Every finding on record at Thrive Rehabilitation of Pearland

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 16.0% based on 4 errors out of 25 opportunities, which involved 2 of 4 residents (Resident #22 and Resident #82) reviewed for medication administration. 1. MA J failed to properly verify and dispense Furosemide (diuretic) according to physician's order with a start date of 01/10/2026 for Resident #22 when on 04/08/2026 MA J dispensed and was going to administer Resident #22 with two 80MG tablets instead of one 80MG tablets until surveyor intervention. 2. MA J failed to administer Calcium-Vitamin D 600-200 MG (supplement) according to physician's order with a start date of 03/17/2026 to Resident #22, when on 04/08/2026 MA J did not administer Calcium-Vitamin D supplement to Resident #22, resulting in a missed dose. 3. LVN A failed to properly verify and dispense Amantadine (antiparkinsonian) according to physician's order with a start date of 4/4/2026 for Resident #82 when on 4/8/2026 LVN A dispensed and administered approximately 16ml instead of 20ml resulting in insufficient amount. 4. LVN A failed to properly verify and dispense Doxazosin Mesylate (anti-hypertensive) according to physician's order with a start date of 4/4/2026 for Resident #82, when on 4/8/2026 LVN A administered additional 4mg on top of 8mg resulting in overdose. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.Findings included: Record review of Resident #22's face sheet dated 04/08/2026 revealed an [AGE] year-old female with an initial admission date of 01/10/2026. Resident #22 had diagnoses which included: end stage renal disease (permanent kidney failure), shortness of breath, chronic kidney disease and atherosclerotic heart disease (damage of the major blood vessels). Record review of Resident #22's MDS (Minimum Data Set) Medicare 5 days assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 8, which indicates the resident has moderate cognitive impairment with thinking and memory. Record review of Resident #22's medication administration record for April 2026 revealed an order with a start date of 01/10/2026 for Furosemide Oral Tablet 80 MG Give 1 tablet by mouth three times a day. and an order with a start date of 3/17/2026 for Calcium-Vitamin D Tablet 600-200 MG Give 1 tablet by mouth one time a day. During medication observation for Resident # 22 on 4/8/2026 at 9:41 Am, MA J dispensed 7 tablets into the medication cup for Resident #22. Prior to MA J entering resident's room, surveyor intervened and stopped MA J and counted the number of pills in the medication cup. Surveyor told MA J that there was an extra pill in the cup. MA J looked at the cup and said all the pills are correct. Surveyor told MA J to count again, and this time MA J identified that she had mistakenly dispensed 2 pills for Furosemide instead on 1 pill. Surveyor instructed MA J to read the instructions on the medication card for Furosemide which stated 80 MG give 1 tablet. MA J said she thought it was a 40 MG tablet and Resident # 22 should receive 2 pills to equal 80 MG. MA J removed the extra Furosemide pill and notified her nurse. MA J administered the correct number of medications to Resident #22. At 9:51 Am charge nurse LVN B discarded the extra pill. During an interview with MA J on 4/8/2026 at 9:50am, MA J stated she should verify the orders against the medication card to prevent errors. MA J stated Resident #22 could have an adverse effect and complication if medications were administered inaccurately. During record review and medication reconciliation it was identified MA J did not administer Calcium-Vitamin D 600-200 to Resident #22 during medication observation on 4/8/2026 at 9:41am. During an interview with the DON on 4/8/2026 at 3:05PM, DON reviewed electronic medication administration record (eMAR) for Resident #22 and stated Calcium-Vitamin D was not administered. DON stated MA J documented in eMAR that this medication was not available. DON stated this medication is over the counter medication and should be available and should not be skipped. DON stated her expectation is for nurses and medication aides to replenish their medication carts with over the counter medications accordingly. Record review of Resident #82's face sheet dated 04/07/2026 revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses include dysphagia following cerebral infarction (difficulty swallowing after a stroke), hypertension (condition where the force of blood pressure against the artery wall is consistently too high), cerebral infarction (a type of stroke caused by blockage of blood vessel leading to cell death due to lack of oxygen) and aneurysm of the ascending aorta without rupture (a weakened, balloon like bulging in the main artery leaving the heart). Record review of Resident #82's MDS Medicare 5 days Nursing Home PPS (NP) assessment dated [DATE] revealed under section C0500 a BIMS score of 99 which indicated resident was unable to complete the interview. Record review of Resident #82's of current physician order revealed an order with start date of 4/4/2026 for Amantadine HCL oral Solution 50MG/5 ML Give 20 ml via Peg tube one time a day. and an order with start date on 4/4/2026 for Doxazosin Mesylate Oral tablet 2MG Give 4 tablets via peg tube one time a day for essential hypertension . administer 4 tabs to = 8MG daily. During an observation of medication administration for Resident #82 on 4/8/2026 at 8:39AM, LVN A dispensed 16ml of Amantadine HCL in medicine cup and administered the medication via g-tube. LVN A dispensed 1 tablet of Doxazosin 8MG and 1 tablet of Doxazosin 4mg in individual pill cups and crushed each medication individually and administered via g-tube. After completing medication reconciliation, it was identified LVN A failed to read the orders correctly and administer the correct amount of Amantadine HCL and Doxazosin Mesylate. During an interview with LVN A on 4/8/2026 at 2:24 PM, she verified the eMAR for Resident #82 and stated there was no order for Doxazosin 4mg. LVN A stated resident should only be receiving 8mg of Doxazosin. LVN A stated she had administered more than Resident #82 required. LVN A stated this could place Resident #82 at risk for negative outcome. LVN A stated she will notify MD. During an interview with the DON on 4/8/2026 at 3:05PM, DON stated LVN A should read the orders correctly and verify the medication card prior to administering the medication. DON stated her expectation is for nurses to administer medications accurately to prevent negative outcomes and complications. DON stated she will do 100 percent cart audit to remove unnecessary medication, will review all medication orders during daily morning meetings and will notify MD. On 4/9/2026 at 9:15am DON stated Resident #82 was put on vital signs monitoring every 4 hours and assessed for any changes. Record review of the facility's job description for Nursing Licensed Vocational Nurse, dated May 2017, read in part . Position Summary: Under the direct supervision of a registered nurse, implements the established plan of care for each assigned group of residents. Responsibilities include. administration of medications .5. POSITION RESPONSIBILITIES/DUTIES: h. Administers medications in a proficient manner, including pain management .

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 observed for sanitization. The facility failed to ensure foods were properly stored, labeled, and dated. These failures placed all residents who consumed food served by the kitchen at risk of food-born illness. Observation of the kitchen on 4/7/2026 at 8:15 a.m. revealed the following: Insulated dome covers and bases and plates were stored on a 5-tiered shelf adjacent to the steam table and next to a floor drain. These stored items had crumb like beige particles noted over the insulated bases on the lowest shelf. There were two unopened packets of ketchup on the bottom shelf in between the insulated bases. There was a cup of white solution on the 3rd shelf covered undated or labeled. The floor area around the shelf was littered with particles on the floor. The shelf was not clean as evidenced by discoloration and particles adhered to the surface of the shelves. In the dry pantry, 3 packaged stacks of corn tortillas with an expiration date of 12/24/2024. One of the stacks was knotted closed without a dated label. In the dry pantry, a partially wrapped package of pasta that was opened to air without a label or date. In the dry pantry, a large clear bin filled with a white substance on the lowest shelf with a label with a handwritten dates that read 1/2/2026. Shelf life 1/6/2026 along with a barcode label that had a delivery date of 6/2/2025. Observation of the walk-in refrigerator on 4/7/2026 at 8:30 a.m. revealed the following: One container of peeled cooked eggs with an expiration date of 3/26/2026. One large gallon size Ziplock back that had solid red contents that was not labeled and dated.3 large plastic clear bins filled with a yellow solution inside that were not labeled and dated.2 white buckets of Rich's chocolate stacked on top of each other with an expiration date of 12/28/2025. Both buckets had furry black spots 1-2 cm in diameter circular areas over the sides and lids. Observation of walk-in freezer on 4/7/2026 at 8:44 a.m. revealed the following: A package of unknown white cubed contents wrapped in clear wrapping that was not labeled or dated and opened to air. One gallon size Ziploc bag of unknown red contents that was not labeled or dated.One bag of Mozzarella breadsticks that was opened to air without a label or date. During an interview on 4/7/2026 at 9:26 a.m., the Head [NAME] stated the kitchen staff did not have a dietary manager. The head [NAME] stated she had worked at the facility for 3 years. The Head [NAME] stated that the former dietary manager's last day was 4/6/2026. The Head [NAME] stated that it is a team effort to keep the kitchen clean, and to discard expired foods. The Head [NAME] stated that whoever opened a food item is responsible for labeling and dating it. The Head [NAME] stated she was not aware of expired, unlabeled and undated food in the pantry, refrigerator, or freezer. The Head [NAME] stated that the three bins of yellow liquid in the refrigerator were lemonade made 4/6/2026 to be served on 4/7/2026. The Head [NAME] stated the lemonade should have been labeled and dated. The Head [NAME] stated the former manager took items out of their boxes and did not label or date food items in the freezer. During an interview on 4/7/2026 at 11:45 am, Dishwasher A stated he worked intermittently at the facility since November 2025. Dishwasher A stated he was not responsible for storing, labelling or dating food items. During an interview on 4/9/2026 at 10:16 a.m., [NAME] A stated she had worked at the facility for one year. [NAME] A stated that all food items that were opened should be dated and labeled. [NAME] A stated that she was not aware of expired food in the kitchen or food being stored without a proper label with date. [NAME] A stated the Head [NAME] trained her for her position as a cook. [NAME] A stated whoever opens food should label and date it. [NAME] A stated if residents ate expired foods it could lead to sickness. During an interview on 4/9/2026 at 10:21 a.m., [NAME] B stated he had worked at the facility for 5-6 months. [NAME] B stated that he was not aware of expired food in the kitchen or food being stored without a proper label with date. [NAME] B stated the training he received from the facility was given by his former manager. [NAME] B stated whoever opens food should label and date it. [NAME] B stated the risk to residents of eating expired food could lead to infection, sickness, or death. During an interview on 4/9/2026 at 10:30 a.m., the Tray Aide stated he had worked at the facility since July 2025. The Tray Aide stated that his main duties include assembling the trays. The Tray Aide stated that he washed dishes at night sometimes and was trained for position by another kitchen employee who no longer works at the facility. The Tray Aide stated the risks to residents of eating expired food could lead to infection, sickness, or death. During an interview on 4/9/2026 at 10:54 a.m., the Interim Administrator stated the newly hired dietary manager would begin his role officially on 4/15/2026. The Administrator stated that the previous dietary manager left the faciity on 4/6/2026. During an interview on 4/9/2026 at 12:27 p.m., the Head [NAME] stated that she had helped train [NAME] A. The Head [NAME] stated the former manager trained all other kitchen staff. The Head [NAME] stated the risk to residents of eating expired food was sickness, infection, or death. During an interview on 4/9/2026 at 12:50 p.m. the Interim Administrator stated that dietary manager was responsible for training kitchen staff in their duties. The Interim Administrator stated that he does not know where training records are located for kitchen staff. The Interim Administrator stated the dietician was a resource for kitchen staff. The Interim Administrator stated the risks to residents of eating expired food were infections. During an interview on 4/9/2026 at 3:20 pm, the Dietician stated he worked for the facility for 2 years. The Dietician stated she was considered PRN and visited the facility 2-3 times a week. The Dietician stated her duties included being present for IDT meetings, completing nutritional assessments, kitchen audits, and orientating dietary members. The Dietician stated that the Dietary manager was responsible for training kitchen staff. The Dietician stated the former dietary manager had a scheduled of audits he would perform which included checking for proper labeling and dating of food items. Record review revealed the Head [NAME] had a certificate labeled Food Handler Essentials Course issued on August 9, 2025, issued by StateFoodSafety. Record review revealed [NAME] A had a certificate labeled Food Handler Essentials Course issued August 2, 2025, valid for 2 years issued by StateFoodSafety. Record reviewed revealed Tray Aide had a certificate labeled Food Handler Essential Course issued August 9, 2025, valid for 2 years issued by StateFoodSafety. Record reviewed revealed certificates issued by StateFoodSafety included training on how to responsibly prepare and store food, prevent foodborne illness, and maintain a sanitary food preparation environment. Record review revealed [NAME] B had a certificate labeled Food Handler Training Program issued on 10/25/2023 by SafeStaff with an expiration date of 10/25/2026. Record review of facility policy titled Food Storage Principles dated April 2020 read in part, 3. Proper food storage is essential for preserving food quality. This applies to foods stored prior to preparation, and also to prepared foods (leftovers) placed in storage.3. Label each package, box, can, etc. with the expiration date, date of receipt, or when the item was stored after preparation.discard foods that have exceeded their expiration date.discard leftover foods that have not been used within 48 hours of preparation.keep food storage areas clean and free of spills and leaks.

Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided a PASRR level II evaluation for 2 of 4 (Resident # 17 and Resident #4) residents reviewed for resident assessments.The facility failed to correctly identify Resident #17 and Resident #4 as having a mental illness in their PASRR Level 1 Screening and completing a PASRR Level II.This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and therapy services in the appropriate setting.Findings included:Resident # 17Record review of facility face sheet revealed Resident # 17 was a [AGE] year-old female with an initial admission date of 9/17/2025. Resident # 17's primary diagnosis upon admission were Epilepsy (a brain condition that causes recurring seizures), as well as Schizophrenia (a serious mental health condition that affects how people think, feel, and behave), Hemiplegia (severe or complete paralysis) and Hemiparesis (mild to moderate weakness) following Nontraumatic Intracerebral Hemorrhage (a severe type of stroke caused by bleeding with brain tissue) affecting left non-dominate side and Cognitive Communication Deficit.Record review of Resident #17's Quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment and detailed active diagnoses of Seizure Disorder or Epilepsy and Schizophrenia.Record review of Resident #17's Care Plan dated 1/27/2026 revealed focus area related to medication for seizure control and Schizophrenia manifested by hallucinations as well as focus area related to left-sided Hemiplegia.Record review of Resident #17's orders revealed medication Olanzapine (treatment for Antipsychotic with behaviors of hallucinations) order date 9/17/2025 and Keppra Oral Solution (treatment for seizures) order dated 1/15/2026.Record review of Resident #n17's PASRR dated 9/17/2025 indicated in Section C NO to Is there evidence or an indicator that this is an individual that has a Mental illness and NO to Is there evidence or an indicator that this is an individual that has a Developmental Disability. No additional or updated PASRR was located or completed for this resident. Resident# 4Record review of facility face sheet revealed Resident #4 was an [AGE] year-old-female with an initial admission date of 4/17/2023 and current admission date of 3/5/2026. Resident #4's primary diagnosis upon admission were Acute Pyelonephritis (a sudden bacterial infection of one or both kidneys), as well as Psychotic Disorder with Delusions (a type of mental health condition in which a person cannot tell what is real from what is imagined) due to known Physiological Disorder (an abnormal physical function or alteration in the body's organs) and Bipolar (a chronic mental health condition characterized by severe mood swings ranging from extreme highs to intense lows).Record review of Resident #4's MDS dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment and detailed active diagnoses of Bipolar and Psychotic Disorder.Record review of Resident #4's care plan dated 3/6/2026 revealed focus area related to medication for bipolar disorder.Record review of Resident #4's medication orders for Risperdal (treatment for bipolar disorder) order date 12/31/2025.Record review of Resident # 4 PASRR dated 4/17/2023 and additional PASRR dated 7/28/2023 indicated in Section C NO to Is there evidence or an indicator that this is an individual that has a Mental illness and NO to Is there evidence or an indicator that this is an individual that has a Developmental Disability. No additional or updated PASRR was located or completed for this resident.Interview on 4/9/2026 at 9:30 am and 4:43pm with Social Services stated Nursing Department looks over any discharge information or hospital records for a new admit regarding diagnoses and care needs. Social services looked over any hospital records for new admits to complete parts of the MDS and review PASRR from previous facility or complete if not coming from a previous facility. Social Services stated if a resident has a change in condition or a history of aggression, sexual abuse, mental disorders then a PASRR Level II screening would be completed. Social Services reviewed records of Resident # 17 current and admitted diagnosis of Epilepsy and Schizophrenia and Resident # 4's current and admitted diagnosis of bipolar disorder. Social Services stated these diagnoses would require Level II PASRR and an updated Level I PASSR to reflect the mental illness. Social Services stated both residents were receiving services for Psychological Services with a contracted provider. Social Services stated he was not present at the facility when Resident #4 was admitted in April 2023 or Resident #17 in September 2025 to have reviewed their PASRR. Social Services stated residents that are short-term stay typically would not have a new PASRR unless the residents were transferred to another facility or a change in conditions happens. Social Services stated residents were not at risk of not receiving services due to having therapy services with a contracted provider.Interview on 4/9/2026 at 2:08pm with the DON she stated her expectations for completing the PASRR Level I and Level II were to follow the policy from the RAI manual. DON stated she has been at the facility for 4 days and was not aware of the incorrect PASSR for Resident #17 or Resident #4.Interview on 4/9/2026 at 2:32 pm with MDS Nurse she stated she began working with the facility December 2025. MDS Nurse reviewed records of Resident #4 had a Bipolar diagnosis in [DATE]. MDS Nurse stated Section C of the PASRR should have been changed in July of 2023 to reflect most recent PASRR date for Resident #4. MDS Nurse reviewed records of Resident # 17's diagnosis of Schizophora. MDS Nurse stated a Level II PASRR would not be eligible for Resident #17 due to being private pay, however Resident #17 would still need outside services for her diagnosis. MDS Nurse stated they (MDS, Nursing, Social Services) are to review Level I PASRR along with admitting diagnosis to verify information. MDS Nurse stated if a resident was at the facility for over 2 weeks, they are to redo PASRR and contact PASRR with any changes if needed. MDS Nurse stated she was not aware of Resident #17 or Resident #4 diagnoses due to not having access to notes/ records for either resident. MDS Nurse stated the purpose of PASRR Level II was to be sure residents get needed services like therapy and a PASRR that was not accurate could risk a resident not getting the services they needed.Interview on 4/9/2026 at 4:31 pm with Administrator he stated he began at the facility March 2026. He stated when there was an admission of a resident the documentation was reviewed by Social or Case management to see if there was a need for a PASRR Level II. Administrator stated his duties would be to review the PASRR was completed and accurately by the Social Worker or Care manager. Administrator said potential risks were services not being provided. He stated he was unsure of staff training for PASRR since he began at the facility.Record review of facility policy Pre-admission Screening and Resident Review (PASRR) dated December 2022 read in part The facility shall ensure that all prospective residents undergo the PASRR Level I screening before admission. If a Level I screening indicates the presence of SMI, ID, or DD, a PASRR Level II evaluation will be conducted before admission. The facility will comply with all state and federal regulations to ensure appropriate placement and services for PASRR-identified individuals.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #82) of 3 residents reviewed for enteral nutrition. -The facility failed to ensure LVN A followed the appropriate procedure for verifying tube placement, administering flushes and medication during enteral tube medication administration. -The facility failed to ensure LVN A inserted small amount of air into the tube to listen for stomach gurgling sound or aspirate stomach content to check for placement. -The facility failed to ensure LVN A used the appropriates amount of water to dilute medication and to flush in between medication administration. These failures could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #82's face sheet dated 04/07/2026 revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included dysphagia following cerebral infarction (difficulty swallowing after a stroke), hypertension (condition where the force of blood pressure against the artery wall is consistently too high), cerebral infarction (a type of stroke caused by blockage of blood vessel leading to cell death due to lack of oxygen) and aneurysm of the ascending aorta without rupture (a weakened, balloon like bulging in the main artery leaving the heart) Record review of Resident #82's MDS Medicare 5 days (Nursing Home PPS (NP) assessment dated [DATE] revealed under section C0500 a BIMS score of 99 which indicated resident was unable to complete the interview. Record review of Resident #82's clinical physician's order read in part .check tube placement before initiation of formula, medication administration and flushing tube. document residual. Hold feeding for residual >150. Record review of Resident #82's medication administration record for April 2026 read in part .flush feeding tube. 30cc of water before and after medication administration. During an observation of medication administration for Resident #82 on 04/08/26 at 8:39 a.m., LVN A took the following medications from the med cart to prepare for medication administration: Amantadine HCL 50mg/5ml give 20ml via g-tube every morning and evening, Amlodipine 10mg give 1 tab via g-tube daily, Amoxicillin-Pot Clavulanate Tablet 875-125mg take 1 cap via g-tube every 12 hours, Vitamin C 500mg take 1 tab twice daily, Donepezil HCL 10mg take 1 tab daily, Doxazosin Mesylate 8mg tab take 1 tab daily, Doxazosin 4mg take 1 tab daily, Metoclopramide 10mg take 1 tab every 6 hours. LVN A poured approximately 16ml of Amantadine HCL into the medicine cup and crushed the remaining tablets separately and poured into individual medicine cup. LVN A poured 5ml of water into each medication cup containing the crushed medication. LVN A put the plunger into the end of the g-tube and poured 30ml of water and let it flow via gravity. LVN A stated she uses 30ml of water before and after medication administration and 10 ml of water in between each medication. LVN A started administering each crushed medication one by one followed by 10ml of water in between each medication via flow of gravity. LVN A completed the medication administration with 30ml of water after administering the last crushed medication. LVN A turned around and looked at the individual medicine cups and stated there were residuals of the crushed medication remaining in some of the cups. 5 of the 8 medicine cups had residuals of the crushed medications. LVN A stated she should have brought a spoon to stir the crushed medications so that it was dissolved completely. LVN A stated she could not identify which were the medications that had the crushed medicine residual in the medicine cups. LVN A gathered more water and spoon. LVN A poured 5 ml of water into each of the 5 remaining cups and stirred the residual crushed medications to completely dissolve. LVN A proceeded to administer the remaining 5 residual crushed medications starting with 30ml water with 10 ml of water in between each medication and ending with 30 ml water. During an interview with LVN A on 4/8/26 at 9:15am, LVN A stated she did not check for placement prior to initiating medication administration. LVN A stated she did not aspirate stomach content. She stated she just looks at the water going down the g-tube and knows that the medications are going into the stomach. LVN A stated she was using the right amount of water to dilute the mediation and to flush in between medications. LVN A stated if the g-tube placement is not verified, Resident #82 could have complications from medications going into other areas. LVN A stated Resident #82 would not get the full benefit of his medications if there were residuals of crushed medications remaining in medicine cup. LVN A stated if the mediations are not dissolved completely, it could get stuck in the g-tube. LVN A checked the physician's orders for Resident #82 and stated she did not administer 20ml of Amantadine HCL as per physician's orders. LVN A stated Resident #82 will not get the full benefit of the prescribed medication if the correct amount is not administered. During an interview with the DON on 4/8/26 at 9:20am, DON stated she will need to verify the Enteral Feeding Policy to determine g-tube placement verification and water flushes for medication administration. DON stated it was important to check for placement prior to medication administration to prevent complications. DON stated she will work with pharmacy to change Resident #82's medication into liquid form to ensure Resident #82 receives the full amount of his medications. Record review of the facility policy titled POLICIES AND PROCEDURES - Pharmacy Services for Nursing Facilities 2006 - Specific Medication Administration Procedures IIB13: Enteral Tube Medication Administration read in part. The purpose: To safely and accurately administer oral medications through an enteral tube.Procedures:.#N. Verify tube placement, #13) Unclamp tube and use either of the following procedures: #a. Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope or gurgling sound; or #b. Aspirate stomach contents with syringe.#16) Crush tablet and dissolve in 30ml of warm water or other appropriate liquid.#T. Administer each medication separately, flushing tube with 5ml of water after each dose.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 2 (400 hall cart and 600 hall cart) out of 3 medication carts reviewed for labeling and storage of drugs.The facility failed to ensure Resident # 31's Ipratropim Bromide 0.02 mg/Albuterol sulfate (a medication that helps open the airways and reduces breathing difficulties) 2.5ml/3 ml inhalation solution was labeled with the expiration date and discarded after 14 days according to facility policy.The facility failed to ensure Resident #6's Ipratropium 0.02%/2.5ml (a medication that helps open the airways and reduces breathing difficulties) inhalation solution was labeled with the expiration date and discarded after 14 days and according to facility policy.The facility failed to ensure Resident #6's Levalbuterol 1.25 mg/3ml (a medication that helps open the airways and reduces breathing difficulties) inhalation solution was labeled with the expiration date and discarded after 14 days and according to facility policyThe facility failed to ensure Resident #6's Ipratropium Bromide 0.5 mg/Albuterol sulfate 2.5 mg/3ml (a medication that helps open the airways and reduces breathing difficulties) inhalation solution was unlabeled with the open date.These failures could place residents at risk of not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from expired prescribed medications. Record review of Resident #31's admission face sheet dated 4/9/2026 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included unspecified dementia (refers to cases where the specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss), unspecified respiratory disorder (broadly refers to any condition affecting the airways or lung tissue that prevents the respiratory system from functioning properly, resulting in symptoms like breathlessness, chronic coughing, or low oxygen levels), and essential hypertension (a type of high blood pressure that has no identifiable cause).Record review of Resident #6's admission face sheet dated 4/9/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Chronic respiratory failure (a long-term condition where the lungs cannot adequately transfer oxygen into the blood or remove carbon dioxide) and pleural effusion (abnormal buildup of excess fluid between the thin membranes lining the lungs and the chest cavity).During an observation on 4/8/2026 at 9:51 a.m. of the 400-hall medication cart with LVN D, Resident #31 had1. One opened box of Ipratropim Bromide 0.02 mg/Albuterol sulfate 2.5ml/3 ml with an opened foil packet inside with 3 vials inside with a written date of 1/16/2026.During an interview on 4/8/2026 at 9:55 a.m., LVN D stated she was not sure what the facility policy was on expiration of opened foil packet inhalation solutions. LVN D stated the risk to residents who received expired medication was residents not receiving the full relief of their symptoms.During an observation on 4/8/2026 at 10:15 a.m. of the 600-hall medication cart with LVN N, Resident #6 hadOne opened box of Ipratropium 0.02%/2.5ml inhalation solution with an opened foil packet with 2 vials and a written date of 3/18/2026.One opened box of Levalbuterol 1.25 mg/3ml inhalation solution with an opened foil packet with 2 vials and a written date of 3/14/2026.One opened box of Ipratropium Bromide 0.5 mg/Albuterol sulfate 2.5 mg/3ml inhalation solution with an undated opened foil packet with 4 vials inside. During an interview on 4/8/2026 at 10:20 a.m., LVN N stated opened foil packets of inhalation packets have an expiration date of 30 days but was not completely sure. LVN N stated she was not aware that Resident #6 had an undated medication in her cart. LVN N stated that the risk of administering expired medications to a resident included not getting the full intended benefit of the medication or adverse reactions. LVN N stated she had worked at the facility since 2025.During an interview on 4/9/2026 at 8:46 a.m., the DON stated that 4/9/2026 was her third day at the facility in the capacity as the DON. The DON stated she spoke to the facility's pharmacy who stated that opened foil packets of inhalation solution expired 14 days after opened. The DON stated that all opened foil packets of inhalation solutions expired 14 days and should be labeled with the opened date and expiration date. The DON stated that the risks involved with administering expired medications to residents included medication not being effective and continued symptoms.During an interview on 4/9/2026 at 9:45 a.m., the ADON stated that she had worked at the facility since September 2025. The ADON stated that opened foil packets of inhalation solutions have an expiration date of 14 days. The ADON stated the risk to residents of receiving expired medications was ineffectiveness of medication. The ADON stated that all nurses are expected to discard expired medication and to label medication with the opened and expiration date.During an interview on 4/9/2026 at 9:54 a.m., the DOD stated she helped conduct in-services for nurses and medication aides. The DOD stated that less than 2 weeks ago, she conducted an in-service on medication carts and when to remove medication from the cart. The DOD stated that opened foil packets of inhalation solutions expired in 14 days, but every medication has a different discard date. The ADON stated the risk to residents of receiving expired medication included less relief and ineffectiveness. The DOD stated the former DON checked medication carts every morning. The DOD stated that she does not use the recommendations from spot checks performed by the consultant pharmacy.Record review of facility policy titled Medication Storage Review not dated, read in part. Inhaled items must have date open on the inhaler itself or HHN foil packet.foil packets of HHN expire 14 days after foil open.Record review of facility policy titled Medication Storage in the Facility dated 2006, read in part. M. Outdated, contaminated, or deteriorated medication and those in containers that cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal.

Based on interview and record review, the facility failed to ensure that residents with pressure ulcers receive necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for wound care. The facility failed to ensure that CR#1, who was identified as being at risk for pressure ulcer development, received necessary preventative interventions to maintain skin integrity. CR#1 was admitted to the facility on [DATE] with skin intact but was an identified risk for pressure ulcers. On 02/02/26, CR#1 was placed in her comfort chair at 1:10 p.m. and remained there until the morning of 02/03/26 at an unknown time. CNA A observed an open dark purple wound on CR #1's sacrum at 6:15 a.m. while providing peri care on 02/03/26. On 02/04/26, The ADON identified the red open sore of CR#1's sacrum as a stage 2 pressure ulcer. These failures could place residents at risk for worsening skin break down, progression of the ulcer to more severe stages, and overall decline in quality of life Findings Include:Record review of CR #1's facesheet revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were dementia, senile degeneration of the brain (progressive decline of the brain), heart failure, encounter for palliative care (care that provides symptom relief, comfort, and support to people living with serious or chronic illness), body mass index 19.9 or less, bed confined, and a need for assistance with personal care. She was discharged on 02/07/26. Record review of CR #1's baseline care plan initiated 02/01/26 revealed the resident was to receive respite care and facility would maintain comfort related to hospice status until she returned to the community. Record review of CR#1's admission assessment under section J titled Integumentary System and Braden Skin Risk Score completed by LVN A on 02/01/26 revealed that CR#1's sensory perception was very limited, skin was occasionally moist, she was bedfast, friction and shear were a potential problem, and her mobility was very limited. Skin was documented as good/intact and no skin issues were identified. Under section G: Physical function, CR#1 was a 2 person assist with transfers and a one person assist with bed mobility. She also required total dependence of staff for locomotion, transfer, and bed mobility. Record review of CR#1's Braden Skin Assessments (tool used to assess the risk of developing pressure injuries, guiding preventative care) revealed one assessment was completed on 02/05/26 by the WCN. The assessment revealed that CR#1 had a very limited response to pressure related discomfort, she was bedfast, she had very limited ability to change and control her body position, had adequate nutrition, and had a potential problem of friction and shear. Scoring for this assessment ranged from 6-23. CR#1's Braden Skin assessment revealed a score of 13, meaning moderate risk for developing pressure ulcers. No admissions skin assessment was found in the assessments. Record review of CR#1's BIMS Assessment (assessment used to assess resident's cognitive function) revealed a score of 0 (severe impairment). Record review of CR#1 Nursing Order Note from the HRN revealed on 02/02/26 that CR#1 needed to be placed in a chair with arms several times daily and nystatin powder (used to treat fungal infection of the skin) should be used after each change. Record review of CR#1's progress notes revealed on 02/04/26 at 4:56 p.m. by the ADON revealed: This writer was called into the guest's room. Nurse aides reported an area on the guest's back. Noted an open abrasion lower mid coccyx, wound has crater but has dry tissue present in the wound bed. Zero drainage, no edema (swelling In the legs due to fluid buildup), no erythema (superficial reddening) to the surrounding skin. Area cleansed with moistened gauze, Zinc paste applied and top with Bordered gauze. Showed no s/s of pain and discomfort. Resting well. Staff placed her on her side with pillow tucked to the side for pressure relief measures. Calls made to Hospice to update the assigned nurse of new skin area. Record review of CR#1's skin observation tool completed on 02/04/26 by the ADON revealed an open abrasion on her lower coccyx. The wound bed was dry, no active drainage, and the wound had a crater with depth. Measurements were 2.2 x 1.4 cm and 0.2 depth. Record review of CR#1's orders revealed that wound care was initiated on 02/04/26. Orders revealed to cleanse the wound on mid lower coccyx (bone of the pelvis) with moistened gauze, apply zinc paste, top with bordered gauze daily, and a prn order was entered for dislodgement. On 02/05/26, a low air mattress was ordered, and CR#1 was ordered to start Vitamin C oral tablet and amino acids oral liquid. Record review of CR#1's skin observation tool completed on 02/06/26 by the ADON revealed a new coccyx wound found on 02/04/26 and reassessed on 02/06/26 with worsening, surrounding skin discolored, red/purple around entire lower buttocks, and the left butt cheek macerated (softened by soaking in liquid). The HRN updated. Record review of CR#1's care plan revealed that the care plan was closed from view until 02/06/26 (original admission [DATE] for periodic respite care services) and reopened by the ADON. The care plan was updated on 02/06/26 to include wound prevention. CR#1's care plan revealed that CR#1 had a stage 2 pressure ulcer on her sacrum r/t disease process hospice, diagnosis dementia, history of ulcers, and immobility. Interventions listed to avoid positioning the resident on sacrum. Record review of CR#1's Kardex tool (reference for essential patient information) for CNAs revealed to avoid positioning the resident on her sacrum and to follow the facility policies/protocols for the prevention/treatment of skin breakdown. Record review of CR#1's POC Response History for Task Chair/bed to chair transfer revealed on 02/02/26 at 1:10 p.m., CR#1 was transferred by CNA A and required partial/moderate assistance. On 02/03/26 at 1:10 am, CNA B documented an independent transfer, described as a transfer completed by CR#1 with no assistance from a helper. In an interview on 02/18/26 at 11:38 a.m., CR#1's FM stated that on 02/02/26, CR#1 was left in her chair overnight. She stated that CR#1 was last seen in the comfort chair in her room by FM2 around 6 p.m. When CNA A returned to work on the 6 a.m. to 6 p.m. shift on 02/03/26, CR #1 was sitting in the comfort chair where she had placed her during her 6 a.m. to 6 p.m. on 02/02/26. The FM stated herself and the HRN was informed by the ADON that CR#1 developed a stage 2 pressure ulcer on 02/04/26. The HRN was very mad because she did not have skin issues when she was admitted . She explained CR#1 to be very laid back and not combative. She stated that if CR#1 was left in the chair all night and said no when she was asked to get into bed, it was evident that staff did not come back around to ask again if she wanted to get into bed. In an interview on 02/18/26 at 11:47 a.m. with the HRN, he stated that he was CR#1's nurse and he had worked with CR#1 and her family for several months. On Monday 02/02/26, HRN spoke with CR#1's floor nurse and explained to him what needed to be done. He ordered for CR#1 to be moved from the bed to the chair several times a day so that she didn't get bed sores and they assisted her in the chair while the HRN was on site. When the HRN returned to the facility around 10:30 a.m. on 02/03/26, he stated that CR#1 was in bed and it took him 10 to 15 minutes to arouse her awake which was uncharacteristic of her. When she woke up, she looked exhausted and like she had been through the ringer. He asked CNA A if anything was wrong with CR#1, and CNA A stated that she found her in the chair that morning when she began her shift. The HRN stated that he had been taking clients at this facility for many years and he knew that staff did not wake residents up and take them out of bed very early in the morning. When the HRN informed the ADON that CR#1 had been left in the chair overnight, the first thing the ADON said was Who told you that?. The ADON told the HRN that when she asked CNA B why CR#1 was left in the chair overnight, that CNA B stated CR#1 refused to get out of the chair. The HRN stated that CR#1 was the easiest person to take care of and she would not have refused to do anything. He stated that if the nurse on the 6 p.m. shift would have been doing her rounds the night of 02/02/26, she would have seen her in the chair and CR#1 refusing care was an excuse. The HRN stated [CR#1] is senile, 94lbs, and 91 years. Are you a nurse or a doormat. Instead, CR#1 had to sleep in a hard plastic chair with plastic arms. He explained that the second to last time she stayed at the facility for respite care (November 2025), she developed a stage 1 pressure ulcer to her sacrum. She normally would stay for respite care at the facility for 3-4 days, but her last admission [DATE]- 02/07/26) was her longest stay. HRN stated that CR#1 had a stage 2 pressure ulcer that he measured at 1.5 x 1.5 cm. The HRN stated that he tried to obtain an air mattress from the hospice company but they told him no because CR#1 did not currently have a pressure ulcer. At the facility, he asked the ADON two times if CR#1 could have an air mattress and she told him no because she didn't have any pressure ulcers, although he informed her that she developed a wound prior to this admission. The HRN explained that he received a call on 02/03/26 that CR#1 had developed a pressure ulcer and on 02/04/26, they created treatment orders. When informed of the wound, the HRN did not complete a full body head to toe assessment but he checked her from the waist up. He explained that because she was acting out of character that morning, he was more so focused on her mental state and that is why he didn't do a head-to-toe assessment. In an interview on 02/18/26 at 12:11 p.m. CNA A stated that she worked Hall A on 02/02/26 from 6 a.m. to 6 p.m. She stated that when she spoke with the HRN, he told her that CR#1 liked to get up in the comfort chair and sit up. She told him okay and she sat her in the chair around 3pm. Before she left her shift at 6 p.m. she let her relief, CNA B, know that CR#1 was currently in her chair and she left. When CNA A returned to the facility on [DATE] at 6:15 a.m., she saw CR#1 in her chair and she was wearing the same clothes as the day before so she assumed that she had been in her chair overnight. Usually during shift changes, aides were supposed to disclose what happened during their shift, but she did not receive any new updates from CNA B. Once found in the chair, CNA A changed CR#1 and put her back into bed. She explained CR#1 to be easy to redirect and she was able to communicate sometimes. CNA A stated that when she worked with her on 02/02/26, her skin was discolored but she did not have any wounds on her bottom. On 02/03/26 after she found her in the chair that morning, her bottom had an open, dark purple wound on her sacrum. The ADON was notified and she informed CR#1's HRN. In an interview on 02/18/26 at 1:22 p.m., CNA B stated that she worked from 6 p.m. to 6 a.m. on 02/02/26. She explained that 02/02/26 was the first time she met CR#1. She sat in the comfort chair in her room and CNA B greeted her then continued with rounds. She came back to CR#1's room to attempt to change her (could not recall time) but she was not wet. She tried to talk to CR#1 but she was very sleepy. CNA B stated that when she tried to touch CR#1 she would lean back but she did not verbalize or say anything to her. She stated that she refused so she left her seated in the chair. During CNA B's last round around 4am, CR#1 was still sleeping in the chair. She could not recall if she changed her in the bed or the chair, but she said she made sure CR#1 was clean before she left and stated, I probably left her in the chair instead of getting her in the bed, but she was comfortable in that chair and it wasn't a dangerous situation. CNA B attempted to recall the sore on CR#1's bottom during peri care and stated that she thought the sore on her bottom was old because she had been doing this (CNA work) for a while. She stated that she did not review CR#1's medical history or her admitting paperwork so she could confirm the sore was old. When asked to describe how the wound looked, she responded that it was an open sore. CNA B denied informing LVN B, the ADON, DON or the oncoming aide, CNA B stated CR#1 had refused to get out of the chair or that there was a sore on her bottom. She could not state why she did not inform any other staff regarding the sore. In an interview on 02/18/26 at 1:06 p.m., RN A stated that she worked on 02/02/26 from 6 p.m.- 6 a.m. Her responsibilities as a night nurse included rounding on patients every 2 hours, patient care, and medication administration. She recalled that CR#1 was at the facility for respite care and she first saw her that night around 6pm. She stated that she was supposed to round every 2 hours with residents and when she saw CR#1 at 6 a.m., she stated that she thought she saw her in bed, but she could not confirm that. In an interview on 12/18/26 at 2:12 p.m., the ADON stated the DON was currently on personal leave. The ADON first met CR#1 on 02/02/26 and she could not remember if she changed her or an aide changed her, but she saw old scar tissue on her bottom. She described the scar tissue as dry skin located in the mid center of the sacrum and could not say why evidence of a pervious scar was not mentioned during the admission assessments. The ADON stated that the HRN informed the ADON and CNA A to not keep CR#1 in the bed and always put her in the recliner. The ADON reviewed the order that was written by the HRN and read aloud that the order said to place CR#1 in the comfort chair several times a day and she stated that the order could have been misinterpreted by staff to mean let CR#1 sleep in the chair. The ADON stated that CR#1 did not weigh a lot so sitting on anything for too long could be bad. The ADON stated that if a patient had poor mobility, was on morphine, and had impaired tissue perfusion, they could be at risk for developing skin issues, but not checking on CR#1 did not help. She explained that the care plan was not opened during admission because some staff members may have been intimidated by opening documents and that was something she would need to reeducate nurses on. The ADON stated her expectations of the night shift staff were to complete frequent rounds and make sure residents were turned and repositioned. In an interview on 12/18/26 at 3:16 p.m., CR#1's FM2 stated that she visited CR#1 in the facility on 02/02/26 at 5 p.m. and she was in the comfort chair inside her room. Record review of the facility's policy titled: Skin Breakdown, Prevention, and Management revised March 2017 documented that it was the goal of the nursing staff with the assistance of the IDT team (interdisciplinary team) using the nursing process to identify, assess, plan, prevent, intervene, and monitor progress of care for all residents at risk for developing and or developed any type of pressure or no pressure skin discoloration or breakdown.PURPOSE:To identify the presence of any pressure or non-pressure skin discoloration and/or breakdown.To identify the residents at risk for developing pressure ulcers, the level and nature of riskTo provide practice guidelines for assessment, prevention, intervention andmonitoring of pressure and non-pressure skin discoloration and/or breakdown.To ensure that all causes of pressure or non-pressure skin discoloration and/or breakdown are investigated and documented in a timely, thorough mannerPROCEDURE:1. Upon admission, all residents will receive an initial skin and risk assessment.a. A skin assessment will be completed upon admission for all resident, which will include pressure and non-pressure skin discoloration and/or any type of skin breakdown.b. A description of the residents' skin condition will be included in the nursing documentation upon admission and every shift for seventy-two (72} hours thereafter.c. The resident's risk for developing pressure ulcer will be assessed using the Braden Scale Skin Risk Assessment. The Braden Scale Skin Risk Assessment will be completed upon admission, weekly for four (4} weeks thereafter, quarterly thereafter and with any significant change of condition as defined by the RAI Manual. 2. The licensed nurse assigned to a resident who is identified to be at risk for developing pressure ulcer will initiate preventive measures. Preventive measures will be updated as often as the Braden Scale skin risk assessment is completed based on supported clinical practice guidelines. 3. Upon admission and when a resident is identified to have a pressure ulcer, non-pressure skin discoloration and/or skin breakdown, the licensed nurse will contact the attending independent licensed practitioner for any sites or area that requires any form of treatment.a. The licensed nurse assigned to the resident will assess, evaluate and initiate a change of condition nursing documentation to last for at least seventy-two (72) hours every shift.4. A Weekly Skin Condition Documentation Form will be initiated and completed for any non-pressure skin discoloration and/or skin breakdown. A weekly assessment will be completed until the non-pressure skin, discoloration and/or skin breakdown is resolved.5. An individualized care plan will be developed for residents at risk of developing! pressure ulcers and/or presence pressure and non-pressure skin discoloration ' and/or breakdown.a. An admission care plan for prevention must be developed within 24 hours of admission for residents with a Braden score of 8 or above.b. A comprehensive care plan pressure and non-pressure skin discoloration and/or breakdown will include pressure relieving devices, turning and appropriate positioning, incontinence management, and protection of the skin from moisture, nutrition and fluid intake.c. Care plan interventions for treatment of open skin, whether pressure or non-pressure skin discoloration and/or breakdown should include the treatment prescribed by the independent licensed practitioner and infection control precautions, if any. The care plan should also include the following interventions:a. Resident Choiceb. Advance Directivec. Repositioningd. Nutritional Interventione. Treatmentf. Support Surfaces and Pressure Redistribution

Based on interviews and record review the facility failed to promptly provide lab results outside of clinical reference ranges to the ordering practitioner for 1 (CR# 1) of 8 residents reviewed for lab services.The facility failed to report a critical Glucose level of 42 to the physician when CR #1 had a change in condition on 11/24/25. CR# 1 was pronounced deceased at the facility on 11/25/25 by EMS. An Immediate Jeopardy (IJ) was identified on 11/26/25. The IJ template was provided to the facility on [DATE] at 4:06 p.m. While the IJ was removed on 11/28/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.These failures could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death.Findings included:Record review of CR #1's undated face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of malignant neoplasm (cancerous tumor) of lower-inner quadrant of left female breast, secondary and unspecified malignant neoplasm of axilla (the space below the shoulder through which vessels and nerves enter and leave the upper arm) and upper limb lymph nodes, secondary neoplasm of bone, secondary neoplasm of unspecified adrenal gland, anemia (a condition of not having enough healthy red blood cells to carry oxygen to the body's tissues) in neoplastic disease, chronic combined systolic (congestive) and diastolic (congestive) heart failure, and acute kidney failure (rapid loss of the kidney's ability to remove waste). Further review of CR #1's face sheet under Advanced Directive indicated she was full code.Record review of CR #1's MDS dated [DATE] indicated she had a BIMS score of 15 indicating cognition was intact.Record review of CR #1's orders with a start date of 11/16/25 indicated vital signs to be taken every shift.Record review of CR#1's baseline care plan dated 11/6/25 revealed she needed nursing services for the following: wound management, pain management, laboratory testing, dialysis treatment, oncology, and physician services-other specialty/clinic follow-up appointment.Record review of CR #1's care plan dated 11/16/25 indicated she needed hemodialysis r/t ESRD. Interventions included: check and change dressing daily at access site, document. Do not draw blood or take B/P in arm with graft. Monitor labs and report to doctor as needed. Monitor vital signs/labs. Notify MD of significant abnormalities. The client is at risk of abnormal vital signs and labs r/t current diagnosis and conditions.Record review of progress note dated 11/24/25 at 8:00 pm entered by LVN B, read, late entry: guest was clean and dry at this time. Hands are cold to touch and O2 could not be obtained at this time. Guest responding verbally to baseline.Record review of progress notes dated 11/24/25 9:30pm by LVN B documented O2 obtained at this time. Hands are warm to the touch. Pulse oximetry measures 94% on RA.Record review of progress notes dated 11/25/25 12:54 am by LVN B documented Spoke with representative from Clinical Lab. Blood glucose measured 42. Blood was drawn at dialysis between 1:00pm-2:00pm. MD notified.Record review of the Lab Results Report dated 11/25/25 indicated a low critical glucose value of 42.During a telephone interview with the Family Member on 11/25/25 at 12:33 pm, the Family Member said a family friend was there to visit CR #1 around 8:00 pm on 11/24/25 and the family friend told her CR #1 was fine. The Family Member said RN A told her the last set of vitals for CR #1 were taken at 10:30 pm on 11/24/25.During a telephone interview with CNA B on 11/25/25 at 12:49 PM, she said she checked on CR #1 between 5:45 am to 5:50 am on 11/25/25. CNA B said she went into CR #1's room and told her I'm going to check on you before I leave. CR #1 responded to CNA B softly mmm, ok. CNA B said the last set of vitals for CR #1 were done around 10:00 pm on 11/24/25. CNA B said she had a hard time getting an O2 reading because CR #1's hands were extremely cold. CNA B said she reported this to LVN B. CNA B said she and LVN B even tried to take an O2 reading from CR #1's toes and that did not work. CNA B said LVN B went in about 30 minutes later and was able to take the O2 reading. During a telephone interview with LVN B on 11/25/25 at 12:59 PM, she said the last time she saw CR #1 was at 5:00 AM (11/25/25). LVN B said she peeked into the room and saw that CR #1 was sleeping, no vitals were taken at that time. LVN B said the night before on 11/24/25, she and CNA B had trouble getting an O2 reading for CR #1. LVN B said she waited and came back later and was able to get a reading, she said the O2 reading was above 92. LVN B said the chest x-ray was done last night on 11/25/25 between 1:45 am and 2:45 am, she could not remember the exact time.During an interview with CNA A on 11/25/25 at 10:54 AM, she said during shift change this morning (11/25/25), CNA B told her all residents in the 600 hall were checked at approximately 4:00 am and everyone was fine. CNA A said at 6:30 am she went to CR #1's room to take her vitals and she was not responsive. She said CR #1 was lying on her back in bed and her fingers were cool. CNA A said she told RN A that CR#1 was not responsive. CNA A said when EMS arrived, the EMTs had stated CR #1 had been gone awhile. CNA A said on 11/24/25, CR #1 was confused and anxious. CNA A said she immediately reported the change to RN A on 11/24/25. CNA A said CR #1 left for dialysis the morning of 11/24/24 and returned later that evening. She said CR #1 seemed more settled and not as anxious when she returned from dialysis.During a follow-up interview with CNA A on 11/26/25 at 11:00 am, she said CR #1's baseline was vibrant and responsive, she would be able to let staff know if something was wrong. CNA A said on the morning of 11/24/25, CR #1 was quite confused, and she was making statements that did not make any sense. CNA A said CR #1 would press the call light and she when entered her room, CR #1 did not need anything. CNA A said after she turned off the call light, and before she could exit the room, CR #1 would press the call light again. CNA A said this happened multiple times on the morning of 11/24/25. CNA A said when CR #1 returned from dialysis that evening, CR #1 was calmer, and she ate a little bit of her food which was normal for her. CNA A said the last time she saw CR #1 was towards the end of her shift (6:00 pm) and said CR #1 was calm, clean, and content.During an interview with RN A on 11/25/25 at 10:37 AM, she said she did her walking rounds on 11/25/25 at 6:00 am. RN A said she looked into CR #1's room from the doorway and CR #1 appeared to be sleeping. RN A said at 6:35 am, CNA B alerted her that she could not get vitals off CR #1 and CR #1 was cold. RN A immediately called for a crash cart, nursing backup and initiated CPR. RN A said she called 911 around 6:40 am and said it was not very long before EMS arrived because they were located right around the corner from the facility. RN A said when EMS arrived, they took over. RN A said the EMTs rolled CR #1 over and told her there was pooling of blood in her back and there was no use to do CPR anymore. She said EMS called the death at 7:05 am. RN A said the day before (11/24/25), CR #1 was not feeling well. RN A said the NP ordered for labs to be drawn at dialysis, CBC, BMP and ordered a stat chest x-ray. RN A said she did not document a change of condition because the NP was in the building, and the NP saw CR #1 that same day. RN A said CR #1 came back from dialysis at the end of her shift yesterday (11/24/25), at approximately 6:00 pm. RN A said the risk to the resident when they are not provided treatment in a timely manner could compromise their health and they could die.During a follow-up interview with the Family Member on 12/1/25 at 3:16 pm, the Family Member said no one had notified her about CR #1's change of condition on 11/24/25. The Family Member said about a week before CR #1 passed away, the MD had recommended for blood work to be taken at dialysis because the lab people were having a hard time drawing her blood. The Family Member said CR #1 had disappearing veins. The Family Member said RN A told her the night shift had a hard time taking CR #1's vitals on 11/24/25. The Family Member said CR #1 should have been checked at least every 2 hours because she had to be repositioned.During a telephone interview with the NP on 11/28/25 at 12:46 pm, she said on the morning of 11/24/25, RN A told her CR #1 was feeling weak. The NP said she ordered some labs and a chest x-ray. The NP said she saw CR #1 on 11/24/25 before she left for dialysis and CR #1 told her she was feeling ok. The NP said no one contacted her for the results of the x-rays or labs, but she did see the results the on her computer the next morning. The NP said a blood glucose level of 42 was a result she saw often. She said if CR #1 was on any type of medication for low blood glucose levels, she would have reviewed the medications and ordered an A1C . The NP said she could not recall CR #1 having medication for low blood glucose level. She said for a one-time low blood glucose level, the sample could have been sitting around for a while.During a follow-up telephone interview with LVN B on 11/26/25 at 11:39 AM, she said she attempted to contact the MD on 11/25/25 at about 1:00 am to let her know the lab results. LVN B said she could not get a hold of the MD, so she sent a text, but never got a response. LVN B said in the event of an emergency she would contact the DON. LVN B said when she saw the lab results, she thought that the low number for glucose was completely off because CR #1's blood was collected between 1 and 2 pm, and her blood was dialyzed. LVN B said the facility's lab technician picked up the blood 4 to 5 hours later. She said she did not attempt to call anyone else about the low blood glucose level. LVN B said she talked to CR #1 on the evening of 11/24/25 and she was at her baseline when she talked to her. LVN B said the risk to the resident when a critical lab result was not reported to the physician was theoretically their health could get worse from not feeling good, to getting rushed to the hospital, or even death. LVN B the same risks could apply to a resident when a change of condition occurred, and the resident was not closely monitored.During an interview with the DON on 11/25/25 at 4:59 PM, she said the CNAs take vitals for the nurses and med aides. The DON said if there was an abnormal reading from the vitals, the CNA would redo the vitals and if the reading was still abnormal, this would get reported to the nurse. The DON said the expectation for nurses when they are rounding was to get the report from the nurse for the previous shift; in the morning, the nurse should check that the resident was in bed, make sure they're breathing . She said in the afternoon when nurses make the rounds, they should be checking residents to see if they are awake and alert. The DON said the nurse should notify her or the MD if there were any abnormal readings or having trouble with getting a reading for vitals. The DON said when a critical lab result was not reported to the physician, the nurses should physically look at the resident to see if they were ok. She said if the lab results were skewed, the nurses may need to get another order for a lab draw to get a valid number. The DON said the risk to the resident when a critical lab result was not reported would result in a delay of care. The DON said the risk to the resident when a change of condition occurred, and the resident was not closely monitored was the resident would continue to decline.Interview with the Administrator on 11/26/25 at 4:00 pm, she said the system they used for CR #1 with having her blood drawn at dialysis instead of the facility was not a good one. She said CR #1 refused to get her blood drawn at the facility. The Administrator said LVN B should have called the DON first and then the Medical Director since she was unable to get a hold of the doctor. The Administrator said the risk to the resident when a critical lab result was not reported to the physician was, they could decline or die. The Administrator said the risk to the resident when a change of condition occurred, and the resident was not closely monitored was they could decline or die.Record review of the facility's Job Description for Licensed Vocational Nurse dated 05/2017 read in part . 6. Position Responsibilities/Duties: b. completes initial and ongoing assessments by gathering data in a timely manner, incorporating functional/development age factors into the assessment process. c. correctly differentiates between normal and abnormal clinical findings and intervenes in accordance with clinical standards of practice and per physician orders. f. proficiently and accurately monitors and reports resident condition changes to the Registered Nurse, attending physician, family, and interdisciplinary team members .Record review of the facility's policy titled Change of Condition, dated 08/2017 read in part . 1. Acute medical changes or any sudden or serious change in condition manifest by a marked change in physical, mental, and psychosocial status: a. Licensed nurse will notify the physician, b. If unable to contact attending physician or alternate physician, notify the Medical Director. c. Notify and inform legal surrogate for any change of condition. 2. Using the Interact Tool SBAR - notify physician for all signs and symptoms manifested by the patient. The form will be used to initiate change of condition documentation for any decline or improvement .On 11/26/25 at 4:06 p.m., the Administrator was informed that an Immediate Jeopardy situation was identified due to the above failures.The following Plan of Removal was submitted by the facility and accepted on 11/27/25 at 10:07 a.m.:The following was the Immediate Plan for Removal for F684 Quality of Care Version 2. 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies.1. Immediate Action: Upon discovery of CR #1 unresponsive on 11/25/25, RN A initiated CPR immediately after being notified by CNA B that no vital signs could be obtained. 911 was called at approximately 6:40 AM, and EMS assumed care upon arrival. When EMS determined the presence of post-mortem changes and pronounced death at 7:05 AM, the resident was respectfully prepared, and family/representatives were notified according to facility protocol.2. Immediate Action: RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition on 11/26/25. During this education, the DON/designee reviewed the Handoff Communication policy to clarify what are the expectations of correctly rounding residents at end and beginning of the shift.3. Immediate Action: CNA B and LVN B were provided with 1:1 education by DON/designee on how to obtain vital signs on 11/26/25 according to vital signs policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with both employees to clarify when immediate notification with licensed nurse or RN supervisor and/or physician notification is required for abnormal vital signs.4. Immediate Action: LVN B received 1:1 education from the DON/designee on the proper steps for reporting critical lab results and abnormal vital signs in accordance with the facility's Change of Condition policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with LVN B to clarify when immediate physician notification is required for critical labs and abnormal vital signs. The training education of LVN B reinforced the requirement to contact the Medical Director when the attending physician or NP is not available, ensuring timely escalation and resident safety. 5. Immediate Action: Inservice training was provided by DON/designee initiated on 11/26/2025 with all CNAs on when vitals signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 11/26/25 with 12 total CNAs attending and targeted completion date of 11/28/25. 6. Immediate Action: Inservice training was provided by DON/designee initiated on 11/26/2025 with all licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 11/26/25 with 10 total licensed nurses attending and targeted completion date of 11/28/25 with the following education:a. Completing change of condition evaluation for residentsb. Notifying physicians for any change of conditionsc. Notifying the party responsible for change of conditions.d. Notifying Medical Director in case of attending physician not answering calls.e. Reporting critical and abnormal lab results to physician or covering physicianf. Reporting abnormal vital signs to physicians or covering physiciansg. Performing walking rounds at beginning and end of shift were doorway check only are not permitted unless preferred by the patient.2. Governing Body - QAPI committeea. Immediate Action: During the ad hoc QAPI Committee meeting on 11/26/25, a root cause analysis (RCA) revealed multiple system-level factors that contributed to the poor medical event follow up which includes handoff communication issue, monitoring follow up, training and possible competency gaps and timely physician notification. The RCA identified the root cause as the proper communication and handoff follow up for identified care issues and physician notification for changes of conditions for any medical events.b. The NHA will oversee corrective actions initiated on 11/26/25 and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, medication administration pass audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action. c. Any new issues found during medical record audits and medication pass administration audit will be presented to the QAPI team members for immediate action. The DON will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.3. Specific staff involved in implementing the corrective actions.a. Team Members: Medical Director, Nursing Home Administrator (NHA), Director of Nurses (DON), Assistant Director of Nurses (ADON). Each member will perform:i. Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce medical events.ii. NHA: The NHA will oversee all corrective actions initiated on 11/26/25 and continue monthly reviews during QAPI meetings.iii. DON: The DON will oversee the investigation, reporting, and resolution of medication administration errors, ensuring patient safety and regulatory compliance. The DON will implement corrective actions, conduct audits, monitor staff adherence to policies, and collaborate with the ADON to provide ongoing training, reinforcing best practices in medication management.iv. ADON: This role will include educating staff and plays a critical role in addressing medical events intervention by providing targeted training and education to licensed nursing staff, ensuring compliance with facility policies and regulatory standards. The role includes conducting in-service sessions on proper medication administration, change of condition, overseeing competency evaluations, and implementing corrective action plans to prevent future errors while promoting a culture of accountability and continuous improvement.4. Identification of other residents who may need to be included (who may have been affected by the deficient practice:a. All residents were identified to be at risk for the identified deficient practice. On 11/26/2025, a random audit of all in-house patients was completed by DON/designee and found a total of 8 residents have abnormal vital signs that needed to be reported to physicians. i. A random audit of all vital signs taken on 11/26/2025 for all 60 residents completed by DON or designee showed that there was a total of 8 residents potentially affected by the deficient practice. The assigned licensed nurse completed a review of the abnormal vital signs and was reported to the attending physician. ii. A random audit of all vital signs taken on 11/24/25 for NOC shift when incident happened was completed by DON or designee using the exception report from EMR and showed that there was a total of 8 residents meeting criteria. The following reviews and interventions were conducted by the 8 residents:1. BP monitoring parameters for 1 resident that is not on antihypertensive medication were added after the physician was notified.2. BP monitoring parameters for 1 resident that is below 100 SBP after the physician was notified.3. PR parameter for 1 resident that is not on any ACE, ARBs , Calcium or beta blocker was added after physician notification.4. 2 resident triggered as abnormal but after review is within normal limits of resident range of BP.5. 3 residents had over 100 PR but have medications administered5. Systemic Changes and Measures:iii. System Change: Training in change of condition, monitoring and reporting.6. Systemic Changes and Measures:a. System Change: Training in change of condition, monitoring and reporting will be included for new hires and will be reviewed yearly by DON and DSD during the annual performance review. The annual training calendar will include change of condition monitoring for its annual in-service for licensed nurses and CNAs beginning the month of November 2025. b. System Change: Starting 11/26/25, the ADON/designee will conduct a random audit of residents with change of condition to determine that physicians were notified following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.c. System Change: Starting 11/26/25, the ADON/designee will conduct a random audit of residents with change of condition to determine that monitoring occurred for 72 hours following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.d. System Change: Starting 11/26/26, weekly for 2 weeks and monthly thereafter 3 months, a random verification of licensed nurses' knowledge and training will be conducted by ADON/designee using a mock change of condition drill to test responses of nurses on what conditions including abnormal vital signs will be reported to physicians. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.7. Training and Education Started on 11/25/2026 by DON and/or Designee.a. Immediate Action: RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition on 11/26/25.b. Immediate Action: CNA B and LVN B were provided 1:1 education by DON/designee on how to obtain vital signs on 11/26/25c. Immediate Action: LVN B was provided 1;1 education by DON/designee on reporting critical lab and reporting abnormal vital signs and on contacting Medical Director in case attending physician is not available.d. Immediate Action: Inservice training was provided by DON/designee initiated on 11/26/2025 with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 11/26/25 with 12 total CNAs attending and targeted completion date of 11/28/25e. Immediate Action: Inservice training was provided by DON/designee initiated on 11/26/2025 with all LNs. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 11/26/25 with 10 total LVN and RN's attending and targeted completion date of 11/28/25with the following education:i. Completing change of condition evaluation for residentsii. Notifying physicians for any change of conditionsiii. Notifying the party responsible for change of conditions.iv. Notifying Medical Director in case of attending physician not answering calls.v. Reporting critical and abnormal lab results to physician or covering physicianvi. Reporting abnormal vital signs to physicians or covering physiciansvii. Performing walking rounds at beginning and end of shift were doorway check only are not permitted unless preferred by the patient. Monitoring of the plan of removal included the following (11/27/25 - 11/28/25):Record review of in-service dated 11/26/25 provided by the DON indicated a verbal 1 on1 with CNA B covered vital signs- how to obtain, change of condition and when to notify nurse of abnormal vitals.Record review of in-service dated 11/26/25 provided by the DON indicated a verbal 1 on 1 with RN A that covered reporting change of condition, documenting all efforts made and providing a report to oncoming nurse, hand off communications. Rounds must include walking in the room and looking at residents to observe respiratory status and condition.Record review of in-service dated 11/26/25 provided by the DON indicated a verbal 1 on 1 with LVN B that covered what to do if no response from MD, critical labs and MD notification. Notify supervisor, DON, ADON, Administrator and Medical Director. Rounds must include walking in the room and looking at the guest.Record review of in-service dated 11/26/25 indicated all nursing staff covered how to perform vital signs.Record review of in-service dated 11/26/25 provided by the DON indicated all nursing staff went over the change of condition policy. Notification of doctor, RP, emergency contact. If primary doctor does not answer, Medical Director needs to be notified of COC. Notify DON and RP as well.Record review of in-service dated 11/26/25 provided by the DON indicated all nursing staff went over checking and reporting abnormal vitals, who to notify when a critical lab value is received, follow change of condition and call doctor for intervention, if doctor not available call Medical Director. All nursing staff went over the Handoff Communication & Rounds policy. Walking rounds must be done at the beginning and end of each shift with oncoming and outgoing nurses. Progress notes must be completed stating patient status.Record review of the IDT Meeting Sign-in sheet dated 11/26/25 indicated state concerns and root cause analysis were discussed. Attendees included the MD, Administrator, DON, ADON, MDS Nurse, and Unit Manager.Interviews were conducted on 11/27/25 -11/28/25 with all nursing staff (via phone and in person) on all shifts (6:00 am - 6:00 pm and 6:00 pm - 6:00 am) and included RN A, RN B, LVN B, LVN C, LVN D, LVN E, LVN F, MA A, CNA A, CNA B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, Wound Care Nurse, Unit Manager, DON, and Administrator to verify the in-services were conducted and to validate the staff understanding of the information presented to them. Nursing staff were able to identify the proper procedures to follow when a change of condition occurred in a resident, vitals could not be obtained, or when a resident had abnormal vitals. All licensed clinical staff knew when to complete a change of condition for a resident and who to notify, what to do when a critical lab result was reported and who to notify, and what a walking round should include and when to do a walking round. The Administrator was notified on 11/28/25 at 2:48 p.m., the Immediate Jeopardy was removed. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for dialysis.- The facility failed to ensure Resident #5 had a physician's order for hemodialysis (machine filters the blood when kidneys do not work) on 9/26/25, when he went to dialysis 3 x week on Tuesday, Thursday, and Saturday.This failure could place residents at risk of complications of hemodialysis, not receiving proper care and/or treatment, and missed treatments.The findings included:Record review of Resident #5's undated face sheet revealed he was an [AGE] year-old male admitted on [DATE] with diagnoses of heart failure (heart does not pump effectively), seizures, and chronic kidney disease (kidneys do not filter). Resident #5's MDS assessment had not been completed yet.Record review of Resident #5's Baseline Care Plan dated 9/20/25 by the DON, revealed a diagnosis of dependence on renal dialysis but there was no mention of the resident receiving dialysis as part of the Care Plan.Record review of Resident #5's previous hospital records dated 9/15/25 at 7:16am by MD K, revealed the resident had ESRD (kidneys do not work) and was on HD (dialysis) TTS (Tuesday, Thursday, Saturday). He had a LUE fistula [dialysis access] with good thrill and bruit [the feeling of blood rushing through the access].Record review of Resident #5's admission assessment dated [DATE] at 5:04am by LVN E, revealed the resident was receiving dialysis.Record review of Resident #5's admission summary dated [DATE] at 7:47pm by an unknown nurse, revealed he received dialysis three times a week.Record review of Resident #5's Dialysis Communication Form dated 9/20/25, revealed he had dialysis from 11:18am-12:25pm and 1.5L of fluid was removed from his body via his LUA AVF (dialysis access).Record review of Resident #5's Physician Orders by MD B, reviewed on 9/26/25, revealed no orders for dialysis.In an interview and observation on 9/26/25 at 9:59am, Resident #5 was sitting up in bed with family present. The resident had a LUA fistula present. The resident's family member said she had concerns about his dialysis bandage not being changed when he got back.In an interview on 9/26/25 at 12:40pm, RN A said he knew a resident was on dialysis because the resident would tell him themselves, or the off going nurse would tell him in report. He said there should also be an order for the dialysis that would specify the days and the facility the resident went to. RN A said if there was not an order for dialysis, someone who was not familiar with the resident would not know they were on dialysis.In an interview on 9/26/25 at 4:25pm, the DON said if there was not an order in the resident's chart it could cause harm, or the resident could miss treatment.Record review of the facility's policy and procedure on Hemodialysis, Care of Residents (Updated August 2017) read in part: The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes.Review and ensure orders upon admission are received for follow-up dialysis center appointments, shunt care, diet and fluid restriction (physician discretionary). Place a colored armband that indicates No BP this Arm on the Resident's arm that has the shunt.Provide routine AV Shunt Care and Monitoring per physician order and/or facility policy. Check vital signs upon arrival post-dialysis according to physician's order. Do not take blood pressure on arm with dialysis shunt.Check graft site for bleeding every 4 hours or twice during the shift after which the resident returns, or per physician's order.Monitor lab work. Notify physician as ordered or when lab values are abnormal.Record review of the facility's policy and procedure on Physician's Services (Updated June 2022) read in part: It is the facility's policy to ensure that its residents are provided with an attending physician that will supervise and direct its medical care. The medical supervision of the care of each resident by a physician will include orders for immediate need and care throughout resident's stay. The physician supervises the medical care of residents by means of participating in the resident's. assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when contacted by the facility. It also includes, but is not limited to, prescribing medications and therapy.Physician Visits. During physicians' visit, the attending physician will: Review the resident's total program of care, including medications and treatments, at each visit; Physician visits will include an evaluation of the resident's condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen.Write, sign, and date progress notes at each visit as well as sign and date all orders. During visits, the physician will also sign and date all orders.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #1) reviewed for infection control. - RN N failed to wear a gown during incontinence care on 9/26/25, when Resident #1 was on EBP.- RN N failed to change her gloves during incontinence care on 9/26/25, after removing the dirty brief and putting a clean one on for Resident #1.- RN N failed to clean Resident #1's suprapubic catheter (a tube inserted into the abdomen and directly into the bladder to drain urine) away from the insertion site and instead cleaned towards the insertion site on 9/26/25. These failures could place residents at risk for infection, cross contamination, and hospitalizations. Findings included: Record review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE]. There were no diagnoses listed on the face sheet.Resident #1's MDS assessment had not been completed yet.Record review of Resident #1's Baseline Care Plan dated 9/24/25 by RN P, revealed he was receiving antibiotic therapy and had a urinary catheter.Record review of Resident #1's previous hospital records dated 9/23/25 at 1:49pm by MD O, revealed the resident was being treated for an acute CVA (stroke) and a UTI (urinary infection). He had diagnoses of neurogenic bladder (bladder does not function properly due to damaged nerves) with a suprapubic catheter.Record review of Resident #1's admission summary dated [DATE] at 4:10pm by RN P, revealed the resident had a Mid lower suprapubic catheter 14 fr 10cc inflated.Guest is on antibiotics Cefepime [type of antibiotic] 1 gram in 500 ml (1gram into venous catheter every 8 hrs.).Record review of Resident #1's admission assessment dated [DATE] at 4:37pm by RN P, revealed he had diagnoses of AMS (confused) after a fall, CVA, HTN (high blood pressure), AKI (kidneys not working properly), Parkinson's, and afib (irregular heart rate). It also revealed the resident had a suprapubic catheter and was on antibiotic therapy. The assessment revealed the resident was totally dependent on staff for physical function and required 1-person physical assistance. The assessment revealed the resident had an IV, and he had left side weakness with right side facial droop.Record review of Resident #1's Progress Notes dated 9/26/25 at 4:32am by LVN H, revealed the resident was on Cefepime 1gm TID through his R AC (right elbow) midline for Pseudomonas UTI.Record review of Resident #1's Physician Orders revealed the following orders from MD B:- Enhanced Barrier Precautions: Wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line [long, thin tube inserted into large vein], urinary catheter, feeding tube, tracheostomy), wound care (any skin opening requiring a dressing), every shift for indwelling medical devices, wound, MDRO (antibiotic resistant bacteria) (current or HX of), suprapubic catheter mid lower abdomen, IV midline (type of IV inserted into larger vein). Ordered on 9/24/25 at 4:15pm.- Cefepime HCl Solution 1 GM/50ml, 1gm IV TID for infection- UTI Pseudomonas (type of bacteria) until 9/29/25, via R AC Midline. Ordered 9/25/25 at 2:03am.- Indwelling Suprapubic Catheter 14 Fr with 10 cc bulb connect to straight drainage. Notify MD as needed for non-patency of S/P catheter, every shift for neurogenic bladder and obstructive uropathy (urine flow is blocked in the urinary tract). Ordered on 9/25/25 at 11:56pm.In an interview and observation on 9/26/25 at 10:31am, Resident #1 had a midline to his R AC attached to an IV line that was hanging on a pole next to his bed. The IV bag was for Cefepime. He also had a foley bag hanging to the left side of the bed. The resident said his bottom hurt and wanted to change positions.In an interview and observation on 9/26/25 at 10:36am, RN N provided incontinent care to Resident #1 without wearing a gown when Resident #1 was on EBP. RN N opened Resident #1's brief while he was lying on his back and wiped between his legs with 1 wipe several times. Without changing gloves or sanitizing, she then got a new wipe and cleaned Resident #1's genitals with the same wipe several times. Then RN N turned the resident to his side and wiped some feces off his bottom, without sanitizing or changing her gloves. RN N proceeded to put a clean brief on the resident without sanitizing her hands and changing her gloves and then turned him back on his back. She continued to clean his suprapubic catheter (without sanitizing her hands and changing gloves) from outwards towards the abdomen. She did this several times with the same wipe. When she was finished, she put the resident's bedding back on him with the same dirty gloves.In an interview on 9/26/25 at 10:47am, RN N said EBP was for any openings like IVs, wounds, or tracheostomies (hole in the neck for breathing tube). She said for a nurse, they have to wear PPE anytime they go into a room on EBP. She said she should have worn PPE for Resident #1, and she forgot because there was not any cart outside the room and the resident was a new admit. She said she cleaned the catheter towards the abdomen because she did not want to pull the catheter out. She did not think about the infection control issue. She said she forgot to change her gloves. RN N said all these things could cause contamination and infection.In an interview on 9/26/25 at 4:25pm, the DON said EBP was for foleys, wounds, midlines, and tracheostomies. She said the PPE worn was a gown and gloves and staff should wear it when they were providing close patient care. She said when cleaning a catheter line, it should be cleaned from inside to outside because you could pull the germs to you. She also said when providing incontinent care staff should change their gloves between the dirty and clean brief. She said doing these things caused cross contamination and infections.Record review of the facility's policy and procedure on Scope of Infection Control Program (Updated June 2022) read in part: The policy will provide the scope of the infection control program for the facility. The infection control program is a comprehensive compilation of policies and procedures for implementation at the facility. The scope of the program includes prevention, detection, management and control of spread of infection. The infection control policies and procedures implementation and oversight isfacilitated by the Infection Control Preventionist. The Infection Control Committee will provide complete oversight of facilityimplementation and infection control program .Staff will refer to infection control program policies for guidance on how [to] manage infection prevention, control and management for both residents and employees. Staff will follow standard and transmission-based precautions to prevent spread of infections. Staff will use isolation precautions for a resident; including but not limited to: The type and duration of the isolation, depending upon the infectious agent or organism involved, and.The hand hygiene procedures to be followed by staff involved in direct resident contact.Record review of the facility's policy and procedure on Enhanced Barrier Precaution (Updated June 29, 2022) read in part: It is the policy of this facility to ensure that isolation procedure standard is based on the most up-to-date infection control practice. The purpose of this policy is to establish and provide guidelines for isolation precautions as well as prevent transmission of infectious agents in the facility. The Director of Nurses (DON) and/or its designee shall be responsible for implementation and enforcement of this policy. This responsibility maybe designated to the Facility's Infection Control Preventionist. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Wounds or indwelling medical devices, regardless of MDRO colonization status. All residents with any of the following: Infection or colonization with an MDRO when Contact Precautions do not otherwise apply, Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. During high-contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing.Record review of the facility's policy and procedure on Indwelling Catheter Care (Updated February 2017) read in part: To ensure the care of the urinary catheter is carried out in a manner that minimizes trauma and infection risks.Perform hand hygiene and put on gloves.For male patients, cleanse suprapubic [above the pelvic bone] and pubic [private area] area with approved cleanser and washcloth. Grasp the shaft of the penis firmly. Cleanse urinary meatus and glans [top part] with approved cleanser and washcloth beginning at the urethral opening.Cleanse in a circular motion moving from the meatus downward and outward towards the shaft [bottom] of the penis.Remove gloves, perform hand hygiene and don [apply] a new pair of nonsterile gloves.Clean the catheter from the insertion site to approximately six (6) inches distally [away] with hospital approved cleanser and washcloths.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 7 residents (Resident #5) reviewed for oxygen.- The facility failed to ensure Resident #5 had a physician's order for oxygen, when he was being administered 3L O2 via NC on 9/26/25.This failure could place residents at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment.Findings included:Record review of Resident #5's undated face sheet revealed he was an [AGE] year-old male admitted on [DATE] with diagnoses of heart failure (heart does not pump effectively), seizures, and chronic kidney disease (kidneys do not filter). The picture of the resident on the face sheet revealed he had oxygen on via NC.Resident #5's MDS assessment had not been completed yet.Record review of Resident #5's Baseline Care Plan dated 9/20/25 by the DON, revealed the resident was receiving oxygen under Therapy and Nursing Services.Record review of Resident #5's previous hospital records dated 9/15/25 at 7:16am by MD K, revealed the resident was on 3 L/min O2 via NC.Record review of Resident #5's admission summary dated [DATE] at 7:47pm by unknown nurse, revealed the resident was on continuous oxygen.Record review of Resident #5's Physician Orders by MD B, reviewed on 9/26/25, revealed no orders listed for oxygen.In an interview and observation on 9/26/25 at 9:59am, Resident #5 was sitting up in bed with family present. He had 3L O2 via NC on. The resident said he was on continuous oxygen and used it continuously at home as well.In an interview on 9/26/25 at 12:40pm, RN A said he knew how much oxygen to put a resident on by looking at the order in the chart. He said the oxygen administration was also documented in the MAR-TAR. He said there was not an order for Resident #5's oxygen but he knew he was on 3L. He did not know why there was not an order for the oxygen. He said if someone was taking care of the resident and did not know him well, they would not know how much oxygen he was supposed to be on. RN A called the DON and informed her the resident was on 3L O2 via NC and there was not an order. She told him to go ahead and put an order in for it.In an interview on 9/26/25 at 4:25, the DON said if there was not an order in the resident's chart it could cause harm, or the resident could miss treatment.Record review of the facility's policy and procedures on Oxygen Administration, Nasal Cannula (Updated August 2017) read in part: It is the policy of this facility to provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident.Oxygen is a drug and as such there must be a physician's order for its use.Document O2 administration in Nurses Notes according to order, reason for use and resident's response to treatment. Post the Oxygen sign and explain to the resident, his/her roommate and all visitors the regulations regarding the use of smoking materials near oxygen.Record the oxygen use in the resident medical record.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 7 residents (Resident #3) reviewed for care plan revisions.- The facility failed to ensure Resident #3's care plan was updated to reflect his new diet of Level 4 (food is pureed smooth with no lumps or bumps) pureed after a choking incident (7/31/25) and had Level 6 (food cut into small, bite sized pieces that are tender and soft) soft and bite sized on 9/26/25.This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #3's undated face sheet revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of dysphagia (trouble swallowing), chronic kidney disease (kidneys are not filtering well), muscle weakness, type 2 diabetes mellitus (body does not produce insulin or resists it), and cognitive communication deficit (difficulty with communication skills caused by impairments in thinking processes).Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 out of 15, which indicated moderately impaired cognition. The MDS revealed the resident had a mechanically altered diet which required a change in the texture of food, like a pureed diet. It also revealed he was receiving Speech Therapy.Record review of Resident #3's Care Plan dated 6/25/23, revealed a Focus: Resident had a swallowing problem r/t difficulty with thin liquids. Diet: Renal/LCS Level 6 soft & bite sized texture, Level 0 (no modification) thin consistency. The goal was for the resident to not have any choking episodes when eating through the review date (Target Date: 3/8/25). Interventions included for the staff to be informed of the resident's special dietary and safety needs, the diet to be followed as prescribed, keeping the head of the bed elevated for 45 degrees during the meal and 30min after, monitoring for SOB or choking, and for the resident to eat with supervision.Record review of Resident #3's Change in Condition Note dated 7/31/25 at 5:52pm by RN G, revealed the resident was in the dining room eating dinner when he started choking. He was found blue, and unresponsive, so CPR was initiated. A chest thrust produced food particles in the back of the resident's throat, so a finger sweep was performed and the resident gasped. The resident was then transferred to the hospital.Record review of Resident #3's ER Notes dated 7/31/25 at 5:16pm by MD L, revealed .Per EMS, nursing home staff saw him choking and put him down from his wheelchair and started doing chest compressions. After 2 to 3 minutes of chest compressions a piece of food came up from his mouth and a finger sweep was done. Once EMS got there patient had his own pulse and was breathing. They are unsure if he ever lost his pulses. Patient now is awake and alert and breathing on his own.Record review of Resident #3's Physician Orders from MD T, revealed an order for Renal/LCS diet, Level 4 puree texture, Level 0 thin consistency. Ordered on 8/1/25.Record review of Resident #3's Nurse's Note dated 8/1/25 at 6:00pm by RN A, revealed the resident's diet had been changed to pureed and a Speech Therapy consult was entered.In an interview on 9/26/25 at 9:53am, Resident #3 said he remembered choking on a piece of meat, but he did not remember what it was. He said he did not remember what happened after he started choking. Resident #3 said he was on a pureed diet now.In an interview on 9/26/25 at 4:25pm, the DON said nursing staff would be responsible for updating the Care Plan with the correct diet. She said she did not know why it was not updated. She did not think anything would happen to the resident since the diet order in the chart was correct.Record review of the facility's policy and procedure on Comprehensive Plan of Care (Updated December 2016) read in part: It is the policy of this facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs identified during comprehensive assessment. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive plan of care will include: Address the resident's individual needs, strengths, and preferences.Be periodically reviewed and revised by the interdisciplinary team as changesin the resident's care and treatment occur. The Director of Nurses (DON) and/or its designee shall be responsible for implementation of this policy. Re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment, quarterly, and with significant change in status assessment. Care plan evaluation must occur in response to changes in the resident'sphysical, emotional, functional, psychosocial, or communicative status as they occur, as well as following the RAI guidelines.

Based on interview and record review, the facility failed to provide notice as soon as practicable before transfer or discharge for 1 of 5 residents reviewed for admission, transfer, and discharge. -CR #1 was notified on 10/07/25 that she had to transfer to another facility or discharge somewhere else by 10/07/25. This failure could place residents at risk of not receiving appropriate care and required notifications being made. Findings included: Record review of CR #1's admission Record, dated 10/14/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), muscle weakness, unspecified lack of coordination, type 2 diabetes mellitus with hyperglycemia (high levels of blood sugar in the blood), morbid (severe) obesity (abnormal or excessive fat accumulation) due to excess calories, and functional quadriplegia (complete inability to move due to severe disability or frailty resulting from conditions such as severe obesity or other debilitating diseases). Record review of CR #1's Discharge MDS Resident Assessment, dated 10/07/25, Section A, revealed a planned discharged on 10/07/25, to home/community. Further review revealed a BIMS score of 15, indicating intact cognition. Section GG, Functional Abilities, revealed resident required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe, upper and lower body dressing, and personal hygiene. Record review of CR #1's Care Plan report, undated, revealed resident was non-compliant with facilities non-smoking policies. Interventions included medications as ordered and to observe behaviors and try to determine cause. Record review of CR #1's progress notes, dated 10/07/25 at 11:56 a.m., entered by Admissions, read in part pt was notified on 10/03/25 that we are a non smoking facility per pt she know (sic) and she has not been smoking inside, provided a copy of do not bring in items and put it on top of the dresses below tv. Record review of CR #1's progress notes, dated 10/07/25 at 11:59 a.m., entered by Social Services - Social Worker, read Due to patient being caught with a vape, she was advised that the facility can assist with finding another facility that can accommodate her smoking, or we can discharge her home with home health services. Patient stated she needs time to think. SW will follow up. Record review of CR #1's progress notes, dated 10/08/25 at 17:44 (5:44 p.m.), entered by Social Services - Social Worker, read On 10/07/25, Patient decided to discharge home with HH services. SW set up HH services and ordered a wheelchair for the patient. SW will follow-up. Record review of CR #1's Discharge IDT Recapitulation of Stay assessment, dated 10/07/25, reflected discharge location was to a hotel. Record review of CR #1's clinical records revealed no discharge notice or notice sent to ombudsman. During a telephone interview on 10/14/25 at 10:54 a.m., CR #1 said her discharge was facility initiated, that she was safe, discharged with her medications, and discharged home with her family members, she believed this past Tuesday, 10/07/25. She said the facility did not give her much of a choice and told her on 10/07/25 that she had to leave. She said CNA A reported to staff that she was smoking in her room on Friday, and the Social Worker told her she could not smoke in her room. She said the Social Worker told her that that her significant other told him CR #1 admitted to smoking. She said the facility sent her paperwork to another facility, in a different town, that allowed smoking but said she told the Social Worker she did not want to go to that facility. She said the Social Worker told her she had to be discharged home or to the other facility because she was a smoker. She said she asked if she could stay if she agreed not to smoke and was told no. She said she requested to be sent to a different facility but was told by the Social Worker she could not go to the facility that she requested. During an interview on 10/14/25 at 11:33 a.m., the Social Worker said CR #1 was a smoker and they were a non-smoking facility. He said the transfer was facility initiated but the discharge home was resident initiated. He said they let CR #1 know she could be discharged to another facility or home because they found a vape, cigarette butts, and cigar fillings, in her room. He said the resident and her family made the decision to discharge because she did not want to stop smoking. He said they gave her a 24-48-hour notice to go to another facility, because she had violated the smoking policy, but she did not want to go. During a follow-up interview on 10/14/25 at 1:07 p.m., the Social Worker said on 10/03/25 the resident was allegedly smoking in the courtyard, right outside her room, and given the smoking policy by the Admissions Coordinator. He said on 10/07/25, CNA said resident was found with a weed vape and that she was smoking. He said on 10/07/25 he went to the resident's room around 4:30/5:00 p.m. and he told the resident she was accepted to another facility, but they only had semi-private rooms, and since her family could not go with her, she did not want to go. He said she got a hotel room for 2 days and was not sure what she did after those 2 days. He said home health services were set up before resident left the faciity on [DATE]. He said the non-smoking policy was given to her on 10/03/25 and violated on the 10/07/25. He said they told the resident they could help her find a facility within that same day. He said it was not urgent that she leave that same day. He said on 10/07/25 they found a marijuana and vape and cigarette butts and told her that the other facility could accommodate her smoking needs. He said around 4:30/5:00 p.m. on 10/07/25, the resident had her room packed up and she asked him if he could help them arrange transportation which he said he did. During an interview on 10/14/25 at 1:39 p.m., the admission Coordinator said she and the Social Worker went to CR #1's room on 10/07/25 and the Social Worker told the resident in front of her family that she had 30 minutes to make a decision to discharge to a hotel or to another facility. She said the Social Worker told the resident the facility was not allowing smoking anymore and her only option was to go to a different facility or somewhere else. She said the Social Worker told CR #1 she had to get out of the facility today, 10/07/25. She said around 1:30/2:00 p.m., the Social Worker told her the resident said she was going to a hotel. During an interview on 10/14/25 at 4:36 p.m., the Administrator said the facility is a non-smoking facility. She said they sometimes do admit resident's that smoke, but not knowingly. She said if they find out about them being non-compliant, they will try to get them to comply, whether it be wearing a patch, or finding alternate placement. She said the facility does not have a smoking policy. She said if they see residents smoke, they will let the case manager know. She said CR #1 was discharged because she was smoking and was not compliant with non-smoking. She said she believes the Social Worker and the resident worked on her discharge together. She said the Social Worker found them a safe place to go and set up home health services. She said she believed their discharge procedures were followed. She said they had been talking with CR #1 about discharge for weeks because of resident's insurance denials and appeals and does not feel like she was blindsided. She said she does not know how much time she was given to make a decision to leave. She said the resident agreed to go after the Social Worker found her a place to go. She said it was not done in a day; it was done over weeks. She said she also had to worry about the other residents and fire hazards. She said it could cause stress on someone when given same day notice. Record review of email, dated 10/07/25 at 4:19 p.m., reflected Social Worker sent referral for CR #1 to home health services agency for RN, OT, and PT services. Home health agency representative sent a thanks response email back to Social Worker on 10/07/25 at 4:20 p.m. Record review of the facility's Admissions Agreement, read in part .Health, Safety, and Personal Rights.2. [nursing facility name] is a non-smoking facility and therefore will not admit any smokers into the facility. *This includes E-cigarettes and vapes. Record review of the facility's Transfer & Discharge policy, release date: December 2016, read in part .The transfer and discharge process must provide sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility.

Based on interviews and record reviews, the facility failed to develop a person-centered care plan to meet practicable physical needs for 1 (Resident #2) reviewed for care plans. Based on record reviews and interviews facility failed to develop or implement a care plan with goals or interventions related to use of adaptive devices for Resident # 2. On 10/23/2025 at 05:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/24/2025, the facility remained out of compliance at a severity level of isolation with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place Residents at risk of not receiving necessary care and services for not having their individual medical, physical, psychological and/or emotional needs met. Findings included: Record review of Resident # 2's face sheet dated 08/18/2025, revealed an [AGE] year-old male admitted on [DATE] following a joint replacement surgery on 06/25/2025. His diagnoses included: joint replacement surgery, type 2 diabetes(high levels of sugar in the blood stream), hypertension (high blood pressure), parathyroid( overactive thyroid glands), hyperlipidemia ( high levels of fat in the blood stream), dementia, depression, degenerative disease of nervous system, epilepsy (repeated seizures caused by damaged brain cells), Transient-Cerebral Ischemic Attack (brief blockage of blood flow to the brain), generalized muscle weakness, acute kidney failure, dysphagia (difficulty swallowing), tremors, lack of coordination, cognitive communication deficit (communication challenge caused by problem with thinking abilities like attention, memory, and executive function rather than a language or speech problem), fracture of left femur(fracture of the hip bone), closed fracture with routine healing (a non-surgical procedure used to align and immobilize broken bones without the need for surgery. Resident # 2 was initially admitted on [DATE]. Record review of Resident # 2's MDS dated [DATE], cognition section C0400 was coded 1 which indicates able to recall after cueing. Cognition section C0500 was coded 06, which indicated severe cognitive impairment. Record review of Resident # 2's care plan dated 08/15/2025 revealed Resident # 2 had a fracture with goal to remain free of complication related to hip fracture, such as contracture formation, embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and immobilization. Resident # 2 had ADL self-care performance deficit with the following intervention: needs transfer with two people assisting from bed to chair or vice versa.Record review of Resident # 2's hospital discharged paperwork, dated 06/25/2025 revealed, gait assistance, needs two person assist with a gait belt, maximal assistance. Scooting: needs two total assistance (sitting and supine scooting). Sit to supine: total assistance. Needs two. Precautions: fall precautions, posterior hip precautions. Abdominal pillow in the lower extremity while in bed, as well as hip abduction pillow. Pillow for hip replacement surgery for leg support and prevention of dislocation. Record review of facility's New admission Report Sheet, dated 06/25/2025, did not reveal any special equipment or type of assistance needed during transfer for Resident # 2.Record review of Resident # 2's admission report dated 06/25/2025, revealed no special equipment, amount or type of mobility assistance for transfer. Record review of Resident # 2's baseline care plan, dated 06/25/2025, revealed no special or adaptive devices such as a hip abduction pillow, wedge or cushion to be used. Resident # 2's care plan indicated he had a fracture with goal to remain free of complications related to hip fracture, such as contracture formation, embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and immobilization. Resident # 2's care plan for ADL self-care deficit with the following intervention: transfer with two people assisting from bed to chair and vice versa. Record review of Resident # 2's Physician orders revealed no special adaptive devices like a hip abduction pillow, wedge or cushion to be used for proper body alignment. Record review, of Resident # 2's electronic health revealed no use of special or adaptive devices. Further review revealed no precautions or interventions related Resident # 2's hip or transferring assistance.Record review of video placed by family member in Resident # 2's room, dated 07/07/2025, at 3:20 p.m. revealed CNA C transferred Resident # 2 without a second person assist. In the video, CNA C said, I am going to transfer you by myself. The video revealed CNA C transferred Resident # 2 from a wheelchair to his bed without using a gait belt. CNA C left the cushion in between Resident # 2's legs. CNA C removed the cushion from between his legs as he was sitting up in bed with pillows behind him. CNA C proceeded to remove his pants; CNA C, pushed on the left side of his legs on knees. Resident # 2 said whoa whoa. CNA C said, I am just taking your pants off and then pushed on his right side of his legs on knees to lower his pants. CNA C then put the cushion back between his legs. Record review of hospital care team progress notes revealed: on 07/09/2025 at 1:45 p.m., radiographs for orders placed on 07/09/2025 for bilateral (both) hips shows dislocation of the right total hip arthroplasty (a surgical procedure that involves creating, repairing, or replacing a damaged or diseased joint with an artificial joint called a prosthesis). There is a left hip hemiarthroplasty (a surgical procedure that replaces only half of a damaged joint, most commonly the hip with a prosthetic) without acute changes. The care team advised Resident # 2 be taken to the ED for attempt to close the reduction with possibility of OR if unable to reduce in the ED. Record review of facility's Post-Surgical Orthopedic Care, dated 08/2025 on section Mobility and Rehabilitation, revealed: re-enforce hip / knee/shoulder precautions to prevent dislocation or injury. Further documentation revealed that: Record all assessments, interventions, resident responses, and communications with the physician / family. Update the care plan and interdisciplinary notes routinely to reflect progress or new problems. During an interview with the MDS Coordinator on 10/08/2025 at 2:32 p.m., he stated Resident 2 #'s care plan did not change because the facility does not change care plans when residents return from hospitalization. He said the only update would be medication changes. He said there were no changes made to Resident # 2's care plan. During an interview with CNA D on 10/22/2025 at 10:45 am, she said Resident # 2 was a two person assist. She said Resident # 2 could get hurt or being dropped if an inappropriate transfer was performed. CNA D said staff used a cushion between Resident # 2's legs to prevent stiffness. CNA D said the nurse and therapy staff educated her on how to use the leg separator. CNA D said, the cushion stays on Resident # 2 during transfer and is taken off when he is in bed. She said the wedges are used when Resident # 2 is in bed. She said, when patient care is provided to Resident # 2, all the pillows and wedges are removed to enable Resident # 2 to lie on his back. During an interview with CNA E, he said he checks the electronic medical records every morning to know how to transfer a Resident. He said, Resident 2 required 2 people during transfer. CNA E said, if he had to transfer Resident # 2, he would request assistance. He said, if Resident # 2 was in bed, the wedge and cushion was placed between his legs, a wedge behind his back, a pillow to support his head. CNA E said during patient care for Resident # 2, the assistive devices were removed. CNA E said if a Resident # was transferred inappropriately, it could result to death or get further injured. During an interview with the Occupational Therapy Assistant and Physical Therapy Assistant on 10/22/2025 at 12:48 pm, they both stated any adaptive devices would have an order which is written in the Resident's electronic health records and should be reflected in the care plan. The PTA said, supervising OT and PT would update with electronic records with the appropriate adaptive devices, which is determined on a case basis. PT A and OTA said, the adaptive device should be in place while the Resident is in bed and while sitting, and this order would be specified by a physician. PTA said, based on his professional opinion, the device should be removed before transfer and put it back once Resident is safely in bed. The device is used as a precaution to prevent the hip from rotating. PTA/OTA said, if the wedge was removed, a pillow needed to be put in place. The PTA said, there could be a risk of dislocation due to the hip moving inward or rotating without a device or pillow in place during transfers or patient care. During an interview with CNA F on 10/22/2025 at 2:40 p.m., she said the nurse would update her on the Residents' care. She said she would also ask family members if there had been any changes with the Resident. CNA F said, she remembered Resident # 2 had a catheter but did not remember any type of cushion. During an interview with the MDS Coordinator, he said the IDT team had the ability to revise the care plans. He said he was not sure if Resident # 2 was admitted to the facility with assistive devices. The MDS Coordinated said; we used the hospital clinicals, and what the therapy identifies for the resident. He said, the baseline care plan was created within the first forty-eight hours. The Therapy team evaluates the Resident within forty-eight to seventy-two hours. They have all the information on the Net health. During an interview with the DON on 10/22/2025 at 2:55 p.m., she said the WCN, SW, CN and the therapy team reviewed the plan of care from the hospital clinicals, physician orders and skin assessment to determine interventions. The DON said the MDS Coordinator created the care plans. She said the transfer training was based on one -two-person transfer or a Hoyer lift. The DON said, if a wedge or pillow was used for a Resident, the nurses would demonstrate to the CNAs on how to use the device. She said, there is ongoing training on the use of transfer devices. She said after a care plan is completed, any special equipment or devices are added in the resident's electronic health records for certified nurse aids to review for care needs. The DON said physician orders would indicate if special equipment needed to be removed or added at a certain time during Resident's care. The DON said, I don't think he's used a hip abduction pillow since he's been here. Not aware of any special equipment after he was admitted to the facility. Resident # 2 was a two person assist. On 07/09/2025, the orthopedic team admitted him to the hospital for hip surgery. Resident # 2 returned to the facility on 8/8/2025. On 8/9/25 x-ray revealed a right hip dislocation (right hip displacement). Change of condition was documented on 8/9/25. Yes, an inappropriate transfer could result in a possible hip dislocation. During an interview with the Administrator on 10/23/25 at 10:38 a.m., she said she was not aware of care plans not being updated. She said we could have done better. She said updating the care plan is a team effort, by different disciplines. She said adjustments are made during morning meetings. The Administrator said the CNAs get a report at the beginning of their shift, they have access to the Kardex, she did not believe the CNAs had access to the care plan. The Administrator said Resident # 2 did not get the attention needed. She said there is an outside company that is currently auditing the care plans. The Administrator said she was not aware of the inappropriate transfer. There were issues with CNA C. Families would complain every other week. CNA C was told to stay away from Resident # 2's room. The Administrator said, before Resident # 2 returned to the facility, CNA C went into his room and made his bed, she made a comment, I don't care if there was a camera in the room. The Administrator said the Therapy team is responsible for transfer and position trainings. The Administrator said her expectation of staff as far as transferring residents, staff should follow the plan of care, if they don't know, they should find out. If they are in doubt, they should ask for help. She said staff can get information on care/services for the Residents from the morning report or the Kardex. During an interview on 10/24/2025 at 4:32 p.m., Nurse A said pain assessment/monitoring was when the patient was complaining of pain. She said an order for pain monitoring was an assessment of acute or chronic pain based on resident's health report. She said she would ask residents on a scale 1 to 10 and note any facial expression or behavior and check vitals. She said they were to complete an assessment every day according to a physician order. She said the assessment was regarding any surgeries and all the components of the body. She said for Resident # 2 she would check for pain in hip. She said she was not sure if she completed an assessment for Resident # 2 on 07/07/2025 or 07/08/2025. She said she may have completed pain monitoring on a pain assessment tool sheet. She said the risk of not completing or documenting a pain assessment could aggravate other causes and triggers for the resident. This nurse did not answer the question; if she assessed or administered pain medication. A record review of the facility's Residents' right policy dated November 2017, revealed: facility behaviors designed to support and encourage resident participation and goals as documented in the resident assessment and care plan are not interference or coercion. Review of the facility patient safety lifting and transfer policy, dated July 2016 revealed that: It is the responsibility of the facility that all resident/patient transfer/lifting is done safely and appropriately to protect the employees and residents/patients from injury. The purpose of this policy is to remove as many opportunities for caregivers to incur injuries to themselves as well as the residents/patients when transferring, ambulating or lifting residents/patients. All employees will be instructed in and expected to use the proper body mechanics and the use of the available mechanical lift equipment when lifting or transferring residents/patients. Failure to follow the guidelines established by this policy could result in disciplinary action up to and including termination. The Charge Nurse should be consulted when any change in a resident's/patient's mobility/transfer/lift status is indicated. The Charge Nurse is responsible for updating and communicating the changing lift needs of each resident/patient. Valuable assessment input will be necessary from CNAs, licensed professionals, including Physical and Occupational Therapists.Communication Vehicle for Patient Needs to Caregiver: Immediate communication to the caregiver regarding the patient's transfer/mobility needs is essential in ensuring our patients are properly handled without injury to the patient or employee. Gait Belts - It is the policy of this center that residents/patients assessed are moved with a gait belt to minimize the possibility of skin tears, dislocations or falls. The proper use of a gait belt reduces unexpected falls, soften falls when gently eased to the floor with this equipment and consequently, there is less possibility of injury to the caregiver as well. Utilize the proper transfer/lift procedure for each resident/patient. Rehab will help to evaluate incidents involving the transfer of residents/patients Review of the facility's CNA's job description revealed responsibilities and accountabilities as follows: Provides patient care in a manner conducive to safety and comfort. Patient care includes, but is not limited to:-Assist patients with ambulation and transfers.-Positions patients in correct body alignment in and out of bed. This was determined to be an IJ, on 10/23/2025 at 05:05 p.m. The Administrator was notified. The Investigator/Surveyor provided the IJ template to the Administrator on10/23/2025 at 05:05 p.m. The POR summitted by the Administrator was accepted on 10/24/2025 at 10:30 am. The POR revealed: Immediate Jeopardy, POR, 10/24/2025 at 10:30 a.m. The facility failed to ensure all residents received adequate supervision and assistive devices to prevent accidents. The facility failed to ensure proper transfer of Resident #2's who required a two person assistance during transfers. CNAC transferred Resident #2, from his wheelchair to his bed, by one person assist. On 7/7/25 CNA C inappropriately transferred Resident #2 from his wheelchair to his bed, instead of doing a 2-person assist transfer. On 7/9/25 x-rays confirmed Resident #2, who had a recent hip replacement, had a right hip dislocation. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies.- Resident # 2 was discharged on 7/9/25. Resident # 2 was readmitted on [DATE] and discharged on 8/9/25. - Resident # 2 was re-admitted to facility on 8/15/25. The IDT reviewed current Resident 2's condition regarding medical condition and transfer need. The MDS Coordinator updated the plan of care on 10/23/25 to include and show any current need for special or adaptive devices like a Hip Abduction Pillow, wedge or cushion to be used. MD orders were reviewed by DON/designee on 10/23/25 and orders were updated and reviewed.-Immediate Action: DON provided 1:1 in-service with MDS coordinator on completion of personalized baseline care plans and comprehensive care plans on 10/23/25.- During the ad hoc QAPI Committee meeting on 10/23/25 with Medical Director, DON and DSD and IP, the deficient practice was discussed the alleged deficient practice and plan of removal. -The Administrator will oversee corrective actions initiated on 10/23/25 and monthly thereafter during QAPI meetings and plan of corrections for the findings during survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, will be reviewed and revised monthly with the QAPI Committee for revision, further evaluation, and recommendations, with a designated IDT member assigned to each corrective action. DON will monitor the immediate actions for implementation of monitoring/audit need at least monthly for the next three months or until compliance is one hundred percent or is achieved.-Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions related to post surgical orthopedic care.-Administrator: The Administrator will oversee all corrective actions initiated on 10/23/2025 and continue monthly reviews during QAPI meetings.-Director of Nurses (DON): The DON or designee will regularly review orthopedic patients, assess intervention effectiveness, and adjust care plans as needed.- Director of Staff Development (DSD): This role involves educating staff on care planning and documentation. Responsibilities include training new hires on resident safety, conducting competency assessments, emphasizing risk assessment, and ensuring accurate documentation related to post surgical orthopedic care. All residents who post-surgical orthopedic care were identified as affected by the deficient practice. A total of twelve Residents were identified by the DON/Designee as receiving post-surgical orthopedic care on 10/23/25. MD orders were updated on 10/23/25 for affected residents to include devices used by DON/Designee, including EMR patient banner update to include special instructions for devices and one -two-person assistance.An admission audit will be conducted by MDS or designee for all residents who are post-surgical every Monday-Friday to determine whether residents' MD orders a care plan for one-two person assist and any devices are included. Immediately following completion of audits, any findings will be referred to DON for further review and recommendations. admission nurses, RN supervisor/designee will complete reviews on weekends and holidays. Beginning 10/23/25, all residents care plans will be updated in coordination with the rehab evaluations by the Rehabilitation Department to determine the appropriateness and safety of one-two-person assist and any needed devices for post orthopedic patients as needed. Immediately following completion of audits, the DON or designee will follow up and coordinate with MDS Coordinator any need for updates and revisions to the care plan. The MDS Coordinator/ Designee will ensure that this information is accurately entered into the special Instructions individual patient profile banner in EMR and/or patient Kardex making it readily visible for all nursing staff to see and review prior to performing any ADL performed. In-service training was conducted by DON or and/or DSD regarding one-two person assistance and transfers for post-surgical orthopedic care initiated on 10/23/2025 for nursing staff and will be completed on 10/26/2025.Staff who were not trained /in-serviced were not allowed to provide direct care until training has been completed. In-service training was conducted by DON and or designee for admission nurses to include personalized baseline care plans for one-two person assist and devices beginning 10/23/25 and completed on 10/24/25. Any staff that have not been trained yet will not be allowed to provide direct care until training has been completed Inservice training was conducted by DON and/or DSD regarding policy on post-surgical orthopedic care initiated on 10/23/2025 for nursing staff and will be completed on 10/26/2025. Any staff that have not been trained yet will not be allowed to provide direct care until training has been completed. Training in care planning and one-two person transfers will be included for new hires and will be reviewed yearly by DSD/ and DON during the annual performance review. The annual training calendar for licensed nurses and CNAs will include providing care planning and patient transfer competencies as part of its annual in-service for licensed nurses beginning the month of October 2025. Monitoring of the plan for removal included: Following acceptance of the facility's plan of removal, the facility was monitored from 10/24/2025 from 10:30 am to 10/24/2025 at 5:39 pm., to remove the IJ which will continue until every staff is trained by: Record review of facility ongoing training and policies updates for nurses and certified nursing assistants. Resident # 2's care plan was updated to reflect adaptive devices. CNAs, master competency worksheet updated to reflect training on transfer, gait, one-two person assist and Hoyer lift (a medical device used to assist individuals with limited mobility in transferring between surfaces such as beds, chairs, or wheelchairs) during new employee orientation. An ongoing training rosters for gait belt, Hoyer lift, and one-two person transfer were presented with staff signatures. Staff who were not working on 10/22/2025 to 10/24/2025 would be trained upon their return to work. Observation of CNA H and CNA I on 10/24/2025 at 2:03 pm, revealed they successfully completed a gait belt transfer from wheelchair to bed and vice versa. Observation and examination on 10/24/2025 at 11:48 a.m., revealed all mechanical lift devices were functioning properly, including charging locations on the halls. A total of fifteen direct care staff were trained. Interviews were conducted with CNAs , therapists, and nurses on 10/24/2025 at 12:119 p.m., to 10/24/2025 at 4:35 p.m., CNA B, CNA G, CNA H, CNA I, CNA J, RN B, RN C, LVN A, LVN B, LVN C, revealed they were reeducated on the use of mechanical lift, gait belt, one-two persons transfer, reviewing the Kardex prior to Resident transfer.Administrator was informed that the IJ was removed on 10/24/2025 at 05:39 p.m. The facility remained out of compliance at a severity of removed. The facility remained out of compliance potential for more than minimal harm that is immediate treat due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

The facility failed to provide adequate supervision to prevent accidents for 1 (Resident # 2) of 1 resident reviewed for accident and supervision. Based on record reviews and interviews, the facility failed to ensure adequate supervision when CNA C transferred Resident # 2 alone using a stand and pivot method instead of a two-person transfer. The facility failed to ensure CNA C improperly transferred Resident # 2 by performing a two person transfer alone using a stand and pivot method on 07/07/2025 at 15:20 p.m. On 10/23/2025 at 05:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/24/2025, the facility remained out of compliance at a severity level of isolation with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of Removal. This failure could place residents at risk for experiencing pain, injuries, bruises, dislocation and fracture from possible accidents which could result in a diminished quality of life and hospitalization. Findings included: Record review of Resident # 2's face sheet dated 08/18/2025, revealed an [AGE] year-old male admitted on [DATE] following a joint replacement surgery on 06/25/2025. His diagnoses included: joint replacement surgery, type 2 diabetes(high levels of sugar in the blood stream), hypertension (high blood pressure), parathyroid( overactive thyroid glands), hyperlipidemia ( high levels of fat in the blood stream), dementia, depression, degenerative disease of nervous system, epilepsy (repeated seizures caused by damaged brain cells), Transient-Cerebral Ischemic Attack (brief blockage of blood flow to the brain), generalized muscle weakness, acute kidney failure, dysphagia (difficulty swallowing), tremors, lack of coordination, cognitive communication deficit (communication challenge caused by problem with thinking abilities like attention, memory, and executive function rather than a language or speech problem), fracture of left femur(fracture of the hip bone), closed fracture with routine healing (a non-surgical procedure used to align and immobilize broken bones without the need for surgery. Resident # 2 was initially admitted on [DATE]. Record review of Resident # 2's MDS dated [DATE], cognition section C0400 was coded 1 which indicated able to recall after cueing. Cognition section C0500 was coded 06, which indicated severe cognitive impairment.Record review of Resident # 2's care plan dated 08/15/2025 revealed Resident # 2 had a fracture with a goal to remain free of complications related to hip fracture, such as contracture formation, embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and immobilization. Resident # 2 had ADL self-care performance deficit with the following intervention: needs transfer with two people assisting from bed to chair or vice versa. Record review of video placed by family member in Resident # 2's room, dated 07/07/2025, at 3:20 p.m. revealed CNA C transferred Resident # 2 without a second person assist. In the video, CNA C said, I am going to transfer you by myself. The video revealed CNA C transferred Resident # 2 from a wheelchair to his bed without using a gait belt. CNA C left the cushion in between Resident # 2's legs. CNA C removed the cushion from between his legs as he was sitting up in bed with pillows behind him. CNA C proceeded to remove his pants; CNA C, pushed on the left side of his legs on knees. Resident # 2 said whoa whoa. CNA C said, I am just taking your pants off and then pushed on his right side of his legs on knees to lower his pants. CNA C then put the cushion back between his legs. Record review of hospital care team progress notes revealed: on 07/09/2025 at 1:45 p.m., radiographs for orders placed on 07/09/2025 for bilateral (both) hips shows dislocation of the right total hip arthroplasty (a surgical procedure that involves creating, repairing, or replacing a damaged or diseased joint with an artificial joint called a prosthesis). There is a left hip hemiarthroplasty (a surgical procedure that replaces only half of a damaged joint, most commonly the hip with a prosthetic) without acute changes. The care team advised Resident # 2 be taken to the ED for attempt to close the reduction with possibility of OR if unable to reduce in the ED. During an interview with CNA A, on 10/08/2025 at 2:19 pm, she said if a resident required two staff members during transfer and only one staff member was used, the resident might fall. During an interview with the MDS Coordinator on 10/08/2025 at 2:32 p.m., he stated Resident 2 #'s care plan did not change because the facility does not change care plans when residents return from hospitalization. He said the only update would be medication changes. He said there were no changes made to Resident # 2's care plan. During an interview with the DON, on 10/08/2025 at3:18 pm, she stated an inappropriate transfer might result to an injury, or death. During an interview with CNA B on 10/08/2025 at 4:20 pm, she stated that Resident # 2 required two staff during transfer. She said if one staff member attempted to transfer Resident # 2, he might be injured and that might lead to a change in condition. During an interview with RN A on 10/08/2025 at 5:11 p.m., she stated Resident # 2 required two staff during transfer. She said an inappropriate transfer could result in a fall, and Resident # 2 was a fall risk as indicated on his care plan. During an interview with the Administrator, on 10/09/2025 at 12:29 p.m., she stated an inappropriate transfer could cause injury to the Resident and staff member. During an interview with CNA C, on 10/09/2025 at 2:09 pm, she stated that her transfer on 07/07/2025 was a good transfer. She said that was not the first time she was transferring Resident # 2 without a second person, because he was a tiny man. CNA C said after the video review, the facility therapist conducted an in-service with all certified nurse assistants using a gait belt to demonstrate a safe transfer. During an interview with CNA D on 10/22/2025 at 10:45 a.m., CNA D said she only worked with Resident #2 a few times. She said she helped his aide, CNA C. CNA D said Resident #2 would whisper, but he did not really talk, he mumbled. She said he never complained of pain when she assisted him. CNA D said she could tell if Resident #2 was in pain because he would pull back or grimace (twisted expression on a person's face, typically expressing disgust, or pain. She said Resident #2 was a two person assist. She said the risk when a resident was not transferred appropriately, the resident could get hurt or staff could accidentally drop the resident. CNA D said Resident #2 used a cushion between his legs, she said the cushion helped to keep his legs open, to prevent stiffness. CNA D said therapy and the nurses taught her how to use the leg separator and how to put it on. She said the cushion stayed on the resident as they were getting transferred and it was taken off when they were in bed. CNA D said the wedges were used when Resident #2 was lying in bed. She said when patient care was provided for Resident #2 all the pillows and wedges were removed so that Resident #2 can lie on his back. She said Resident #2 could not be turned. During an interview on 10/22/2025 at 11:42 am, said every morning he would check the Kardex which showed him the seizure risk, how you bath the Resident, and how to transfer a resident. He said Resident #2 required a 2-person assist. He said when he had to transfer Resident #2, he would get one other person to help. CNA E said if a male staff member was assisting him, he would grab the top part of his body, and the other person would grab the bottom half of his body. CNA E said when Resident # 2 was in bed, the wedge cushion was placed in between his legs. He said during patient care, his leg boots, cushions and pillows were taken off. CNA E said during patient care, Resident #2 was expected to stay on his back. He said the risk for inappropriate transfers, could be death, or the resident can get injured even more. Review of the facility patient safety lifting and transfer policy dated July 2016 revealed that: It is the responsibility of the facility that all resident/patient transfer/lifting is done safely and appropriately to protect the employees and residents/patients from injury. The purpose of this policy is to remove as many opportunities for caregivers to incur injuries to themselves as well as the residents/patients when transferring, ambulating or lifting residents/patients. All employees will be instructed in and expected to use the proper body mechanics and the use of the available mechanical lift equipment when lifting or transferring residents/patients. Failure to follow the guidelines established by this policy could result in disciplinary action up to and including termination. The Charge Nurse should be consulted when any change in a resident's/patient's mobility/transfer/lift status is indicated. The Charge Nurse is responsible for updating and communicating the changing lift needs of each resident/patient. Valuable assessment input will be necessary from CNAs, licensed professionals, including Physical and Occupational Therapists.Communication Vehicle for Patient Needs to Caregiver: Immediate communication to the caregiver regarding the patient's transfer/mobility needs is essential in ensuring our patients are properly handled without injury to the patient or employee.Gait Belts - It is the policy of this center that residents/patients assessed are moved with a gait belt to minimize the possibility of skin tears, dislocations or falls. The proper use of a gait belt reduces unexpected falls, soften falls when gently eased to the floor with this equipment and consequently, there is less possibility of injury to the caregiver as well. Utilize the proper transfer/lift procedure for each resident/patient. Rehab will help to evaluate incidents involving the transfer of residents/patients Review of the facility's CNA's job description revealed responsibilities and accountabilities as follows: Provides patient care in a manner conducive to safety and comfort. Patient care includes, but is notlimited to: -Assist patients with ambulation and transfers.- Positions patients in correct body alignment in and out of bed.On 10/23/2025 at 5:05 p.m., the Administrator was notified of an Immediate Jeopardy (IJ). The Investigator/Surveyor provided the IT template to the Administrator on 10/23/2025 at 05:05 p.m. The POR summitted by the Administrator was accepted on 10/24/2025 at 10:30 am. The POR revealed: The following Plan of Removal submitted by the facility was accepted on 10/24/2025 at 10:30 p.m. N4030, Free of Accident Hazards. Supervision/Devices The facility failed to ensure all residents received adequate supervision and assistance devices to prevent accidents. The facility failed to ensure proper transfer of Resident #2's which required a two-person as/sist and instead transferred Resident #2, from his wheelchair to his bed, by 1-person assist. On 7/7/25 CNA C inappropriately transferred Resident #2 from his wheelchair to his bed, instead of doing a two person assist transfer. On 7/9/25 x-rays confirmed Resident #2, who had a recent hip replacement, had a right hip dislocation. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies.- Resident # 2 was discharged on 7/9/25. Resident 2 was readmitted on [DATE] and discharged on 8/9/25. - Resident # 2 was re-admitted to facility on 8/15/25. The IDT reviewed current Resident 2's condition regarding medical condition and transfer need. The MDS Coordinator updated the plan of care on 10/23/25 to include and show any current need for special or adaptive devices like a Hip Abduction Pillow, wedge or cushion to be used. MD orders were reviewed by DON/designee on 10/23/25 and orders were updated and reviewed.Immediate Action: During the ad hoc QAPI Committee meeting on 10/23/25 with Medical Director, DON and DSD and IP, the deficient practice was discussed with the alleged deficient practice and plan of removal.-The Administrator will oversee corrective actions initiated on 10/23/25 and monthly thereafter during QAPI meetings and plan of corrections for the findings during survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, will be reviewed and revised monthly with the QAPI Committee for revision, further evaluation, and recommendations, with a designated IDT member assigned to each corrective action. DON will monitor the immediate actions for implementation of monitoring/audit need at least monthly for the next three months or until compliance is one hundred percent or is achieved.Specific staff involved in implementing the corrective actions. Team Members: Medical Director, Executive Director, DON or designee. Each member will perform:-Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions related to post surgical orthopedic care.-Administrator: The Administrator will oversee all corrective actions initiated on 10/23/2025 and continue monthly reviews during QAPI meetings.-Director of Nurses (DON): The DON or designee will regularly review orthopedic patients, assess intervention effectiveness, and adjust care plans as needed.-Director of Staff Development (DSD): This role involves educating staff on care planning and documentation. Responsibilities include training new hires on resident safety, conducting competency assessments, emphasizing risk assessment, and ensuring accurate documentation related to post surgical orthopedic care. Identification of other residents who may need to be included (who may have been affected by the deficient practice:All residents who post-surgical orthopedic care were identified as affected by the deficient practice. A total of twelve residents were identified by the DON/Designee as receiving post-surgical orthopedic care on 10/23/25. MD orders were updated on 10/23/25 for affected residents to include devices used by DON/Designee, including EMR patient banner update to include special instructions for devices and one-to-two-person assistance.System Change: An admission audit will be conducted by MRD or designee for all residents who were post-surgical every Monday through Friday to determine whether residents' MD orders care plan to reflect one -two-person assistance and any devices were included. Any findings will be referred to DON for further review and recommendations. admission nurses, RN supervisor/designee will complete reviews on weekends and holidays. Beginning 10/23/25, all residents care plans will be updated in coordination with the rehabilitation evaluations by the Rehabilitation Department to determine the appropriateness and safety of 1-2-person assist and any needed devices for post orthopedic patients as needed. Immediately following completion of audits, the DON or designee will follow up and coordinate with MDS Coordinator any need for updates and revisions to the care plan. The MDS Coordinator/ Designee will ensure that this information is accurately entered into the special Instructions individual patient profile banner in EMR and/or patient Kardex making it readily visible for all nursing staff to see and review prior to performing any ADL performed.Training and Education Started on 10/23/25 by Director of Staff Director and/or Designee.Immediate Action: In-service training was conducted by DON or and/or MRD regarding one-two person assistance and transfers for post-surgical orthopedic care initiated on 10/23/2025 for nursing staff and will be completed on 10/26/2025. Any staff that have not been trained yet will not be allowed to provide direct care until training has been completed. Immediate Action: In-service training was conducted by DON and or designee for admission nurses to include personalized baseline care plans for one -two-person assistance and devices beginning 10/23/25 and completed on 10/24/25. Any staff that have not been trained yet will not be allowed to provide direct care until training has been completed Immediate Action: Inservice training was conducted by DON and/or DSD regarding policy on post-surgical orthopedic care initiated on 10/23/2025 for nursing staff and will be completed on 10/26/2025. Any staff that have not been trained yet will not be allowed to provide direct care until training has been completed. Training in care planning and one-two person transfers will be included for new hires and will be reviewed yearly by DSD/ and DON during the annual performance review. The annual training calendar for licensed nurses and CNAs will include providing care planning and patient transfer competencies as part of its annual in-service for licensed nurses beginning the month of October 2025. Monitoring of the plan of removal included: Following acceptance of the facility's plan of removal, the facility was monitored from 10/24/2025 from 10:30 a.m., to 10/24/2025 at 5:39 pm., to remove the IT by: Record review of facility ongoing training and policies updates for nurses and certified nursing assistants. Resident # 2's care plan was updated to reflect adaptive devices. CNAs, master competency worksheet updated to reflect training on transfer, gait, one or two persons assist and Hoyer lift during new employee orientation. An ongoing training rosters for gait belt, Hoyer lift, and one -two persons transfer were presented with staff signatures. This will continue until every staff is trained. Staff who were not working on 10/22/2025 to 10/24/2025 would be trained upon their return to work. Observation of CNA H and CNA I on 10/24/2025 at 2:03 p.m., revealed they successfully completed a gait belt transfer from wheelchair to bed and vice versa. Observation and examination on 10/24/2025 at 11:48 am, revealed all mechanical lift devices were functioning properly, including charging locations on the halls. Interviews were conducted with CNAs , therapists, and nurses on 10/24/2025 at 12:119 p.m., to 10/24/2025 at 4:35 p.m., CNA B, CNA G, CNA H, CNA I, CNA J, RN B, RN C, LVN A, LVN B, LVN C, revealed they were reeducated on the use of mechanical lift, gait belt, one -two persons transfer, reviewing the Kardex prior to Resident transfer. While the training was ongoing, a total of fifteen direct-care staff were in-serviced on proper transfer with the right equipment.Administrator was informed that the IJ was removed on 10/24/2025 at 05:39 p.m. The facility remained out of compliance at a severity of isolation with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

The facility failed to provide and document sufficient preparation and orientation to resident or resident's family member on the facility bed-hold policies for 1 of 5 residents (Resident # 1) reviewed for discharge. S/S 1/D Based on interview and record review, the facility failed to provide discharge notice and document sufficient preparation and orientation to residents or resident's family member on the facility's bed -hold policies for 1 of 5 Residents (Resident # 1) reviewed for discharge rights. This failure could place residents at risk of not receiving notice of the facility's bed hold policy during transfer from the facility to a hospital which could result in anxiety, distress and displacement. Findings included: Record review of Resident # 1's face sheet dated 07/23/2025 revealed she was a [AGE] year old female admitted [DATE] with the following medical diagnoses: rheumatoid arthritis9 a chronic autoimmune disease that causes inflammation in the joints) restless legs(an irresistible urge to move the legs, typically accompanied by unpleasant sensation) tinea unguinous (a fungal infection of the nail), anemia,(lower-than-normal level of red blood cells) immunodeficiency due to drugs, (a person's immune system has a reduced ability to fight off infections as a result of taking certain medications) d deficiency, obesity, multiple sclerosis, myelin oligodendrocyte ( protein found on the brain and spinal cord), migraine, insomnia, narcolepsy ( excessive daytime sleepiness),carpal tunnel syndrome of the left upper limb, lesion of lateral popliteal ( damage to the nerve that causes foot drop), hereditary and idiopathic neuropathies ( nerve damage of undetermined cause), Guillain-Barre syndrome (weakness, numbness and paralysis), chronic pain, visual disturbance, asthma, gastro-esophageal reflux disease (stomach acid flowing back into the esophagus), calculus of bladder without obstruction(bladder stone without obstruction), sacroiliitis (painful, inflammation and stiffness of the joints), cervical disc displacement, radiculopathy (pinched nerve), generalized muscle weakness, shortness of breath, wound infection and traumatic brain injury (brain injury caused by external force, which can result to temporary or permanent impairment). Record review of Resident #1's MDS assessment dated [DATE], revealed she had a BIMS score of 12,which indicated she had moderate cognitive impairment. Section A0310 F, assessment type for entry/discharge report was coded 11, indicating discharge assessment with return anticipation. Section A0310 G, type of discharge was coded 2, indicating unplanned discharge. Record review of resident #1 s care plan dated 07/23/2025, revealed an Activities of daily living self-care performance deficit with bowel incontinence that required a check every two hours and assistance with peri care after each incontinence episode. Record review of the NP's documentation dated 07/28/2025 ,revealed Resident #1 was assessed for abdominal pain, fleet enema ( a pre-filled saline laxative used to relieve occasional constipation by drawing water into the colon to soften stool and stimulate a bowel movement within one to five minutes) , blood work and STAT KUB (a kidney, ureter and bladder x-ray to assess the abdominal area for causes of abdominal pain) was ordered. Record review of the facility progress notes, dated 07/28/2025, for Resident # 1 revealedno discharge order, discharge summary, or handwritten progress note from the physician to reflect the details of the discharge. During an interview with Resident # 1 on 10/8/2025 at 11:07a.m, she stated the facility coordinator promised her if she ever went to the Emergency Room, she would be allowed to return to the facility. Resident # 1 said: I found out later that; while I was at the hospital, they discharged me from the facility. One of the counselors from the hospital came to my hospital room to talk to me. The counselor said when she called the facility when I was getting close to discharge, the facility told the counselor, I was not allowed to come back. I called the facility to ask why I could not come back; I was told it was because I was refusing care and complaining too much. I anticipated returning to the facility, because they promised me at the beginning if I ever go to the ER, I would be able to come back. Resident # 1 stated she did not pack her belongings out of the room because she was not notified, she was not allowed to return. Resident # 1 stated her family member made a special trip to the facility to pack and remove her belongings from the facility.During an interview with the admission Coordinator on 10/08/2025 at 3:04 p.m., she stated the resident had called her from the hospital, and she told her she was not allowed to return to the facility due to aggressive behavior and she was non-compliant with treatment when she refused an enema ordered by the NP on the day she went to the ER. The coordinator stated, during the facility's morning meetings, they discussed residents' behaviors such as yelling at staff. The admission Coordinator stated Resident #1 yelled and screamed at the staff. The admission Coordinator said, Resident # 1's family member yelled and screamed at the front desk. The coordinator said, she called the resident at the hospital to let her know the facility was unable to accept her after her hospital discharge. During an interview with the DON on 10/09/2025 at 11:50 am, she stated Resident #1 was not allowed to return because of her family's aggressive behavior. The DON reviewed the facility's documentation and said there was no documentation of Resident #1's or her family's aggressive behavior. During an interview with the ADON on 10/09/2025 at 12:05 pm. she stated she heard of Resident # 1's family member's behavior but did not witness any. She heard the family member was demanding but she could not remember what resolutions were arrived at during the morning meetings. The ADON stated she did not know why Resident #1 was not allowed to return to the facility. During an interview with the Administrator on 10/09/2025 at 12:29 pm, the Administrator stated Resident #1 was not allowed to return because her family member was yelling at staff at the front desk on 07/28/2025. On 10/09/2025 at 12: 29 p.m., the Administrator said, Resident #1's family member said they were not returning to the facility. The Administrator stated she did not know if the resident went to the hospital with all her belongings. Record review of the transfer and discharge policy, dated December 2016, defined transfer as, moving the resident from the facility to another institutional setting, such as a hospital or another long-term care facility, or discharge with return anticipated. Discharge per facility record review was moving the resident to a non-institutional setting such as home, or discharge without expectation of return. The transfer and discharge process must provide sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility.-Criteria for Transfer/DischargeThe facility does not transfer or discharge a resident, unless:-The transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility.-Supporting information is documented in the resident's medical record. This includes documentation provided by the resident's physician.- The transfer or discharge is appropriate because the residents' health has improved sufficiently so the residents no longer need the services provided by the facility. Supporting information is documented in the resident's medical record. This includes documentation provided by the residents' physicians.- The safety of individuals in the facility is endangered. Supporting information is documented in the resident's medical record.-The health of individuals in the facility would otherwise be endangered.- Supporting information is documented in the resident's medical record.- The facility ceases operating.-Refusal of treatment would not constitute grounds for transfer.-A discharge order is obtained by nursing from the physician indicating where the resident is being discharged , why the resident is being discharged , and if the resident is to be discharged with or without medication.-Nursing notifies the business office of the transfer or discharge so that appropriate procedures can be implemented. Provide the information in wring and in a language and manner they understand.-Explain the residents' right to appeal the transfer/discharge.-Provide the name, address, and phone number of the state long term care ombudsman- Review the plan with the resident, and/or his or her family or responsible party, at least 24 hours before the resident's discharge from the facility.-The interdisciplinary team prepares the discharge summary-On the day of transfer or discharge, nursing prepares the resident-Provide notice, in writing, of the facility's bed-hold and readmission policies to the resident and an immediate family member, surrogate or representative.-Residents who were transferred for hospitalization or therapeutic leave, and whose absence exceeds the bed-hold period are permitted to return to the facility in the first available bed. The progress notes must include at least the following, as they may apply:-The reason(s) for the transfer or discharge.- That an appropriate notice of discharge was provided to the resident and/or representative.- That the residents and/or representative participated in a pre-discharge orientation program.-The date and time of the transfer or discharge. -The mode of transportation.- A summary of the resident's overall medical (including the condition of the skin), physical, and mental condition.- If medications are sent with the resident (list names, dosages, and amounts if medications are given to the resident).-Disposition of personal effects.- The signature of the person recording the data in the medical record

The facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice in performing physician ordered daily pain monitoring for 1 of 3 residents (Resident # 2) reviewed for pain assessment. Based on record reviews and interviews the facility failed to ensure Resident # 2 was assessed for pain according to physician's orders on 07/07/2025 and 07/08/2025.This failure could place, dependent residents at risk of experiencing pain, injuries, bruises, and fractures from possible accidents which could result in a diminished quality of life and hospitalizationFindings include: Record review of Resident # 2's face sheet dated 08/18/2025, revealed an [AGE] year-old male admitted on [DATE] following a joint replacement surgery on 06/25/2025. His diagnoses included: joint replacement surgery, type 2 diabetes(high levels of sugar in the blood stream), hypertension (high blood pressure), parathyroid( overactive thyroid glands), hyperlipidemia ( high levels of fat in the blood stream), dementia, depression, degenerative disease of nervous system, epilepsy (repeated seizures caused by damaged brain cells), Transient-Cerebral Ischemic Attack (brief blockage of blood flow to the brain), generalized muscle weakness, acute kidney failure, dysphagia (difficulty swallowing), tremors, lack of coordination, cognitive communication deficit, fracture of left femur(fracture of the hip bone), closed fracture with routine healing(a non-surgical procedure used to align and immobilize broken bones without the need for surgery.Record review of Resident # 2's MDS dated [DATE], cognition section C0400 was coded 1 which indicated able to recall after cueing. Cognition section C0500 was coded 06, which indicated severe cognitive impairment. Record review of Resident # 2's care plan dated 08/15/2025 revealed Resident # 2 had a fracture with a goal to remain free of complications related to hip fracture, such as contracture formation, embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and immobilization. Resident # 2 had ADL self-care performance deficit with the following intervention: needs transfer with two people assisting from bed to chair or vice versa. Record review of Resident # 2 Physician Orders dated 6/25/2025 revealed Pain Monitoring using verbal/nonverbal 0 -10 scale. Frequency: every shift everyday. Start Date:6/25/2025 - End Date: indefinite (Discontinued 7/14/2025).Record review of facility Physician progress notes dated 7/2/2025 revealed Assessment/Plan: 85 you male, with deficits in mobility, endurance and ADLs secondary to left hip FX , S/P repair. Pain due to fracture, neuropathy. New Problem: Impact on therapy causing imbalance, instability, decreased strength. Workup: Continue with PT/OT. Emphasis on AD training, static and dynamic balance training, functional activity tolerance, sensorimotor skills, increase body awareness, improve range of motion, strengthening, endurance training and neuromuscular training and control. Record review of Resident # 2's MAR, dated 07/ 2025 revealed Acetaminophen two tablet by mouth every six hours as needed for Headache: Pain. Tramadol HCl Give one tablet by mouth every 6 hours as needed for pain did not reveal pain level documented in MAR. Further review of progress notes, assessments, or vitals did not reveal notes for Pain Monitoring or Pain Level for dates 7/7/2025 - 7/8/2025. Record review of video placed by family member in Resident # 2's room, dated 07/07/2025, at 3:20 p.m. revealed CNA C transferred Resident # 2 without a second person assist. In the video, CNA C said, I am going to transfer you by myself. The video revealed CNA C transferred Resident # 2 from a wheelchair to his bed without using a gait belt. CNA C left the cushion in between Resident # 2's legs. CNA C removed the cushion from between his legs as he was sitting up in bed with pillows behind him. CNA C proceeded to remove his pants; CNA C, pushed on the left side of his legs on knees. Resident # 2 said whoa whoa. CNA C said, I am just taking your pants off and then pushed on his right side of his legs on knees to lower his pants. CNA C then put the cushion back between his legs. Further review of the video did not reveal CNA C assessing Resident # 2 for pain using verbal or non-verbal scale. Further review did not reveal CNA C informing a facility nurse to assess Resident # 2 for pain. During an interview on 10/22/2025 at 10:45 a.m., CNA D said she worked with Resident # 2 sometimes, when she helped his aide, CNA C. CNA D said Resident # 2 could not verbalize pain and he could only whisper certain words. CNA D said, she could tell if Resident # 2 was in pain because of his facial grimaces. CNAF said if any nonverbal resident was in pain, he or she would make facial grimaces. During an interview 10/22/2025 at 2:41 p.m., CNA F said Resident # 2 was moved from 100 hall to 600 hall. CNAF said when she provided care to Resident # 2, she had to be careful during repositioning. She said Resident # 2 could verbalize his pain. CNA F said she could not recall Resident # 2 exhibiting any signs of pain when she took care of him. During an interview on 10/23/205 at 10:38 a.m., the Administrator said, the CNA's get a report at the beginning of the shift and through electronic record on how to care for Resident # 2 which included transfer needs and other concerns. She said prior to investigation, she was not aware Resident # 2 had a dislocation of the right hip. She said she was aware of a communication issue with CNA C insisting on completing tasks without assistance. She said CNA C was no longer employed at the facility. She said she was not aware Resident #2 had pain or injury.During an interview on 10/23/2025 at 3:25 p.m., Nurse A said, she remembered Resident # 2. She said Resident #2, was first admitted to her hallway. She said Resident# 2 had a small blister on his leg because of the stocking (ted hose), which was discontinued. She said there was swelling of the right foot. She said the ankle x-ray result was negative with no displacement of the ankle. She said the plan was to elevate the right leg during the day shift. She said Resident # 2's family member was concerned about Resident # 2 being roughly transferred. She said Resident # 2 always complained of pain when staff had to put on the stocking and he would say ow ow ow, and they would have to come back later to apply the stocking before it was discontinued. She said she was not aware of the dislocation of hip or fracture of hip and did not hear anything about it. During an interview on 10/24/2025 at 2:13 p.m., CNA G said the nurses completed pain assessments for the Residents and the CNAs would ask questions like are you in pain or look to see if there were facial signs when touching body parts and report to the nurse. She said CNA's document the pain assessment completed in charting sheet a written in the online system's progress notes. During an interview on 10/24/2025 at 2:19 p.m., the ADON said on admission they asked the new guest if they had any pain. She said based on the resident's diagnoses, history and physical they are assessed for pain in areas of concern for each pain assessment/ monitoring. She said once the facility received reports or orders from the hospital, or PCP, the Resident would have medications available like narcotics. She said an order for pain assessment could be for medication and physician assessment. She said she would check Resident # 2's leg when there was an ankle complaint due to his history of hip replacement surgery and would ask who transferred and order x ray of whole leg. She said if bruising was noticed, they were to check for swelling in feet or pain when touched and if Resident # 2's body was touching anything that hit that area. She said pain monitoring was two hours every shift and the family was notified. The ADON stated skin observations was completed every hour or two hours. During an interview on 10/24/2025 at 3:22 p.m., Nurse B said in the facility electronic records portal, pain assessments were in Vitals. He said when completing the pain monitoring order in the system he would click on the medication order under the Residents name in the MAR then click nonverbal and completed. He said he had to ask the patient if he/she was in pain and looked for non-verbal cues and would ask before point to the non-verbal cues' images. Nurse B said, if Resident # 2 was given medication it was also entered and would complete a follow up for effectiveness of the medication and call the doctor. He said Resident # 2 was monitored every shift for pain assessment. He said on 07/07/2025 and 07/08/2025 pain monitoring was not recorded. He said the pain assessment task would be located in the MAR and would not be cleared up until completed. During an interview on 10/24/2025 at 4:32 p.m., Nurse 1 said pain assessment/monitoring was when the patient was complaining of pain. She said an order for pain monitoring was an assessment of acute or chronic pain based on resident's health report. She said she would ask residents on a scale 1 to 10 and note any facial expression or behavior and check vitals. She said they were to complete an assessment every day according to a physician order. She said the assessment was regarding any surgeries and all the components of the body. She said for Resident # 2 she would check for pain in hip. She said she was not sure if she completed an assessment for Resident # 2 on 07/07/2025 or 07/08/2025. She said she may have completed pain monitoring on a pain assessment tool sheet. She said the risk of not completing or documenting a pain assessment could aggravate other causes and triggers for the resident. During an interview on 10/24/2025 at 4:38 p.m., Nurse C said there was an order on every shift for assessing pain and there was an option for 0 - 10, and documentation was located on the TAR. Nurse C said if the resident's pain was level 0 that was to be entered. She said if the resident was alert you took whatever the resident told you or observed if the resident was making an expression or holding on to the body part and make a note. She said some residents did not tell you when they were in pain and would say they are not in pain. She said an assessment was to reposition residents that cannot move themselves and to view any skin breakdowns document in progress notes. She said she cannot remember and if Resident # 2 had pain medications or complained of pain. She said if pain assessment was not completed it could be a risk, this could intervene with therapy which was why Resident # 2 was admitted to the facility.Record review of the facility's pain screening and assessment policy dated 11/2024 revealed:-It is the policy of the facility to screen and assess each resident for pain.-Every shift, a pain score will be documented for each Resident.-Nursing will document a comprehensive pain assessment for Residents with a positive pain score. -Reassessments will occur at specific intervals following the initiation of a pain treatment plan.-Reassessment will minimally include pain location, intensity, side effects, functional status and adherence or substance abuse concerns.-Pain treatment effectiveness/outcomes and resulting revisions in the pain treatment plan will be documented in the medical records.-Anytime routine vitals are taken, the 0-10 pain intensity rating scale must be included as the 5th vital sign.-The screening of cognitively impaired residents may also required the observation of behavioral factors that signal pain or discomfort.-When possible, the [NAME] Faces pain rating scale may be used.

Based on interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (CR#1) of 7 residents reviewed for quality of care. The facility failed to send CR#1 to the hospital when her blood sugar was extremely low, despite EMS being called before and arriving 13 hours before her eventual transport to the local hospital. The facility failed to monitor CR#1's blood sugar for approximately 13 hours after it was documented as critically low. This lapse led to a second hypoglycemic episode during which CR#1 was found unresponsive and required emergency medical care. An Immediate Jeopardy (IJ) was identified on 10/03/2025 The IJ template was provided to the facility (administrator) on 10/3/25at12:26pm While the IJ was removed on 10/04/2025, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for possible serious injuries, harm and death. Findings Include: Record review of CR#1's face sheet dated 6/10/2025 reflected a [AGE] year-old female, with an original admission date of 10/1/2003 with diagnoses of ESRD (Kidney failure), hypertension (high blood pressure), diabetes mellitus without complications (type 2) and UTI (bladder infection). Record review of CR#1's MDS dated [DATE], revealed CR#1's cognitive skills were severely impaired, and she was dependent on staff for all her needs; there was no BIMS score listed. Record review of CR#1's orders dated 6/13/2025 revealed, CR#1 was prescribed Glipizide (5mg) for diabetes mellitus without complications. Blood glucose greater than 100 on 6/11/25 and D/C on 6/13/25 at 6:42am; Gabapentin (100MG) (1 tablet by mouth 3 times a day) for diabetes mellitus without complications on 6/11/25 and D/C on 6/16/25.Record review of CR #1's baseline care plan dated 6/10/25, revealed hypoglycemic medications. Record Review of nursing notes dated 6/12/25 at 5:30pm written by LVN A revealed, pt found lethargic during rounds, vitals assessed blood sugar monitor read low, bp 128/57, spo2 94, r 18, temp 97.5, glucagon (medicine that treats low blood sugar) administered x 1, rechecked 10 min later blood sugar 25, ems called, pt stabilized and remains on unit. rp notified. will continue to monitor. Record Review of nursing notes dated 6/13/25 at 6:07am written by LVN B revealed, Patient found lethargic, unable to arouse, vitals assessed blood sugar monitor read low, bp 120/50, spo2 91, r 10, temp 97.5, P 65 , glucagon administered x1, 911 was called, Rales to Bilateral lungs (crackling sound in both lungs), recheck sugar 3x and got a reading of 21, EMS, unable to rouse patient, patient was routed to Local hospital. Record Review of Facility's last vitals taken for CR#1 reflected:6/12/2025 Blood Sugar taken at 5:30pm_25 6/12/2025 Blood Pressure taken at 7:17pm 120/72 6/12/2025 Pulse taken at 5:30pm 59 bpm 6/13/2025 O2 stats taken at 1:02am 98.0% 6/12/2025 Temp taken at 7:10pm 97.8F Record Review of Nursing notes on 6/12/25 and 6/13/25 revealed no SBAR, Monitoring, assessing or follow-up notes by nursing. Record Review of the EMS run report dated 6/13/25 revealed, the FD responded to a call from the NF of an unconscious person. The report indicated the chief complaint was low BLG. EMS arrived to find the patient sitting up in bed, snoring. The patient was unresponsive with a GS of six. EMS assessed CR#1's vital signs which revealed, CR#1 was unresponsive at 5:56 AM with a blood pressure of 99/50, pulse 60 R, respiratory 14 R, oxygen 96%, blood sugar low did not register. The RN reported CR#1 was found with a low blood level of 21 and was administered glucagon and CR#1 did not respond, and 911 was called. The RN reported CR#1 had a hypoglycemic episode (low blood sugar) last night, was given glucagon, and treated with IV glucose by EMS and not transported to the ER. Record review of the Local Hospital B notes dated 6/13/25 revealed, CR#1 transferred to ER due to AMS and hypoglycemia. She was initially admitted to IMU (a step down or progressive care) and started on cefepime (treat bacteria) and Vanco (treat infection) but was transferred to ICU (highest level of care for critically ill patients) overnight due to worsening hypotension (low blood pressure) requiring vasopressors (used to treat dangerously low blood pressure). Record review of facility Diabetic Management Policy dated January 2021 revealed the following: HYPOGLYCEMIA PROTOCOLMild reactions: For a mild reaction when the resident is awake but signs or symptoms of low blood sugar or has a blood sugar level less than 70 mg/dl: Rule of 15 Give 1/2 cup of juice (apple or orange juice [for Renal patients, avoid orange juice Give a 15 gram dose of glucose gel (read labels) or glucose tablets. Brands vary. Wait 15 minutes and recheck the blood sugar. If the resident continues to have low blood sugar or has a blood sugar level below 70 mg/dl. Repeat the treatment. Recheck the blood sugar in 15 minutes and prepare to treat for a serious reaction if the resident does not recover. Moderate reactions: For a moderate reaction where the resident blood sugar is less than 45 mg/dL, but if they are awake, give 30 gm of carbohydrate orally by using two of the items listed above and continue the Rule of 15. Prepare glucagon if the individual does not recover immediately. Severe reactions: For a severe reaction where the resident cannot drink or swallow, isunconscious, or is having seizures: Administer 1 mg of glucagon intramuscularly. Position the resident on their side in case of vomiting. The CR#1 should awaken within minutes. If not, administer an additional dose of 1 mg glucagon intramuscularly and call for emergency assistance. Some facilities can provide intravenous dextrose 50% which should provide recovery. Once fully awake and not vomiting, the resident should eat. The following alert strategy could be considered: Call provider immediately in cases of low blood glucose levels (<70 mg/dL [3.9 mmol/L]). Call provider as soon as possible when glucose values are 70 100 mg/dL (3.9 5.6 mmol/L) (regimen may need to be adjusted), Record review of Quality of Life - Homelike Environment policy dated April 2018 revealed the following:PURPOSE: 1. Staff shall provide person-centered care that emphasizes the resident comfort, independence and personal needs and preferences. During a telephone interview on 10/1/25 at 2:10pm with LVN A she stated on 6/12/25, CNA A reported CR#1 was not looking well and didn't eat her lunch or dinner. LVN A stated on 6/12/25 at 5:30pm, she observed CR#1 to be lethargic at which time she began checking CR#1's vitals. She stated CR#1's blood sugar didn't register, which means the levels were low and the machine is unable to get a reading, and she administered glucagon (medicine that treat low blood sugar). CR#1's blood sugar was rechecked 10 minutes later the blood sugar registered at a 25. LVN A stated she called EMS on 6/12/25 and CR#1's representative, but not the doctor. LVN A stated she couldn't remember why she didn't call the doctor and knows she should have because of CR#1's change of condition. During an interview on 10/1/25 at 3:28pm the DON stated the two nurses should have called the doctor for an order to check the blood sugar continuously by the oncoming nurse (LVN B) (6p-6a), because she stated CR#1's blood sugar should have been checked every 20-30 minutes and follow-up documentation should have been completed on this. The DON stated waiting 13 hours to complete a round on CR#1 was unacceptable. The DON stated a failure to check blood sugar could result in a negative outcome, which could be coma, or death.During a telephone interview on 10/1/25 at 7:23pm with LVN B she stated on 6/13/25 at 6:07am she observed CR#1 foaming at the mouth. LVN B stated she was unable to arouse CR#1 so she began assessing her vitals. She stated CR#1's blood sugar was low, and LVN B administered glucagon, then called 911 (6/13/25). LVN B stated after 3 times and rechecking blood sugar levels she got a reading of 21. LVN B described CR#1 as being in an ICU state, where she was unable to respond to verbal commands. LVN B stated she made a nursing judgement to call 911 since she was informed by LVN A that on 6/12/25, EMS arrived at the facility earlier when called by LVN A but was advised by ADON that CR#1 was stable based on her blood sugar level, and there was no need to send CR#1 out to the hospital. LVN B stated in her professional opinion CR#1 should have been sent out earlier, via EMS. She stated CR#1's condition may have created a pancreas issue, fluid retention, and her kidneys were suffering. LVN B stated CR#1 was not eating or drinking fluids. LVN stated CR#1 was conscious when she left the facility. LVN B stated she did call CR#1's representative and the doctor but failed to complete documentation. LVN B stated she monitored CR#1 throughout the night, per orders, but did not note it in the nursing notes.During a follow-up telephone interview on 10/1/25 at 8:21pm with LVN A, she stated ADON was present on 6/12/25, during the first time EMS was tending to CR#1. She stated when CR#1's blood sugar registered to 21 at which time, the ADON informed EMS the resident was stable and there was no need to transport to the hospital at that time. LVN A stated she completed her documentation and shift change with LVN B, then left the facility because her shift was over at 6pm, During an interview on 10/2/25 at 11:00am the Hospital Medical Records Administrator stated CR#1 arrived at the ER on [DATE] a little after 6:00am transported by the local fire department and was admitted in the emergency room with a diagnosis of AMS and Hypoglycemia. During a telephone interview on 10/2/25 at 2:19pm CNA A stated he remembered CR#1 and working on 6/12/25. He stated during lunch he observed CR#1 had not eaten her lunch and reminded her that she needed to eat. CNA A stated after dinner he observed she hadn't eaten dinner and became concerned. He stated he again told CR#1 that she should eat, and she responded incoherently. CNA A stated he informed LVN A about CR#1 not eating her lunch and dinner meals and that she sounded incoherent, like babbling. CNA A stated LVN A rushed to CR#1's room and began her assessments and vitals. He stated then EMS arrived, which is when he left to tend to other residents before his shift ended at 6:00pm. During an Interview on 10/2/25 at 3:02pm the ADON stated she did not make the decision for EMS not to take CR#1 to the hospital on 6/12/25 at 5:30pm. ADON A stated she does not remember hearing CR#1 say she didn't want to go to the hospital, but if she did then she wouldn't be taken. The ADON stated the decision for EMS not taking CR#1 was between CR#1 and EMS. The ADON stated that she was informed after the fact that EMS was not going to transport CR#1 to the hospital. The ADON stated a change of condition could have been made, but she would have to see what the change of condition policy says. The ADON stated there should have been a follow-up with CR#1 after the initial event (6/12/25) and documented. The ADON stated she would have liked to have seen an Accu-Chek (device to check blood glucose/sugar levels) with a good number. She stated CR#1 crashed (a sudden change for the worse in CR#1's health) a little over 12 hours (between the time she was evaluated by LVN A and LVN B), but follow-up from the nurses may not have prevented it. The ADON stated a negative outcome could potentially result in death. During a telephone interview on 10/2/25 at 3:50pm with the MD, she stated any calls after 6:00pm are forwarded to the on-call answering services; however, if she wasn't on call she would have gotten the message anyway. The MD stated she was not notified on 6/12/2025 nor 6/13/2025 of CR#1's condition. The MD stated blood sugar numbers under 40 are not good numbers and this was a critical event, and a doctor should have been notified immediately. The MD stated since nursing staff didn't send CR#1 out to the hospital, CR#1 should've been monitored every 20 minutes by finger stick to get a more recent reading and to determine if the blood sugar is rising to an acceptable range within 2 to 4 hours at the most. She stated CR#1's eating and fluid intake should have been monitored as well. During the 2 to 4 hour monitoring range, if blood sugar levels were not within range during this period, then EMS should have been called based on resident's medical history and condition. The MD stated blood sugar ranges of 21 & 25 are not acceptable numbers and a resident is still not cognitive to make decisions. The MD stated that there should have been more details documented in nursing notes of how the resident was doing based on nurse monitoring. The MD stated the resident was taking medication for diabetes and glucagon not being monitored could have had a dangerous effect. Record review of the Change of Condition policy reflected:PROCEDURE:1. Acute medical changes or any sudden or serious change in condition manifestedby a marked change in physical, mental and psychosocial status:a Licensed Nurse will notify the physician,b If unable to contact attending physician or alternate physician, notify the Medical Director,Notify and inform legal surrogate for any change of condition.2. Using the Interact Tool SBAR - notify physician for all signs and symptomsmanifested by the patient. The form will be used to initiate change of conditiondocumentation for any decline or improvement. An Immediate Jeopardy (IJ) was identified on 10/03/2025 The IJ template was provided to the facility (administrator) on 10/3/25at12:26pm While the IJ was removed on 10/04/2025, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Review of the facility's Plan of Removal reflected:[Facility name]October 3, 2025 F684 The facility failed to ensure CR#1 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The facility failed to seek medical Guidance from CR # 1's physician or sent her out to emergency care when she experienced a change of condition related to hypoglycemia. Facility nurse failed to follow monitor CR #1's blood sugar for approximate 13 hours after it was noted to be critically low. This resulted in a second occurrence of hypoglycemia and CR #1 was noted to be unresponsive and required emergency medical care. The following are the Immediate Plan for Removal for F684 Free Quality of Care Version 4. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies. 1. Immediate Action: On 6/13/25 CR#1 has been discharged to [the hospital] via 911. 2. Immediate Action: LPN A no longer works at the facility since _7/15/25__. 3. Immediate Action: LPN B no longer works at the facility since __8/20/25_____. 4. Immediate Action: CNA-A was provided 1:1 in-service on 10/3/2025 on reporting changes and any meal intake less than 75% to license nurse to offer supplement or other substitute meal available. 5. Immediate Action: Inservice training was provided by DON/designee with all CNAs on ensuring that any changes in meal intake less than 75% and also changes in condition observed are reported to license nurse assigned. Training initiated on 10/3/2025 with _8_ total CNA's attending and targeted completion date of _10/4/25_. 6. Immediate Action: Inservice training was provided by DON/designee initiated on 10/3/2025 with all LNs. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 10/3/2025 with _6_ total LN's attending and targeted completion date of __10/3/25_ with the following education: a. Completing change of condition evaluation for residents b. Notifying physicians for any change of conditions c. Notifying the party responsible for change of conditions. d. Review of hypo/hyperglycemic protocols, monitoring blood sugar according to the protocol/MD order including discussion signs and symptoms of hyper/hypoglycemia that requires physician intervention and notification. 2. Governing Body - QAPI committee a. Immediate Action: During the ad hoc QAPI Committee meeting on 10/3/2025, a root cause analysis (RCA) revealed multiple system-level factors that contributed to the poor medical event follow up which includes handoff communication issue, monitoring follow up, training and possible competency gaps and timely physician notification. The RCA identified the root cause as the proper communication and handoff follow up for identified care issues and physician notification for changes of conditions for any medical events. b. The NHA will oversee corrective actions initiated on 10/3/2025 and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, medication administration pass audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action. c. Any new issues found during medical record audits and medication pass administration audit will be presented to the QAPI team members for immediate action. The DON will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.3. Specific staff involved in implementing the corrective actions.a. Team Members: Medical Director, Nursing Home Administrator (NHA), Director of Nurses (DON), Assistant Director of Nurses (ADON). Each member will perform:i. Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce medical events.ii. NHA: The NHA will oversee all corrective actions initiated on 9/9/2025 and continue monthly reviews during QAPI meetings.iii. DON: The DON will oversee the investigation, reporting, and resolution of medication administration errors, ensuring patient safety and regulatory compliance. The DON will implement corrective actions, conduct audits, monitor staff adherence to policies, and collaborate with the ADON to provide ongoing training, reinforcing best practices in medication management.iv. ADON: This role will include educating staff and plays a critical role in addressing medical events intervention by providing targeted training and education to licensed nursing staff, ensuring compliance with facility policies and regulatory standards. The role includes conducting in-service sessions on proper medication administration, change of condition, overseeing competency evaluations, and implementing corrective action plans to prevent future errors while promoting a culture of accountability and continuous improvement.4. Identification of other residents who may need to be included (who may have been affected by the deficient practice: a. All residents with diagnosis of diabetes were identified to be at risk for the identified deficient practice. On 10/3/2025, a random audit of all in-house patients was completed by DON/designee and found a total of _26_ residents to have Diabetes.i. A random audit of lunch administered on 10/3/2025 for all 78 residents completed by ADON or designee showed that there was no other resident affected by any meal intakes less than 75% that were reported to licensed nurses and documented by CNAs.ii A random audit by DON or designee of all 26 residents with diabetes and blood sugar checks showed zero affected resident with blood sugar results of less than 70 for completed fingerstick done prior to lunch.5. Systemic Changes and Measures:a. System Change: Training in change of condition monitoring and reporting will be included for new hires and will be reviewed yearly by ADON during the annual performance review. The annual training calendar will include change of condition monitoring for its annual in-service for LNs beginning the month of October-2025. b. System Change: Training in meal intake monitoring and reporting will be included for new hires and will be reviewed yearly by ADON during the annual performance review. The annual training calendar will include meal % monitoring its annual in-service for CNAs beginning the month of October-2025.c. System Change: Starting 10/4/25, the MDS Nurse will conduct audits of blood sugar monitoring using BS audit tool to determine if notification of physician and patient representative occurred and change of condition was initiated. Audits will be conducted daily for three (3) days, then weekly for two (2) weeks, and monthly thereafter. The MDS Nurse will submit the findings of the audits to the DON for review, analysis, and implementation of necessary corrective actions to improve medication administration practices and ensure regulatory compliance. Issues found by the DON will refer to the QAPI Committee for further review and revision of action plan and/or to determine any further training needs for staff involved d. System Change: Starting 10/4/25, the MDS Nurse will conduct audits of meal intake and LN notification using meal intake report from EHR. Audits will be conducted daily for three (3) days, then weekly for two (2) weeks, and monthly thereafter. The MDS Nurse will submit the findings of the audits to the DON for review, analysis, and implementation of necessary corrective actions to improve medication administration practices and ensure regulatory compliance. Issues found by the DON will refer to the QAPI Committee for further review and revision of action plan and/or determining any further training needs for staff involved.e. System Change: Starting 10/4/25, the MDS Nurse will conduct change of condition audit using a COC audit tool. Audits will be conducted daily for three (3) days, then weekly for two (2) weeks, and monthly thereafter. The MDS Nurse will review and submit the findings of the audits to the DON for review, analysis, and implementation of necessary corrective actions to improve medication administration practices and ensure regulatory compliance. Issues found by the DON will refer to the QAPI Committee for further review and revision of action plan and/or to determine any further training needs for staff involved f. System Change: Starting 10/4/25, the ADON/designee will conduct a random audit of residents with change of condition to determine that monitor occurred for 72 hours following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions. g. System Change: Starting 10/4/25, weekly for 2 weeks and monthly thereafter for 3 months, a random verification of licensed nurses' knowledge and training will be conducted by ADON/designee using a mock hypo/hyperglycemia drill to test responses of nurses based on physician's order and/or diabetic protocol ordered. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.6. Training and Education Started on 10/3/2025 by DON and/or Designee. a. Immediate Action: CNA-A was provided 1:1 in-service on 10/3/2025 on reporting changes and any meal intake less than 75% to license nurse to offer supplement or other substitute meal available. b. Immediate Action: Inservice training was provided by DON/designee with all CNAs on ensuring that any changes in meal intake less than 75% and also changes in condition observed are reported to license nurse assigned. Training initiated on 10/3/2025 with _8_ total CNA's attending and targeted completion date of _10/4/25__.c. Immediate Action: Inservice training was provided by DON/designee initiated on 10/3/2025 with all LNs. Training initiated on 10/3/2025 with _6_ total LN's attending and targeted completion date of _10/3/25_ with the following education: a. Completing change of condition evaluation for residents b. Notifying physicians for any change of conditions c. Notifying the party responsible for change of conditions. d. Review of hypo/hyperglycemic protocols, monitoring blood sugar according to the protocol/MD order including discussion signs and symptoms of hyper/hypoglycemia that requires physician intervention and notification.Please review the following POR.Sincerely,[name], Record Review of facility monitoring plan, confirmed the facility implemented their plan of removal and monitoring began on 10/4/2025. The following was confirmed: LVN A no longer employedLVN B no longer employedCNA A in-serviced 1:1In-services for CNAsIn-services for LVNsAudit that identified 26 residents with diabetesLunch audit on 10/3The audit of the 26 residents with diabetesThe blood sugar audit toolThe meal intake formThe change of condition audit tool During an interview on 10/4/25 at 4:46pm with RN A she stated she received in-service yesterday and today. She stated the dietary intake guide monitors the nutrition intake in a resident and anything less than 70% is to be reported immediately to the charge nurse. She stated the SBAR is the most important thing to communicate to physicians during the Change of Condition (sudden changes, vitals, etc. and anything unusual). Any change of condition should be reported to the doctor, resident rep, and DON. She stated during 9:15am staff morning 24-hour report, all resident information is reported. She stated when a resident is hypoglycemic the resident will not be alert, will be sweating and unable to arouse. RN A stated there were three required steps before calling the doctor when a resident has a change of condition. Those requirements are perform a head to toe assessment, obtain vital signs (including any relevant measurements like O2 saturation, glucose, and pain score), and clarify doctor orders, check code status. She stated the two signs of a glucose emergency are hypoglycemia or hyperglycemia (high blood sugar). She stated the protocol for hypoglycemic is to complete head to toe assessment, give juice honey, administer glucagon and recheck every 15 minutes and call 911 if the blood sugar is under 70. Call the MD, RP; and the protocol for hyperglycemic is to ensure residents have lot of fluids, administer insulin, look for consciousness, complete head to toe assessments, notify the MD, RP. During a telephone interview on 10/4/25 at 5:00pm CNA B stated she received in-service training yesterday and today on changes in conditions, dietary intake monitoring and reporting to the nurse in charge. She stated an example of a change in condition is anything unusual with a resident, which is the change in eating, and sleeping patterns. She stated a dietary intake guide is a monitoring tool of how much a resident has eaten. She stated anything below 70% is reported to the charge nurse.During an interview on 10/4/25 at 5:26pm with CNA C she stated today is day two for in-service training on change of condition, reporting, vitals, physical and mental changes, and dietary intake. She stated that a resident who arrived coherent, and is now confused, is considered to have a change in condition. She stated a dietary intake guide is a monitoring form that tells nursing staff when a resident has eaten and how much. She stated anything under 70% - 75% the charge nurse should be notified due to factors of underlying conditions and conditions worsening for the resident. During an interview on 10/4/25 at 5:38pm with CNA D she stated she was in-serviced yesterday on change of condition for residents and their food intake. She stated changes in condition are considered abnormal. One of the changes would be if a resident is not eating, eating less than usual, their vital signs and if their behavior has changed. She stated the dietary intake guide shows the percentage of food residents have eaten. She stated if food intake is 70% or lower it should be reported to the charge nurse because something could be wrong.During a telephone interview on 10/4/25 at 6:00pm LVN C stated she was in-serviced on change in condition, and proper documentation. She stated an example is a resident may have diarrhea or 3 or more stools in a day. It is a concern and should be reported as a change in condition. She stated a dietary intake guide is a measurement of resident meal intake and must be reported if it is below 70% by the CNA. She stated as a charge nurse she reports changes in condition to the DON, MD, and RP. She stated it is important to report changes because the changes could be severe and detrimental to the resident up to death if not addressed. There could be early signs that could lead to more serious conditions and reporting could reduce the risk. The two signs of a glucose emergency are hypoglycemia and hyperglycemia. She stated the protocol for hypoglycemic is to complete head to toe assessment, give juice honey, glucagon and recheck every 15 minutes and call 911 if the blood sugar is under 70. Call the MD, RP; and the protocol for hyperglycemic is to ensure residents have lot of fluids, administer insulin, look for consciousness, complete head to toe assessments, notify the MD, RP. During a telephone interview on 10/4/25 at 6:15pm RN B stated she was in-serviced on change in condition, and proper documentation. She stated an example is a resident may have diarrhea or 3 or more stools in a day. It is a concern and should be reported as a change in condition. She stated a dietary intake guide is a measurement of resident meal intake and must be reported if it is below 70% by the CNA. She stated as a charge nurse she reports changes in condition to the DON, MD, and RP. She stated it is important to report changes because the changes could be severe and detrimental to the resident up to death if not addressed. There could be early signs that could lead to more serious conditions and reporting could reduce the risk. The two signs of a glucose emergency are hypoglycemia and hyperglycemia. She stated the protocol for hypoglycemic is to complete head to toe assessment, give juice honey, glucagon and recheck every 15 minutes and call 911 if the blood sugar is under 70. Call the MD, RP; and the protocol for hyperglycemic is to ensure residents have lot of fluids, administer insulin, look for consciousness, complete head to toe assessments, notify the MD, RP. During a telephone interview on 10/4/25 at 6:25pm CNA E stated she was in serviced this morning on changes in condition and reporting to charge nurse. She stated that a change in condition regarding a resident is a sign or symptom that is a new onset out of the norm. She stated like if a resident stopped talking all of a sudden. It should be reported to the charge nurse. She stated a dietary intake guide measures the amount of food residents have eaten and gives a percentage that requires you to report to the charge nurse. It should be reported to the charge nurse if the food intake is below 70%. During a telephone interview on 10/4/25 at 6:40pm RN C stated she received in-service yesterday on changes in condition, which was on signs and symptoms and a new onset of behaviors not in the resident's norm. It's out of character. Also, the importance of documentation, and reporting to the MD, DON, and Resident Representative. An example of a change is a resident not eating or drinking like they did in the past. The dietary intake guide should be used to measure resident meal intake and if the resident intake is below a 70% the CNA must report to the charge nurse who will report to the doctor after a head-to-toe assessment, then to the resident rep. The changes could be severe and detrimental to the resident up to death if not

Based on interviews, and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (CR#1) of 7 residents reviewed for change of condition, in that,The facility failed to consult with or establish contact with the MD or on-call medical personnel for guidance on 6/12/25 at 5:30pm, when CR#1 had a serious medical event, in which she was noted to have an altered mental status and her blood sugar was critically low. CR#1 experienced a second event 13 hours later and was noted to be unresponsive, which resulted in immediate hospitalization where she was treated for hypoglycemia and an Altered Mental Status.An Immediate Jeopardy (IJ) was identified on 10/03/2025 The IJ template was provided to the facility (administrator) on 10/3/25at12:26pm While the IJ was removed on 10/04/2025, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could expose residents to delay in treatment, worsening of condition, hospitalization, and death. Findings Include: Record review of CR#1's face sheet dated 6/10/2025 reflected a [AGE] year-old female, with an original admission date of 10/1/2003 with diagnoses of ESRD (Kidney failure), hypertension (high blood pressure), diabetes mellitus without complications (type 2) and UTI (bladder infection). Record review of CR#1's MDS dated [DATE], revealed CR#1's cognitive skills were severely impaired, and she was dependent on staff for all her needs; there was no BIMS score listed. Record review of CR#1's orders dated 6/13/2025 revealed, CR#1 was prescribed Glipizide (5mg) for diabetes mellitus without complications. Blood glucose greater than 100 on 6/11/25 and D/C on 6/13/25 at 6:42am; Gabapentin (100MG) (1 tablet by mouth 3 times a day) for diabetes mellitus without complications on 6/11/25 and D/C on 6/16/25. Record review of CR #1's baseline care plan dated 6/10/25, revealed dialysis treatment and to be educated on medication order for cardiovascular medications, anticoagulants, hypoglycemic medications/insulin. Record Review of nursing notes dated 6/12/25 at 5:30pm written by LVN A revealed, pt found lethargic during rounds, vitals assessed blood sugar monitor read low, bp 128/57, spo2 94, r 18, temp 97.5, glucagon (medicine that treats low blood sugar) administered x 1, rechecked 10 min later blood sugar 25, ems called, pt stabilized and remains on unit. rp notified. will continue to monitor. Record Review of nursing notes dated 6/13/25 at 6:07am written by LVN B revealed, Patient found lethargic, unable to arouse, vitals assessed blood sugar monitor read low, bp 120/50, spo2 91, r 10, temp 97.5, P 65 , glucagon administered x1, 911 was called, Rales to Bilateral lungs (crackling sound in both lungs), recheck sugar 3x and got a reading of 21, EMS, unable to rouse patient, patient was routed to Local hospital. Record Review of Nursing notes on 6/12/25 and 6/13/25 revealed no SBAR, no Monitoring, and/or no assessment of CR#1's level of consciousness or any follow-up notes by nursing between 6/12/25 at 7:17pm when the last blood pressure was taken and 6/13/25 at 6:07am when CR#1 was found in her bed non-responsive.Record Review of Facility's last vitals taken for CR#1 reflected:6/12/2025 Blood Sugar taken at 5:30pm_25 6/12/2025 Blood Pressure taken at 7:17pm 120/72 6/12/2025 Pulse taken at 5:30pm 59 bpm 6/13/2025 O2 stats taken at 1:02am 98.0% 6/12/2025 Temp taken at 7:10pm 97.8F Record Review of Nursing notes on 6/12/25 and 6/13/25 revealed no SBAR, Monitoring, assessing or follow-up notes by nursing. Record Review of the EMS run report dated 6/13/25 revealed, the FD responded to a call from the NF of an unconscious person. The report indicated the chief complaint was low BLG. EMS arrived to find the patient sitting up in bed, snoring. The patient was unresponsive with a GS of six. EMS assessed CR#1's vital signs which revealed, CR#1 was unresponsive at 5:56 AM with a blood pressure of 99/50, pulse 60 R, respiratory 14 R, oxygen 96%, blood sugar low did not register. The RN reported CR#1 was found with a low blood level of 21 and was administered glucagon and CR#1 did not respond, and 911 was called. The RN reported CR#1 had a hypoglycemic episode (low blood sugar) last night, was given glucagon, and treated with IV glucose by EMS and not transported to the ER. Record review of the Local Hospital B notes dated 6/13/25 revealed, CR#1 transferred to ER due to AMS and hypoglycemia. She was initially admitted to IMU (a step down or progressive care) and started on cefepime (treat bacteria) and Vanco (treat infection) but was transferred to ICU (highest level of care for critically ill patients) overnight due to worsening hypotension (low blood pressure) requiring vasopressors (used to treat dangerously low blood pressure). During a telephone interview on 10/1/25 at 2:10pm with LVN A she stated on 6/12/25, CNA A reported CR#1 was not looking well and didn't eat her lunch or dinner. LVN A stated on 6/12/25 at 5:30pm, she observed CR#1 to be lethargic at which time she began checking CR#1's vitals. She stated CR#1's blood sugar didn't register, which means the levels were low and the machine is unable to get a reading, and she administered glucagon (medicine that treat low blood sugar). CR#1's blood sugar was rechecked 10 minutes later the blood sugar registered at a 25. LVN A stated she called EMS on 6/12/25 and CR#1's representative, but not the doctor. LVN A stated she couldn't remember why she didn't call the doctor and knows she should have because of CR#1's change of condition. During an interview on 10/1/25 at 3:28pm the DON stated the two nurses should have called the doctor for an order to check the blood sugar continuously by the oncoming nurse (LVN B) (6p-6a), because she stated CR#1's blood sugar should have been checked every 20-30 minutes and follow-up documentation should have been completed on this. The DON stated waiting 13 hours to complete a round on CR#1 was unacceptable. The DON stated a failure to check blood sugar could result in a negative outcome, which could be coma, or death. During a telephone interview on 10/1/25 at 7:23pm with LVN B she stated on 6/13/25 at 6:07am she observed CR#1 foaming at the mouth. LVN B stated she was unable to arouse CR#1 so she began assessing her vitals. She stated CR#1's blood sugar was low, and LVN B administered glucagon, then called 911 (6/13/25). LVN B stated after 3 times and rechecking blood sugar levels she got a reading of 21. LVN B described CR#1 as being in an ICU state, where she was unable to respond to verbal commands. LVN B stated she made a nursing judgement to call 911 since she was informed by LVN A that on 6/12/25, EMS arrived at the facility earlier when called by LVN A but was advised by ADON that CR#1 was stable based on her blood sugar level, and there was no need to send CR#1 out to the hospital. LVN B stated in her professional opinion CR#1 should have been sent out earlier, via EMS. She stated CR#1's condition may have created a pancreas issue, fluid retention, and her kidneys were suffering. LVN B stated CR#1 was not eating or drinking fluids. LVN stated CR#1 was conscious when she left the facility. LVN B stated she did call CR#1's representative and the doctor but failed to complete documentation. LVN B stated she monitored CR#1 throughout the night, per orders, but did not note it in the nursing notes. During a follow-up telephone interview on 10/1/25 at 8:21pm with LVN A, she stated ADON was present during the time EMS was tending to CR#1. She stated when CR#1's blood sugar registered the ADON informed them the resident was stable and there was no need to transport to the hospital at that time. During an interview on 10/2/25 at 11:00am the Hospital Medical Records Administrator stated CR#1 arrived at the ER on [DATE] a little after 6:00am transported by the local fire department and was admitted in the emergency room with a diagnosis of AMS and Hypoglycemia. During a telephone interview on 10/2/25 at 2:19pm CNA A stated he remembered CR#1 and working on 6/12/25. He stated during lunch he observed CR#1 had not eaten her lunch and reminded her that she needed to eat. CNA A stated after dinner he observed she hadn't eaten dinner and became concerned. He stated he again told CR#1 that she should eat, and she responded incoherently. CNA A stated he informed LVN A about CR#1 not eating her lunch and dinner meals and that she sounded incoherent, like babbling. CNA A stated LVN A rushed to CR#1's room and began her assessments and vitals. He stated then EMS arrived, which is when he left to tend to other residents before his shift ended at 6:00pm. During an Interview on 10/2/25 at 3:02pm the ADON stated she did not make the decision for EMS not to take CR#1 to the hospital on 6/12/25 at 5:30pm. ADON A stated she does not remember hearing CR#1 say she didn't want to go to the hospital, but if she did then she wouldn't be taken. The ADON stated the decision for EMS not taking CR#1 was between CR#1 and EMS. The ADON stated that she was informed after the fact that EMS was not going to transport CR#1 to the hospital. The ADON stated a change of condition could have been made, but she would have to see what the change of condition policy says. The ADON stated there should have been a follow-up with CR#1 after the initial event (6/12/25) and documented. The ADON stated she would have liked to have seen an Accu-Chek (device to check blood glucose/sugar levels) with a good number. She stated CR#1 crashed (a sudden change for the worse in CR#1's health) a little over 12 hours (between the time she was evaluated by LVN A and LVN B), but follow-up from the nurses may not have prevented it. The ADON stated a negative outcome could potentially result in death. During a telephone interview on 10/2/25 at 3:50pm with the MD, she stated any calls after 6:00pm are forwarded to the on-call answering services; however, if she wasn't on call she would have gotten the message anyway. The MD stated she was not notified on 6/12/2025 nor 6/13/2025 of CR#1's condition. The MD stated blood sugar numbers under 40 are not good numbers and this was a critical event, and a doctor should have been notified immediately. The MD stated since nursing staff didn't send CR#1 out to the hospital, CR#1 should've been monitored every 20 minutes by finger stick to get a more recent reading and to determine if the blood sugar is rising to an acceptable range within 2 to 4 hours at the most. She stated CR#1's eating and fluid intake should have been monitored as well. During the 2 to 4 hour monitoring range, if blood sugar levels were not within range during this period, then EMS should have been called based on resident's medical history and condition. The MD stated blood sugar ranges of 21 & 25 are not acceptable numbers and a resident is still not cognitive to make decisions. The MD stated that there should have been more details documented in nursing notes of how the resident was doing based on nurse monitoring. The MD stated the resident was taking medication for diabetes and glucagon not being monitored could have had a dangerous effect. Record review of the Change of Condition policy reflected:PROCEDURE:1. Acute medical changes or any sudden or serious change in condition manifestedby a marked change in physical, mental and psychosocial status:a Licensed Nurse will notify the physician,b If unable to contact attending physician or alternate physician, notify the Medical Director,Notify and inform legal surrogate for any change of condition.2. Using the Interact Tool SBAR - notify physician for all signs and symptomsmanifested by the patient. The form will be used to initiate change of conditiondocumentation for any decline or improvement.3. Follow notification guideline for physicians using Interact Tool Change of Condition File Cards4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 5. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. An Immediate Jeopardy (IJ) was identified on 10/03/2025 The IJ template was provided to the facility (administrator) on 10/3/25at12:26pm While the IJ was removed on 10/04/2025, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Review of the facility's Plan of Removal reflected:[Facility name] October 3, 2025 F580 Notification of Changes The facility failed to consult with resident's physician when there was a significant change in the resident's physical, mental or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). The following are the Immediate Plan for Removal for F580 Notification of Changes Version 2 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies. 2. Immediate Action: On 6/13/25 CR#1 has been discharged to [the hospital] via 911. 3. Immediate Action: LPN A no longer works at the facility since _7/15/25__. 4. Immediate Action: LPN B no longer works at the facility since __8/20/25_____. CNA-A was provided 1:1 in-service on 10/3/2025 on reporting changes and any meal intake less than 75% to license nurse to offer supplement or other substitute meal available. 5. Immediate Action: Inservice training was provided by DON/designee with all CNAs on ensuring that any changes in meal intake less than 75% and also changes in condition observed are reported to license nurse assigned. Training initiated on 10/3/2025 with _8_ total CNA's attending and targeted completion date of _10/4/25_. 6. Immediate Action: Inservice training was provided by DON/designee initiated on 10/3/2025 with all LNs. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 10/3/2025 with _6_ total LN's attending and targeted completion date of __10/3/25_ with the following education: a. Completing change of condition evaluation for residents b. Notifying physicians for any change of conditions c. Notifying the party responsible for change of conditions. 2. Governing Body - QAPI committee a. Immediate Action: During the ad hoc QAPI Committee meeting on 10/3/2025, a root cause analysis (RCA) revealed multiple system-level factors that contributed to the poor medical event follow up which includes handoff communication issue, monitoring follow up, training and possible competency gaps and timely physician notification. The RCA identified the root cause as the proper communication and handoff follow up for identified care issues and physician notification for changes of conditions for any medical events. b. The NHA will oversee corrective actions initiated on 10/3/2025 and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, medication administration pass audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action. c. Any new issues found during medical record audits and medication pass administration audit will be presented to the QAPI team members for immediate action. The DON will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved. 3. Specific staff involved in implementing the corrective actions.a. Team Members: Medical Director, Nursing Home Administrator (NHA), Director of Nurses (DON), Assistant Director of Nurses (ADON). Each member will perform:i. Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce medical events.ii. NHA: The NHA will oversee all corrective actions initiated on 9/9/2025 and continue monthly reviews during QAPI meetings.iii. DON: The DON will oversee the investigation, reporting, and resolution of medication administration errors, ensuring patient safety and regulatory compliance. The DON will implement corrective actions, conduct audits, monitor staff adherence to policies, and collaborate with the ADON to provide ongoing training, reinforcing best practices in medication management.iv. ADON: This role will include educating staff and plays a critical role in addressing medical events intervention by providing targeted training and education to licensed nursing staff, ensuring compliance with facility policies and regulatory standards. The role includes conducting in-service sessions on proper medication administration, change of condition, overseeing competency evaluations, and implementing corrective action plans to prevent future errors while promoting a culture of accountability and continuous improvement.4. Identification of other residents who may need to be included (who may have been affected by the deficient practice: a. All residents with diagnosis of diabetes were identified to be at risk for the identified deficient practice. On 10/3/2025, a random audit of all in-house patients was completed by DON/designee and found a total of _26_ residents to have Diabetes.i. A random audit of lunch administered on 10/3/2025 for all 78 residents completed by ADON or designee showed that there was no other resident affected by any meal intakes less than 75% that were reported to licensed nurses and documented by CNAs.ii A random audit by DON or designee of all 26 residents with diabetes and blood sugar checks showed zero affected resident with blood sugar results of less than 70 for completed fingerstick done prior to lunch.5. Systemic Changes and Measures: 1. System Change: Training in change of condition monitoring and reporting will be included for new hires and will be reviewed yearly by ADON during the annual performance review. The annual training calendar will include change of condition monitoring for its annual in-service for LNs beginning the month of October-2025.b. System Change: Training in meal intake monitoring and reporting will be included for new hires and will be reviewed yearly by ADON during the annual performance review. The annual training calendar will include meal % monitoring its annual in-service for CNAs beginning the month of October-2025.c. System Change: Starting 10/4/25, the MDS Nurse will conduct audits of blood sugar monitoring using BS audit tool to determine if notification of physician and patient representative occurred and change of condition was initiated. Audits will be conducted daily for three (3) days, then weekly for two (2) weeks, and monthly thereafter. The MDS Nurse will submit the findings of the audits to the DON for review, analysis, and implementation of necessary corrective actions to improve medication administration practices and ensure regulatory compliance. Issues found by the DON will refer to the QAPI Committee for further review and revision of action plan and/or to determine any further training needs for staff involved d. System Change: Starting 10/4/25, the MDS Nurse will conduct audits of meal intake and LN notification using meal intake report from EHR. Audits will be conducted daily for three (3) days, then weekly for two (2) weeks, and monthly thereafter. The MDS Nurse will submit the findings of the audits to the DON for review, analysis, and implementation of necessary corrective actions to improve medication administration practices and ensure regulatory compliance. Issues found by the DON will refer to the QAPI Committee for further review and revision of action plan and/or determining any further training needs for staff involved.e. System Change: Starting 10/4/25, the MDS Nurse will conduct change of condition audit using a COC audit tool. Audits will be conducted daily for three (3) days, then weekly for two (2) weeks, and monthly thereafter. The MDS Nurse will review and submit the findings of the audits to the DON for review, analysis, and implementation of necessary corrective actions to improve medication administration practices and ensure regulatory compliance. Issues found by the DON will refer to the QAPI Committee for further review and revision of action plan and/or to determine any further training needs for staff involved 6. Training and Education Started on 10/3/2025 by DON and/or Designee. a. Immediate Action: CNA-A was provided 1:1 in-service on 10/3/2025 on reporting changes and any meal intake less than 75% to license nurse to offer supplement or other substitute meal available. b. Immediate Action: Inservice training was provided by DON/designee with all CNAs on ensuring that any changes in meal intake less than 75% and also changes in condition observed are reported to license nurse assigned. Training initiated on 10/3/2025 with _8_ total CNA's attending and targeted completion date of _10/4/25__.7. Immediate Action: Inservice training was provided by DON/designee initiated on 10/3/2025 with all LNs. Training initiated on 10/3/2025 with _6_ total LN's attending and targeted completion date of _10/3/25_ with the following education: a. Completing change of condition evaluation for residents b. Notifying physicians for any change of conditions c. Notifying the party responsible for change of conditions. Please review the following POR.Sincerely,[name], Monitoring On 10/4/2025 at 10:50pm the Administrator was informed the IJ was removed. During a telephone interview on 10/5/25 at 5:00PM with the MDS Nurse it was revealed that on 10/4/25, the MDS Nurse conducted audits of blood sugar monitoring using a blood sugar audit tool, which will alert nursing staff for out-of-range blood sugars. This is a change in the system that was implemented after the IJ. At this time management roles are currently being expanded where there may be another ADON; however, until one is hired, he will be responsible for the audits, to determine if notification of physician and patient representative occurred and change of condition was initiated. The MDS stated he found that notifications were initiated. The MDS stated this process will be the same using the change of condition audits. The MDS stated the process he will use to ensure the audits are completed is conduct audits multiple times daily for the next 3 days, then weekly for the next 2 weeks and then monthly thereafter. The MDS Nurse will submit the findings of the audits to the DON for review, analysis, and implementation of necessary corrective actions to improve medication administration practices and ensure regulatory compliance. Any issue found by the DON will be referred to the QAPI Committee for further review and revision of action plan and/or to determine any further training needs for staff involved. The MDS stated implementation will be discussed in the morning clinical meetings. This will be daily. Whoever takes over this responsibility will be informed this information is to be shared with the staff in the morning clinical meetings. The MDS Nurse stated experience has shown that there needs to be a system created from management at the top and comes down to the doctor. He stated the facility's main goal is to ensure residents are safe and being taken care of. The person-centered care is very important, and it is what drives excellent customer service. During an interview on 10/5/25 at 5:50PM with ADON who stated the DON conducted random audits of change of condition. She stated she is aware of the policy for quality of care and change of condition. The ADON stated she is aware of completing audits and ensuring the SBAR and all people are notified, provided in -services and required to follow up on issues and ensure that the documentation is completed properly. She stated she felt like the nurses did what they needed to do during CR#1's event. She stated the whole event taught her that there needs to be a follow up note/chart.During an interview on 10/5/25 at 6:15PM the DON stated she took the initiative to ensure all the change of conditions were completed. She stated she has learned that the nurses need to make sure that they are following through with all their charting. She stated she is committed to doing random audits to ensure proper documentation has been completed. She stated in-service training will be ongoing in all areas, especially areas of change of condition. She stated the CNAs complete their charting on the ADL platform and she will be monitoring their documentation as well.During an interview on 10/5/25 at 7:00PM the Admin stated it requires accountability in all areas from staff. She stated she is a RN herself and able to read charts, diagnosis, protocols for change of conditions and assessments. She stated this IJ has taught her that there needs to be an accountability system in place to ensure resident safety and maintain that person-centered care. She stated the process that is in place for the change of condition, reporting, dietary intake monitoring will be continued on a daily basis. An Immediate Jeopardy (IJ) was identified on 10/03/2025 The IJ template was provided to the facility (Administrator) on 10/3/25 at 12:26pm While the IJ was removed on 10/04/2025, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record review, the facility failed to develop and complete a baseline care within 48 hours of a resident's admission for 3 of 25 residents (Resident #18, Resident #24, and Resident #126) reviewed for baseline care plan . The facility failed to complete a baseline care plan within 48 hours of admission for Resident #18, Resident #24, and Resident #126 This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs were met. Findings included: Record review of Resident #18's Face Sheet noted the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with primary diagnoses of hemiplegia (a condition characterized by paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction affecting left non-dominant side. Record review of Discharge MDS dated [DATE] did not indicate a BIMS score. Assessment of mental status indicated the resident had a memory problem with some difficulty in new situations, no psychosis noted, and occasionally incontinent. Record review of Resident #18's Baseline Care Plan revealed it was completed on and dated 12/18/24, by the DON. Record review of Resident #24's Face Sheet undated noted the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with primary diagnosis encounter for surgical aftercare following surgery on the circulatory system. Record review of Resident #24's Discharge MDS dated [DATE] did not indicate a BIMS score. Assessment of mental status indicated the resident's short-term memory was ok and independently made decisions regarding tasks of daily life. Her functional abilities needed setup or clean up assistance for sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, car transfer, walk 50 feet with two turns, and walking 150 feet. Record review of Resident #24's Baseline Care Plan revealed it was completed on and dated 11/19/2024, by the DON. Record review of Resident #126's Face Sheet undated noted the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #126 had diagnoses of spinal stenosis, lumbar region without neurogenic claudication (narrowing of the lumbar spinal canal that compresses the nerve rootlets and nerve roots). Record review of Resident #126's Initial MDS dated [DATE] noted a BIMS score of 12 indicating moderate cognitive impairment. The resident used a walker for mobility and needed supervision or touching assistance with eating and oral hygiene, partial/moderate assistance with toileting hygiene, shower/bath self, upper body dressing and personal hygiene, and dependent on lower body dressing and putting on/taking off footwear. Record review of Resident #126's Baseline Care Plan revealed it was completed on and dated 01/21/2025, by the DON. In an interview on 01/30/2025 at 11:00AM the MDS Nurse said for the Base Line Care Plan, the admission nurse opened the Care Plan tab in the system and the admitting nurse did the assessment. That information was transferred from that assessment into the Care Plan and information from the admission assessment was transferred to the Baseline Care plan form. She said the Base Line Care Plan was written within 48 hours of admission. She said the Base line Care Plan was complete when the nurse signed it. She said the DON signed the Base Line Care plans. She said she and the DON were responsible for the Base Line Care Plans. She said the risk to residents was if the policy was not followed, the residents might not get the care they needed. In an interview on 01/30/2025 at 11:21AM the DON said she signed them, and the nurses started them. She said when she signed the Base Line Care Plan that meant it was complete. She said according to the company, the Base Line Care Plan needed to be complete within 5 days. She reviewed the Base Line Care Plans for Resident #18 and #24. She said Resident #18' Base Line Care Plan was not done within 48 hours. She saw that Resident #24's Base Line Care Plan was not done within 48 hours. She said she did not know why the Base Line Care Plans were done late. She said the risk to residents if policy/procedure were not followed was staff would not know how to properly care for the resident and the worst thing was staff were not able to follow through with things for the resident. She said she last had training on Base Line Care Plans when she first started 8 months ago. She said she was responsible for ensuring policy/procedure were followed. In an interview on 01/30/2025 at 11:34AM the Administrator said the MDS nurse, or the DON wrote the Base Line Care Plans. She said it needed to be an RN. She said the first care plan was done within 48 hours, normally. She said the reason the Base Line Care Plans were not completed in time was she thought it was too much work for the DON to have signed them in time. She had not recently had training on Base Line Care Plans. She said the risk to residents was if policy/procedure were not followed and the Base Line Care Plan was late, the residents potentially would not get the care they needed, and the worst thing to happen to a resident when policy/procedure was not followed was death. Record review of the facility's policy titled, Baseline (Initial) Plan of Care Summary dated December 2016 read in part . Policy: It is the policy of this facility to provide each resident with an interim (initial) plan of care developed within 48 hours of admission that addresses identified risk areas and resident's initial individual needs and baseline summary will be completed before a comprehensive care plan is completed. Purpose: The Baseline (Initial) Plan of Care documents and communicates the resident's needs within 48 hours of admission and until the Comprehensive Plan of Care is finalized by the interdisciplinary team .

Based on observation, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 (Dryer #2 the one in the middle) of 3 dryers reviewed for accident hazards. The facility failed to check and clean the lint filters at appropriate times: - The facility failed to clean the lint filter in Dryer #2 for 19hrs, which caused a buildup of lint on the filter, above the filter, and around the filter. This failure could place residents at risk of harm and hospitalization by causing a fire risk to the facility. Findings included: In an observation on 1/29/25 at 2:45pm, the Maintenance Director pulled out the lint filter for Dryer #1. There was a thick sheet of lint on the filter, as well as lint above where the filter slides into place, and around where the filter was kept. There were no laundry staff anywhere. In an interview with the Maintenance Director on 1/29/25 at 2:57pm, he said staff checked the lint filters twice a day. He said staff must have forgotten to check the filters and that was a hazard to the residents and could cause a fire. The Maintenance Director said he oversaw the laundry room. Record review on 1/29/25 at 2:55pm, of the facility's Lint Trap Cleaning Log for January 2025 revealed spots to sign off every hour indicating the lint trap was cleaned. There were no initials for the whole day and the last initials were from 1/28/25 at 7am. Record review of the facility's policy and procedure on Laundry Equipment (Revised [DATE]) read in part: Laundry equipment is inspected and maintained periodically to ensure proper configuration and operation. Laundry equipment maintenance is an essential function of the preventative maintenance program to assure employee and resident safety .Clean dryer lint traps several times each day to help limit fires, and increase the life of the dryers .

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choice for 1 (CR #1) of 30 residents reviewed for quality of care. -The facility failed to have a care plan for CR #1's Type II Diabetes. - The facility failed to provide routine insulin to CR #1. - The facility failed to have a care plan for CR #1's advanced directive. - The facility provided CPR to CR#1 without knowing CR #1's choice regarding her advanced directives. - The facility failed to have a care plan for CR #1's COVID-19 status. -The facility failed to monitor CR#1's symptoms for COVID-19. These failures resulted in an Immediate Jeopardy on [DATE] at 7:39 p.m. when the Administrator and DON were informed. While the I.J. was lowered on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could affect residents and place them at risk of receiving inadequate care resulting in neglect and death. The facility submitted a Plan of Removal - Quality of Care and after revisions was accepted on [DATE]. Findings included: CR#1 During an Interview on [DATE] at 3:21 p.m. with an anonymous person, they said that they were concerned about CR #1's care provided by (facility name). She said the facility never communicated a change of condition for CR #1. The facility said CR#1 was fine, and then on Friday at 4:30 they called and told her the resident (CR #1) was gone. They said they were concerned about CR #1's death. Record review of the face sheet for CR #1 revealed she was a [AGE] year old female, admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident died in the facility on [DATE]. Attempted record review of the admission base-line care plan for CR #1 revealed no base-line care plan available. Record review of CR #1's Admission Minimum Data Set Assessment (MDS) dated [DATE] revealed she was severely impaired cognitively, ADL activity with assistance one-person physical assist. CR #1 was documented to be occasionally incontinent of urine and bowel continence was not rated. Record review of CR #1's Discharge MDS assessment dated [DATE] revealed resident died in the facility on [DATE]. Record review of discharges by death in facility list revealed that CR #1 was not listed. Record review of the (city name) Police Department Incident Investigation report dated [DATE] at 16:24 (4:24 p.m.) revealed a death investigation for CR #1. Record review of an email dated [DATE] from a local forensic sciences institute revealed no record for CR #1. Interview on [DATE] at 11:20 a.m. with the Corporate LVN, when she was asked about CR #1's records, progress notes, death and discharge documentation she said CR #1 should have been on the facility death list. During a telephone interview on [DATE] at 3:38 p.m. with Administrator A, when asked about CR #1's records, progress notes, death and discharge documentation she said that when the facility doesn't know they call the justice of the peace and family, no one has followed up with the family and CR # 1 should have been documented on the death report. She also said if she would have been the Administrator at this time, she probably would have reported CR #1's death to the State. Interview on [DATE] at 10:38 a.m. with former ADON M and Infection Preventionist, she said she worked on [DATE] and she rechecked CR # 1's blood sugar because it was high earlier. She said she left the facility for an appointment and did not report the result because 200 was better than the other earlier blood sugar of 250. She said she didn't think 250 was a change of condition. LVN 1 (MDS Nurse) is the one that checked the blood sugar that was 250, she re-checked it when she returned from her appointment. She said she had no knowledge regarding the missed scheduled insulin doses, or the medication wasn't available. Though CR #1 was on the COVID unit CR # 1's temperature of 102 was not a change in condition because CR #1 was running a low-grade temp since admission, but she did give CR #1 a Tylenol, she said she didn't know why CR #1's vitals and daily COVID monitoring wasn't documented every shift. She said they are supposed to monitor for COVID-19 every shift. She added that she worked with LVN 1 (MDS Nurse) on CR #1 during the code and she didn't remember if there was an AED because if it were, they would have used it. She said LVN G called the justice of the peace to pronounce CR # 1's death. She worked from 6 am-6pm and when she left CR #1's remains were still in the facility because the Justice of Peace hadn't arrived. The code was called around 3:00 p.m. She said she had no knowledge of what happened to CR #1 after that. She documented what she did after she arrived home. Staffing was a major issue, she had been working 22-hour shifts, there were no staff so she couldn't remember some of the things. She couldn't continue to work the floor and complete her other duties. During an interview on [DATE] at 3:09 p.m. and 3:27 p.m. with CNA R, she said that she was the one that found CR #1 unresponsive, CR # 1 wasn't breathing, CNA R ran to get the charge nurse she didn't stay in the room while they were doing CPR. CNA R added that she never received training while working at the facility. On [DATE] at 5:30 a.m. in an Interview with the Corporate DON, she was asked had the facility had or received any updates or documentation for CR #1, the name of the justice of the peace that called CR #1's death the location of the remains, and if they received a death certificate from the physician, she said she will because it was the weekend, and it would be difficult to reach anyone that may have that information she would contact them on Monday. On [DATE] at 11:31 a.m. with Administrator B, he said that they attempted to get the information for CR #1, and they could not find out the name of the justice of the peace, they did not have a death certificate and did not have any additional information regarding CR # 1. After calling and leaving messages for a return call from MD A or the Nurse Practitioner. On [DATE] at 9:39 a.m. and 9:53 a.m. the calls were returned and interviews with MD (Medical Doctor) A's staff were conducted. When asked had the MD's office received any information regarding CR #1's change of condition or death, the MD's staff stated they were not aware of CR#1's change of condition or death. The MD's staff also stated they were not aware of any documentation for these events. Record review of CR #1's Clinical record revealed no documentation for -Admit/Re-admit Screening -Functional Abilities and Goals - Braden Scale (skin assessment) - COVID-19 screening -Discharge Summary Interview on [DATE] at 11:09 a.m. with the Corporate DON, she said none of CR #1's assessments were done, and if assessments were not completed by the Nurse, the responsibility falls on the DON. Interview on [DATE] at 12:05 p.m. with the MDS Nurse, she said she worked on [DATE] with CR #1. She said when she left at 6 pm that day, she did not know who came to pronounce CR #1 but ADON M was the Charge Nurse who was documenting on CR #1. She said the blood sugars weren't done by her. She said she reported to ADON M who she was helping with CR #1. She said she did not know why vitals and other documentation was not done, because that was ADON M's responsibility. She said the former DON C was responsible for the care plans for CR #1. She said DON C did not do them before she quit, and she did not complete any of the missing care plans, assessments, or vital signs because no one ever told her too. She said the code was called a little before 3:00 p.m. She said they washed CR #1's body but did not bag it because they did not have one. She said she could not remember if there was an AED on the crash cart. She said she did not see or use one. She said she had no additional knowledge of CR #1's death or remains after this. She said she would have called the physician on the blood sugar value of 250 when she took them. She said she did not document them because she did not have access to facility electronic medical record. Record review of a Physician's Order dated [DATE], read in part, . [MEDICATION(S)] N Suspension 100 UNIT/ML (Insulin NPH (Human) ([MEDICATION(S)]) -Inject 4 unit subcutaneously at bedtime for DM II related to TYPE LL DM W/O COMPLICATIONS dated [DATE] . Record review of a Physician's Order dated [DATE] read in part, . [MEDICATION(S)] N Suspension 100 UNIT/ML (Insulin NPH (Human) ([MEDICATION(S)])-Inject 16 unit subcutaneously two times a day for DM II related to TYPE 2 DM W/O COMPLICATIONS . Record review of a Physician's Order dated [DATE] read in part, . Acetaminophen Tablet 325 MG Give 2 tablet via PEG-Tube every 6 hours as needed for Pain . Record review of a Physician's Order dated [DATE] read in part, . [MEDICATION(S)] N Suspension 100 UNIT/ML (Insulin NPH (Human) ([MEDICATION(S)]) -Inject 4 unit subcutaneously at bedtime for DM II related to TYPE LL DM W/O COMPLICATIONS . Record review of a Physician's Order in CR #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] N Suspension 100 UNIT/ML (Insulin NPH (Human) ([MEDICATION(S)]) -Inject 4 unit subcutaneously at 2100 .start date of [DATE] . Record review of the MAR for [MEDICATION(S)] N Suspension 100 unit/ml - inject 4 unit subcutaneously at 2100 revealed on [DATE] and [DATE] at 2100 (9:00 p.m.) was coded 11 which was noted on the Chart code/follow up codes to mean the medication was not available/ordered from the pharmacy, and the dose was not administered, for the dated [DATE] the 2100 (9:00 p.m.) revealed no documentation. Record review of a Physician's Order in CR #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] N Suspension 100 UNIT/ML (Insulin NPH (Human) ([MEDICATION(S)])) Inject 8 unit subcutaneously one time a day for DM TYPE II W/O COMPLICATIONS at 0500 (5:00 a.m.) . start date [DATE] . Record review of the MAR for [MEDICATION(S)] N Suspension 100 UNIT/ML (Insulin NPH (Human) ([MEDICATION(S)])) Inject 8 unit subcutaneously one time a day for DM TYPE II W/O COMPLICATIONS at 0500 (5:00 a.m.) on dates [DATE], [DATE], and 1711 at 0500 (5:00 a.m.) was coded 11 which was noted on the Chart code/follow up codes to mean the medication was not available/ordered from the pharmacy, and the dose was not administered, Record review of a Physician's Order in CR # 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] N Suspension 100 UNIT/ML (Insulin NPH (Human) ([MEDICATION(S)]) Inject 16 unit subcutaneously two times a day for DM II related to TYPE 2 DM W/O COMPLICATIONS at 5:00 a.m. and 5:00 p.m. start date [DATE] . Record review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -On ,d+[DATE] at 5:00 a.m. the notation was coded 11 which is noted on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -On [DATE] at 5:00 p.m. the notation was coded 11 which is noted on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the chart had a checkmark which means the medication was administered according to Chart code/follow up codes. -On [DATE] at 5:00 a.m. the code was marked 11, not administered and at 5:00 p.m. the area for coding was blank. An interview on [DATE] at 10:38 a.m. with former ADON M and Infection Preventionist, provided care for CR #1 revealed no knowledge of the missing administered doses of insulin. An interview on [DATE] time unknown with the MDS Nurse that provided care for CR #1 revealed no knowledge of the missing administered doses of insulin. Record review of the Daily Skilled Nurse's Note dated [DATE] revealed CR #1 was unable to speak, incontinent of bowel and bladder, had a gastrostomy tube, PICC line to right inner upper arm and bruising to right posterior hand and wrist. CR #1 had an upper respiratory infection and was on droplet isolation with comments has COVID-19 and West Nile disease. Record review of CR #1's progress notes dated [DATE] through [DATE] revealed: [DATE] 00:00 (12:00 a.m.) Nurse's note - Note Text: 35 y/o female arrived on [DATE] @6:30pm via stretcher from the medical resorts and{sic} Sugar Land under the care of Dr. A. Admitting Dx: COVID-19 w/ pmh of [CONDITION(S)] status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Py{sic}. is NPO, receives meds and nutrition via PEG tube .pt is AA0X1, her eyes are open but does not follow command. pt is incontinent and is NPO. Skin is warm, dry and intact. DR. A notified for orders to be put in bed rails are raied {sic} on both side and bed placed in the lowest position. [DATE] 16:40 (4:40 p.m.) Nurse's note-Note Text: Approximately 3:40 p.m., CNA making incontinent round on Resident, CNA noted resident not moving per pt's normal. CNA came out of room told LVN #1 and this nurse that she didn't see movement, LVN #1 assessed lungs, no air movement noted, no pulse identified. LVN # 2 called 911, this nurse started CPR. CPR started approximately at 3:50pm, Parametis{sic} arrived at 4:02pm, which at this time report of findings given, and LVN #1 and LVN #3 asked to step out of room. Pearland PD arrived, investigation started, information given to PD by LVN's x3.LVN #2 notified family and MD A.LVN # 2 attempted to notify corporate nurse to pronounce, but no response. Awaiting JP to come to pronounce. Family came. They were very upset, asking questions, and this nurse explained that there had been no change in condition prior to the event. [DATE] 16:11 (4:11 p.m.) Nurse's note-Late Entry: Note Text: Resident resting in bed, bed in low position. Lungs remain clear. Covid-19 monitoring continues. Remains on continuous enteral feeding via pump, tolerating well. No s/s of hypo/[CONDITION(S)] noted. Incontinent care given every 2 hours. Turned and repositioned every 2 hours. All needs met by staff. Will continue to monitor safety. [DATE] 16:23 (4:23 p.m.) eMAR - Orders Administration Note Note Text: Insulin [MEDICATION(S)] Solution Inject as per sliding scale: if 0 - 140 = 0; 141 - 180 = 2; 181 - 220 = 4; 221 - 280 = 6; 281 - 300 = 8 notify md/np, subcutaneously before meals and at bedtime for DM TYPE 2 W/O COMPLICATIONS [DATE] 10:36 (8:36 a.m.) Nurse's note- Note Text: Resident remains on low bed, Abdomen soft and nondistended, with BSx4. G-tube patent and flushes easily/ Remains on Continuous feeding with continuous flushes. G-tube site C/D/I. Picc line remains to left inner upper arm. Bruising remains to Right posterior hand and wrist. Incontinent of B and B. Requires staff to make needs met. Resident continues to have neck bent toward right shoulder, with right arm bent in upward position. Constant clinching of bilat fists. Staff continues to monitor every 2 hrs., with daily blood sugar checks ac and Hs. Resident turned and repositioned every 2 hours. Will continue to monitor for covid symptoms, and safety. [DATE] 14:50 (2:50 p.m.) Nurse's note-Note Text: Nurse rechecked blood sugar d/t noon blood sugar result of 250, which was higher than it has been. blood sugar result of 200 at this time. Resident resting in bed with no discomfort observed . Record review of CR#1's Blood Sugar Summary from [DATE] through [DATE] read in part . [DATE] 12:59 250.0 mg/dL [DATE] 09:32 132.0 mg/dL [DATE] 21:14 110.0 mg/dL [DATE] 21:14 110.0 mg/dL incorrect documentation. [DATE] 16:28 126.0 mg/dL [DATE] 16:23 128.0 mg/dL [DATE] 16:22 144.0 mg/dL [DATE] 08:42 144.0 mg/dL [DATE] 22:34 121.0 mg/dL [DATE] 13:12 134.0 mg/dL [DATE] 13:07 125.0 mg/dL [DATE] 18:35 110.0 mg/dL . Review of CR#1's temperature log from [DATE] through [DATE] read as follows: [DATE] 10:52 98.6 °F Forehead (non-contact) [DATE] 09:00 102.0 °F Forehead (non-contact) [DATE] 18:35 98.7 °F Temporal Artery Record review for a lab order on [DATE] for the following: CBC w/Auto Diff, [CONDITION(S)] Stimulating Hormone, Comprehensive Metabolic Panel, Magnesium, Phosphorus Pre-[MEDICATION(S)], Lipid Panel ([NAME]), Lipid Panel, Hemoglobin A-1C/PDF Document, Completed Chemistry LAB Values-Hemoglobin A-1C was elevated Record review of the undated facility policy and procedure SCE (Senior Care Excellence) RESIDENT CARE MANAGEMENT SYSTEM 12 ASSESSMENTS, read in part . 1. The nursing assessments must be completed within 24 hours of admission/ re-admission. These assessments will consist of the below listed assessments. - Aims - Bowel and Bladder. - Braden. - Fall risk - Neurological - Pain. - Physical functioning. - Skin. 2. Upon admission / re-admission the medication orders must be approved by physician upon verification. 3. Interim care plans will be initiated within 24 hours of admission. This care plans will be derived from the below listed assessments. This care-plan will be located in guests' chart under the care-plan tab and in C.N.A ADL binder located at each nurse's station. - Aims - Bowel and Bladder. - Braden. - Fall risk - Neurological - Pain. - Physical functioning. - Skin. 4. A final care plan must be completed by the 21st day after admission (or within 7 days of ARD) 5. On discharge always make sure that a thorough head to toe assessment is documented by discharging nurse. Record review of the facility policy and procedure entitled Administering Medications dated revised [DATE], read in part . Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed . 3. Medications must be administered in accordance with the orders, including any required time frame . 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . Record review of the facility policy and procedure entitled Care Plans -Preliminary dated revised [DATE] read in part .A preliminary plan of care for the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. Policy Interpretation and Implementation: 1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. 2. The Interdisciplinary Team will review the Attending Physician's order (e.g., dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident's immediate needs. 3. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan Record review of the facility policy and procedure entitled Diabetes Clinical Protocol dated revised [DATE] read in part .As part of the initial assessment, the physician will help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes In addition, the nurse shall assess and document/report the following: a. Any signs of infection .f. Resident's blood sugar history over 48 hours .h. Onset, duration of any changes .Monitoring and follow-up: 5. The staff will identify and report complications . Record review of the facility written in-service training report with the topic Change of Condition and when to notify the DON and Physician dated [DATE] and conducted by the Corporate DON read in part . Change in condition-Complete interact change in condition assessment tab, notify MD, notify DON example Change in condition-Critical labs, abnormal vitals, new onset pain, etc. Record review of the facility in-service written policy and procedure entitled AED Use in Emergency Situations dated [DATE], conducted by the Corporate DON read in part . Start CPR and instruct someone to obtain the crash cart, apply AED pads per picture on pads and follow prompt on machine . The immediacy was lowered on Friday [DATE] at 12:41 p.m. with Administrator B and the Corporate DON, the facility remained out of compliance at a scope of a Isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal - Quality Care Immediate Action: The following actions have been taken regarding Quality of Care: 1. Medical Director was notified of Immediate Jeopardy on [DATE] 2. Audit of all current patients with insulin orders and review of medication at facility to ensure insulin is available by the Director of Nursing. Audit was initiated on [DATE] and completed on [DATE]. All residents on anti-glycemic medication had medication available at facility. All 7 residents identified with orders for insulin had their insulin available in the facility and are receiving their insulin as ordered unless refused. Registered Nurse assessed diabetics on receiving insulin on [DATE] during skin sweep. 3. Currently the facility does not have any COVID+ patients and no patients with suspected or unknown COVID status, therefore there are no covid positive residents to teach monitoring and to audit process complete. The nursing staff will be in-serviced on COVID Policies and Procedures by DON beginning [DATE] and will be completed on [DATE]. Nurses that have not completed the in-service by this date will be removed from the schedule until in-service is completed 4. Inservice on all staff on location of the AED devices and what to do in an emergency was conducted. Inservice was initiated on [DATE] and will be completed on [DATE] by the Administrator and Director of Nursing. Any staff that have not completed the in-service by this date will be removed from the schedule until in-service is completed. The facility has two AED located on each crash cart; one on hall 500 and the other on hall 200. Prior to the COVID unit re-opening the facility will ensure the AED is available and functioning on the COVID unit by physically checking to make sure all supplies are available. 5. The Director of Nursing or designee will in-service all nurses/medication aides on notifying the Director of Nurses if medication not available. Inservice was initiated on [DATE] and will be completed on [DATE]. Any staff that have not completed the in-service by this date will be removed from the schedule until in-service is completed. The Director of Nursing or designee will ensure medications are available by auditing the EMR and monitoring the meds by pulling the medication audit report with any identified missed medications immediately ordered. The Director of Nursing or designee will monitor the availability of injectable medications by pulling the medication audit report from the EMR system with any identified missed injections immediately ordered. The licensed nursing staff were in-serviced beginning on [DATE] and complete on [DATE] regarding the facility P&P for med availability, ordering, and missing meds. 6. The facility Director of Nursing or designee will run a missed medication report from PCC every morning to assure medications have been given as ordered by the physician beginning [DATE]. The Director of Nursing or designee will review the report, and meds will be ordered if needed, and/or med error report will be completed if missed, and the pharmacy will be notified. 7. The facility currently has advertisements on; Indeed and has conducted weekly job fairs to hire more nursing staff including RN, LVN, CMA, and CNA. The facility has hired 6 LVN, 5 CNA, 1 CMA, and 1 TNA recently as well as utilizing staff from sister facilities to ensure sufficient staff. The Administrator, DON, HR and staffing coordinator hold daily meeting to discuss staffing needs and to ensure sufficient staff. 8. The nursing staff have been in-serviced, by The Director of Nursing beginning [DATE] and will be competed [DATE] regarding change in condition assessment, response, actions, notifications. Any staff who have not completed the in-service by this date will not work until in-service is completed. Residents will have been assessed for any change of condition to determine whether any residents need emergency intervention by [DATE], by the Director of Nursing or designee. Any residents identified with change of condition will be addressed. 9. The pharmacy system will be reviewed by the pharmacist on [DATE]. The nursing staff were in-serviced beginning [DATE] and will be completed on [DATE] by the Administrator and Director of Nursing on the facility P&P for medication availability and notification, and steps to take to immediately obtain needed medications. Any staff that have not completed the Inservice by this date will be removed from the schedule until in-service is completed. New DON and administrator will meet with Pharmacy Provider to develop a notification system from pharmacy to administrative staff when delays in medications occur. Meeting with pharmacy occurred on [DATE]. State Surveyor Monitored the plan of removal as follows: Record reviews from [DATE] to [DATE] of audits of the EMR, and monitoring of the medication audit report with any identified missed medications immediately ordered. Record review from [DATE] to [DATE] of the missed medication report from the facility electronic medical record every morning to assure medications had been administered as ordered by the physician. Record reviews and interviews from [DATE] to [DATE] of the licensed nursing staff that received in-services on the facility policy and procedure for medication availability, ordering, and missing meds. Record reviews from [DATE] to [DATE] of the facility advertisements on a job website, a job fair to hire more nursing staff including RN, LVN, CMA, and CNA pamphlet. Record reviews and various times of in-services regarding change in condition, AED, crash carts, CPR, infection control, Covid 19, enteral feedings, medication availability, call-lights, skin/wound care assessment, response, actions, notifications. Record review of resident assessments from [DATE] through [DATE] for any change of condition to determine whether any residents need emergency intervention. Record review of the of the pharmacy system reviewed from [DATE] through [DATE]. Record review and interviews from [DATE] through [DATE] of the scheduled nursing staff in-serviced on the facility policy and procedure for medication availability and notification, and steps to take to immediately to obtain needed medications. Observation with the Administrator A and Corporate DON of both AEDs in the facility on [DATE]. The facility had two AEDs located on each crash cart; one on hall 500 and the other on hall 200. Interviews with facility staff for monitoring the facility Plan of Removal with LVN L, LVN J, PTA A, CNA L, on [DATE]. On [DATE] LVN K, LVN I, LVN G, CNA, N, CNA W, CNA X, CNA V, CNA R. On [DATE] with Receptionist B, CNA V, CMA T, CNA U, LVN I and LVN G revealed the staff received in-services and verified knowledge of systems in place. Interviews with staff from [DATE] through [DATE] at various times revealed the facility did not have any COVID+ patients and no patients with suspected or unknown COVID status, therefore there were no covid positive residents to teach monitoring and to audit process complete. Interviews with staff and record review of in-service sign-in sheets from [DATE] through [DATE] at various times revealed In-services on all scheduled staff on location of the AED devices and what to do in an emergency were conducted. Interview and Record Review [DATE] through [DATE] at various times revealed In-services on all scheduled-on in-services for all scheduled all nurses/medication aides on notifying the Director of Nurses if medication not available. [DATE]. The immediacy was lowered on Friday [DATE] at 12:41 p.m. with Administrator B and the Corporate DON. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure ulcers for 1 (Resident #1) of 2 residents reviewed for pressure ulcers. -The facility failed to provide daily wound care and skin care treatments as ordered for Resident #1 by the doctor. -The Wound Care Nurse failed to enter and implement orders from the Wound Care Doctor for Resident #1. -The facility Nurses failed to document wound condition and measurements for Resident #1 who developed an additional open area to the left hip. -The facility failed to identify and report a change of skin condition to the physician for Resident #1. These failures resulted in an Immediate Jeopardy on 3/1/22 at 7:39 p.m. when the Administrator and DON were informed. While the I.J. was lowered on 3/11/22, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents with wounds at risk of wound deterioration, wound development, and infection. The facility submitted a Plan of Removal - Wounds and after revisions was accepted on 03/04/2022 by email to the Corporate DON. Findings included: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's admission MDS dated [DATE] identified as in progress. Section C, BIMS score was a 2 of 15 indicating severe cognitive impairment. The MDS further reflected Section G, functional status, ADL's were not completed. Record review of Resident #1's baseline care plan dated 2/8/22 identified reason for admission: COVID-19, IV therapy, and wound care. Resident #1 was totally dependent on staff for bed mobility, transfers, and toilet use. Record review of Resident #1's skin assessment tool dated 2/8/22 identified 6 areas of skin integrity issues and read in part -Right upper arm, IV/ implanted port. -Right hip, stage 4 pressure wound. No measurement documented. -Left hip stage 1 pressure wound. No measurement documented. -Buttocks (sacrum), stage 4 pressure wound. No measurement documented. -Right inner knee, stage 2 pressure ulcer. No measurement documented. -Left inner knee, stage 2 pressure ulcer. No measurement documented . Record review of Resident #1's assessments dated 2/7/22 through 2/25/22 revealed there were no weekly Skin Assessment documented for 2/14/22 and 2/22/22. Record review of Resident #1's WAR for February 2022 dated 2/24/22 revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Complete Braden Scale weekly x 4 weeks and as needed, start date 2/14/22 Further review of the record revealed entry date 2/14/22 was blank. Weekly head to toe skin assessment, start date 2/14/22 . Further review of the record revealed entry date 2/14/22 was blank. Wound care stage 4 pressure injury of the sacrum. Clean sacrum with normal saline or wound cleanser apply calcium alginate with silver and cover with dry dressing every day, start date of 2/24/22 . Further review of the record revealed entry date 2/24/22 was blank. Wound care stage 4 pressure injury right hip, clean with normal saline or wound cleanser, apply calcium alginate and cover with a dry dressing every day, start date 2/24/22 . Further review of the record revealed entry date 2/24/22 was blank. Wound care stage 4 pressure injury of sacrum. Clean sacrum with normal saline or wound cleanser. Apply calcium alginate with silver and cover with dry dressing as needed may replace for dislodgement or soiled dressing, start date 2/25/22 . Wound care stage 4 pressure injury right hip. Clean right hip with normal saline or wound cleanser, apply calcium alginate and cover with a dry dressing as needed may replace for dislodgement or soiled dressing, start date 2/25/22 . Record review of Resident #1's Order Summary Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's progress note dated 2/17/22 at 5:50 a.m. by LVN C reflected in part . Continues on IV [MEDICATION(S)] 500mg every 6 hours related to wound infection . Record review of Resident #1's progress note dated 2/15/22 at 5:56 p.m. by LVN D reflected in part . Wound care to sacrum and right hip changed this shift . Record review of Resident #1's progress note dated 2/8/22 at 3:44 a.m. by LVN C reflected in part . Multiple pressure sores noted; #1 stage 4 to sacrum, #2 stage 4 to right hip, #3 stage 1 to left hip, #4 inner right knee and #5 inner left knee. Dressings clean, dry, and intact to all . Record review of Specialty Physician Wound Evaluation and Management Summary date 2/9/22 reflected in part . Stage 4 pressure wound sacrum full thickness . Etiology (quality) Pressure . Wound size (L x W x D): 3 x 5 x 0.3cm . Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing gauze island with bandage once daily . Stage 4 pressure wound of the right hip full thickness . Wound size (L x W x D) 2.5 x 1 x 0.5cm Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing gauze island with bandage daily . Record review of Specialty Physician Wound Evaluation and Management Summary date 2/16/22 reflected in part . Stage 4 pressure wound sacrum full thickness . Etiology (quality) Pressure . Wound size (L x W x D): 2 x 5 x 0.3 cm . Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing gauze island with bandage once daily . Stage 4 pressure wound of the right hip full thickness . Wound size (L x W x D) 2 x 1 x 0.5 cm . Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing gauze island with bandage daily . Record review of Specialty Physician Wound Evaluation and Management Summary date 2/23/22 reflected in part . Stage 4 pressure wound sacrum full thickness . Etiology (quality) Pressure . Wound size (L x W x D): 2.5 x 4 x 0.3cm . Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing gauze island with bandage once daily . Stage 4 pressure wound of the right hip full thickness . Wound size (L x W x D) 2 x 1 x 0.3 cm . Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing gauze island with bandage daily . Interview on 2/25/22 at 10:21 a.m. with Wound Care Nurse B, she said today was his first day working at the facility. He said he had wound care experience and training while working in the hospital. He said he completed the facility web training. He said today was his first day working on the floor as a wound care nurse. He explained RN B was providing bedside training and assistance while doing skin assessments and wound care. Observation on 2/25/22 at 11:37 a.m. of Resident #1's skin assessment and wound care provided by Wound Care Nurse B and RN B revealed Resident #1 was lying on her left side. They exposed a dressing to the right hip that was saturated with drainage from the wound and the dressing was dated 2/24/22. Wound Care Nurse B removed the right hip dressing and exposed an open area approximately (L x W x H) 2 cm x 2 cm x 2 cm with exposed muscle tissue. There was bloody drainage and a small amount of white tissue around the edge of the wound bed. Then Wound Care Nurse B removed the sacral dressing that was dated 2/24/22 and exposed a full thickness wound to her buttocks area approximately 2.5 inches x 2.5 inches with pink tissue covering the area. Resident #1 was turned onto her right side exposing an area to her left hip, approximately 6 inches x 6 inches, discolored purple and the center was approximately 3 cm x 3 cm exposed open area or skin shearing. Further skin assessment completed by Wound Care Nurse B revealed a black area on Resident #1's left heel approximately 1 cm x 1 cm. Interview on 2/25/22 at 1:22 p.m. with Wound Care Nurse B said he was hired on 2/24/22 as the wound care nurse. He said he completed new hire documents online on 2/24/22. He said he was being trained by RN B who had been following him around since the start of his shift at 6 a.m. He said he just received the facility Wound Care Training checkoff list. Interview on 2/25/22 at 1:27 p.m. with RN B said she was employed as a DON for a sister facility. She said on 2/24/22 she was asked to assist the wound care nurse with the skin assessments. She said she was not aware it was Wound Care Nurse B's first day at the facility until she arrived that morning. She said she did not know she would be training the wound care nurse. She said she thought the wound care nurse received an official on boarding that would include a wound care checklist for a reference point, infection control, and how to locate or request orders for wound care. RN B said she was asked later by the Administrator to educate Wound Care Nurse on infection control and the wound care checklist. Interview on 2/28/22 at 10:23 a.m. with the Administrator said the facility had a daily morning meeting to discuss resident change of status including skin integrity issues. She said management will identify a skin integrity concern and write it down on a white board. She said the DON or ADON were responsible then to follow-up to make sure the implementation of orders, treatments, interventions, and assessments were done. She said it was the corporate nurse's job duty at this time because the DON was out sick for an extended period. She said if a resident did not receive proper care or orders for a wound the resident could get ill or have a negative outcome or change in status. Interview on 2/28/22 at 11:01 a.m. the MDS Nurse said the residents are to have a weekly Braden Scale (assessment) upon admission and then weekly. She said the Wound Care Nurse was responsible for the resident's wound care. She said the floor nurses could do wound care because they had the supplies available and everyone had the Wound Care Physician's number to get physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 2/28/22 at 2:07 p.m. with LVN D said his first day working with Resident #1 was on 2/24/22 when he completed a full body assessment. He said he identified 3 wounds on Resident #1, sacral, right hip and left hip. He said the most intense wound was the sacral because there was a dressing barely on the wound and mangled looking. He said there was a purplish area to the left hip. He said when a resident was admitted to the facility the floor nurse will do an admission assessment which included a skin assessment. He said the wound care nurse should also do an assessment shortly after the resident was admitted . He said he worked as a management nurse but decided to go back to a floor nurse because he was being pulled to the floor often and he did not have time to do his designated job duties. He said auxiliary nurses such as Wound Care Nurse, MDS Nurse, Charge Nurse, and ADON were pulled to work on the floor often because of short staffing. LVN A said he had concerns of wound care dressings not being done. He said he had seen old dressings on resident wounds. He said some of his coworkers had assumed the wound care would get done by the Wound Care Nurse. Record review of Wound Care Nurse B in-service dated 2/25/22 revealed he watched a video on dressing changes, received a handout on pressure ulcer classification system and a dressing change checklist. Record review of undated facility policy, Guide for Wound Evaluation and Documentation reflected in part . Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given, 5. Any change in the resident's condition. 6. All assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound . Record review of facility policy, Pressure Ulcers/Skin Breakdown Revised 2/2014) reflected in part . the nurse shall describe and document/report the following: a. Full Assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . Record review of facility policy, Prevention of Pressure Ulcers (Rev. 2/2014 read in part . 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed . The facility submitted the following Plan of Removal - Wounds and after revisions was accepted on 03/04/2022 by email to the Corporate DON. Plan of Removal - Wounds Immediate Action: The following actions have been taken regarding Prevention/Services to Prevent/treat pressure sores: 1. Medical Director was notified of Immediate Jeopardy. Policy and Procedure was reviewed and approved by Medical Director on 3/3/2022 2. A facility skin sweep was conducted on 02/24/2022 and all residents had - Braden Scales, Weekly Skin Assessments completed. Any issues identified had a Weekly Pressure Ulcer Assessment, Orders reviewed, and Physician notified of any discrepancies with update to treatment orders competed. The assessments were completed by Registered Nurse and 2 Licensed Vocational Nurses. -Resident #1 wound care assessments, orders and treatment were completed on 02/24/2022. By RN and LVN. Wound care physician will see patient on 03/02/2022 and a review of her wound care will be done. 3. Treatment nurse completed American Medical Technologies training on wound care on 02/26/2022 and had skills check off completed by the Director of Nurses on 03/01/2022. 4. A Weekly Skin meeting is being conducted weekly by Director of Nursing who is a Corporate Nurse, as part of the Standard of Care to assure all components of the skin program are in place and verify compliance. Weekly skin meeting will be held on Thursdays starting 3/03/2022. Wound care nurse will be part of this meeting and will report on any wound improvements and declines. All new wounds will also be discussed 5. In-service was competed by the Administrator and Director of Nursing for all nursing staff on completing New Admit/Re-Admit Admission Audit form for all new admission. Inservice was initiated on 03/01/2022 and will be completed by 3/03/2022. After that time all staff not inserviced will be removed from the schedule until inservice is complete. The ADON/DON will review audits in morning clinicals for completion and compliance starting 03/02/2022. No agency staff are being used at this time, however if they are used they will be educated during first shift working. DON will do visual observations to ensure treatments are being completed. 6. The Director of Nursing to in-service nursing staff on identifying, documenting, and notification of skin concerns. CNAs were on 3/3/2022 trained to notify nurse if they identified any new wounds, undressed wounds when providing personal care. 7. The Floor Nurses or Nursing Management responsible for completing wound care when wound care nurse is out. Staff was in-serviced on 3/3/2022 by Administrator and Director of Nursing. Director of Nursing or designee will verbally notify the nurses when the wound care nurse is out and will also document it on the assignment book. 8. The Wound Assessment Record was reviewed and printed by Vice President of Clinical Services on 3/3/2022 to reflect all residents wound care completed. 9. Facility in process of training and completing skill competencies with the floor nurses with training anticipated to completed on 3/4/2022. Any nurses that have not completed the Inservice by this date will be removed from the schedule until Inservice is completed. Monitoring: Record review on 3/2/22 at 8:30 a.m. Surveyor r equested in-service binders and general staff trainings for review. Interview on 3/2/22 10:33 a.m. with Wound Care Nurse B who said he had been trained on new admissions audit tool. and AED locations. Interview with Corporate DON on 3/2/22 at 11:18 a.m. who said she was still working on the POR's and training staff. Interview on 3/3/22 at 11:28 am with MA M who said she had received no new trainings or in-services from anyone and had not worked for approximately 1 week. She said she was never advised that she would have to complete any trainings and was never told she would be removed from the schedule if trainings/in-services had not been completed. Interview on 3/3/22 at 11:38 a.m. with Charge Nurse R who said she had not been trained on facility wound care or any audit tools. She said that she had no access to medication rooms or Pyxis because she was helping from a sister facility. Record review on 3/4/22 at 10:38 a.m. of Medical Director notification of IJ and QAPI with root cause analysis and policies and procedures that had been completed by the facility on 3/3/22. Walking rounds and observations on 3/4/22 between 8:42 am and 1:12 p.m. of Administrator B and Corporate DON conducting walking rounds and actively in-servicing staff. Observations of Administrator B and Corporate DON on 3/10/22 at 8:33 a.m. conducting walking rounds and actively in-servicing staff. Interview with Wound Care Nurse on 3/10/22 at 10:28 am who said he had been trained and in-serviced on all the new policies and procedures regarding, admissions/readmissions, weights, enteral feedings, AED's, Insulins, changes in condition and documentation/audit tools and was able to articulate the trainings. The immediacy was lowered on 3/11/22 at 12:41 p.m. with Administrator B and the Corporate DON. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to establish and maintain infection control procedures that provided a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 16 of 16 staff (CNA T, Dietary Aide A, Cook, LVN O, Maintenance Director, LVN N, CNA Z, CNA X, LVN G, LVN Q, CNA A, CNA E, LVN A, CNA D, CNA K, and RN A.) - The COVID positive facility failed to ensure staff on the 6 am - 6 pm who self-screened completed the process with accurate temperatures. - The COVID positive facility failed to ensure staff who worked on the COVID positive unit doffed PPE prior to leaving the unit. - The COVID positive facility failed to ensure staff working the non-COVID unit on the 6 am - 6 pm shift completed a screening prior to entrance. - The COVID positive facility failed to ensure staff followed CDC guidance wearing PPE properly/correctly. - The COVID positive facility failed to keep a log of all staff and visitors screening results. An Immediate Jeopardy (IJ) was identified on 9/19/20. While the IJ was lowered on 10/2/2020 at 3:01pm the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeorpardy and a scope of widespread as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures could affect all residents and placed them at risk of infections. Findings include: Observation and interview on 9/11/20 at 10:45 am revealed CNA T was observed on the COVID unit wearing a gown and N95 mask in a resident's room standing next to his bed. She said that was considered full PPE. When asked about a face shield she said she wore them sometimes. When asked about training regarding PPE she said, I never had training. Observation and interview on 9/11/20 at 10:45 am revealed CNA T observed on the COVID unit wearing a gown and N95 mask. She said that was considered full PPE. When asked about a face shield she said she wore it sometimes. When asked about training regarding PPE she said, I never had training. Observation on 9/16/20 at 11:29 am revealed Dietary Aide A and the Cook in the kitchen. The cook had his mask pulled down under his chin and moving between pots on the stove. The Dietary Aide was not wearing a mask at all and standing in front of the stove. Observation and interview on 9/16/2020 at 11:30 am revealed LVN O in the PPE supply room in the front lobby area and she was not wearing a face mask. She said she had already been working since 6:00am in the COVID positive halls and her mask had broken. She searched all the boxes on the table and searched a closet in the room and could not locate an N-95 mask. She left the PPE supply room, wearing a surgical mask, went through the door that had a sign posted No Exit. She was not wearing a gown, gloves, or face shield, only the surgical mask. After she left the room, the DON brought in a box of face shields. During an interview on 9/16/20 at 11:32 am Dietary Aide A said she was trained by the Dietary Manager that they did not have to wear a mask unless they came out of the kitchen. During an interview on 9/16/20 at 11:35 am the Cook said he was trained by the Dietary manager that masks were supposed to be worn at all times. When asked why he was not wearing one he said he just got to the facility. He said the Dietary Manager called him and informed him there was not a cook today, so he came in. He said he did not know where the Dietary Manager was and had not seen her. Observation and interview on 9/16/2020 at 11:45am revealed the Maintenance Director wearing a surgical mask only. He did not have on an N-95 mask, gloves, or gown. He said he was not aware he needed to wear the N-95 mask or other PPE, since he was not on the COVID halls. During an interview on 9/16/20 at 12:10 pm, the DON said her first day at the facility was 9/15/20. When asked the expectations on PPE when entering the facility, she said an N95 was required. She said nursing staff were to wear it all times but would see what the protocol was for dietary staff. The protocol was never received nor verbalized to survey team prior to exiting. Observation and interview on 9/17/20 at 5:55 am revealed LVN N walking to the lobby wearing full PPE. Her N95 was only secured around her head with one strap. The mask was not sealed and her chin was visible. The other strap was hanging below her chin. When asked the expectations on doffing PPE she said they were supposed to take it off before entering the lobby area, but she came to complete the screening on the surveyor. When asked how to properly wear an N95 she said with both straps secured around her head. Observation and interview on 9/17/20 at 6:10 am revealed CNA Z walking from back of the facility. She filled out the screening and took her own temperature 5 times. She said, Am I doing this right? She said she came in the facility through the back exit and self-screened. She said there was never anyone at the desk to conduct the screening. Observation and interview on 9/17/20 at 6:15 am revealed CNA X walking into the lobby from the back side of the building not wearing a mask. She self-screened and took her own temperature. Am I freezing? She said she entered through the back exit of the facility. Record review of CNA X's screening dated 9/17/20 revealed her recorded temperature was 83.8 degrees Fahrenheit. Observation and interview on 9/17/20 at 6:25 am revealed LVN G and LVN Q on the cold unit. LVN Q was wearing a cloth mask and LVN G was wearing a surgical mask. When asked what they were trained on regarding masks LVN Q said they only had to wear an N95 when on the floor. When asked if they did a screening and temperature check before starting their shift they both said no. When asked why they did not complete a screening or temperature check LVN Q said they used to but it stopped about 3 weeks ago when the units were moved around. Further review revealed no screening forms or logs at the entrance for the unit. During an interview on 9/17/20 at 8:05 am, the Administrator said the expectation was whoever let a visitor in should conduct the screening. When asked how staff were screened on the 6 am - 2 pm shift she said there was no one sitting up front, so she expected staff to enter through the lobby, put on PPE, let a staff member know they were here, head back to the lobby where the screening would be conducted. She said PPE should be removed prior to entering the lobby area. She said staff on the cold unit screen each other. When asked if there were logs kept of screening results from staff and visitors, she said she was unaware a log was required. During an interview with the Administrator on 9/18/2020 at 2:00pm she said staff were last tested by Omnicare on 7/3/2020 in the facility. She said since then the staff were getting themselves tested through outside community resources on their own. She said she had been talking with the health department and had requested assistance for staff testing again but had not received any assistance. She said they had recently received a testing machine the week of 9/7/2020 - 9/13/2020 to test the staff themselves, but it was missing parts. She said contacted the company that sent it to her and her corporate office. She was asked if she needed assistance through the Rapid Response system and she said Yes, with the testing supplies and staff to perform the tests. Services were offered by the Emergency Medical Task Force contacted her on 9/20/2020 for additional information for testing the 150 staff. The Administrator declined at that time, stating she had received the parts for the [MEDICATION NAME] Sofia 2- Testing Machine and the facility would be testing the staff on their own During an interview on 9/23/2020 at 12:40pm the Administrator said they were still completing the staff testing using their new machine. They had started testing staff on 9/16/2020- 9/21/2020. They had negative results so far for 39 staff and they are waiting for 28 results that had been sent to the lab on 9/19-9/20/2020. The DON and the ADON were the only ones who had been trained to administer the tests. The Administrator said she had tested positive for Covid in 6/10/2020. She said she had tested negative on 7/31/2020 when all staff was last tested . Record review of CMS' Interim Final Rule regarding staff testing dated 8/26/20 revealed the minimum testing frequency for a county with a COVID positivity rate less than 5% was once per month, between 5%-10% was once per week, and if greater than 10% twice per week. Further review revealed If the county positivity rate increases to a higher level of activity, the facility should begin testing staff at the frequency shown in the table as soon as the criteria for the higher activity are met. If the county positivity rate decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the county positivity rate has remained at the lower activity level for at least two weeks before reducing testing frequency. Record review of https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/, dated 10/4/2020 revealed: COVID-19 Testing: As part of CMS' commitment to protecting nursing home residents, and to boost the surveillance of COVID-19, nursing homes are now required to conduct testing of residents and staff. These guidelines include testing staff on a certain frequency based on the COVID-19 positivity rate for the county the nursing home resides in. Facilities should monitor these rates every other week and adjust staff testing accordingly. The positivity rates listed for the county the facility is in read in part:- 8/19/20 revealed a positivity rate of 9.6%. - 8/26/20 revealed a positivity rate of 7.4%. - 9/2/20 revealed a positivity rate of 5.9%. - 9/9/20 revealed a positivity rate of 5.2%. - 9/16/20 revealed a positivity rate of 4.5%. - 9/23/20 revealed a positivity rate of 4.7%. - 9/30/20 revealed a positivity rate of 4.7%. Further review revealed there were no positivity rates posted prior to these dates. The Regional Nurse Consultant was notified on 9/19/20 at 2:35 pm that an immediate jeopardy was identified due to the above failures. A copy of the IJ template was provided at this time and a plan of removal was requested. The final plan of removal was accepted on 9/20/20 at 6:12 pm after several revisions were made. IJ plan of removal included: Immediate action: On 9/19/2020, DON and ADON began testing all current employees and documenting in Employee COVID Testing Spreadsheet. Lab swab tests will be used by DON and ADON until the [MEDICATION NAME] (Sofia 2) machine is up and running. Executive Director will call Sofia Machine company on Monday morning to see if it is approved to start utilizing. Company was not available for immediate approval on 9.19.2020. Testing has started on 9.19.20 by DON and ADON and will be completed with current employees by 9.22.2020. Example of the spreadsheet to keep track of testing for employees states their name, title, phone number, date tested and results of each weekly test. This will be updated each time employee is tested . On 9/19/2020, the following in-services have been initiated. All in-services outside of nursing will be completed by all current staff and will be completed by midnight 9.22.2020. Social services and nursing in-services will also be completed by midnight 9.22.2020 for nursing staff and social worker. The following numbers have competency checks 1-2, 4-10, 12, 15-16. 1. Hand Washing- all staff 2. Doffing and Donning PPE- all staff 3. Grievances- how to complete form- all staff, social services 4. COVID 19 Testing- Competencies completed with DON and ADON by Regional Nurse Consultant- nursing 5. ADL Charting for CNAs- nursing 6. Nursing Documentation- nursing 7. MAR indicated [REDACTED] 8. Discharge Protocols- social services, nursing 9. 48 Hour Care Plan and Care Planning- nursing 10. Proper way to enter the facility- COVID and Non COVID- all staff 11. Recovering COVID residents- nursing 12. COVID Screening upon entering building- COVID Unit and Non COVID Unit- all staff 13. Abuse and Neglect and Reporting- all staff 14. Change of Condition- nursing 15. Weekly COVID testing for all current employees- all staff 16. Medication Administration- nursing 17. Inventory Sheets- nursing 18. When to call resident families- nursing 19. Falls- documenting/reporting- nursing 20. Resident Rights- all staff 21. Infection Control- all staff On 9/19/2020, RN Coverage will be scheduled each weekend, completed immediately by Regional Nurse Consultant RN Coverage. Regional Nurse Consultants will come into the facility to work if RN calls off shift. Weekend Supervisor will notify all Regional Nurse Consultants to ensure RN weekly coverage. Their names and contact information will be in-serviced on. On 9/19/2020, Abuse Coordinator has been re-educated on Abuse/Neglect and Reporting, completed with Executive Director and Regional Nurse Consultant. Executive Director will continue to be the Abuse Coordinator. On 9/19/2020, Immediate recruiting and interviewing will follow for the following open positions. Corporate HR posting of open positions and will assist with Executive Director in setting up interviews. On 9.21.2020, social worker from a sister facility will be in place as Social Worker at the facility as well, in meantime of hiring full time Social Worker. She will report to facility on 9.21.2020. Social Worker tasks and duties will be handled by Social Workers from sister facilities. SW from a sister facility schedule will be as follow: Monday/Tue/Wed/Thur until full time SW hired at the facility. SW from a sister facility schedule will be Friday all day every week until full time SW hired at the facility. Their information will be in-serviced with all staff with names and emails so they know who to reach out to in regards to Social Worker position. Both SW will train new full time SW when hired to ensure smooth transition. Corporate Human Resources will also be utilized from sister facilities until full time Human Resources is hired. Both Corporate Human Resources will report to facility on 9.21.2020. Corporate Human Resources from a sister facility will be at facility Monday, Tuesday, Wednesday. Corporate Human Resources from a sister facility will be at facility Thursday/Friday. Both Corporate Human Resource employees will train new FT HR so there is smooth transition. Business Office Manager and Corporate Accountant will be assisting until full time Business Office Manager is hired. Business Office Manager and Corporate Accountant will split M-F days to ensure someone is present at the facility until full Business Office Manager is hired. Business Office Manager which is split from a sister facility days will be Monday, Wednesday, Friday. Corporate Accountant days will be Tuesday and Thursday. They will both train new full time Business Office Manager to ensure smooth transition. Their information will be shared with staff so they know who to reach out to until full time BOM is hired. Dietician will be reporting 9.21.2020 and will be at facility until full time Dietary Manger is hired. Dietician will be full time at facility until facility hires and trains Dietary Manager. Discharge Planner will report at Pearland 9.21.2020 and will be assisting Social Worker with discharge planning as well until full time employee hired. Discharge Planner will be at facility full time until replacement is hired and train appropriately. Activity Director from a sister facility will also report on 9.21.2020 and assist until Full Time Activity Director is hired. Activity Director will be at facility split between a sister facility until full time Activity Director hired and will train new hire to ensure smooth transition. In-service has been initiated to existing staff in regards to contacting new staff members for assistance. In-service has and will continue to be educated by Nursing Management, Executive Director and Weekend Supervisor. Residents and family members will be notified by letter of these positions filled and by whom so if they require assistance, they have their name and contact information. This letter will be composed by the Executive Director sent out 9.21.2020 to all residents in house and family address on file to ensure all parties are aware. 1. Social Worker 2. Human Resources 3. Business Office Manager 4. Business Development 5. Dietary Manager 6. Activity Director Competency checks has been completed by Regional Nurse Consultant to DON and ADON for testing staff and resident for COVID 19. I have highlighted all in-services that will have competencies as well, which has been educated from Regional Nurse Consultant to DON, ADON and DON and ADON will educate staff. 9/19/2020, Regional Nurse Consultant re-educated and demonstrated COVID testing with DON and ADON and had nursing management demonstrate that they understood COVID testing. DON and ADON will be the only authorized nursing staff that are able to test employees and residents to ensure there are no discrepancies in testing. Testing began 9.19.2020. DON and ADON will test staff weekly either through Lab or the Sofia Testing Machine once it has been approved by the [MEDICATION NAME] company. Executive Director has enrolled the Sofia Testing Machine on 9/9/2020, and awaiting email from [MEDICATION NAME] to show able to use the testing machine at facility for employees. On 9/19/2020 and ongoing, all staff will be re-educated that testing will be provided at facility weekly and they must test to continue to be on the schedule. County emails the Executive Director the % in the county, which is kept in file in Executive Director email of all percentages sent. Reporting of staff and residents will be handled by Executive Director and accompanied by Regional Nurse Consultants. This has been initiated 9.19.2020. Monitoring Observation on 9/21/20 at 2:46 pm of signage on 300 hallway COVID positive unit that read: HOT ZONE PPE REQUIRED MUST WEAR PPE ENTIRE TIME ON UNIT. Observations on 9/21/20 at 2:52 pm of blue disposable gown, and face shield hanging in hallway along chair rail just inside the 300-hallway COVID positive unit, doors. Interviews with unidentified staff members passing by, who all said they did not know who that PPE belonged to or why it had not been discarded. Record review of the immediate jeopardy binder reviewed on 9/22/20 revealed in-services initiated on Hand Washing, Doffing and Donning PPE, Grievances - how to complete form, COVID 19 Testing- Competencies completed with DON and ADON by Regional Nurse Consultant, ADL Charting for CNAs, Nursing Documentation, MAR indicated [REDACTED]. Observation on 9/22/20 at 2:00 pm revealed a sign on the doors leading to the COVID unit that read Do not enter through this door per management and Fire doors to remain closed. Observation on 9/22/20 at 2:10 pm revealed maintenance staff walking down the hallway no the cold unit carrying a bag and talking on the phone. His mask was underneath his nose. During an interview on 9/22/20 at 2:30 pm, the ADON said they still needed to test about two more staff members. She said so far, none have tested positive for COVID. She said they were still waiting on results from the tests taken on Sunday 9/20 that were sent out to a lab. She said a full-time Activity Director was just hired. She said she and the DON were trained by the Regional Nurse Consultant on how to conduct the COVID tests and were the only two who would perform them regularly. She said if both she and the DON were not in the facility LVN S was trained how to perform the tests. She said according to the CDC's new guidance released on September 11th, residents were considered recovered 20 days after the first positive test and they were using that guidance to recover residents. She said the Regional Nurse Consultant completed the competencies on hand hygiene and she did some competencies with the department heads and therapy today. All the competencies for the in-services were requested but not received prior to exiting for the day. Observation on 9/22/20 at 3:16 pm revealed an unidentified dietary staff member in the kitchen with her mask pulled down to her chin. Observation and interview on 9/22/20 at 3:20 pm revealed CNA A working on the COVID unit. She was dressed in full PPE. The second strap on her N95 mask was hanging below her chin and not secured behind her head. When asked what training she had regarding wearing her mask, she said they just had a recent training on PPE. She said the mask should be worn over the mouth and nose with both straps behind the head. When asked why the second strap was not behind her head she said Oh sorry. I just came from break. She then took of her face shield and readjusted her mask to have both straps in place. During an interview on 9/22/20 at 3:45 pm, the Administrator was informed about staff wearing PPE improperly. She said she continuously trained staff, but they do what they want to do. Observations and interview on 9/23/2020 at 10:05am revealed CNA E and LVN A were unpacking boxes outside of the supply room. CNA E had a face mask in her hand. She said she should be wearing full PPE, which consisted of a gown and mask, but it was too hot while putting up all of the supplies. LVN A was wearing his face mask around his neck. He was wearing a gown. During an interview on 9/23/2020 at 12:40pm the Administrator said they were still completing the staff testing using their new machine. They had started testing staff on 9/16/2020- 9/21/2020. They had negative results so far for 39 staff and they are waiting for 28 results that had been sent to the lab on 9/19-9/20/2020. The DON and the ADON were the only ones who have been trained to administer the tests. The Administrator said she had tested positive for COVID in 6/10/2020. She said she had tested negative on 7/31/2020 when all staff was last tested . Observation and record reviews on 9/23/2020 at 2:30pm of the facility revealed the PPE supply room had boxes of gowns, shoe covers, hair covers, face shields and N-95 masks. the Doffing area right outside the supply room had a table with hand sanitizer, shoe spray and face shields, along with the PPE disposal containers. Continued observations revealed the signs posted on the entry/closed fire doors to hall #100 that read Do not enter through this door, Hot Zone PPE required, Must wear PPE on the entire unit, Doors to remain closed. Hall # 600 had signs posted on the entry/closed fire doors that read Do not enter through this door, Face mask at all times, fire doors remain closed, cold zone N-95 mask required. The Maintenance Director were observed in the front lobby area, both were wearing N-95 masks. Hall #300 had signs posted on the entry/closed fire doors that read Hot Zone PPE required, Must wear PPE on the entire unit, Doors to remain closed. CNA E, LVN R, Housekeeper A, LVN O, MA B, and an unknown therapist were all weraing the required PPE of gowns, N-95 masks, and face shields. Observation on 9/25/20 at 4:45 am revealed CNA D standing at the nursing station in the non-COVID unit with her N95 pulled under her chin. During an interview on 9/25/20 at 4:50 am, LVN T was interviewed regarding all the in-services conducted recently with nursing staff. She provided comprehensive understanding of trainings regarding infection control. During an interview on 9/25/20 at 5:00 am, CNA D said she was an orientee and it was her first week. When asked what training she received regarding PPE, she said that an N95 had to be worn at all times. When asked why it was pulled down she said her nose was running. When asked about the recent in-services provided to nursing staff, she said she did not receive them. She said she did not have access to POC to chart ADLs on residents. She provided comprehensive understanding of how to enter/exit the facility and perform the screening prior to her shift. During an interview on 9/25/20 at 5:10 am, CNA P was interviewed regarding all the in-services conducted recently with nursing staff and provided comprehensive understanding regarding infection control trainings. She said she did not have access to POC to chart ADLs and only did shower sheets after giving resident's a bath which was then provided to the nurse for review. Observation and interview on 9/25/20 at 5:25 am revealed CNA K sitting in a chair in the middle of the COVID wing. He was wearing an N95 mask with the mask pulled below his chin. When asked what training he received regarding PPE he said, it should be worn at all times. When asked why his mask was not on he said he was taking a break. When asked what training he received on hand hygiene he said to wash hands for two minutes straight. When asked how often staff would be tested for COVID he said, every two weeks I think. He said he did not have access to POC to chart ADLs on residents. He provided comprehensive understanding of how to enter/exit the facility and perform the screening prior to his shift. During an interview on 9/25/20 at 5:30 am, 5:35 am, and 5:40 am CNA S, CNA B and LVN K were interviewed regarding all the in-services conducted recently with nursing staff. They provided comprehensive understanding of the trainings regarding infection control. Observation on 9/25/20 at 5:47 am revealed an unidentified staff member walk in the front entrance and self-screen. He filled out the form, took his temperature, documented it, and walked down the hall towards the COVID wing. Observation and interview on 9/25/20 at 5:57 am revealed RN A walk into the facility not wearing a mask. She said it was her 5th day working at the facility. When asked what training she received regarding masks she did not answer the question. She said she signed in and walked straight to the donning area to suit up and then go to the COVID hall. Observations on 9/26/2020 between 1:30am - 2:45pm and on 9/27/2020 between 5:30pm - 6:30pm revealed all staff observed in the facility were wearing N-95 masks. The staff on the COVID positive halls were wearing N-95 masks, gowns and face shields. Observations and interview on 9/27/2020 at 4:45pm of the Laundry Staff A was wearing full PPE of a gown, N095 mask and a face shield. Housekeeper B was in the front lobby and was wearing a N-95 mask. He said he worked every other weekend. He said he was working on the covid halls and would have a face shield and gown when he went on those positive covid halls. LVN A and RN A were observed on halls 100 and 200 with full PPE of gowns, N-95 masks, and gowns. Observation on 9/29/20 at 2:45 pm revealed a table set up at the entrance with hand sanitizer and N95 masks. Upon entrance, staff were having an in-service in the activity room. They were all wearing masks properly. The RN consultant said they were resending everything, and documents would be received shortly. Interviews conducted on 9/29/20 with the Human Resources Director at 3:22 pm and the Business Office Manager at 3:52 pm regarding all the in-services conducted recently on infection control and provided comprehensive understanding. Observations on 10/1/2020 between 10:25am - 11:35 revealed all staff wearing the proper PPE. The facility did not have a policy regarding COVID-19 testing. The policy entitled 2019 Novel Coronavirus, updated on 7/29/2020 and 9/9/2020 did not address testing/re-testing staff according to the county positivity rates. On 10/2/20 at 3:01pm, the facility Administration were notified the IJ was lowered. However, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of widespread because the facility continued to educate their staff and monitor the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician for a significant change in the resident's physical, mental, or psychosocial status for 1 of 33 residents (Resident # 1) reviewed for physician consultation. --The facility failed to immediately consult with Resident #1's physician when she had a change in condition of elevated blood pressure, elevated blood sugar, and howling/crying out on 9/5/19 that extended into 9/6/19. The physician was not consulted until the resident was sent out via 911 at the request of family. An immediate jeopardy (IJ) was identified on 09/11/19. While the IJ was lowered on 09/19/2019, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy. This failure affected 1 resident and placed her at risk of delayed medical treatment, worsening health condition, and hospitalization . Findings include: Record review of Resident #1's admission sheet revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment dated [DATE] revealed she had a SAMS score of 2 indicating moderately impaired cognitive skills for daily decision-making. She had short and long term memory problems. She required limited assistance of one staff for bed mobility, dressing, and personal hygiene. She required extensive assistance of one staff for eating and bathing. She used a walker and a wheelchair for mobility. She was always incontinent of bowel and bladder. Her active [DIAGNOSES REDACTED]. She was assessed as having received no as needed or scheduled pain medications. The staff assessment for pain was documented as vocal complaints of pain and indicators of pain or possible pain 1 to 2 days during the past 5 days of the assessment period. She was assessed as having no behaviors, no rejection of care, and no shortness of breath. She received a diuretic for 6 of the past 7 days in the assessment period. Record review of Resident #1's MAR for 9/1/19-9/30/19 to review for any insulin coverage on 9/5/19 at 5:58 p.m. revealed on 9/5/19 the resident was administered her Basaglar KwikPen Solution (Insulin [MEDICATION NAME]) on 9/5/19 but not until 9:00 p.m. Further review of the document revealed there was no documentation of any orders for a sliding scale insulin for coverage or of any insulin given on 9/5/19 at or about 5:58 p.m. Record review of Resident #1's Order Listing Report dated for 7/1/19-9/30/19 revealed the following physician orders: -[MEDICATION NAME] 0.5 mg give 1 tablet via [DEVICE] every 8 hours as needed for anxiety. There was no order start date. -Basaglar KwikPen Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION NAME]) Inject 7 unit (sic) subcutaneously at bedtime for Diabetes. There was no order start date. -Monitor anti-anxiety medication every 12 hours . -There were no orders for sliding scale coverage insulin. -There was no physician order for [REDACTED].>Record review of Resident #1's Administration records for 9/1/19 through 9/30/19 revealed there was no documentation of the administration of oxygen. Record review of Resident #1's MARs and TARS for 9/1/19-9/30/19 revealed staff documented monitoring anti-anxiety medication every 12 hours. They documented with their initials and a checkmark indicating Administered per the legend on the document. The documentation did not include any information on number of episodes, if any, what the behavior was, the intervention, the outcome, or any side effects, as requested on the document. There was no documentation of administration of Oxygen. Record review of Resident #1's physician orders dated as printed on 9/9/19 for a range of 9/1/19-9/30/19 revealed the following physician orders: -ACCU Checks HS AC before meals and at bedtime for Routine. There were no parameters for notifying the physician. -[MEDICATION NAME] 0.5 mg give 1 tablet via [DEVICE] every 8 hours as needed for anxiety. -Transfer Out 911, Resp. (Respiratory) Distress -There was no physician order for [REDACTED].>Record review of Resident #1's undated care plan revealed the following: -Resident #1 has Diabetes Mellitus .Resident #1 will not have complications related to diabetes through the review date. Target Date: 11/19/19 .Interventions .*Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. *Humalog Solution 100 Units/ML Inject 7 units SQ before meals (TID) -[MEDICATION NAME] 100 UNITS/ML Inject 15 units SQ once daily . The care plan was not updated to reflect her current insulin order of Basaglarand had no interventions addressing when to consult with the physician. -There were no care plans for oxygen use or [MEDICAL CONDITION]. Record review of the EMR for Resident #1 revealed the following nursing documentation: - .9/5/19 17:58 (5:58 p.m.) nurse's note: Resident BP was up 168/101, BP MEDS WAS JUST GIVEN BS WAS 328 GAVE INSULIN COVERAGE BP WAS RECHECKED AND BP WENT DOWN TO 145/86 GAVE NEXT DOSE OF BP MEDS AND THE RESIDENT STABLE AND NO C/O PAIN NO SIGN OF DISTRESS NOTED A THIS TIME. There was a vital signs entry for Resident #1's blood sugar dated 9/5/19 at 10:07 p.m. for a blood sugar test result of 340 mg/dl. There was no documentation on any physician consultation or nursing/administrative notification or intervention regarding Resident #1's blood sugar of 340 mg/dl at 10:30 pm on 9/5/19 through Resident #1's discharge to the hospital on [DATE] at 9:31 am. Record review of Resident #1's MAR for 9/1/19-9/30/19 revealed on 9/5/19 the resident was administered her Basaglar KwikPen Solution (Insulin [MEDICATION NAME]) on 9/5/19 but not until 9:00 p.m. Further review of the document revealed there was no documentation of any orders for a sliding scale insulin for coverage or of any insulin given on 9/5/19 at or about 5:58 p.m. There was no documentation of any insulin orders available to cover any as needed administrations for elevated blood sugars. Further record review of Resident #1's nurse's notes revealed the 9/5/19 note was followed by a note created by RN B that read as follows: 9/5/19 22:30 (10:30 p.m.) [MEDICATION NAME] Tablet 0.5 MG give 1 tablet via [DEVICE] every 8 hours as needed for anxiety guest was howling and anxious. 9/6/19 07:00 (7:00 a.m.) [MEDICATION NAME] Tablet 0.5 MG Give 1 tablet via [DEVICE] every 8 hours as needed for anxiety PRN Administration was: Ineffective. There was no documentation of physician consultation or nursing/administrative notification or intervention regarding Resident #1's [MEDICATION NAME] being Ineffective, in helping Resident #1's symptoms of howling and anxious. Observation of Resident #1 on 9/5/19 at 02:56 pm revealed she was observed awake, alert, and oriented X 3 and speaking on her cell phone. Observation and interview on 9/6/19 at 09:00 am of Resident #1 revealed she was overheard moaning from the hallway. Her room door was slightly ajar, and after knocking for consented entry, Resident #1 was observed to be sitting up in her bed with the head of the bed raised. The sunlight from the window appeared to be directly in the resident's eyes and her call light was located just behind her, out of reach, and hanging from the assist railing, to her right side. She was mumbling and moaning and said the word pain repeatedly. Her breakfast tray was untouched and not set-up at the bedside. Resident #1's gastrostomy tube feeding formula had settings that read 60 ml/hr and were dated for 9/6/19 at 4:50 am and infusing via pump. Resident #1's family member then presented at the bedside and said that Resident #1 did not look good and was not in the same condition as yesterday. Resident #1 was sluggish, lethargic, and had very little neck control in that she had trouble holding her head up and her head was bobbing back and forth. Resident #1 was struggling to keep her eyes open as her family member kept calling her name and Resident #1 then began to drool on herself. Resident #1 cried out in pain, in waves, almost like spasms and would reach down into her groin area each time she moaned loudly. Her indwelling urinary catheter tubing was observed to the left side of the bed and the collection bag had approximately 200 cc of cloudy, amber-colored urine in the reservoir. Resident #1 had a rectal tube to left side of the bed drainage was also observed and the tubing appeared to have brown colored liquid stool. She was receiving oxygen via nasal cannula at 3 L/min via a concentrator at the bedside, without a physician's order. There was no oxygen in use signage on the door of Resident #1's room. Resident #1's family member pushed the call light, still located looped around the assist railing on the right side of the bed and behind the resident. RN A responded to the bedside. Observation and interview with RN A on 9/6/19 at 09:06 am she said she did not know Resident #1 was in any distress, and the last time she rounded on Resident #1 was earlier that morning around 07:00 am when she gave the resident her scheduled medications. RN A said Resident #1 was not in any distress at that time and said she had not received any report from the previous shift of Resident #1 having any issues or concerns. When asked what RN A was going to do to assist Resident #1 at this time, RN A said she would go and get Resident #1 something for pain because Resident #1 had prn medications. RN A was asked if this was normal behavior for Resident #1 and she replied No. RN A left the bedside without conducting any full body, pain scale, or PAINAD assessment of Resident #1. Observation and interview with RN A on 9/6/19 at 09:09 am to administer the prn pain medication revealed that upon re-entry she donned gloves and placed the crushed medication on the bedside table. She proceeded to pause the [DEVICE] pump and checked for residual with a syringe after removing the plunger. The syringe immediately regurgitated formula up to the 60-cc mark, filling the syringe. RN A, a charge nurse, did not have a cup or basin to empty the residual into, and immediately turned off the valve to the [DEVICE], stopping the backflow of formula. RN A did not continue to check the residual volume to determine full residual amount. RN A returned the contents of the syringe into Resident #1 by gravity. RN A did not have a stethoscope or any kind of equipment to obtain vital signs for Resident #1. When RN A was asked if she was going to check Resident #1's [DEVICE] for placement and how much residual did she have to discover before having to report to the physician per orders, RN A, appeared to get flustered and said she was going to call Resident #1's physician. When RN A was asked how she normally checked for [DEVICE] placement, she did not reply. She had no stethoscope at the bedside and was not observed checking for placement or additional residual. When asked when the last time Resident #1 had been checked on by any staff members, RN A said she did not know when the aide had last checked on Resident #1, but she gave Resident #1 all her morning medications and everything was fine. Resident #1's family member then began to question RN A on what Resident #1's vital signs were and RN A told the family member Resident #1's blood pressure had been a little elevated at 171/97 but when she rechecked the blood pressure a short while later it was down to 131/74. RN A said she did not remember what Resident #1's blood sugar was and would have to check. RN A said she had not reported the blood pressure or blood sugar level to the physician. RN A repeated that she had given Resident #1 her medications via [DEVICE] and nebulizer treatment as prescribed. Resident #1's family member then began saying that the nurse needed to send the resident to the hospital because something was definitely wrong. RN A began to leave the room, leaving the crushed medication at the bedside table. RN A was stopped just as she reached the door and asked if she was going to leave the medication at the bedside. She quickly replied, No, and returned to get it. Resident #1's family member then said loudly, They always leave medicines and things at the bedside like this, that's nothing new. RN A said she would discard the medicine in the toilet and was observed flushing it down the toilet in Resident #1's attached bathroom. Resident #1 did not receive any pain medications at this time. RN A did not assess Resident #1. Record review of Resident #1's MAR indicated [REDACTED]. Additionally, RN A had documented administering [MEDICATION NAME] 0.5 mg on the morning of 9/6/19 at 7:00 a.m. Resident #1 had two blood sugar testing results documented as 9/5/19 at 9:00 p.m. 340, and 9/6/19 303 at 8:00 a.m. During an interview on 9/6/19 at 09:21 am with CNA A at Resident #1's bedside, CNA A said she had last checked on Resident #1 around 07:00 am when she came in to work. CNA A said Resident #1 looked fine at that time and said Resident #1 was sitting up in bed and had her nebulizer mask on, getting a treatment, so she just dropped off the breakfast tray and left. CNA A said she did not reposition Resident #1, change her gown, or perform any morning ADL care. CNA A said she did not empty Resident #1's indwelling urinary catheter bag or rectal tube bag because the previous shift should have already done that and then admitted that she had not checked those things at 07:00 am to ensure they had been done. CNA A denied the previous shift had reported any changes in Resident #1's condition to her, but said the previous shift CNA had already left when she got to work, so she had never spoken with them. During an observation and interview with the DON on 09/06/2019 at 09:24 am the DON was asked if Resident #1 was on the facility pressure ulcer/wound care list and she said she would have to check, but she believed so. The DON said she knew that Resident #1 had a sacral wound but was not sure what stage it was without checking. Resident #1 was rolled to her left side, by CNA A and the DON, for observation of skin, with family member consent, as family member said they wanted to see what the resident's bottom looked like now. [DEVICE] infusion was paused. Resident #1 did not tolerate the repositioning well and began moaning loudly again. Observed an uncovered, not bandaged, silver dollar sized hemorrhoid above the rectum. There was no drainage or odor. The center was a dark beefy red color and the edges appeared to be peeled back, uneven and flayed like an orange peel with pink open areas around the flayed edges that resembled a starburst. There was a small amount of fecal stained mucous observed on the chux pad that had been underneath Resident #1. The indwelling catheter tubing was not secured to Resident #1's leg and was pulling slightly because the adhesive backing on the device was observed stuck onto itself and the bed linens. The resident continued to moan and grab for her groin and was repositioned for comfort. The DON said she did not know why the resident had no dressings in place and would have to check the treatment order. Resident #1's family member than began demanding that the resident be sent to the hospital and told staff to call 911 if they had to. Resident #1 then began to cough or attempt to cough and her breathing became labored. Resident #1 started choking and her chest began heaving and she began to drool more and became less responsive. The DON had no equipment or stethoscope to assess Resident #1 but the DON reached over and turned the knob up on the oxygen concentrator to increase the rate of the oxygen being administered. CNA A was sent to retrieve RN A but the DON did not call any type of code or internal emergency. The family member stated loudly, Y'all need to go ahead and send Resident #1 out. RN A returned to bedside to assist the DON but did not bring any equipment with her and had to leave the bedside again to retrieve a stethoscope, pulse oximeter, and blood pressure cuff from the nursing cart in the hallway. Observation on 9/6/19 at 09:31 am revealed EMS at Resident #1's bedside and Resident #1 being transferred out of the facility via stretcher with EMS. During a telephone interview on 9/6/19 at 6:19 pm with RN B who said that she normally worked night shift and was familiar with Resident #1. RN B said that Resident #1 was taking antibiotics for [MEDICAL CONDITION] and that she did not know why Resident #1 was not on contact isolation. RN B said that she had last worked with Resident #1 the previous night. When asked if Resident #1 had a change in condition during the night shift, RN B said that sometimes Resident #1 says she is in pain and hollers or screams. RN B said that Resident #1 had an episode of yelling last night so she gave the resident what she was supposed to give her and also gave the resident her prn medication [MEDICATION NAME]. When asked if she documented that the resident was howling and anxious, RN B said that she did document that. When asked if she documented that the medication was subsequently ineffective, RN B said yes. When asked if she documented Resident #1's blood sugar as 340 mg/dl at 10:07 pm, she said she was not sure and would have to look at the documentation. When asked if this was considered a change in condition for Resident #1, RN B said she did not understand the question. RN B then said that she gave Resident #1 everything she was supposed to give her and that she reported to the day shift nurse that the resident had a bad night. She said that normally they write things down on the 24-hour report, but she could not remember if she wrote anything down. When asked if she had been trained on how to care for Resident #1's rectal tube, RN B stated, honestly, no, not really. RN B said she had not changed the rectal tube or emptied it while caring for Resident #1 since her readmission and said that Resident #1 had been sent out to theER on [DATE] to have it changed because it was leaking. She said she did not know why that was not documented in the daily skilled nurse's notes or the 24-hour nurse shift to shift report. Interview on 9/6/19 at 7:07 pm with the DON who said she did not know why there was little or no documentation on Resident #1 and her changes in condition from 9/3/19 through 9/6/19. Follow up record review of Resident #1's Progress Notes/Nurse's Notes printed on 9/9/19 at 4:14 p.m. revealed RN A had entered a Nurse's Note dated 9/6/19 and timed 10:00 a.m. which read in part, .Guest is alert, closely monitored.Blood sugar; 303,V/S checked,BP-174/97, pulse -132,Resp- 18, Temp -97.7, Oxygen sat- 98 on oxygen.Medicaton administered including blood pressure medication via [DEVICE] and breathing treatment.Re-check blood pressure: 131/97 ,pulse-126,Resp- 16.Guest complained of pain, when the writer try (sic) to give her PRN [MEDICATION NAME] 325mg,the residual was more than 60ml,the medicatrion (sic) was (sic) hold.Guest condition changed when she was repositioned,she started having resp distress, DON called Physician A and informed her about the patient condition,she called 911 also, 911 came and patient was taken to (name of local hospital). Patient relative was around and she went to the hospital with 911. Record review of Resident #1's emergency room records dated 9/6/19 revealed EKG results dated 9/6/19 and timed 10:51 a.m. of [MEDICAL CONDITION] with a rapid ventricular response, right axis deviation, anteroseptal infarction age undetermined, and abnormal EKG. Her ventricular pulse was 132. Further record review of the emergency room records read in part, .ED Department Triage .Chief Complaint: Pt (patient) brought by PL 5 for altered mental status since 0930 (9:30 a.m.) today. Pt comes from (nursing home), .Tracking Acuity: 2-Emergent .Systolic Blood Pressure: 148 .Diastolic Blood Pressure: 84 .Peripheral Pulse Rate: 130 .Cardiovascular Heart Rhythm: Irregular .Respiratory Pattern: Tachypnea .Neurological Symptoms: Confused Orientation: Disoriented x 3 .Triage Information .EMS reports glucose of 390-A&Ox4 is baseline, currently A&Ox1 .admitted to Critical Care .ICU . During an interview with Physician A on 9/9/19 at approximately 10:50 am she said that in reviewing Resident #1's clinical information she wanted to clarify that she felt RN B had provided an appropriate intervention for Resident #1's being howling and anxious. She said that the [MEDICATION NAME] was ordered every 8 hours and so if the medication was given around 10:00 pm then, documented again at the end of her night shift that it was ineffective RN B worked within the 8 hour parameter. When asked if an elevated blood sugar or blood pressure were things that should have been reported, all she would say is that the nurse provided an intervention with the [MEDICATION NAME]. Physician A said the communication piece was lacking and agreed that the communication could have been better between the staff. When asked if an elevated blood sugar or blood pressure would normally be reported to her, she would only say that the nurse did the right thing by giving [MEDICATION NAME]. Interview with DON on 9/11/19 at 2:14 pm who said she trained nursing staff on how to assess for changes in condition. She said there was a written protocol to follow for changes in condition and the staff were to notify her and the doctor and follow any of the doctor's orders and notify the resident's family. The DON said things such as any blood pressures or blood sugars that were out of parameters, altered mental status, lethargy or just anything outside of the normal baseline of a resident would be an example of a change in condition. The DON said some of the doctor's had standing orders in their binders at the nursing stations but said that if the nurses were ever in doubt they should call the doctor and give report. The DON said nursing staff should know what a change in condition was and how to identify one. The DON said she had started trying to complete nursing competencies because after the incident with Resident #1 the IDT identified it as a concern. Interview with LVN [NAME] on 9/11/19 at 2:00 pm who said she would consider any reading above 150 ml/dl to be an elevated blood sugar, especially if it was a fasting blood sugar, and said she would report this to a physician. LVN [NAME] said that whenever there was a change in condition in a resident, she notified the doctor, DON, and resident RP. Interview with ADON on 9/11/19 at 2:10 pm who said there were SBAR binders located at the nursing stations for nurse review. The ADON said the nursing staff had been in-serviced on change in condition and the SBAR binders in the past. The ADON said when nurses get MEDICATION ORDERS FOR [REDACTED]. Record review of the facility's policy and procedure for Resident Rights revised (MONTH) 2009 read in part, .3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Record review of the facility's policy and procedure for Change in a Resident's Condition or Status revised (MONTH) 2011 read in part, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.).1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .d. A significant change in the resident's physical/emotional/mental condition; .2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one area of the resident's health status; .6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Record review of the facility's policy and procedure for Nursing Care of the Resident with Diabetes Mellitus revised (MONTH) 2011 read in part, .Documentation .Documentation should reflect the carefully assessed diabetic resident and include the following: 1. Vital signs as ordered; 2. Level of consciousness; .4. Accurate intake and output; .6. Emotional reactions, moods; 7. Careful assessment of pain (including symptoms such as discomfort and/or paresthesias (numbness, tingling) should include the following: a. Characteristics of pain: (1) intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g., constant or intermittent); (4) Location of pain; and (5) Frequency, timing and duration of pain. b. Impact of pain on quality of life; c. Factors that precipitate or exacerbate pain; d. Factors and strategies that reduce pain; and e. Symptoms that accompany pain (e.g., nausea, anxiety); .14. Blood sugar results and other pertinent laboratory studies. On 9/11/19 at 3:52 p.m. with the Administrator and the DON they were informed that an Immediate Jeopardy had been identified due to the above failures and were asked to provide a plan of removal at that time. The plan of removal was accepted on 09/12/19 at 1:12 pm after revisions. The POR read in part: IMMEDIATE ACTIONS The Medical Director was notified of the Immediate Jeopardy on 9/11/2019. Resident #1 went to the hospital on [DATE] (sic) (9/6/19) at approximately 9:30 am. Initiated audit on 9/11/19 of patients to assess for a potential change in condition. Audit will be completed by 9/12/19 at 10am. Any changes in condition will follow the policy and procedure to alert DON, Patient's Responsible Party, and Physician, as necessary. Completed audit of patients with diabetes on 9/11/19. There were no adverse findings. Any patient that did not have blood sugar parameters, the physician was contacted. Parameters were received and entered into patient's medical record. Completed audit of patients with [MEDICAL CONDITION] medications on 9/11/19. There were no adverse findings. Audit included time of medication administration, follow-up, and effectiveness for all medications for all medications given on 9/11/19. Audit also included ensuring all patients with [MEDICAL CONDITION] medications had an appropriate [DIAGNOSES REDACTED]. Room rounds completed to ensure call lights are in place on 9/11/2019. Department Head managers have been assigned to QA Rounds to ensure that call lights are within resident's reach. Each Department head will be assigned a time to make a full facility round during the week. When Department Heads are not present, the weekend supervisor will be responsible to make round throughout the building at minimum once every two hours. Each patients' call light will be checked for placement at minimum once every two hours. During this time, if any change in condition is noted, the staff member will follow policy and procedure. A nursing competency training program has been implemented to include policies and procedures such as Resident Rights, Physician Notification, Documentation, and Stop & Watch Forms. These competencies will be reviewed quarterly and upon hire to be monitored by the DON. RESIDENT RIGHTS The Vice President of Operations reeducated the Administrator, Director of Nursing, and Assistant Director of Nursing on Resident Rights on 9/11/2019. The Administrator and Designee began an in-service to all staff regarding Resident Rights. This in-service will be completed by 9/12/2019. This Resident Rights in-service will be monitored by the Administrator. In-Service was reviewed by Medical Director. If an employee notices a patient may be experiencing a change in condition (i.e: Jane Doe is not engaging in conversation today when usually she will discuss the weather.), the staff member will alert the nurse with a Stop and Watch Form. A copy of the form will be placed in a locked box at the reception desk. The Stop & Watch Forms will be located at the Nurses Station in a Green Binder on Bright Green Paper, and there will also be copies by the locked box at the front reception desk. The nurse will assess the patient promptly for any potential changes in condition. The nurse will notify the DON, patient's responsible party, and physician, as necessary. The nurse will complete the necessary documentation and a change in condition form if a change in condition is identified. The nurse will sign the Stop & Watch Form and turn it in to the DON and/or designee. The DON and/or designee will check the locked box for Stop & Watch forms and perform an audit daily to ensure potential changes of conditions have been addressed. Any adverse findings will be reported promptly to the Administrator. When DON and ADON are not in facility, the RN supervisor will review all Stop & Watch forms and new physician orders and report to the Nursing Management Staff any change in conditions. Nursing Management (i.e: DON, ADON, MDS Nurse, Admissions Nurse, and/or weekend supervisor) will make rounds at minimum once every two hours to monitor residents for any potential change in conditions. The DON and/or designee will review the forms in the Morning Clinical Meeting along with any new physician orders. Any adverse findings will be discussed in the Quality Assurance Performance Improvement Meeting for six months. This will be monitored by the DON starting on 9/11/2019. Monitoring: Observations on 9/12/19 of random residents revealed call-lights in place. Interviews on 9/12/19 with three staff on all halls to verify training on Resident Rights, Change in Condition, Comprehensive Resident Centered Care Plans. Questions asked of the staff were what the steps were to take when residents experience a change in condition. Answers were to assess for a potential change in condition, any changes in condition will follow the policy and procedure to alert DON, Patient's Responsible Party, and Physician, as necessary. Record review on 9/12/19 confirmed audits to include audits performed and completed on 9/11/19 for Residents with a change in condition, residents with a [DIAGNOSES REDACTED]. Record review of nursing competency training program provided on 9/11/19 evening shift and 9/12/19 morning shift to include policies and procedures such as Resident Rights, Physician Notification, Documentation, and Stop & Watch Forms. Observation rounds on 9/12/19 and 9/13/19 of random residents revealed call-lights were in place. Staff members were observed making rounds and checking on the status of residents. Interviews on 9/13/19 with six staff on all halls spanning two shifts confirmed training on Resident Rights, Change in Condition, Comprehensive Resident Centered Care Plans. Questions asked were what the steps were to take when residents experience a change in condition. Answers were

Based on observation, interview, and record review the facility failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with facility policy and procedure 1 of 33 residents ( Resident #1) reviewed for quality of care in that: -- Direct care, clinical staff, failed to assess Resident #1 and treat a change in condition. Resident #1 was transferred to the hospital where she was found to have [MEDICAL CONDITION] with RVR and was admitted to the ICU. -RNA and the DON failed to promptly assess Resident #1 when her condition worsened on 9/6/19. --Staff were not trained how to manage Resident #1's rectal tube causing Resident #1 to be transferred to the hospital twice rectal tube care. --Resident #1 had a blood sugar of 340 mg/dl and the physician was not consulted. An immediate jeopardy (IJ) was identified on 09/11/19. While the IJ was lowered on 09/19/2019, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy. These failures affected 1 resident and placed her at risk of injury, harm, delayed medical treatment, intervention, and hospitalization . Findings include: Record review of Resident #1's admission sheet revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment dated [DATE] revealed she had a SAMS score of 2 indicating moderately impaired cognitive skills for daily decision-making. She had short and long term memory problems. She required limited assistance of one staff for bed mobility, dressing, and personal hygiene. She required extensive assistance of one staff for eating and bathing. She used a walker and a wheelchair for mobility. She was always incontinent of bowel and bladder. Her active [DIAGNOSES REDACTED]. She was assessed as having received no as needed or scheduled pain medications. The staff assessment for pain was documented as vocal complaints of pain and indicators of pain or possible pain 1 to 2 days during the past 5 days of the assessment period. She was assessed as having no behaviors, no rejection of care, and no shortness of breath. She received a diuretic for 6 of the past 7 days in the assessment period. Record review of Resident #1's Order Listing Report dated for 7/1/19-9/30/19 revealed the following physician orders: -[MEDICATION NAME] 0.5 mg give 1 tablet via [DEVICE] every 8 hours as needed for anxiety. There was no order start date. -Basaglar KwikPen Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION NAME]) Inject 7 unit (sic) subcutaneously at bedtime for Diabetes. There was no order start date. -Monitor anti-anxiety medication every 12 hours . -There were no orders for sliding scale coverage insulin. -There was no physician order for [REDACTED].>Record review of Resident #1's Administration records for 9/1/19 through 9/30/19 revealed there was no documentation of the administration of oxygen. Record review of Resident #1's MARs and TARS for 9/1/19-9/30/19 revealed staff documented monitoring anti-anxiety medication every 12 hours. They documented with their initials and a checkmark indicating Administered per the legend on the document. The documentation did not include any information on number of episodes, if any, what the behavior was, the intervention, the outcome, or any side effects, as requested on the document. There was no documentation of administration of Oxygen. Record review of Resident #1's physician orders dated as printed on 9/9/19 for a range of 9/1/19-9/30/19 revealed the following physician orders: -ACCU Checks HS AC before meals and at bedtime for Routine. There were no parameters for notifying the physician. -[MEDICATION NAME] 0.5 mg give 1 tablet via [DEVICE] every 8 hours as needed for anxiety. -Transfer Out 911, Resp. (Respiratory) Distress -There was no physician order for [REDACTED].>Record review of Resident #1's undated care plan revealed the following: -Resident #1 has Diabetes Mellitus .Resident #1 will not have complications related to diabetes through the review date. Target Date: 11/19/19 .Interventions .*Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. *Humalog Solution 100 Units/ML Inject 7 units SQ before meals (TID) -[MEDICATION NAME] 100 UNITS/ML Inject 15 units SQ once daily . The care plan was not updated to reflect her current insulin order of Basaglar and had no interventions addressing when to notify the physician. -There were no care plans for oxygen use or [MEDICAL CONDITION]. Record review of Resident #1's physician progress notes [REDACTED]. Under the heading of current diagnoses, Physician A documented (A04.72) [MEDICATION NAME] due to [MEDICAL CONDITION], not specified as recurrent. Under Assessment, Physician A documented, .[DIAGNOSES REDACTED]. Physician A then documented the following narrative: seen for follow up she was sent to the hospital last night for leaking rectal tube patient apparently had stool all over and high BP yes was kept in the ER for 5 hrs and sent right back with the same rectal tube now is lying in bed, has rectal tube in place, denies complaints rectal tube cannot be managed here needs it removed prior to coming to nursing home setting spoke with ER physician at (hospital name) they will be accepting her back and managing before she can be sent here for long term care a fib with rvr likely needs [MEDICATION NAME] IV she will be going to ER Patient has[DIAGNOSES REDACTED] diarrhea was contained with rectal tube. however, the tube is now leaking. unable to be contained. sending back to hospital. The note was updated on 9/6/19 at 7:27 pm by Physician A, after telephone interview and read, Incomplete medical records available from hospital regarding update of[DIAGNOSES REDACTED] status. per nursing 24-hour report, discharging nurse reported[DIAGNOSES REDACTED] was actually resolved and rectal tube is in place for sacral wound protection. Record review of the EMR for Resident #1 revealed the following nursing documentation: - .9/5/19 17:58 (5:58 p.m.) nurse's note: Resident BP was up 168/101, BP MEDS WAS JUST GIVEN BS WAS 328 GAVE INSULIN COVERAGE BP WAS RECHECKED AND BP WENT DOWN TO 145/86 GAVE NEXT DOSE OF BP MEDS AND THE RESIDENT STABLE AND NO C/O PAIN NO SIGN OF DISTRESS NOTED A THIS TIME. There was a vital signs entry for Resident #1's blood sugar dated 9/5/19 at 10:07 p.m. for a blood sugar test result of 340 mg/dl. There was no documentation on any physician consultation or nursing/administrative notification or intervention regarding Resident #1's blood sugar of 340 mg/dl at 10:30 pm on 9/5/19 through Resident #1's discharge to the hospital on [DATE] at 9:31 am. Record review of Resident #1's MAR for 9/1/19-9/30/19 revealed on 9/5/19 the resident was administered her Basaglar KwikPen Solution (Insulin [MEDICATION NAME]) on 9/5/19 but not until 9:00 p.m. Further review of the document revealed there was no documentation of any orders for a sliding scale insulin for coverage or of any insulin given on 9/5/19 at or about 5:58 p.m. There was no documentation of any insulin orders available to cover any as needed administrations for elevated blood sugars. Further record review of Resident #1's nurse's notes revealed the 9/5/19 note was followed by a note created by RN B that read as follows: 9/5/19 22:30 (10:30 p.m.) [MEDICATION NAME] Tablet 0.5 MG give 1 tablet via [DEVICE] every 8 hours as needed for anxiety guest was howling and anxious. 9/6/19 07:00 (7:00 a.m.) [MEDICATION NAME] Tablet 0.5 MG Give 1 tablet via [DEVICE] every 8 hours as needed for anxiety PRN Administration was: Ineffective. There was no documentation of physician consultation or nursing/administrative notification or intervention regarding Resident #1's [MEDICATION NAME] being Ineffective, in helping Resident #1's symptoms of howling and anxious. Observation of Resident #1 on 9/5/19 at 02:56 pm revealed she was observed awake, alert, and oriented X 3 and speaking on her cell phone. Observation and interview on 9/6/19 at 09:00 am of Resident #1 revealed she was overheard moaning from the hallway. Her room door was slightly ajar, and after knocking for consented entry, Resident #1 was observed to be sitting up in her bed with the head of the bed raised. The sunlight from the window appeared to be directly in the resident's eyes and her call light was located just behind her, out of reach, and hanging from the assist railing, to her right side. She was mumbling and moaning and said the word pain repeatedly. Her breakfast tray was untouched and not set-up at the bedside. Resident #1's gastrostomy tube feeding formula had settings that read 60 ml/hr and were dated for 9/6/19 at 4:50 am and infusing via pump. Resident #1's family member then presented at the bedside and said that Resident #1 did not look good and was not in the same condition as yesterday. Resident #1 was sluggish, lethargic, and had very little neck control in that she had trouble holding her head up and her head was bobbing back and forth. Resident #1 was struggling to keep her eyes open as her family member kept calling her name and Resident #1 then began to drool on herself. Resident #1 cried out in pain, in waves, almost like spasms and would reach down into her groin area each time she moaned loudly. Her indwelling urinary catheter tubing was observed to the left side of the bed and the collection bag had approximately 200 cc of cloudy, amber-colored urine in the reservoir. Resident #1 had a rectal tube to left side of the bed drainage was also observed and the tubing appeared to have brown colored liquid stool. She was receiving oxygen via nasal cannula at 3 L/min via a concentrator at the bedside, without a physician's order. There was no oxygen in use signage on the door of Resident #1's room. Resident #1's family member pushed the call light, still located looped around the assist railing on the right side of the bed and behind the resident. RN A responded to the bedside. Observation and interview with RN A on 9/6/19 at 09:06 am she said she did not know Resident #1 was in any distress, and the last time she rounded on Resident #1 was earlier that morning around 07:00 am when she gave the resident her scheduled medications. RN A said Resident #1 was not in any distress at that time and said she had not received any report from the previous shift of Resident #1 having any issues or concerns. When asked what RN A was going to do to assist Resident #1 at this time, RN A said she would go and get Resident #1 something for pain because Resident #1 had prn medications. RN A was asked if this was normal behavior for Resident #1 and she replied No. RN A left the bedside without conducting any full body, pain scale, or PAINAD assessment of Resident #1. Observation and interview with RN A on 9/6/19 at 09:09 am to administer the prn pain medication revealed that upon re-entry she donned gloves and placed the crushed medication on the bedside table. She proceeded to pause the [DEVICE] pump and checked for residual with a syringe after removing the plunger. The syringe immediately regurgitated formula up to the 60-cc mark, filling the syringe. RN A, a charge nurse, did not have a cup or basin to empty the residual into, and immediately turned off the valve to the [DEVICE], stopping the backflow of formula. RN A did not continue to check the residual volume to determine full residual amount. RN A returned the contents of the syringe into Resident #1 by gravity. RN A did not have a stethoscope or any kind of equipment to obtain vital signs for Resident #1. When RN A was asked if she was going to check Resident #1's [DEVICE] for placement and how much residual did she have to discover before having to report to the physician per orders, RN A, appeared to get flustered and said she was going to call Resident #1's physician. When RN A was asked how she normally checked for [DEVICE] placement, she did not reply. She had no stethoscope at the bedside and was not observed checking for placement or additional residual. When asked when the last time Resident #1 had been checked on by any staff members, RN A said she did not know when the aide had last checked on Resident #1, but she gave Resident #1 all her morning medications and everything was fine. Resident #1's family member then began to question RN A on what Resident #1's vital signs were and RN A told the family member Resident #1's blood pressure had been a little elevated at 171/97 but when she rechecked the blood pressure a short while later it was down to 131/74. RN A said she did not remember what Resident #1's blood sugar was and would have to check. RN A said she had not reported the blood pressure or blood sugar level to the physician. RN A repeated that she had given Resident #1 her medications via [DEVICE] and nebulizer treatment as prescribed. Resident #1's family member then began saying that the nurse needed to send the resident to the hospital because something was definitely wrong. RN A began to leave the room, leaving the crushed medication at the bedside table. RN A was stopped just as she reached the door and asked if she was going to leave the medication at the bedside. She quickly replied, No, and returned to get it. Resident #1's family member then said loudly, They always leave medicines and things at the bedside like this, that's nothing new. RN A said she would discard the medicine in the toilet and was observed flushing it down the toilet in Resident #1's attached bathroom. Resident #1 did not receive any pain medications at this time. RN A did not assess Resident #1. Record review of Resident #1's MAR indicated [REDACTED]. Additionally, RN A had documented administering [MEDICATION NAME] 0.5 mg on the morning of 9/6/19 at 7:00 a.m. Resident #1 had two blood sugar testing results documented as 9/5/19 at 9:00 p.m. 340, and 9/6/19 303 at 8:00 a.m. During an interview on 9/6/19 at 09:21 am with CNA A at Resident #1's bedside, CNA A said that she had last checked on Resident #1 around 07:00 am when she came in to work. CNA A denied that Resident #1 was in any distress at that time and said that Resident #1 was sitting up in bed and had her nebulizer mask on, getting a treatment, so she just dropped off the breakfast tray. CNA A said that she did not reposition Resident #1, change her gown, or perform any morning ADL care. CNA A said that she did not empty Resident #1's indwelling urinary catheter bag or rectal tube bag because the previous shift should have already done that and then admitted that she had not checked those things at 07:00 am to ensure they had been done. CNA A said that the water in the water pitcher at the bedside was the same water from the night before, as she had not refilled it yet this shift. CNA A denied that the previous shift had reported any changes in Resident #1's condition to her, but said that the previous shift CNA had already left when she got to work, so she had never spoken with them. During an observation and interview with the DON on 09/06/2019 at 09:24 am the DON was asked if Resident #1 was on the facility pressure ulcer/wound care list and she said she would have to check, but she believed so. The DON said she knew that Resident #1 had a sacral wound but was not sure what stage it was without checking. Resident #1 was rolled to her left side, by CNA A and the DON, for observation of skin, with family member consent, as family member said they wanted to see what the resident's bottom looked like now. [DEVICE] infusion was paused. Resident #1 did not tolerate the repositioning well and began moaning loudly again. Observed an uncovered, not bandaged, silver dollar sized hemorrhoid above the rectum. There was no drainage or odor. The center was a dark beefy red color and the edges appeared to be peeled back, uneven and flayed like an orange peel with pink open areas around the flayed edges that resembled a starburst. There was a small amount of fecal stained mucous observed on the chux pad that had been underneath Resident #1. The indwelling catheter tubing was not secured to Resident #1's leg and was pulling slightly because the adhesive backing on the device was observed stuck onto itself and the bed linens. The resident continued to moan and grab for her groin and was repositioned for comfort. The DON said she did not know why the resident had no dressings in place and would have to check the treatment order. Resident #1's family member than began demanding that the resident be sent to the hospital and told staff to call 911 if they had to. Resident #1 then began to cough or attempt to cough and her breathing became labored. Resident #1 started choking and her chest began heaving and she began to drool more and became less responsive. The DON had no equipment or stethoscope to assess Resident #1 but the DON reached over and turned the knob up on the oxygen concentrator to increase the rate of the oxygen being administered. CNA A was sent to retrieve RN A but the DON did not call any type of code or internal emergency. The family member stated loudly, Y'all need to go ahead and send Resident #1 out. RN A returned to bedside to assist the DON but did not bring any equipment with her and had to leave the bedside again to retrieve a stethoscope, pulse oximeter, and blood pressure cuff from the nursing cart in the hallway. Observation on 9/6/19 at 09:31 am revealed EMS at Resident #1's bedside and Resident #1 being transferred out of the facility via stretcher with EMS. Record review of Resident #1's EMR on 9/6/19 at 10:28 am revealed Resident #1 was identified as having been sent to the ED for further evaluation of her rectal tube on both 9/3/19 and 9/4/19. The facility nursing progress notes or daily skilled notes, did not have any documentation on 9/3/19 of the 9/3/19 ED visit or of any change in condition for Resident #1 on 9/3/19. Further record review of hospital documentation dated 9/4/19 at 18:19 (6:19 p.m.) read in part, .The patient presents with Rectal Tube Problem.presents to ED for a rectal tube problem. Patient was sent to ED by her nursing home because the nursing home was unable to change the patient's rectal tube bag. The patient's rectal tube bag was changed in the ED yesterday and the patient was discharged back to the nursing home. Today, the patient's family reports the nursing staff told them an ED physician told them the patient needed to come back to the ED, but (sic) ED physician was told by the nursing staff that they were not trained to change the patient's rectal tube bag. Nursing home staff told the ED physician that they could not properly care for the patient because they did not have the proper training to change a rectal tube bag. During an interview with the DON and the Administrator on 9/6/19 at approximately 3:30 pm they said they did not know of any changes in condition for Resident #1 between her 8/30/19 readmission to the facility and her recent 9/4/19 discharge and reentry to the facility on [DATE]. They both denied any knowledge of a 9/3/19 ER visit for Resident #1 and said that any and all documentation should be in the EMR. They said they would have to check the nursing 24-hour report to see if there was any additional information but said they had no record of Resident #1 discharging to the ER for a change of condition and readmitting to the facility on [DATE]. Interview with RN A on 9/6/19 at 4:28 pm who said Resident #1 was the first person she had ever taken care of that had a rectal tube. RN A said Resident #1 had readmitted back in (MONTH) with the rectal tube and she had never changed it since the resident had been readmitted . RN A said she worked prn at the facility and she had not been trained on how to change or care for the resident's rectal tube until earlier today when she had an in-service after Resident #1 went out to the hospital. Interview with the DON, the Administrator, VP of Operations, and VP of Clinical Services on 9/6/19 at approximately 5:19 pm who said that they were looking into Resident #1's possible ER hospitalization on [DATE]. The DON provided documentation of rectal tube in-servicing being conducted on 9/3/19 but when asked admitted she had just done staff in-servicing today, 9/6/19, and not on 9/3/19. The DON said she must have put the incorrect date on the staff in-service sheet. Interview with the Administrator, DON, VP of Operations and VP of Clinical Services on 9/6/19 at 5:44 pm regarding Resident #1 and ER and physician documentation of the 9/3/19 ER visit and [MEDICAL CONDITION] diagnosis. The DON said that she did not know about the resident's discharge on 9/3/19 or [MEDICAL CONDITION] [DIAGNOSES REDACTED]. When asked why Resident #1 was taking the antibiotic [MEDICATION NAME] the DON said that she did not know. When asked if the nursing staff were required to enter a [DIAGNOSES REDACTED]. She said she did not know why there was no contact isolation set-up for Resident #1 and said the MDS Coordinator was responsible for entering [DIAGNOSES REDACTED]. During an interview with the Administrator, the DON, VP of Operations, and the VP of Clinical Services on 9/6/19 at 6:15 pm the VP of Operations said Physician A advised him that Resident #1's [MEDICAL CONDITION] had been resolved but he said that there were no physician progress notes [REDACTED]. When asked what could happen if a resident had [MEDICAL CONDITION] and was not on contact isolation the DON said that the infection could be spread to other residents, staff members, and visitors. The DON said that there should not be any other residents in the facility at this time on contact isolation for [MEDICAL CONDITION]. The DON said that on 9/4/19 Physician A was in the facility and evaluated Resident #1. The DON said Physician A, at that time, communicated directly with the ED to evaluate Resident #1's rectal tube and discontinue it, but by the time Resident #1 got to the hospital, that ED physician had gone home, and a new ED Physician was on duty and did not remove the rectal tube. The DON said Physician A was supposed to come to the facility today and remove Resident #1's rectal tube, but Resident #1 ended up going out to the hospital via 911. During a telephone interview on 9/6/19 at 6:19 pm with RN B who said that she normally worked night shift and was familiar with Resident #1. RN B said that Resident #1 was taking antibiotics for [MEDICAL CONDITION] and that she did not know why Resident #1 was not on contact isolation. RN B said that she had last worked with Resident #1 the previous night. When asked if Resident #1 had a change in condition during the night shift, RN B said that sometimes Resident #1 says she is in pain and hollers or screams. RN B said that Resident #1 had an episode of yelling last night so she gave the resident what she was supposed to give her and also gave the resident her prn medication [MEDICATION NAME]. When asked if she documented that the resident was howling and anxious, RN B said that she did document that. When asked if she documented that the medication was subsequently ineffective, RN B said yes. When asked if she documented Resident #1's blood sugar as 340 mg/dl at 10:07 pm, she said she was not sure and would have to look at the documentation. When asked if this was considered a change in condition for Resident #1, RN B said she did not understand the question. RN B then said that she gave Resident #1 everything she was supposed to give her and that she reported to the day shift nurse that the resident had a bad night. She said that normally they write things down on the 24-hour report, but she could not remember if she wrote anything down. When asked if she had been trained on how to care for Resident #1's rectal tube, RN B stated, honestly, no, not really. RN B said she had not changed the rectal tube or emptied it while caring for Resident #1 since her readmission and said that Resident #1 had been sent out to theER on [DATE] to have it changed because it was leaking. She said she did not know why that was not documented in the daily skilled nurse's notes or the 24-hour nurse shift to shift report. On 9/6/19 at 6:52 pm an attempt was made to contact the Charge nurse ( LVN A) who worked on 9/3/19. Did not receive call back and nurse not on shift prior to exit. During a telephone interview with Physician A on 9/6/19 at 6:58 pm who said that she accepted Resident #1 to the facility because she believed that Resident #1's [MEDICAL CONDITION] was controlled and the ADON told her the facility could manage a resident with a rectal tube. Physician A said she received a frantic call on 9/3/19 in the evening from the Charge Nurse on duty, that Resident #1 had diarrhea everywhere and that the charge nurse said they did not know what to do, so she gave the order for Resident #1 to be sent out to the hospital. When asked if Resident #1 should have been on contact isolation for [MEDICAL CONDITION], Physician A said that she did not write the order, because it was contained up until the rectal tube began leaking. Physician A said that the hospital ER kept Resident #1 for a couple of hours even though the resident had diarrhea and was [MEDICAL CONDITION]. Physician A said that when she came in to the facility on [DATE], Resident #1 was in the same condition, so she called the ER herself and spoke with the ER physician about discontinuing the rectal tube and/or admitting Resident #1. Physician A said that she had a plan of care worked out with the ER physician, but for some reason it took the facility too long to send Resident #1 and by that time 3-4 hours later the ER physician she had formulated the plan of care with, was off shift and a new ER physician had come on shift and would not discontinue the rectal tube or readmit Resident #1. Physician A said she called hospital case management herself and tried to get Resident #1 readmitted , but the ER physician and case management kept saying Resident #1 was stable. Physician A said that Resident #1 was not stable because of the diarrhea and [MEDICAL CONDITION] but when Resident #1 came back to facility 9/5/19 she left the rectal tube in place because Resident #1 had a sacral pressure ulcer and she was concerned that with all of the diarrhea, it could have gotten infected. When asked if she knew what stage Resident #1's sacral pressure ulcer was, Physician A said she did not off hand but that Resident #1 was being followed by consultant wound care MD. When advised that Resident #1 was never seen or evaluated by consultant wound care MD, she replied, Oh no. That's not good. Interview on 9/6/19 at 7:07 pm with the DON who said that they confirmed that Resident #1 discharged on [DATE] around 7:00 pm and readmitted to facility on 9/4/19 around 1:00 am. The DON then said that none of the administrative staff had been aware of Resident #1's discharge to ED on 9/3 19 and subsequent reentry to facility. The DON said that she was aware that on 9/4/19, Physician A assessed Resident #1 and sent her back to ER. The DON said that everyone believed that Resident #1's [MEDICAL CONDITION] was resolved. The DON said that an SBAR should have been done for the 9/3/19 discharge to the ER and the 9/4/19 discharge to the ER and did not know why the SBAR's were never done. The DON said that there should have at least been some documentation in a detailed nursing progress note or the 24 hour shift to shift nursing report. The DON said she did not know why there was little or no documentation on Resident #1 and her changes in condition from 9/3/19 through 9/6/19. Follow up record review of Resident #1's Progress Notes/Nurse's Notes printed on 9/9/19 at 4:14 p.m. revealed RN A had entered a Nurse's Note dated 9/6/19 and timed 10:00 a.m. which read in part, .Guest is alert, closely monitored.Blood sugar; 303,V/S checked,BP-174/97, pulse -132,Resp- 18, Temp -97.7, Oxygen sat- 98 on oxygen.Medicaton administered including blood pressure medication via [DEVICE] and breathing treatment.Re-check blood pressure: 131/97 ,pulse-126,Resp- 16.Guest complained of pain, when the writer try (sic) to give her PRN [MEDICATION NAME] 325mg,the residual was more than 60ml,the medicatrion (sic) was (sic) hold.Guest condition changed when she was repositioned,she started having resp distress, DON called Physician A and informed her about the patient condition,she called 911 also, 911 came and patient was taken to (name of local hospital). Patient relative was around and she went to the hospital with 911. Record review of Resident #1's emergency room records dated 9/6/19 revealed EKG results dated 9/6/19 and timed 10:51 a.m. of [MEDICAL CONDITION] with a rapid ventricular response, right axis deviation, anteroseptal infarction age undetermined, and abnormal EKG. Her ventricular pulse was 132. Further record review of the emergency room records read in part, .ED Department Triage .Chief Complaint: Pt (patient) brought by PL 5 for altered mental status since 0930 (9:30 a.m.) today. Pt comes from (nursing home), .Tracking Acuity: 2-Emergent .Systolic Blood Pressure: 148 .Diastolic Blood Pressure: 84 .Peripheral Pulse Rate: 130 .Cardiovascular Heart Rhythm: Irregular .Respiratory Pattern: Tachypnea .Neurological Symptoms: Confused Orientation: Disoriented x 3 .Triage Information .EMS reports glucose of 390-A&Ox4 is baseline, currently A&Ox1 .admitted to Critical Care .ICU . During an interview with Physician A on 9/9/19 at approximately 10:50 am she said that in reviewing Resident #1's clinical information she wanted to clarify that she felt RN B had provided an appropriate intervention for Resident #1's being howling and anxious. She said that the [MEDICATION NAME] was ordered every 8 hours and so if the medication was given around 10:00 pm then, documented again at the end of her night shift that it was ineffective RN B worked within the 8 hour parameter. Physician A said that the communication piece was lacking and she agreed that the communication could have been better between the staff. Interview with DON on 9/11/19 at 2:14 pm who said that she trained nursing staff on how to assess for changes in condition. She said that there was a written protocol to follow for changes in condition and that the staff are to notify her and the doctor and follow any of the doctor's orders and notify the resident's family. The DON said that things such as any blood pressures or blood sugars that are out of parameters, altered mental status, lethargy or just anything outside of the normal baseline of a resident would be an example of a change in condition. The DON said that some of the doctor's have standing orders in their binders at the nursing stations but said that if the nurses were ever in doubt they should call the MD and give report. The DON said that nursing staff should know what a change in condition is and how to identify one. The DON said that she had started trying to complete nursing competencies because after the incident with Resident #1 the IDT identified it as a concern. Interview with