Every finding on record at Trucare Living Centers-Columbus

Based on observation, interview record review the facility failed to ensure, based on the comprehensive assessment of a resident, that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents (Resident #1) reviewed for pressure ulcers. The wound care nurse failed to clean Resident #1's pressure wound to coccyx (tailbone) before applying a wound dressing triad paste (a wound dressing that consists of zinc-oxide-based used to manage and protect minor or hard-to-dress wounds with light-to moderate moisture) to the resident wound bed on 07/21/26. This failure could place residents at risk for infections, delayed healing, and medication failure. Findings include: Record review of Resident #1's face sheet, dated 07/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and again in 06/2024. Resident #1 had diagnoses which included the following: overactive bladder, muscle wasting and atrophy (loss of muscle tissue cause by disuse, nerve damage or aging), contracture of muscle multiple sites (permanent shortening of muscle tissue across different parts of the body, making the affected area stiff and hard to move), osteoarthritis (joint pain, stiffness, and the breakdown of protective joint cartilage [what cushions the joints to reduce friction between the bones]) heart failure, and cerebral infarction (sudden blockage of blood flow to the brain). Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 4, which indicated the resident cognition was severely impaired. Section H-Bladder and Bowel reflected the resident was always incontinent of urine and bowel. Section M-Skin Conditions reflected the residents was at risk of developing pressure ulcers/injuries with no pressure ulcer/injuries. Record review of Resident #1's Comprehensive Care Plan reflected the resident was being care planned for stage 2 coccyx (tailbone) wound, dated 07/16/26, with an intervention to administer treatment as ordered. Record review of Resident #1's Physician Order Summary Report for the month of July 2026 reflected the following order: -Dated 07/21/26 cleanse coccyx with NS, pat dry, and apply triad paste (a wound dressing that consist of zinc-oxide-based used to manage and protect minor or hard-to-dress wounds with light-to moderate moisture) daily one time a day for wound care. Observation on 07/21/26 at 1:18 PM of wound care with the Wound Care Nurse and the Wound Care Doctor for Resident #1 revealed both the Wound Care Nurse and the Wound Care Doctor placed on their PPE which consisted of disposable gown and gloves and proceeded to go inside of Resident #1's room. The Wound Care Doctor positioned Resident #1 to his right side and opened the resident brief. The Wound Care Nurse had the triad paste inside of a medication cup. The skin to resident's coccyx area had a small open area that was a pale pink in color. The Wound Care Nurse proceeded to apply the triad paste to the resident's coccyx area without cleaning the coccyx (tailbone) wound. Interview on 07/21/26 at 2:15 PM, the Wound Care Nurse said she should have cleaned Resident #1's wound bed to the coccyx region before applying the triad paste. The Wound Care Nurse said by not cleaning the resident wound bed first place the resident was at risk for infections. The Wound Care Nurse said she was nervous and therefore made a mistake. Interview on 07/21/26 at 4:07 PM, the DON said when the Wound Care Nurse assisted the Wound Care Doctor with wound rounds, the Wound Care Nurse should have cleaned Resident #1's wound bed to the coccyx area before applying the triad paste to prevent infections to the wound. Interview on 07/21/26 at 4:22 PM, the Wound Care Doctor said a resident with a wound, the wound needed to be cleaned first. The Wound Care Doctor said it was best to clean wounds prior to applying any treatment to prevent infections to the wound. Record review of the facility's policy on Infection Prevention and Control Program, revised in April 2025, reflected in part: .The Infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.Goals: recognize infection control practices while providing care.

Based on observation, interview and record review the facility to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. 1.The facility failed to ensure divided plates, bowls, and cups with dried food particles and water were not stored with clean plates, bowls and cups. 2. The facility failed to ensure clean knives, fork and spoons were free of food dried food particles, and water stains. 3. The facility failed to ensure the dry storage room was free of dented cans.4. The facility failed to ensure the oil in the deep fat fryer was not black. 5. The facility failed to ensure the floor of the dry storage room was free of dust and black substance. These failures could place residents at risk of foodborne disease and other illnesses. Observation during initial tour on 4/22/2026 at 6:35 AM to 7:00AM of the facility's kitchen with [NAME] A and the Dietary Manager revealed the following: -Divided plates with water and food stains in them. -Knives forks and spoons with dry food particles and water stains on them.-Cups, bowls and plates had dry food particles and food stains on them.-The oil in the deep fat fryer was black. Observation on 4/22/2026 at 6:55 AM of the food pantry revealed one dented can of 6.5lbs sliced apples. The floor of the food pantry had dust, dirt and black substances in the corner. The Dietary Manager took the broom, mop and mop bucket and began cleaning the floor. In an interview on 4/22/2026 at 6:40AM with [NAME] A, she said the afternoon staff was the one who cleaned the dishes. She said she was going to remove all the divided plates and clean them. The dishes were brought to the dish room to be rewashed. In an interview with the Dietary Manager on 4/22/2026 at 7:05 AM, the Dietary Manager said the black substances on the floor was due to the condensation from the walk-in Cooler and freezer. She said they were working to get the issues corrected. Interview on 4/24/2026 at 1:30 PM with the Dietary Manager and the District Manager revealed not having clean utensils and bowls and dishes could cause germs and residents could get sick. She said she was going to in-service the staff on kitchen sanitation. Record review of the policy and procedure for Sanitation and Food handling reflected. Sanitization can occur by means of application of heat or concentration of chemicals for enough time to reduce bacterial count on equipment and utensils. Once utensils and equipment have been cleaned and sanitized, they should be allowed to air dry. The use of towels may re-contaminate sanitized surface.

Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 19 residents (Resident #39) reviewed for medication. The facility failed to ensure Resident #39's thyroid medication was administered as ordered by the physician. This failure could place residents at risk of the body system slowing down resulting fatigue, weight gain, hair loss, fluid retention and decreased quality of life Record review of Resident #39's admission face sheet, dated 4/24/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), diabetes (high blood sugar), depression (mood disorder causing sadness), malnutrition (a condition where the body in not getting enough of the right foods) and hyperlipidemia (high levels of fat in the blood) hypothyroidism (a common condition where the thyroid is underactive failing to produce sufficient hormones to meet the body needs and anemia (sufficient red blood cells to carry oxygen to the tissues), Record review of Resident #39's quarterly MDS, dated [DATE], revealed Section C0500 coded the resident's as having BIMS score of 14, which indicated the resident was cognitively aware for decision making, For Section E: Behavior: The resident was coded as having no behaviors. Section H0300/0400: Bowel and Bladder, she coded as always incontinent. Record review of Resident #39's physician's order, dated 01/27/2026, revealed an order for Levothyroxine sodium oral tablet 125 mcg give 1 tablet by mouth one time a day for hypothyroidism at 5:30AM Record review of Resident #39's MARs for April 2026 revealed the following. April 2026 Levothyroxine was not documented as given at 5:30AM on 4/2/2026, 4/3/2026 and 4/4/2026. Further review of the nurse's notes revealed no documented reason why the medication was not held. Record review of Resident #39's clinical record for April 2026 revealed no documentation the doctor was notified the medication was not given for 3 days. In an interview on 4/24/2026 at 4:45 PM with the DON regarding Resident #39's Levothyroxine not documented as given for days, he said in nursing if it's not documented it was not given. Asked what could happen if the medication was not given, he said the resident could cause the levels to drop resulting in, fatigue, feeling cold and depressed. He said his expectations of the nurses were to ensure medications were given as ordered by the physician. He said he would be in-servicing the staff on documentation of medication administration. Interview with the Administrator on 4/24/25 at 5:10 PM, she stated that her expectation for medication pass was to be timely, accurate and zero errors. Record review of the facility's policy on Administering Medications revised April of 2025 reflected in part: .Medications are administered in a safe and timely manner, and as prescribed. Record review of the facility-provided policy titled Administering Medications, Revised dated 11/25/2017, reflected: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. The individual administering the medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 5%, based two errors out of 38 opportunities, which involved two of 2 residents (Residents #33 and #38) and 2 of 4 staff observed during medications administration reviewed for medication error. 1. The facility failed to ensure Medication Aide FF administered Resident #33 Prednisone (used to quickly reduce inflammation [swelling, heat and redness]) and suppress and overactive immune system, as ordered by the Physician on 4/22/26.2. The facility failed to ensure Medication Aide RR administered Resident #38's Finasteride (drug use for enlarge prostate) as ordered by the Physician on 4/22/26.These failures could place residents at risk of side effect and a decrease in quality of life. Finding include: 1. Record review of Resident #33's face sheet, dated 04/24/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #33 had diagnoses which included lobar pneumonia (a serious bacterial infection that causes intense inflammation and fills an entire section [lobe] of the lung with fluid and pus), heart failure (a chronic condition where the heart muscle becomes too weak or stiff to pump blood efficiently, failing to meet the body' s need for oxygen), essential (primary ) hypertension ( high blood pressure) and chronic kidney disease (long -term condition where the kidneys are damaged and gradually lose their ability to filter waste, toxins, and excess water from the blood.)Record review of Resident #33's Care Plan, dated 04/16/26, reflected the resident being care planned for at risk for heart failure. The intervention included administering Prednisone medication per physician orders.Record review of Resident #33's 5-day MDS, dated [DATE], reflected a BIMS score of 10, which indicated the resident cognition was moderately intactRecord review of Resident #33's Physician Order Summary Report reflected the following:- physician's order, dated 4/15/26, reflected prednisone Oral Tablet 2.5 MG (Prednisone) Give 1 tablet by mouth one time a day related to heart failure, Give with food in stomach -Order Date 04/15/2026.Record review of Resident #33's MAR for the month of April 2026 reflected Prednisone was being administered once a day at 9:00 AM. Record review of the facility menu for breakfast posted was from 7:00 AM to 8:00 AM.Observation and interview on 4/22/26 at 7:41 AM, of medication pass with MA FF revealed MA FF administered Prednisone 2.5 mg to Resident #33 on an empty stomach. Resident #33 said she had not eaten breakfast and MA FF said the breakfast tray would be out shortly and at 8:16 AM the breakfast for the hall was served to Resident #33.Interview with MA FF on 04/23/26 at 1:19 PM, she said she always checked blister packet if it was the right resident, medication, direction and expiration date and she said not giving medication as directed could mess up the resident stomach. 2. Record review of Resident #38's face sheet, dated 04/23/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and was re-admitted [DATE]. Resident #38 had diagnoses which included spinal stenosis ( a narrowing of the spaces within your spine ( backbone), hypertension (high blood pressure), benign prostatic hyperplasia (a common, noncancerous condition in aging men where the prostate gland enlarges) and urinary retention (difficulty urinating and completely emptying the bladder).Record review of Resident #38's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated the resident cognition was intact. Record review of Resident #38's Care Plan, dated 04/16/26, reflected the resident was care planned for at risk for benign prostatic hyperplasia ( a non cancerous, age-related enlargement of the prostate gland in men) with lower urinary tract symptom.Record review of Resident #38's Physician Orders for the month of July 2025 reflected the following order- Dated 6/11/25 Finasteride Oral Tablet 5 MG (Finasteride) Give 1 tablet by mouth one time a day related to benign prostatic hyperplasia with lower urinary tract symptomRecord review of Resident #38's MAR for the month of April 2026 reflected Finasteride 5mg was being administered once a day at 9:00AM.Observation on 04/23/26 at 9:05 AM of medication pass for Resident #38 by MA RR, she punched Finasteride 5mg twice (10 mg) in the medication cup and other medications totaling 16 tablets and administered to Resident #38 by mouth. Interview with MA RR on 4/23/26 at 1:11 PM, regarding punching Finasteride 5 mg twice, MA RR denied it, stated you wrote it wrong, I was very careful. She said we both counted the total medication administered was 16 tablets. Medication Aid RR said she had been working at the facility for 3 years and been a medication aid for 20 years and she had been very careful. Medication RR said it was the nurses who did observation of medication pass with her but could not remember the last time this was done and who the nurse was that did the medication pass competency with her. Interview on 04/24/26 at 2:42 PM with the DON said the medication aids did skill competencies annually and was trying to do it quarterly as well. The DON said it was the ADON who observed medication pass with the medication aides randomly once and sometime twice weekly. The DON said not administering medication as ordered could cause serious side effects. The DON said her expectation for medication was for nurses to avoid a negative outcome for the residents. Interview with the Administration on 4/24/25 at 5:10 PM, she stated her expectation for medication pass was timely and accurate and zero errors. Record review of the facility's policy on Administering Medications, revised April of 2025, reflected in part: .Medications are administered in a safe and timely manner, and as prescribed. Record review of the facility-provided policy titled Administering Medications, revised dated 11/25/2017, reflected: Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame.7. The individual administering the medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed to act upon pharmaceutical recommendation to assured the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 6 residents (Residents #60) reviewed for pharmaceutical services. The facility failed to act upon pharmacy recommendations on 2/25/26 for Resident #60 on Calcium Carbonate (Antacid medication used for heartburn) to be given as needed. Calcium Carbonate was administered daily on 4/22/26.This failure could place residents at risk of adverse drug reaction and could result in diminished health and well-being. Findings include: Record review of Resident #60's face sheet, dated 04/22/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #60 had diagnoses which included: cognitive communication deficit, gastroesophageal reflux disease (GERD), gastric ulcer ( gastric reflux) and hypertension (high blood pressure). Record review of Resident #60's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated the resident cognition was moderately intact. Record review of Resident #60's Care Plan, dated 04/16/26, reflected the resident being care planned for at risk for free from discomfort, complications or s/s (sign/symptom) related to dx (diagnosis) of GERD Record review of Resident #60's Physician Orders for the month of 11/18/25 reflected the included the following orderDate Order Summary:11/17/25 Tums Oral Tablet Chewable 500 MG (Calcium Carbonate (Antacid),Give 2 tablet by mouth one time a day for GERD.- Record review of the facility Drug Regime review date February 25, 2026, reflected Recommended: - Further review revealed pharmacy recommendation for reducing the Tums to PRN (Calcium carbonate can cause acid rebound) was not done.- Record review of Resident #60's MAR for the month of April 2026 reflected Pantoprazole 40 mg PO ( by mouth) QD, (Calcium Carbonate (Antacid Chewable Tums 2 tabs PO QD was being administered once a day at 9:00AM and Famotidine 20 mg BID was being administered twice a day at 9:00AM and 5:00 PM.Observation on 04/23/26 at 7:55 AM of medication pass for Resident #60 by MA FF, Antacid Chewable Tums 2 tabs PO was administered to Resident #60 by MA FF.Interview with the DON on 4/24/26 at 2:46 PM, regarding Pharmacy recommendation for Calcium Carbonate (Antacid Chewable Tums 2 tabs PO QD on 2/2026 to be given to Resident #60 as as needed or PRN, the DON said it was oversight. He said it was his duty and the ADON's to monitor the pharmacy drug review. The DON said he would be the RN's involved to ensure all pharmacy recommendations were to be followed up. Record review of the facility medication regimen policy statement dated 7/1/2018The Consultant Pharmacist shall review the medication regimen or each resident at least monthly. Policy Interpretation and ImplementationThe Consultant Pharmacist will perform a medication regiemen review (MRR) for every resident in the facilityRoutine reviews will be done monthlyReviews for short stay individuals( those who are expected to stay for 30 days or less) will be done as needed to identify individuals with high-risk medications and those who may be experiencing adverse consequences from their medications.4. Additional reviews for long-stay individuals will be done as indicated or as requested by the physician and staff to help manage drug regimens and identify and address suspected or confirmed adverse consequences.5.The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. 6. As part of the MRR,the Consultant Pharmacist will: a. Evaluate whether any medications in a drug regimen present potentially significant drug-drug or drug-food interactionsb. Determine if the resident is receiving the correct medications as ordered.c. Determine if medications are administered at the prescribed items.d. D if medications are administered in the correct dosage and form.e. Be alert to medications with potentially significant medication-related adverse consequences and to actual signs and symptoms that could represent adverse consequences, andf. Identify medication errors, including those related to documentation. 7.The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report.8. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the physician directly to report the information to the physician and will document such contacts. If the physician does not provide a pertinent response, or the consultant pharmacist identifies that no action been taken, he/she will then contact the Medical Director, or-if the Medical Director is the Physician of record -the Administrator. 9. The Consultant Pharmacist will provide the Director of Nursing services and medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions.

Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 0f 5 residents ( Resident #39's and Resident #9) reviewed for comprehensive care plans. 1.The facility failed to ensure Resident #39's care plans were revised to address her psychosocial well-being, communication and incontinence.2. The facility failed to incorporate Resident #9's immediate mental health needs, and diagnosis of depression, into the care plan. This deficient practice could place residents at risk for unmet psychosocial needs, lack of appropriate interventions, and potential decline in mental health statusRecord review of Resident #39's admission face sheet, dated 4/24/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), diabetes (high blood sugar), depression (mood disorder causing sadness), malnutrition (it is a condition where the body in not getting enough of the right foods) and hyperlipidemia (high levels of fat in the blood) and anemia (sufficient red blood cells to carry oxygen to the tissues), Record review of Resident #39's quarterly MDS, dated [DATE], revealed Section C0500 coded the resident's had a BIMS score of 14 which indicated the resident was cognitively aware for decision making, For Section E: Behavior: The resident was coded as having no behaviors for Section GG: ADL's were coded for eating, oral hygiene and personal hygiene as needing set up only. For toileting and putting on or taking off shoes, she was coded as dependent on staff with 2 persons assisted, for upper body dressing, shower/bath, taking off footwear she needed maximal assistance from staff. Bowel and Bladder, she coded as incontinent of bladder and bowel. Observation on 4/22/2026 at 7:45 AM of Resident #39 revealed she was up in bed. She was alert and oriented and could make her needs known. She was clean and groomed with no lingering odor. In an interview on 4/23/2026 at 1:30 PM with Resident #39 regarding the care and services she received, she said she had no problems getting a shower. She said when she was up, she had to wait for a long time for them to put her back to bed. She said she was never abused or neglected by the staff. Record review of Resident #39's care plan, dated 1/27/2026, revealed her care plan did not address triggered areas of communication, incontinence and psychosocial well-being. Interview on 4/24/2026 at 2:28 PM with MDS Coordinator revealed she was the only person who did the MDS and care plans. She said care plans were completed quarterly, annually and when there was a change in condition. She said she did not realize Resident #39's care plan did not address all triggered areas of Resident 39's MDS. She said she did not know why it was not done. She said she just missed it. At that point she said she was going to update Resident #39's care plan to address the triggered areas on her MDS. In an interview on 4/24/2026 at 5:15PM with the DON, he said it was the MDS Coordinator's duty to assess the resident triggered areas of the care plan, and if there were any new issues, she should address it on the care plan. He said he was going to in-service staff and complete an audit of the care plans. Record review of Resident #9's face sheet, last captured on 04/22/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included myopathy (a disease that cause muscle fiber dysfunction resulting in voluntary skeletal muscle weakness), unspecified dementia (memory loss), adjustment disorder with depressed mood (a short-term related condition occurring within three months of life change or event), epilepsy (involuntary movement), hypertension (high blood pressure), heart disease (disease of the heart that damage the heart structure), and kidney disease (gradual loss of kidney function). Record review of Resident #9's MDS, dated [DATE], indicated she required supervision or touching assistance for most ADLs such as dressing, footwear, and toileting. Resident #9 had depression listed as one of her active diagnoses within the last seven days. Her mood interview (Section D) revealed she had been feeling down, depressed, and hopeless for several days. Record review of Resident #9's care plan, dated 03/17/2026, did not include a focus, goal, interventions, or tasks for her mood or diagnosis of depression. Record review of Resident #9's MAR revealed she was taking Citalopram 20 mg once daily for major depressive disorder, which had been ordered on 03/04/2026. Interview with Resident #9 on 4/22/26 at 10:05 a.m. revealed she cried and stated, I don't like it here, I want to go home. She said she felt alone and most of her family members were gone. Resident #9 stated she had not spoken to her nurses or doctor but reported a family member told her she had to stay at the facility. She stated, I'm not crazy. Resident #9 stated the staff talked about her behind her back and she did not trust anyone. She did not recall what was said about her or why she felt that way. The resident stated, no, they better not! when asked if she had experienced any abuse or neglect while at the facility. During an interview with the MDS Coordinator on 4/24/26 at 11:25 a.m., she was asked whether Resident #9's diagnosis of major depressive disorder had been care planned. The MDS Coordinator reviewed the care plan and acknowledged the diagnosis had not been included. She stated, I see what you mean, and she would revise the care plan that day. When asked about the risk of not adding depression/mood to the care plan, she replied, staff wouldn't be aware of her diagnosis or how to address it, and stated it could lead to a negative outcome. During an interview with the LVN on 4/24/26 at 12:50 p.m., she was asked about Resident #9. The LVN described Resident #9 as sassy and reported she mainly stayed to herself and was not as active as she had been previously. The LVN stated Resident #9 was admitted on [DATE] and she noticed a decline since then. She reported Resident #9 was not as outgoing as before and did not participate in activities. The LVN stated she noticed the change after Resident #9 was informed she would not be leaving the facility. She explained the resident believed she would leave in a couple of months but later learned her apartment had been cleaned out and she would remain at the facility. The LVN stated she believed this was the reason for the change in Resident #9's mood. During an interview with the Administrator and DON on 4/24/2026 at 4:46 p.m., they were asked about the potential harm of not adding a depression diagnosis to the comprehensive care plan. The DON stated, direct care staff would not know the resident suffered from depressive disorder and would not know the medication she would be taking for it, or the side effects associated with the medication. The DON said care plans were completed by the MDS coordinator who would review the doctor's orders and add them to the care plan within 48 hours. At that point the DON said he did not know why depression was not added to Resident #9's care plan. Record review of the facility's policy on Care Planning, last revised 03/01/2022, read in part:Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). 2. The care plan is based on the residents' comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The residents' Attending Physician. b. The Registered Nurse who has responsibility for the resident. c. The Dietary Manager/Dietician. d. The Social Services Worker responsible for the resident. e. The Activity Director/Coordinator; f. Therapists (speech, occupational, recreational, etc.), as applicable. g. Consultants (as appropriate). h. The Director of Nursing (as applicable). i. The Charge Nurse responsible for resident care. j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the residents. 3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of the day for the residents and family. Social Services or Designee must document this effort as a progress note in Point Click Care. 5. The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan (e.g., face-to-face, teleconference, written communication, etc.) is at the discretion of the Care Planning Committee.

Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents for one of 6 residents (Resident #13) reviewed for laboratory services. The facility failed to ensure the facility followed the Pharmacy review recommended labs (Vitamin D level and Lipid panel) be drawn for Resident #13. 2. The facility failed to ensure the order for labs was forwarded to the lab services.These failures could place the resident at risk for staff not having diagnostic information, placing the resident at risk for decline in health. Findings included:Record review of the admission Record for Resident #13, dated 04/23/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included, but were not limited to, Alzheimer's Disease (cognitive decline), muscle wasting (decreased ability to use muscles), and age-related physical debility (decreased ability to move associated with aging).Record review of Resident #13's Quarterly MDS assessment, dated 01/19/2026, revealed she scored 7 of 15 on the BIMS, indicative of severely impaired cognition. Record review of Resident #13's Care Plan, dated 10/15/2025, revealed the facility nurses were to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of Resident #13's Drug Regimen Review, dated 03/26/2026, revealed the Pharmacist recommended the following labs: Vitamin D level and lipid panel (blood test to measure cholesterol). Record review of the facility's Pharmacy Recommendation Letter Record Log for the Month of March revealed the physician agreed with the pharmacist's recommendation for the labs. Record review of a NN, dated 04/10/2026 at 12:06 p.m., revealed the physician ordered Resident #13 had the following labs drawn: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipid Panel, and Vitamin D level. The NN was written by LPN J. Record review of Resident #13's Physician's Orders (04/23/2026) revealed no orders for the CBC, CMP, Lipid Panel, or Vitamin D labs. Record review of Resident #13's electronic medical chart revealed no results of CBC, CMP, Lipid Panel, or Vitamin D labs, dated post 04/10/2026.In an interview on 04/23/2026 at 2:40 p.m., LPN J said she was in charge of Medical Records. She said when a pharmacy recommendation was received, it was sent to the physician to approve or disagree. LPN J said the facility received the response from the physician on 04/10/2026. She said the labs for Resident #13 were ordered, and she would obtain the results and enter them into the electronic chart.In an interview on 04/23/2026 at 3:35 p.m., LPN J said the lab orders for Resident #13 had not been forwarded by the facility to the lab company. She said she did not know why the orders were not forwarded. She said she would contact the physician and order the labs. She said a negative outcome for the resident could be the levels would be incorrect.In an interview on 04/23/2026 at 4:20 p.m., the DON said a negative outcome for the resident would be potentially critical lab levels could go unnoted. Record review of the facility's policy Lab and Diagnostic Test Results - Clinical Protocol (revised 06/04/2012) revealed 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #8) observed for infection control. LVN A did not sanitize her hands before wearing gloves and wore gloves taken from her pocket before performing direct care for Resident #8 on 03/19/2026. These failures could place the residents at risk of cross-contamination and development of infection. Record review of Resident #8's face sheet last captured 03/19/2026 reflected a [AGE] year-old female originally admitted on [DATE] with medical diagnoses including hypertension (high blood pressure), lobar pneumonia (infection that causes inflammation of the air sacs in the lungs where they may fill with fluid or pus and cause symptoms like cough, fever, chills and difficulty breathing), rheumatoid arthritis (a chronic autoimmune disease affecting the joints and can cause pain, swelling, stiffness and other body systems), and atherosclerotic heart disease of native coronary artery without angina pectoris (when there is a buildup of fatty deposits in the heart's arteries, leading to reduced blood flow to the heart muscles and does not have symptoms of chest pain).Record review of Resident #8's functional abilities and goals dated 03/04/2026, she required partial to moderate assistance for eating, oral hygiene and was totally dependent on staff for other ADLs such as dressing, footwear and toileting. Resident #8 required substantial to maximal assistance for bed mobility like sitting to lying, lying to sitting on the side of the bed, and rolling left and right.Record review of Resident #8's care plan last captured 03/19/2026, indicated she was at risk for UTI and upper respiratory infections related to her admitting diagnosis of UTI and lobar pneumonia with interventions including treatment/medications as ordered and indicated. Resident #8 was receiving oxygen therapy due to a plethora catheter (a type of tube that helps drain recurring fluid buildup between the lungs and chest cavity) to the right chest with interventions including having the catheter be changed by the hospice nurse every two to three days and monitor for s/sx of respiratory distress and report to the MD PRN such as respirations, increased heart rate, lethargy, confusion, cough and skin color. Resident #8 was also care-planned for being on hospice services related to her atherosclerotic heart disease and at risk for shortness of breath, anxiety and pain related to this diagnosis with interventions including administer medications as per order, monitor, reassess, if indicated report to the MD. Observation and interview with Resident #8 on 03/19/2026 at 9:30 a.m., Resident #8 was in bed, with head turned to the left side. Resident #8 said something was stuck in her throat and ran her right hand from top to bottom of neck, indicating where she felt discomfort. LVN A was told about Resident #8's situation in the hallway. LVN A stood in the hallway and did not sanitize her hands before taking gloves out of the box on her medication cart. She put the gloves in her left pant pocket, then proceeded to wear a gown. LVN A then took the gloves out of her pocket and wore them before entering Resident #8's room. LVN A asked Resident #8 about her discomfort and took a tissue paper and placed it near Resident #8's mouth and instructed her to try to spit out whatever was stuck in her throat. Resident #8 coughed and produced some greenish phlegm and LVN A used the tissue to wipe the phlegm from Resident #8's mouth and discarded the tissue. Interview with LVN A on 03/19/2026 around 9:50 a.m., LVN A said that she should not have taken gloves out from her pocket and worn them for resident care since that could be an infection control issue but said that since Resident #8 did not have a wound that was draining, she was on hospice, so it was not as bad. LVN A said that if there was a resident with an open wound, she would have used fresh gloves from her cart. Interview with the IPN on 03/19/2026 at 12:13 p.m., she said that LVN A should have thrown the gloves away once it had been in her pocket and that she should not have worn it to provide care. The IPN said that with the type of care LVN A provided it would not have been bad and that she would look into whether gloves could be used if they had been in a nurse's pocket, but that nurses should take a new pair from the box. The IPN said LVN A should have sanitized her hands before wearing PPE. As of exit, the IPN had not provided a response as to whether it was okay for LVN A to take the gloves from her pocket before providing direct resident care.Interview with the DON on 03/19/2026 at 3:57 p.m., the DON said nurses should sanitize their hands before wearing gloves and that they should not use gloves that had been in their pockets since that was an infection control issue. Infection control practices and enhanced barrier precaution protocols were to protect residents. Interview with the Administrator on 03/19/2026 at 4:20 p.m., she said not sanitizing hands before putting on gloves and taking gloves from the pocket to use before resident care could cause cross-contamination. Record review of the facility's policy on PPE for gloves last revised 07/17/2012 read in part, . Miscellaneous 1. When gloves are indicated, use disposable single-use gloves. When to Use Gloves1. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin;2. When the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis, etc.;3. When cleaning up spills or splashes of blood or body fluids;4. When cleaning potentially contaminated items; and5. Whenever in doubt.Record review of the facility's policy on PPE for gowns last revised 07/17/2012 read in part, Procedure GuidelinesPutting on the Gown1. Obtain the gown (disposable or reusable).2. If long sleeves are being worn, roll the sleeves above the elbows.3. Wash hands.4. Unfold the gown so that the opening is at the back.5. Put your arms into the sleeves of the gown.6. Fit the gown at the neck.7. Secure at the neck (tie or Velcro).8. Overlap the gown at the back. Be sure clothing is completely covered.9. Secure at the waste (tie or Velcro).

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #55) reviewed for supervision. -Resident #55 was observed with a skin tear on 02/04/2025 which she stated resulted from a CNA transferring the resident into bed. This failure could place residents at risk of being injured from being improperly transferred. Findings included: Record review of Resident #55's face sheet last captured on 02/06/2025 revealed an [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included Parkinson's Disease (a degenerative neurological disease-causing loss of motor function control), osteoarthritis (inflammation and pain at joints), hypertension (high blood pressure), vertigo (dizziness), intervertebral disc degeneration lumbar region (lower spine bone loss), muscle weakness, and general pain. Record review of Resident #55's Comprehensive MDS (a resident assessment tool) dated 11/13/2024 revealed a BIMS (Brief Interview for Mental Status) score of 15, meaning she was cognitively intact. Resident #55 was usually able to make herself understood and usually understood others. Resident #55 was documented having a wheelchair. She required some supervision with toileting and upper body dressing and partial assistance with transferring from the chair to bed and bed to chair and going to the toilet. Record review of Resident #55's care plan last reviewed 11/26/2024 revealed on 11/10/2023 she had an initiated focus area for being at risk for falls related to vertigo, muscle weakness and muscle spasms, with interventions including educating resident on using call light for assistance with ADLs and transfers and being monitored frequently for unspoken needs. Record review of Resident #55's progress notes revealed no documentation regarding her bruising or skin tear. Record review of Resident #55's weekly/monthly skin evaluation completed on 01/12/2025 revealed no skin concerns and no pain. Record review of Resident #55's Physician Orders revealed she had an order for monthly skin assessment every shift for one month starting on the 12th for 1 day with an order date of 03/14/2024. Record review of Resident #55's TAR (Treatment Administration Record) for January and February 2025 revealed she had no orders related to a skin tear or bruising. Record review of the facility's Incident and Accidents from 08/05/2025 to 02/05/2025 revealed no record of injuries for Resident #55. Observation and interview with Resident #55 on 02/04/2025 at 9:38 a.m., Resident #55 said she was doing well, and that staff treated her well. She was observed having a reddish bruise with purple outline on her left outer forearm shaped like a half-moon and had two white strips taped over another part of the bruise at the center of her forearm with a short black line drawn connecting both strips. The bruising appeared to be healing. She denied pain from the bruise. Resident #55 said she got the injury when a CNA was helping her from her wheelchair to the bed. The CNA told Resident #55 to hug her to help with the transfer and when Resident #55 reached for the aide, the aide's nails scratched her arm. Resident #55 said this incident happened the previous week on 01/30/2025. She said she was not complaining and did not want to disclose the CNA's name. She said no one had done any treatment on the injury since it was bandaged that night. A later observation and interview on 02/06/2025 at 10:50 a.m., she said that staff told her the two strips would fall out on its own, and she said she got the injury due to staff taking her to the restroom at night and it must've been the staff member's jewelry or nails that scratched her. Interview with LVN B on 02/06/2025 at 11:43 a.m., she said she was the treatment nurse as well. LVN A said head-to-toe skin assessments are done after incidents, monthly as scheduled, or if residents are triggered for pressure sources. LVN A was not aware of Resident #55's skin tear and said she would look at it. LVN A said CNAs have shower sheets and if they notice anything they'll add it on there and that would be reviewed by the DON and treatment nurse. Interview with CNA A on 02/06/2025 at 01:43pm, she said she worked with Resident #55 on 02/06/2025 and said she saw the two strips on her left arm but could not remember when she noticed it. She denied doing any documentation on Resident #55 as she was not under CNA A's direct care that day. Attempted interview with CNA C on 02/06/2025, she documented on 2/2/25 at 12:21a.m., that Resident #55 had no skin issues. The phone number did not have voicemail capabilities and the phone call was not returned. Interview with CNA D on 02/06/2025 at 12:23 pm, she documented on 01/31/2025 at 9:59 p.m., that Resident #55 had no skin issues. CNA D said Resident #55 had no changes in condition that she was aware of. She said she saw Resident #55's skin tear after she returned to work. CNA D asked Resident #55 told her someone took her to the restroom and accidentally scratched her. CNA D said she did not ask for further details, but that Resident #55 was in her right mind and could tell who did it. CNA D documented she had no skin issues because Resident #55 already brought up her skin tear to someone else. Interview with RN A on 02/06/2025 at 12:01 p.m., she was the evening shift nurse on 01/30/2025 for Resident #55's hall. RN A was not aware of Resident #55's skin tear and that Resident #55 did not talk to her about it. Interview with MA A on 02/06/2025 at 12:16 p.m., she was the medication aide on 01/30/2025 for evening shift. MA A denied seeing any bruising or injuries on Resident #55 and that if she saw anything she would've reported it. Interview with CNA B on 02/06/2025 at 01:51 p.m., she was the evening and night aide on 01/30/2025 for Resident #55's hall. She said she did not notice any bruising or skin tears on Resident #55 that night. She said Resident #55 could vocalize her needs. Interview with LVN A on 02/06/2025 at 2:30 p.m., she was the night shift nurse on 1/30/2025 for Resident #55's hall. She said that she was not aware of Resident #55's skin tear. Interview with the DON on 2/6/25 at 12:29 p.m., he said that he first heard of the skin tear on 02/06/2025. In a later interview on 02/06/2025 at 03:19 p.m., he said a risk to residents from not recognizing and documenting a skin tear would be an infection could happen later on. Interview with the Administrator on 02/06/2025 at 11:30 a.m., the facility did not have a policy on skin assessments. At a later interview on 04:49 p.m., she said that if Resident #55 was scratched by staff, she expected that it should be reported up so the wound care nurse could treat it and see if the facility needed to do any further action on it. The Administrator said that changes in condition should be reported to the charge nurse, and that a risk of not reporting would be a resident's decline. Record review of the facility's Charting and Documentation policy statement last revised 03/01/2022 read in part, All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical records. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care, which included objective observations, treatments or services performed, and changes in the resident's condition and events.

Based on observation and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 1 (shared medication cart between Hall 100 and 300 ) of 4 medication carts reviewed for medication storage. - The facility failed to ensure the back of 100 and 300 hall medication carts did not contain eyedrops and nasal spray that were opened but not labeled with the resident's name and not dated. This failure could place residents at risk of adverse medication reactions and infections. Findings Include: During observation on 02/05/25 at 9:49 AM, the following medications were found in the medication carts for back of 100 and 300 hall with MA A: 1. Timolol ophthalmic solution USP 0.5% eyedrop open not dated 2. Dorzol/Timolol solution - eyedrop open and not dated 3. Brimonidine Solution 0.2 % eyedrop open and not dated 4. Fluticasone USP 50 mcg nasal spray open and not dated 5. Fluticasone USP 50 mcg nasal spray open and not dated 6. Fluticasone USP 50 mcg nasal spray open and not dated Interview with MA D on 2/5/25 at 10:00 Am, regarding above medication open and not dated, MA D said eyedrops and nasal spray should be dated when open to alert the nurse about how long it is good for 30 days. MA D said the MA's where responsible to date nasal spray and eyedrops when open Interview with DON on 2/5/25 at 5:15PM regarding the medication open not dated she said it should be dated when open for it effectiveness and when open it's should be good for 30 days . Requested for medication labels policy on 2/5/25 at 5:15 PM, 2/6/25 at 9:50 AM, 2:00 PM and at 4:30PM from DON and the Administrator, none provided before exit. According to the United [NAME] health trust, recommendations were that drops and ointments are used within one month (https://www.ghc.nhs.uk/wp-content/uploads/CHST-Expiry-Dates-of-Medication.pdf).

Based on observations, interviews, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 10 % based on 2 errors out of 28 opportunities, which involved 3 of 4 residents (Resident # 47, #53 and Resident #63) reviewed for medication administration. 1. MA D failed to administer Citalopram (antidepressants is used to treat depression) to Resident #47, according to physician orders. 2. MA D failed to administer Refresh tear Ophthalmic solution (used to treat dry eyes) to Resident #53. MA D used Resident # 36's Systane ( eyedrop used to lubricate the eyes and treat symptoms of dry eyes) to Resident # 53 These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. Record review of Resident #47's face sheet dated 2/4/25 revealed a [AGE] year-old female with an admitted [DATE]. Resident #47 had diagnoses which included: acute on chronic systolic (congestive) heart failure ( the left chamber of your heart responsible for pumping blood throughout the body is weakened over time and cannot squeeze hard enough to push out enough blood with each beat, causing symptoms like shortness of breath, fatigue and swelling in the legs) altered mental status, unspecified, age-related cognitive decline Record review of Resident #47's quarterly MDS dated ,d+[DATE]//24, BIMS score was not checked, which indicated the resident was severely impaired cognitively. Record review of Resident #47's current physicians orders revealed an order with a start date of 2/3/25, for Citalopram tab 10 mg 1 tablet po by mouth one time per day for anxiety at 08:00 AM. Record review of Resident #47's medication administration record (MAR) dated 2/3/25 reflected Citalopram tab 10 mg 1 tablet po by mouth one time per day for anxiety at 08:00 AM. MA D initialed as given on 2/4//25. During a medication administration observation on 2/4/25 at 8:20 AM for Resident #63, MA A dispensed one Citalopram tab 20 mg 1 tablet into a medication cup and administered the medication to Resident #47 by mouth. 2. Record review of Resident #53's face sheet dated 2/4/25 revealed a [AGE] year-old female with an admitted [DATE]. Resident #53 had diagnoses which included: multiple fractures of pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing, dry eyes and glaucoma. Record review of Resident #53's admission MDS dated ,d+[DATE]//24, BIMS score was 7, which indicated the resident was moderately impaired cognitively. Record review of Resident #53's current physicians orders revealed an order with a start date of 1/22/25, for Refresh tear ophthalmic solution (Carboxymethylcellulose Sodium Ophthalmic) instill 2 drop in each eye, two times a day for dry eyes. Record review of Resident #53's medication administration record (MAR) dated 2/3/25 reflected Refresh tear ophthalmic solution (Carboxymethylcellulose Sodium Ophthalmic) Instill 2 drop in each eye, two times a day for dry eyes. MA A initialed as given on 2/4/25. During a medication administration observation on 2/4/25 at 9:24 AM for Resident #53, MA D picked up Systane Lubricant and instill 1 drop to each eye for Resident #53 belonging a Resident #36. Interview with MA D on 2/6/25 at 9:45 AM regarding not giving the right medication and using another Resident's medication, she said it was medication error she should have checked it several times before giving and she was nervous. During an interview on 2/6/25 at 4:21 PM, the DON said he expected the medications to be given as ordered. He said the resident could suffer decline or adverse side effects. He expected both the medication aides to give the medications as ordered. He would have to in-service MA's. DON was asked what would happen when rights dose of medication not given , DON said if the right dose of medication was not given, Residents would not receive the right strength of the medication for its effectiveness He said the pharmacist observed MA's with medication administration last month and sometimes the cooperate nurse does. DON was asked for the in-services the pharmacist and the corporate nurse did for medication aide but was not provided before exit. During an interview on 2/6/25 at 5:10 PM, the Administrator said she expected the staff to administer the medications per the physician's order. She said she expected the medication aide to notify the nurse and medication aides so that the doctor can get the medication that appropriate form. She said she expected the correct medication to be given. She said the resident could suffer harm as a result of errors in medication administration. Interview Administration on 2/6/25 at 5:26 PM, she stated that her expectation for medication pass was timely and accurately, zero errors, but errors were to be reported immediately. She was made aware of the observe eye drop errors. Stated nursed used the wrong eye drops for Resident #53. The nurse said she made the error because the Surveyor makde her extremely nerve. She stated that the adverse effect of residents receiving the wrong medications can be different for each resident, dependent upon their diagnosis. Resident #53 had no adverse effects, checked with MD, no issue with the medication resident received. No issues post either. Staff has been in-served on policy for medication pass, and answered her questions. Requested for medication skilled check for MA A and MA D from DON but was not provided before exit. Record review of facility-provided policy titled Administering Medications, Revised dated 11/25/2017, revealed: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame. . 7. The individual administering the medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 of 6 residents (Resident #55) reviewed for resident assessments. -RN A failed to document pain level for Resident #55 on 1/30/2025 during the 2pm to 10pm shift. -Resident #55 was observed with a skin tear on 02/04/2025 that was not documented in her medical records. -Resident #55's Physician Orders for Calcium + Vitamin D (Calcium = used to help build and maintain bones and teeth. Vitamin D (Cholecalciferol = used for vitamin D deficiency = also used with calcium to maintain bone strength) did not match with their MAR when MA A failed to administer this medication according to Physician Orders. This failure could lead to a resident's decline in health due to incomplete reflection of a resident's current condition and failure to act on potential changes in condition. Findings included: Record review of Resident #55's face sheet last captured on 2/6/25 revealed an [AGE] year-old female originally admitted on [DATE]. Her medical diagnoses included Parkinson's Disease (a degenerative neurological disease causing loss of motor function control), osteoarthritis (inflammation and pain at joints), hypertension (high blood pressure), vertigo (dizziness), intervertebral disc degeneration lumbar region (lower spine bone loss), muscle weakness, and general pain. Record review of Resident #55's Comprehensive MDS ( a resident assessment tool) dated 11/13/2024 revealed a BIMS (Brief Interview for Mental Status) score of 15, meaning she was cognitively intact. Resident #55 was usually able to make herself understood and usually understood others. Resident #55 was documented having a wheelchair. She required some supervision with toileting and upper body dressing and partial assistance with transferring from the chair to bed and bed to chair and going to the toilet. Record review of Resident #55's care plan last reviewed 11/26/2024 revealed on 11/10/23 she had an initiated focus area for being at risk for falls related to vertigo, muscle weakness and muscle spasms, with interventions including educating resident on using call light for assistance with ADLs and transfers and being monitored frequently for unspoken needs. Record review of Resident #55's progress notes revealed no documentation regarding her bruising or skin tear. Record review of Resident #55's weekly/monthly skin evaluation completed on 1/12/2025 revealed no skin concerns and no pain. Record review of Resident #55's Physician Orders revealed she had pain evaluation every shift with a start date of 11/09/2023. Record review of Resident #55's TAR (Treatment Administration Record) for January 2025 revealed she was not assessed for pain levels during the evening shift on 1/30/2025, when she allegedly was scratched. There were no other concerns related to pain for the month. Observation and interview with Resident #55 on 2/4/25 at 09:38am, Resident #55 said she was doing well and that staff treat her well. She was observed having a reddish bruise with purple outline on her left outer forearm shaped like a half-moon and had two white strips taped over another part of the bruise with a short black line drawn connecting both strips. It appeared to be healing. She denied pain from the bruise. Resident #55 said she got the injury when a CNA was helping her from her wheelchair to the bed. The CNA told Resident #55 to hug her to help with the transfer and when Resident #55 reached for the aide, the aide's nails scratched her arm. Resident #55 said this incident happened the previous week on 01/30/2025. She said she was not complaining and did not want to disclose the CNA's name. She said no one had done any treatment on the injury since it was bandaged that night. A later observation and interview on 2/6/25 at 10:50am, she said that staff told her the two strips would fall out on its own, and she said she got the injury due to staff taking her to the restroom at night and it must've been the staff member's jewelry or nails that scratched her. Interview with LVN B on 2/6/25 at 11:43am, she said she was the treatment nurse as well. LVN A said head-to-toe skin assessments are done after incidents, monthly as scheduled, or if residents are triggered for pressure sources. LVN A was not aware of Resident #55's skin tear and said she would look at it. LVN A said CNAs have shower sheets and if they notice anything they'll add it on there and that would be reviewed by the DON and treatment nurse. Interview with CNA A on 2/6/25 at 1:43pm, she said she worked with Resident #55 on 2/6/25 and said she saw the two strips on her left arm but could not remember when she noticed it. She denied doing any documentation on Resident #55 as she was not under CNA A's direct care that day. Attempted interview with CNA C on 2/6/25, she documented on 2/2/25 at 12:21am that Resident #55 had no skin issues. The phone number did not have voicemail capabilities and the phone call was not returned. Interview with CNA D on 2/6/25 at 12:23pm, she documented on 1/31/25 at 9:59pm that Resident #55 had no skin issues. CNA D said Resident #55 had no changes in condition that she was aware of. She said she saw Resident #55's skin tear after she returned to work. CNA D asked Resident #55 told her someone took her to the restroom and accidentally scratched her. CNA D said she did not ask for further details, but that Resident #55 was in her right mind and could tell who did it. CNA D documented she had no skin issues because Resident #55 already brought up her skin tear to someone else. Interview with RN A on 2/6/25 at 12:01pm, she was the evening shift nurse on 01/30/2025 for Resident #55's hall. She stated that she documented pain for Resident #55 on PCC (Point Click Care, a medical records system) and that when staff ask Resident #55 how she is doing she always said she was fine. RN A said that if pain levels are not documented, the pain could increase for a resident and staff would not be aware about the pain in order to treat it. RN A was not aware of Resident #55's skin tear and that Resident #55 did not talk to her about it. Interview with MA A on 02/06/2025 at 12:16 p.m., she was the medication aide on 01/30/2025 for evening shift. MA A denied seeing any bruising or injuries on Resident #55 and that if she saw anything she would've reported it. Interview with CNA B on0 2/06/2025 at 01:51 p.m., she was the evening and night aide on 01/30/2025 for Resident #55's hall. She said she did not notice any bruising or skin tears on Resident #55 that night. She said Resident #55 could vocalize her needs. Interview with LVN A on 02/06/2025 at 2:30 p.m., she was the night shift nurse on 1/30/2025 for Resident #55's hall. She said that she was not aware of Resident #55's skin tear. Interview with the DON on 02/06/2025 at 12:29 p.m. he said that he first heard of the skin tear on 2/6/25. In a later interview on 2/6/25 at 3:19pm, he said a risk to residents from not recognizing and documenting a skin tear would be an infection could happen later on, and that pain assessments, including vitals and non-verbal signs of pain should be observed and done so that pain can be addressed in that moment. The DON said missing pain assessments should not happen and that staff have 24 hours to chart if they are aware of anything. Interview with the Administrator on 02/06/2025 at 11:30 a.m., the facility did not have a policy on skin assessments. At a later interview on 4:49pm, she said that if Resident #55 was scratched by staff, it should be reported so the wound care nurse could treat it and see if the facility needed to do any further action on it. The Administrator said that changes in condition should be reported to the charge nurse, and that a risk of not reporting would be a resident's decline. Record review of Resident #63's face sheet dated 2/4/25 revealed a [AGE] year-old female with an admitted [DATE]. Resident #63 had diagnoses which included: venous insufficiency (chronic peripheral = occurs when leg veins do not allow blood to flow back up to your heart), cystitis without hematuria ( inflammation of the bladder without blood in the urine), gastro-esophageal reflux disease without esophagitis ( back flow of stomach content or heartburn). Record review of Resident #63's quarterly MDS dated ,d+[DATE]//25 revealed a BIMS of 08, which indicated the resident was moderately impaired cognitively. Record review of Resident #63's current physicians orders revealed an order with a start date of 1/1/25, for Calcium 600 mg +Vitamin D10 mcg, 1 tablet by mouth one time per day for anemia at 08:00 AM. Record review of Resident #63's medication administration record (MAR) dated 1/1/25 reflected Calcium 600 mg +Vitamin D3.125mg, 1 tablet by mouth one time per day for supplement at 08:00 AM. MA A initialed as given on 2/4//25. During a medication administration observation on 2/4/25 at 8:20 AM for Resident #63, MA A dispensed one Calcium 600 mg +Vitamin D10 mcg 1 tablet into a medication cup and administered the medication to Resident #63 by mouth. During an interview on 2/6/25 at 4:21 PM, the DON said he expected the medications to be given as ordered. He said the resident could suffer decline or adverse side effects. He expected both the medication aides to give the medications as ordered. He said the medication aide should have notified the DON about the Calcium 600mg + D3.125mg not available in house and he would have reached out to the doctor about Calcium 600mg + D3.125mg order. He would have to in-service MA's. DON was asked what would happen when rights dose of medication not given , DON said if the right dose of medication was not given, Residents would not receive the right strength of the medication for its effectiveness He said the pharmacist observed MA's with medication administration last month and sometimes the cooperate nurse does. DON was asked for the in-services the pharmacist and the corporate nurse did for medication aide but was not provided before exit. During an interview on 2/6/25 at 5:10 PM, the Administrator said she expected the staff to administer the medications per the physician's order. She said she expected the medication aide to notify the nurse and medication aides so that the doctor can get the medication that appropriate form. She said she expected the correct medication to be given. She said the resident could suffer harm as a result of errors in medication administration. Interview with the Administrator on 2/6/25 at 5:26 PM, she stated that her expectation for medication pass was timely and accurately, zero errors, but errors were to be reported immediately. She was made aware of the observe eye drop errors. Stated nursed used the wrong eye drops for Resident #53. The nurse said she made the error because the Surveyor makde her extremely nerve. She stated that the adverse effect of residents receiving the wrong medications can be different for each resident, dependent upon their diagnosis. Resident #53 had no adverse effects, checked with MD, no issue with the medication resident received. No issues post either. Staff has been in-served on policy for medication pass, and answered her questions. Requested for medication skilled check for MA A and MA D from DON but was not provided before exit. Record review of the facility's Charting and Documentation policy statement last revised 03/01/2022 read in part, All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical records. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care, which included objective observations, treatments or services performed, and changes in the resident's condition and events. Record review of facility-provided policy titled Administering Medications, Revised dated 11/25/2017, revealed: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame. . 7. The individual administering the medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Residents #49) reviewed for indwelling catheters. -The facility failed to ensure Resident #49's Foley catheter (F/C) (tubing inserted into the bladder to drain urine) was placed below the bladder during incontinent care. These failures could place residents at risk for discomfort and urinary tract infections. Findings included: Record review of Resident #49's face sheet revealed an [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses were, dementia ( impaired ability to remember, think, or make decisions that interferes with doing everyday activities), with other behavioral disturbance, age-related cognitive decline, anxiety disorder, unspecified, benign prostatic hyperplasia (enlarged prostate gland) with lower urinary tract symptom, major depressive disorder ( a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), neuromuscular dysfunction of bladder ( A hollow organ in the lower abdomen that stores urine) and retention of urine. Record review of Resident #49's quarterly MDS assessment, dated 11/04/2023, revealed a BIMS score of 09 out of 15, which indicated the resident's cognition was moderately impaired. Resident #49's functional status revealed he required total assistance with one to two staff for bed mobility, transfer, dressing, and personal hygiene. Resident #49 was always incontinent of bowel and continent of bladder using a suprapubic catheter ( a medical device that helps drain urine from your bladder) Record review of Resident #49's care plan dated 11/07/2023 revealed the resident had ADL (activity of daily living) self-care performance deficit: Intervention included: the resident needed total assist with one to two person assistance with personal hygiene. It also revealed the resident had a suprapubic catheter related to neuromuscular dysfunction bladder and was at risk for increased urinary tract infections. Interventions included: Monitor/record/ report to MD (medical doctor) for signs and symptoms of UTI, pain, burning, blood tinted urine, cloudiness, and no output. Record review of Resident #49's care plan of on 1/19/2024 revealed he was treated for a UTI (Urinary Tract Infection) with antibiotic treatment (ABT) on following dates with their completed dates. ABT for UTI 8/5/23 completed on 8/10/23. ABT for UTI 8/20/23 completed on 8/27/23. ABT for UTI 10/25/23 at hospital. Observation during incontinent care on 01/19/24 at 10:53 AM with CNA A and CNA B revealed, Resident #49 was lying in bed with a suprapubic catheter. During incontinent care, CNA A placed the suprapubic catheter bag, with 225 cc of urine, ion the bed throughout the procedure. CNA A used wet wipes and did not clean around Resident # 49's buttocks. In an interview with CNA A on 1/19/24 at 11:10 AM, she stated she forgot to wipe the buttocks and should not have placed the catheter on the bed. She stated it was wrong because it could cause an infection. She stated she had training on infection control and forgot to place the catheter below the resident's bladder. In an interview with the DON on 01/19/24 at 3:30 PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with incontinent care. The DON said the catheter bag should not be place on the bed, it would result with urine in the bag flowing back in Resident #49's bladder and cause urinary tract infection. DON said C.NA A knew she should clean around the buttocks before placing a cleaned brief. DON said he would be performing more in-services for incontinent care. In an interview on 01/19/2024 at 3:35 PM, the Administrator stated his expectation was that the catheters were always placed below the bladder to prevent infection. Record review for CNA A's skilled checkoff list for incontinent care and F/C care revealed, she had an in-service on 11/14/2023 done by the DON. The policy requested for incontinent/catheter care did not address placement of the catheter bag with urine during incontinent care. The C.NA A competency checked dated 11/14/23: Perineal Care . Male: Cleanse pubic area across, wipe the rectal area and buttocks thoroughly . extending over the buttocks . changing area of wipe with each stroke. Wipe across sacrum.

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 01-17-24 at 9:10 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and the door was wide open. Interview on 01-17-23 at 9:20 am, with the Food Service Manager, she stated that the dumpster doors always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of facility's, revised 9/16/ 2016 Sanitation Policy Interpretation and Implementation revealed . 2.All garbage and rubbish must be kept covered. 5. Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin . 7. Outside Dumpster provided by garbage pick up service will be kept closed and free with surrounding litter.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen. 1. The facility did not keep baking sheets free of carbon build-up. 2. The facility did not keep steam pans clean. These failures could place residents who receive meals from the kitchen at risk for food borne illnesses. Findings included: During an observation and interview on 11/15/22 at 10:55 a.m. there were 5 large cookie sheets stacked together. Two had a dark brown substance build up on the outside and inside of the pans. There were two 1/2 sized cookie sheets stacked together. One had a dark brown substance build up inside the corners and along the outer edge. There were 4 large deep steam table pans stacked together. Two of the pans had a brown sticky substance and build up on the outer edge. The DM said she was not aware of the condition of the pans and would get them cleaned or replaced. DM said she did not realize the cookie sheets had the carbon build up on them. She said she would clean them. During an interview on 11/16/22 at 11:27 p.m., the DM said she was not able to get the cookie sheets and pans clean, so she was ordering new ones. According to the Texas Food Establishment Rules revised October 2015 S228.113. Cleaning of Equipment and Utensils. Equipment, food-contact surfaces, nonfood-contact surfaces, and utensils. (1) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (2) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations

Based on interview and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 1 resident (Resident# 65) reviewed for [CONDITION(S)] and for 4 of 5 months reviewed for in-room and one on one activities. 1. The facility did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The facility AD did not keep records of in-room and one on one activities for June, July, August, September, and October 2022. The AD did not have the records scanned into the EMRs. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 11/17/22 indicated Resident #65 was a [AGE] year-old male admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a care plan dated 04/01/22 indicated Resident #65 had [CONDITION(S)] and received [CONDITION(S)]. Record review of an admission MDS assessment dated [DATE] indicated Resident #65 received [CONDITION(S)]. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #65 received [CONDITION(S)]. Record review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/16/22 at 07:23 a.m. Resident #65 indicated he received [CONDITION(S)] three times a week on Tuesday, Thursday, and Saturday. He said he had no issues with his transportation to and from [CONDITION(S)]. During an interview on 11/17/2022 at 11:40 LVN A indicated she was unsure if there were supposed to be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/17/22 at 11:45 a.m. the DON indicated that there should have been an order in the batch orders for [CONDITION(S)] for any resident on [CONDITION(S)]. He indicated the order should include what days [CONDITION(S)] took place and his chair time. He indicated that the process for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He indicated the nurse who received the resident at the time of reentry would have been responsible for obtaining an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Record review of the in-room and one on one activities documentation indicated there was no documentation for July, August, September, and October 2022. During an interview on 11/15/22 at 10:30 a.m. the AD said she did not have the documentation of the In-Room and One on One Activity except for November 2022. During an interview on 11/17/22 at 11:16 a.m. the AD said she did not realize her documentation of one-on-one and in-room activities were part of the resident clinical record, so she did not keep copies. She said there were 8 residents who received one-on-one or in-room activities. Record review of the policy provided was not relevant to the lack of documentation. A policy for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interviews and record review, the facility failed to coordinate assessments for the PASARR program for 2 of 7 residents (Residents #20 and #14) reviewed for PASARR. The facility failed to re-screen Residents #20 and #14 for specialized mental disorder services after the residents received new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents with mental illness at risk for not receiving appropriate services and a decreased quality of life. Findings included: A face sheet dated 11/17/22 indicated Resident #20 was an [AGE] year-old female admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/07/22, a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . PASARR Level 1 Screening dated 08/18/21 Section C was answered No for mental illness, intellectual disability and developmental disability. A face sheet dated 11/17/22 indicated Resident #14 was an [AGE] year-old female admitted on [DATE] with an original admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . PASARR Level 1 Screening dated 04/01/2018 Section C was answered No for mental illness, intellectual disability and developmental disability. During an interview on 11/17/2022 at 09:52 a.m., the DON said the conference he was at was covering the psychosocial and PASARR. He said he realized that the PASARR 2 had not been done . He said going forward, he would be focusing more on PASARR and the evaluations for the residents and would make sure they were complete. He said he was responsible along with the MDS in making sure the PASARR screening was done correctly. During an interview on 11/17/22 at 11:03 a.m., the MDS Nurse said every resident must be screened for PASSAR when admitted . She said if the resident's PASARR was positive, it triggered in the portal. She said she then notified the DON, the Administrator, and the PASSAR Ccoordinator with LMHA. An email is also sent to the PASARR Coordinator. She said in a perfect world, she would have alerted the PASARR Coordinator that a PASARR Level 2 was needed, and an assessment needed to be done due to new diagnosis. During an interview on 11/17/22 at 12:36 p.m., the DON said they did not have a policy and procedure for PASARR. He said they followed CMS guidelines. He said he had also received information from the PASARR Coordinator with LMHA. On 11/17/22 at 12:38 p.m., an unsuccessfil attempt was made, by phone made to contact the PASARR Coordinator. A voice message was left.

Based on observation, record review, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation and storage. -The facility failed to ensure that open food and leftovers in the walk-in refrigerator and walk in freezer were labeled, dated, and sealed. - The facility failed to ensure the open food was not sealed and not expired in the dry pantry -The facility failed to ensure the walk-in refrigerator was in a safe operating condition. This deficient practice placed the residents at risk of exposure to foodborne illnesses The findings included: Observation on [DATE] at 7:02 a.m. in the walk-in refrigerator revealed the following: Water droplets dropping into a green bucket that was overflowing onto an open box of tomatoes and an open box of lettuce. 8 small medicine cups of yellow liquid - not dated, not labeled, and not covered/sealed Lunch meat - not sealed Observation on [DATE] at 7:03 a.m. in the walk-in freezer revealed the following: Open box of white frozen dough - not sealed Open box of meat - not dated, not sealed. Frozen bag of unknown food item - not dated, not labeled. Observation on [DATE] at 7:05 a.m. in the dry pantry revealed the following: Bag of dry potatoes - not sealed One 5-pound bucket of creamy peanut butter - best buy date [DATE], a date written in black marker on the side [DATE], another date written on the top [DATE] Interview on [DATE] at 7:07 a.m. with Dietary Aide A said he had worked in the facility's kitchen for 3 years. Dietary Aide A said he did not know about labeling or dating open food items. He said the cooks or the manager took care of that. Interview on [DATE] at 7:10 a.m. with Cook A said she had worked in the kitchen for at least a year. Cook A said open food or leftovers should be labeled, dated, and put in a sealed container or plastic bags that can be sealed. Cook A said food should be dated, sealed, and labeled so the food will not spoil and for anyone who comes into the kitchen would know how log to keep the food or throw it out. Cook A said all kitchen staff are responsible for labeling, dating and sealing open food items. Cook A said she usually looks through the refrigerator in the morning for food that needed to be thrown out and labeled, but she had not this morning because she was cooking breakfast. Cook A said the evening shift yesterday should have checked the food the day before. Cook A said she was not sure how long the condensation had been dripping onto the lettuce and tomatoes. Cook A later said she thought it had been at least a week that the condensation was dripping. Cook A said she would move the boxes from under the dripping condensation. Cook A said if something is not working, then maintenance should be notified, and he will either fix it or call a vendor to fix it. Interview on [DATE] at 8:38 a.m. with Dietary Manager (arrived after initial observation of the kitchen) said she or the staff emptied the bucket that the condensation had dripped and overflowed onto the tomatoes. The Dietary Manager said she was not sure why the bucket had overflowed and was dripping onto the food below. The Dietary Manager said maintenance was informed and they were waiting on the part to fix the part that had the condensation. The Dietary Manager said leftovers and open food items should be dated, put in a sealed container or zip lock bag to prevent spoilage. She said all food items should be labeled and dated. The Dietary Manager said all training for the kitchen is computer based. She said she did not have in-services. The Dietary Manager said everyone who worked in the kitchen is trained on food storage. Observation on [DATE] at 11:20 a.m. of the kitchen walk-in refrigerator revealed the box of tomatoes and lettuce remained under the dripping condensation. Interview on [DATE] at 11:22 a.m. with the Dietary Manager said she was off yesterday because she had worked the floor as an aide. She said she had not inspected the kitchen in the last day for food that needed to be discarded. Interview on [DATE] 11:24 a.m. with the District Manager said he visits weekly to the facility to inspect the kitchen. The District Manager said it was acceptable to move the tomatoes and lettuce that had condensation dripping on them from under the bucket and the food was edible. He said, the tomatoes and lettuce can be washed off and used. He said it was unusual to have had that many items not labeled or sealed. He said they should have to dry potatoes should have been sealed better that what they were to prevent the food from spoiling. The District Manager said the peanut butter should have been thrown out since he was not dated properly. He said all food items should be dated, labeled and sealed to prevent spoilage. The District Manager said it may be human error that the food was not sealed, dated and labeled. Observation on [DATE] at 11:40 a.m. in the walk-in refrigerator revealed the condensation continued to drip onto the tomatoes and lettuce. Interview on [DATE] at 11:41 a.m. with the Dietary Manager said the bucket was full again she would move the tomatoes and lettuce to another shelf. Interview on [DATE] 11:44 a.m. with Maintenance said the kitchen staff should inform him by filling out a work order as soon as they have identified something is not working properly in the kitchen. He said he received a maintenance work order on [DATE] that stated the refrigerator had a drip. He said the part is not allowing what is usually condensation that is drained to the outside and it now dripping into the walk-in refrigerator. He said the condensation is what travels through the coils and the fan and is supposed to drain on the outside. He said it goes thought the defrost and it cleans the condenser and should drop in the fan and then go outside. Interview on [DATE] at 12:28 p.m. with the District Manager for dietary said they later decided to discard the tomatoes and lettuce after deciding that there could have been other contaminates in the condensation. Record review of facility policy Food Storage-Cold (revision date [DATE]) revealed the following in part: Food Storage: Cold .Action Steps . 5. The Food Services Director/Cook(s) insures [sic] that ll food items are stored properly in covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination. Record review of facility policy Food Storage-Dry Good (revision date [DATE]) revealed the following in part: .Action Steps: Dry Storage . 3. The Food Services Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed.

Based on observation, record review and interview, the facility failed to post the daily nurse staffing data at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name, resident census, the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care at the facility for 4 days. The facility did not post the required staffing with hours worked daily on 8/28/2021, 8/29/2021, 08/30/21 and 8/31/2021. The last posted staffing information was 8/27/2021. This failure could place the residents, families, and visitors at risk of not having access to information regarding the daily nurse staffing data. Findings included: During observation on 8/31/2021 at 6:45AM, revealed a posting by the DON's office dated 8/27/2021. Observation and interview on 08/31/21 at 11:55AM, revealed a daily staffing posted by the DON's office dated 08/31/21. During an interview at this time, the DON said he was responsible for posting the daily staffing. He said he usually get to work between 8AM and not later than 9:00AM. He said he checked on the schedule to make sure that those who are scheduled to work are present then post the daily staffing. When asked who would post the staffing data in his absenc, he said no one. He said that was his responsibility. He said he worked Monday through Friday and sometimes on weekend. When asked about the missing 4 days, he said he was not aware that the daily staffing data was not posted on those days. During an interview on 08/31/21 at 1:00 PM, the DON said the facility does not have policy on posting the Daily staffing data.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 4 of 17 residents (Resident #162, #49, #36, and #35) reviewed for comprehensive care plans. -The facility failed to develop a comprehensive person-centered care plan for Resident #162. -The facility failed to develop a comprehensive person-centered care plan to include Resident #49's pacemaker. - The facility failed to develop a comprehensive person-centered care plan for Resident #36. - The facility failed to develop a comprehensive person-centered care plan for Resident #35. These failures placed residents at risk for not receiving care according to their individually assessed needs. Findings Included: #162 Record review of Resident #162's face sheet dated 8/31/2021 revealed she was an [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review (9/1/2021 at 11:12 a.m.) of Resident #162's baseline care plan was attempted, and it was revealed there was not a baseline care plan. Record review of Resident #162's Admission MDS dated [DATE] revealed Resident #162 had a BIMS of 5 which indicated severe cognitive impairment. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/31/2021 at 8:01 a.m. of Resident #162's room revealed a pacemaker transmitter in her room. It was not connected to a phone line. #49 Record review of Resident #49's face sheet dated 9/1/2021 revealed she was an [AGE] year-old male who was admitted originally on 4/23/2021 and most recent 8/2/2021. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #49's care plan last reviewed 7/14/2021 revealed the Resident #49's care plan addressed nutrition, anti-depressant, skin integrity, anti-anxiety, elopement, DNR code status, and fall risk. Presence of pacemaker was not listed in the care plan for Resident #49. Record review of Resident #49's MDS dated [DATE] revealed Resident #49's had a BIMS that was not indicated on the MDS. Presence of pacemaker was an additional active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #49's electronic record revealed Resident #49 had a pacemaker card (Implanted 3/22/2018) #36 Record review of Resident #36's face sheet dated 9/1/2021 revealed she was a [AGE] year-old female who was admitted on 2/22/2021. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #36's care plan last reviewed 7/14/2021 revealed the Resident #36's care plan addressed nutrition, hypertension, [CONDITION(S)], [CONDITION(S)], impaired visual, pain, anti-depressant, anti-anxiety, fragile skin, falls code status, ADL's, mood, physical mobility. Presence of pacemaker was not listed in the care plan for Resident #36. Record review of Resident #36's H&P dated 2/19/2021 revealed Resident #36's had a biventricular pacemaker implanted 5/2013. Resident #36 had a [NAME] device implanted 7/2/2018 (The [NAME] implant is a permanent heart device. The implant is designed to prevent blood clots caused by [CONDITION(S)] (A-fib) from getting into the bloodstream. A-fib prevents the heart from pumping blood correctly.) #35 Record review of Resident #35's face sheet dated 8/31/2021 revealed she was an [AGE] year-old female who was originally admitted on [DATE] and most recent 7/6/2021. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #35's care plan (date initiated 7/19/2021) revealed one focus area which was Resident #35's code status (full code) and it was created by RN E. Record review of Resident #35's Admission MDS dated [DATE] revealed Resident #35's had a BIMS that was not completed. Interview on 9/1/2021 at 12:37 a.m. with the RN E said all resident care plans should be updated quarterly, upon any significant change and within 7 days of admission. RN E said the care plans should be resident center to include care areas specific to the resident and address risk to be monitored. RN E said she did not have a reason why Resident #162's care plan, who was admitted on [DATE], was not completed. RN E said she was new to the position and had been the MDS coordinator for 2 months. She said she had tried to catch up on old care plans while she tried to keep up to date on the new one. RN E said she had been in touch with her corporate MDS consultant, but she had not been able to update all of the care plans in the 2 months she had been in the position. Interview on 9/1/2021 at 2:09 p.m. with the Corp. MDS said care plans should be completed within 7 days of admission into the facility. The Corp. MDS said she trained RN E initially when RN E started the position 2 months ago. The Corp. MDS said she talks to RN E by phone and said they follow the RAI and care plans facility policy. The Corp. MDS said the care plan should be resident centered to meet the care needs and risk of the resident. Interview on 9/1/2021 at 3:02 p.m. with the DON said he was responsible to ensure resident care plan was completed. The DON said it had been identified in June of this year that the care plans were behind and incomplete, and they were working on catching them up as a team. The DON said he could not explain why the new admissions had not been completed or updated. The DON said the care plan should be person centered, accurate and anything personal to that resident. The DOON said he and RN E along with the IDT should work together to complete care plans that address the needs of the residents and should be completed within 7 days of admission. Record review of facility policy Care Plans - Comprehensive (revised 8/2/2018) revealed the following in part: An individual Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . 4. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive (MDS). 5. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly and any significant change in status.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program designed to help prevent the development and transmission of disease and infection for 1 of 4 residents (Residents #21) reviewed for infection control, in that: CNA 30 failed to wash her hands after leaving contact isolation room. Resident #21's right heel infected pressure ulcers culture result indicated heavy growth of Staphylococcus aureus and Escherichia coli, Multi-drug resistant organism (MDRO) and ESBL producer and recommended that resident isolation which the facility did not consider. Resident #21 was taken off contact isolation and allowed to ambulate around the facility, interacting with other residents and staff with an ongoing infection [MEDICAL CONDITION] to her right heel pressure ulcers which had drainage and was not contained . Facility wound Care Nurse contaminated his gloves and Resident #21's wound bed during wound care . PPE cart kept inside of Resident #21's room was not immediately accessible upon entrance of the room. An Immediate Jeopardy (IJ) was identified on 9/13/2019. While the IJ was lowered on 9/17/2019, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of widespread because the facility continued to train staff and monitor the effectiveness of the plan of removal. These failures affected one current resident and placed all residents in the facility at risk of contracting infections and decline in their health. Findings included: Resident #21 Record review of Resident #21's face sheet revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Admission Braden scale for Resident #21 dated 06/21/2019 revealed a score of 16 indicating mild risk of developing pressure ulcer /injury. Record review of Resident #21's Progress Notes dated 6/21/2019 revealed [AGE] year-old female arrived via Non-emergent on stretcher. No discomfort or distress noted at this time. PERRL[NAME] VS T 98.2, P 72, R 18, BP 136/67, O2 @ 97% via RA, No pain noted at this time. Alert and oriented x4. Heart sounds strong and regular. Lung sounds clear in all lobes upon inspiration/expiration both anterior/posterior. Able to move all extremities without difficulty or discomfort. Toe touch weight bearing to right lower extremity due to right femur replacement. Skin clean, dry, and intact except for 3 incisions to right hip with 17 stitches in place. No s/s of infection present at this time. Bruising noted to left hand, right thumb due to IV, and right forehead. PT/OT/ST to evaluate and treat. Physician notified of arrival and orders. Resident oriented to room and roommate, as well as safety precautions reinforced. Currently up at bedside, call bell in reach Record review of Resident #21's Admission MDS dated [DATE] revealed she had a BIMS score of 13, which indicated intact cognition. MDS further revealed Resident #21 required extensive assistance with one-person physical assist for bed mobility, locomotion on unit, dressing, and bathing. Resident #21 required extensive assistance with two-person physical assist for transfers, toilet use and personal hygiene. MDS indicated Resident #21 used a wheelchair for locomotion/ambulation. Resident #21 was frequently incontinent of bladder and occasionally incontinent of bowel. Active [DIAGNOSES REDACTED]. MDS did not reveal any documentation of a pressure ulcer. Record review of Resident #21's Progress Notes dated 7/8/2019 revealed right heel noted with sdti measures 10.5cmx6.4cmx0cm, wound is closed at this time [MEDICATION NAME] applied and covered with protective foam dressing for comfort, heels floated. Physician notified and received orders for above treatment-attempted to notify emergency contact there was no answer at this time. will monitor and treat daily apt being made for physician clinic at next available apt . Record review of Resident #21's Care Plan dated 07/09/19 revealed Resident #21's skin was impaired related to stdi right heel. Wound care trimmed eschar areas revealing stage III to right heel. Staff are to follow protocols for treatment of [REDACTED].#21 at all times. Resident #21 had been seen scooting herself with her heels due to her weight bearing status possibly contributing to the wound formation. Educated Resident #21 on importance of not doing this. Resident #21 is to be on contact isolation. Record review of Resident #21's MDS dated [DATE] revealed she had a BIMS score of 15, which indicated intact cognition. MDS further revealed Resident #21 required extensive assistance with one-person physical assist for bed mobility, transfers, toilet use, personal hygiene and bathing. Resident #21 required supervision only for locomotion on the unit and dressing. MDS indicated Resident #21 used a wheelchair to ambulate. Resident #21 was occasionally incontinent of bowel and bladder. Active [DIAGNOSES REDACTED]. MDS indicated that Resident #21 had 1 stage III pressure ulcer and that 0 pressure ulcers were present upon admission/entry or reentry. Record review of Resident #21's Progress Notes dated 08/23/19 revealed right heel with stage III pressure ulcer measures 3.1cmx5.5cmx0.2cm, , wound bed is pink with 80/20 gran/slough, new orders for cleanse with ns apply [MEDICATION NAME] to peri tissue, silver cell and then bordered dressing Monday , Wednesday , Friday and prn. there is mod sero sang drainage. heels floated. continue to be followed at wound clinic weekly- will monitor and treat as ordered. plan of care discussed with resident is own r/p and gave verbalized understanding. Wound discussed in weekly IDT meeting this week. Will continue offloading heels and ensuring heel protectors in place. Resident on air mattress, receiving nutritional sub vit c and juven for healing aid. Physician called with orders for [MEDICATION NAME] for culture of right heel with ESBL and E.coli, resident notified, and med ordered Record review of Resident #21's physician orders [REDACTED].contact isolation every shift for heel wound start date 08/25/19. Record review of Resident #21's physician orders [REDACTED]. Change m-w-f and prn soiled or dislodged dressing. Every day shift every Mon, Wed, Fri related to pressure ulcer right heel unstageable start date 09/07/19. Record review of Resident #21's preliminary lab report collected 09/10/19 revealed preliminary finding that read in part . Preliminary #1 dated 9/11/19 at 10;58am revealed Heavy growth of presumptive Staphylococcus Aureus and Gram-negative bacillus. Preliminary #2 dated 9/12/19 at 11:14am revealed heavy growth of presumptive Staphylococcus Aureus and E. Coli, multi drug resistant organism (MDRO), ESBL producer. Patient isolation should be considered. Lab report indicated it was called in to the facility staff on 9/12/19 at 11:14am and was also faxed to facility. Record review of Resident #21's Lab Report dated 09/13/19 at 9 :24am revealed Microbiology Lab .Source .Wound, Site .right heel. Final Results .Heavy growth of presumptive Staphylococcus aureus and Escherichia coli, Multi-drug resistant organism (MDRO), ESBL producer, Patient isolation should be considered. Organism 1.Staphylococcus aureus, Organism 2.Escherichia coli Record review of Resident #21's physician orders [REDACTED]. Change daily except wed wound clinic will change and prn soiled or dislodged dressing. Every day shift related to pressure ulcer or right heal unstageable start date 09/12/19. Record review of Resident #21's physician orders [REDACTED]. Change m-w-f and prn soiled or dislodged dressing. Every day shift related to pressure ulcer of right heel, unstageable . Start date 09/13/19. Record review of Resident #21's Progress Notes dated 09/12/19 revealed Obtained results from culture. Provider contacted. Orders to discontinue isolation. Resident remains afebrile and has not mounted an elevated white count post-surgical procedure. Wound is without drainage, [DIAGNOSES REDACTED], foul odor. Board certified infection Prevention specialist review labs and wound condition with provider who is a certified wound care physician. Collaborative decision made to remove isolation and allow resident into community with intact dressing protected by boarder bandage Record review of Resident #21's Progress Notes dated 09/12/19 revealed Second call placed to physician regarding concern of not re-culturing wound. The IFCC discussed my concerns regarding all other residents and possibilities of this resident not healing well. He feels as if it is colonized d/t no s/sx of infection and does not feel she needs to be isolated. Physician agreed to re-culture on Monday. Stating it would not be beneficial to re-culture until Monday. Wound is covered at all times with a bandage, a sock, and a walking shoe. Resident is A&ox3 Observation on 09/10/19 at 9:28 AM of room [ROOM NUMBER] ( Resident #21's room ) revealed contact isolation sign on door, PPE cart was observed inside the resident's room requiring full entry into room to be accessible. There were biohazard bins open in the room without lids. Observation on 09/10/19 at 10:34 AM revealed Resident #21 was sitting in wheel chair, in bedroom. Resident had wrap on right foot, open shoe soft boot on foot. Resident in pleasant mood, biohazard bins in bedroom, open, no lid. In an interview on 09/10/19 at 10:33 AM CNA 12 stated Resident #21 was on contact isolation. She had a wound on her foot, but it is contained. Observation and interview on 09/10/19 at 11:00 AM revealed Resident #21 in wheelchair in physical therapy room with other residents and staff. Resident #21 said she goes to physical therapy multiple times a day and she wheels herself down to physical therapy using her feet as staff has removed foot pedals, so she can use her feet to propel. Resident #21 said she loves going to physical therapy several times a day as she is trying to build up her strength to go home. Observation on 09/11/19 at 3:15 PM revealed PPE cart inside the room, open biohazard bin in room. Observation on 09/11/19 at 3:30 PM revealed Resident #21 was walking down the hallway, with therapy. Resident had on an open toe soft boot, wound dressing covered back of heel. Observation on 09/12/19 at 10:58 AM revealed resident not in room, contact isolation PPE cart, bins, caution sign not in room. Interview on 09/12/2019 at 9:49 AM with LVN 8, she was asked where was the isolation cart for Resident #21's room. LVN #8 said Resident #21 was no longer on isolation because her right heel pressure wound culture came back negative. Observation on 09/12/2019 at 9:50 AM of wound care for Resident #21's right heel pressure wound, performed by Wound Care Nurse who was assisted by LVN #8 for Resident #21 revealed the following . LVN #8 put 2 small red biohazard bags at the foot of Resident #21's bed. Resident #21 had an ABD dressing to right heel wound that was moderately stained and wet with light yellowish with pink stint/ drainage . Wound Care Nurse confirmed moderate drainage of the wound on the dressing . Wound Care Nurse wiped wound with 4 x 4 gauze soaked in normal saline. LVN #8 then lifted a biohazard bag with her gloved hand and held it near Resident #21's right heel pressure ulcer so Wound Care Nurse could dispose of the soiled 4 x4 gauze. The biohazard bag held by LVN #8 touched the right heel pressure wound bed contaminating the wound. Wound care continued, and Wound Care Nurse wiped wound bed again with a 4 x 4 gauze soaked in normal saline and LVN #8, till holding the biohazard bag moved it towards Wound Care Nurse and when he disposed of soiled 4x4 gauze, his gloved hand went inside the biohazard bag and his gloved hand touched the inside of the biohazard bag. Wound Care Nurse continued with wound care and did not change gloves or wash hands following the contamination of his glove. Interview with LVN #8 on 09/12/2019 at 10:10 AM, she said that she did not realize that the biohazard bag had touched Resident #21's right heel wound bed. She said that she had been told it was ok to put the biohazard bags at the foot of the bed during wound care and thought it would be alright to hold the bag for the Wound Care Nurse. Interview on 9/12/2019 at 10:11 AM with Wound Care Nurse, he said that he did not realize during the wound care that his hand touched the inside of the biohazard bag. Wound Care Nurse was asked if he normally had someone hold the biohazard bag for him during wound care and he said no. Wound Care Nurse said that only the small biohazard bags were available so that is why they were put at the foot of the bed and LVN #8 held the biohazard bag for him during wound care. Observation on 09/12/19 at 11:30 AM in room [ROOM NUMBER] revealed contact isolation sign off door. No sign, no PPE cart or biohazard bins in the room. Observation and interview on 9/12/2019 at 12:10 PM revealed Resident #21 was sitting in bedroom with regular lunch tray. Interview with Resident #21 at same time, she said that staff deliver her food to the room daily, but they never put on a gown when they come in the room to deliver food. Resident #21 said she was confused as to why the isolation cart and biohazard bins were back in her room when she arrived in her room following therapy as she had been told the infection was clear. Surveyor asked if anyone had notified her of the final result from the heel culture and she said no. Surveyor asked if she would like a nurse to come in and explain why she was put on isolation and she said yes, please. Surveyor notified nursing staff. Observation on 09/12/19 at 12:11 PM revealed PPE cart in room, bio hazard bins open, at door way, contact isolation sign at door. Observation on 09/12/19 at 12:25 PM revealed CNA 30 go into Resident #21's room took out food tray and placed on cart. CNA 30 did not gown up or put on gloves, did not wash hands after leaving resident 21's room, then went into several other rooms to get lunch trays. Observation on 09/12/19 at 12:40 PM revealed LVN 5 walking down hallway with bio hazard bin and PPE cart from room [ROOM NUMBER]. Observation on 09/12/19 at 1:35 PM revealed Resident #21 wheeling down hallway, no shoes on feet, bandage on heel with tape, sock not covering heel. In an interview on 09/12/19 at 10:59 AM CNA 13 stated they did not place lids on biohazard bins, Resident #21 was continent of bowel and bladder. The biohazard bins are for linen and trash. The facility normally keeps them inside the bedroom. When the bins become full staff take them out. Resident #21 is no longer on contact isolation. She believed housekeeping cleaned the room this morning. Interview on 9/12/19 at 11:16 AM with LVN 5 stated she said that PPE is kept inside the room against the wall near the door for residents on isolation. LVN 5 confirmed that you have to enter the room to put on PPE as it is kept inside the room. LVN 5 said the biohazard bins for linens and solid trash are kept in the room behind the door so you could remove your PPE before exiting the room. LVN 5 asked if the biohazard bins were normally kept in the resident room instead of in the bathroom and the LVN 5 said Yes. LVN 5 said that there are no tops/covers for the bins and they just close them when they are full. LVN 5 said Resident #21 was still in therapy. Surveyor asked if she went to therapy when she was on isolation and she said she goes down to therapy every day. LVN 5 said Resident #21 is going back on isolation as the final report confirmed she still had E.coli to the wound bed of her heel and she also [MEDICAL CONDITION] of the wound bed. LVN 5 said she was getting ready to set up everything in the room for isolation, since resident will be going back on isolation [MEDICAL CONDITION] and E. Coli. LVN 5 did not say why resident was taken off of isolation when they received the preliminary report or why they did not wait for the final report. In an interview on 09/12/19 at 12:40 PM LVN 5 stated resident is no longer on contact isolation, the physician called and said the wound is contained so they don't need to put the resident on contact isolation anymore. In an interview on 09/12/19 at 1:13 PM CNA 2 stated when residents are on contact isolation staff put on gloves and gowns, dispose of plastic plate, cup, and silverware in trash. Staff take off gown and gloves and dispose of them, then take out tray. Staff are to wash hands before providing care to other residents. In interview on 09/12/19 at 1:22 PM CNA 13 stated when staff go into room to give a resident on contact isolation a tray staff don't put on gown and gloves because staff are not in contact with the resident. When staff leaves the room, they should wash their hands. In an interview on 09/12/19 at 1:37 PM CNA 30 stated she was confused about Resident #21 and her contact isolation status. Residents usually have paper plates, cups, and silverware on contact isolation. The agency sends them to the facility and the facility does training for infection control. She did not wash her hands after getting residents tray out of the room. She will keep that in mind to wash her hands in the future. In an interview on 09/12/19 at 1:50 PM the Dietary Manager stated the facility uses regular silverware, they used to use paper utensils but was told they don't have to anymore, so they can use regular silverware. The dishwasher temperature is over 120 degrees. It was a resident's rights issues. In an interview on 09/12/19 at 3:15 PM Laundry Aide stated when staff get the linen from the contact isolation those clothes are washed separately. Those clothes come in yellow bags. In an interview on 09/12/19 at 3:17 PM CNA 12 stated staff are to wash hands after leaving room, when giving resident tray and removing tray if resident is on contact isolation. In an interview on 09/13/19 at 1:40 PM Housekeeper 1 stated when a resident is on contact isolation that is the last room to be cleaned. Housekeeping staff put on gloves on the clean the room. Housekeeping staff empty out the trash in the biohazard bins, after moping the floor they take off the mop head and put in a bag. After a resident comes off contact isolation housekeeping staff deep clean the bedroom, clean the bed, walls, floor, wipe down everything in the room. He did not do a deep cleaning of Resident #21's room yet. Resident #21 was off and on contact isolation yesterday. In an interview on 9/14/19 at 2:04 PM, the DON was asked what training she ensured the nurses had in order to care for residents with pressure ulcers, infection control and change in condition. DON said that I was told the competencies were done at the corporate level. I had assurance that it was done by corporate. I teach if there is a problem or if a question is brought up. The DON said she uses return demonstration for issues that require hands on demonstration. The DON was asked what type of plans were in place for change in condition, infection control and pressures ulcers, she said the Wound Care Nurse was responsible for weekly skin assessments of all residents in the facility and that staff had in-services on infection control, change in condition and neglect. The DON said the facility had all types of in-services a week before surveyors entered facility. The DON said she could not recall what in-services they had done with staff. DON said she started her employment with the facility on 08/26/2019 or 08/27/2019. When the DON was asked how she thought the IJ's came about, she said she is not familiar with the new survey process. She said I believe it's a decision tree. If there is a breach in the precautions or discrepancies or breaks, that's how I believe the IJ came about. The DON was asked what resources she did, staff and the facility have available and she said they have policies and procedures, nursing judgement, medical director that is very reachable advocates and cares for the residents. In an interview on 9/14/19 at 8:15 AM, the Administrator said that he performs walking rounds, interviews residents, talks with staff and DON to make sure the needs of the residents are met. The Administrator said that he monitors staff and the DON by direct observation, follow up and he reviews policies and procedures and makes recommendations as needed. The Administrator said he was not aware of the IJ situation prior to the IJ being called, but he was aware of the situation but was not aware of the immediacy. The Administrator said that he guessed the IJ had to do with documentation. He said one of the residents had a change in condition and the physician was not notified. He said that he thought it was a lack of documentation or just the documentation. Administrator was asked about the infection control and pressure ulcer and he said he was trying to figure out how the resident would get E. Coli in a wound on her heel and that he was investigating that. Record review of Isolation-Initiating Transmission-Based Precautions policy dated 11/28/16 and provided by the facility read in part . Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease, Transmission -Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. If a resident is suspected of, or identified as, having a communicable infectious disease, the charge nurse or Nursing Supervisor shall notify the Infection Control Coordinator and the resident's Attending Physician for appropriate Transmission Based Precautions. If the Attending Physician or his/her alternate fails to respond appropriately to notification of a suspected or confirmed communicable infectious disease, the staff will inform the Medical Director and Administrator. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Control Coordinator or designee) shall: Ensure that PPE is maintained near the resident's room so that everyone entering the room can access what they need; Post the appropriate notice on the room entrance door, and on the front of the resident's chart so that all personnel will be aware of precautions or be aware that they must first see a nurse to obtain additional information about situation before entering the room. Record review of Isolation-Categories of Transmission- Based Precautions dated 11/28/16 provided by facility read in part . Standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Contact Precautions In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Examples of infections requiring Contact Precautions include, but are not limited to: Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (MRSA, VISA, VRSA, VRE) [MEDICATION NAME] Escherichia coli Abscesses, [MEDICAL CONDITION], or decubiti with non-contained drainage. The Administrator, DON, and Corporate nurse was notified of Immediate Jeopardy (IJ) on 9/13/19 at 6:19PM due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on 9/16/2019 at 1:03PM after several revisions were made. Plan of Removal The following information is in relation to the immediate jeopardy, immediate threat, and Sub-Quality of Care cited on 9/13/2019. This serves as notification of our plan to remove immediate threat. Preparation and/or execution of this Plan of Removal does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusions set forth on the Statement of Deficiencies. This Plan of Removal is prepared solely because required by one or more of the following: The Texas Department of Human Resource's ICF/SNF Standards for participation, Texas Department for Health's Licensure Standard's, and Code of Federal Regulations 42 Part 442 Sub. The following actions have taken place to remove immediate threat. ISOLATION: CONTACT ISOLATION FOR ESBL Resident placed in contact isolation: At 6:48p on 9.13.19 the resident was updated to isolation status. As she is her own RP, she was notified of her change in status requiring isolation. administrator notified residents Son on 9/13/19. Notification of the following was completed on 9/13/19 @ 6:48p by administrator. Ancillary services notification was completed on 9/13/19 by administrator. Housekeeping staff was notified. Therapy staff was notified. Resident's physician was informed. Direct care facility staff were informed systematically through verbal and written communication by the DON or designee that the resident was placed on CONTACT isolation for ESBL on 9/13/19. Off-duty staff must complete isolation training prior to returning to work. Isolation supplies were put in place: Exterior cart including signage and interior biohazard boxes for linen and waste with appropriate signage. A visitor note was placed on the door prompting visitors to check-in at the nurses' station. INFECTION CONTROL Establishing systems for infection control measures. The following action have taken place to remove the immediate jeopardy: Nursing management assessed all residents to ensure no other residents needed prompt intervention. No resident was identified as needing prompt intervention. Assessment completed: 9/13/19 @ 9:15p. The Therapy Department, the resident's room, and the path traveled by the resident with ESBL was cleaned and disinfected by housekeeping services supervisor. Cleaning completed: 9/13/19 @ 9:15p On-site staff was immediately in-serviced by DON or designee on 9/13/19 on the company policy based on CDC guidelines. This policy is professionally accepted and is in accordance with CDC guidance on infection control. All nursing and therapy staff will be in-serviced and checked off. Those not able to attend the training will not be allowed to work until completed. On-Site Nursing staff were immediately in-serviced by the DON or designee on 9/13/19 and checked off on the following: Handwashing Donning and Doffing gowns and gloves These skills were done with return demonstration to the DON or designee to ensure compliance to prevent cross contamination as well as health care associated infections. All staff were trained on types of isolation by the DON or designee on 9/13/19 to include: Contact isolations and indications for use. Droplet isolation and indication for use. Airborne isolation and indications for use (noting that a negative pressure room is required for this type of isolation). All staff were provided with a post-after return demonstration by the DON or designee on 9/13/19. Staff that were Off-site will be trained prior to returning to work. The resident was educated by the DON on 9/13/19 @ 6:48p about: the organism that present in her wound, Reason for isolation, Ways to prevent the further spread of the organism, Length of time she would be expected to be on isolation, Overall treatment plan as prescribed by the physician. Pressure Ulcer Policy All nursing staff were educated on company policy regarding prevention of pressure ulcer 9-13-2019 to include: Identification of risk factors General preventative measures to include: Turning Repositioning Reducing friction and moisture Use of special mattresses Immobility Poor nutrition Mental awareness Charge nurses will be trained by the DON or designee on company policy starting on 9-13-2019 regarding: Proper wound care techniques, Methods to prevent the spread of infection Signs and symptoms of wound infections All off-site staff will be trained prior to returning to work. Administrator or Designee will verify that all staff have completed all of the above in-services and trainings before returning to work. Completed 9-14-2019 Monitoring of Plan of Removal Monitoring of the facility plan of removal began on 9/16/19 at 2:00PM. Facility staff from the morning, evening and night shift were interviewed over identifying changes in condition, monitoring residents, shift to shift reporting, DNR's, Infection control protocols, Neglect, and wound care. The staff interviewed included 7 nurses and 11 CNA's. The staff interviewed were able to confidently demonstrate knowledge in the areas of in-services completed in the plan of removal. Shift change procedures were observed on 9/16/19 and 9/17/19, and staff (nurses and CNA's) demonstrated the shift to shift communication outlined in the plan of removal. The DON was observed out monitoring shift change to ensure staff were following procedure. Record review of the facility's list of residents with pressure ulcers revealed there was only two residents with pressure ulcers in the facility, Resident #11 who was on the original survey sample and Resident #21 who was also on the original sample. Resident #11 was noted and observed to be non-compliant with care and physician orders [REDACTED]. Resident #21's wound care was observed during standard survey and cited at IJ level. Resident #21's wound was observed during monitoring period (9/16/19 - 9/17/19) to be dressed properly per treatment orders. Resident #21 denied having any pain in her wound and confirmed staff were coming and doing her dressing changes within the correct times frames. Observations on 6/16/19 and 6/17/19, revealed staff were going into residents' rooms checking for pain, repositioning them, getting them out of bed, and making sure pressure ulcer precautions were in place (heel protectors, heels floated, chair cushions, etc.). Resident #50 wound care was observed on 9/17/19 and staff completed wound care without error or wound contamination. Resident #21 was observed to be in her room on 9/16/19 and 9/17/19 with proper isolatio (TRUNCATED)

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 18 residents (CR #47) reviewed for quality of care, in that; The facility failed to identify and promptly intervene on the morning of [DATE] when CR #47 was found breathing but unresponsive. CR #47's transfer to the hospital was delayed when the nursing staff did not call for emergent services but instead called the DON, Resident's family and doctor due the resident 's DNR status . CR#47 died the next morning at the hospital. The facility failed to identify CR #47 had change in condition of fluid buildup in bilateral upper extremities and abdomen on [DATE]. The facility failed to continue to assess and monitor CR #47 after a change in condition was identified. The facility staff failed to communicate CR #47's changes in condition with each other and between shifts. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one resident who died in the hospital and placed all residents with change in condition and all residents with DNR status at risk of delay in treatment. Findings include: CR #47 Record review of CR #47's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. It can be acute or chronic. Chronic heart failure develops slowly, while acute occurs suddenly), pneumonia, [MEDICAL CONDITIONS], hypo-osmolality and [MEDICAL CONDITION], metabolic [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] embolism without acute cor pulmonale (Pulmonary embolism is a blockage in one of the [MEDICAL CONDITION] arteries in your lungs. In most cases, [MEDICAL CONDITION] embolism is caused by blood clots that travel to the lungs from the legs or, rarely, other parts of the body), [MEDICAL CONDITION] reflux disease, and hypoxemia (Hypoxemia is an abnormally low level of oxygen in the blood. Hypoxemia has many causes, often respiratory disorders, and can cause tissue [MEDICAL CONDITION] as the blood is not supplying enough oxygen to the body.). CR #47's face sheet also revealed she had advanced directives of Do Not Resuscitate (DNR). Record review of CR #47's Quarterly MDS dated [DATE] revealed a Staff Assessment for Mental Status was completed that noted the resident had short term and long-term memory problems and her cognitive skills were severely impaired. Further review of the MDS revealed she received oxygen therapy and had [DIAGNOSES REDACTED]. Record review of CR #47's care plan dated [DATE] revealed resident had a potential/actual impairment to skin integrity related to fragile skin and several skin tears noted between [DATE] and [DATE]. Her interventions included to pad wheel chair arms with lamb's wool, encourage good nutrition and hydration, facility protocol for treatment of [REDACTED]. CR #47's care plan dated [DATE] noted she had [MEDICAL CONDITION] and her interventions were: follow facility protocol/doctor's orders for Oxygen therapy, testing and use of equipment, give medication as ordered, monitor intake and output, monitor/document/report to doctor PRN any signs/symptoms of [MEDICAL CONDITION]: dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate ([MEDICAL CONDITION] lethargy and disorientation. Record review of CR #47's progress notes dated [DATE] at 11:31AM revealed the doctor was called about CR #47 not responding to the antibiotic therapy initiated on [DATE], her [MEDICAL CONDITION] of right foot was not better, and her chest x-ray results revealed infiltrate of bilateral lungs. The family requested resident be sent to emergency room (ER), 911 was called. Resident vital signs were T 97.5, P 56, R 6, B/P ,[DATE], O2 saturation was 72 on 3L's. The resident was alert and speaking. She was transported to ER at 11:48AM. Interview on [DATE] at 1:45PM, Family member number #2 said the family's private sitter for CR #47 noticed the resident felt hot on [DATE] and told the staff about it. She said the staff came down to check the resident and she had a fever of 101 degrees. She said the facility gave the resident Tylenol and the sitter reported they did not come back down to the room to check on the resident. The sitter said she had to go and ask staff if they were going to come back down and check on CR #47. Family member #2 said they were upset because the sitter was told by staff they only check temperatures once during the shift. Family member #2 said a nurse did eventually come down and recheck her temperature and the fever had broken. She said Family member #1 then went to visit CR #47 because he was concerned about the fever and when he came into the room he tickled her feet as he usually did to greet her, and the resident jerked her foot back. She said he asked CR #47 if it hurt when he did that, and she said yes. She said it was at that time they pulled back the resident covers and took her sock off and saw her whole foot was swollen and blue expanding above her ankle. She said they had to notify the staff about the resident's foot. Family member #2 said the facility was not aware of the wound on CR #47's toe or that it was infected before Family member #1 had found and reported it on [DATE]. She said they were particularly upset because the resident shower days were Monday, Wednesday, and Friday, and they were told the resident received a shower that morning of [DATE] (Monday). She said there's no way they should have missed the infection on her foot if she was given a shower like they said they did or if staff had done a full assessment when she presented with the fever that afternoon. Record review of CR #47's physician order [REDACTED]. 166cc/hour infuse over 90 minutes on [DATE] - [DATE]. Her orders and MAR indicated [REDACTED]. Both medications were ordered on [DATE]. Record review of CR #47's physician's progress note dated [DATE] revealed she was recently hospitalized for [REDACTED]. Her toenail was noted to be coming off at site of [MEDICAL CONDITION] which the physician noted to be likely caused by an ingrown toenail. The note added the family had reported CR #47 was coughing after drinking despite nectar thick liquids. The note also revealed the family was considering hospice services for CR #47 and she had some blue color to her right fingertip on occasions. The resident physical exam was noted to reveal right great toenail only attached by dead skin at distal portion . toe nail bed with yellow slough but no erosion though skin noted. The physicians plan noted, right toenail removed with scissors by cutting skin that had it attached. Continue [MEDICATION NAME] for [MEDICAL CONDITION], O2 stable on supplemental O2. Appetite stable along with mental status. Increase nectar thick to honey thickened liquids to see if this improves swallowing as patient also had concern for aspiration pneumonia during last hospital stay and is coughing when drinking. Further review of the plan revealed, Discussed option of hospice and daughter is still interested in hospital stays, IV medications, and labs should they be appropriate, so will reconsider hospice at this time. Patient is DNR and they do not desire any surgery. Done with IV antibiotics, will discontinue Peripherally Inserted Central Catheter (PICC). Record review of the facility's 24-hour report/change of condition report dated [DATE] revealed 10PM-6AM shift noted, CR #47 to be admitted to Hospice, Discontinue PICC Line. Record review of CR #47's progress notes dated [DATE] at 10:53PM revealed resident had labored breaths with movement, lung sounds with bilateral crackles to upper lobes, O2 saturations 93% on room air, she had a PRN nebulizer treatment administered and tolerated well. Resident remained afebrile with temperature of 98.2. Record review of the facility's 24-hour report/change of condition report dated [DATE] revealed a note for CR #47 to monitor for cough from the 2PM -10PM shift. Record review of CR #47's progress notes dated [DATE] at 3:48PM revealed, V/S - ,[DATE]-98XXX[DATE]-87% Room air, resident in bed with intermittent moist sounding nonproductive cough, Bilateral Upper Extremities (BUE) swollen with fluid filled appearance at bicep/elbow areas, abdomen slightly distended but soft/nontender, resident had bowel movement (BM) today, O2 increased to 3L/Minute per nasal cannula to help keep saturation above 90%, breath sounds clear, head of bed elevated and all staff and family reminded of resident liquid consistency changed to honey, family present and aware of all symptoms, doctor notified of resident condition and new orders received to give additional 10mg [MEDICATION NAME] today and to increase [MEDICATION NAME] to 20mg by mouth daily starting the morning, and draw CBC and CMP in morning for [DIAGNOSES REDACTED]. Note was entered by LVN #9. Record review of the facility's 24-hour report/change of condition report dated [DATE] revealed 2PM -10PM shift nurse (LVN #9) noted CR #47 had 1 extra 10mg [MEDICATION NAME] given, increase to 20mg every day, CBC/CMP in AM. Record review of the facility's 24-hour report/change of condition report dated [DATE] revealed 10PM - 6AM shift nurse (LVN #2) noted CR #47's [MEDICATION NAME] increased from 10MG to 20MG every day and Lab - CBC/CMP. Record review of CR #47's progress note dated [DATE] at 8:37AM revealed, Resident noted laying in bed with eyes closed, labored breathing, and unresponsive. O2 sat noted at 81% on 3L of oxygen via nasal cannula. Unable to raise sats above 81%. EMS notified. Resident transported to ER for evaluation. Note was entered by LVN #11. Record review of CR #47's progress note dated [DATE] at 8:47AM revealed, call placed to RP explained to him resident is de-sating even on O2 at 3 liters via nasal cannula. Slow to respond the morning and noted rapid respirations. Resident is a DNR, but family does want her sent to ER. Family will be over to accompany her to ER. Note was entered by LVN #8. Record review of CR #47's progress note dated [DATE] at 8:49AM written by LVN #8 revealed medics were in the facility to assess resident and they took her out. Record review of CR #47's EMS report dated [DATE] revealed they received dispatch call at 8:33AM and arrived on scene at 8:38AM. The report noted a primary impression of CR #47 was Septic shock. Vitals were recorded at 8:47AM by EMS that were BP ,[DATE], P 92, RR 30, SPO2 95Ox, and no temp. EMS assessment completed at 8:40AM revealed in part; Mental status - unresponsive Skin - cold Chest - accessory muscle Lung sounds - Left lower: decreased, left upper: decreased, Right Lower: Rhonchi Abdomen - Distension, guarding, Mass, Tenderness Extremities - [MEDICAL CONDITION] (left arm, right arm, left leg, right leg) Further review of the EMS report revealed a narrative that noted, in part, .Patient has low O2 and is unresponsive. Nursing home staff on scene providing history. They state that starting this morning patient became unresponsive and started to have difficulty breathing. They state the patients room air O2 saturations were 76% so the placed her on a nonrebreather (NRB) at 25 liters per minute (LPM) prior to EMS arrival . Patient is normally able to speak and follow commands but today she in unable to do so . Patient found laying on her hospital bed breathing at an accelerated rate with accessory muscle usage. Patient is completely unresponsive with a Glasgow Coma Scale (GCS) (the most common scoring system used to describe the level of consciousness in a person following a [MEDICAL CONDITION]) of 3 (GCS of 8 or less indicates severe [MEDICAL CONDITION]). Patients skin feels cold to the touch and her radial pulse is thread. Patient appears to be in severe septic shock . Further review of the Narrative revealed in part, .In ambulance . patient is hypotensive . GCS is still 3. Axillary temperature was attempted but EMS was unable to obtain a reading . At hospital, a rectal temperature was obtained by the RN's and patient core body temperature was 94.6 (Hypothermia is body temperature below 95 F). Record review of CR #47's emergency Department Records dated [DATE] at 9:01AM revealed the chief complaint was weakness. The report further revealed her initial vitals were BP ,[DATE], Temp 94.6 degrees Fahrenheit Rectal, HR 64. RR 24, O2 saturations 99% 15 LPM via NRB mask. [MEDICAL CONDITION] screening was completed that revealed in part, .The patient's presentation is suggestive of a new significant infection and pneumonia/empyema . The following signs and symptoms are notes: hypothermia less than 36C (96.8F) and leukocytosis (WBC greater than 12,000). There is no evidence of organ dysfunction at a remote site from the site of infection that is not considered to be a chronic condition . The resident was ill-appearing, no speech was present, skin integrity was positive for wound(s) and not intact, redness and dressing to the right great toe, and resident was not responsive when orientation checked. The focused assessment revealed, the onset/occurrence was unknown. The symptoms came on gradually and there was associate shortness of breath. The examination revealed in part, .Right lung positive for superior rhonchi (Rhonchi are continuous low pitched, rattling lung sounds that often resemble snoring. Obstruction or secretions in larger airways are frequent causes of rhonchi.). Right lung negative for superior wheezes and rales. Right breath sounds were not diminished. Left lung positive for superior rhonchi. Left lung negative for superior wheezes and tales. Left breath sounds were not diminished . Treatment notes from the ER revealed in part, Nurse from facility stated the patient was okay yesterday, but today she was noted to be unresponsive . She stated last night it was reported that she had some coughing spells. The patient noted to have rhonchi upon arrival . The patient saturations had been in the 80's at the nursing home, even after oxygen was applied. Record review of CR #47's labs obtained in the hospital collected on [DATE] at 9:22AM revealed a High WBC of 14.7 with a range of 4.0 - 10.5. Record review of CR #47's Physician history and physical dated [DATE] at 4:18PM revealed in part, .Diagnosis: [REDACTED]. presenting with increased soft tissue swelling for about 3 days and then hypoxemia and [MEDICAL CONDITION] developing today with [MEDICAL CONDITION] exacerbation . Impression: Patient has had rapid decline in status starting 3 days ago and significantly worsening this morning. She recently was hospitalized for [REDACTED]. She has had decreased urinary output (UOP) in addition to fluid retention with chest x-ray showing bilateral pleural effusions. O2 sat to 70's on Nasal cannula this morning . She has history of dysphagia with aspiration and has been on [MEDICATION NAME] until this point . she also had low temperature in the emergency department on Bear hugger now. Respirations are shallow and somewhat irregular . Record review of CR #47's hospital Discharge Note Narrative dated [DATE] at 7:30AM revealed, Shortly after weaning patient down to Nasal Cannula from NRB, she stopped breathing and passed away peacefully. Discharge Diagnosis: [REDACTED]. Interview on [DATE] at 9:55AM, CR #47's Family member #1 said CR #47 had passed away yesterday ([DATE]). He said he was unhappy with the way some things were handled at the facility. The family member said the facility neglected to send the resident to the hospital when she presented signs of change in condition. The family said he felt that way because the hospital staff told him the resident internal body temperature was 94 degrees which indicated the resident had a change in condition before the facility identified she had one. He said the facility called him around 8:40AM or so on [DATE] to tell him they were sending CR #47 to the hospital. The family member said the hospital suggested the resident would have been showing signs around 12AM -2AM given her condition when she arrived at the hospital. The family member said he had concerns of how they had monitored the resident in the past and said the facility staff did not check on the resident every 2 hours like they were supposed to. He said he knew this because the family and CR #47's private sitter alerted the staff of several changes in condition that he felt the staff should have noticed. He said he was the one who noticed CR #47 had swelling in her abdomen and upper extremities on [DATE] and reported it to the nurse. He said he was not aware why the nursing staff had not noticed it themselves. He said he came to visit and uncovered the resident during his visit which caused him to notice the swelling. He said it was 2:00PM when he noticed the swelling and informed the nurse at the nurse's station (LVN #9). He said he left the facility and went to the doctor's office to speak with him about what he had observed. He said the nurse at the doctor's office told him the physician had ordered an additional dose of [MEDICATION NAME] for CR #47 and then to increase the dose starting the next day. He said he was also told they would be doing labs the following morning. He said before he left the facility the resident was awake but appeared to be in bad shape. He said the resident had some coughing when he last saw her on [DATE] but nothing excessive or concerning. Interview on [DATE] at 1:48PM, Family member #2 said this was the worse experience of my life and said the facility did not check on the resident every 2 hours like they were supposed to. She said there were times she would be at the facility in CR #47's room visiting with her and 4 hours would pass without any staff coming into the room to check on her. Family member #2 clarified she had not spoken to anyone at the facility about CR #47 being on hospice. She said she met with a Hospice agency in the lobby one day to get information about what Hospice was and what they offered but had not officially signed any paper work or told the facility anything. She said she heard staff saw her meeting with them in the lobby and assumed she was on Hospice. Family member #2 said her and Family member #1 expected the facility to still intervene and treat CR #47's if she showed a change in condition. She said the resident was a DNR but that did not mean the facility should withhold care to stabilize the resident if she was still alive. Family member #2 added that on [DATE] when CR #47 was observed to have increased [MEDICAL CONDITION] in upper extremities, the facility was supposed update Family member #1 on how CR #47 responded to the addition dose of [MEDICATION NAME]. She said she had last talked to Family member #1 around 8:30PM on [DATE] and he reported he had not heard anything from the facility yet. Interview on [DATE] at 2:00PM, LVN #9 said she had just come in for her 2PM - 10PM shift on [DATE] when CR #47's family member (Family member #1) came and told her the resident had some swelling. She said she went down and observed the resident did have some increased swelling in her upper extremities and abdomen. She said she did assessed the resident and check her vitals and her O2 saturations were low. She said she called the doctor and he ordered to give an additional 10MG dose of [MEDICATION NAME] right away and then increase her dose to 20MG starting the following morning. She said she administered the extra dose of [MEDICATION NAME] as ordered and put in the other orders for labs and increased [MEDICATION NAME] for the next morning. She said she did re asses the resident before she left for her shift and her O2 saturations had went up but her swollen extremities had no change. She said the resident's private sitter was in the room and had her arms elevated up on pillows. She said she had documented the follow up O2 saturation level on the resident MAR under her PRN Oxygen order. She said she did give report to the night shift nurse to monitor the resident and informed him about the resident's change in condition. Record review of CR #47's (MONTH) 2019 MAR indicated [REDACTED]> 92% every shift related to Hypoxemia ordered on [DATE] was administered [DATE] on 2PM - 10PM shift and the O2 saturation level recorded for the shift was 94%. Interview on [DATE] at 3:33PM, CNA #11 said she came in for her shift at 6PM on [DATE] and worked until 6AM ([DATE]). CNA #11 said she did rounds around 6PM and observed CR #47's sitter in her room and the sitter told her CR #47 had been coughing. She said she went in the room again around 8PM and checked on CR #47 and observed her to be coughing a lot and said all the coughing made her slide down in the bed. She said she checked the residents brief but she was not wet so her and another CNA just pulled her back up in bed. She said she checked the resident again around 10PM and she continued to cough a lot and slide down in bed. She said the resident was repositioned again and her brief was still dry. CNA #11 said the next time she checked on CR #47 was around 12:30AM and she was wet so incontinent care was done. She said the resident was still coughing a lot and did not look well at all. She said at that time she told the night nurse (LVN #2) about the resident coughing a lot and not looking well. She said she wasn't sure if or when LVN #2 went to check on CR #47 because after she told him she continued doing her round in other rooms and did not see him go into CR #47's room. Interview with CNA#11 continued and she further said she checked on CR #47 again around 2:00AM and she was not coughing anymore and said when she went to check if she was wet the resident did not wake up, which she said was unusual for the resident. She said she thought the resident was in a deep sleep because the nurse had come down and given her something that made her sleep. The CNA added the resident was still dry at that time. CNA #11 said she last checked on CR #47 around 5AM. She said CR #47 was only wet a little bit at that time which she said was also strange because she said usually the resident was a heavy wetter and was usually wet every time she checked her. She said she went ahead and changed the resident's brief even though she wasn't really that wet and the resident did not wake or assist with the changing as she usually did. CNA #11 said she gave report to the oncoming morning CNA (CNA #28) at 6AM and told her about the resident not having a good night because of the coughing and drowsiness. Interview on [DATE] at 4:00PM, LVN #2 said CR #47 was okay and on oxygen overnight from 10PM - 6AM on [DATE] to [DATE]. He said he did not get any report of the resident having any issues from the previous shift (2PM - 10PM). He said he checked on CR #47 every 2 - 3 hours and she was sleeping. LVN #2 said CNA #11 did report to him concerns of the resident coughing around 5:15AM on [DATE]. He said he went in to check the resident and her nasal cannula had shifted to the side where it wasn't over her nostrils, so he fixed her NC and sat her up at 90-degree angle in the bed. He said he did assessed the resident , checked her vital signs but did not document them because he did not think the resident was having a change in condition. He said he remembered her O2 saturation was at 93% and he listened to her lung sounds and could hear rhonchi. He said he went back and checked on the resident about 30 minutes (5:45AM) later and she was doing much better. He said she was still coughing but it was better, and she was awake and spoke with him. He said he administered her morning medications at 5:45AM that was crushed and mixed in pudding. LVN #2 said he did check her vitals again before he left and her O2 sat went up to 94% which was documented on the resident's MAR under her PRN oxygen order. He said the resident's lung sounds had also become clearer. He said he gave shift report to the morning nurse (LVN #11) about the resident coughing but told her CR #47 had an okay night. LVN #2 said he had documented what happened overnight in the 24-hour report as well. LVN #2 added he did not give CR #47 any PRN medications or treatments overnight and said he checked CR #47's orders when the CNA reported the coughing and did not see she had anything that could be given. LVN #2 said he did not observe CR #47 to have any swelling in her extremities overnight. Record review of CR #47's (MONTH) 2019 MAR indicated [REDACTED]> 92% every shift related to Hypoxemia ordered on [DATE] was administered [DATE] on 10PM - 6AM shift and the O2 saturation level recorded for the shift was 94%. Record review of CR #47's (MONTH) 2019 MAR indicated [REDACTED]= clear, 1 = wheezing, 2 = rales, 3 = diminished, 4 = crackles ordered on [DATE] was not administered in the month of (MONTH) 2019. Record review of CR #47's (MONTH) 2019 MAR indicated [REDACTED]. Interview on [DATE] at 4:49PM, CNA #28 said she came in for her shift at 5:45AM on [DATE] and CNA #11 from the night shift gave her report that CR #47 had a cough all night. She said she went down to check on the resident after she got report and said the resident was sleeping in bed. She said the resident was covered so she did not see any swelling, but she said she could hear a gurgling noise while the resident slept that sounded like she had a cold in her chest. She said she did let the morning nurse (LVN #11) know about the report she got from the night shift and saw her go down the hall, but she did not know if she went into CR #47's room. CNA #28 said she went in to get CR #47 ready for breakfast around 7:30AM and did notice she was more tired than usual. She said CR #47 would usually speak back to her when she talked to her, but she was not saying anything back to her. She said the resident did wake/open her eyes when she put her dentures in that morning and sat her up for breakfast. CNA #28 said she brought in the breakfast tray around 8AM and attempted to feed the resident and she was looking really bad. She said the food she tried to feed the resident fell out of her mouth and the resident started leaning to the side in the bed, so she went to get the nurse (LVN #11). She said the nurses took over from there. CNA #28 added she did check the resident brief that morning and she was dry. Interview on [DATE] at 1:45PM, LVN #11 said she came in on [DATE] and did rounds with the night nurse (LVN #2) around 6:00AM and he did not report anything unusual or any issues with CR #47. She said she checked on CR #47 between 6:45AM - 7:00AM and said the resident was fine. She said she observed CR #47 to be sleeping and said she did not observe if her arms or abdomen were swollen because the resident was covered up with a blanket and she did not uncover her. She said the next time she saw CR #47 was at breakfast time (between 7:45AM - 8:00AM). She said CNA #28 came and alerted her that CR #47 wasn't eating. She said she went down to the room and found the resident to be unresponsive. She said she attempted to arouse the resident with chest rubs but resident did not respond. She said she checked CR #47's O2 saturation and it was low, she could not remember what the level was. She said she also observed the resident to have labored breathing. She said she knew the resident was a DNR and wasn't sure on whether to send the resident out to the hospital , so she consulted the DON. She said the DON came down to check CR #47 and the decision was made to send her to the hospital after consulting with the physician. LVN #11 said she did not check CR #47's other vitals during her assessment, but said the DON did while they were waiting on EMS to arrive. LVN #11 added that she worked with CR #47 the morning of [DATE] and she had an episode where her O2 had dropped below 90%, so she put her oxygen on and it went back up. LVN #11 said it appeared the resident remained with her oxygen on the remainder of day and night. Interview on [DATE] at 1:25PM, LVN #8 said she was the nurse assigned to the desk on the morning of [DATE]. She said she was at the desk and told to notify the family and call 911. She said she spoke with the family first before calling 911 and they agreed to send the resident out, so she hung up with him and then called 911. She said CR #47 was a DNR which is why she wanted to talk to the family first. LVN #8 said they usually didn't send out resident's who are DNR's which is why she wanted to consult the family on what they wanted to do. She said she also knew the family was very involved in CR #47's care and would want to be consulted before doing anything with the resident. She said someone else called the Physician while she was on the phone with the family. LVN #8 said she went ahead and gathered all of CR #47's paper work for her to be sent to the hospital and had it ready for when EMS arrived. LVN #8 said she was not one of the nurses down in the room assessing the resident, but it was reported to her that CR #47 was unresponsive, and her 02 saturations were low. Interview on [DATE] at 3:29PM, the DON said she had not been back working at the facility for long so was not familiar with CR #47. She said the morning of [DATE] around 8AM it was reported to her that CR #47 was difficult to arouse. She said she got down to the room and se noted the resident was unresponsive and right away saw the resident's condition was not good, her breathing was shallow. She said she called the Physician and he said to send the resident to the ER. The DON said while she was calling the physician LVN #8 was calling the family and then 911. She said she did check CR #47's vital but could not remember what they were but said they were not good. She said she remembered CR #47's and blood pressure and O2 saturation were low. The DON said she did not notice if CR #47 extremities were swollen and the resident had protective sleeves on. She said she did not document the resident's vital from her assessment but gave them to LVN #8 to document because she was the recorder while they were assessing and working on the resident. She said the resident was still unresponsive when EMS arrived and took her out. The DON said she was not aware of CR #47 having a change in condition on [DATE] and the increased swelling she experienced. In an interview on [DATE] at 2:04 PM, the DON was asked what training did she ensure the nurses had i (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 (Resident #21) of 2 residents reviewed for pressure ulcers. The facility failed to ensure Resident #21 who admitted to the facility with low risk of pressure ulcer development did not develop a Stage III pressure ulcer to her right heel. The facility failed to prevent the development of infection to Resident #21's right heel pressure ulcer . Resident #21's right heel pressure ulcer was infected by E.coli , an unusual bacterial to infect wounds in the lower extremities of the body. The facility failed to ensure the licensed staff providing wound care were knowledgeable and competent in the assessment, documentation, treatment to include infection control techniques. The facility wound care nurse contaminated his gloved hands from touching inside of a used biohazard bag and continued wound care with the contaminated gloves. An Immediate Jeopardy (IJ) was identified on 9/13/2019. While the IJ was lowered on 9/17/2019, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolation because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one current resident and placed her at risk for her wound worsening,[MEDICAL CONDITION], and/or death. Findings include: Resident #21 Record review of Resident #21's face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #21's Admission MDS dated [DATE] revealed she had a BIMS score of 13, which indicated intact cognition. MDS further revealed Resident #21 required extensive assistance with one-person physical assist for bed mobility, locomotion on unit, dressing, and bathing. Resident #21 required extensive assistance with two-person physical assist for transfers, toilet use and personal hygiene. MDS indicated Resident #21 used a wheelchair for locomotion/ambulation. Resident #21 was frequently incontinent of bladder and occasionally incontinent of bowel. Active [DIAGNOSES REDACTED]. MDS did not reveal any documentation of a pressure ulcer. Record review of Resident #21's MDS dated [DATE] revealed she had a BIMS score of 15, which indicated intact cognition. MDS further revealed Resident #21 required extensive assistance with one-person physical assist for bed mobility, transfers, toilet use, personal hygiene and bathing. Resident #21 required supervision only for locomotion on the unit and dressing. MDS indicated Resident #21 used a wheelchair to ambulate. Resident #21 was occasionally incontinent of bowel and bladder. Active [DIAGNOSES REDACTED]. MDS indicated that Resident #21 had 1 stage III pressure ulcer and that 0 pressure ulcers were present upon admission/entry or reentry. Record review of Admission Braden scale for Resident #21 dated 06/21/2019 revealed a score of 16 indicating mild risk of developing pressure ulcer /injury. Record review of re-admission Braden scale for Resident #21 dated 07/19/2019 revealed a score of 16 indicating mild risk of developing pressure ulcer /injury. Record review of Braden Scale dated 08/19/2019 for Resident #21 revealed a score of 19 indicating no risk of developing pressure ulcer /injury. Record review of Resident #21's Progress Notes dated 6/21/2019 written by LVN #5 revealed [AGE] year-old female arrived via Non-emergent on stretcher. No discomfort or distress noted at this time. PERRL[NAME] VS T 98.2, P 72, R 18, BP 136/67, O2 @ 97% via RA, no pain noted at this time. Alert and oriented x4. Heart sounds strong and regular. Lung sounds clear in all lobes upon inspiration/expiration both anterior/posterior. Able to move all extremities without difficulty or discomfort. Toe touch weight bearing to right lower extremity due to right femur replacement. Skin clean, dry, and intact except for 3 incisions to right hip with 17 stitches in place. No s/s of infection present at this time. Bruising noted to left hand, right thumb due to IV, and right forehead. PT/OT/ST to evaluate and treat. Physician notified of arrival and orders. Resident oriented to room and roommate, as well as safety precautions reinforced. Currently up at bedside, call bell in reach Record review of Resident #21's Care Plans revealed the following which read in part . Resident #21 has limited physical mobility related to unspecified [MEDICATION NAME] fracture of right femur dated 06/24/2019. Interventions: Follow physician orders [REDACTED]. Resident #21 has an Activities of daily living self-care performance deficit related to fracture of hip dated 07/04/2019. Interventions: (MONTH) use mobility bars for positioning/mobility aid, Resident requires physical help in part of bathing activity/one person physical assist with bathing/showering 3 times a week and prn, requires extensive assistance/two person physical assist with personal hygiene and oral care, requires extensive assistance/one person physical assist with dressing, requires extensive assistance/two person physical assist with transferring, and required extensive assistance by two persons for toilet use. Resident #21 has right [MEDICAL CONDITION] related to fall dated 07/04/19. Interventions: Anticipate and meet needs, be sure call light is within reach and respond promptly to all requests for assistance, follow physician orders [REDACTED]. Resident #21 has potential for pressure ulcer development due to immobility and Braden's score of 16 (low risk) dated 07/04/2019. Interventions: Encourage good nutrition and hydration in order to promote healthier skin, keep skin clean and dry and use moisturizer applied daily to skin. Resident #21 has actual impairment to skin integrity related to stdi (suspected deep-tissue injury) right heel dated 07/09/2019. Interventions: Apply [MEDICATION NAME] to right heel, may cover with protective foam dressing and Keflex daily, float heels. Educate resident of causative factors and measures to prevent skin injury. Follow daily protocols for treatment of [REDACTED]. Podus boots applied to left heel wound to be worn as tolerated by resident. Resident has been seen scooting herself with her heels due to her weight bearing status possibly contributing to the wound formation, educated on importance of not doing this. Resident is in contact isolation, supplements as ordered, wound care consult due to deep tissue injury. Additional area of focus added to care plan on 08/16/2019- Wound care trimmed eschar areas revealing stage III to right heel . Record review of Weekly Skin Evaluation document signed by ADON/LVN #1 dated 06/21/2019 for Resident #21 did not reveal any documentation about a heel wound. Record review of Weekly Skin Evaluation document not signed by nursing staff and dated 06/25/2019 for Resident #21 did not reveal any documentation about a heel wound. Record review of Weekly Skin Evaluation document signed by Wound Care Nurse and dated 07/02/2019 for Resident #21 did not reveal any documentation about a heel wound. Record review of Weekly Skin Evaluation document signed by Wound Care Nurse and dated 07/08/2019 and 07/19/2019 for Resident #21 revealed she had a suspected deep tissue injury to her right heel, no wound measurements documented. Record review of Weekly Skin Evaluation document signed by Wound Care Nurse and dated 07/24/2019, 07/30/2019 , 08/06/2019 , 08/13/2019, 08/20/2019 and 08/27/2019 for Resident #21 revealed she had an unstageable pressure wound to her right heel, no measurements documented. Record review of Weekly Skin Evaluation document signed by Wound Care Nurse and dated 09/03/2019 for Resident #21 revealed she had Stage III, right heel pressure wound, no measurements documented. Record review of physician order [REDACTED]. Cleanse right heel wound with normal saline, apply [MEDICATION NAME] to peritissue then Santyl ointment to wound bed, cover with 4x4 and abd pad and tape. Change daily, except Wednesday-wound clinic will change. Order date of 9/12/19. Contact isolation every shift for heel wound. Order date of 8/25/2019. Offload heels while in bed. Must wear heel protectors, check every shift. Order date of 07/22/2019 . Record review of Resident #21's Progress Notes dated 7/8/2019 written by Wound Care Nurse revealed right heel noted with suspected deep tissue injury (sdti) measures 10.5cm x 6.4cmx 0cm, wound is closed at this time [MEDICATION NAME] applied and covered with protective foam dressing for comfort, heels floated. Physician notified and received orders for above treatment. Appointment being made for wound clinic at next available appointment Record review of Resident #21's wound care note dated 07/10/2019 written by Wound Care Nurse, read in part . Right heel with suspected deep tissue injury measures 10.5cm x 6.4cm x 0cm, wound is closed at this time, [MEDICATION NAME] applied and covered with protective foam dressing for comfort, heels floated. Record review of wound care note for Resident #21 dated 07/25/2019 at written by Wound Care Nurse read in part . Right heel with sdti, measures 10.7cm x 8.2cm x 0cm. Wound covered with dark black eschar at this time, [MEDICATION NAME] applied and covered with protective foam dressing for comfort, heels floated. Continue to be followed at wound clinic weekly-will monitor and treat daily. Record review of wound care nurse notes for Resident #21 dated 08/15/2019 and written by Wound Care Nurse, read in part .Right heel with stage III pressure ulcer. Measures 3.0cm x 5.2cm x0.1cm, wound was debrided at wound clinic this week, all dark eschar is gone. Wound bed now pink with 80/20 granulation/slough, new orders for cleanse with normal saline, apply hydrogel and then bordered dressing Monday, Wednesday and Friday and as needed. Heels floated. Continue to follow at wound clinic weekly. Record review of nurse notes for Resident #21 dated 08/23/2019 at 2:31 PM, written by LVN #7, read in part . Heel wound culture results and new orders received from physician per wound care nurse to place Resident #21 on contact isolation. Antibiotic ordered, [MEDICATION NAME] 100 mg capsule- 1 capsule by mouth twice daily for 10 days. Diagnoses, heel wound. Resident educated. Record review of Resident #21's Wound Care Notes dated 08/23/19 at 5:15 PM and written by Wound Care Nurse read in part . right heel with stage3 pressure ulcer measures 3.1cm x 5.5cm x 0.2cm, wound bed is pink with 80/20 gran/slough, new orders for cleanse with ns apply [MEDICATION NAME] to peri-tissue, silver cell and then bordered dressing Monday, Wednesday, Friday and prn. There is moderate sero sang drainage (serosanguineous drainage is composed of serum and blood , thin, like water. It usually has a light red or pink tinge ) . Heels floated. Continue to be followed at wound clinic weekly- will monitor and treat as ordered. Plan of care discussed with resident is own responsible party and gave verbalized understanding. Wound discussed in weekly IDT meeting this week. Will continue offloading heels and ensuring heel protectors in place. Resident on air mattress, receiving nutritional supplement, vitamin c and Juven for healing aid. Physician called with orders for [MEDICATION NAME] for culture of right heel with ESBL and E.coli. Resident notified, and medication ordered. Record review of Resident #21's Lab Report dated 09/10/19 revealed Microbiology Lab .Source .Wound, Site .right heel. Final Results .Heavy growth of presumptive Staphylococcus aureus and Escherichia coli, Multi-drug resistant organism (MDRO), ESBL producer, Patient isolation should be considered. Organism 1. Staphylococcus aureus, Organism 2. Escherichia coli Interview on 09/12/2019 at 9:49 AM with LVN 8, she was asked where was the isolation cart for Resident #21's room. LVN #8 said Resident #21 was no longer on isolation because her right heel pressure wound culture came back negative. Observation on 09/12/2019 at 9:50 AM of wound care for Resident #21's right heel pressure wound, performed by Wound Care Nurse who was assisted by LVN #8 for Resident #21 revealed the following . LVN #8 put 2 small red biohazard bags at the foot of Resident #21's bed. Wound Care Nurse wiped wound with 4 x 4 gauze soaked in normal saline. LVN #8 then lifted a biohazard bag with her gloved hand and held it near Resident #21's right heel pressure ulcer so Wound Care Nurse could dispose of the soiled 4 x4 gauze. The biohazard bag held by LVN #8 touched the right heel pressure wound bed contaminating the wound. Wound care continued, and Wound Care Nurse wiped wound bed again with a 4 x 4 gauze soaked in normal saline and LVN #8, still holding the biohazard bag moved it towards Wound Care Nurse and when he disposed of soiled 4x4 gauze, his gloved hand went inside the biohazard bag and his gloved hand touched the inside of the biohazard bag. Wound Care Nurse continued with wound care and did not change gloves or wash hands following the contamination of his glove. Interview with LVN #8 on 09/12/2019 at 10:10 AM, she said that she did not realize that the biohazard bag had touched Resident #21's right heel wound bed. She said that she had been told it was ok to put the biohazard bags at the foot of the bed during wound care and thought it would be alright to hold the bag for the Wound Care Nurse. Interview on 9/12/2019 at 10:11 AM with Wound Care Nurse, he said that he did not realize during the wound care that his hand touched the inside of the biohazard bag. Wound Care Nurse was asked if he normally had someone hold the biohazard bag for him during wound care and he said no. Wound Care Nurse said that only the small biohazard bags were available so that is why they were put at the foot of the bed and LVN #8 held the biohazard bag for him during wound care. Record review of Nurse Notes for Resident #21 dated 09/12/2019 at 12:25 PM, written by the Regional Nurse/LVN #30 read in part . Obtained results from culture. Provider contacted. Orders to discontinue isolation. Resident #21 remains afebrile and has not mounted an elevated white count post-surgical procedure. Wound is without drainage, [DIAGNOSES REDACTED], foul odor. Board certified infection prevention specialist review labs and wound condition with provider who is a certified wound care physician. Collaborative decision made to remove isolation and allow resident into community with intact protected by boarder bandage. Record review of Nurse Note on 09/12/2019 at 1:04 PM for Resident #21 written by Regional Nurse/LVN#30, read in part . Second call placed to physician (wound care physician) regarding concern of not re-culturing wound. The IFCC discussed my concerns regarding all other residents and possibilities of this resident not healing well. He feels as if it is colonized due to no signs or symptoms of infection and does not feel she needs to be isolated. Wound care physician agreed to re-culture on Monday. Stating it would not be beneficial to re-culture until Monday. Wound is covered at all times with bandage, a sock, and a walking shoe. Resident alert and oriented x 3. Observation on 09/09/2019 at 11:48 AM revealed resident in bed with eyes closed, isolation signage on the door and PPE in cart outside of the room in the hall. Interview with LVN #5 on 09/09/2019 at 11:50 AM, she said Resident #21 has a pressure ulcer to the right heel that is positive for E. Coli. LVN #5 said that the wound needs to be re-cultured and that Resident #21 just completed her antibiotics on 09/08/2019. Observation and interview on 09/10/19 at 11:00 AM revealed Resident #21 in wheelchair in physical therapy room with other residents and staff. Resident #21 said she goes to physical therapy multiple times a day and she wheels herself down to physical therapy using her feet as staff has removed foot pedals, so she can use her feet to propel. Resident #21 said she loves going to physical therapy several times a day as she is trying to build up her strength to go home. In an interview on 09/12/19 at 12:40 PM LVN 5 stated resident is no longer on contact isolation, the physician called and said the wound is contained so they don't need to put the resident on contact isolation anymore. Record review of Nurse Note on 09/12/2019 at 1:20 PM written by Regional Nurse/LVN #30, read in part . Physician called stating he wants to be the one to do the re-culture and will do it at her wound care appointment on Monday. Resident #21 notified. Observation on 09/12/19 at 1:35 PM revealed Resident #21 wheeling down hallway, no shoes on feet, bandage on heal with tape, sock not covering heel. Record review of Resident #21's Wound care note dated 9/12/2019 at 5:11 PM, written by Wound Care Nurse read in part .Right heel with Stage III pressure ulcer. Measures 2.5cm x 4.7cm x 0.2cm, per wound clinic. Wound bed is pink with 80/20 granulation/slough, new orders for cleanse with normal saline, apply [MEDICATION NAME] to peri-tissue, Santyl to wound bed then 4x4 and abd, tape daily and as needed. There is moderate sero sang drainage. Heels floated. Continue to be followed at wound clinic weekly- will monitor and treat as ordered. Plan of care discussed with Resident #21 who is her own responsible party and gave verbalized understanding. Wound discussed in weekly IDT meeting this week. Resident removed from isolation at this time. Has completed antibiotic and per physician. Record review of Resident #21's Lab Report dated 09/10/19 revealed Microbiology Lab .Source .Wound, Site .right heed. Final Results .Heavy growth of presumptive Staphylococcus aureus and Escherichia coli, Multi-drug resistant organism (MDRO), ESBL producer, Patient isolation should be considered. Organism 1.Staphylococcus aureus, Organism 2.Escherichia coli Interview with Regional Nurse/LVN #30 on 09/12/2019 at 2:00 PM, she said that Resident's lab culture preliminary result received on 09/12/2019 revealed Resident #30 was positive for E. Coli of the right heel wound bed. We put her on isolation and then discussed it with Medical Director and he thinks the specimen was contaminated as there were 3 different organisms on the final lab culture. Regional Nurse/LVN #30 said that he is also a wound care physician who see's Resident #21 weekly. Regional Nurse/LVN #30 said that the physician said he was not going to treat the organisms because he was sure it was a contaminated specimen. The Regional Nurse/LVN#30 said I feel it needs to be re-cultured and that is what she told the physician and he said no. Regional Nurse/LVN #30 said she is not sure what she could have done and asked the surveyor How do I go about it, because he said no. Surveyor informed Regional Nurse/LVN #30 that surveyors could not tell her what to do and asked her if she had facility had policies and sister facilities. Regional Nurse/LVN #30 was asked who made the decision to take Resident #21 off of isolation with the preliminary lab culture result. Regional Nurse/LVN #30 said the Infection Control Coordinator makes the decision. She was asked who the Infection Control Coordinator was, and she said that she was the Infection Control Coordinator. She was asked how she decides who can come off of isolation with a preliminary lab culture report. Regional Nurse/LVN #30 said that it depends on the treatment the resident has had previously, if treatments have been completed and if the wound is responding. Regional Nurse/LVN #30 said the preliminary report was the report sent out after the culture had been growing for 48 hours so she thought it would be alright. She said Resident #21 has never had an elevated white blood count. Interview with Regional Nurse/LVN#30 on 09/12/2019 at 2:51 PM, she said that she spoke with Resident #21's physician, who is also her wound care physician and informed him that the surveyor would like to speak with him. Regional Nurse/LVN#30 said the physician was at a medical conference and he would be available for the next 20-30 minutes but that was over 20 minutes ago. Surveyor asked for physician's phone number and number not received. Regional Nurse/LVN #30 said that the physician said he wanted to culture the wound himself on Wednesday 09/18/2019 so a DNA culture could be performed on the wound to make sure he treats with the correct antibiotics. In an interview on 09/12/19 at 5:39 PM the Wound Care Nurse stated he does the wound measurement every week. Resident #21 had a facility acquired pressure ulcer. Record review of Nurse Notes for Resident #21 written by DON and dated 09/13/2019 at 6:48 PM read in part .Final culture results received from lab. Placed on isolation. Resident #21 informed of provider order to initiate Intravenous therapy (IV). Resident #21 informed of length of treatment, therapy plan going ford. Resident #21 encouraged to call for nursing and/or staff intervention in the event she began to feel lonely or depressed. Nursing assessment determined no acute signs or symptoms of systematic infection. Interview with Administrator on 09/18/2019 at 12:57 PM, he said that the Wound Care Nurse had been suspended and would be returning to work at the facility in a different capacity and would no longer be providing wound care. In an interview on 9/14/19 at 2:04 PM, the DON was asked what training did she ensure the nurses had in order to care for residents with pressure ulcers, infection control and change in condition. DON said that I was told the competencies were done at the corporate level. I had assurance that it was done by corporate. I teach if there is a problem or if a question is brought up. The DON said she uses return demonstration for issues that require hands on demonstration. The DON was asked what type of plans were in place for change in condition, infection control and pressures ulcers, she said the Wound Care Nurse was responsible for weekly skin assessments of all residents in the facility and that staff had in-services on infection control, change in condition and neglect. The DON said the facility had all types of in-services a week before surveyors entered facility. The DON said she could not recall what in-services they had done with staff. DON said she started her employment with the facility on 08/26/2019 or 08/27/2019. When the DON was asked how she thought the IJ's came about, she said she is not familiar with the new survey process. She said I believe it's a decision tree. If there is a breach in the precautions or discrepancies or breaks, that's how I believe the IJ came about. The DON was asked what resources she did, staff and the facility have available and she said they have policies and procedures, nursing judgement, medical director that is very reachable advocates and cares for the residents. In an interview on 9/14/19 at 8:15 AM, the Administrator said that he performs walking rounds, interviews residents, talks with staff and DON to make sure the needs of the residents are met. The Administrator said that he monitors staff and the DON by direct observation, follow up and he reviews policies and procedures and makes recommendations as needed. The Administrator said he was not aware of the IJ situation prior to the IJ being called, but he was aware of the situation but was not aware of the immediacy. The Administrator said that he guessed the IJ had to do with documentation. He said one of the residents had a change in condition and the physician was not notified. He said that he thought it was a lack of documentation or just the documentation. Administrator was asked about the infection control and pressure ulcer and he said he was trying to figure out how the resident would get E. Coli in a wound on her heel and that he was investigating that. In telephone interview with Wound Care Physician on 09/16/2019 at 5:10 PM, he said that he thought Resident #21's right heel pressure wound was colonized because she had been treated previously and the cultures showed a small amount. Physician said he wanted to wait until Wednesday 09/18/2019 to repeat the culture as his wound clinic is open on Wednesday and they have a specific DNA specific test. Wound Care physician said Resident #21 had become terribly depressed due to her isolation and the fact that she was driving alone from Arizona to Florida and got out at a rest area for a walk and fell and fractured her hip and ended up at the facility for therapy following her surgery. Wound Care Physician said that he made the decision unilaterally to take her off of isolation. He said he was at a wound conference and spoke with other physicians including Infectious Disease physician at conference and the Infectious Disease physician suggested to put Resident #21 back on isolation. Wound Care Physician said the decision to take Resident #21 off of isolation, wait on repeating culture and starting new treatment was all his decisions and not the facility's. Wound Care Physician said he wanted to wait for the result of the DNA culture he was performing on Wednesday 09/18/2019 to treat as he wanted to preserve her kidney function and make sure the infection was treated with the correct medication and one that was not resistant. Wound Care Physician said he did not know how E. Coli had started growing in Resident #21's right heel wound because that organism is not normally found in a pressure ulcer of the heel. Interview with Regional Nurse/LVN #30 on 09/18/2019 at 2:05 PM, she said the Wound Care Nurse was suspended due to wound care issues. The Administrator, DON, and Corporate nurse was notified of Immediate Jeopardy (IJ) on 9/13/19 at 6:19PM due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on 9/16/2019 at 1:03PM after several revisions were made. Plan of Removal The following information is in relation to the immediate jeopardy, immediate threat, and Sub-Quality of Care cited on 9/13/2019. This serves as notification of our plan to remove immediate threat. Preparation and/or execution of this Plan of Removal does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusions set forth on the Statement of Deficiencies. This Plan of Removal is prepared solely because required by one or more of the following: The Texas Department of Human Resource's ICF/SNF Standards for participation, Texas Department for Health's Licensure Standard's, and Code of Federal Regulations 42 Part 442 Sub. QUALITY OF CARE- Pressure Ulcer Policy All nursing staff were educated on company policy regarding prevention of pressure ulcer 9-13-2019 to include: Identification of risk factors General preventative measures to include: Turning Repositioning Reducing friction and moisture Use of special mattresses Immobility Poor nutrition Mental awareness Charge nurses will be trained by the DON or designee on company policy starting on 9-13-2019 regarding: Proper wound care techniques, Methods to prevent the spread of infection Signs and symptoms of wound infections All off-site staff will be trained prior to returning to work. INFECTION CONTROL Establishing systems for infection control measures. The following action have taken place to remove the immediate jeopardy: Nursing management assessed all residents to ensure no other residents needed prompt intervention. No resident was identified as needing prompt intervention. Assessment completed: 9/13/19 @ 9:15p. The Therapy Department, the resident's room, and the path traveled by the resident with ESBL was cleaned and disinfected by housekeeping services supervisor. Cleaning completed: 9/13/19 @ 9:15p On-site staff was immediately in-serviced by DON or designee on 9/13/19 on the company policy based on CDC guidelines. This policy is professionally accepted and is in accordance with CDC guidance on infection control. All nursing and therapy staff will be in-serviced and checked off. Those not able to attend the training will not be allowed to work until completed. On-Site Nursing staff were immediately in-serviced by the DON or designee on 9/13/19 and checked off on the following: Handwashing Donning and Doffing gowns and gloves These skills were done with return demonstration to the DON or designee to ensure compliance to prevent cross contamination as well as health care associated infections. All staff were trained on types of isolation by the DON or designee on 9/13/19 to include: Contact isolations and indications for use. Droplet isolation and indication for use. Airborne isolation and indications for use (noting that a negative pressure room is required for this type of isolation). All staff were provided with a post-after return demonstration by the DON or designee on 9/13/19. Staff that were Off-site will be trained prior to returning to work. The resident was educated by the DON on 9/13/19 @ 6:48p about: the organism that present in her wound, Reason for isolation, Ways to prevent the further spread of the organism, Length of time she would be expected to be on isolation, Overall treatment plan as prescribed by the physician. IN-SERVICES Those staff members hat have not attended the mandatory training will not be allowed to work until the abuse and neglect training is completed. Administrator or Designee will verify that all staff have completed all of the above in-services and trainings before returning to work. Completed 9-14-2019 Monitoring of Plan of Removal Monitoring of the facility plan of removal began on 9/16/19 at 2:00PM. Facility staff from the morning, evening and night shift were interviewed over identifying changes in condition, monitoring residents, shift to shift reporting, DNR's, Infection control protocols, Neglect, and wound care. The staff interviewed included 7 nurses and 11 CNA's. The staff interviewed were able to confidently demonstrate knowledge in the areas of in-services completed in the plan of removal. Record review of the facility's list of residents with pressure ulcers revealed there was only two residents with pressure ulcers in the facility, Resident #11 who was on the original survey sample and Resident #21 who was also (TRUNCATED)

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable weight range for one resident of 18 residents (Resident #15) reviewed for nutrition , in that; The facility dialed to ensure Dietitian's recommendation and physician ordered daily health shake for Resident #15 was implemented resulting in significant weight loss of more than 5% in one month and a severe weight loss of more than 17% in 3 months. This failure affected one resident and placed her at risk for additional weight loss, skin breakdown and decline in overall health. Findings included: Resident #15 Record review of Resident #15's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #15's quarterly MDS dated [DATE] revealed a Staff Assessment of Mental Status indicating resident had short- and long-term memory problems and had severe cognitive deficits. The MDS revealed resident had an unplanned significant weight loss and required extensive assistance for one person for eating. Record review of Resident #15's care plan dated 7/29/19 revealed she had a potential nutritional problem related to diet: Regular diet/ Mechanical Texture, no raw vegetable. Her interventions included: provide, serve diet as order. Monitor intake and record every meal. RD to evaluate and make diet change recommendation PRN. Further review of care plan revealed no focus area for weight loss. Record review of Resident #15's weights revealed in part; 3/19/19 - 170.8Lbs 4/3/19 - 173.0Lbs 5/1/19 - 170.0Lbs 5/30/19 - 161.2Lbs 6/3/19 - 161.2Lbs 6/19/19 - 161.2Lbs 7/3/19 - 164.2Lbs 7/29/19 - 164.2Lbs 8/3/19 - 150.4Lbs 9/3/19 - 141.6Lbs Record review of Resident #15's progress notes dated 6/4/19 at 12:25PM revealed in part, .weight:161.2lb loss (5.2%) X 1 month . Diet regular. Resident feeds self. Intakes have decreased - started on [MEDICATION NAME] acetate. No wounds, no [MEDICAL CONDITION] per nursing . Involuntary weight loss related to decreased intake as evidence by recent weight loss. Goals: no significant weight change > or + 5% of 161.2lbs X 1 month. Recommend to physician - shake every day. Recommend weekly weights X 4 weeks . Note was entered by RD. Record review of Resident #15's Dietician Communication Form dated 6/4/19 revealed a recommendation of shakes every day. The bottom of the form was checked off and signed by the physician on 6/10/19 that he agreed with the recommendation. Record review of Resident #15's progress notes dated 6/10/19 at 3:48PM revealed, New order received per dietary recommendation to add a shake daily. Dietary notified. MD also wants to check pre-[MEDICATION NAME] level. RP aware. Record review of Resident #15's clinical records from (MONTH) 2019 to present revealed no orders for shake every day. Record review of Resident #15's progress notes dated 7/3/19 at 2:42PM revealed, Resident with unplanned/unexpected weight loss, she is on [MEDICATION NAME] Acetate Suspension 400MG/10ML and weekly weights. Record review of Resident #15's progress notes dated 7/10/19 at 2:31PM revealed, Resident with unplanned/unexpected weight loss, she is on [MEDICATION NAME] Acetate Suspension 400MG/10ML and weekly weights. She is assisted with meals per staff. Resident weight is trending up. Continue plan of care . Record review of Resident #15's physician order [REDACTED]. Record review of Resident #15's progress notes dated 7/19/19, 7/30/19, and 8/20/19 revealed resident had been pocketing her food, had poor appetite, and had a decline in cognitive status. Notes indicated Physician was notified, she was assessed by speech therapy and downgraded to pureed diet. Record review of Resident #15's progress notes dated 8/26/19 at 12:03PM revealed in part, .weight 150.4lbs, 13.8lb loss (8.4%) X 1 month, 19.8lb loss (11.5%) X 3 months, 19.8lbs loss (11.6%) X 6 months . Mechanical soft diet, no raw vegetables, resident feeds self. Intakes have decreased - started on [MEDICATION NAME] acetate. No wounds, no [MEDICAL CONDITION] per nursing . Involuntary weight loss related to decreased intakes as evidenced by recent weight loss related to decreased intakes as evidenced by recent weight loss. Goal: no significant weight change > or + 5% of 150.4lbs X 1 month. Recommend to physician - med pass 2.0, 120Ml twice a day. Recommend - weekly weights X 4 weeks . Note was entered by RD. Record review of Resident #15's physician's orders [REDACTED]. Record review of Resident #15's progress notes dated 9/2/19 at 5:53AM revealed, MD and family aware of resident's weight loss. Interventions are in place. Dietitian reviewed. Will monitor weekly weights until stable. Observation, interview and record review on 9/13/19 at 12:25PM, Resident #15 was in dining room sitting in Geri chair pulled up to dining table. She had a meal tray in front of her that consisted of collard greens, corn bread, macaroni and cheese, ground fish with sauce on top. Resident was eating her food with assistance of CNA #9. Only beverage on tray was a cup of tea. Resident #15 meal ticket was on her tray. Review of the meal ticket revealed resident had a mechanical soft diet. Meal ticket did not mention resident requiring shake. Further observation at that time revealed other residents at the table (two residents) with cups of white milk like substance on their tray. CNA #9 said the cups consisted of house shake that was used to help resident maintain weight. She said if they get house shakes it was usually served with meal and would be on their meal ticket. Review of the meal tickets of the residents who had house shakes at the table revealed house shake was written at the top of their meal tickets. Record review of Resident #15's progress notes dated 9/15/19 and 9/16/19 revealed resident had been pocketing her food and had poor appetite. Notes indicated Physician was notified. Record review of Resident #15's progress notes dated 9/16/19 at 11:48AM revealed, .weight 141.6lbs, 8.8lb loss (5.9%) X 1 month, 19.6lb loss (12.2%) X 3 months, 29.2lb loss (17.1%) X 6 months . Receiving speech therapy. Nursing states resident pockets food. Meds: KCl (Potassium chloride), [MEDICATION NAME] acetate. Appetite is poor per nursing/observation . Recommend to physician - shakes with meals. Recommend weekly weights X 4 weeks . Note entered by RD. Observation and record review on 9/16/19 at 12:23PM, Resident #15 was in dining room being assisted with eating her meal. Resident had a house shake on her tray. Review of her meal ticket still revealed no mention of house shake. Speech Therapist also came over while resident being fed and observed how she was eating her food. Observation and record review on 9/18/19 at 12:30PM, Resident #15 was in dining room being assisted with eating her meal. Resident did not have a house shake on her tray and record review of her meal ticket revealed no mention of house shake. CNA #9 was assisting Resident #15 with eating and said she did not know if Resident #15 was ordered to have house shake's, but the staff would offer her one at meals if she didn't eat her food. Interview on 9/18/19 at 2:00PM, the Administrator said Resident #15 had unplanned weight loss but it was unavoidable due to her decreased food intake and the rapid decline in health she had. The Administrator said the shakes are served with meals. The Administrator did not know if Resident #15 was ordered to have house shake but said the staff were probably offering her one anyway because of her not eating her food. The Administrator said they did not put orders for house shake in the resident physician orders [REDACTED]. Administrator was told about surveyor's observations of Resident #15 and the recommendation that was accepted on 6/10/19 for her to receive house shakes every day and Administrator said he would look into it. Interview on 9/18/19 at 2:17PM, the RD said she had just come in and saw Resident #15 on 9/16/19 and gave recommendation for health shake due to her weight loss and poor consumption of food. The RD said she did not have her notes with her, so she could not recall the previous recommendation of shakes every day back on 6/4/19. She said she could usually tell if a resident was getting a house shake by their physician orders [REDACTED].#15 or if she was getting them and recommended to discontinue it. Interview on 9/18/19 at 2:25PM, the Administrator said he had investigated what happened to Resident #15's house shakes. He said she was getting the shakes and then her weight stabilized in July, so the weight loss committee decided to discontinue the shake. He said the committee was no longer active, but it was something the facility was doing to try and manage weight loss in the facility. He said the committee consisted of himself, DON, ADON, therapy, and dietary manager. He said the facility did not have documentation to show the resident had been getting the shakes, but the facility would now start documenting shake orders in resident physician orders, so it could be monitored through the MAR. The Administrator added that he knew Resident #15 was getting a house shake at least once a day because the resident had not been eating her food and he knows the staff would offer her a shake if she didn't eat but had no documentation to support. Interview on 9/18/19 at 2:41PM, the DON said she had only been back working at the facility for a month, so she was not sure what the facility process was for resident who had orders for house shake. The DON added when she previously worked at the facility she knew the process was to document in the resident's physicians' orders if there was an order for [REDACTED]. The DON said she did not know what they were doing now to monitor that shakes were ordered and given. Record review of Resident Weight Assessment and Intervention (Revision Date: 8/26/16) revealed in part, .3. Any weight change of 5% of more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the dietician. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. B. 3 month - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe . 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment .

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of fifteen residents (Resident #57) reviewed for care. Resident #57's pain was not adequately controlled. She was grimacing in pain while chewing her food and unable to finish her lunch. Resident #57 did not have a care plan to address her pain. Resident #57's was admitted on [DATE] with a [DIAGNOSES REDACTED]. This failure affected one resident and placed eight other residents at risk of not receiving prompt assessments and interventions concerning pain, which would cause a delay in treatment, a decline in mental and physical health and psychosocial well-being. Findings include: Resident #57 Record review of Resident #57's face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #57's MDS dated [DATE] revealed a BIMS score of 15, indicating she was cognitively intact. Further review of this MDS revealed she frequently had pain. When Resident #57 rated her pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain, she rated her pain at a seven. Record review of Resident #57's care plan with a last care plan review date of 9/26/16 revealed no plan of care or interventions to address the resident's facial pain. Record review of Resident #57's physician's orders [REDACTED]. [MEDICATION NAME] 300 MG give 1 capsule by moth two times a day related to Acute Pain Due to Trauma. [MEDICATION NAME] HCL 50 MG give 1 tablet by mouth every 8 hours as needed for Pain. Pain assessment scale pain scale: 1-4=mild; 5-8=moderate; 9-10=excruciating, every shift. Start date 9/21/16. Record review of Resident #57's Medication Administration Record [REDACTED]. Resident #57 reported pain levels up to a ten on the zero to ten scale. Further review revealed no follow-up on effectiveness of the pain medication. Further review of this MAR indicated [REDACTED]. Observation and interview of Resident #57 during initial tour on 09/27/16 at 9:20 a.m. revealed the resident in her room, groomed and dressed appropriately, ambulating from the restroom without assistance. Resident #57 said she wished someone could help her with her pain. She stated the left side of her face hurt all the time and it had gotten worse even though she was receiving medication for it. Observation and interview of Resident #57 on 09/28/16 at 12:30 p.m. revealed resident in the dining room eating lunch. She was holding the left side of her face and grimacing in pain. She appeared to be having trouble chewing. Resident #57 stated that her face was hurting so badly she was having trouble chewing her food. She further said she had told her nurse and taken a pain pill that morning, but it was not working. Resident #57 was only able to eat 50% of this meal. During an interview on 09/28/16 at 12:35 p.m. the DON said she was aware of Resident #57's pain. She further said she needed to check what medications had been given to the resident for pain. During an interview on 09/28/16 at 2:00 p.m., the DON stated she had called Resident #57's physician and received an order to increase her [MEDICATION NAME] dosage to three times daily. The DON said when Resident #57 was at the hospital, she was getting the [MEDICATION NAME] three times a day. The DON further said she did not know why the [MEDICATION NAME] was decreased to two times a day. During an interview on 9/29/16 at 8:57 a.m., LVN #4 said she was aware of Resident #57's frequent complaints of pain. She further said she was unable to find a care plan that addressed Resident #57's pain. On 9/29/16 at 9:15 a.m. the DON stated Resident #57 should have a care plan for her facial pain. At 9:45 a.m. the DON presented a care plan for Resident #57 dated 9/29/16. The focus of this care plan stated (Resident #57) has acute pain related to facial pain and included goals and interventions for this focus. Record review of the facility's policy Care Plans-Comprehensive MDS 3.0 which was last revised 4/30/12 stated in part . Each resident's comprehensive care plan is designed to a. Incorporate identified problem areas g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels . CMS form 672 dated 09/27/16 revealed 9 residents on a pain management program.

Based on interview and record review, the facility failed to implement policies and procedures that prohibited neglect for one of seven residents (CR# 1) reviewed for care provided after a change of condition had been identified. The facility failed to consult the physician, conduct on-going assessments, and interventions for CR#1 following a change in condition concerning a drop in his blood sugar and oxygen saturation on [DATE]. CR#1 was found unresponsive on [DATE] and sent to the hospital and was had severe respiratory distress, cyanotic skin and a cough. CR #1 was transferred to a higher acuity hospital where he died on [DATE]. The facility failed to assess and treat CR #1's skin disorder and eight wounds and unstageable pressure areas were identified when CR #1 was transferred to the hospital on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility continued to train its staff to monitor, assess, and promptly consult physicians when a change in condition was identified. This failure affected one resident who required hospitalization and placed 68 residents in the facility at risk of not receiving prompt intervention and having their physicians promptly consulted concerning a change in condition which could cause a delay in treatment and decline in health or death. Findings include: Intake # 3 Record review of CR#1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's hospital record revealed the patient was transferred to an acute care hospital on [DATE] where he died on [DATE]. Record review of CR#1's physician's orders [REDACTED]. Give one tube sublingually. Further review of the same physician's orders [REDACTED]. Record review of CR #1's MDS dated [DATE] revealed a cognition score of 0, indicating he was severely cognitively impaired for daily decision making skills. Continued review revealed he was dependent on staff for all ADLs except transfers which did not occur. Record review of CR #1's care plan dated [DATE] revealed the resident had diabetes mellitus. Goal was the resident would have no complications related to diabetes mellitus through the next review date. Approaches included: diabetes mellitus as ordered by doctor, dietary consult for nutritional regimen and ongoing monitoring, fasting serum blood sugar as ordered by doctor, monitor acceptance of prescribed diet and document any problem, monitor /document/report to MD as needed signs and symptoms of [DIAGNOSES REDACTED], sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech. Lack of coordination, staggering gait, monitor /document /report to MD as needed for signs and symptoms of infection to any open areas, redness, pain, heat swelling or pus formation. Record review of CR #1's MAR indicated [REDACTED]. Further review revealed he received the insulin every day in October until discharged on [DATE] Record review of CR #1's MAR indicated [REDACTED] 60 - 200 give 0 units 200 - 250 give 2 units 251 -300 give 4 units 301 - 350 give 6 units 351 -400 give 8 units Administer subcutaneously before meals and at bedtime related to diabetes mellitus type II. Further review of the same MAR indicated [REDACTED]. CR #1's blood sugars on Friday [DATE], one day prior to the resident's change of condition, revealed blood sugars of: 6:30 a.m. 116 11:30 a.m. 250 4:30 p.m. 274 8:00 p.m. 224. On the same MAR indicated [REDACTED] 6:30 a.m. 65 11:30 a.m. 120 4:30 p.m. 107 8:00 p.m. 109 The 8:00 p.m. medication, [MEDICATION NAME] 20 units, was administered everyday in October except [DATE] when it was held. Record review of CR#1's MAR indicated [REDACTED] [DATE] at 6:30 a.m., blood sugar was 63 [DATE] at 6:30 a.m., blood sugar was 65 [DATE] at 6:30 a.m., blood sugar was 55 There was no documentation on the October MAR indicated [REDACTED] Record review of CR #1's skilled nursing note/every shift dated [DATE] at 2:53 P.M. revealed no emesis noted, oxygen at 2 liters via nasal cannula with saturation 98%, no pain or distress. Record review of CR #1's skilled nursing note/every shift dated [DATE] at 5:55 p.m. revealed resident alert and oriented to self, resident was mostly non-verbal, will say a few small words at times, resident is incontinent of bowel with foley catheter draining light yellow clear urine to bedside. Peri care done every 2 hours and as needed. Total care required for activities of daily living, toileting and transfers, respiration even and unlabored with lungs clear through auscultation bilaterally. Abdomen soft and non-tender with slight bowel sounds on 4 quadrants, no pain or distress noted will continue to monitor. Record review of CR #1's MAR indicated [REDACTED]. Record review of CR#1's nurses' notes dated [DATE] at 8:45 a.m., revealed resident noted with blood sugar 65. RN notified. Provided orange juice, resident tolerated well, Blood pressure ,[DATE], oxygen saturation was 77, and pulse 81. Provided oxygen at 2 liters with nasal cannula, rechecked blood sugar and oxygen at 8:30 a.m Blood sugar was 66, and oxygen saturation was 98. Resident currently eating breakfast and tolerating well. Will continue to monitor, MD notified. Record review of CR#1's clinical record revealed a fax sheet to CR#1's physician dated Saturday [DATE] (no time). Notes read FYI, Resident noted with blood sugar 65, RN notified, provided orange juice, resident tolerated well, blood pressure ,[DATE], oxygen saturation 77, pulse-81. Provided oxygen at 2 liters with nasal cannula. Rechecked blood sugar and oxygen saturation at 8; 30 a.m., blood sugar 66 and oxygen saturation 98. Resident currently eating breakfast and toleration well. Will continue to monitor. Continued review of a hand written physician note revealed ok, initials and date-[DATE]. Review of CR #1's medical record revealed no consultation with the physician other than the fax sent to his office Saturday morning [DATE], with the blood sugar of 65 noted. Record review of CR#1's MAR indicated [REDACTED]. Record review of CR #1's skilled nursing note/every shift dated [DATE] at 2:53 p.m. revealed no emesis noted, oxygen at 2 liters via nasal cannula with saturation 98%, no pain or distress. Record review of CR #1's skilled nursing note/every shift dated [DATE] at 5:55 p.m. revealed resident alert and oriented to self, resident was mostly non-verbal, will say a few small word at times. Resident is incontinent of bowel with Foley catheter draining light yellow clear urine to bedside. Peri care done every 2 hours and as needed. Total care required for activities of daily living, toileting and transfers, respiration even and unlabored with lungs clear through auscultation bilaterally. Abdomen soft and non-tender with slight bowel sounds on 4 quadrants, no pain or distress noted will continue to monitor. Record review of CR #1's nurses notes written by LVN #1 dated [DATE] at 7:15 a.m., revealed Resident blood sugar 55 and rechecked blood sugar. Provided orange juice but did not tolerate well. Resident unresponsive to verbal and external stimuli. Vitals-blood pressure ,[DATE], temperature 101.5, oxygen saturation 85 via nasal cannula with labored breathing, pulse 54. Called EMS. Resident transported to community hospital, spouse notified, MD and DON notified. Will continue to follow up with resident . Record review of CR #1's nurses notes dated [DATE] at 8:16 a.m., written by RN #1 revealed notified at 7:05 a.m. that CR #1 was unable to take his meds and seemed very drowsy. Checked CR#1. He did not respond to verbal stimuli or to more robust stimuli. Blood sugar checked twice, 55 and 58. Oxygen saturation at 2 liters-78% flow increased to 4 liters. Call made to 911 for transfer to community hospital. Call placed to MD no answer at this time, will continue to try to notify. Vitals were ,[DATE], pulse 58; respiration 20 slightly wet and labored, temperature- 101.5. DON notified, transferred to hospital about 7:30 a.m. Interview on [DATE] at 2:00 p.m., the DON said CR #1 had readmission orders [REDACTED]. Interview on [DATE] at 2:40 p.m., the DON said she was approached by the resident's family member on Thursday ([DATE]) evening who asked her to check on CR #1. The DON said CR #1's family member told her the resident did not look well and had not spoken well that day. The family member was concerned and needed someone to check on CR #1. The DON said after her assessment, she did not notice any change. The DON further stated on [DATE] when CR#1 was found with a change in condition, neither LVN #1 or RN #1 called or notified her. The DON said she knew about CR #1's condition from the previous night when she had assessed him. The DON said the staff believed their interventions were adequate and worked. The DON agreed CR#1 had a significant change that should have been promptly communicated to his physician despite staff's temporary interventions. Interview on [DATE] at 3:10 p.m., LVN #1 stated when she identified CR #1's change in condition on [DATE] (Saturday), she assessed the resident, put him on oxygen, notified the RN weekend supervisor and then sent the resident's physician a fax. LVN #1 said the next morning ([DATE]) the Medication aide notified her that CR#1 was unable to take his morning medications. LVN #1 stated she went to CR #1's room and found him unresponsive and drowsy. She called 911 and CR #1 was transferred to the hospital. LVN #1 said she recalled the resident's glucose gel order had parameters but did not know why they were not administered when his blood sugar was low. LVN #1 said the glucose gel was available. Interview on [DATE] about 3:30 p.m., RN #1 said she was told CR #1 had a change of condition the morning of [DATE]. RN #1 said she assessed the resident with LVN#1, placed him on oxygen via nasal cannula and gave him orange juice for his low blood sugar. RN #1 said the interventions worked and LVN #1 was to notify the physician. RN#1 said LVN#1 told her she notified the physician and she believed her. RN #1 said she did not know how LVN #1 notified CR#1's physician. Record review of CR#1's nurse notes written by the wound /treatment nurse LVN #2 dated [DATE] at 7:09 p.m., revealed the resident was admitted with a systemic rash to the trunk, back and all extremities as well as the face. The rash was in small blotched areas and bright red in color. The resident had severe [MEDICAL CONDITION] to the entire back with moisture associated skin damage. Portions of the skin were noted to be open with active bleeding to the open areas. Skin on the back was dark red to bright red in color. The note documented the staff would continue with current treatment of [REDACTED]. They would turn and reposition every 2 hours and would have an air mattress for pressure relief. Resident had a special pressure relieving cushion in place on his wheelchair while in use. Resident was also noted with excoriations to his buttocks and scrotum and care staff would continue to provide incontinent care as needed and apply moisture barrier to these areas. Record review of CR #1's MDS dated [DATE] revealed cognition score of 0 which meant he was severely cognitively impaired. Resident CR #1 was dependent on staff for all ADLs except transfers which did not occur. The MDS also identified the resident was incontinent of bowel and bladder. Further review of MDS revealed CR#1 had moisture associated skin damage and received application of ointment/medication for it. There were no wound or pressure ulcer documented. Record review of CR #1's nurse notes written by the wound/treatment nurse LVN #2 dated [DATE] at 5:50 p.m., and on [DATE] at 7:05 P.M. revealed CR#1's [MEDICAL CONDITION] continued with the same skin assessment as on [DATE]. The Systemic rash had resolved and the excoriations to buttocks had improved since admission. Treatments remained the same with the addition of an air mattress. There were no other skin assessments documented after [DATE] and when requested of the nursing staff none were provided for review. Record review of CR#1's [DATE] Treatment Administration Record revealed the following physician's orders [REDACTED].>Barrier cream with Zinc, apply to back areas every shift for itching. Ordered [DATE] and discontinued [DATE] and was reordered [DATE]. [MEDICATION NAME] powder, apply to back area topically, twice a day for itching, ordered [DATE] [MEDICATION NAME] cream 0.1%, apply to back area topically twice a day for itching, ordered [DATE]. Record review of CR #1's care plan dated [DATE] revealed the resident had a potential/actual impairment to skin integrity related to [MEDICAL CONDITION] and a history of skin issues and moisture associated skin damage. Goal was the resident will have no complications from skin infection through the review date. Approaches include: encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocol for treatment of [REDACTED]. to MD. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Record review of CR #1's hospital record dated [DATE] revealed CR #1's had wounds on the following areas: Two wounds to his mid back and one to his lower back surrounded by dry excoriated skin. Wound to his coccyx and buttock area. Two unstageable wounds to right lower extremity foot, ankle and heel (foot - one medial to right inner ankle and another to anterior foot - top of foot) . Unstageable to right posterior leg. Unstageable to left heel. Unstageable to top of left foot. Record review of CR #1's hospital record dated [DATE] revealed the chief complaint was respiratory distress/failure. Physical examination revealed the patient appeared ill with severe respiratory distress, cyanotic skin, an moaned with painful stimuli. There was an associated cough, fever and leg swelling. CR #1 was transferred from the nursing home with complaints of low blood sugar of 55, ( EMS reported blood sugar of 45) temperature was 101.5 with congested respirations. Diagnostic considerations were cardiogenic shock, [MEDICAL CONDITION], pneumonia, [MEDICAL CONDITION] embolism and [MEDICAL CONDITIONS]. Further review of this record revealed impressions as hyperosmolality and [MEDICAL CONDITION], [DIAGNOSES REDACTED], lobar pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION], altered mental status, diabetic mellitus with [DIAGNOSES REDACTED] with coma and [MEDICAL CONDITION]. Further review of above record revealed CR #1 was transferred to an acute care hospital on [DATE] where he died [DATE]. Record review of facility's policy on abuse and neglect revised [DATE] defined neglect as failure to provide goods, treatment and services necessary to avoid physical harm, mental anguish or mental illness. Record review of facility policy on acute condition changes not dated revealed any resident is at risk of an acute change in condition, upon admission the interim plan of care will address [DIAGNOSES REDACTED]. Before contacting the physician the nurse should fully assess the resident, this will allow accurate and pertinent collections of the resident status. This can be provided orally or by fax. The nursing staff will contact the physician based on the urgency of the situation for emergencies, they will call or page the physician and request a prompt response (within approximately half an hour). 7b-a significant change in condition is any change noted in your resident that does not return them to their baseline within two hour time frame. Change in mention, major variations in vital signs or any injury that requires more than first aide and signs of impending stroke etc. if unable to reach a physician in a timely manner in an emergency situation, it is appropriate to call 911, document all attempts to contact physician and the reason for calling emergency services. The facility Administrator and DON were notified on [DATE] at 2:24 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ : 1. All available licensed staff were in-serviced on [DATE] at 4:00 p.m. on appropriate identification for a resident's change of condition. This in-service was conducted by the DON. Any staff not available will not be eligible to return to work until training has been conducted. 2. Staff were educated on physician notification. They will be following the Interact Protocol for immediate notification. Vital Sign Policy Immediate physician notification (including the weekends) should occur with the following vital signs/change in condition indicators: · Blood Pressures that are > ,[DATE] or < ,[DATE] · Resting pulse >100, <60 · Respirations >28, <10/minute · Oral temp >100.5 · O2 saturation <90% · Blood Sugar that are >400 or <60. (based on universal sliding scales) THIS MEANS A PHONE CALL WITH A RESPONSE. IF NO RESPONSE IS OBTAINED WITHIN 30 MINUTES YOU MUST NOTIFY THE DON WHO WILL INSTRUCT YOU ON FURTHER ACTION. 3. A list of residents that have had a condition change was provided by the ADON at 6:25 p.m. on [DATE]. These residents were assessed by the DON on [DATE] at 7:00 p.m. and no further action was necessary. All necessary notifications and care was provided by licensed staff per protocol. 4. Every day, there will be a morning and afternoon clinical meeting with licensed staff to discuss any areas of concern that require further monitoring. This meeting will be conducted by the DON, ADON or designee. The minutes of this meeting will be kept in a binder and maintained by the DON. This meeting will also be conducted by the weekend RN and returned to the DON. Initiated on [DATE]. 5. The Weekend supervisor will also be provided with a report and a task list of areas of concern that must be assessed for further follow up and care. The task list will require the weekend RN to sign off and return this task list to the DON. This task list will be prepared each week by the DON, ADON or designee. Initiated on [DATE]. 6. Audits will be conducted by the DON, ADON or corporate nurse on identified resident concerns. These audits will be conducted daily until there is 100% compliance with this protocol. Results of all audits will be reported to the Administrator daily and as necessary and will also be reported to the QA committee at least monthly. Initiated on [DATE]. This constitutes our plan of removal for the immediate jeopardy cited on [DATE]. The plan of removal was accepted on [DATE] at 4:00 P.M. Plan of Removal Monitoring: 1. Reviewed newly implemented Vital Sign Policy dated ,[DATE]. 2. Reviewed documentation dated [DATE] and [DATE] that licensed staff, medication aides and CNAs were in-serviced on the new Vital Sign Policy, change in condition and when to report. 3. Interviews were conducted on [DATE] and [DATE] with the following results: 100% of all licensed staff, medications aides and CNAs on duty during two shifts had been in-serviced and were able to identify the protocol for vital sign policy, change in condition and when to report . The DON stated on [DATE] all staff had been in-serviced on the new Vital Sign Policy, change in condition and when to report as of [DATE]. 4. Reviewed documentation dated [DATE] of review made on four Resident who experienced a change of condition. 5. Reviewed documentation on two of the four Residents who experienced a change of condition who remained in the facility. On [DATE] at 4:36 P.M., the DON stated two of the four Residents identified with a change in condition were no longer residing in the facility. She stated there were no new residents identified with a change in condition. She stated they were continuing to monitor all residents identified with a change in condition daily and this information would be reviewed by the QA committee at least monthly. On [DATE] at 4:36 P.M. the DON was notified the IJ was removed. However, the facility remained out of compliance at a severity level of the actual harm with a scope of isolated. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning changes in condition. Facility ADON reported 68 residents on [DATE].

Based on interview, and record review, the facility failed to consult with the resident's physician when there was a change in condition in one of seven residents (CR#1) reviewed for consulting with the physician. CR#1's physician was not consulted on Saturday [DATE] but staff faxed information to the physician's office on Saturday, [DATE] when the resident had a significant change in condition where his blood sugar and oxygen saturation dropped. CR #1's respiratory status continued to deteriorate on [DATE] when he was discovered unresponsive and was transferred to the local hospital where he was diagnosed with [REDACTED]. CR#1 later died on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to train its staff to assess residents and promptly consult physicians when a change of condition was identified. This failure affected one resident who required hospitalization for a significant change in condition and later died and placed 68 residents in the facility at risk of not receiving prompt interventions for their medical changes due to their physician not being promptly consulted which could cause a decline in health or death. Findings include: Intake # 3 CR#1 Record review of CR#1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR#1's MDS dated [DATE] revealed a cognition score of 0, indicating he was severely cognitively impaired for daily decision making skills. Continued review revealed he was dependent on staff for all ADLs except transfers which did not occur. Record review of CR#1's care plan dated [DATE] revealed the resident had diabetes mellitus. Goal was the resident would have no complications related to diabetes mellitus through the next review date. Approaches included: diabetes mellitus as ordered by doctor, dietary consult for nutritional regimen and ongoing monitoring, fasting serum blood sugar as ordered by doctor, monitor acceptance of prescribed diet and document any problem, monitor /document/report to MD as needed signs and symptoms of [DIAGNOSES REDACTED], sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech. Lack of coordination, staggering gait, monitor /document /report to MD as needed for signs and symptoms of infection to any open areas, redness, pain, heat swelling or pus formation. Record review of CR #1's MAR dated [DATE] revealed the resident received [MEDICATION NAME] Solution 100 unit/ml 20 units subcutaneously routinely at bedtime for his diabetes mellitus type II. Further review revealed he received the insulin every day in October until discharged on [DATE] Record review of CR #1's MAR dated [DATE] revealed an additional physician's order [REDACTED]. 60 - 200 give 0 units 200 - 250 give 2 units 251 -300 give 4 units 301 - 350 give 6 units 351 -400 give 8 units Administer subcutaneously before meals and at bedtime related to diabetes mellitus type II. Further review of the same MAR revealed CR #1's blood sugars from [DATE] till [DATE] at 8:00 pm ranged from a high of 368 to a low of 134 with 14 of the 23 days having readings in the 200s. CR #1 ' s blood sugars on Friday [DATE], one day prior to the resident ' s change of condition, revealed blood sugars of: 6:30 a.m. 116 11:30 a.m. 250 4:30 p.m. 274 8:00 p.m. 224. On the same MAR dated [DATE] revealed blood sugars of 6:30 a.m. 65 11:30 a.m. 120 4:30 p.m. 107 8:00 p.m. 109, documented on the MAR the medication was not administered. Record review of CR#1's nurses' notes dated [DATE] at 8:45 a.m., revealed resident noted with blood sugar 65. RN notified. Provided orange juice, resident tolerated well, Blood pressure ,[DATE], oxygen saturation was 77, and pulse 81. Provided oxygen at 2 liters with nasal cannula, rechecked blood sugar and oxygen at 8:30 am. Blood sugar was 66, and oxygen saturation was 98. Resident currently eating breakfast and tolerating well. Will continue to monitor, MD notified. Record review of CR#1's clinical record revealed a fax sheet to CR#1's physician dated [DATE] (no time). Notes read FYI, Resident noted with blood sugar 65, RN notified, provided orange juice, resident tolerated well, blood pressure ,[DATE], oxygen saturation 77, pulse-81. Provided oxygen at 2 liters with nasal cannula. Rechecked blood sugar and oxygen saturation at 8:30 am, blood sugar 66 and oxygen saturation 98. Resident currently eating breakfast and toleration well. Will continue to monitor. Continued review of a hand written physician note revealed ok, initialed and dated by the physician on [DATE]. Review of CR #1's medical record revealed no consultation with the physician other than the fax sent to his office Saturday morning [DATE], with the blood sugar of 65 noted. Interview on [DATE] at 2:40 p.m., the DON said she was approached by the resident's family member on Thursday ([DATE]) evening who asked her to come and check on CR #1. The DON said CR#1's family member told her the resident did not look well and had not spoken well that day. The family member was concerned and needed someone to check on CR #1. The DON said after her assessment, she did not notice any change. The DON further stated on [DATE] when CR#1 was found with a change in condition, neither LVN #1 or RN#1 called or notified her. The DON said she knew about CR#1's condition from the previous night when she assessed him for the family. The DON said the staff believed their interventions of orange juice and oxygen were adequate interventions and had worked. The DON agreed CR#1 had a significant change that should have been promptly communicated to his physician despite staff's temporary interventions. Interview on [DATE] at 3:10 p.m., LVN # 1 stated when she identified CR#1's change in condition on [DATE], she assessed the resident, put him on oxygen, notified the RN weekend supervisor and then sent the resident's physician a fax to notify him. LVN #1 said the next morning ([DATE]) the Medication aide notified her that CR#1 was unable to take his morning medications. LVN #1 stated she went to CR #1's room and found him unresponsive and drowsy. She called 911 and CR #1 was transferred to the hospital. Interview on [DATE] at 3:30 pm, RN #1 said she was told CR #1 had a change of condition the morning of [DATE]. RN #1 said she assessed the resident with LVN#1, placed him on oxygen via a nasal cannula and gave him orange juice for his low blood sugar. RN #1 said the interventions worked and LVN #1 was to notify the physician. RN#1 said LVN#1 told her she notified the physician and she believed her. RN #1 said she did not know how LVN #1 notified CR#1's physician. Record review of CR#1's hospital record dated [DATE] revealed the chief complaint was respiratory distress/failure. Physical examination revealed patient appeared ill with severe respiratory distress, cyanotic skin, an moaned with painful stimuli. There was an associated cough, fever and leg swelling. CR #1 was transferred from the nursing home with complaints of low blood sugar of 55, ( EMS reported blood sugar of 45) temperature was 101.5, and congested respirations. Diagnostic considerations were cardiogenic shock, [MEDICAL CONDITION], pneumonia, [MEDICAL CONDITION] embolism and [MEDICAL CONDITIONS]. Further review of this record revealed impressions as hyperosmolality and [MEDICAL CONDITION], [DIAGNOSES REDACTED], lobar pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION], altered mental status, diabetic mellitus with [DIAGNOSES REDACTED] with coma and [MEDICAL CONDITION]. Further review of above record revealed the patient was transferred to an acute care hospital on [DATE] where he died on [DATE]. Record review of facility policy on acute condition changes not dated revealed any resident is at risk of an acute change in condition, upon admission the interim plan of care will address [DIAGNOSES REDACTED]. Before contacting the physician the nurse should fully assess the resident, this will allow accurate and pertinent collections of the resident status. This can be provided orally or by fax. The nursing staff will contact the physician based on the urgency of the situation for emergencies, they will call or page the physician and request a prompt response (within approximately half an hour). 7b-a significant change in condition is any change noted in your resident that does not return them to their baseline within two hour time frame. Change in mention, major variations in vital signs or any injury that requires more that first aide and signs of impending stroke etc. if unable to reach a physician in a timely manner in an emergency situation, it is appropriate to call 911, document all attempts to contact physician and the reason for calling emergency services. The facility Administrator and DON were notified on [DATE] at 2:24 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ and SQC: 1. All available licensed staff were in-serviced on [DATE] at 4:00 pm on appropriate identification for a resident ' s change of condition. This in-service was conducted by the DON. Any staff not available will not be eligible to return to work until training has been conducted. 2. Staff were educated on physician notification. They will be following the Interact Protocol for immediate notification. Vital Sign Policy Immediate physician notification (including the weekends) should occur with the following vital signs/change in condition indicators: · Blood Pressures that are > ,[DATE] or < ,[DATE] · Resting pulse >100, <60 · Respirations >28, <10/minute · Oral temp >100.5 · O2 saturation <90% · Blood Sugar that are >400 or <60. (based on universal sliding scales) THIS MEANS A PHONE CALL WITH A RESPONSE. IF NO RESPONSE IS OBTAINED WITHIN 30 MINUTES YOU MUST NOTIFY THE DON WHO WILL INSTRUCT YOU ON FURTHER ACTION. 3. A list of residents that have had a condition change was provided by the ADON at 6:25 PM on [DATE]. These residents were assessed by the DON on [DATE] at 7:00 pm and no further action was necessary. All necessary notifications and care was provided by licensed staff per protocol. 4. Every day, there will be a morning and afternoon clinical meeting with licensed staff to discuss any areas of concern that require further monitoring. This meeting will be conducted by the DON, ADON or designee. The minutes of this meeting will be kept in a binder and maintained by the DON. This meeting will also be conducted by the weekend RN and returned to the DON. Initiated on [DATE]. 5. The Weekend supervisor will also be provided with a report and a task list of areas of concern that must be assessed for further follow up and care. The task list will require the weekend RN to sign off and return this task list to the DON. This task list will be prepared each week by the DON, ADON or designee. Initiated on [DATE]. 6. Audits will be conducted by the DON, ADON or corporate nurse on identified resident concerns. These audits will be conducted daily until there is 100% compliance with this protocol. Results of all audits will be reported to the Administrator daily and as necessary and will also be reported to the QA committee at least monthly. Initiated on [DATE]. This constitutes our plan of removal for the immediate jeopardy cited on [DATE]. The plan of removal was accepted on [DATE] at 4:00 P.M. Plan of Removal Monitoring: 1. Reviewed newly implemented Vital Sign Policy dated ,[DATE]. 2. Reviewed documentation dated [DATE] and [DATE] that licensed staff, medication aides and CNAs were in-serviced on the new Vital Sign Policy, change in condition and when to report. 3. Interviews were conducted on [DATE] and [DATE] with the following results: 100% of all licensed staff, medications aides and CNAs on duty during two shifts had been in-serviced and were able to identify the protocol for vital sign policy,change in condition and when to report . The DON stated on [DATE] all staff had been in-serviced on the new Vital Sign Policy, change in condition and when to report as of [DATE]. 4. Reviewed documentation dated [DATE] of review was made on four Resident who experienced a change of condition without any discrepancies noted outside of the new policies. 5. Reviewed documentation on two of the four Residents who experienced a change of condition who remained in the facility with no problems identified On [DATE] at 4:36 P.M., the DON stated two of the four Residents identified with a change in condition were no longer residing in the facility. She stated there were no new residents identified with a change in condition. She stated staff were continuing to monitor all residents identified with a change in condition daily and this information would be reviewed by the QA committee at least monthly. On [DATE] at 4:36 P.M. the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of isolated. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning changes in condition. Facility ADON reported 68 residents on [DATE].

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable mental and physical well-being in accordance with the comprehensive assessment and plan of care for one of seven residents (CR#1) reviewed for quality of care. The facility failed to assess and treat CR #1's skin disorder and the eight wounds and unstageable pressure areas identified when CR #1 was transferred to the hospital on [DATE]. The facility failed to consult the physician when CR #1 had a change in condition on [DATE] concerning a decline in his respiratory status and blood sugars. The staff failed to provide the physician ordered treatment for [REDACTED]. The resident became unresponsive on [DATE] and was transferred to the hospital where he was diagnosed with [REDACTED]. CR #1 died in the hospital on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility continued to train its staff to provide skin assessments, treatments as ordered and promptly consult physicians when a change in condition was identified. This failure affected one resident who required hospitalization following a significant change of condition on [DATE] and [DATE] and placed 68 residents in the facility at risk of not receiving prompt intervention and having their physicians promptly consulted concerning a change in condition which could cause a delay in treatment and a decline in health or death. Findings include: Intake # 3 Record review of CR #1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's hospital record revealed the patient was transferred to an acute care hospital on [DATE] where he died on [DATE]. Record review of CR #1's nurse notes written by the wound /treatment nurse LVN #2 dated [DATE] at 7:09 p.m., revealed the resident was admitted with a systemic rash to the trunk, back and all extremities as well as the face. The rash was in small blotched areas and bright red in color. The resident had severe [MEDICAL CONDITION] to the entire back with moisture associated skin damage. Portions of the skin were noted to be open with active bleeding to the open areas. Skin on the back was dark red to bright red in color. The note documented the staff would continue with current treatment of [REDACTED]. They would turn and reposition every 2 hours and would have an air mattress for pressure relief. Resident had a special pressure relieving cushion in place on his wheelchair while in use. Resident was also noted with excoriations to his buttocks and scrotum and care staff would continue to provide incontinent care as needed and apply moisture barrier to these areas. Record review of CR #1's MDS dated [DATE] revealed cognition score of 0 which meant he was severely cognitively impaired. Resident CR #1 was dependent on staff for all ADLs except transfers which did not occur. The MDS also identified the resident was incontinent of bowel and bladder. Further review of MDS revealed CR#1 had moisture associated skin damage and received application of ointment/medication for it. There were no wound or pressure ulcer documented. Record review of CR #1's nurse notes written by the wound/treatment nurse LVN #2 dated [DATE] at 5:50 p.m., and on [DATE] at 7:05 P.M. revealed CR#1's [MEDICAL CONDITION] continued with the same skin assessment as on [DATE]. The Systemic rash had resolved and the excoriations to buttocks had improved since admission. Treatments remained the same with the addition of an air mattress. There were no other skin assessments documented after [DATE] and when requested of the nursing staff none were provided for review. Record review of CR #1's [DATE] Treatment Administration Record revealed the following physician's orders: Barrier cream with Zinc, apply to back areas every shift for itching. Ordered [DATE] and discontinued [DATE] and was reordered [DATE]. [MEDICATION NAME] powder, apply to back area topically, twice a day for itching, ordered [DATE] [MEDICATION NAME] cream 0.1%, apply to back area topically twice a day for itching, ordered [DATE]. Record review of CR #1's care plan dated [DATE] revealed the resident had a potential/actual impairment to skin integrity related to [MEDICAL CONDITION] and a history of skin issues and moisture associated skin damage. Goal was the resident will have no complications from skin infection through the review date. Approaches include: encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocol for treatment of [REDACTED]. to MD. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Interview on [DATE] at 11:40a.m., hospital staff said CR#1 was brought in by the EMS in severe respiratory distress, very congested and coma. CR #1's blood sugar was 45 according the EMS crew and he was given [MEDICATION NAME] water on transit. Hospital staff said the resident was transferred from the nursing home for low blood sugar and there was no mention of his respiratory distress and elevated temperature. Hospital staff said the resident was very critical and needed to immediately intubated, he was found to be septic, had pneumonia and wounds all over his body. Hospital staff stated it was unclear how no one identified all the symptoms he presented. Resident was not groomed; he had a buildup of dirt around his peri-area. Hospital staff said the resident had a very poor prognosis and was transferred to a high acuity hospital. Interview on [DATE] about 2:25 p.m., CNA #1 said the resident had a lot of rashes to his skin and described the resident's skin as flaky. CNA #1 stated the skin was worse when he was admitted . She said staff were supposed to apply barrier cream to CR #1's back, buttocks and scrotum areas. She said the resident had a small area to his heel (left), which was not open and dark in color. She further expressed the skin issues got better some times. CNA #1 said the resident, before he was transferred to the hospital, did not look well. She stated one of the nights she worked with him she had notified the nurse that he just did not look good. She stated the resident was not eating well and his breathing was off. Before he was sent to the hospital, he could no longer talk. Interview on [DATE] at 2:43 p.m., LVN #3 said CR #1 had [MEDICAL CONDITION] to his back. CR #1 received treatment -[MEDICATION NAME] cream to his back and his excoriations to the buttocks and scrotum. LVN #3 stated she completed monthly summaries (general assessments) on the resident but the wound/treatment nurse was responsible for the weekly skin assessment. LVN #3 said the resident also had an indwelling catheter that leaked from time to time. The leaking stopped when the catheter was changed. Interview on [DATE] at 4:00 p.m., LVN #2, wound /treatment nurses, said the charge nurses were responsible for weekly skin assessment for at risk residents. He said he did some assessment on CR #1 when the resident was first admitted . He recalled the resident had a lot of skin issues, rashes, [MEDICAL CONDITION] and excoriations. He also stated the areas got better but he was not following up on him because the charge nurses should be doing weekly skin assessments and report any wounds or any other skin issues that required his attention. Interview on [DATE] at 3:00 p.m., the DON said the resident admitted to the facility from a wound specialty hospital. He had an unusual skin [MEDICAL CONDITION] which got better while he was in the facility. The DON said CR #1 had some kind of moisture associated skin damage. She believed the resident was at high risk for pressure ulcers due to his bed bound status and being incontinence of bowel and bladder. She agreed staff should have been doing skin assessment to evaluate the treatment provided and identify new skin issues. Record review of CR #1's physician's order dated [DATE] revealed Glucose gel 40% ([MEDICATION NAME] Diabetic Use), give one applicator full by mouth as needed for Diabetes mellitus, if blood sugar was ,[DATE]. Give one tube sublingually. Further review of the same physician's order dated [DATE] revealed give two applicators full by mouth as needed if blood sugar was less than 55. Record review of CR #1's care plan dated [DATE] revealed the resident had diabetes mellitus. Goal was the resident would have no complications related to diabetes mellitus through the next review date. Approaches included: diabetes mellitus treatments as ordered by doctor, dietary consult for nutritional regimen and ongoing monitoring, fasting serum blood sugar as ordered by doctor, monitor acceptance of prescribed diet and document any problem, monitor/document/report to MD as needed signs and symptoms of [DIAGNOSES REDACTED], sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech. Lack of coordination, staggering gait, monitor /document /report to MD as needed for signs and symptoms of infection to any open areas, redness, pain, heat swelling or pus formation. Record review of CR #1's MAR indicated [REDACTED]. Further review revealed he received the insulin every day in October until discharged on [DATE]. Record review of CR #1's MAR indicated [REDACTED] 60 - 200 give 0 units 200 - 250 give 2 units 251 -300 give 4 units 301 - 350 give 6 units 351 -400 give 8 units Administer subcutaneously before meals and at bedtime related to diabetes mellitus type II. Further review of the same MAR indicated [REDACTED]. CR #1's blood sugars on Friday [DATE], one day prior to the resident ' s change of condition, revealed blood sugars of: 6:30 a.m. 116 11:30 a.m. 250 4:30 p.m. 274 8:00 p.m. 224 On the same MAR indicated [REDACTED] 6:30 a.m. 65 11:30 a.m. 120 4:30 p.m. 107 8:00 p.m. 109 The 8:00 p.m. medication, [MEDICATION NAME] 20 units, was administered every day in October except [DATE] when it was held. Record review of CR #1's MAR indicated [REDACTED] [DATE] at 6:30 a.m., blood sugar was 63 [DATE] at 6:30 a.m., blood sugar was 65 [DATE] at 6:30 a.m., blood sugar was 55 Continued review of CR #1's [DATE] MAR indicated [REDACTED]. Record review of CR #1's nurses notes dated [DATE] at 8:45a.m., revealed resident noted with blood sugar 65. RN notified. Provided orange juice, resident tolerated well, Blood pressure ,[DATE], oxygen saturation was 77, and pulse 81. Provided oxygen at 2 liters with nasal cannula, rechecked blood sugar and oxygen at 8:30a.m. Blood sugar was 66, and oxygen saturation was 98. Resident currently eating breakfast and tolerating well. Will continue to monitor, MD notified. Record review of CR #1's clinical records revealed a fax sheet to CR #1's physician on [DATE] (no time). Notes read FYI, Resident noted with blood sugar 65, RN notified, provided orange juice, resident tolerated well, blood pressure ,[DATE], oxygen saturation 77, pulse-81. Provided oxygen at 2 liters with nasal cannula. Rechecked blood sugar and oxygen saturation at 8:30a.m., blood sugar 66 and oxygen saturation 98. Resident currently eating breakfast and toleration well. Will continue to monitor. There was a hand written from the physician ok initialed and dated-[DATE]. Review of CR #1's medical record revealed no consultation with the physician other than the fax sent to his office Saturday morning[DATE], with the blood sugar of 65 noted. Record review of CR #1's nurses notes written by LVN #1 dated [DATE] at 7:15 a.m., revealed Resident blood sugar 55 and rechecked blood sugar. Provided orange juice but did not tolerate well. Resident unresponsive to verbal and external stimuli. Vitals-blood pressure ,[DATE], temperature 101.5, oxygen saturation 85 via nasal cannula with labored breathing, pulse 54. Called EMS. Resident transported to community hospital, spouse notified, MD and DON notified. Will continue to follow up with resident. Record review of CR #1's skilled nursing note/every shift dated [DATE] at 2:53 P.M. revealed no emesis noted, oxygen at 2 liters via nasal cannula with saturation 98%, no pain or distress. Record review of CR #1's skilled nursing note/every shift dated [DATE] at 5:55 p.m. revealed resident alert and oriented to self, resident was mostly non-verbal, will say a few small words at times, resident is incontinent of bowel with foley catheter draining light yellow clear urine to bedside. Peri care done every 2 hours and as needed. Total care required for activities of daily living, toileting and transfers, respiration even and unlabored with lungs clear through auscultation bilaterally. Abdomen soft and non-tender with slight bowel sounds on 4 quadrants, no pain or distress noted will continue to monitor. Record review of CR #1's MAR indicated [REDACTED]. Record review of CR #1's nurses notes dated [DATE] at 8:16 a.m., written by RN #1 revealed notified at 7:05 a.m. that CR #1 was unable to take his meds and seemed very drowsy. Checked CR #1. He did not respond to verbal stimuli or to more robust stimuli. Blood sugar checked twice, 55 and 58. Oxygen saturation at 2 liters-78% flow increased to 4 liters. Call made to 911 for transfer to community hospital. Call placed to MD no answer at this time, will continue to try to notify. Vitals were ,[DATE], pulse 58; respiration 20 slightly wet and labored, temperature- 101.5. DON notified, transferred to hospital about 7:30 a.m. Interview on [DATE] at 2:00 p.m., the DON said CR #1 had readmission orders [REDACTED]. Interview on [DATE] at 2:40 p.m., the DON said she was approached by the CR #1's family member on Thursday ([DATE]) evening who asked if she could come and check on CR #1. The DON said CR #1's family member said the resident did not look well and had not spoken to her well that day. The family member was concerned and needed someone to check on the resident for her. The DON said after her assessment she did not notice any change. The DON further said on [DATE] when CR #1 was assessed with [REDACTED].#1 nor RN #1 called or notified her. She said she kind of knew about CR #1 from the previous night when she had assessed him. The DON said the staff believed their interventions were adequate and worked. The DON agreed CR #1 had a significant change that should have been promptly communicated to his physician despite the staff 's temporary interventions. Interview on [DATE] at 3:10 p.m., LVN #1 said CR #1 had low grade fever/temperature; he was noted moaning out loud on [DATE]. She stated the resident was noted to have coughed once or twice, and made a gurgling noisy sound while breathing. LVN #1 said CR #1 was provided oxygen via nasal cannula and orange juice for low blood sugar. LVN #1 did not know why other symptoms (cough and congestions) presented by the resident were not addressed. LVN #1 said she was a new nurse and would have done things different now. LVN #1 stated she remembered the resident had parameters on the Glucose gel and did not know why it was not administered. Interview on [DATE] about 3:30 p.m., RN #1 said she was told CR #1 had a change in condition the morning of [DATE]. She assessed the resident with LVN#1, placed him on oxygen via nasal cannula and gave him orange juice for his low blood sugar. RN #1 said the interventions worked. LVN #1 was to notify the physician. RN#1 said LVN#1 told her that she did notify the physician and she believed her. RN #1 said she did not know how LVN #1 notified CR #1's physician. Record review of CR #1's hospital record dated [DATE] revealed the chief complaint - respiratory distress/failure. Physical examination revealed the patient was ill appearing with severe respiratory distress, and cyanotic skin. The patient's speech was moans with painful stimuli. There was associated cough, fever and leg swelling. Transferred from the nursing home with complaints of low blood sugar of 55, ( EMS reported blood sugar of 45) temperature was 101.5, congested respirations. Diagnostic considerations were cardiogenic shock, [MEDICAL CONDITION], pneumonia, [MEDICAL CONDITION] embolism and [MEDICAL CONDITIONS]. Further review of the record revealed impressions as hyperosmolality and [MEDICAL CONDITION], [DIAGNOSES REDACTED], lobar pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION], altered mental status, diabetic mellitus with [DIAGNOSES REDACTED] with coma and [MEDICAL CONDITION]. Record review of CR #1's hospital record dated [DATE] revealed also that CR #1's had wounds on the following areas: Two wounds to his mid back and one to his lower back surrounded by dry excoriated skin. Wound to his coccyx and buttock area. Two unstageable wounds to right lower extremity foot, ankle and heel (foot - one medial to right inner ankle and another to anterior foot - top of foot) . Unstageable to right posterior leg. Unstageable to left heel. Unstageable to top of left foot. Further review of CR #1's hospital record revealed the patient was transferred to an acute care hospital on [DATE]. Record review of facility's policy on abuse and neglect revised [DATE] defined neglect as failure to provide goods, treatment and services necessary to avoid physical harm, mental anguish or mental illness. Record review of the facility policy on acute condition changes not dated revealed any resident is at risk of an acute change in condition, upon admission the interim plan of care will address [DIAGNOSES REDACTED]. Before contacting the physician the nurse should fully assess the resident, this will allow accurate and pertinent collection of the resident status. This can be provided orally or by fax. The nursing staff will contact the physician based on the urgency of the situation for emergencies. They will call or page the physician and request a prompt response (within approximately half an hour) . 7b-a significant change in condition is any change noted in your resident that does not return them to their baseline within a two hour time frame. Change in condition, major variations in vital signs, of any injury that requires more than first aide and signs of impending stroke etc. If unable to reach a physician in a timely manner in an emergency situation, it is appropriate to call 911, document all attempts to contact the physician and the reason for calling emergency services. Record review of facility policy on pressure ulcers/skin breakdown -clinical protocol revised [DATE] revealed the nursing staff will assess and document an individual's significant risk factors for developing pressure sores, example immobility, nutrition status, incontinence status and history of pressure ulcers. The staff will examine the skin of the new admission for impaired skin integrity. All new, returning residents will have weekly skin assessments for 4 weeks and then if identified as a high risk per the Braden scale assessment, will continue to have weekly skin assessment. All residents unless identified as high risk will have a monthly skin assessment conducted. All new skin concerns or a change in existing wound will be promptly reported to the attending physician and the DON. The family/responsible party will also be notified of the change in condition. Notification of all parties concerned will be documented in the clinical record. The plan of care will be updated, as appropriate with changes in the treatment protocol of the condition and the documented wound. The facility Administrator and DON were notified on [DATE] at 2:24 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ: 1. All available licensed staff were in-serviced on [DATE] at 4:00 p.m. on appropriate identification for a resident's change of condition. This in-service was conducted by the DON. Any staff not available will not be eligible to return to work until training has been conducted. 2. Staff were educated on physician notification. They will be following the Interact Protocol for immediate notification. Vital Sign Policy Immediate physician notification (including the weekends) should occur with the following vital signs/change in condition indicators: · Blood Pressures that are > ,[DATE] or < ,[DATE] · Resting pulse >100, <60 · Respirations >28, <10/minute · Oral temp >100.5 · O2 saturation <90% · Blood Sugar that are >400 or <60. (based on universal sliding scales) THIS MEANS A PHONE CALL WITH A RESPONSE. IF NO RESPONSE IS OBTAINED WITHIN 30 MINUTES YOU MUST NOTIFY THE DON WHO WILL INSTRUCT YOU ON FURTHER ACTION. 3. A list of residents that have had a condition change was provided by the ADON at 6:25 p.m. on [DATE]. These residents were assessed by the DON on [DATE] at 7:00 p.m. and no further action was necessary. All necessary notifications and care was provided by licensed staff per protocol. 4. Every day, there will be a morning and afternoon clinical meeting with licensed staff to discuss any areas of concern that require further monitoring. This meeting will be conducted by the DON, ADON or designee. The minutes of this meeting will be kept in a binder and maintained by the DON. This meeting will also be conducted by the weekend RN and returned to the DON. Initiated on [DATE]. 5. The Weekend supervisor will also be provided with a report and a task list of areas of concern that must be assessed for further follow up and care. The task list will require the weekend RN to sign off and return this task list to the DON. This task list will be prepared each week by the DON, ADON or designee. Initiated on [DATE]. 6. Audits will be conducted by the DON, ADON or corporate nurse on identified resident concerns. These audits will be conducted daily until there is 100% compliance with this protocol. Results of all audits will be reported to the Administrator daily and as necessary and will also be reported to the QA committee at least monthly. Initiated on [DATE]. This constitutes our plan of removal for the immediate jeopardy cited on [DATE]. The plan of removal was accepted on [DATE] at 4:00 P.M. Plan of Removal Monitoring: 1. Reviewed newly implemented Vital Sign Policy dated ,[DATE]. 2. Reviewed documentation dated [DATE] and [DATE] that licensed staff, medication aides and CNAs were in- serviced on the new Vital Sign Policy, change in condition and when to report. 3. Interviews were conducted on [DATE] and [DATE] with the following results: 100% of all licensed staff, medications aides and CNAs on duty during two shifts had been in-serviced and were able to identify the protocol for vital sign policy, change in condition and when to report . The DON stated on [DATE] all staff had been in-serviced on the new Vital Sign Policy, change in condition and when to report as of [DATE]. 4. Reviewed documentation dated [DATE] of review made on four Resident who experienced a change of condition. 5. Reviewed documentation on two of the four Residents who experienced a change of condition who remained in the facility. On [DATE] at 4:36 p.m., the DON stated two of the four Residents identified with a change in condition were no longer residing in the facility. She stated there were no new residents identified with a change in condition. She stated they were continuing to monitor all residents identified with a change in condition daily and this information would be reviewed by the QA committee at least monthly. On [DATE] at 4:36 p.m. the DON was notified the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of isolated. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning changes in condition. Facility ADON reported 68 residents on [DATE].

Based on record review, and interviews, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being of one of seven residents (CR #1) reviewed for quality of care. The Administrator failed to oversee and assist with the development and implementation of effective policies and procedures on identifying change in condition, promptly consulting with the physician and preventing neglect. The Administrator failed to supervise the DON on training and monitoring the nursing staff to assess, and consult physicians concerning changes of condition of residents. The DON failed to ensure staff were trained to monitor, assess, treat and consult physicians timely concerning changes in condition of residents. The DON failed to ensure staff were trained to assess, monitor and treat skin conditions on residents with increased risk for pressure sores. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility continued to train its staff to provide skin assessments, treatments as ordered and promptly consult physicians when a change in condition was identified. This failure affected one resident who died [DATE] in the hospital and placed 68 residents in the facility at risk of not being assessed, treated, monitored and having their physician consulted for prompt interventions which could cause a delay in treatment, a decline in health, and death. Findings include: Intake # 3 Record review of CR#1's face sheet revealed a 93 male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR#1's MDS dated [DATE] revealed cognition score of 0 which meant he was severely cognitively impaired. Record review of CR#1's nurses notes dated [DATE] at 8:45 a.m., revealed CR #1 had a blood sugar of 65 and a oxygen saturation of 77. Oxygen was applied and orange juice was administered. The blood sugar rose to 66 and oxygen saturation elevated to 98. The physician was not consulted directly but a fax was sent to the closed physician's office on Saturday [DATE]. Record review of CR#1's nurses notes dated [DATE] at 7:15 a.m. revealed the resident was assessed as not responsive to verbal stimuli, blood sugar of 55 to 58, oxygen saturation at 78% while receiving 2 liters of oxygen. 911 was called and resident was transferred to the hospital. Record review of CR#1's physician's order dated [DATE] revealed Glucose gel 40% ([MEDICATION NAME] Diabetic Use), give one applicator full by mouth as needed for Diabetes mellitus, if blood sugar was ,[DATE]. Give one tube sublingually. Further review of the same physician's order dated [DATE] revealed give two applicators full by mouth as needed if blood sugar was less than 55. Record review of CR#1 ' s October Medication Administration Record [REDACTED]. Interview on [DATE] at 3:10 p.m., LVN # 1 said CR#1 had low grade fever/temperature; he was noted moaning out loud on [DATE]. She stated the resident was noted to have a coughed once or twice, and made a gurgling noisy sound while breathing. LVN#1 said CR#1 was provided oxygen via nasal cannula and orange juice for low blood sugar. LVN #1 did not know why other symptoms (cough and congestions) presented by the resident were not addressed. LVN#1 said she was a new nurse and would have done things different now. LVN #1 stated she remembered the resident had perameters on the Glucose gel and did not know why it was not administered. Record review of CR#1's hospital record dated [DATE] revealed the chief complaint - respiratory distress/failure. Physical examination revealed the patient was ill appearing with severe respiratory distress, and cyanotic skin. The patient's speech was moans with painful stimuli. There was associated cough, fever and leg swelling. Transferred from the nursing home with complaints of low blood sugar of 55, ( EMS reported blood sugar of 45) temperature was 101.5, congested respirations. Diagnostic considerations were cardiogenic shock, [MEDICAL CONDITION], pneumonia, [MEDICAL CONDITION] embolism and [MEDICAL CONDITIONS]. Further review of the record revealed impressions as hyperosmolality and [MEDICAL CONDITION], [DIAGNOSES REDACTED], lobar pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION], altered mental status, diabetic mellitus with [DIAGNOSES REDACTED] with coma and [MEDICAL CONDITION]. Interview on [DATE] at 11:40a.m., hospital staff said CR#1 was brought in by the EMS in severe respiratory distress, very congested and coma. CR#1's blood sugar was 45 according the EMS crew and he was given [MEDICATION NAME] water on transit. Hospital staff said the resident was transferred from the nursing home for low blood sugar and there was no mention of his respiratory distress and elevated temperature. Hospital staff said the resident was very critical and needed to immediately intubated, he was found to be septic, had pneumonia and wounds all over his body. Hospital staff stated it was unclear how no one identified all the symptoms he presented. Resident was not groomed; he had a buildup of dirt around his peri-area. Hospital staff said the resident had a very poor prognosis and was transferred to a high acuity hospital. Please refer to CMS form 2567 tags F157, 224, 282, and 309 for additional information. Interview of [DATE] at 3:27 p.m., the facility administrator said she had no idea of the incident that resulted in the immediate jeopardy and substandard quality of care. She said the facility had support and help from sister facilities and the cooperation in ensuring the needs of the resident were met. She also said the DON and ADON provided feedback for her to evaluate the effectiveness of the actions in place. Interview on [DATE] at 3:32 p.m., the DON said staff were provided twice monthly in-services, instant in services, coaching tools with the corperate office overseeing these. She said she had implemented new approaches since their last Immediate jeopardy and was still enforcing them. She stated she had continued to educate staff and evaluate their understanding through patient outcome. She said she would continue to improve the facility's processes, had named an ADON and an office was newly created to provide assistance and monitoring of patient care and education. The DON said she believed the IJ and incident came about because the staff felt their interventions when CR#1 had a change in condition on [DATE] worked. Staff notified the physician by fax (on a weekend). The DON said she agreed staff interventions were temporary but staff should have continued to monitor and assess CR#1. CR#1's physician should have been consulted by a phone call not a fax. Record review of facility's policy on abuse and neglect revised [DATE] defined neglect as failure to provide goods, treatment and services necessary to avoid physical harm, mental anguish or mental illness. Record review of the facility policy on acute condition changes not dated revealed any resident is at risk of an acute change in condition, upon admission the interim plan of care will address [DIAGNOSES REDACTED]. Before contacting the physician the nurse should fully assess the resident, this will allow accurate and pertinent collection of the resident status. This can be provided orally or by fax. The nursing staff will contact the physician based on the urgency of the situation for emergencies. They will call or page the physician and request a prompt response (within approximately half an hour) . 7b-a significant change in condition is any change noted in your resident that does not return them to their baseline within a two hour time frame. Change in condition, major variations in vital signs, of any injury that requires more than first aide and signs of impending stroke etc. If unable to reach a physician in a timely manner in an emergency situation, it is appropriate to call 911, document all attempts to contact the physician and the reason for calling emergency services. Record review of facility policy on pressure ulcers/skin breakdown -clinical protocol revised [DATE] revealed the nursing staff will assess and document an individual's significant risk factors for developing pressure sores, example immobility, nutrition status, incontinence status and history of pressure ulcers. The staff will examine the skin of the new admission for impaired skin integrity. All new, returning residents will have weekly skin assessments for 4 weeks and then if identified as a high risk per the Braden scale assessment, will continue to have weekly skin assessment. All residents unless identified as high risk will have a monthly skin assessment conducted. All new skin concerns or a change in existing wounds will be promptly reported to the attending physician and the DON. The family/responsible party will also be notified of the change in condition. Notification of all parties concerned will be documented in the clinical record. The plan of care will be updated, as appropriate with changes in the treatment protocol of the condition and the documented wound. The facility Administrator and DON were notified on [DATE] at 2:24 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ : 1. All available licensed staff were in-serviced on [DATE] at 4:00 p.m. on appropriate identification for a resident's change of condition. This in-service was conducted by the DON. Any staff not available will not be eligible to return to work until training has been conducted. 2. Staff were educated on physician notification. They will be following the Interact Protocol for immediate notification. Vital Sign Policy Immediate physician notification (including the weekends) should occur with the following vital signs/change in condition indicators: · Blood Pressures that are > ,[DATE] or < ,[DATE] · Resting pulse >100, <60 · Respirations >28, <10/minute · Oral temp >100.5 · O2 saturation <90% · Blood Sugar that are >400 or <60. (based on universal sliding scales) THIS MEANS A PHONE CALL WITH A RESPONSE. IF NO RESPONSE IS OBTAINED WITHIN 30 MINUTES YOU MUST NOTIFY THE DON WHO WILL INSTRUCT YOU ON FURTHER ACTION. 3. A list of residents that have had a condition change was provided by the ADON at 6:25 p.m. on [DATE]. These residents were assessed by the DON on [DATE] at 7:00 p.m. and no further action was necessary. All necessary notifications and care was provided by licensed staff per protocol. 4. Every day, there will be a morning and afternoon clinical meeting with licensed staff to discuss any areas of concern that require further monitoring. This meeting will be conducted by the DON, ADON or designee. The minutes of this meeting will be kept in a binder and maintained by the DON. This meeting will also be conducted by the weekend RN and returned to the DON. Initiated on [DATE]. 5. The Weekend supervisor will also be provided with a report and a task list of areas of concern that must be assessed for further follow up and care. The task list will require the weekend RN to sign off and return this task list to the DON. This task list will be prepared each week by the DON, ADON or designee. Initiated on [DATE]. 6. Audits will be conducted by the DON, ADON or corporate nurse on identified resident concerns. These audits will be conducted daily until there is 100% compliance with this protocol. Results of all audits will be reported to the Administrator daily and as necessary and will also be reported to the QA committee at least monthly. Initiated on [DATE]. This constitutes our plan of removal for the immediate jeopardy cited on [DATE]. The plan of removal was accepted on [DATE] at 4:00 P.M. Plan of Removal Monitoring: 1. Reviewed newly implemented Vital Sign Policy dated ,[DATE]. 2. Reviewed documentation dated [DATE] and [DATE] that licensed staff, medication aides and CNAs were in- serviced on the new Vital Sign Policy, change in condition and when to report. 3. Interviews were conducted on [DATE] and [DATE] with the following results: 100% of all licensed staff, medications aides and CNAs on duty during two shifts had been in-serviced and were able to identify the protocol for vital sign policy, change in condition and when to report . The DON stated on [DATE] all staff had been in-serviced on the new Vital Sign Policy, change in condition and when to report as of [DATE]. 4. Reviewed documentation dated [DATE] of review made on four Resident who experienced a change of condition. 5. Reviewed documentation on two of the four Residents who experienced a change of condition who remained in the facility. On [DATE] at 4:36 P.M., the DON stated two of the four Residents identified with a change in condition were no longer residing in the facility. She stated there were no new residents identified with a change in condition. She stated they were continuing to monitor all residents identified with a change in condition daily and this information would be reviewed by the QA committee at least monthly. On [DATE] at 4:36 P.M. the DON was notified the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of isolated. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning changes in condition. Facility ADON reported 68 residents on [DATE].

Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there was a change in condition in two of 13 residents (Residents #36 and #65) reviewed for consulting with the physician. Resident #36 ' s physician was never consulted when the resident ' s blood pressure readings were elevated for 18 of 23 days in 9/2015. Some of the resident's blood pressures were as high as 190/127 without the physician being consulted. Resident #65 ' s physician was not consulted when the resident ' s blood pressure was 163/121 on 9/3/2015. The physician had an order to direct staff to consult with him if Resident #65's blood pressure was over 150/100. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/25/2015. While the IJ was removed on 9/26/2015, the facility remained out of compliance at a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. These failures affected two residents placing them at risk for [MEDICAL CONDITION] placed 25 other residents with a [DIAGNOSES REDACTED]. Findings include: Resident #36 Record review of Resident #36's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #36 ' s annual MDS dated [DATE] revealed the resident was assessed as moderately impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident had an active [DIAGNOSES REDACTED]. Record review of Resident #36 ' s care plan for hypertension initiated 2/12/15 and reviewed 7/13/15 revealed no interventions to notify physician of any abnormal readings. Record review of Resident#36 ' s September consolidated physician's orders [REDACTED]. Give 5 mg by mouth one time a day related to essential hypertension, benign. Hold for systolic blood pressure less than 100. Record review of Resident #36 ' s September 2015 MAR indicated [REDACTED].M. daily with the scheduled [MEDICATION NAME]. 9/1-182/131, 9/2 -175/124, 9/3-190/98, 9/4-175/132, 9/5-170/120, 9/9-177/129, 9/12-174/118, 9/13-162/116, 9/14-190/127, 9/15-186/135, 9/16-185/139, 9/17-185/103, 9/18-178/100, 9/19-164/124, 9/20-174/118, 9/21-196/100, 9/22-177/114, and 9/23-159/191. Record review of a publication from the American Heart Association dated 4/28/2015 revealed in part the following: .categories defined by the American Heart Association for hypertension include Stage 2 hypertension systolic BP of 160 or higher and diastolic BP of 100 or higher. Hypertensive crisis (emergency care needed) systolic BP higher than 180 and diastolic BP higher than 110. Observation of Resident #36 on 9/24/15 at 5:45 P.M. revealed the resident was sitting in a wheelchair in his room alert and able to respond to verbal stimuli by smiling, and shaking his head in response to yes or no questions. Record review of Resident #36 ' s medical record revealed no documentation of any physician consultation concerning the resident's elevated blood pressure readings in the physician or nurse progress notes. Interview on 9/25/15 at 12:15 P.M. LVN #12 stated the MA took the blood pressure before administering the blood pressure medications. She stated she was not aware Resident #36 ' s blood pressure readings were elevated. Interview on 9/24/15 at 2:30 p.m. the DON, was ask why there were no blood pressure (BP) parameters in place on several of the residents reviewed that were on hypertension (HTN) medications. The DON stated the resident ' s physicians did not believe in BP parameters and wanted total control. She stated should a resident ' s BP read high or low, the physician wanted to be contacted and they would decide what the next step would be. The DON stated when she first started at the facility she noticed the lack of BP parameters and quickly learned the physician ' s instructions. She stated she had repeatedly requested something from the physicians and each time she received the same negative response. The DON stated she understood the importance of parameters concerning hypertension and should any problems arise from the lack of parameters. The DON stated she would like to establish parameters for the facility and inform the physicians they were holding the hypertensive medications for all residents and then notifying the physicians. Interview on 9/25/15 at 12:30 P.M. MA #7 stated she had administered blood pressure medications to Resident #36 and had taken his blood pressure prior to administrating them. She stated she checked the blood pressure prior to administering any blood pressure medication by using the wrist cuff. She said if the blood pressure was high she would administer the blood pressure medication and notify the charge nurse. She said sometimes she would re-check the blood pressure and write it down on her paper but she did not document the blood pressure in the resident ' s chart. She stated she would notify the charge nurse if the blood pressure was in the 150 ' s systolic or in the 90 ' s diastolic. She stated by not documenting in the resident ' s medical record there was no way to verify the readings or that anyone was notified. Interview on 9/25/15 at 12:45 P.M. the DON stated she did not know Resident #36 had such high blood pressure readings. She stated she would expect the MA to notify the nurse and the nurse to notify the physician. She said the facility was having a hard time getting physicians to order parameters of their expected ranges of acceptable blood pressures to direct the staff as to when to notify them concerning the blood pressures. She stated the physicians did not want to establish parameters for the blood pressures and wanted to be called if there was a concern or problem. The DON also stated she had now notified Resident #36 ' s physician of his blood pressure patterns. She stated the physician responded by saying he was not going to just change his medications and would see the resident within the next week to evaluate and assess him for the best treatment. Record review of Resident #36's monthly nursing review dated 8/22/15 presented by the DON revealed the following: Blood pressure 158/91. Pulse 81. Elevated BP is normal for this resident. MD aware. Interview on 9/25/15 at 1:00 P.M the DON was asked as to whether the physician should have been notified of the higher blood pressure readings of Resident #36 and the DON agreed he should have and she stated he probably was not because the nursing staff thought he was already aware. Resident #65 Record review of Resident #65's face sheet revealed a [AGE] year old female, admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #65 ' s MDS dated [DATE] revealed the resident was assessed as severely impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident had an active [DIAGNOSES REDACTED]. Record review of Resident #65's Care Plan dated 08/21/15 revealed she had a care plan for hypertension. One of the goals was No complication related to hypertension experienced by (resident #65) will go unnoticed through the next review date. Interventions included .give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate .Monitor/document/report to MD PRN any s/sx (signs/symptons) of malignant hypertension .Obtain blood pressure readings as ordered . Record review of Resident#65 ' s September, 2015 consolidated physician's orders [REDACTED]. Record review of Resident #65 ' s September 2015 MAR indicated [REDACTED].M. of 163/121 with the scheduled [MEDICATION NAME]. Further review of the September 2015 MAR indicated [REDACTED]. Record review of Resident #65 ' s medical record for the time period of 9/3/2015 revealed no documentation of physician consultation of the blood pressure reading in the progress notes. Interview on 09/25/15 at 1:45 P.M. the DON revealed she was unable to find documentation that Resident #65 ' s physician was notified of her BP reading on 09/03/15. Interview on 9/25/15 at 2:45 p.m. Dr. #1 stated he was against establishing BP parameters and having the facility come up with a number for everyone. He was under the impression he would not be involved in the entire process. The DON explained the facility would like to have parameters that would guide staff if the resident ' s blood pressure was above or below the parameter to consult the physician and the physician would be the one to provided staff with further direction. The DON asked the MD if the facility was able to establish a baseline for each one of his residents and come up with an average, would that be acceptable. He stated it would be as long as he was contacted and was able to tell the facility staff to hold, to change or to give the medication. The DON stated she was going to bring this matter up at the next Q & A meeting. Interview on 9/25/2015 at 3:00 P.M. the pharmacy consultant stated she was very frustrated concerning the responses she received back from the physicians concerning her recommendations. She stated lots of times they would not respond and when they did she stated the physicians would just disapprove and not give a reason why they disapproved. Record review of the pharmacy consultant letters dated September 15, 2015 revealed only one recommendation letter concerning parameters. The recommendation was a resident was having low pulses of 55 and 56 and the pharmacist had asked if the medication Amiodorone could be held. At the time of the review the physician had not responded. Observation of Resident #65 on 9/23/15 at 1:32 P.M., 3:37 P.M. and 5:00 P.M.; 09/24/15 at 8:25 A.M., 1:35 P.M. and 5:00 P.M. and 09/25/15 at 8:25 A.M. revealed the resident was in bed in her room asleep. A facility policy to address consulting the physician of change in condition was requested of the DON but not provided prior to exit. The facility Administrator and DON were notified on 9/25/2015 at 3:08 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ 1. On 9/25/15 at 1:45 P.M. a list of residents with a [DIAGNOSES REDACTED]. The list consisted of 26 residents that did not have clinical parameters established by the physician. 2. A new clinical protocol was developed by the DON so that clinical monitoring could be conducted by staff for residents without parameters. This protocol states that any resident with a blood pressure below 90/50 or greater than 160/100 or with a pulse of less than 60 or greater than 100 will be sent to the attending physician via fax or per a telephone call. The attending physician will be allowed to develop their own protocol based upon the individual resident ' s needs. The medication aide will document notification of the charge nurse in their progress notes and the LN (licensed nurse) will document in the clinical record. If this is on a week-end or the physician is otherwise available, the on-call physician will be notified. If no response is received within 20 minutes, the Medical Director will be notified for guidance. This was sent to the physicians via fax at 1:50 P.M. on 9/25/15 by Nursing Administration. 3. All clinical staff onsite were immediately educated regarding this new clinical protocol by the DON on 9/25/15 at 2:00 PM. The remaining clinical staff will receive education on 9/25/15 by 6:00 PM. Those not able to attend due to unforeseen circumstances will not be able to return to active duty until this training has been conducted and approved by the DON. 4. An Audit was conducted by the MDSC, Medical Records Coordinator and the Staff Development coordinator, (LVN ' s), of the Blood Pressures of these residents. This audit was done on 9/25/15 at 1:45 PM, under the supervision of the DON. Those that had Blood Pressures outside of the newly established protocol received a fax notifying them of this information. This will be documented in the clinical record by the Medical Records LVN or staff development LVN by 1800 on 9/25/15. 5. All physicians will be notified via Fax and a copy of the new protocol by 9/25/15, this will be done by the DON. 6. All Licensed staff and Medication Aides will be trained on the appropriate notification to the attending physician regarding any clinical concerns and abnormal assessment findings. All staff available will be trained by the DON on 9/25/15 at 2:00 P.M Any staff not able to attend this training will not be allowed to return to work until this training has been completed. The plan of removal was accepted on 9/26/15 at 10:45 A.M. Plan of Removal Monitoring: 1. Reviewed documentation dated 9/25/15 of rounds made on every resident with a [DIAGNOSES REDACTED]. 2. Reviewed documentation on 9/26/15 of five random residents with a [DIAGNOSES REDACTED]. 3. Reviewed documentation of the notification to all physicians of the new protocol for vital signs monitoring. 4. Reviewed documentation dated 9/25/15 that licensed staff and medication aides were in-serviced on the new protocol for vital sign monitoring, documentation and physician follow-up on vital signs outside of the stated parameters. 5. Interviews were conducted on 9/26/15 by two surveyors with the following results: 100% of all licensed staff and medication aides on duty had been in-serviced and were able to identify the protocol for vital sign monitoring and physician follow-up and documentation. Of the remaining staff not on duty three LVN ' s and four medication aides were interviewed by phone and all were able to identify the steps in the protocol for vital sign monitoring. The DON stated on 9/26/2015 at 3:00 P.M. there were three full-time and three PRN staff that had not been in-serviced. She stated they would not be allowed to work until in-serviced on the new protocol for vital sign monitoring and follow-up. The DON stated the facility will continue to monitor daily the vital signs of all residents with a [DIAGNOSES REDACTED]. She further stated this information would be reviewed daily and would become part of QA. On 9/26/15 at 3:33 P.M. the Administrator and DON were notified the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. The facility identified 27 residents with [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility neglected to implement their policies and procedures that prohibited mistreatment and neglect of two of 13 residents (Residents #36 and #65) who were reviewed for hypertension monitoring. The facility staff failed to intervene or consult the physician when Resident #36 ' s blood pressure readings were elevated, some as high as 190/127, for 18 of 23 days in 9/2015. The facility staff failed to intervene or consult the physician when Resident #65 ' s blood pressure was elevated at 163/121 on 9/3/2015 even though the physician had s specific order to be consulted if the resident ' s blood pressure exceeded 0. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/25/2015. While the IJ was removed on 9/26/2015, the facility remained out of compliance at a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. These failures affected two residents with one who experienced a prolonged period of elevated blood pressure and placed 25 residents with a [DIAGNOSES REDACTED]. Findings include: Resident #36 Record review of Resident #36's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #36 ' s annual MDS dated [DATE] revealed the resident was assessed as moderately impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident had an active [DIAGNOSES REDACTED]. Record review of Resident #36 ' s care plan for hypertension initiated 2/12/15 and reviewed 7/13/15 revealed no interventions to notify physician of any abnormal readings. Record review of Resident #36 ' s September 2015 consolidated physician's orders [REDACTED]. Give 5 mg by mouth one time a day related to essential hypertension, benign. Hold for systolic blood pressure less than 100. There was no diastolic parameter listed on the orders. Record review of Resident #36 ' s September 2015 MAR indicated [REDACTED].M. daily with the scheduled [MEDICATION NAME]. 9/1-182/131, 9/2 -175/124, 9/3-190/98, 9/4-175/132, 9/5-170/120, 9/9-177/129, 9/12-174/118, 9/13-162/116, 9/14-190/127, 9/15-186/135, 9/16-185/139, 9/17-185/103, 9/18-178/100, 9/19-164/124, 9/20-174/118, 9/21-196/100, 9/22-177/114, and 9/23-159/191. Record review of a publication from the American Heart Association dated 4/28/2015 revealed in part the following: .categories defined by the American Heart Association for hypertension include Stage 2 hypertension systolic BP of 160 or higher and diastolic BP of 100 or higher. Hypertensive crisis (emergency care needed) systolic BP higher than 180 and diastolic BP higher than 110. Record review of Resident #36 ' s medical record revealed no documentation of any physician consultation concerning the resident's elevated blood pressure readings in the physician or nurse progress notes. Observation of Resident #36 on 9/24/15 at 5:45 P.M. revealed the resident was sitting in a wheelchair in his room alert and able to respond to verbal stimuli by smiling, and shaking his head in response to yes or no questions. Interview on 9/25/15 at 12:15 P.M. LVN #12 stated the MA took the resident's blood pressure before administering the blood pressure medications. She stated she was not aware Resident #36 ' s blood pressure readings were elevated. Interview on 9/25/15 at 12:30 P.M. MA #7 stated she had administered blood pressure medication to Resident #36 and had taken his blood pressure. She stated she checked the blood pressure prior to administering any blood pressure medication by using the wrist cuff. She said if the blood pressure was high she would administer the blood pressure medication and notify the charge nurse. She said sometimes she would re-check the blood pressure and would write it down on her paper but she did not document in the resident ' s chart. She stated she would notify the charge nurse if the blood pressure was in the 150 ' s systolic or 90 ' s diastolic. She stated by not documenting in the resident ' s medical record there was no way to verify the readings or that anyone was notified. Interview on 9/25/15 at 12:45 P.M. the DON stated she did not know Resident #36 had such high blood pressure readings. She stated she would expect the MA to notify the nurse and the nurse to notify the physician. She said the facility was having a hard time getting physicians to order parameters for notification of vital signs. She stated the physicians did not want the parameter notifications and wanted to be called if there was a concern or problem. The DON also stated she notified Resident #36 ' s physician today of the resident ' s blood pressure patterns. She stated the physician responded by saying he was not going to just change his medications and would see the resident within the next week to evaluate and assess him for the best treatment. Record review of the monthly nursing review for Resident #36 dated 8/22/15 presented by the DON revealed the following: Blood pressure 158/91. Pulse 81. Elevated BP is normal for this resident. MD aware. Interview on 9/24/15 at 2:30 p.m. the DON, was ask why there were no blood pressure (BP) parameters in place on several of the residents reviewed that were on hypertension (HTN) medications. The DON stated the resident ' s physicians did not believe in BP parameters and wanted total control. She stated should a resident ' s BP read high or low, the physician wanted to be contacted and they would decide what the next step would be. The DON stated when she first started at the facility she noticed the lack of BP parameters and quickly learned the physician ' s instructions. She stated she had repeatedly requested something from the physicians and each time she received the same negative response. The DON stated she understood the importance of parameters concerning hypertension and should any problems arise from the lack of parameters, it could potentially reflect negatively on the facility. Interview on 9/25/2015 at 1:30 P.M. the DON stated the physician should have been notified of the higher blood pressure readings and then stated the physician probably was not notified because nursing staff thought he was already aware. Resident #65 Record review of Resident #65's face sheet revealed a [AGE] year old female, admitted to the facility on [DATE] and re-admitted on [DATE]. The resident had the following Diagnoses: [REDACTED]. Record review of Resident #65 ' s MDS dated [DATE] revealed the resident was assessed as severely impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident had an active [DIAGNOSES REDACTED]. Record review of Resident #65's Care Plan dated 08/21/15 revealed she had a care plan for hypertension. One of the goals was No complication related to hypertension experienced by (Resident #65) will go unnoticed through the next review date. Interventions included .give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate .Monitor/document/report to MD PRN any s/sx (signs/symptons) of malignant hypertension .Obtain blood pressure readings as ordered . Record review of Resident #65 ' s September consolidated physician's orders [REDACTED]. Further review of this order revealed Check blood pressure daily, call if BP exceeds 150/100 every day and night shift. Record review of Resident #65 ' s September 2015 MAR indicated [REDACTED].M. of 163/121 with the scheduled [MEDICATION NAME]. Further review of the September 2015 MAR indicated [REDACTED]. Record review of Resident #65 ' s medical record for the time period of 9/3/2015 revealed no documentation of physician consultation of the blood pressure reading in the progress notes. Observation of Resident #65 on 9/23/15 at 1:32 P.M., 3:37 P.M. and 5:00 P.M.; 09/24/15 at 8:25 A.M., 1:35 P.M. and 5:00 P.M. and 09/25/15 at 8:25 A.M. revealed the resident in bed in her room asleep. Interview with the DON on 09/25/15 at 1:45 P.M. revealed she was unable to find documentation that Resident #65 ' s physician was notified of her BP reading on 09/03/15 so she was unsure if the physician was aware of the resident ' s BP. Interview on 9/25/15 at 2:45 p.m. with the DON and Dr. #1 the doctor stated he was against establishing BP parameters and having the facility come up with a number for everyone. He was under the impression he would not be involved in the entire process. The DON explained the facility would like to have parameters that would guide staff on what to do if the resident ' s blood pressure was above or below the parameter to consult the physician and the physician would be the one to provided staff with further direction. The DON asked the MD if the facility was able to establish a baseline for each one of his residents and come up with an average, would that be acceptable. He stated it would be as long as he was contacted and was able to tell the facility staff to hold, to change or to give the medication. The DON stated she was going to bring this matter up at the next Q & A meeting. Interview on 9/25/2015 at 3:00 P.M. the pharmacy consultant stated she was very frustrated concerning the responses she received back from the physicians concerning her recommendations. She stated lots of times they would not respond and when they did she stated the physicians would just disapprove and not give a reason why they disapproved. Record review of the pharmacy consultant letters dated September 15, 2015 revealed only one recommendation letter concerning parameters. The recommendation was a resident was having low pulses of 55 and 56 and the pharmacist had asked if the medication Amiodorone could be held. At the time of the review the physician had not responded. A facility policy to address consultation of the physician of change in condition was requested of the DON but not provided prior to exit. Record review of the facility's Abuse & Neglect Policy & Procedure dated 12-26-14 revealed Neglect - is defined as failure to provide goods, treatments and services necessary to avoid physical harm, mental anguish, or mental illness . Identification Procedure .Individual conditions are important to take into consideration, certain changes in that condition warrant further investigation: .1c. Weight loss, poor hygiene, significant changes of condition or psychological changes could be signs of neglect of various causes .2. Signs of abuse, neglect or misappropriation of property may also be ascertained by communication and observation . The facility Administrator and DON were notified on 9/25/2015 at 3:08 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ 1. On 9/25/15 at 1:45 P.M. a list of residents with a [DIAGNOSES REDACTED]. The list consisted of 26 residents that did not have clinical parameters established by the physician. 2. A new clinical protocol was developed by the DON so that clinical monitoring could be conducted by staff for residents without parameters. This protocol states that any resident with a blood pressure below 90/50 or greater than 160/100 or with a pulse of less than 60 or greater than 100 will be sent to the attending physician via fax or per a telephone call. The attending physician will be allowed to develop their own protocol based upon the individual resident ' s needs. The medication aide will document notification of the charge nurse in their progress notes and the LN (licensed nurse) will document in the clinical record. If this is on a week-end or the physician is otherwise available, the on-call physician will be notified. If no response is received within 20 minutes, the Medical Director will be notified for guidance. This was sent to the physicians via fax at 1:50 P.M. on 9/25/15 by Nursing Administration. 3. All clinical staff onsite were immediately educated regarding this new clinical protocol by the DON on 9/25/15 at 2:00 PM. The remaining clinical staff will receive education on 9/25/15 by 6:00 PM. Those not able to attend due to unforeseen circumstances will not be able to return to active duty until this training has been conducted and approved by the DON. 4. An Audit was conducted by the MDSC, Medical Records Coordinator and the Staff Development coordinator, (LVN ' s), of the Blood Pressures of these residents. This audit was done on 9/25/15 at 1:45 PM, under the supervision of the DON. Those that had Blood Pressures outside of the newly established protocol received a fax notifying them of this information. This will be documented in the clinical record by the Medical Records LVN or staff development LVN by 1800 on 9/25/15. 5. All physicians will be notified via Fax and a copy of the new protocol by 9/25/15, this will be done by the DON. 6. All Licensed staff and Medication Aides will be trained on the appropriate notification to the attending physician regarding any clinical concerns and abnormal assessment findings. All staff available will be trained by the DON on 9/25/15 at 2:00 P.M Any staff not able to attend this training will not be allowed to return to work until this training has been completed. The plan of removal was accepted on 9/26/15 at 10:45 A.M. Plan of Removal Monitoring: 1. Reviewed documentation dated 9/25/15 of rounds made on every resident with a [DIAGNOSES REDACTED]. 2. Reviewed documentation on 9/26/15 of five random residents with a [DIAGNOSES REDACTED]. 3. Reviewed documentation of the notification to all physicians of the new protocol for vital signs monitoring. 4. Reviewed documentation dated 9/25/15 that licensed staff and medication aides were in-serviced on the new protocol for vital sign monitoring, documentation and physician follow-up on vital signs outside of the stated parameters. 5. Interviews were conducted on 9/26/15 by two surveyors with the following results: 100% of all licensed staff and medication aides on duty had been in-serviced and were able to identify the protocol for vital sign monitoring and physician follow-up and documentation. Of the remaining staff not on duty three LVN ' s and four medication aides were interviewed by phone and all were able to identify the steps in the protocol for vital sign monitoring. The DON stated on 9/26/2015 at 3:00 P.M. there were three full-time and three PRN staff that had not been in-serviced. She stated they would not be allowed to work until in-serviced on the new protocol for vital sign monitoring and follow-up. The DON stated the facility will continue to monitor daily the vital signs of all residents with a [DIAGNOSES REDACTED]. She further stated this information would be reviewed daily and would become part of QA. On 9/26/15 at 3:33 P.M. the Administrator and DON were notified the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. The facility identified 27 residents with [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility neglected to implement their policies and procedures that prohibited mistreatment and neglect of two of 13 residents (Residents #36 and #65) who were reviewed for hypertension monitoring. The facility staff did not intervene or consult the physician when Resident #36 ' s blood pressure readings were elevated, some as high as 190/127, for 18 of 23 days in 9/2015. The facility staff failed to intervene or consult the physician when Resident #65 ' s blood pressure was elevated at 163/121 on 9/3/2015 even though the physician had s specific order to be consulted if the resident ' s blood pressure exceeded 0. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/25/2015. While the IJ was removed on 9/26/2015, the facility remained out of compliance at a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. These failures affected two residents with one who experienced a prolonged period of elevated blood pressure and placed 25 residents with a [DIAGNOSES REDACTED]. Findings include: Record review of the facility's Abuse & Neglect Policy & Procedure dated 12-26-14 revealed Neglect - is defined as failure to provide goods, treatments and services necessary to avoid physical harm, mental anguish, or mental illness . Identification Procedure .Individual conditions are important to take into consideration, certain changes in that condition warrant further investigation: .1c. Weight loss, poor hygiene, significant changes of condition or psychological changes could be signs of neglect of various causes .2. Signs of abuse, neglect or misappropriation of property may also be ascertained by communication and observation . Resident #36 Record review of Resident #36's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #36 ' s annual MDS dated [DATE] revealed the resident was assessed as moderately impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident had an active [DIAGNOSES REDACTED]. Record review of Resident #36 ' s care plan for hypertension initiated 2/12/15 and reviewed 7/13/15 revealed no interventions to notify physician of any abnormal readings. Record review of Resident #36 ' s September 2015 consolidated physician's orders [REDACTED]. Give 5 mg by mouth one time a day related to essential hypertension, benign. Hold for systolic blood pressure less than 100. There was no diastolic parameter listed on the orders. Record review of Resident #36 ' s September 2015 MAR indicated [REDACTED].M. daily with the scheduled [MEDICATION NAME]. 9/1-182/131, 9/2 -175/124, 9/3-190/98, 9/4-175/132, 9/5-170/120, 9/9-177/129, 9/12-174/118, 9/13-162/116, 9/14-190/127, 9/15-186/135, 9/16-185/139, 9/17-185/103, 9/18-178/100, 9/19-164/124, 9/20-174/118, 9/21-196/100, 9/22-177/114, and 9/23-159/191. Record review of a publication from the American Heart Association dated 4/28/2015 revealed in part the following: .categories defined by the American Heart Association for hypertension include Stage 2 hypertension systolic BP of 160 or higher and diastolic BP of 100 or higher. Hypertensive crisis (emergency care needed) systolic BP higher than 180 and diastolic BP higher than 110. Record review of Resident #36 ' s medical record revealed no documentation of any physician consultation concerning the resident's elevated blood pressure readings in the physician or nurse progress notes. Observation of Resident #36 on 9/24/15 at 5:45 P.M. revealed the resident was sitting in a wheelchair in his room alert and able to respond to verbal stimuli by smiling, and shaking his head in response to yes or no questions. Interview on 9/25/15 at 12:15 P.M. LVN #12 stated the MA took the resident's blood pressure before administering the blood pressure medications. She stated she was not aware Resident #36 ' s blood pressure readings were elevated. Interview on 9/25/15 at 12:30 P.M. MA #7 stated she had administered blood pressure medication to Resident #36 and had taken his blood pressure. She stated she checked the blood pressure prior to administering any blood pressure medication by using the wrist cuff. She said if the blood pressure was high she would administer the blood pressure medication and notify the charge nurse. She said sometimes she would re-check the blood pressure and would write it down on her paper but she did not document in the resident ' s chart. She stated she would notify the charge nurse if the blood pressure was in the 150 ' s systolic or 90 ' s diastolic. She stated by not documenting in the resident ' s medical record there was no way to verify the readings or that anyone was notified. Interview on 9/25/15 at 12:45 P.M. the DON stated she did not know Resident #36 had such high blood pressure readings. She stated she would expect the MA to notify the nurse and the nurse to notify the physician. She said the facility was having a hard time getting physicians to order parameters for notification of vital signs. She stated the physicians did not want the parameter notifications and wanted to be called if there was a concern or problem. The DON also stated she notified Resident #36 ' s physician today of the resident ' s blood pressure patterns. She stated the physician responded by saying he was not going to just change his medications and would see the resident within the next week to evaluate and assess him for the best treatment. Record review of the monthly nursing review for Resident #36 dated 8/22/15 presented by the DON revealed the following: Blood pressure 158/91. Pulse 81. Elevated BP is normal for this resident. MD aware. Interview on 9/24/15 at 2:30 p.m. the DON, was ask why there were no blood pressure (BP) parameters in place on several of the residents reviewed that were on hypertension (HTN) medications. The DON stated the resident ' s physicians did not believe in BP parameters and wanted total control. She stated should a resident ' s BP read high or low, the physician wanted to be contacted and they would decide what the next step would be. The DON stated when she first started at the facility she noticed the lack of BP parameters and quickly learned the physician ' s instructions. She stated she had repeatedly requested something from the physicians and each time she received the same negative response. The DON stated she understood the importance of parameters concerning hypertension and should any problems arise from the lack of parameters, it could potentially reflect negatively on the facility. Interview on 9/25/2015 at 1:30 P.M. the DON stated the physician should have been notified of the higher blood pressure readings and then stated the physician probably was not notified because nursing staff thought he was already aware. Resident #65 Record review of Resident #65's face sheet revealed a [AGE] year old female, admitted to the facility on [DATE] and re-admitted on [DATE]. The resident had the following Diagnoses: [REDACTED]. Record review of Resident #65 ' s MDS dated [DATE] revealed the resident was assessed as severely impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident had an active [DIAGNOSES REDACTED]. Record review of Resident #65's Care Plan dated 08/21/15 revealed she had a care plan for hypertension. One of the goals was No complication related to hypertension experienced by (Resident #65) will go unnoticed through the next review date. Interventions included .give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate .Monitor/document/report to MD PRN any s/sx (signs/symptons) of malignant hypertension .Obtain blood pressure readings as ordered . Record review of Resident #65 ' s September consolidated physician's orders [REDACTED]. Further review of this order revealed Check blood pressure daily, call if BP exceeds 150/100 every day and night shift. Record review of Resident #65 ' s September 2015 MAR indicated [REDACTED].M. of 163/121 with the scheduled [MEDICATION NAME]. Further review of the September 2015 MAR indicated [REDACTED]. Record review of Resident #65 ' s medical record for the time period of 9/3/2015 revealed no documentation of physician consultation of the blood pressure reading in the progress notes. Observation of Resident #65 on 9/23/15 at 1:32 P.M., 3:37 P.M. and 5:00 P.M.; 09/24/15 at 8:25 A.M., 1:35 P.M. and 5:00 P.M. and 09/25/15 at 8:25 A.M. revealed the resident in bed in her room asleep. Interview with the DON on 09/25/15 at 1:45 P.M. revealed she was unable to find documentation that Resident #65 ' s physician was notified of her BP reading on 09/03/15 so she was unsure if the physician was aware of the resident ' s BP. Interview on 9/25/15 at 2:45 p.m. with the DON and Dr. #1 the doctor stated he was against establishing BP parameters and having the facility come up with a number for everyone. He was under the impression he would not be involved in the entire process. The DON explained the facility would like to have parameters that would guide staff on what to do if the resident ' s blood pressure was above or below the parameter to consult the physician and the physician would be the one to provided staff with further direction. The DON asked the MD if the facility was able to establish a baseline for each one of his residents and come up with an average, would that be acceptable. He stated it would be as long as he was contacted and was able to tell the facility staff to hold, to change or to give the medication. The DON stated she was going to bring this matter up at the next Q & A meeting. Interview on 9/25/2015 at 3:00 P.M. the pharmacy consultant stated she was very frustrated concerning the responses she received back from the physicians concerning her recommendations. She stated lots of times they would not respond and when they did she stated the physicians would just disapprove and not give a reason why they disapproved. Record review of the pharmacy consultant letters dated September 15, 2015 revealed only one recommendation letter concerning parameters. The recommendation was a resident was having low pulses of 55 and 56 and the pharmacist had asked if the medication Amiodorone could be held. At the time of the review the physician had not responded. A facility policy to address consultation of the physician of change in condition was requested of the DON but not provided prior to exit. The facility Administrator and DON were notified on 9/25/2015 at 3:08 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ 1. On 9/25/15 at 1:45 P.M. a list of residents with a [DIAGNOSES REDACTED]. The list consisted of 26 residents that did not have clinical parameters established by the physician. 2. A new clinical protocol was developed by the DON so that clinical monitoring could be conducted by staff for residents without parameters. This protocol states that any resident with a blood pressure below 90/50 or greater than 160/100 or with a pulse of less than 60 or greater than 100 will be sent to the attending physician via fax or per a telephone call. The attending physician will be allowed to develop their own protocol based upon the individual resident ' s needs. The medication aide will document notification of the charge nurse in their progress notes and the LN (licensed nurse) will document in the clinical record. If this is on a week-end or the physician is otherwise available, the on-call physician will be notified. If no response is received within 20 minutes, the Medical Director will be notified for guidance. This was sent to the physicians via fax at 1:50 P.M. on 9/25/15 by Nursing Administration. 3. All clinical staff onsite were immediately educated regarding this new clinical protocol by the DON on 9/25/15 at 2:00 PM. The remaining clinical staff will receive education on 9/25/15 by 6:00 PM. Those not able to attend due to unforeseen circumstances will not be able to return to active duty until this training has been conducted and approved by the DON. 4. An Audit was conducted by the MDSC, Medical Records Coordinator and the Staff Development coordinator, (LVN ' s), of the Blood Pressures of these residents. This audit was done on 9/25/15 at 1:45 PM, under the supervision of the DON. Those that had Blood Pressures outside of the newly established protocol received a fax notifying them of this information. This will be documented in the clinical record by the Medical Records LVN or staff development LVN by 1800 on 9/25/15. 5. All physicians will be notified via Fax and a copy of the new protocol by 9/25/15, this will be done by the DON. 6. All Licensed staff and Medication Aides will be trained on the appropriate notification to the attending physician regarding any clinical concerns and abnormal assessment findings. All staff available will be trained by the DON on 9/25/15 at 2:00 P.M Any staff not able to attend this training will not be allowed to return to work until this training has been completed. The plan of removal was accepted on 9/26/15 at 10:45 A.M. Plan of Removal Monitoring: 1. Reviewed documentation dated 9/25/15 of rounds made on every resident with a [DIAGNOSES REDACTED]. 2. Reviewed documentation on 9/26/15 of five random residents with a [DIAGNOSES REDACTED]. 3. Reviewed documentation of the notification to all physicians of the new protocol for vital signs monitoring. 4. Reviewed documentation dated 9/25/15 that licensed staff and medication aides were in-serviced on the new protocol for vital sign monitoring, documentation and physician follow-up on vital signs outside of the stated parameters. 5. Interviews were conducted on 9/26/15 by two surveyors with the following results: 100% of all licensed staff and medication aides on duty had been in-serviced and were able to identify the protocol for vital sign monitoring and physician follow-up and documentation. Of the remaining staff not on duty three LVN ' s and four medication aides were interviewed by phone and all were able to identify the steps in the protocol for vital sign monitoring. The DON stated on 9/26/2015 at 3:00 P.M. there were three full-time and three PRN staff that had not been in-serviced. She stated they would not be allowed to work until in-serviced on the new protocol for vital sign monitoring and follow-up. The DON stated the facility will continue to monitor daily the vital signs of all residents with a [DIAGNOSES REDACTED]. She further stated this information would be reviewed daily and would become part of QA. On 9/26/15 at 3:33 P.M. the Administrator and DON were notified the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. The facility identified 27 residents with [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to provide care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for two of 13 residents (Residents #36 and #65) reviewed for care. The facility staff failed to intervene or consult the physician when Resident #36 ' s blood pressure readings were elevated, some as high as 190/127, for 18 of 23 days in 9/2015. The facility staff failed to intervene or consult the physician when Resident #65 ' s blood pressure was elevated at 163/121 on 9/3/2015 even though the physician had s specific order to be consulted if the resident ' s blood pressure exceeded 0. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/25/2015. While the IJ was removed on 9/26/2015, the facility remained out of compliance at a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. These failures affected two residents with one who experienced a prolonged period of elevated blood pressure and placed 25 residents with a [DIAGNOSES REDACTED]. Findings include: Resident #36 Record review of Resident #36's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #36 ' s annual MDS dated [DATE] revealed the resident was assessed as moderately impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident had an active [DIAGNOSES REDACTED]. Record review of Resident #36 ' s care plan for hypertension initiated 2/12/15 and reviewed 7/13/15 revealed no interventions to notify physician of any abnormal readings. Record review of Resident #36 ' s September 2015 consolidated physician's orders [REDACTED]. Give 5 mg by mouth one time a day related to essential hypertension, benign. Hold for systolic blood pressure less than 100. There was no diastolic parameter listed on the orders. Record review of Resident #36 ' s September 2015 MAR indicated [REDACTED].M. daily with the scheduled [MEDICATION NAME]. 9/1-182/131, 9/2 -175/124, 9/3-190/98, 9/4-175/132, 9/5-170/120, 9/9-177/129, 9/12-174/118, 9/13-162/116, 9/14-190/127, 9/15-186/135, 9/16-185/139, 9/17-185/103, 9/18-178/100, 9/19-164/124, 9/20-174/118, 9/21-196/100, 9/22-177/114, and 9/23-159/191. Record review of a publication from the American Heart Association dated 4/28/2015 revealed in part the following: .categories defined by the American Heart Association for hypertension include Stage 2 hypertension systolic BP of 160 or higher and diastolic BP of 100 or higher. Hypertensive crisis (emergency care needed) systolic BP higher than 180 and diastolic BP higher than 110. Record review of Resident #36 ' s medical record revealed no documentation of any physician consultation concerning the resident's elevated blood pressure readings in the physician or nurse progress notes. Observation of Resident #36 on 9/24/15 at 5:45 P.M. revealed the resident was sitting in a wheelchair in his room alert and able to respond to verbal stimuli by smiling, and shaking his head in response to yes or no questions. Interview on 9/25/15 at 12:15 P.M. LVN #12 stated the MA took the resident's blood pressure before administering the blood pressure medications. She stated she was not aware Resident #36 ' s blood pressure readings were elevated. Interview on 9/25/15 at 12:30 P.M. MA #7 stated she had administered blood pressure medication to Resident #36 and had taken his blood pressure. She stated she checked the blood pressure prior to administering any blood pressure medication by using the wrist cuff. She said if the blood pressure was high she would administer the blood pressure medication and notify the charge nurse. She said sometimes she would re-check the blood pressure and would write it down on her paper but she did not document in the resident ' s chart. She stated she would notify the charge nurse if the blood pressure was in the 150 ' s systolic or 90 ' s diastolic. She stated by not documenting in the resident ' s medical record there was no way to verify the readings or that anyone was notified. Interview on 9/25/15 at 12:45 P.M. the DON stated she did not know Resident #36 had such high blood pressure readings. She stated she would expect the MA to notify the nurse and the nurse to notify the physician. She said the facility was having a hard time getting physicians to order parameters for notification of vital signs. She stated the physicians did not want the parameter notifications and wanted to be called if there was a concern or problem. The DON also stated she notified Resident #36 ' s physician today of the resident ' s blood pressure patterns. She stated the physician responded by saying he was not going to just change his medications and would see the resident within the next week to evaluate and assess him for the best treatment. Record review of the monthly nursing review for Resident #36 dated 8/22/15 presented by the DON revealed the following: Blood pressure 158/91. Pulse 81. Elevated BP is normal for this resident. MD aware. Interview on 9/24/15 at 2:30 p.m. the DON, was ask why there were no blood pressure (BP) parameters in place on several of the residents reviewed that were on hypertension (HTN) medications. The DON stated the resident ' s physicians did not believe in BP parameters and wanted total control. She stated should a resident ' s BP read high or low, the physician wanted to be contacted and they would decide what the next step would be. The DON stated when she first started at the facility she noticed the lack of BP parameters and quickly learned the physician ' s instructions. She stated she had repeatedly requested something from the physicians and each time she received the same negative response. The DON stated she understood the importance of parameters concerning hypertension and should any problems arise from the lack of parameters, it could potentially reflect negatively on the facility. Interview on 9/25/2015 at 1:30 P.M. the DON stated the physician should have been notified of the higher blood pressure readings and then stated the physician probably was not notified because nursing staff thought he was already aware. Resident #65 Record review of Resident #65's face sheet revealed a [AGE] year old female, admitted to the facility on [DATE] and re-admitted on [DATE]. The resident had the following Diagnoses: [REDACTED]. Record review of Resident #65 ' s MDS dated [DATE] revealed the resident was assessed as severely impaired in cognition for daily decision making skills. Continued review of the same MDS revealed the resident had an active [DIAGNOSES REDACTED]. Record review of Resident #65's Care Plan dated 08/21/15 revealed she had a care plan for hypertension. One of the goals was No complication related to hypertension experienced by (Resident #65) will go unnoticed through the next review date. Interventions included .give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate .Monitor/document/report to MD PRN any s/sx (signs/symptons) of malignant hypertension .Obtain blood pressure readings as ordered . Record review of Resident #65 ' s September consolidated physician's orders [REDACTED]. Further review of this order revealed Check blood pressure daily, call if BP exceeds 150/100 every day and night shift. Record review of Resident #65 ' s September 2015 MAR indicated [REDACTED].M. of 163/121 with the scheduled [MEDICATION NAME]. Further review of the September 2015 MAR indicated [REDACTED]. Record review of Resident #65 ' s medical record for the time period of 9/3/2015 revealed no documentation of physician consultation of the blood pressure reading in the progress notes. Observation of Resident #65 on 9/23/15 at 1:32 P.M., 3:37 P.M. and 5:00 P.M.; 09/24/15 at 8:25 A.M., 1:35 P.M. and 5:00 P.M. and 09/25/15 at 8:25 A.M. revealed the resident in bed in her room asleep. Interview with the DON on 09/25/15 at 1:45 P.M. revealed she was unable to find documentation that Resident #65 ' s physician was notified of her BP reading on 09/03/15 so she was unsure if the physician was aware of the resident ' s BP. Interview on 9/25/15 at 2:45 p.m. with the DON and Dr. #1 the doctor stated he was against establishing BP parameters and having the facility come up with a number for everyone. He was under the impression he would not be involved in the entire process. The DON explained the facility would like to have parameters that would guide staff on what to do if the resident ' s blood pressure was above or below the parameter to consult the physician and the physician would be the one to provided staff with further direction. The DON asked the MD if the facility was able to establish a baseline for each one of his residents and come up with an average, would that be acceptable. He stated it would be as long as he was contacted and was able to tell the facility staff to hold, to change or to give the medication. The DON stated she was going to bring this matter up at the next Q & A meeting. Interview on 9/25/2015 at 3:00 P.M. the pharmacy consultant stated she was very frustrated concerning the responses she received back from the physicians concerning her recommendations. She stated lots of times they would not respond and when they did she stated the physicians would just disapprove and not give a reason why they disapproved. Record review of the pharmacy consultant letters dated September 15, 2015 revealed only one recommendation letter concerning parameters. The recommendation was a resident was having low pulses of 55 and 56 and the pharmacist had asked if the medication Amiodorone could be held. At the time of the review the physician had not responded. A facility policy to address consultation of the physician of change in condition was requested of the DON but not provided prior to exit. The facility Administrator and DON were notified on 9/25/2015 at 3:08 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ 1. On 9/25/15 at 1:45 P.M. a list of residents with a [DIAGNOSES REDACTED]. The list consisted of 26 residents that did not have clinical parameters established by the physician. 2. A new clinical protocol was developed by the DON so that clinical monitoring could be conducted by staff for residents without parameters. This protocol states that any resident with a blood pressure below 90/50 or greater than 160/100 or with a pulse of less than 60 or greater than 100 will be sent to the attending physician via fax or per a telephone call. The attending physician will be allowed to develop their own protocol based upon the individual resident ' s needs. The medication aide will document notification of the charge nurse in their progress notes and the LN (licensed nurse) will document in the clinical record. If this is on a week-end or the physician is otherwise available, the on-call physician will be notified. If no response is received within 20 minutes, the Medical Director will be notified for guidance. This was sent to the physicians via fax at 1:50 P.M. on 9/25/15 by Nursing Administration. 3. All clinical staff onsite were immediately educated regarding this new clinical protocol by the DON on 9/25/15 at 2:00 PM. The remaining clinical staff will receive education on 9/25/15 by 6:00 PM. Those not able to attend due to unforeseen circumstances will not be able to return to active duty until this training has been conducted and approved by the DON. 4. An Audit was conducted by the MDSC, Medical Records Coordinator and the Staff Development coordinator, (LVN ' s), of the Blood Pressures of these residents. This audit was done on 9/25/15 at 1:45 PM, under the supervision of the DON. Those that had Blood Pressures outside of the newly established protocol received a fax notifying them of this information. This will be documented in the clinical record by the Medical Records LVN or staff development LVN by 1800 on 9/25/15. 5. All physicians will be notified via Fax and a copy of the new protocol by 9/25/15, this will be done by the DON. 6. All Licensed staff and Medication Aides will be trained on the appropriate notification to the attending physician regarding any clinical concerns and abnormal assessment findings. All staff available will be trained by the DON on 9/25/15 at 2:00 P.M Any staff not able to attend this training will not be allowed to return to work until this training has been completed. The plan of removal was accepted on 9/26/15 at 10:45 A.M. Plan of Removal Monitoring: 1. Reviewed documentation dated 9/25/15 of rounds made on every resident with a [DIAGNOSES REDACTED]. 2. Reviewed documentation on 9/26/15 of five random residents with a [DIAGNOSES REDACTED]. 3. Reviewed documentation of the notification to all physicians of the new protocol for vital signs monitoring. 4. Reviewed documentation dated 9/25/15 that licensed staff and medication aides were in-serviced on the new protocol for vital sign monitoring, documentation and physician follow-up on vital signs outside of the stated parameters. 5. Interviews were conducted on 9/26/15 by two surveyors with the following results: 100% of all licensed staff and medication aides on duty had been in-serviced and were able to identify the protocol for vital sign monitoring and physician follow-up and documentation. Of the remaining staff not on duty three LVN ' s and four medication aides were interviewed by phone and all were able to identify the steps in the protocol for vital sign monitoring. The DON stated on 9/26/2015 at 3:00 P.M. there were three full-time and three PRN staff that had not been in-serviced. She stated they would not be allowed to work until in-serviced on the new protocol for vital sign monitoring and follow-up. The DON stated the facility will continue to monitor daily the vital signs of all residents with a [DIAGNOSES REDACTED]. She further stated this information would be reviewed daily and would become part of QA. On 9/26/15 at 3:33 P.M. the Administrator and DON were notified the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. The facility identified 27 residents with [DIAGNOSES REDACTED].

Based on observations, record review, and interviews, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well being of two of 15 residents (Residents #36 and #65) who were reviewed for hypertension management. The Administrator failed to oversee and assist with the development and implementation of effective policies and procedures on identifying adverse signs of hypertension and consulting with the physicians. The Administrator failed to supervise the DON on training and monitoring the nursing staff to monitor, assess, and consult physicians concerning adverse blood pressures of residents with a [DIAGNOSES REDACTED]. The DON failed to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. The DON failed to monitor the nursing staff on consulting with the physician when a resident had adverse signs concerning hypertension. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/25/2015. While the IJ was removed on 9/26/2015, the facility remained out of compliance at a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. These failures affected two residents with one who experienced a prolonged period of elevated blood pressure and placed 25 residents with a [DIAGNOSES REDACTED]. Findings include: Resident #36 Record review of Resident #36's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Resident #36 ' s blood pressure readings were elevated, some as high as 190/127, for 18 of 23 days in 9/2015 without staff intervention or physician consultation. Resident #65 Record review of Resident #65's face sheet revealed a [AGE] year old female, admitted to the facility on [DATE] and re-admitted on [DATE]. The resident had the following Diagnoses: [REDACTED]. Resident #65 ' s blood pressure was elevated at 163/121 on 9/3/2015. The facility staff did not intervene even though the physician had specific orders to direct staff to consult with him if Resident's #65's blood pressure was over 150/100. Interview on 09/25/2015 at 6:00 P.M. the Administrator stated they had already started acting on the vital sign and physician notification issues of the residents. She could not recall being advised of this practice prior to the survey. She stated she monitored the effectiveness of the DON through various ways. Some of those ways included clinical audit, weekly subcommittee meetings and the monthly QA meetings. She stated the QA committee had identified that there was a documentation problem but not specifically concerning parameters. She stated the DON had already been working with training staff on proper documentation. During the same interview she stated the company provided numerous resources for the Administrator and the DON to utilize to assist in training and monitoring staff. She stated the company had a Medical Director, Regional Director, Corporate Staff and Corporate Nursing staff to assist the facility. During the interview on 09/25/2015 at 6:00 P.M. the DON stated she had numerous ways on how she checked the competency of the nursing staff. She said one way was by verifying their training and previous employment upon hire. Another way was through annual competency reviews of staff every December as well as ongoing monitoring and supervision. She stated a third way was through a new in-service protocol she had developed to insure the staff had the skills and training needed to handle abnormal vital signs and hypertension parameters. The DON stated she was concerned about the lack of blood pressure parameters when she first became the DON and notified the physicians, but they refused to give her parameters. She stated staff had been treating abnormal vital signs as normal because the physicians were aware of the high blood pressure and had told the nurses it was normal for that particular resident. The DON further stated there was a lack of documentation by the staff that the physicians had been notified. She said some more training was needed and that she had already started this training and would ensure it was completed by each nurse especially in the area of vital signs and notifying physicians. The DON stated she had already notified all physicians by fax that any blood pressure readings over 160/100 or less than 90/50 and any pulse 60 or less or greater than 100 would be reported to the physicians without exception. Record review of a publication from the American Heart Association dated 4/28/2015 revealed in part the following: .categories defined by the American Heart Association for hypertension include Stage 2 hypertension systolic BP of 160 or higher and diastolic BP of 100 or higher. Hypertensive crisis (emergency care needed) systolic BP higher than 180 and diastolic BP higher than 110. A facility policy to address consultation of the physician of change in condition was requested but not provided. Refer to tags F157, F224, F226 and F309 for additional evidence of the deficient practices. The facility Administrator and DON were notified on 9/25/2015 at 3:08 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ 1. On 9/25/15 at 1:45 P.M. a list of residents with a [DIAGNOSES REDACTED]. The list consisted of 26 residents that did not have clinical parameters established by the physician. 2. A new clinical protocol was developed by the DON so that clinical monitoring could be conducted by staff for residents without parameters. This protocol states that any resident with a blood pressure below 90/50 or greater than 160/100 or with a pulse of less than 60 or greater than 100 will be sent to the attending physician via fax or per a telephone call. The attending physician will be allowed to develop their own protocol based upon the individual resident ' s needs. The medication aide will document notification of the charge nurse in their progress notes and the LN (licensed nurse) will document in the clinical record. If this is on a week-end or the physician is otherwise available, the on-call physician will be notified. If no response is received within 20 minutes, the Medical Director will be notified for guidance. This was sent to the physicians via fax at 1:50 P.M. on 9/25/15 by Nursing Administration. 3. All clinical staff onsite were immediately educated regarding this new clinical protocol by the DON on 9/25/15 at 2:00 PM. The remaining clinical staff will receive education on 9/25/15 by 6:00 PM. Those not able to attend due to unforeseen circumstances will not be able to return to active duty until this training has been conducted and approved by the DON. 4. An Audit was conducted by the MDSC, Medical Records Coordinator and the Staff Development coordinator, (LVN ' s), of the Blood Pressures of these residents. This audit was done on 9/25/15 at 1:45 PM, under the supervision of the DON. Those that had Blood Pressures outside of the newly established protocol received a fax notifying them of this information. This will be documented in the clinical record by the Medical Records LVN or staff development LVN by 1800 on 9/25/15. 5. All physicians will be notified via Fax and a copy of the new protocol by 9/25/15, this will be done by the DON. 6. All Licensed staff and Medication Aides will be trained on the appropriate notification to the attending physician regarding any clinical concerns and abnormal assessment findings. All staff available will be trained by the DON on 9/25/15 at 2:00 P.M. Any staff not able to attend this training will not be allowed to return to work until this training has been completed. The plan of removal was accepted on 9/26/15 at 10:45 A.M. Plan of Removal Monitoring: 1. Reviewed documentation dated 9/25/15 of rounds made on every resident with a [DIAGNOSES REDACTED]. 2. Reviewed documentation on 9/26/15 of five random residents with a [DIAGNOSES REDACTED]. 3. Reviewed documentation of the notification to all physicians of the new protocol for vital signs monitoring. 4. Reviewed documentation dated 9/25/15 that licensed staff and medication aides were in-serviced on the new protocol for vital sign monitoring, documentation and physician follow-up on vital signs outside of the stated parameters. 5. Interviews were conducted on 9/26/15 by two surveyors with the following results: 100% of all licensed staff and medication aides on duty had been in-serviced and were able to identify the protocol for vital sign monitoring and physician follow-up and documentation. Of the remaining staff not on duty three LVN ' s and four medication aides were interviewed by phone and all were able to identify the steps in the protocol for vital sign monitoring. The DON stated on 9/26/2015 at 3:00 P.M. there were three full-time and three PRN staff that had not been in-serviced. She stated they would not be allowed to work until in-serviced on the new protocol for vital sign monitoring and follow-up. The DON stated the facility will continue to monitor daily the vital signs of all residents with a [DIAGNOSES REDACTED]. She further stated this information would be reviewed daily and would become part of QA. On 9/26/15 at 3:33 P.M. the Administrator and DON were notified the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern. The facility was continuing to monitor to ensure all staff were trained to monitor, assess, and consult physicians concerning blood pressures of residents with a [DIAGNOSES REDACTED]. The facility identified 27 residents with [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to provide the necessary care and services to attain the highest practicable well-being for 1 (Resident #48) of 9 residents reviewed for services provided. The facility failed to ensure Resident #48's physician's triple script prescription for pain medication was received and filled so there was not an 8 day delay/interruption in his pain treatments when he returned from the hospital. This failure caused Resident # 48 severe pain and anguish and placed 48 residents at risk of not having their pain treated promptly which could cause them severe pain both mental and physical decline. Findings included: Record review of the Resident #48 ' s admission information revealed he was admitted to the facility on [DATE] and readmit on 8/9/2012 from the hospital. The resident was [AGE] years old. His admission [DIAGNOSES REDACTED]. Record review of Resident # 48's MDS dated [DATE] revealed a BIMs (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Record review of Resident #48's care plan dated 5/18/12 revealed the following: "Focus- Resident has chronic pain related to [MEDICAL CONDITION] (muscle spasms) Interventions- Administer [MEDICATION NAME] ([MEDICATION NAME] Patch, [MEDICATION NAME]) as per orders Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain" Record review of the fax sent to Resident #48 ' s primary physician on 8/10/12 by RN #1 revealed the following: " ...Resident had a new order for [MEDICATION NAME] 100 mcg/hr but they {the hospital}did not send a triplicate {prescription}for the patch. Spoke to the hospital but they said to refer back to primary {physician}. Please advise on what to do ... " Record review of Resident #48 ' s nursing progress notes revealed the following: 8/10/12 at 1423 (2:23 P.M.) entry by RN #1 " ...Called resident ' s physician ' s office and spoke with the staff there and was told they had just received the resident ' s discharge paperwork from the hospital and for RN#1 to fax over the concerns. Office staff said the physician would let the facility know which orders he would want the resident to continue. Will await a response ... " 8/15/12 at 1421 (2:21 P.M.) entry by RN #1 " ...Attempted to call resident ' s physician again in regards to resident ' s [MEDICATION NAME]. Was transferred to his nurse ' s voice mail. Left a message asking her to please return call today. Also called and left a message for her on Monday 8/13/12 at 4:30 P.M. Have not had a response from the clinic ... " [MEDICATION NAME] 100 mcg/hour topically every 72 hours pain Observation and interview on 8/16/12 at 9:00 A.M. revealed Resident #48 lying in bed with a towel over his head. He stated he spent most of his day in bed because of his pain. He stated he was agitated and in pain because he had not received his [MEDICATION NAME] since he returned to the facility on [DATE]. He stated he had not had a new patch in 6 days and he had been using the [MEDICATION NAME] for the past 2 years to control his pain. He stated before he went into the hospital he was taking [MEDICATION NAME] 7.5 mg 2 tablets every four hours as needed and [MEDICATION NAME] 75 mcg every 72 hours to control his pain. When he went into the hospital the [MEDICATION NAME] was decreased to 10 mg one every four hours as needed and the [MEDICATION NAME] was increased to 100 mcg every 72 hours. He continued, he had been asking for the pain patch several times every day to numerous staff since he returned from the hospital and still had not gotten a new patch. RN#1 told him she had made several attempts to contact his primary physician about getting the patch but had no success. He had begged her to help him switch doctors, to make an appointment for him to go back to the doctor at the hospital, anything to get him the patch. He also stated he had been very irritable lately because the [MEDICATION NAME] only provided him temporary relief. He said was still experiencing pain that was affecting his sleep and appetite. He said he had not been sleeping well at all due to the pain and he did not want to get out of bed during the day due to the pain. Record review of the resident's MAR indicated [REDACTED] 8/10/12 at 12:36 A.M., 4:00 A.M., 8:32 A.M. 12:35 P.M. and 6:36 P.M. 8/11/12 at 4:25 A.M. 8:31 A.M., 12:34 A.M., 4:51 P.M. and 10:39 P.M. 8/12/12 at 1:21 A.M., 5:18 A.M., 9:39 A.M., 1:52 P.M., and 11:54 P.M. 8/13/12 at 2:50 A.M., 7:22 A.M. , 11:44 A.M. 8/14/12 at 12:30 A.M., 4:44 A.M., 8:42 A.M., 7:50 P.M. 8/15/12 at 2:25 A.M. and 7:11 A.M. During an interview on 8/16/12 at this same time LVN #9 stated the staff had called and faxed the physician's office several times with no response. Interview on 8/16/12 at 9:30 A.M., RN #1 stated she had made several attempts to contact Resident #48 ' s physician with no response. She also stated Resident #48 ' s physician was not the Medical Director of the facility and she had not contacted the Medical Director to help facilitate the resident in obtaining his [MEDICATION NAME]. Interview on 8/16/12 at 9:45 A.M. the DON stated the Medical Director should have been contacted if there was no response from the resident ' s physician within 24-48 hours. The DON further stated she was not aware of the issue with the [MEDICATION NAME]. Record review of the facility policy titled Pain Assessment and Management Revised March 2009 revealed the following: "...Assessing Pain: 1. During the comprehensive pain assessment gather the following information as indicated from the resident a. History of pain and its treatment c. Impact of pain on quality of life e. Factors and strategies that reduce pain Defining Goals and Appropriate Interventions: 1. the pain management interventions shall be consistent with the resident's goals for treatment. Monitoring and Modifying Approaches: 4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated..." The facility's CMS 801 form revealed 49 resident's were assessed with [REDACTED].