time after 5:00 AM to pick up specimens, so she was trying to get it done before then. LVN B stated Resident #1 was asleep when they entered her room, so they woke her up. She stated she explained to Resident #1 she was there to do the straight catheter procedure to get a urine sample and Resident #1 replied that she had already done one. She stated Resident #1 asked why she could not do it on the toilet, and she explained they needed a clean sample. LVN B stated she did not recall if Resident #1 had any other questions after that. LVN B stated she told Resident #1 that the UA was contaminated, and they needed another specimen. LVN B stated Resident #1 did not say anything to her after that, so she began the procedure. LVN B stated she explained to Resident #1 that she was going to put a tube in her. She stated Resident #1 said ouch, so she stopped and asked if she was okay, Resident #1 said yes, so she collected the specimen and completed the procedure, and then her brief was changed by CNA A. LVN B stated again she did not remember Resident #1 saying anything after she explained the procedure. She stated she felt she got informed consent from Resident #1 to complete the procedure because Resident #1 was cooperative during the procedure by spreading her legs when asked and Resident #1 allowed her to do the pre-cleaning without any issues. She stated Resident #1 also did not refuse the procedure when she told her about it, or she would not have done it. She stated she explained to Resident #1 every time she was going to do something and told her it would be uncomfortable. She stated she did the straight catheter procedure because Resident #1 was incontinent and symptomatic by complaining of not feeling well. LVN B stated Resident #1 had lab work done as well, and she believed they did the lab work when they did the first UA. She stated the facility did admission labs when residents first came in. LVN B stated she did not ask Resident #1 if she wanted to provide a urine sample by urine collection hat because she was incontinent at night and because the previous sample that was collected in that manner was contaminated and she wanted a clean specimen. LVN B stated part of the consent was verbal and part of it was demeanor. She stated Resident #1 responded to what she asked her to do and did not state she did not want to do it. She stated she did not know if residents had to say the exact words I agree, or I refuse. She stated, If they don't agree but they cooperate .I recall her saying okay and being aware of what we were doing. If she had said don't do that, then I wouldn't have done it. I believe she consented. She stated she felt Resident #1 was fully awake during the procedure because Resident #1 cooperated when she asked her to do things, such as scoot her bottom down and then spread her legs. LVN B stated she did not recall if there was any other conversation during the process. LVN B stated Resident #1 did not say anything afterwards and she left. LVN B stated later during the shift, she went to give Resident #1 some medication and Resident #1 asked LVN B why she did that to her and LVN B explained to Resident #1 that the previous test was contaminated, and they needed to get another urine sample and Resident #1 said okay. LVN B stated she did not call the FNP to get orders to perform the straight catheter procedure on Resident #1 because she was under the impression from report given to her by RN D that there was a physician's orders for the collection of the urine specimen from Resident #1, but she did not check to verify if there were orders. LVN B stated staff were supposed to have orders before doing an invasive procedure like that. She stated the order usually specified the way the urine specimen was collected, but she would clarify if that information was not written on the order. She stated she did not recall if RN D told her there was an order in the chart. She stated she was trained to verify orders before performing a procedure. LVN B stated, I don't guess I did that day. I do not remember seeing any physician orders. I don't recall if [RN D] told me he had notified the physician or if he had gotten an order. I just knew that I needed to collect a UA through the conversation with [RN D]. She stated no one told her that day that Resident #1 was upset. She stated she did not remember if the ADM or the DON spoke to her about the incident. She stated she was told Resident #1 was sent for a medical exam. She stated she did not recall if she was told the reason for the exam. She stated she was off the next day. She stated she went into the facility and explained the procedure to the ADM and the DON. She stated she did not recall if they told her the incident was reported. She stated she was suspended for one day so they could investigate things, but it was her day off, so she did not miss any scheduled work. She stated when she

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 residents (R#1, R#2, R#3, R#4, and R#5) of 10 residents observed for infection control, in that: A. The facility failed to protect residents from exposure to COVID 19 by not designating staff to work positive and negatives units and cohorting residents with positive and negative residents. B. The facility failed to ensure all staff on the positive unit (Hall 100) were wearing PPE correctly. C. The facility failed to ensure staff use infection control practices that would prevent cross-contamination by not washing hands or using hand sanitizer between residents' care; D. The facility failed to ensure housekeeping cleaning carts were sanitized when going from positive and to negative units. This failed practice affected 64 residents who tested positive for COVID-19 and had the potential to affect all resident putting them at risk for COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. These failures could place residents at risk for being exposed to COVID-19, health complications, and death. Findings include: During an observation on [DATE] at 09:55 pm approximately 10 staff at nurse's station standing shoulder to shoulder talking wearing a N95 and face shield but no social distancing. During an observation and review of facility's floor plan on [DATE] at 10:00 pm of the facility's layout indicated there were four halls with a nurse's station in the middle forming the appearance of a wagon wheel: The West side of the building had two halls: Hall 100 and Hall 200. The East side of the building had two halls: Hall 300 was split half way down the hall with a plastic sheet barrier and hall 400. The West side area was separated from the East side area by a nurse's station. The facility's administrative offices are located on the south end of building and separated by a wall barrier. The entrance to facility is located on the south end of building and the reception area to the right of entrance door was the area used by the screener to screen staff for all work areas. During an interview on [DATE] at 10:10 pm DON stated that hall 100, 200 and the back half of 300 are COVID-19 positive units and the front half of hall 300 is the warm unit. Don stated hall 400 is COVID-19 negative. DON stated all residents on hall 100 (27 residents) and 200 (26 residents) are positive for COVID-19; Hall 300 is split the front half (7 residents) are presumptive and the back half (17 residents) are COVID-19 positive; and residents on hall 400 (21 residents) are negative for COVID-19. During an interview on [DATE] at 10:10 pm DON stated staff has been educated on social distances and her expectations are for them to be 6 feet apart unless caring for a resident. During an observation on [DATE] at 10:15 pm orange cones at entrance of hall 100, one on right side next wall and one on left side next to wall. Hall 200 had orange cones placed at entrance, one on right side by wall and the one on left side by the wall. Donning and doffing station at entrance of hall 100 and 200 and a cardboard box lined with trash bag with used PPE over flowing with used PPE on the floor at the entrance of hall 100. Observed approximately 18 resident's doors open on hall 100 and approximately 15 resident's doors open on hall 200. During an observation on [DATE] at 10:20 pm LVN #1 observed walking from back end of hall 100 (positive unit) to entrance of hall 100 (positive unit) wearing only a face shield and N95, but no gown or gloves. According to the facilities Coronavirus Management Plan Texas Phase 3 proper PPE use on suspect and confirmed cases to include gowns, gloves, N95 masks and face shield/goggles. During an interview on [DATE] at 10:20 pm LVN#1 stated he was the charge nurse for hall 100 (positive unit) from 2pm-10pm and is working a double and will be working hall 200 (positive unit) and front half of 300 (warm unit) from 10pm-6am. When asked what the proper PPE was for hall 100 is LVN #1 stated we are to wear N95 mask, face shield, gloves and gown. During an observation on [DATE] at 11:02 pm nurse LVN #2 exited hall 100 (positive unit) without doffing PPE she wore while caring for COVID-19 positive residents and walked to nurse's station with PPE on (N95, face shield and gown) retrieved paper and walk back to medication cart on hall 100 (positive unit). During an interview on [DATE] at 11:28 pm LVN #2 stated I am to doff PPE and wash hands when exiting hall 100 (positive unit). During an observation on [DATE] at 11:10 pm LVN #1 and CNA #1 at nurse's station standing shoulder to shoulder talking, both staff members were wearing a mask and face shield but not social distancing. During an interview on [DATE] at 10:55 pm Administrator stated, staff at the nurse's station were giving shift report and they are not to mingle at the nurse's stations, I will in-service all staff. During an interview on [DATE] at 11:28 pm LVN #2 stated I am scheduled to work hall 100 (positive unit) and 400 (negative unit). During an observation on [DATE] at 12:51 am LVN #2 exited room [ROOM NUMBER] which has one positive resident removed gown at end of hall and placed in trash container. No handwashing or use of ABHR was observed. LVN #2 went to nurse's station sat down in front of computer and worked on computer. Got up from nurse's station went to medication cart at nurse's station and pulled medication and placed in pill cup and poured glass of water. Then LVN #2 walked down hall 400 (negative unit) to resident's room [ROOM NUMBER] and entered room. No observation of donning or doffing PPE before entering resident room [ROOM NUMBER]. She exited room [ROOM NUMBER] and walked across the hall leaning on door facing talking with CNA #2. LVN #2 then walked back to nurse's station and sat down in front of computer and started working on computer. No observation of hand washing or use of ABHR. During an interview on [DATE] at 11:28 pm LVN #2 Stated she is to doff PPE and wash hands when exiting hall 100 (positive unit) and when she goes into a resident's room on hall 400 (negative unit) she is to don a new gown when entering and doff when exiting the room and wash hands or use ABHR. LVN #2 stated she did not wash her hand in resident's room or use ABHR. RESIDENT #4: Record review current bed status dated [DATE] revealed Resident # 4 in room [ROOM NUMBER]A (Negative unit). Review of facility's COVID test results on [DATE] revealed R#4 positive for COVID-19. Record Review of R#4's face sheet indicated he was an [AGE] year-old male, who was admitted to facility on [DATE] reveals the following Diagnosis: [REDACTED]. Review of facility's COVID test results on [DATE] revealed R#4 positive for COVID-19. Review of R#4's Quarterly Minimum Data Set (MDS) [DATE] indicated the following: -BIMS Summary score was a 12 indicating he was moderately impairment. -Required limited assistance with one-person assist for bed mobility, transfer, dressing, toilet use and personal hygiene. -Required supervision with setup help only for locomotion on unit and supervision with one-person physical assist for eating and walking and locomotion off unit did not occur. During an interview on [DATE] at 01:15 am Administrator stated nurses are not supposed to be scheduled to both positive and negative halls at the same time. Administrator stated we should have dedicated staff for the positive unit and the negative unit. During an interview on [DATE] at 01:15 am DON stated, I did not change the schedule. DON stated that the schedule has always been the 10p-6a nurse is scheduled to either halls 100 and 400 or halls 200 and 300. DON stated, I will get that changed. Record review on [DATE] at 01:13 am Daily Staffing Dated: [DATE] Day: Thursday revealed LVN #1 scheduled to halls 200 (positive unit) / 300 (warm unit) and LVN #2 scheduled to halls 100 (positive unit) / 400 (negative unit). During an observation on [DATE] at 11:38 pm LVN #1 on hall 200 (positive unit) walked to entrance of hall 200 and removed gown. No observation of LVN #1 hand washing or using alcohol base hand rub (ABHR). LVN #1 walk to the nourishment room, to the main facility kitchen touching multiple surfaces. LVN #1 walked to hall 300 (presumptive unit) entrance and donned new gown only keeping the same N95 mask & face shield on and walked down the hall to the medication cart. No observation of LVN #1 washing his hand or using ABHR when donning new PPE. During an interview on [DATE] at 11:41 pm with LVN #1 stated I am to remove my gown and use ABHR when leaving hall 200. When asked why he did not use ABHR LVN #1 stated, I forgot. During an observation on [DATE] at 11:42 pm LVN #1 and CNA #1 at nurse's station standing approximately 2 feet from each other, both staff were wearing N95 and face shield but not social distancing. During an interview on [DATE] at 11:42 pm LVN #1 asked what the policy was for social distancing LVN #1 stated 6 feet. During an observed on [DATE] at 12:01 am CMA #1 remove gown at entrance to hall 100 (positive unit). Pulled gown overhead and slinging it around before rolling it up and placing in trash container. During an interview on [DATE] at 12:01 am CMA #1 stated he had be trained on how to don and doff PPE. CMA #1 stated I am just tired and ready to go home. During an observation on [DATE] from 09:50 pm to [DATE] 01:30 am no high touch surface areas being cleaned. Multiple observation during this time of multiple staff members touching handrails, door handles to residents rooms, nurses station counter and equipment (phone, computers). During an interview on [DATE] at 01:18 pm HSK supervisor states she does not know who does high touch surface areas at night. States her staff does high touch surface areas at the end of shift which is around 07:00 pm During an observation on [DATE] at 10:15 am Admission coordinator assisting hall 100 (positive unit) with breakfast trays. She is wearing PPE (gown, N95, face shield and gloves). She entered room [ROOM NUMBER] with meal, exited room [ROOM NUMBER], went to main facility kitchen where all resident's food is prepared, then back to room [ROOM NUMBER] to deliver health shake. No observation of admission coordinator doffing PPE or hand washing when exiting hall 100 (positive unit). During an interview on [DATE] at 10:20 am Admission Coordinator stated I did not take PPE off when leaving hall 100 (positive unit), I normally do. I was just trying to help. We were told to don PPE at front hall entrance, wash hands and don new gown and glove and when we leave the hall we are to take off gown and gloves and wash hands. During an interview on [DATE] at 10:40 am HSK Aide #1 stated when she finishes hall 200 (positive unit), she goes to hall 300 (warm unit) the front half. During an observation on [DATE] at 11:30 am HSK Aide #1 pushing cleaning cart from hall 200 (positive unit) to inside Hall 300 (warm unit) parking cleaning cart outside resident's room. No observation of HSK Aide #1 sanitizing cleaning cart before entering hall 300 (warm unit). During an interview on [DATE] at 11:35 am HSK Aide #1 stated I have not been trained on COVID, I did not clean cart and I wasn't told to clean cart between hall 200 (positive unit) and hall 300 (warm unit). During an interview on [DATE] at 11:45 am HSK Supervisor stated carts are to be cleaned between halls with Lysol spray focusing on supply compartments and where the mop bucket goes. HSK Supervisor stated they do have a designated cleaning cart for the back half of hall 300 (positive unit). During an observation on [DATE] at 12:25 pm PTA #1 wearing KN95 mask and face shield. According to facility Coronavirus Management Plan Texas Phase 3 stated while in the facility during Phase 3 all staff are to wear N95 respirator until contained. During an interview on [DATE] at 12:25 pm PTA #1 stated this was what was given to me from the facility. PTA #1 stated she has not been in-serviced on the facility Phase 3 plan. During an observation on [DATE] at 12:49 pm CNA #3 on hall 100 (positive unit) passing meal trays with PPE (N95, face shield, gown and gloves) on. Entered room [ROOM NUMBER] through 116. No observation of CNA #3 changing gloves, handwashing or use of ABHR. During an interview on [DATE] at 12:58 pm CNA #3 stated she is to change gloves after every resident. When asked did you change your gloves while passing meals from rooms 111 through 116 she states no. I did not start changing my gloves until the charge nurse reminded me. During an observation on [DATE] from 08:45 am to 01:18 pm no observation of cleaning high touch surface area or nurse's station area. During an interview on [DATE] at 01:18 pm HSK supervisor stated I am running behind, I have not done it, but I will get to it as soon as I put my stuff up and wash my hands. HSK supervisor stated it is supposed to be done every two hours. During an interview on [DATE] at 01:00 pm Administrator stated they had completed all resident testing today and there were 19 new positives throughout the building additional to the 56 that were positive upon entrance. Administrator stated 8 residents on hall 100 (Positive COVID-19 Hall) was tested ; 6 residents out of 8 tested positive. The 2 residents (Resident #8 and Resident #9) that tested negative remained on Hall 100 (Positive COVID-19 Hall). Administrator stated Resident #8 stays in bed all the time but has a roommate (Resident #10) who tested positive [DATE]. Resident #9's roommate was sent to the hospital on [DATE] and tested positive [DATE]. Administrator stated she did not move negative residents from Hall 100 (Positive COVID-19 Hall) since they had already been exposed by the roommates; if she moved them to a negative hall that would expose the other residents who had not tested positive. During an interview on [DATE] at 01:22 pm Administrator stated everything happened so fast on Monday and that is when we made hall 100 and 200 the COVID-19 positive halls. Record review current bed status revealed the following residents who tested positive on [DATE] on Hall 100 (Positive COVID-19 Hall) are: Resident #11, Resident #12, Resident #13, Resident #14 Resident #15 and Resident #16. The residents who tested negative on Hall 100 (Positive COVID-19 Hall) are Resident #8 and Resident #9 and both residents remained on Hall 100 (Positive hall). According to the Nursing Facility Response Plan positive and negative residents cannot be cohorting in the same room. FACILITIES POLICY AND PROCEDURE revealed the following: Coronavirus Management Plan Texas Phase 3 (Known cases in Facility) Phase 3 = Monitoring, Containment, & Rapid Identification of Cases Dated [DATE] On Page 6 reveals the following: Encourage HCW to abide by physical distancing, masking, and group gatherings per local authority when not at work. On Page 15 reveals the following: If resident is symptomatic: 1. Will be moved to the step-down unit, placed in a single room (no roommate) with the door closed until testing confirms or rules out COVID-19. If positive the resident will move to the COVID positive unit and the facility will be in phase 3. 2. The roommate is a symptomatic resident: - The roommate will stay in their current room alone, without a roommate. Also, be put on droplet precautions with full PPE (gowns, N95/KN95 mask, gloves and a face shield or goggles) - If their original symptomatic resident is positive, the roommate will be moved to the step-down unit and quarantine for 14 days from the last date of exposure to the positive resident. On Page 16 reveals the following: 4. Infection Control Follow proper hand hygiene Designate HCWs for each of the 3 units (1. Hot/COVID Positive/Isolation; 2. Warm/step- down/Quarantine, 3. Cold/Negative) and staff should not work with more than one unit. Once staff are designated to work on a given unit staff should not change units from one day to another, unless required in order to maintain adequate staffing. On Page 17 reveals the following: Follow proper transmission-based precautions COVID-19. 1. While in the facility during phase 3 all staff are to wear -N95 respirators until contained (see contained above) once contained those on cold unit and office staff may use surgical mask. -Eye protection either face shield or goggles are appropriate, but face shields are preferred, continue to wear a face shield or goggles on the cold unit until no longer in phase 3 when within 6 feet of anyone (resident or staff) for more than 15 minutes. Continue physical distancing when possible. It also continues to be recommended that all staff on the cold unit wear a face shield or goggles whenever within 6 feet for more than 15 minutes even when you are no longer in phase 3 to reduce staff exposure. 2. Step Down/Quarantine unit and COVID positive unit all suggested PPE includes: -N95 respirator -Eye protection either face shield or goggles -Gown -Gloves 3. Negative/Cold Unit -N95 respirator, until contain then once contained cold unit and office staff may wear a surgical mask. -Eye protection, either face shield or goggles continue to wear a face shield or goggles on the cold unit until no longer in phase 3 when within 6 feet of anyone resident or staff for more than 15 minutes. Continue physical distancing when possible it also continues to be recommended that all staff on the cold unit wear a face shield or goggles whenever within 6 feet for more than 15 minutes even when you are no longer in phase 3 to reduce staff exposure. -Gown and gloves while performing personal care on the resident On Page 18 reveals the following: Review Step-Down Unit (Quarantine unit, Warm Zone) and COVID positive (Droplet, Hot Zone) to meet the following. 1. COVID positive and quarantine units must remain separated. All units require PPE noted above. 2. If able put barriers up between the Hot Zone (COVID positive unit) Warm Zone (Step-Down) and Cold Zone. The isolation space should be separated so essential personnel maintaining the building or providing services to residence in the isolation space are not required to go through areas where the negative are asymptomatic residents are receiving care. Note a curtain removable screen does not provide meaningful separation. 3. Provide an area for donning and doffing in positive unit with hand hygiene available if able. 4. If able provide a break area in each unit for staff to take breaks. 5. Separate entrance if preferred. 6. Use a private bedroom with its own bathroom for each resident when possible. 7. Staff working on Step-Down unit and COVID Positive unit are dedicated to that unit. 1. On the quarantine/step down unit staff must change counts between residence. -A single gown for each staff member that is going in the room can be hung inside the room and discard it at the end of the shift. Be sure hung gowns do not touch each other while hanging. When supply allows resume, regular gown use of a new gown upon each entry into room which is discarded on exit. 2. On the COVID Positive unit staff can wear a single gown to care for multiple residents if you are in gown conservation mode. -If resident has other infections conditions such as [MEDICAL CONDITIONS], etc. you will have to change your gown after caring for that resident. On Page 20 reveals the following: Patients/residents to continue following physical distancing (staying 6 feet or greater apart from each other). Should remain in room as much as possible. Staff following physical distancing (staying 6 feet or greater apart from each other) when not performing services for patients/residents that cannot be performed while apart such as personal care and transfers requiring more than one staff member. Limit movement of staff from COVID Positive/Isolation unit and Step-Down/Quarantine unit to other parts of the facility. On Page 21 reveals the following When providing a dedicated area for donning and doffing of PPE (If you can have a separate area for donning and one for doffing do so, if not follow the guidelines below) 1. Provide hand hygiene in that area 2. Adequate disposal receptacle for PPE 3. Only donning or doffing in that area (do not have one person donning and one doffing at the same time) It is preferred to have separate areas if possible. High touch cleaning of all isolation and step-down rooms every 2 hours, as possible. Interview on [DATE] at 06:12 pm Administrator was notified by both surveyors that at 06:12 pm an immediate jeopardy was called due to the facility failed to following infection control policy and procedure, related to the outbreak of COVID-19 in the facility. The administrator was notified on [DATE] at 02:54 pm of the acceptance of plan of removal and the Immediate Jeopardy was lowered. The facility provided a plan of removal and was accepted by HHSC to include: 1. Apply colored tape on the floors to indicate hot, warm, and cold zone 2. Nursing station will be considered hot zone station 3. Dedicated staff will work on hot unit (100, 200, back 300), warm unit (300 front), and cold unit (400) 4. Hot units: staff will be entering and exiting through back doors of dedicated hot units, staff will be screened at the dedicated doors of the hot units. 5. Staff who works on Warm and Cold units can enter and exit through front entrance and be screened 6. Encourage residents to close doors on 100 and 200 units 7. Hot units - Full PPE at all times as states per Phase 3 8. DON or designee will complete PPE use education with LVN (1:1), Education with CNA (1:1) 9. DON or designee will complete PPE use education for staff, new hire, and agency staffing 10. DON or designee will complete hand hygiene education for staff, new hire, and agency staffing 11. Barrels with lids replaced trash boxes on all hallways 12. Each unit will complete shift to shift report on their dedicated units - Staff education will be completed by DON or designee. No congregation at Nursing station besides 100 and 200 units 13. Social distancing: Education will be completed by DON or designee and tape marks will be applied on the floors in the common places 14. Scheduling posted at the front of the facility to notify staff which unit each staff member works 15. Next 2-weeks staffing schedule reviewed by Administrator or designee 16. Manager on duty schedule updated by Administrator or designee 17. Medical Director notified by DON 18. Designated housekeeping carts on each unit 19. Staff complete Post-test for Infection Prevention & Control for validation of adherence to the education/practices Survey continued observation: During an interview on [DATE] at 12:00 pm Corporate Administrator stated current administrator is out on leave and he will be taking over until Monday. Corporate Administrator stated his plan is to remove plastic barriers from hall 200 (positive unit) and hall 400 (negative unit) and use color tape on floor as the barrier. During an observation on [DATE] at 01:10 pm red tape on floor from left side of hall 100 (positive unit) to nurse's station and from right side of hall 200 (positive unit) to nursed station connecting the two halls. Hall 300 (warm unit) was marked with yellow tape across entrance at closed double doors. Blue tap was placed on floor at entrance to hall 400 (negative unit) and in front of nurse's station. There is also red tape placed on floor down the center of the nurse's station dividing it as hot zone and cold zone. During an observation on [DATE] at 01:35 pm Corporate Administrator in-servicing staff on new tape barriers at nurse's station. Interview on [DATE] at 03:00 pm Corporate Administrator stated he has started in-servicing on floor plan (color tape barrier), social distancing and staff not working on 2 units. Record reviewed training documentation done on [DATE] of training and in-services of competency of handwashing, floor plan, workflow, social distancing, staff not working on two units, PPE usage on each unit and Donning/Doffing of PPE. During an interview on [DATE] at 02:20 pm CMA #2 states she has been in-services on floor plan, workflow, social distancing, staff not working more than 1 unit, PPE usage on each unit, donning and doffing, and hand hygiene. CMA #2 stated yes, I did take a quiz on infection control. Record review training presented by DON dated [DATE] on PPE usage on each unit, donning and doffing and hand hygiene revealed CMA #2 name and signature. Record review training presented by Corporate Administrator dated [DATE] on floor plan, workflow, social distancing and staff not working on 2 units revealed CMA #2 name and signature. During an interview on [DATE] at 02:25 pm RN #1 stated she has been in-services on floor plan, workflow, social distancing, staff not working more than 1 unit, PPE usage on each unit, donning and doffing, and hand hygiene. RN#1 stated Yes, I did take a quiz on infection control. Record review training presented by DON dated [DATE] on PPE usage on each unit, donning and doffing and hand hygiene revealed RN #1 name and signature. Record review training presented by Corporate Administrator dated [DATE] on floor plan, workflow, social distancing and staff not working on 2 units revealed RN #1 name and signature. During an interview on [DATE] at 02:31 pm LVN #3 stated she has been in-services on floor plan, workflow, social distancing, staff not working more than 1 unit, PPE usage on each unit, donning and doffing, and hand hygiene. LVN #3 stated Yes, I did take a quiz on infection control this morning. Record review training presented by DON dated [DATE] on PPE usage on each unit, donning and doffing and hand hygiene revealed LVN #3 name and signature. Record review training presented by Corporate Administrator dated [DATE] on floor plan, workflow, social distancing and staff not working on 2 units revealed LVN #3 name and signature. During an interview on [DATE] at 02:35 pm LVN #4 stated she had been in-services on floor plan, workflow, social distancing, staff not working more than 1 unit, PPE usage on each unit, donning and doffing, and hand hygiene. LVN #4 stated she did take a quiz on infection control. Record review training presented by DON dated [DATE] on PPE usage on each unit, donning and doffing and hand hygiene revealed LVN #4 name and signature. Record review training presented by Corporate Administrator dated [DATE] on floor plan, workflow, social distancing and staff not working on 2 units revealed LVN #4 name and signature. During an interview on [DATE] at 02:40 pm HSK supervisor stated she has been in-services on floor plan, workflow, social distancing, and staff not working more than 1 unit. HSK Supervisor stated she has placed a dedicated cleaning cart to each unit. HSK supervisor stated she did take a quiz on infection control. Record review training presented by Corporate Administrator dated [DATE] on floor plan, workflow, social distancing and staff not working on 2 units revealed HSK Supervisor name and signature. During an interview on [DATE] at 02:44 pm CNA #4 stated she has been in-services on floor plan, workflow, social distancing, staff not working more than 1 unit, PPE usage on each unit, donning and doffing, and hand hygiene. CAN #4 stated Yes, I did take a quiz on infection control. Record review training presented by DON dated [DATE] on PPE usage on each unit, donning and doffing and hand hygiene revealed CNA #4 name and signature. Record review training presented by Corporate Administrator dated [DATE] on floor plan, workflow, social distancing and staff not working on 2 units revealed CNA #4 name and signature. During an interview on [DATE] at 02:48 pm CMA #3 stated she has been in-services on floor plan, workflow, social distancing, staff not working more than 1 unit, PPE usage on each unit, donning and doffing, and hand hygiene. CMA #3 stated Yes, I did take a quiz on infection control. Record review training presented by DON dated [DATE] on PPE usage on each unit, donning and doffing and hand hygiene revealed CMA #3 name and signature. Record review training presented by Corporate Administrator dated [DATE] on floor plan, workflow, social distancing and staff not working on 2 units revealed CMA #3 name and signature. During an interview on [DATE] at 02:52 pm CNA #5 stated she has been in-services on floor plan, workflow, social distancing, staff not working more than 1 unit, PPE usage on each unit, donning and doffing, and hand hygiene. Stated she did take a quiz on infection control. Record review training presented by DON dated [DATE] on PPE usage on each unit, donning and doffing and hand hygiene revealed CNA #5 name and signature. Record review training presented by Corporate Administrator dated [DATE] on floor plan, workflow, social distancing and staff not working on 2 units revealed CNA #5 name and signature. During an observation on [DATE] at 03:05 pm staff at nurse's station social distancing and not crossing the red barrier tape. During an interview on [DATE] at 09:40 corporate administrator reported DON had tested positive this am during routine testing and has been sent home. Record review COVID-19 spread sheet reveals: 2 additional positive staff on [DATE] (HSK Aide #2 and CNA #6), Res. #18 tested positive on [DATE] and expired in hospital on [DATE], Res. # 19 tested positive on [DATE] and expired in facility on [DATE]. On [DATE] at 03:00 pm the corporate administrator was informed of the IJ was removed but facility remained out of compliance at a level of actual harm with a scope identified as a pattern. The facility was continuing to monitor their infection control procedures.

Based on interview and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for 1 of 6 residents (Resident #1) reviewed for supervision as evidence by: The facility failed to ensure Resident #1 was supervised after dietary staff assisted her outside and left her in the heat in temperatures between 95 to 99 degrees and remained outside for approximately 2 hours from 1:30 PM until 3:35 PM, resident later expired. This was determined to be an Immediate Jeopardy at Past Non-Compliance from [DATE] until [DATE], due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. Failure to leave residents unsupervised in extreme weather conditions could place all residents at risk of severe heat injury or death. The evidence is as follows: Record review of the face sheet for Resident #1 documented her admission date of [DATE] and she had [DIAGNOSES REDACTED]. Record review of the Minimum (MDS) data set [DATE] for Resident #1 documented her functional levels for locomotion on unit self-performance as 3 = extensive assistance and support as 2 = one-person physical assistance, locomotion off the unit self-performance as 3= extensive assistance and support as 2 = one-person physical assistance. Eating self-performance as 3= extensive assistance and support as 2 one-person physical assistance. Functional Limitation in Range of Motion upper extremity 2 = Impaired on both side, lower extremity 2= impaired on both side and mobility devices as wheelchair. Her Brief Interview for Mental Status (BIMS) as 3. Record review of Care Plan dated [DATE] documented Resident #1 is at risk for falls, decreased Range of Motion to bilateral upper and lower extremities, generalized weakness and side effects from medication. Interventions listed are as follows: Anticipate residents needs and check frequently. Cognitive status: Severely Impaired. Resident #1 is at risk for Impaired Physical Mobility, Interventions Provide appropriate level of assistance to promote safety of resident. Resident #1 generalized weakness, Intervention requires assistance of tow staff, requires extensive assistance dated [DATE]. Record review of the Facility Investigation Report documented staff was summoned to the dining room at approximately 3:35 PM, by a family member saying resident #1 was outside near the gazebo area and did not look right. Staff responded to the gazebo area and found resident #1 sitting in her wheelchair with her head tilted back, legs out in front of her and both arms to each side of the wheelchair. Staff brought resident #1 back in the facility and called other staff members for help. Resident #1 was observed to have agonal breathing ( a type of breathing that usually follows a pattern of gasping succeeded by apnea. It generally indicates the onset of respiratory arrest. - Mosby's Medical, Nursing & Allied Health Dictionary, second edition, page 36) and unresponsive to tactile stimuli at this time. Staff took resident #1 to her room vital signs were taken blood pressure unable to read, pulse oximeter unable to read, resident #1 noted to be warm to touch, redness to her abdomen and bilateral thighs. Redness and discoloration to bilateral feet and small skin tears to left pinky and right two middle toes. Noted with discoloration to her bottom. Skin was dry and flaky, mucus membranes noted to be dry. Staff changed resident #1 from her clothes to a hospital gown and turned the air conditioning on. Staff notified Administrator, Physician, Lubbock Police Department (LPD) and family. Resident was pronounced by Emergency Medical Services (EMS). Medical Examiner's (ME) office was notified and responded to the facility. It was later determined in the investigation a facility staff member Dietary Aide #1 assisted resident #1 outside to the gazebo area without staff supervision at approximately 1:30 PM and failed to inform any staff member resident #1 was outside and he then clocked out of work at approximately 1:57 - 1:58 PM. The temperatures outside for 1:53 PM, 95 degrees, 2:53 PM, 98 degrees, and 3:53 PM, 99 degrees according to timeanddate.com for Lubbock, Texas Weather History. During an interview on [DATE] at 10:30 AM with the Administrator she stated she received a call from LVN #1 stating resident #1 was found outside and brought back inside and had expired. She stated she asked LVN #1 if she had notified the physician and to immediately notify him. She stated she called the DON and for both of them to report to the facility and she notified Maintenance Supervisor to go to the facility as well to start checking all doors to see if functioning properly. She stated once she arrived at the facility she went to the resident's room and noticed the resident was lying in bed in a hospital gown resident was warm to touch no visible signs of sun exposure had small split areas of to one toe on each foot. She stated she spoke with the family that found resident #1 outside and he stated she didn't look right so he went and got a nurse. I started my investigation thinking maybe the doors were not functioning properly and I started interviewing staff. During my staff interviews a staff member told me she saw a tall skinny man from dietary assist a female resident outside to the gazebo area. That staff member was able to describe the staff to me, so I called Dietary Aide #1 and interviewed him. He verified he did work that day and he did assist a female resident outside to the gazebo area, placed her in the shade and then returned to work. He said this happened after lunch sometime between 1:30 PM and 2:00 PM and he returned to work. He then clocked out around 1:57 PM-1:58 PM (without notifying any staff resident #1 was outside unsupervised). I then knew it was not an issue with the doors that staff had assisted her outside of the building. During an interview on [DATE] at 11:40 AM with Dietary Manager when asked about assisting residents outside of the building she replied, we need to know where the residents are at all times and we should be doing checks on them and report anything we see to the nurses. They gave me a book in orientation and they covered letting the nurses know what's going on with the residents. During an interview on [DATE] at 11:50 AM with Dietary Aide # 2 when asked about assisting residents outside of the building she replied, I know I am not to assist a resident outside of the building because we do not know their mental status and so we should not take them out. If a resident were to ask me to take them outside I would tell the resident I have to go and check with the nurses at the desk. This morning when I came to work we had a meeting and they covered different topics about the residents and monitoring them talking wit the nurses before doing anything for a resident, and not to let any resident outside without talking with the nurses. During an interview on [DATE] at 12:25 PM with the Administrator when asked if Dietary Aide #1 should have told staff he had assisted resident #1 outside she replied, probably so, with him not knowing the patient that well he should have reported it. She stated that Dietary Aide #1 put in his written statement he didn't notify any staff he had assisted resident #1 outside, that he saw another resident outside and he assumed when staff went outside to get that resident they would see resident #1. When asked if that is what staff would normally do assume Administrator replied no. At this point I knew it was not a door issue that it was a deficient practice, staff took her outside and left her in the heat, that he was at error. During an interview on [DATE] at 1:52 PM ADON said she I received a call from the DON around 3:30 -3:45 PM on [DATE] and was asked how soon could she get to the facility because they had found resident #1 outside dead. When I arrived at the facility I asked what happened and I was told another family member had found resident #1 outside in the gazebo area. I had staff show me exactly where resident #1 was found outside. Resident #1 was found between the bench and chair to the side area of where the gazebo is at. Staff told me they found her outside facing the sun and her head was leaned back. Staff told me they brought her in and placed her in her room. I went and spoke with the family member that found her and he told me resident #1 was in her wheelchair arms out to the side her head leaned back, and the sun was hitting her and she didn't look right. I was told that Medication Aide #1 went outside and then yelled for the nurses to come and help her, staff told me at that time resident #1 was having agonal breathing. They put resident #1 in her bed and check vitals and no vitals. They changed her clothes because they said she was hot they put her in a gown and turned the air-conditioning (A/C) on and then called the Administrator and she told them to call the doctor. I went to her room and looked at her and I noticed two toes on both feet had red skin. I asked LVN #1 what happened to her feet and she said when we took her socks off the skin on her toes came with it. I touched the resident and noticed she was warm asked if they took a temp staff said no I asked them to take one it was 98.2 this was about 4:,[DATE]:25 PM. I came out and told the Administrator I was going to call the non-emergency police department. Lubbock Police department (LPD) called Emergency Medical Services (EMS) and asked them to come out and pronounce. EMS hooked her to the machine and no signs of life, so they called that she had passed. They called the Medical Examiner's Office (ME) to come out. I explained to the ME resident #1 was outside and I was unsure for how long, then she was placed back in her bed and no signs of life. He said he would come out and start the process. The ME arrived and looked at resident #1 and asked if we could help roll her for him to take pictures of her back. The ME told us to put gloves on that her skin was slipping. Administrative staff continued with staff interviews and that is when we found out that staff had seen Dietary Aide #1 take resident #1 outside. The Administrator called Dietary Aide #1 on speaker phone and he said he did take resident #1 outside that he had checked on her then clocked out and left for the day. He didn't tell anyone she was out there because he assumed when staff went out there to help another resident in they would see her and take her in. Administrative staff and I started in-serving staff and continued with all in-services until all staff had been in-serviced. I conducted interviews with staff and I asked the nurses and medication aides when was the last time you laid eyes on her and they are responded around 12:30 PM. The nurse aides and nurses do rounds q2 hours. The shift coming on at 2:00 PM should have seen her because we do walking rounds or the ,[DATE] shift should have known where she was to tell the oncoming shift. My thought when staff said we last saw her at 12:30 PM was we should know where residents are. The staff is responsible for them and should be rounding (making nursing observation rounds) on the residents. It is still staff's responsibly to check the residents. When asked about a policy for supervision of residents she stated she had spoken with corporate and they told her they do not have a policy for supervision of residents it is done on the care plan and MDS based on each residents needs. During an interview on [DATE] at 3:33 PM LVN #2 stated I heard Medication Aide #1 call for help and I went in the dining room and saw her bringing in a resident from outside. Resident #1 had agonal breathing and we took her to her room. We put her in her bed and we tried to cool her off she was warm to touch so we took her clothes off her and put a gown on her. During an interview on [DATE] at 3:40 PM with LVN #1 she stated I was the nurse for resident #1 that weekend. The last time I saw her it was a little after lunch and she was around the TV area. Lunch starts at 11:30 AM and is over around 12:30 PM. I was in the dining room from 12:,[DATE]:30 PM. I saw her in the Assisted Dining Room (ADR), I believe I did see her. I do rounds every two hours. My next round would have been shift change, I don't remember seeing her. Usually if the aides say they can't find some we look for them. I know around shift change we were working on trying to find a CNA to come in and work my hall. I started doing my rounds, but I didn't finish doing my rounds. None of the CNA's reported to me not seeing resident #1 on their rounds. Around 3:40 PM a kitchen staff said they needed me outside, I went walking down towards the dining room and Medication Aide #1 came in the door from the gazebo area with resident #1. Resident #1 was in her chair leaning down and her head was back, and she had some agonal breathing. LVN #2 and I took her to her room then staff came in and helped us check for her vitals we couldn't get any vitals, we didn't do a temperature on her. We put her in bed and got her clothes off and put a gown on her and then I went to call the Administrator and the doctor. She didn't have any vital signs. I called and notified everyone I went to her room and then later maybe 30 minutes or, so I checked her temp 98.2 I looked at her skin she had redness on her abdomen and thighs she had a skin tear on her toes that I think happened when we took her socks off. Her bottom was discolored it was reddish purplish type color same as her feet from her ankles down. No one had told me they were going to take her outside that day. During an interview on [DATE] at 4:46 PM Medication Aide #1 stated I was in the dining room and someone said there is a lady outside that didn't look good. I started to go outside and when I saw resident #1 then when I got close enough to see her color and I hollered for staff to go get the nurses. I got to her she was agonal breathing a short breath in and I could see her agonal breathing. She was pale she was laying in the wheelchair her legs out in front of her. I started getting her inside and staff LVN #1 and LVN #2 meet up with the nurses took her to her room. I didn't go in her room I stayed out at the desk since I am not working as a nurse here at the facility. What I remember next was seeing LVN at the desk and I asked did resident #1 not make it and LVN #1 answered me that the resident did not make it. I do remember seeing resident #1 that day at different times not sure what times. I do not know how she got outside. There was a resident and her husband outside and they are the ones who said she needed help. During an interview on [DATE] at 5:00 PM with RN #1 she stated, I saw resident #1 at breakfast she was in the ADR dining room. I saw her after breakfast when I made my rounds. I did not see her at lunch I did not check on the residents in the ADR. I was told she was in there and had her meal. I was managing the dining room, so I didn't go in the ADR. I didn't see her the rest of the day. I usually make rounds every morning in all 4 halls then one in the afternoon after lunch. I didn't see her after lunch. Usually the nurse or CNA will come and tell me if they cannot locate a resident, no one told me that had not seen her that afternoon. I would be more aware of the situation if the resident was having a problem and I was following up on them more often. The DON told me someone had taken resident #1 outside and didn't inform anyone that had taken her outside, and that resident #1 had passed. No one had mentioned to me that day they had taken her outside, I had no knowledge of her being outside. During an interview on [DATE] at 5:13 PM Dietary Aide #1 stated, I was washing dishes after lunch we finish serving around 1:00 PM and we are usually out by 2:00 PM from work. I noticed a resident sitting by the door that goes to the dish room and the door outside. I asked if she needed help she said she would like to go outside. I noticed another resident outside and I assumed someone would be coming to get him. I took her to area by the gazebo in the shade and I checked on her two times before leaving work. She had moved a little but not far from where I left her. I didn't tell anyone I had taken her out there or left her outside. As far as I can remember I do not recall being trained on not taking a resident outside, I look at it as more of a common sense and I should have told someone. It was towards the end of my shift I returned to work and it totally left my mind I had taken resident #1 outside. I clocked out around 2:00 PM and went home without telling anyone I had taken resident #1 outside. Record review of Incident/Accident report note by LVN #1 documented the following at approximately 1535 was summoned to the dining room by Medication Aide #1. LVN #1 observed resident #1 in her wheelchair and noted with agonal breathing and unresponsive to tactile stimuli. Resident #1 assisted to her room. Once in room vital were taken. Blood pressure unable to read, pulse oximeter unable to read, resident #1 warm to touch. What looked like dried food noted on side of mouth. Resident #1 assisted to bed. LVN #1 went to call Administrator, DON and Physician. LVN #1 went back to resident #1's room to check her temperature 98.2, skin noted to be warm to touch. Skin noted with redness to her abdomen and bilateral thighs. Redness and discoloration to bilateral feet and small skin tear to left pinky and right two middle toes. Noted with discoloration to her bottom. Skin was dry and flaky as noted before. Mucous membranes noted to be dry. Resident left in semi fowlers position with a gown in place and bed in low position. It was determined the facility failed to provide adequate supervision placed resident #1 in an Immediate Jeopardy situation on [DATE] resulting in her death. The facility took the following actions to correct the non-compliance on [DATE] & [DATE]. Record review of the facility's Training In-service form dated [DATE] titled Door Security documented staff was trained and in-serviced by facility Maintenance Director on Door Security. Facility Education and Training Record dated [DATE] titled Resident Rounds, make sure all staff do resident rounds and know where residents are, Presented by ADON #1. Facility Education and Training Record dated [DATE] titled Ensure doors are locked at all times, if you take a resident outside notify the charge nurse, do not take a resident out in this heat presented by ADON #1. Facility education and Training Recorded dated [DATE] titled Signs and Symptoms of heat related illness, flushed skin, sweating zero sweat, dry skin, lethargy: keep hydration cart passed around, keep residents hydrated presented by ADON #1. The facility had staff members take a quiz on Monitoring residents who express a desire to go outside. The facility provided staff with education on Best Practice Recommendations to Prevent and Manage Dehydration, Warning Signs and Symptoms of Heat - Related Illness form Center for Disease and Prevention, and Heat Precautions from Texas Health and Human services. Facility staff updated Care Plans for residents that go outside. Facility staff posted signs on all exit doors and walls about do not assisting residents outside without speaking with the charge nurse first. The facility has purchased coolers to keep on facility transportation for residents requiring transportation during high heat temperature. Administrative staff will be making observations to ensure staff is making nursing observation rounds on residents. Staff will be making outside checks of the grounds of the build to ensure residents are not being left outside. Staff will be monitor and check residents that are going outside to the gazebo area. The gazebo area is in the center part of the building, staff is not able to see this area when entering or exiting the building. Staff will be making regular checks of the gazebo area for any residents. During interviews completed on [DATE] between 11:40 AM - 5:00 PM with LVN #1, LVN#2, Medication Aide #1, RN #1, Dietary Aide # 2 and Dietary Manager all stated they received in-service on the following: not taking a resident outside in the heat, not taking a resident outside without notifying the nurse, hydrating residents and hydration carts, signs and symptoms of heat related illness, and door security after the incident occurred.

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 10 residents reviewed for neglect (Resident #1). The facility failed to provide Resident #1 with care and services to ensure her safety and well-being. Resident #1 was given 100units of sliding scale insulin (medication that reduces blood sugar) instead of the physician ordered 4units. The facility failed to have adequate food and snacks available for the residents. This failure resulted in Resident #1 having very low blood sugar, and became unresponsive. This further resulted in Resident #1 having to be transferred by Emergency Medical Personnel to the hospital's emergency room . This failure was determined to be past non-compliance immediate jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of this investigation survey. This failure, could affect 33 residents, who had a [DIAGNOSES REDACTED]. Findings included: Resident #1 is an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 was cognitively intact, and she required one person ' s physical assistance for her activities of daily living. Review of Resident #1's Physician order [REDACTED]. "[MEDICATION NAME] 100units/ml sub-Q (insulin [MEDICATION NAME]) per sliding scale 5 times per day. (12:00 a.m., 7:00 a.m., 11:00 a.m., 4:00 p.m., and 10:00 p.m.) - 61-150 = 0 units, - 151-200 = 1 units, - 201-250 = 2 units, - 251-300 = 3 units, - 301-350 = 4 units, - 351-400 = 5 units, - 401-450 = 6 units, - 451-500 = 7 units, - 501-550 = 8 units, - (above) 551 = 9 units then call MD (doctor)." Record review of the provider incident report revealed that on11/13/14 at 12:00 a.m.; LVN A took Resident #1's FSBS. After taking the resident's FSBS, LVN A recorded result as 316. LVN A administered 100 units of [MEDICATION NAME] Insulin to Resident #1. At 1:00 a.m., LVN A called DON and reported the medication error. LVN then called the NP, and noted that FNP stated to monitor the resident, recheck blood sugar every 1-2 hours, and give orange juice or milk to help elevate blood sugar. LVN A checked blood sugars at 1:3 0a.m, 2;30 a.m., 3:30 a.m., 6:00 a.m., called the FNP at 6:00 a.m. when Resident #1 FSBS was 21and resident was unresponsive, received order to transfer to ER. Resident #1 was transferred to ER via ambulance. Review of Resident #1's "Medication Record" dated 11/12/14-11/13/14 revealed at 12:00 a.m. the resident's blood sugar was 316 and 4 units of insulin was charted as administered. Review of nurses notes dated 11/13/14 at 6:50 a.m. revealed that LVN A charted " Resident (Resident #1) was given too much [MEDICATION NAME] for a blood sugar of 316 Contacted DON, and FNP about incident. FNP advised to monitor resident; recheck blood sugar every 1-2 hours, give orange juice or milk to help elevate blood sugar. 1:30 a.m. Blood sugar 62, resident given Hershey ' s chocolate and Dr. Pepper. 2:30 a.m. Blood sugar 111, resident resting comfortably in bed. Will continue to monitor. 3:30 a.m. Blood sugar 29, given fruit juice with 4 packs of sugar X 2; rechecked blood sugar 55. 6:00 a.m. Blood sugar 39, gave [MEDICATION NAME] (medication that increases blood sugar) at 6:15 a.m., rechecked blood sugar was 21. Resident given orange juice with 4 packs of sugar. 6:15 a.m. order received from FNP to send resident to medical center via ambulance. Blood sugar raised to 60, Ambulance arrived at 6:35 a.m., resident left via stretcher. " Nurse ' s notes are electronically signed with LVN B ' s name. Per interview with DON and LVN B at 2;30 p.m. on 12/1/14, it was LVN A that charted this nurse ' s note. Record review of LVN A ' s written statement made on 11/13/14 she stated " Read order for [MEDICATION NAME] wrong and gave 100 units for BS of 316. Realized my error when I went back to check medications. Contacted DON, and FNP. Received instructions to monitor blood sugar every 1-2 hours, and to give orange juice with sugar or milk due to kitchen being locked up. 1:30 a.m. gave resident (Resident #1) Hershey ' s chocolate and Dr. Pepper; rechecked blood sugar was 111. 3:30 a.m. Blood sugar was 29, gave fruit juice with 4 packets of sugar X 2.Rechecked 20 minutes later, blood sugar was 55. Resident was responsive 6:00 a.m. checked blood sugar, was 39 resident given [MEDICATION NAME] at 6:15 a.m., rechecked blood sugar was 21. Day shift had arrived and was giving orange juice with sugar, plus sugar under the tongue, resident was not responding. Called FNP for orders, sent to hospital. " Interview with FNP on 12/1/14 at 1:00 p.m. revealed that she had been called on 11/13/14 at 1:03 a.m. by LVN A to report a medication error. She was told that Resident #1 was given 100units of sliding scale insulin by mistake. She said " I asked her which insulin? And the nurse replied [MEDICATION NAME]. I gave an order for [REDACTED]. I responded with, you need to feed her a full meal now; a sandwich, peanut butter, Dr. Pepper, fruit, chips, and chocolate. LVN A stated that the kitchen was closed, so I asked her if she did not know how to make a sandwich? LVN A stated Ok. I gave orders to call me hourly with a report on the patient, take blood sugars hourly and PRN and to call me immediately with any changes. LVN A stated Ok. I received no calls from the facility. I called at 2:10 a.m., 3:14 a.m., 4:01 a.m., and 5:11 a.m. with no response, and no return calls, all my calls went to the answering machine. Between 6:20am and 6:40am I was called with a blood sugar of 21, patient unresponsive and foaming at the mouth. I asked why I was not called sooner and was told by LVN A that she was busy. I gave an order for [REDACTED]. " She further stated that she felt that this medication error resulted " in a serious medical situation and could have very seriously caused this patient to die. " She further stated that it was not okay to use the hypoglycemic protocol in this situation because this was not typical [DIAGNOSES REDACTED] but caused by an insulin error, which is why she gave such specific instruction on what to feed the Resident. Record review of standing hypoglycemic orders for Resident #1 reflects "blood sugar less than 60, treat for [DIAGNOSES REDACTED] (4oz OJ ith 2 tsp of sugar and repeat blood sugar in 1 hour, if no improvement call NP) ." Review of Resident #1 ' s hospital records from 11/13/14 Emergency Department Report indicates that the resident was responsive and alert when she was assessed by the ER physician at 7:07 a.m.. Her FSBS was 70 at that time after a D-50 IV push and initiating a D-10 IV (intravenous medication used to raise blood sugar) drip to elevate her blood sugar. The resident was stabilized and moved to a room for monitoring. She remained in hospital due to other health issues until 11/17/14 when she returned to the facility. The history and physical notation by FNP on 11/14/14 states Resident #1 was " found to have a blood sugar of 316, our sliding scale calls for 8 units of [MEDICATION NAME]. The patient was inadvertently given 100 units of [MEDICATION NAME]. The nursing home was given instructions to feed the patient a full meal, call me hourly with reports, check blood sugar hourly and as needed. The Plaza was called at 2:10 a.m., 3:14 a.m., 4:01 a.m., and 5:11 a.m. with no answer and no return phone call. At 6:48 a.m., The Plaza called me with a blood sugar of 21. The patient was unresponsive, foaming at the mouth, sent to the ER for evaluation. The patient was found to have blood sugar of 27, given D50 with minimal improvement of 50. The patient denied any acute problems on admission. Blood sugar then was 250. " Interview with Resident #1 on 12/2/14 at 11:30 a.m. revealed that she was not made aware that there had been a medication error, she stated she did not remember much, " except having to eat snacks a lot " , and that someone told her she was going to the hospital because her blood sugar was too low. Interview with the DON on 12/1/14 at 1:20 p.m. revealed that she had instructed LVN A to follow the FNP's orderd in regards to the medication error. She further stated the facility has since given an in-service on insulin administration as well as reading medication orders. She stated at this time, all nurses have been in-serviced. She further stated that she has given a test to each nurse over insulin types, onsets, and durations. She stated that upon her employment at this facility she has been giving a medication competency test at new hire orientation, which includes insulin. She stated she has worked backwards to ensure that all of the nurses that were here prior to her employment and have them take this competency test. She stated LVN A was placed on suspension pending investigation, then was terminated. Record review of a witness statement provided by CNA A on 12/3/14 revealed that she had been working on the 10p-6a shift of 11/12/14-11/13/14. She stated that she had been asked by LVN A to find a snack for Resident #1 because she had been given too much insulin. There were no snacks in the fridge, found ice cream in the freezer and made a small cup for Resident #1 ....CNA B came into the room with me and gave Resident #1 rice cakes with peanut butter. Resident #1 was awake and eating when I left the room to make rounds. " Record review of a witness statement provided by LVN C on 12/3/14 revealed that she was working the 10p-6a shift on the night of 11/12/14-11/13/14. She stated that she was aware of the insulin error. She stated " The kitchen was locked and there were no snacks or milk in the ice room refrigerator. Fruit juice was available and was given to the patient with added sugar. " In an interview with the DON on 12/2/14 at 11:00 a.m. she stated that she had checked the nutrition room refrigerator when she arrived to work around 8:00 a.m. on 11/13/14, and there had been juices, fruit, applesauce, and other snacks available. Review of LVN A ' s employee file revealed that she had taken a Licensed Nurse Orientation-Medication Test on 6/18/14 and a Licensed Nurse Orientation-Skills Test on 6/18/14, passing grade on both test. Review of the facilities Abuse and Neglect Clinical Protocol dated April 2007 reflects that; "Neglect " means the failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facilities Insulin Administration Policy dated April 2007 reflects that; Preparation: ....The type of insulin, dosage requirements, strength, and method of administration must be verified before administration to assure that it corresponds with the order on the medication sheet and the physicians order .... Steps in the Procedure: ....Check blood glucose per physician order [REDACTED]. Check the order for the amount of insulin. Double check the order for the amount of insulin. Recheck the amount of insulin drawn into the syringe matches the amount of insulin ordered. ... Interview with LVN D on 12/2/14 at 11:50 a.m. revealed that she had been tested and in-serviceda on insulin administration and orders on 11/18/14.She also stated that they had in-serviced the nursing staff over protocol in hyposglycemic and medication error situations. Interview with LVN B on 12/1/14 at 2:30 p.m. revealed that she had been tested and in-serviced on insulin administration and orders since this incident. She stated "It was mandatory we all have had to do it." Interview with LVN E on 12/2/14 at 12:00 p.m. revealed that she had been tested and in-serviced on insulin administration and orders sometime in mid october, "I can't remember the exact date, but it happened right after this incident with Resident #1.Interview with LVN D on 12/2/14 at 11:55 a.m. revealed that she had been tested and in-serviced on insulin. Multiple attemtps were made to contact LVN A on 12/1/14 -12/2/14 for an interview, none were successful. On 12/20/13 at 3:13 p.m. the facility administrator was notified the findings were past non-compliance immediate jeopardy, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of this investigation survey. According to a facility generated report for Medication orders-Insulin, generated on 12/1/14, there are 33 diabetic residents with MEDICATION ORDERS FOR [REDACTED]

Based on interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 10 residents reviewed for neglect (Resident #1). The facility failed to provide Resident #1 with care and services to ensure her safety and well-being. Resident #1 was given 100units of sliding scale insulin (medication that reduces blood sugar) instead of the physician ordered 4units. The facility failed to have adequate food and snacks available for the residents. This failure resulted in Resident #1 having very low blood sugar, and became unresponsive. This further resulted in Resident #1 having to be transferred by Emergency Medical Personnel to the hospital's emergency room . This failure was determined to be past non-compliance immediate jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of this investigation survey. This failure, could affect 33 residents, who had a [DIAGNOSES REDACTED]. Findings included: Review of the facilities Abuse and Neglect Clinical Protocol dated April 2007 reflects that; "Neglect " means the failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facilities Insulin Administration Policy dated April 2007 reflects that; Preparation: ....The type of insulin, dosage requirements, strength, and method of administration must be verified before administration to assure that it corresponds with the order on the medication sheet and the physicians order .... Steps in the Procedure: ....Check blood glucose per physician order [REDACTED]. Check the order for the amount of insulin. Double check the order for the amount of insulin. Recheck the amount of insulin drawn into the syringe matches the amount of insulin ordered. ... Resident #1 is an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 was cognitively intact, and she required one person ' s physical assistance for her activities of daily living. Review of Resident #1's Physician order [REDACTED]. "[MEDICATION NAME] 100units/ml sub-Q (insulin [MEDICATION NAME]) per sliding scale 5 times per day. (12:00am, 7:00am, 11:00am, 4:00pm, and 10:00pm) - 61-150 = 0 units, - 151-200 = 1 units, - 201-250 = 2 units, - 251-300 = 3 units, - 301-350 = 4 units, - 351-400 = 5 units, - 401-450 = 6 units, - 451-500 = 7 units, - 501-550 = 8 units, - (above) 551 = 9 units then call MD (doctor)." Record review of the provider incident report revealed that on11/13/14 at 12:00 a.m.; LVN A took Resident #1's FSBS. After taking the resident's FSBS, LVN A recorded result as 316. LVN A administered 100 units of [MEDICATION NAME] Insulin to Resident #1. At 1:00 a.m., LVN A called DON and reported the medication error. LVN then called the FNP, and noted that FNP stated to monitor the resident, recheck blood sugar every 1-2 hours, and give orange juice or milk to help elevate blood sugar. LVN A checked blood sugars at 1:30 a.m., 2:30 a.m., 3:30 .a.m., 6:00 a.m., called the FNP at 6:00 a.m. when Resident #1 FSBS was 21and resident was unresponsive, received order to transfer to ER. Resident #1 was transferred to ER via ambulance. Review of Resident #1's "Medication Record" dated 11/12/13-11/13/14 revealed at 12:00 a.m. the resident's blood sugar was 316 and 4 units of insulin was charted as administered. Review of nurses notes dated 11/13/14 at 6:50 a.m. revealed that LVN A charted " Resident (Resident #1) was given too much [MEDICATION NAME] for a blood sugar of 316 Contacted DON, and FNP about incident. FNP advised to monitor resident; recheck blood sugar every 1-2 hours, give orange juice or milk to help elevate blood sugar. 1:30 a.m. Blood sugar 62, resident given Hershey ' s chocolate and Dr. Pepper. 2:30 a.m. Blood sugar 111, resident resting comfortably in bed. Will continue to monitor. 3:30 a.m. Blood sugar 29, given fruit juice with 4 packs of sugar X 2; rechecked blood sugar 55. 6:00 a.m. Blood sugar 39, gave [MEDICATION NAME] (medication that increases blood sugar) at 6:15 a.m., rechecked blood sugar was 21. Resident given orange juice with 4 packs of sugar. 6:15 a.m. order received from FNP to send resident to medical center via ambulance. Blood sugar raised to 60, Ambulance arrived at 6:35 a.m., resident left via stretcher. " Nurse ' s notes are electronically signed with LVN B ' s name. Per interview with DON and LVN B on 12/1/14 at 2:30 p.m., it was LVN A that charted this nurse ' s note. Record review of LVN A ' s written statement made on 11/13/14 she stated " Read order for [MEDICATION NAME] wrong and gave 100 units for BS of 316. Realized my error when I went back to check medications. Contacted DON, and FNP. Received instructions to monitor blood sugar every 1-2 hours, and to give orange juice with sugar or milk due to kitchen being locked up. 1:30 a.m. gave resident (Resident #1) Hershey ' s chocolate and Dr. Pepper; rechecked blood sugar was 111. 3:30 A.M. Blood sugar was 29, gave fruit juice with 4 packets of sugar X 2.Rechecked 20 minutes later, blood sugar was 55. Resident was responsive 6:00 a.m. checked blood sugar, was 39 resident given [MEDICATION NAME] at 6:15am, rechecked blood sugar was 21. Day shift had arrived and was giving orange juice with sugar, plus sugar under the tongue, resident was not responding. Called FNP for orders, sent to hospital. " Interview with FNP on 12/1/14 at 1:00 p.m. revealed that she had been called on 11/13/14 at 1:03 a.m. by LVN A to report a medication error. She was told that Resident #1 was given 100units of sliding scale insulin by mistake. She said " I asked her which insulin? And the nurse replied [MEDICATION NAME]. I gave an order for [REDACTED]. I responded with, you need to feed her a full meal now; a sandwich, peanut butter, Dr. Pepper, fruit, chips, and chocolate. LVN A stated that the kitchen was closed, so I asked her if she did not know how to make a sandwich? LVN A stated Ok. I gave orders to call me hourly with a report on the patient, take blood sugars hourly and PRN and to call me immediately with any changes. LVN A stated Ok. I received no calls from the facility. I called at 2:10 a.m., 3:14 a.m., 4:01 a.m., and 5:11 a.m. with no response, and no return calls, all my calls went to the answering machine. Between 6:20 a.m. and 6:40 a.m. I was called with a blood sugar of 21, patient unresponsive and foaming at the mouth. I asked why I was not called sooner and was told by LVN A that she was busy. I gave an order for [REDACTED]. " She further stated that she felt that this medication error resulted " in a serious medical situation and could have very seriously caused this patient to die. " She further stated that it was not okay to use the hypoglycemic protocol in this situation because this was not typical [DIAGNOSES REDACTED] but caused by an insulin error, which is why she gave such specific instruction on what to feed the Resident. Record review of standing hypoglycemic orders for Resident #1 reflects "blood sugar less than 60, treat for [DIAGNOSES REDACTED] (4oz OJ ith 2 tsp of sugar and repeat blood sugar in 1 hour, if no improvement call NP) ." Review of Resident #1 ' s hospital records from 11/13/14 Emergency Department Report indicates that the resident was responsive and alert when she was assessed by the ER physician at 7:07 a.m.. Her FSBS was 70 at that time after a D-50 IV push and initiating a D-10 IV (intravenous medication used to raise blood sugar) drip to elevate her blood sugar. The resident was stabilized and moved to a room for monitoring. She remained in hospital due to other health issues until 11/17/14 when she returned to the facility. The history and physical notation by FNP on 11/14/14 states Resident #1 was " found to have a blood sugar of 316, our sliding scale calls for 8 units of [MEDICATION NAME]. The patient was inadvertently given 100 units of [MEDICATION NAME]. The nursing home was given instructions to feed the patient a full meal, call me hourly with reports, check blood sugar hourly and as needed. The Plaza was called at 2:10 a.m., 3:14 a.m., 4:01 a.m., and 5:11 a.m. with no answer and no return phone call. At 6:48 a.m., The Plaza called me with a blood sugar of 21. The patient was unresponsive, foaming at the mouth, sent to the ER for evaluation. The patient was found to have blood sugar of 27, given D50 with minimal improvement of 50. The patient denied any acute problems on admission. Blood sugar then was 250. " Interview with Resident #1 on 12/2/14 at 11:30 a.m. revealed that she was not made aware that there had been a medication error, she stated she did not remember much, " except having to each snacks a lot " , and that someone told her she was going to the hospital because her blood sugar was too low. Interview with the DON on 12/1/14 at 1:20 p.m. revealed that she had instructed LVN A to follow the FNP's orderd in regards to the medication error. She further stated the facility has since given an in-service on insulin administration as well as reading medication orders. She stated at this time, all nurses have been in-serviced. She further stated that she has given a test to each nurse over insulin types, onsets, and durations. She stated that upon her employment at this facility she has been giving a medication competency test at new hire orientation, which includes insulin. She stated she has worked backwards to ensure that all of the nurses that were here prior to her employment and have them take this competency test. She stated LVN A was placed on suspension pending investigation, then was terminated. Record review of a witness statement provided by CNA A on 12/3/14 revealed that she had been working on the 10p-6a shift of 11/12/14-11/13/14. She stated that she had been asked by LVN A to find a snack for Resident #1 because she had been given too much insulin. There were no snacks in the fridge, found ice cream in the freezer and made a small cup for Resident #1 ....CNA B came into the room with me and gave Resident #1 rice cakes with peanut butter. Resident #1 was awake and eating when I left the room to make rounds. " Record review of a witness statement provided by LVN C on 12/3/14 revealed that she was working the 10p-6a shift on the night of 11/12/14-11/13/14. She stated that she was aware of the insulin error. She stated " The kitchen was locked and there were no snacks or milk in the ice room refrigerator. Fruit juice was available and was given to the patient with added sugar. " In an interview with the DON on 12/2/14 at 11:00am she stated that she had checked the nutrition room refrigerator when she arrived to work around 8:00am on 11/13/14, and there had been juices, fruit, applesauce, and other snacks available. Review of LVN A ' s employee file revealed that she had taken a Licensed Nurse Orientation-Medication Test on 6/18/14 and a Licensed Nurse Orientation-Skills Test on 6/18/14, passing grade on both test. Interview with LVN D on 12/2/14 at 11:50 a.m. revealed that she had been tested and in-serviceda on insulin administration and orders on 11/18/14.She also stated that they had in-serviced the nursing staff over protocol in hyposglycemic and medication error situations. Interview with LVN B on 12/1/14 at 2:30 p.m. revealed that she had been tested and in-serviced on insulin administration and orders since this incident. She stated "It was mandatory we all have had to do it." She stated she had completed hers on 11/18/14. Interview with LVN E on 12/2/14 at 12:00 p.m. revealed that she had been tested and in-serviced on insulin administration and orders sometime in mid october, "I can't remember the exact date, but it happened right after this incident with Resident #1. Multiple attemtps were made to contact LVN A on 12/1/14 -12/2/14 for an interview, none were successful. On 12/20/13 at 3:13 p.m. the facility administrator was notified the findings were past non-compliance immediate jeopardy, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of this investigation survey. According to a facility generated report for Medication orders-Insulin, generated on 12/1/14, there are 33 diabetic residents with MEDICATION ORDERS FOR [REDACTED]

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of 10 residents reviewed for medication errors. LVN A administered 100 units of sliding scale insulin ([MEDICATION NAME]) to Resident #1 for a FSBS of 316 when the physician's orders [REDACTED]. This failure affected one resident, (Resident #1), that was diabetic and received insulin during the 10pm-6am shift, and could affect the other 32 residents that receive insulin by placing them at risk for multiple organ failures, chest pain, hypertension, loss of sense of feeling in limbs, kidney failure, [MEDICAL CONDITIONS], a decrease in cognition, and death. This failure resulted in Resident #1 having very low blood sugar, and became unresponsive. This further resulted in Resident #1 having to be transferred by Emergency Medical Personnel to the hospital's emergency room . This was determined to be Past Non-compliance (PNC) Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. Findings included: Resident #1 is an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 was cognitively intact, and she required one person ' s physical assistance for her activities of daily living. Review of Resident #1's Physician order [REDACTED]. [MEDICATION NAME] 100units/ml sub-Q (insulin [MEDICATION NAME]) per sliding scale 5 times per day. (12:00 a.m., 7:00 a.m., 11:00 a.m., 4:00 p.m., and 10:00 p.m.) - 61-150 = 0 units, - 151-200 = 1 units, - 201-250 = 2 units, - 251-300 = 3 units, - 301-350 = 4 units, - 351-400 = 5 units, - 401-450 = 6 units, - 451-500 = 7 units, - 501-550 = 8 units, - (above) 551 = 9 units then call MD (doctor)." Record review of the provider incident report revealed that on11/13/14 at 12:00am; LVN A took Resident #1's FSBS. After taking the resident's FSBS, LVN A recorded result as 316. LVN A administered 100 units of [MEDICATION NAME] Insulin to Resident #1. At 1:00 am, LVN A called DON and reported the medication error. LVN then called the FNP, and noted that FNP stated to monitor the resident, recheck blood sugar every 1-2 hours, and give orange juice or milk to help elevate blood sugar. LVN A checked blood sugars at 0130, 0230, 0330, 0600, called the FNP at 6:00am when Resident #1 FSBS was 21and resident was unresponsive, received order to transfer to ER. Resident #1 was transferred to ER via ambulance. Review of Resident #1's "Medication Record" dated 11/12/13-11/13/14 revealed at 12:00am the resident's blood sugar was 316 and 4 units of insulin was charted as administered. Review of nurses notes dated 11/13/14 at 6:50am revealed that LVN A charted " Resident (Resident #1) was given too much [MEDICATION NAME] for a blood sugar of 316 Contacted DON, and FNP about incident. FNP advised to monitor resident; recheck blood sugar every 1-2 hours, give orange juice or milk to help elevate blood sugar. 1:30am Blood sugar 62, resident given Hershey ' s chocolate and Dr. Pepper. 2:30am Blood sugar 111, resident resting comfortably in bed. Will continue to monitor. 3:30am Blood sugar 29, given fruit juice with 4 packs of sugar X 2; rechecked blood sugar 55. 6:00am Blood sugar 39, gave [MEDICATION NAME] (medication that increases blood sugar) at 6:15, rechecked blood sugar was 21. Resident given orange juice with 4 packs of sugar. 6:15 order received from FNP to send resident to medical center via ambulance. Blood sugar raised to 60, Ambulance arrived at 6:35, resident left via stretcher. " Nurse ' s notes are electronically signed with LVN B ' s name. Per interview with DON and LVN B at 2:30 p.m. on 12/1/14, it was LVN A that charted this nurse ' s note. Record review of LVN A ' s written statement made on 11/13/14 she stated " Read order for [MEDICATION NAME] wrong and gave 100 units for BS of 316. Realized my error when I went back to check medications. Contacted DON, and FNP. Received instructions to monitor blood sugar every 1-2 hours, and to give orange juice with sugar or milk due to kitchen being locked up. 1:30 a.m. gave resident (Resident #1) Hershey ' s chocolate and Dr. Pepper; rechecked blood sugar was 111. 3:30 a.m. Blood sugar was 29, gave fruit juice with 4 packets of sugar X 2.Rechecked 20 minutes later, blood sugar was 55. Resident was responsive 6:00 a.m. checked blood sugar, was 39 resident given [MEDICATION NAME] at 6:15am, rechecked blood sugar was 21. Day shift had arrived and was giving orange juice with sugar, plus sugar under the tongue, resident was not responding. Called FNP for orders, sent to hospital. " Interview with FNP on 12/1/14 at 1:00 p.m. revealed that she had been called on 11/13/14 at 1:03 a.m. by LVN A to report a medication error. She was told that Resident #1 was given 100units of sliding scale insulin by mistake. She said " I asked her which insulin? And the nurse replied [MEDICATION NAME]. I gave an order for [REDACTED]. I responded with, you need to feed her a full meal now; a sandwich, peanut butter, Dr. Pepper, fruit, chips, and chocolate. LVN A stated that the kitchen was closed, so I asked her if she did not know how to make a sandwich? LVN A stated Ok. I gave orders to call me hourly with a report on the patient, take blood sugars hourly and PRN and to call me immediately with any changes. LVN A stated Ok. I received no calls from the facility. I called at 2:10 a.m., 3:14 a.m., 4:01 a.m., and 5:11 a.m. with no response, and no return calls, all my calls went to the answering machine. Between 6:20 a.m. and 6:40 a.m. I was called with a blood sugar of 21, patient unresponsive and foaming at the mouth. I asked why I was not called sooner and was told by LVN A that she was busy. I gave an order for [REDACTED]. " She further stated that she felt that this medication error resulted in " a serious medical situation and could have very seriously caused this patient to die." She further stated that it was not okay to use the hypoglycemic protocol in this situation because this was not typical [DIAGNOSES REDACTED] but caused by an insulin error, which is why she gave such specific instruction on what to feed the Resident. Record review of standing hypoglycemic orders for Resident #1 reflects "blood sugar less than 60, treat for [DIAGNOSES REDACTED] (4oz OJ ith 2 tsp of sugar and repeat blood sugar in 1 hour, if no improvement call NP) ." Review of Resident #1 ' s hospital records from 11/13/14 indicate that the resident was responsive and alert when she was assessed by the ER physician at 7:07 a.m. Her FSBS was 70 at that time after a D-50 IV push and initiating a D-10 IV (intravenous medication used to raise blood sugar) drip to elevate her blood sugar. The resident was stabilized and moved to a room for monitoring. She remained in hospital due to other health issues until 11/17/14 when she returned to the facility. The history and physical notation by FNP on 11/14/14 states Resident #1 was " found to have a blood sugar of 316, our sliding scale calls for 8 units of [MEDICATION NAME]. The patient was inadvertently given 100 units of [MEDICATION NAME]. The nursing home was given instructions to feed the patient a full meal, call me hourly with reports, check blood sugar hourly and as needed. The Plaza was called at 2:10 a.m., 3:14 a.m., 4:01 a.m., and 5:11 a.m. with no answer and no return phone call. At 6:48 a.m., The Plaza called me with a blood sugar of 21. The patient was unresponsive, foaming at the mouth, sent to the ER for evaluation. The patient was found to have blood sugar of 27, given D50 with minimal improvement of 50. The patient denied any acute problems on admission. Blood sugar then was 250. " Interview with Resident #1 on 12/2/14 at 11:30 a.m. revealed that she was not made aware that there had been a medication error, she stated she did not remember much, " except having to eat snacks a lot " , and that someone told her she was going to the hospital because her blood sugar was too low. Interview with the DON on 12/1/14 at 1:20 p.m. revealed that she had instructed LVN A to follow the FNP's orderd in regards to the medication error. She further stated the facility has since given an in-service on insulin administration as well as reading medication orders. She stated at this time, all nurses have been in-serviced. She further stated that she has given a test to each nurse over insulin types, onsets, and durations. She stated that upon her employment at this facility she has been giving a medication competency test at new hire orientation, which includes insulin. She stated she has worked backwards to ensure that all of the nurses that were here prior to her employment and have them take this competency test. She stated LVN A was placed on suspension pending investigation, then was terminated. Review of the facilities in-service records for Medication Errors reflect that all nurses had been inserviced by 11/21/14. Review of LVN A ' s employee file revealed that she had taken a Licensed Nurse Orientation-Medication Test on 6/18/14 and a Licensed Nurse Orientation-Skills Test on 6/18/14, passing grade on both test. Review of the facilities Insulin Administration Policy dated April 2007 reflects that; Preparation: ....The type of insulin, dosage requirements, strength, and method of administration must be verified before administration to assure that it corresponds with the order on the medication sheet and the physicians order .... Steps in the Procedure: ....Check blood glucose per physician order [REDACTED]. Check the order for the amount of insulin. Double check the order for the amount of insulin. Recheck the amount of insulin drawn into the syringe matches the amount of insulin ordered. ... Interview with LVN D on 12/2/14 at 11:50 a.m. revealed that she had been tested and in-serviceda on insulin administration and orders on 11/18/14.She also stated that they had in-serviced the nursing staff over protocol in hyposglycemic and medication error situations. Interview with LVN B on 12/1/14 at 2:30 p.m. revealed that she had been tested and in-serviced on insulin administration and orders since this incident. She stated "It was mandatory we all have had to do it." She stated she had completed hers on 11/18/14. Interview with LVN E on 12/2/14 at 12:00 p.m. revealed that she had been tested and in-serviced on insulin administration and orders sometime in mid october, "I can't remember the exact date, but it happened right after this incident with Resident #1. Multiple attemtps were made to contact LVN A on 12/1/14 -12/2/14 for an interview, none were successful. On 12/1/13 at 4:00 p.m. the DON was notified the findings were past non-compliance immediate jeopardy, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of this investigation survey. According to a facility generated report for Medication orders-Insulin, generated on 12/1/14, there are 33 diabetic residents with MEDICATION ORDERS FOR [REDACTED]