Every finding on record at University Rehabilitation Center

Based on interviews, and record reviews, the facility failed to maintain accurate medical records for two (Residents #1 and #3) of 5 residents reviewed for medical records. The facility failed to ensure Resident #1's Care plan was not added to Resident #3's care plan for being physically abusive to Resident #2 on 08/07/26. The facility did not maintain an accurate representation of the actual experiences of the resident including changes in Resident #1's Plan of Care goals. This failure could place residents at risk of not getting appropriate care which could result in increased behaviors which could affect the residents health and psychosocial well-being.Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 01, indicating severe cognitive impairment. She was diagnosed with dementia with aggression (loss of cognitive functioning affecting memory, mood, and thinking), heart failure, depression (persistent sadness, loss of interest, and decreased energy that interferes with daily life), and anxiety (feelings of worry, nervousness, or unease). Record review of Resident #1's PIR dated 08/07/2026 revealed she had an incident with another resident. According to the PIR, Resident #1 hit Resident #2, there were no injuries or adverse reactions noted. Record review of Nursing Progress Note dated 08/07/2026 1:15 am by LVN A, revealed Res observed striking fell res to back of head while res was lying down on couch with back to res. Res that was struck said 'Oww! Why the hell did you do that?' Residents separated immediately. Record review of Resident #1's Care Plan date initiated 03/25/26 revealed, she had impaired cognitive function/dementia, ADL self-care performance deficit, monitoring for anti-anxiety and anti-psychotic medications and in a secured unit. (Her Care plan had not been updated since her 08/07/26 incident with Resident #2). After surveyor intervention, Record review of Resident #1's Care plan dated 08/26/26 revealed, the resident had potential to demonstrate verbally abusive behaviors dementia. 2) Record review of Resident #3's Care Plan date initiated 08/07/26 revealed, the resident had potential to demonstrate physical behaviors related to dementia. Staff interventions included providing physical and verbal cues to reduce anxiety, assisting residents to verbalize sources of agitation, and giving positive feedback. Other interventions included physically separating the resident if they exhibit physical behaviors toward another resident, calling other staff for assistance, and notifying the charge nurse. (Resident #1's name was not on the care plan). After surveyor intervention, Record review of Resident #3's Care Plan date initiated, on 08/26/26 revealed, a cancelled care plan for the resident had potential to demonstrate physical behaviors related to dementia. Interview with MDS B on 08/26/2026 at 2:07 pm, revealed care plans changes were made by various interdisciplinarians but she is ultimately responsible. She stated that care plan changes are usually made the next business day after incidents of aggression. She stated that the care plan for Resident #3 was changed erroneously due to similar resident last names. She stated that she changed Resident #3's care plan instead of Resident #1's care plan for aggressive behavior. She stated Resident #1's care plan should have been changed and not Resident #3's care plan. (During the interview, MDS A made the correct care plan changes to Resident #1). Interview with the Administrator on 08/26/2026 at 4:50 pm revealed that she was not aware of any care plan issues, and after being notified about Resident #1's care plan change being documented on Resident #3's care plan stated that staff were going to need to make sure they checked the resident's records more carefully. She stated that the DON and three ADONs were responsible for ensuring the resident's care plan and documentation were accurate. She stated that the facility did not have a policy on medical record, or accurate documentation. She stated the risk to the resident having inaccurate information in their medical records could affect the resident's care or treatment they received. Interview on 08/26/26 at 5:17 pm, the DON stated that he was not aware of any care plan or documentation issues with Residents #1 and #3's records. He stated that he was ultimately responsible for the accuracy of resident's records. He stated that errors like this could affect the residents' continuity of care and could be catastrophic for a resident because they may receive the wrong care. Record review of the facility's Training Inservice Name Alert - Documentation on Residents with similar names dated 08/26/2026 at 2:30pm, by MDS Nurse, revealed fifteen staff members signatures. Record review of the facility's Medical records policy was not completed because the Administrator stated they did not have one on 08/26/2026 at 5:30 pm and 5:45 pm

Based on observation, interview, and record review, the facility failed to ensure the resident's right to secure and confidential medical records for seven (Residents #1, #2, #3, #4, #5, #6 and #7)) of 12 residents reviewed for resident rights.A. The facility failed to ensure MA A did not leave her computer tablet unattended, which displayed Resident #1's vital reports screen.B. The facility failed to ensure MA A did not leave Residents #2, #3, #4, #5, #6 and #7's empty medication cards with their names, medications and dosages displayed on them, on top of an unattended medication cart on the 200 hall.These failures could place residents at risk of having their medical information disclosed to residents and visitors which could cause embarrassment, frustration, and feelings of decreased privacy, resulting in a decline in their health and psycho-social well-being. The findings included: Observation on 07/08/26 at 9:40 am revealed an unattended medication cart on the 200 hall. Observation revealed an unlocked computer tablet displaying Resident #1's vital reports screen. Further observation revealed ADON B was giving medications to other residents on the 200 hall. Observation revealed three residents and two employees passed by the medication cart while Resident #1's vital reports screen was displayed. Observation and interview on 07/08/26 at 9:41 am, MA A was standing inside Resident #1's room on the B bed side, with her back towards the door. MA A was observed turning around and quickly walking to the medication cart. MA A closed the computer tablet and said she was about to enter Resident #1's blood pressure vital readings. because her blood pressure was low and she was checking it again. She stated she should have locked the computer before walking away from it. She stated all of the six medication cards on the right side of the medication cart were faced down with no medications in them. MA A stated she left them on top of the medication cart because she needed to replace them with more medications. She stated the six residents ran out of medications and said she normally put empty medication cards in the bottom of the medication cart. MA A grabbed the medication cards and placed them into the bottom drawer of the medication cart. She then locked the medication cart and said this was the only time she forgot to close the tablet and put the medication cards in the medication cart. She stated the medication cards on top of the medication cart revealed: Resident #2 had an order for 25 mg Alogliptin Benzoate, Resident #3 had an order for 20 mg ER Memantine, Resident #4 had orders for .1 mg Fludrocortisone Acetate Tablet, Resident #5 had an order for 75 mg Irbesartan Oral Tablet, Resident #6 had an order for 200 mg Hydroxychloroquine Sulfate and Resident #7 had an order for 4 mg Tizanidine Oral. MA A stated leaving resident information out on an unattended medication cart could result in other people getting the residents' medical information. She stated not everyone was supposed to see or read their medical information. She stated exposing residents' medical information was a HIPAA violation. She stated she had not had a chance to take these medication cards to the shredder or and had not torn the tops with their names on them, because she was trying to finish her med pass. She stated they needed to go to the medication room and knew in the meantime, she needed to secure them because their names were on them still. She stated the last HIPAA training she had was three weeks ago. 1)Record review of Resident #1's Quarterly MDS assessment, dated 04/60/26, revealed an [AGE] year-old female admitted [DATE]. This assessment indicated her BIMS score was 13 (cognitively intact). Record review of Resident #1's July 2026 MAR revealed on 07/08/26, MA A administered 60 mg Nifedipine ER tablet for hypertension (high blood pressure). blood pressure was 125/77. MA A administered 100 mg Hydralazine oral tablet for hypertension (high blood pressure). Resident #1 blood pressure was 125/77. 2)Record review of Resident #2's Quarterly MDS assessment, dated 05/20/26, revealed a [AGE] year-old female who admitted [DATE]. This assessment indicated. her BIMS score was 03 (severe cognitive impairment). Record review of Resident #2's July 2026 MAR revealed on 07/08/26, MA A administered 25 mg of Alogliptin Benzoate Oral tablet 1 tablet by mouth related to Diabetes Mellites (high blood sugar level) without complications. 3)Record review of Resident #3's Quarterly MDS assessment, dated 05/14/26, revealed an [AGE] year-old female admitted [DATE]. For this assessment, her BIMS score was 13 (cognitively intact). Record review of Resident #3's July 2026 MAR, dated 07/08/26, revealed MA A administered 28 mg of Memantine ER by mouth for dementia (decline cognitive abilities). 4)Record review of Resident #4's Quarterly MDS assessment, dated 05/07/26, revealed an [AGE] year-old male admitted [DATE]. For this assessment, his BIMS score was 06 (severe cognitive impairment). Record review of Resident #4's July 2026 MAR on 07/08/26 revealed, MA A administered 0.1 mg Fludrocortisone acetate] tablet by mouth for low blood pressure. 5)Record review of Resident #5's Quarterly MDS assessment, dated 05/24/26, revealed a [AGE] year-old female admitted [DATE]. For this assessment, her Staff Assessment for Mental Status score was 03 (Severe cognitive impairment). Record review of Resident #5's July 2026 MAR on 07/08/26 revealed MA A administered 75 mg of Irbesartan by mouth for hypertension (high blood pressure). 6)Record review of Resident #6's Annual MDS assessment, dated 06/22/26, revealed an [AGE] year-old female admitted [DATE]. For this assessment, her Staff Assessment for Mental Status score was 03 (severe cognitive impairment). Record review of Resident #6's July 2026 MAR on 07/08/26 revealed, MA A administered 200 mg Hydroxychloroquine Sulfate by mouth for polycythemia vera (slowly progressing blood cancer). 7)Record review of Resident #7's Quarterly MDS assessment, dated 04/26/26, revealed a [AGE] year-old female admitted [DATE]. For this assessment, her BIMS score was 14 (no cognitive impairment). Record review of Resident #7's July 2026 MAR dated 07/08/26 revealed MA A administered 4 mg Tizanidine 1 capsule by mouth for muscle spasms. During an interview on 07/08/26 at 5:05 pm, ADON B stated if the medication cards were empty the residents' names should have been torn off. She stated the nurses and MAs should have the medication cards locked in the medication cart, regardless if medications were in them or not, they should be locked in the med cart. She stated what MA A did was a HIPAA violation because the medication cards had patient information, like the resident's names, name of medication and dosage information. She stated the nurses or MAs should not leave the computer screens displayed and unlocked for anybody to look at the patient information. She stated she did notice the medication cards on top of the med cart while seeing MA A talk to HHS. She stated she did a 1:1 training with MA A to ensure she did not leave her medication cart unattended if she did not tear off the tops of the medication cards. She stated the nurses and MAs knew to put the medication cards into the shredder in the medication room or put them in the locked medication cart. She stated she did not know about MA A's tablet being unlocked showing Resident #1's medical information but stated MA A should have known better. During an interview on 07/08/26 at 5:51 pm, the DON stated there were no issues with this facility being HIPAA compliant and was not aware of MA A not following their HIPAA policy and would talk to her about it. He stated when the medication cards were empty the nurses and MAs were supposed to tear off the residents' names to put in the shredder, then discard the cards into the trash. He stated the nurses and MAs could put the medication cards face down on the medication cart as long as no one flipped them up. He stated he was not sure what anyone could do with empty medication cards. He stated the resident's names, pharmacy phone number, medication name, and dosage orders were on the medication cards. He stated the computers needed to be locked before the nurses and MAs walked away from the medication cart to prevent anyone from having access to the residents' records. He stated not securing the residents' information before walking away could result in people knowing what the residents were being treated for, like an infection. He stated everyone who supervised the medication cart or handled medications were responsible for HIPAA compliance, but ultimately, he was responsible.During an interview on 07/08/26 at 6:20 pm, the Administrator stated they were doing a good job with their HIPAA policy and procedures. She stated the expectation was to make sure the computers were off when the nurses and MA's step away from the medication carts. She stated she was unsure of the expectations, but knew the resident's medication cards should be put up, but was not sure where. She stated she was not aware MA A left the resident's empty medication cards on top of the med cart and left the computer up with resident information disclosed. She stated that it was not good to do because the residents or other persons could grab the medication cards and see their information. She stated the computers should be locked or put down before the nurse or MA walked away from the medication carts. She stated the DON and herself was responsible for HIPAA compliance. During an interview on 07/08/26 at 6:30 pm, the facility's HIPAA policy was requested and the Administrator stated they did not have one. During an interview on 07/08/26 at 6:30 pm, the facility's Medication Discarding policy was requested and the Administrator stated they did not have one.Record review of the facility's Resident Rights policy dated 2003 revealed, We believe each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside our facility. We protect and promote the following rights of each resident.22. Each resident is ensured confidential treatment of all information contained in an automatic data bank. The resident=s [sic] written consent is required for the release of information to persons not otherwise authorized under law to receive it.

Based on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one (Incident #1079379) of four incidents reviewed for reporting of alleged violations. The Administrator failed to report the results of an investigation within five working days to the State Survey Agency. This failure could place residents at risk of not receiving timely and appropriate responses to alleged violations of abuse, neglect, and/or exploitation.Findings included: Record review completed on 04/23/26 at 9:00AM of the TULIP (Texas Unified Licensure Information Portal) system revealed that no Provider Investigation Report (Form 3613-A) had been filed for Incident #1079379 (no named/identified residents). The facility had filed the Facility Reported Incident and CII Self-Report Template (the initial reports) with the State Survey Agency on 03/27/26. Record review of the Provider Investigation Report (Form 3613-A) for Incident #1079379, which occurred on 03/27/26, reflected it was completed on 04/02/26. Review of the Provider Investigation Report reflected that a thorough investigation of the alleged incident (regarding an allegation of neglect to unknown residents due to staff members wearing earbuds and being on their cell phones) was completed. During an interview with the Administrator on 04/23/26 at 12:20PM, she stated she completed the Provider Investigation Report (Form 3613-A) for Incident #1079379 but forgot to submit it to the State Survey Agency within the required 5-day timeframe upon completion. The Administrator stated the risk of not submitting the Provider Investigation Report (Form 3613-A) included a lack of timeliness in information being submitted. During an interview with the Administrator on 04/23/26 at 12:49PM, she stated the facility did not have a policy related to submitting Provider Investigation Reports (Form 3613-A) within five working days of the incident.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (Resident #1 and Resident #2) of seven residents reviewed for comprehensive care plans. 1.) The facility failed to ensure that Resident #1's comprehensive care plan identified nebulizer treatments as an intervention for respiratory care. 2.) The facility failed to ensure that Resident #2's comprehensive care plan identified oxygen therapy as an intervention for respiratory care. This failure could place residents at risk of not receiving proper care and services due to inaccurate care plans.Findings included: 1.) Record review of Resident #1's Face Sheet, dated 04/23/26, reflected he was an [AGE] year-old male, who was originally admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia (a sudden, life-threatening inability to maintain oxygen levels, while chronic respiratory failure develops gradually, causing persistent low oxygen in the blood), idiopathic pulmonary fibrosis (a serious lung disease characterized by progressive scarring of lung tissue, making it increasingly difficult to breathe), and acute pulmonary edema (a sudden buildup of fluid in the lungs). Record review of Resident #1's MDS Assessment, dated 04/09/26, reflected he received respiratory treatments both on admission and while a resident at the facility. Record review of Resident #1's Physician's Orders, dated 04/23/26, reflected an active PRN order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial; inhale orally every 4 hours as needed for wheezing/shortness of breath [via nebulizer]. The start date for this order was 04/03/26. Record review of Resident #1's Care Plan, dated 03/30/26 (but active as of 04/23/26), reflected no evidence that Resident #1's order for treatment via nebulizer was included in the plan of care. The only areas pertaining to respiratory status/care were that Resident #1 had pneumonia and was receiving oxygen therapy. 2.) Record review of Resident #2's Face Sheet, dated 04/23/26, reflected she was a [AGE] year-old female, who was originally admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a potentially life-threatening condition characterized by insufficient oxygen in the blood) and chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). Record review of Resident #2's MDS Assessment, dated 04/05/26, reflected she received respiratory treatments both on admission and while a resident at the facility. Record review of Resident #2's Physician's Orders, dated 04/23/26, reflected an active PRN order for continuous oxygen at 2-4 L/Min via nasal cannula to maintain her oxygen stats > 92%. The start date for this order was 04/18/26. Record review of Resident #2's Care Plan, dated 02/25/26 (but active as of 04/23/26), reflected no evidence that Resident #2's order for continuous oxygen was included in the plan of care. The only area pertaining to respiratory status/care was that Resident #2 had Emphysema/COPD. During an interview with the Director of Nursing on 04/23/26 at 10:46AM, he stated the facility had experienced staff turnover and was attempting to catch up on creating and maintaining accurate, comprehensive care plans. The Director of Nursing stated nebulizer treatments and oxygen therapy should be included in care plans. During an interview with the MDS Coordinator on 04/23/26 at 11:28AM, she stated she was responsible for completing comprehensive care plans. She said the facility's electronic charting system was having technological issues, and certain care areas were not reflected in certain care plans as of this morning. She stated she had notified IT of this issue and had initiated a new care plan for Resident #1 with all appropriate care areas triggered. The MDS Coordinator stated the risk of incomplete/inaccurate comprehensive care plans included the potential for reduced efficiency in resident care. Review of the facility's Comprehensive Care Planning policy, undated, reflected, .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. and .Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on observations, interviews, and record review the facility failed to establish and maintain respiratory care including oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen for two (Resident #1 and Resident #2) of seven residents reviewed for respiratory care. 1.) The facility failed to ensure that Resident #1's nebulizer mask and mouthpiece were bagged in a plastic bag. 2.) The facility failed to ensure that Resident #2's oxygen tubing/nasal cannula were bagged in a plastic bag. These failures could place residents receiving respiratory therapy at risk of health-associated infections.Findings included: 1.) Record review of Resident #1's Face Sheet, dated 04/23/26, reflected he was an [AGE] year-old male, who was originally admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia (a sudden, life-threatening inability to maintain oxygen levels, while chronic respiratory failure develops gradually, causing persistent low oxygen in the blood), idiopathic pulmonary fibrosis (a serious lung disease characterized by progressive scarring of lung tissue, making it increasingly difficult to breathe), and acute pulmonary edema (a sudden buildup of fluid in the lungs). Record review of Resident #1's MDS Assessment, dated 04/09/26, reflected he received respiratory treatments both on admission and while a resident at the facility. Record review of Resident #1's Physician's Orders, dated 04/23/26, reflected an active PRN order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial; inhale orally every 4 hours as needed for wheezing/shortness of breath [via nebulizer]. The start date for this order was 04/03/26. Record review of Resident #1's Care Plan, dated 03/30/26 (but active as of 04/23/26), reflected no evidence that Resident #1's order for treatment via nebulizer was included in the plan of care. Observation of Resident #1's nebulizer equipment on 04/23/26 at 9:22AM revealed his nebulizer mask and mouthpiece were not in use and were lying on his bedside table, unbagged. 2.) Record review of Resident #2's Face Sheet, dated 04/23/26, reflected she was a [AGE] year-old female, who was originally admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a potentially life-threatening condition characterized by insufficient oxygen in the blood) and chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). Record review of Resident #2's MDS Assessment, dated 04/05/26, reflected she received respiratory treatments both on admission and while a resident at the facility. Record review of Resident #2's Physician's Orders, dated 04/23/26, reflected an active PRN order for continuous oxygen at 2-4 L/Min via nasal cannula to maintain her oxygen stats > 92%. The start date for this order was 04/18/26. Record review of Resident #2's Care Plan, dated 02/25/26 (but active as of 04/23/26), reflected no evidence that Resident #2's order for continuous oxygen was included in the plan of care. Observation of Resident #2's oxygen equipment on 04/23/26 at 10:09AM revealed her oxygen tubing/nasal cannula was not in use and was lying on a chair, unbagged. During an interview with CNA A on 04/23/26 at 10:57AM, she confirmed observing Resident #1's nebulizer mask and mouthpiece, as well as Resident #2's oxygen tubing/nasal cannula, not in use and unbagged. CNA A stated nebulizer masks, nebulizer mouthpieces, and oxygen tubing/nasal cannulas should all be bagged when not in use. She stated the risk of not bagging the items included the potential for infection. During an interview with the DON on 04/23/26 at 11:40AM, he stated oxygen tubing/nasal cannulas, nebulizer masks, and nebulizer mouthpieces should all be bagged when not in use. He stated the risk of not bagging these items included the potential for infection. The DON stated it was the responsibility of every staff member to ensure respiratory equipment was appropriately bagged when not in use to prevent infection. During an interview with the DON and Administrator on 04/23/26 at 12:22PM, they stated they did not have a policy related to proper storage of respiratory equipment (such as oxygen tubing/nasal cannulas, nebulizer masks, and nebulizer mouthpieces).

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received the correct dosage of levetiracetam (Keppra, and anti-epileptic drug/seizure medication) from 10/09/2025 to 11/26/2025. This failure could place residents at risk of medical complications not receiving the therapeutic effects of their medications.Findings included:Record review of a facility face sheet dated 12/10/2025 for Resident #1 reflected that she was a [AGE] year-old female who initially admitted to the facility on 08.08/2025 with diagnoses that included: TRAUMATIC SUBARACHNOID HEMORRHAGE WITHOUT LOSS OF CONSCIOUSNESS, SUBSEQUENT ENCOUNTER (bleeding in the brain), UNSTEADINESS ON FEET, and UNSPECIFIED CONVULSIONS (seizures).Record review of the Quarterly MDS assessment dated [DATE] for Resident #1 reflected that the resident had a BIMS score of 99 which means that the resident was unable to complete the interview due to nonsensical responses. Resident #1 had a primary medical condition of Non-Traumatic Brain Dysfunction (stroke, internal bleeding in the brain), and the medication section indicated that Resident #1 took an anti-epileptic drug.Record review of a comprehensive care plan dated 09/19/2025 for Resident #1 reflected that the resident is at risk for wandering, at risk for falls and elopement. Record review of a hospital record dated 10/9/2025 for Resident #1 reflected that the hospital physician had ordered an increase of the amount of anti-seizure medication and Resident #1 received from levetiracetam (Keppra), by mouth, 500 milligrams twice a day to, levetiracetam, by mouth, 750 milligrams twice a day. Record review of the facility orders[BR3] dated 10/09/2025 to 11/25/2025 from the Facility Physician found that there were no changes to Resident #1's levetiracetam (Keppra), by mouth, 500 milligrams twice a day, until 11/26/2025 when the order was changed to levetiracetam (Keppra), by mouth, 750 milligrams twice a day.Record review of the Medication Administration Record for Resident #1 dated 10/01/2025 to 10/31/2025 reflected that Resident #1 received levetiracetam (Keppra), by mouth, 500 milligrams twice a day for the entire month.Record review of Medication Administration Record for Resident #1 dated 11/01/2025 to 11/30/2025 reflected that Resident #1 received levetiracetam (Keppra), by mouth, 500 milligrams twice a day until 11/26/2025 after which she started to receive levetiracetam (Keppra), by mouth, 750 milligrams twice a day.Record review of a laboratory result dated 10/11/2025 revealed that Resident #1 had a safe therapeutic level of levetiracetam (Keppra) in her system of 17.83, within the reference parameters (safe levels) of 6.00 to 40.6.Record review of a laboratory result dated 11/12/2025 revealed Resident #1 had a safe therapeutic level of levetiracetam (Keppra) in her system of 12.94, within the reference parameters (safe levels) of 6.00 to 40.6. Record review of a laboratory result dated 11/24/2025 (drawn at hospital) revealed Resident #1 had a safe therapeutic level of levetiracetam (Keppra) in her system of 20.03, within the reference parameters (safe levels) of 6.00 to 40.6.In an observation and interview on 12/10/2025 at 12:30 PM Resident #1 was observed being assisted with eating lunch by RN A who was seated beside her. Resident #1 was unable to answer any questions, and RN A commented that Resident #1 was non-verbal. RN A further revealed that she had been the nurse on duty when Resident #1 fell on [DATE]. RN A stated that Resident #1 was a constant wanderer and that she worked on her charting in the hallway to be able to observe Resident # 1 more often. She stated that Resident #1 had passed her position in the hallway and was behind her less than a minute before she heard Resident #1 fall approximately 10 ft behind her. She stated that she immediately went to Resident #1 who was on the ground and noted that she was convulsing on the ground. She stated that she had not been able to tell if the resident fell because of a seizure, or if the seizure happened because of the fall. She stated that if Resident #1 didn't receive the ordered amount of levetiracetam (Keppra), it could expose her to a higher risk of suffering a seizure.In an interview on 12/10/2025 at 12:56 the Facility Physician revealed that he could not confirm if Resident #1 had a seizure on 10/05/2025 or on 11/24/2025. He stated that he was aware that the hospital had ordered an increase on 10/09/2025 of levetiracetam (Keppra), by mouth, 500 milligrams twice a day to, levetiracetam, by mouth, 750 milligrams twice a day. He stated that the nursing staff had missed inputting that order into the electronic health record system. He stated that if Resident #1 didn't receive the ordered amount of levetiracetam (Keppra), it could expose her to a higher risk of suffering a seizure.In an interview on 12/11/2025 at 2:20 PM the DON revealed that the facility had enacted new systems and a new check list to ensure that all orders were entered into their system. She stated that all re-admissions now had to have a new re-admission check list completed and all new re-admissions were discussed at the morning meeting and the evening meeting each day to ensure all orders were inputted. She stated that if residents did not receive their medications as ordered it could expose them to undue risk.In an interview on 12/11/2025 at 2:34 PM the ADM stated that the new processes that had been put into place for residents readmitted to the facility had been monitored and reviewed at the Quality Assurance process Improvement meeting and had been found to be effective. She stated that all residents' medications had been reconciled and no other instances like Resident #1's had been discovered.Record review of a facility policy titled Standard - Medication Errors dated December 2018 revealed .Significant and Non-significant medication errors are defined by OBRA using the following criteria: .2. Drug Category - If the drug is from a category that usually requires the resident/patient to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity .Examples of drug categories which require titration of resident/patient blood levels may include, but are not limited to, the following agents: anticonvulsants, anticoagulants, antiarrhythmic, anti-anginal, and anti-glaucoma .

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one of thirteen residents (Resident #12) reviewed for accidents and hazards.The facility failed to ensure Resident #12 received the appropriate supervision to prevent elopement from the facility on 6/23/2025 and 07/13/2025.The non-compliance was identified as PNC on 09/11/25 and the IJ template was provided the facility on 09/11/25 at 3:10 PM. The noncompliance began on 07/13/2025 and ended 07/13/2025. The facility corrected the non-compliance before the survey began.These failures could place the residents at risk of serious harm, injury and death from wandering outside the facility in unfamiliar surroundings. . Findings include: Record review of Resident #12's Face Sheet, dated 09/11/2025, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #12 had diagnoses which included moderate dementia with agitation, diabetes, and unsteadiness on his feet. Resident #12 was ambulatory with a walker. Record review of Resident #12's Quarterly MDS (tool used to assess health status) Assessment, dated 07/02/2025, reflected moderately impaired cognition with a BIMS (screening tool to assess cognitive status) score of 09. Section I (Active Diagnoses) reflected Resident #1's diagnoses included hypertension (high blood pressure), dementia (decline in cognitive function that interferes with daily life), and diabetes (the body does not use insulin effectively). Section N (Medications) indicated Resident #12 received a daily insulin (medication to treat elevated blood glucose) injection. Record review of Resident #'12's Comprehensive Care Plan, dated 05/14/25 and updated 06/23/2025, reflected the resident had impaired cognitive function or impaired thought process related to dementia. One intervention, initiated 06/23/2025, was for visual checks every 15 minutes for a 24-hour period until the resident was no longer at risk for elopement. Additional review of Resident #12's Comprehensive Care Plan, dated 05/14/2025 and updated 06/23/2025, reflected Resident #1 was at risk for elopement as evidenced by attempted elopement. Interventions included Psych services to evaluate and treat. Date initiated 06/23/2025… Determine the reason the resident is attempting to elope… Intervene as appropriate. Date initiated 06/24/2025. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated: 06/24/2025. Distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books. Date initiated: 06/24/2025. If the resident is exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system. Date initiated: 06/24/2025.” Record review of Resident #12's Progress Notes, dated 06/23/2025, reflected at about 7:00 PM Resident #12 pushed his way past visitors who were exiting the front door. Staff followed Resident #12 to the parking lot where he was agitated and refused to return to the building. Resident #12's family member was called, and after speaking with the resident, Resident #12 agreed to go back inside the facility. Resident #12 told staff members his family was out of town and there was no one to take care of the farm. Record review of Resident #12's Psychiatry Progress Note, dated 07/09/2025, reflected “Medical Necessity: Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Patient instability or change in condition requiring timely mental status examination to establish appropriate treatment intervention and/or change in treatment intervention…Continue current medication… Monitor patient's behavioral signs and symptoms on each subsequent encounter to determine effectiveness of the medications.” Record review of CNA J's witness statement, dated 07/13/2025, reflected that she answered the facility's phone on 07/13/2025 at about 2:30 PM. A family member reported not seeing Resident #12 on the camera in his room. CNA J checked the resident's room and reported to his nurse a family had called, and the resident was not in his room. An attempt to interview CNA J on 09/11/2025 was unsuccessful. CNA J no longer worked at the facility. Record review of RN I's witness statement, dated 07/13/2025, reflected “This RN visualized resident between 1330 (1:30 PM) and 1400 (2:00 PM) with tray of food on tray table and resident in recliner.” RN I indicated she was called to speak with the family of another resident and then assisted with resident care. “This RN came out of room and weekend manager notified resident was not located. This RN organized staff, building was searched systematically; this RN looked at out on pass log and resident was not signed out. Outside perimeter was checked by this RN and a CNA walking in opposite directions. This RN notified weekend manager unable to locate resident and was going to call 911. This RN called responsible party who stated resident was not out on pass, and was sending family member to facility. This RN called 911. Police dispatched. Provided photo, face sheet description. DON and police assumed search. DON notified this RN resident was found by police, went to hospital, and would discharge to secure unit. This RN notified physician.” An attempt to interview RN I on 09/11/2025 and 09/13/2025 was unsuccessful. Record review of Resident #12's Comprehensive Care Plan, dated 05/14/2025 and updated 07/13/2025, reflected Resident #12 was at risk for wandering. Interventions included “Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television. Date initiated 07/13/2025. If the resident is exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system, etc. Date initiated 07/13/2025. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated 07/13/2025. Date initiated 07/13/2025. Referral to secure care unit. Date initiated: 07/13/2025.” Record review of Resident #12's hospital record, dated 07/13/2025, reflected he was admitted to the intensive care unit and treated for severe hyperthermia (critical condition characterized by elevated body temperature) and acute hypoxic respiratory failure (body does not have enough oxygen in the blood) that required intubation (insertion of a tube into the airway to assist with breathing). The environmental temperature on 07/13/2025 was 93 degrees. During an interview on 09/11/2025 at 9:35 AM, the Social Worker stated Resident #12 eloped on 07/13/2025 and police were able to find him not far from the facility by the train railway. She stated the resident was taken to the hospital. She stated Resident #12's family had recently taken a trip and explained to the resident they would not be visiting. She stated Resident #12 was concerned about the farm and who was going to take care of it. She stated the resident had been distraught about it and she believed he had started trying to figure out how to get back to the farm. She stated Resident #12 was discharged from the hospital to a facility with a secure unit. She stated he had not eloped before. During an interview on 09/11/2025 at 9:55 AM, the DON stated Resident #12 rarely left his room except to get coffee. He stated the resident sat in the recliner in his room. The DON stated about two weeks prior to the elopement on 07/13/2025, Resident #12 went out the front door of the facility with visitors. He stated staff immediately followed after him and the resident refused to come back into the facility. He stated he called the resident's family member who reported telling the resident his family was going out of town and would not be coming to the facility to see him. The family member stated the resident asked who was taking care of the farm and he was reminded he had sold it years prior. The DON stated the family member spoke with the resident on the phone and coaxed him to go back inside the building. The DON stated he felt like it was an isolated incident and the family member stated the resident would not be told in the future when family members were going out of town. The DON stated the resident was placed on 1:1 monitoring for 24 hours and evaluated to ensure the resident was not displaying exit seeking behavior. He stated the physician ordered labs and a urinalysis. He stated the facility changed the door code, referred the resident to psych services, and updated his care plan. The DON stated about two weeks later, on 07/13/2025 at about 2:30 PM, a family member called the facility and asked for staff to check the Resident #12's restroom to see if he needed help because they did not see Resident #12 on the camera in his room. The DON stated the resident could not be located inside or outside the building and the police were called. He stated the resident was located a couple of hours from the time the resident was noticed missing. He stated the resident was located not far from the facility by the train tracks. The DON stated he went to the emergency room to check on the resident and was told the resident was intubated and being treated for hyperthermia (elevated body temperature). He stated the resident was extubated the following day. The DON stated he notified family the resident would not be able to return because the facility did not have a locked unit for males. He stated Resident #12 discharged from the hospital to another facility with a memory care unit. The DON stated all residents had a risk assessment for elopement on admission, quarterly, and as needed. He stated after the elopement on 07/13/2025, a risk assessment was completed for all residents in the building and staff received in-service training on monitoring for exit-seeking behaviors and what to do if alerted of an elopement. The DON stated no residents in the facility had a wander guard. He stated no other residents' assessment indicated a high risk for elopement. He stated the only residents who triggered high risk for elopement were located in the memory care unit. The DON stated staff had also participated in weekly elopement drills since the incident. He stated all exit doors were inspected daily to ensure each door functioned properly, the door access codes were changed, and signs were posted at all exits in English and Spanish notifying visitors to ensure residents did not exit and were given the door code. He stated any female resident identified with exit seeking behavior or was at risk for elopement was transferred to the memory care unit and males displaying exit seeking behavior were transferred to a facility with a memory unit for male residents. The DON stated during the day, when the receptionist was at the front desk, the front door was unlocked. He stated when she went to break or left at the end of the day, the front door was locked and to enter or exit required entering a code on the keypad. He stated the facility had also employed a receptionist on weekends to monitor the front door. During an interview on 09/11/2025 at 10:20 AM, the Administrator stated she was not at the facility at the time of the elopement but the facility provided in-service training and had weekly elopement drills with staff members. She provided a binder with documents, dated 07/13/2025, of in-service training on resident rights, abuse, neglect, and exploitation, and elopement prevention and response. She provided documentation of weekly elopement drills and a log of daily inspections of all exit doors completed since the elopement on 07/13/2025. The Administrator also provided documentation showing all residents were assessed for risk elopement on 07/13/2025. She stated prevention was key and the risk was the safety of the residents. She stated it was important for staff to know policies and procedures and to react appropriately. She stated it was important for staff to be alert for any exit seeking communication or behaviors and notify the nurse, DON, or leadership to assess the resident. During an interview on 09/11/2025 at 12:18 PM, Resident #12's family member stated they called the facility at about 2:30 PM on 07/13/2025, after not observing the resident on the camera in his room for 30 – 45 minutes. The family member stated that after the resident was not located in or around the building, the police were called. The family member stated the police used a drone and located Resident #12 near the train tracks, about one-third to one-half of a mile from the facility and was taken to the hospital where he was treated for a heat stroke. The family member stated he remained in the hospital for about a week before discharging to a nursing facility with a memory care unit. During a follow up interview on 09/11/2025 at 12:40 PM, the DON stated the facility had ongoing elopement drills on different shifts. He stated he hid a mannequin in different locations, including various locations outside the facility. He stated residents had participated as well. The DON stated the staff were provided with a scenario and a printed census of the residents. He stated nurses delegated to CNAs during the code orange (code used for an elopement). He stated on weekends, the weekend manager or unit manager shift took charge of delegating. He stated if the resident was not found within 30 minutes, the police were notified. He stated by that time the DON and Administrator would have already been notified. The DON stated that after all efforts to locate the residents inside the facility were exhausted, including rooms, shower rooms, restrooms, offices, and all other assigned areas, assigned staff would begin to search the perimeter. The DON stated the residents' safety was first. He stated if anyone tried to exit, staff knew to move quickly to the alarming door. He stated the front door alarm was the loudest and could be heard throughout the building. He stated the train was near the facility and the highway was less than a mile away. He stated it was important to prevent resident harm at all costs. He stated staff were in-serviced to be alert and observe residents for any exit seeking communication or behaviors. He stated all staff were required to have dementia care training and what to recognize in residents. He stated leadership had also made the decision to secure the front door at all times, even when a receptionist was on duty. He stated it required a code to be entered on the keypad for anyone to enter or exit the front door. Observation of all exit doors on 09/11/2025 at 1:35 PM revealed the doors closed and locked properly and alarms could be heard at the nurses' stations. Observation of all exit doors on 09/11/2025 at 3:05 PM revealed signs posted in English and Spanish notifying visitors to not allow residents to exit the facility and to not share the door code with the residents. Interviews on 09/11/2025 between 3:30 PM and 4:41 PM were conducted with multiple staff members which included the Administrator, DON, Social Worker A, Maintenance Supervisor B, Treatment Nurse C, Occupational Therapist D, Therapy Director E, Physical Therapist F, Dietary Manager G, COTA H, RN K, LVN N, CNA O, PTA P, Therapy Q, CNA R, Dietary Aide S, Floor Technician T, Student Aide U, CNA V, and LVN X. Interviews revealed staff members received elopement in-service training and participated in elopement drills. Staff were reminded to be alert to signs of exit seeking and to notify the charge nurse or DON to assess the resident as needed. Staff members were educated on their role when a code orange (elopement) was called in the facility. Census sheets were provided to cross reference and ensure each resident was present. The elopement drills included the designation of staff members to an assigned search area which included searching every room in the facility to ensure the resident was in the building and safe. If a resident was not located inside or outside the building, police, family, and the physician must be notified. No lack of knowledge or procedure was identified. The facility initiated the following interventions prior to the state surveyor entry on 09/11/2025: The facility door codes was changed and signs were placed at each exit door notifying all to not allow residents to exit the building.Record review of Resident #12's clinical file on 09/11/2025 at 11:15 AM reflected the following:-Resident #12's risk assessments on 06/23/2025 reflected the resident was not a high risk for elopement. The risk assessment completed on 07/13/2025 reflected the resident was at high risk for elopement. -Resident #12's Comprehensive Care Plan was updated with interventions on 06/23/2025 and 07/13/2025 after the resident exited the building.-Elopement risk assessments and care plans were updated on all residents in the building on 07/13/2025. -The medical doctor, psychiatrist, director of nurse, administrator, and Resident #12's family member was notified of the elopement on 06/23/2025 and 07/13/2025.-Documentation of education of staff on resident rights, abuse, neglect, and exploitation on 07/13/2025.-Documentation of education of staff on elopement prevention and response, exit seeking, and door protocols on 07/13/2025.-Documentation of elopement drills beginning 07/13/2025 and conducted weekly following the elopement. -Log of daily inspection of all exit doors beginning on 07/13/2025.- No additional elopements occurred and Resident #12 no longer resided at the facility.

Based on observation, record review and interview the facility failed to implement services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for ten (Resident # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) reviewed for care plans Based on observation, record review and interview the facility failed to implement services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for ten (Resident # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) reviewed for care plans The facility failed to ensure Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 were properly supervised while smoking in the smoking area of the facility. The facility failed to implement adequate supervision for Resident #1, #2, #3, #4,# 5, #6, #7, #8, #9, and #10 while smoking in the smoking area of the facility. 1. Record review of Resident #1's Face Sheet, dated 09/11/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's Disease (cognitive decline) and COPD.Record review of Resident #1's Quarterly MDS assessment, dated 8/07/25, reflected she had a BIMS score of 7 (severe cognitive impairment). For active diagnosis it reflected COPD. For ADL care it reflected the resident required supervision.Record review of Resident #1's Comprehensive Care Plan, dated 7/17/5, did not reflect a care plan for smoking.Record review of Resident #1's Smoking assessment, dated 9/09/25, reflected the resident required supervision while smoking.2. Record review of Resident #2's Face Sheet, dated 09/11/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included respiratory failure and need for assistance with personal care.Record review of Resident #2's Quarterly MDS assessment, dated 9/04/25, reflected she had a BIMS score of 3 (severe cognitive impairment). For active diagnosis it reflected respiratory failure. For ADL care it reflected the resident required supervision.Record review of Resident #2's Comprehensive Care Plan, dated 8/09/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety.Record review of Resident #2's Smoking assessment, dated 9/03/25, reflected the resident required supervision while smoking.3. Record review of Resident #3's Face Sheet, dated 09/11/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included respiratory failure and COPD (lung disease).Record review of Resident #3's Quarterly MDS assessment, dated 9/07/25, reflected she had a BIMS score of 13 (intact cognitive response). For active diagnosis it reflected acute respiratory failure. Record review of Resident #3's Comprehensive Care Plan, dated 8/09/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety.Record review of Resident #3's Smoking assessment, dated 8/07/25, reflected the resident required supervision while smoking. 4. Record review of Resident #4's Face Sheet, dated 09/11/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included respiratory failure and COPD (lung disease).Record review of Resident #4's Quarterly MDS assessment, dated 8/29/25, reflected she had a BIMS score of 7 (severe cognitive impairment). For active diagnosis it reflected acute respiratory failure. Record review of Resident #4's Comprehensive Care Plan, dated 7/17/25, did not reflect a care plan for smoking.Record review of Resident #4's Smoking assessment, dated 8/07/25, reflected the resident required supervision while smoking. 5. Record review of Resident #5's Face Sheet, dated 09/11/25, reflected she was a [AGE] year-old female admitted to the facility on 2/06//24. Relevant diagnoses included Parkinson's disease (nerve damage) and COPD (lung disease).Record review of Resident #5's Quarterly MDS assessment, dated 8/08/25, reflected she had a BIMS score of 12 (moderate cognitive impairment). For active diagnosis it reflected Parkinson's disease and congestive heart failure. Record review of Resident #5's Comprehensive Care Plan, dated 9/03/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety.Record review of Resident #5's Smoking assessment, dated 8/26/25, reflected the resident required supervision while smoking. 6. Record review of Resident #6's Face Sheet, dated 09/11/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Multiple Sclerosis (nerve damage) and lack of coordination.Record review of Resident #6's Quarterly MDS assessment, dated 8/28/25, reflected she had a BIMS score of 13 (intact cognitive response). For active diagnosis it reflected Multiple Sclerosis and lack of coordination. Record review of Resident #6's Comprehensive Care Plan, dated 08/25/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety.Record review of Resident #6's Smoking assessment, dated 9/09/25, reflected the resident required supervision while smoking.7. Record review of Resident #7's Face Sheet, dated 09/11/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (hallucinations).Record review of Resident #7's Quarterly MDS assessment, dated 9/04/25, reflected she had a BIMS score of 10 (moderate cognitive impairment). For active diagnosis it reflected borderline personality disorder. Record review of Resident #7's Comprehensive Care Plan, dated 08/08/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety.Record review of Resident #7's Smoking assessment, dated 9/09/25, reflected the resident required supervision while smoking. 8. Record review of Resident #8's Face Sheet, dated 09/11/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (hallucinations) and lack of coordination.Record review of Resident #8's Quarterly MDS assessment, dated 7/04/25, reflected he had a BIMS score of 12 (moderate cognitive impairment). For active diagnosis it reflected lung disease. Record review of Resident #8's Comprehensive Care Plan, dated 7/29/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety.Record review of Resident #8's Smoking assessment, dated 9/09/25, reflected the resident required supervision while smoking. 9. Record review of Resident #9's Face Sheet, dated 09/11/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included lack of coordination.Record review of Resident #9's Quarterly MDS assessment, dated 7/04/25, reflected he had a BIMS score of 15 (intact cognitive response). There were no documented active diagnoses. Record review of Resident #9's Comprehensive Care Plan, dated 9/11/25, did not reflect a care plan for smoking.Record review of Resident #9's Smoking assessment, dated 9/09/25, reflected the resident required supervision while smoking. 10. Record review of Resident #10's Face Sheet, dated 09/11/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included lack of coordination and Spina Bifida spinal cord disorder.Record review of Resident #10's Quarterly MDS assessment, dated 9/02/25, reflected he had a BIMS score of 99 (unable to complete the interview). Active diagnoses reflected a lack of coordination and Spina Bifida spinal cord disorder.Record review of Resident #10's Comprehensive Care Plan, dated 8/25/25, did not reflect a care plan for smoking.Record review of Resident #10's Smoking assessment, dated 4/14/25, reflected the resident required supervision while smoking. In an interview and observation on 09/11/25 at 9:15 AM, The Administrator observed Housekeeping W in the smoking area of the facility with approximately 10 residents smoking. She was observed with her head down looking at her phone the entire time she was observed. The Administrator stated Housekeeping W was assigned to monitor residents in the smoking area to ensure they did not harm themselves when smoking. She stated staff was not to be on their phones when monitoring the resident to ensure they were safe.In an interview on 09/11/25 at 2:22 PM Housekeeping W stated she was scheduled to monitor the residents when they were outside smoking. She stated staff were not allowed to be on their phones when watching the residents to ensure there were no accidents. She stated she would ensure that she was not on her phone anymore. The facility's policy Uniform Smoke Free Policy (undated) reflected A resident who is assessed unsafe to smoke without supervision, will be notified of the facilities site-specific smoking times, at which time the resident will have supervision and assistance as needed

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #11) reviewed for respiratory care. The facility failed to ensure Resident 11's oxygen mask was properly stored in a bag when not in use on 09/11/25. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #11's Face Sheet, dated 09/11/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Acute Respiratory Failure (lack of oxygen) and Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #11's Quarterly MDS assessment, dated 9/02/25, reflected he had a BIMS score of 12 (moderate cognitive impairment). For ADL care, it reflected the resident required total assistance and it reflected an active diagnosis of cardiorespiratory conditions. Record review of Resident #11's Comprehensive Care Plan, dated 3/16/2025, reflected the resident had COPD and one of the interventions was to provide oxygen therapy to the resident as needed. Record Review of Resident #11's Physician Orders, dated 9/11/25, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 MG/3ML inhale orallyevery 12 hours as needed for Bronchi muscle spasm resulting from COPD An observation on 09/11/25 at 12:43 PM, revealed Resident #11's oxygen mask unbagged, sitting on the top of a three-drawer chest. In an interview and observation on 09/11/25 at 12:45 PM, RN M stated Resident #11 used his oxygen device on an as needed basis. She stated she did not know when the last time he had used the device. She stated when the breathing device was not in use, the breathing mask should be stored in a plastic bag to avoid an infection. She stated she would discard the mask and get the resident a new one. In an interview on 09/11/25 at 12:59 PM with ADON L, she stated Resident #11 did have a device for breathing treatments on an as needed basis. She was advised of Resident #11 not having his mask bagged and she stated that the mask should be removed or bagged when not in use to avoid an infection. In an interview on 09/11/25 at 4:12 PM, the DON stated he had been at the facility for seven months. He was advised of Resident #11 being observed with an oxygen mask, unbagged while not in use. He stated he expected staff to remove the mask and then replace with a new one if needed or the mask should be bagged to avoid the resident getting an infection. Review of the facility's policy Oxygen Administration, undated, reflected Oxygen therapy includes the administration of oxygen (O2) in liters/minute by cannula or face mask to treat hypoxic conditions caused by pulmonary or cardiac diseases. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. The resident will be free from infection.

Based on observation interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for three of three residents (Residents #7, #26, and #198) reviewed for accidents and hazards. The facility failed to properly maintain wheelchair armrests for Residents #7, #26, and #198 These failures could place residents at risk for equipment that is in unsafe operating condition, which could cause injury. Findings included: 1. Record review of Resident #7's quarterly MDS assessment, dated 02/18/25 reflected a [AGE] year-old female who had been initially admitted to the facility on [DATE]. Resident #7 had diagnoses that included Cerebrovascular Accident (stroke), Alzheimer's Disease, Dementia, repeated falls, and unsteadiness on feet. Record review of Resident #7's plan of care, dated 02/25/2025, reflected goals and approaches to include wheelchair mobility for locomotion. Observation and interview on 04/15/2025 at 11:43 AM revealed Resident #7 was sitting in a wheelchair at a dining table. Resident #7 was wearing long sleeves, but the resident indicated that she had no skin problems. The wheelchairs' left armrest was missing some of the vinyl covering and some of the interior stuffing could be seen. The wheelchairs' right armrest was loosely secured to the wheelchair by silver fibrous tape and clear cellophane tape. The vinyl covering appeared to be split and most of the cushion material appeared to be missing. Resident #7 indicated that she would like to have a new wheelchair armrest. 2. Record review of Resident #26's quarterly MDS assessment, dated 03/22/2025 reflected an [AGE] year-old female who had initially admitted to the facility on [DATE]. Resident #26 had diagnoses that included Coronary Artery Disease, Heart Failure, Alzheimer's Disease, Dementia, and Repeated Falls. Record Review of Resident #26's plan of care, dated 04/07/2025, reflected goals and approaches to include wheelchair mobility for locomotion. Observation and interview on 04/15/2025 at 11:52 AM revealed Resident #26 was sitting in a wheelchair next to a dining room table. Resident #26 was wearing a short sleeve shirt and actively moving her arms, the skin on her arms appeared intact. The left arm rest on Resident #26's wheelchair was split open on the left side and the cushion material from inside of the armrest was hanging down over the side of the armrest. The resident was unable to answer any questions. 3. Record review of Resident #198's MDS quarterly MDS Assessment, dated 02/19/2025 reflected an [AGE] year-old female that had initially admitted to the facility on [DATE]. Resident #198 had diagnoses that included Alzheimer's Disease, Dementia, and Unsteadiness on Feet. Record Review of Resident #198's plan of care, dated 1/30/2025 reflected goals and approaches to include wheelchair mobility for locomotion. Observation and interview on 4/16/2025 at 11:48 AM Resident #198 was sitting in a wheelchair next to a dining room table. Both wheelchair armrests were observed to have the vinyl covering on them to be cracked with sharp edges pointed upwards. The resident stated that she had no wounds or scratches on her arms. She stated that she would like new armrests but denied that she had asked anyone about it. In an interview on 04/17/2025 at 2:30 PM, CNA D stated when a resident's wheelchair needed repair the staff were to enter it into the electronic maintenance system in an app on their phones. CNA A stated she had never wrote anything in the phone app about residents wheelchairs that might have needed repair. In an interview on 04/17/2025 at 2:41 PM, CNA E stated when a resident's wheelchair needed repair the staff were to write it in the electronic maintenance system, tell the maintenance man, who would tell them to place the information in electronic maintenance system. In an interview on 04/17/2025 at 3:02 PM, the Director of Rehab stated that her department repaired wheelchair armrest whenever they saw damaged armrests that may cause discomfort to the resident. She stated that the Rehab Department staff always kept their eyes open for wheelchairs that might need repairs for residents that were currently receiving rehabilitation services and residents that were not currently receiving rehabilitation services. In an interview on 04/17/2025 at 3:12 PM, the Maintenance Supervisor stated he repaired the wheelchairs when there was needed repairs. He stated that generally the Rehabilitation Department did most of the wheelchair maintenance. A record review of the facility's policy and procedure Maintenance, dated July 2018, reflected It is the policy of this community to maintain all equipment provided by the facility, in good working order to ensure the safety and wellbeing of all residents and staff . Equipment provided by the community will be: 1. Maintained in working order.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure dented cans were placed in a separate storage area. 2. The facility failed to ensure food items were discarded by the use by date. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the refrigerator on [DATE] at 9:47am revealed the following: -3 1-gallon milk with a use by date [DATE]. Observation of the dry storage on [DATE] at 9:55am revealed the following: -1 6lb 10oz can of spaghetti sauce dated [DATE] was dented on top right and top left. -1 6lb can of mushrooms dated [DATE] was dented on front bottom and front left. -1 6lb 10oz can of pumpkin dated [DATE] was dented on top right. -1 8lb 4oz can of apple jelly dated [DATE] was dented on top back. Interview with the DM on [DATE] at 11:15am she stated it was the kitchen staff responsibility to sort through food items and properly label and store food items once received from the vendor. She stated dented cans was stored in a separate area in the dry storage. She stated dented cans was identified and returned to the vendor. She stated dented cans could go bad and cause foodborne illnesses. She stated milk that had a use by date did not mean the milk was expired. She stated the kitchen staff must inspect the milk when it passed the use by date to make sure the milk was still good. She stated the expired milk was discarded just to be safe. She stated expired milk could make residents sick. In an interview with [NAME] H on [DATE] at 11:20am she stated once food items were delivered by the vendor, it was the kitchen staff responsibility to inspect food items. She stated dented cans were not stored in the kitchen, and dented cans was returned to the vendor. She stated the metal inside dented cans could cause food poison. She stated residents could get sick from expired milk.

Based on observation, interview and record review, the facility failed to ensure that each resident has the right to privacy to be treated with respect, personal body privacy, and dignity during wound care for 1 of 4 residents (Resident #15) reviewed for respect, privacy and dignity in that: Each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy of not only his or her own physical body, but of his or her personal space, including accommodations and personal care. The facility failed to ensure Treatment Nurse A provided privacy when providing Resident #15 with wound care. The facility failed to ensure Physical Therapist provided privacy and dignity when the Physical Therapist announced in front of Resident #15 to Treatment nurse A that she needed to go and care for another resident's wound because it was leaking blood through the dressing. This failure could place residents at risk of emotional distress and low self-esteem. Findings included: Record review of Resident #15's quarterly MDS dated [DATE] revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included: Coronary Artery Disease (poor circulation), heart failure (heart cannot function well), Diabetes Mellitus (high blood sugar), and anemia. Resident #15 was alert and oriented and able to make decisions. Record review of Resident #15's care plan dated 04/10/2025 reflected the resident had a Diabetic Ulcer r/t Diabetes and an arterial ulcer to the left lower lateral leg. An observation on 04/15/2025 at 9:46 a.m., Treatment nurse A provided wound care to Resident #15's left lower later leg and calf, while he was in his bed. LVN E did not close the door or pull the privacy curtain of Resident #15's room during the entire process. Resident #15's wound care was visible to the hallway. An observation on 04/15/2025 at 9:50 a.m. revealed the Physical Therapist entering the room without knocking or announcing his entrance. The Physical Therapist spoke to Treatment Nurse A as she was performing the wound care to the left leg of Resident #15. The Physical Therapist spoke about another resident's wound Resident #259, the wound bleeding, and how he could not treat her until the wound was treated. Treatment Nurse A answered the Physical Therapist's questions concerning when she could complete the other resident treatments, the Physical Therapist left the room, only to return moments later asking another question concerning the time of treatment of the other resident's wound. During an interview on 4/15/2025 at 11:00 a.m., Resident #15 stated he did not notice if the door and privacy curtain was not closed properly. He said he would be visible to others if the door and the curtain was not closed properly. Resident #15 did not comment when ask about the conversation between the Physical Therapist and Treatment Nurse A. During an interview on 04/15/2025 at 11:35 a.m. with Treatment Nurse A stated, by not closing the door and the curtain, the privacy and dignity of Resident #15 was compromised as anyone passed by the room could see the wound care. When asked about the training she received on resident's rights, Treatment Nurse A stated she was fully aware of resident right to have privacy, dignity, and respect and received in-service on resident's rights at least once a year. During an interview on 04/16/2025 at 12:37 p.m. with Physical Therapist revealed he was aware that what had happened in Resident #15's room on 04/15/2025 was inappropriate. He stated he should not have spoken to treatment Nurse A about another resident's wounds in front of another resident. The Physical Therapist had stated he had been in-serviced on resident rights, dignity, and privacy sometime in the past year. During an interview 04/17/2025 at 4:35 p.m., the DON stated privacy and dignity must be provided during nursing care and the door and privacy curtain to Resident #15 and room should have been closed completely by Treatment Nurse A. He said the training was ongoing process and resident rights was one of them. The DON stated the facility ensured all the new hires had gone through skill checks. Every nursing staff also had to complete an annual evaluation to ensure their nursing skills and knowledge including competency in respecting resident's rights. The DON stated this includes the Physical Therapist and the therapy department. The DON stated the Physical Therapist never should have entered the room unannounced and spoken another resident's conditions in front of another resident. During an interview on 04/17/24 at 4:30 p.m., the Administrator stated the residents' rights at the facility should be maintained during nursing care. She said staff was expected to respect privacy and dignity by making sure doors to rooms were closed, privacy curtains fully drawn, and the window blinds was shut properly. Review of facility's policy Resident Rights dated 2003, reflected: We believe each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside our facility. We protect and promote the following rights of each resident. 8. Each resident is treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for personal needs

Based on observation, interviews, and record reviews, the facility failed to ensure each resident was treated with a clean comfortable environment during care, to include clean linens to support their quality of life, recognizing each resident's individuality for 1 (Resident #15) of 4 residents. The facility failed to ensure Resident #15 was treated with respect, dignity, and care when they failed to ensure Resident #15's linens were clean and the soiled protective boots were removed from the room. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. Findings Included: Record review of Resident #15's quarterly MDS dated [DATE] revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included: Coronary Artery Disease (poor circulation), heart failure (heart cannot function well), Diabetes Mellitus (high blood sugar), and anemia. Resident #15 was alert and oriented and able to make decisions. Record review of Resident #15's care plan dated 04/10/2025 reflected the resident had a Diabetic Ulcer r/t Diabetes and an arterial ulcer to the left lower lateral leg. Observation on 4/15/2025 at 9:46 a.m. revealed Resident #15 in his bed. The bottom linens on the bed had dried dark stains of reddish, brown, and yellow substance. Resident #15's feet were laid upon these stained linens. The bandage to Resident #15's left leg was soiled with dried dark, brown, red, and yellow substance. There were two sets of soiled protective boots piled up on the top of the [NAME] drawers in Resident #15's room. Interview on 4/15/2025 at 9:46 a.m., Treatment Nurse A stated she had found Resident #15's linens soiled on multiple occasions in the past two weeks, just like today. The Treatment nurse stated she had told the staff about it, but it had not changed. The Treatment Nurse A stated that she had come in a couple of mornings and found his leg stuck to the linens and she had to use the saline wound cleanser to soak the dressing away from the linens. Treat Nurse A stated she had told the Wound Care Physician and Resident #15's treatment had been recently changed and the wound was draining less. The Treatment Nurse also stated that she had told them multiple times to remove the soiled protective boots from his room, he no longer uses them. During an interview on 4/15/2025 at 11:00 a.m., Resident #15 stated he did not like his sheets to be dirty and he had told the staff and they would sometimes change him and sometimes not change him. Resident #15 stated when they did not change him, he did not complain to anyone else he just waited until someone came in that would change him. He stated the night shift was the shift that did not change him and then in the morning the day shift would change him after the nurse told them to. Resident #15 stated sometimes his leg would get stuck to the sheets and he was afraid to pull it because the dressing might come off, so he just would lie there. Resident #15 stated he had not had his linens changed since yesterday, when the dressing was changed yesterday. The resident stated the wound was draining less since the wound care physician, saw him last week and had changed the treatment to address the excessive drainage. The resident stated that the doctor had told him the wound was improving, but it would be better if the wound drained less. During an interview on 04/15/2025 at 12:30 p.m. with CNA B, who worked the day shift form 6:00 a.m. to 2:00 p.m., revealed the CNAs were moved around on different halls everyday they worked, they did not stay on the same hall everyday they worked. CNA B stated this was the first time she had worked with Resident #15 and his linens looked like that. CNA B stated Resident #15 had never complained to her about needing his sheets changed and the staff not doing it. An observation on 04/15/2025 at 1:15 p.m. revealed the soiled protective boots remained stacked up on the [NAME] drawers in Resident #15's room, as he sat and ate his lunch. During an interview on 04/16/2025 at 1:03 p.m. with Resident #15 revealed that the soiled protective boots had been removed from his room last night, but they had been stacked up on the dresser for about two weeks, until [you], the Surveyor said something about them. During an interview on 04/16/025 at 12:30 p.m. with LVN C revealed when a resident had soiled dressing that was draining, it should be changed when it is reported. LVN C stated any prudent nurse would change the dressing, not repeat the treatment, but change the soiled dressing and the soiled linens. LVN C was not aware that Resident #15 had a history of the wound draining or the dressing sticking to the linens. LVN C stated it would be uncomfortable to have a draining wound and your dressing stuck to the linens. During an interview on 04/16/2025 at 1:12 p.m. with LVN G revealed if a resident had dressing on their body that was soiled and needed to be changed, any nurse could change the dressing, they do not need an order do that. LVN G stated you would want to let the wound care nurses know that the wound was draining, so they could communicate that to the wound care physician. During an interview on 04/16/2025 at 2:20 p.m. with CNA F revealed if the resident's linens were soiled then they need to be changed. CNA G stated occasionally Resident #15 had soiled linens from the wound on his leg. The CNA would change the linens. CNA G stated she would let the nurse know the leg was draining. The CNA stated she had only seen his sheets soiled from the drainage a couple of times, but she did not work on his all every day, they work on different halls every day they work. During an interview on 04/17/2025 at 4:35 p.m., the DON stated privacy and dignity must be provided during nursing care and the door and privacy curtain to Resident #15 and room should have been closed completely by Treatment Nurse A. He said the training was ongoing process and resident rights was one of them. The DON stated the facility ensured all the new hires had gone through skill checks. Every nursing staff also had to complete an annual evaluation to ensure their nursing skills and knowledge including competency in respecting resident's rights. The DON stated this included the linens of the residents should be changed when they are soiled, as well as dirty items that are left in the residents rooms, they should all be removed. During an interview on 04/17/24 at 4:30 p.m., the Administrator stated the residents' rights/dignity at the facility should be maintained during nursing care. She said staff was expected to protect dignity, including the cleanliness of the resident's items that they were using and their clothing, as well as their linens on their bed. This could affect the quality of the resident's life. Review of facility's policy Resident Rights dated 2003, reflected: We believe each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside our facility. We protect and promote the following rights of each resident. 8. Each resident is treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for personal needs

Based on observations, interviews, and record reviews, the facility failed to ensure residents received care and treatment consistent with professional standards of practice to promote healing and to prevent further development of skin breakdown or pressure ulcers for two (Resident #13 and Resident #87) of four residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #13 was provided with ordered wound care on 12/6/2024, 12/15/2024, 12/16/2024, 12/30/2024, 1/01/2025, 1/03/2025, 1/06/2025, 1/10/2025, 1/13/2025, 1/17/2025, and 2/06/2025 (11 days). 2. The facility failed to ensure Resident #87 was provided with ordered wound care on 1/09/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/15/2025, 1/16/2025, 1/18/2025, 1/19/2025, 1/26/2025, 2/01/2025, 2/06/2025, 2/07/2025, 2/08/2025, 2/09/2025, 2/15/2025, 2/16/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/22/2025, 2/23/2025, and 2/24/2025 (22 days). These failures could place residents at risk for infection and a decline in an existing pressure ulcer. Findings included: 1. Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed Resident #13 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of progressive intellectual disabilities, dehydration, and vitamin deficiency. Section C of the MDS assessment also revealed Resident #13 had severely impaired cognitive skills and was rarely/never understood. Section M of the MDS assessment revealed Resident #13 was at risk for developing pressure ulcers and had one unhealed pressure ulcer. Record review of Resident #13's care plan with a revision date of 1/17/2025 revealed Resident #13 had a pressure ulcer or had potential for pressure ulcers with multiple interventions including to follow facility policies or protocols for the treatment of skin breakdown. Record review of Resident #13's physician orders on 2/25/2025 revealed: Wound care for the right dorsal hallux (great toe/big toe) was ordered from 12/02/24 to 1/22/2025 and revealed wound care was ordered to be provided every 72 hours and as needed. Wound care for another wound on the right first toe (site 3) was ordered from 12/05/2024 to 1/17/2025 and was ordered to be completed every Monday, Wednesday, and Friday. New orders were entered from 1/17/2025 to 2/02/2025 that revealed wound care was ordered to be provided every Monday, Wednesday, and Friday. New orders were entered from 2/02/2025 to 2/24/2025 that revealed wound care was ordered to be provided every Monday, Wednesday, Thursday, and Saturday. Orders for another wound on the right first toe (site 4) was ordered from 12/05/2024 to 1/17/2025 and was ordered to be completed every Monday, Wednesday, and Friday. This order was discontinued on 1/17/2025 with the reason listed as the wound was resolved. Record review of Resident #13's treatment administration record for December 2024 revealed: Wound care for the right dorsal hallux was not performed on 12/6/2024 (Friday), 12/15/2024 (Sunday), and 12/30/2024 (Monday). Wound care for the right first toe (site 3) was not performed on 12/6/2024 (Friday), 12/16/2024 (Monday), 12/23/2024 (Monday), and 12/30/2024 (Monday). Wound care for the right first toe (site 4) was not performed on 12/6/2024 (Friday), 12/16/2024 (Monday), 12/23/2024 (Monday), and 12/30/2024 (Monday). Record review of Resident #13's treatment administration record for January 2025 revealed: Wound care for the right dorsal hallux was completed as ordered until the order was discontinued on 1/22/2025. Wound care for right first toe (site 3) was not performed on 1/01/2025 (Wednesday), 1/03/2025 (Friday), 1/06/2025 (Monday), 1/10/2025 (Friday), 1/13/2025 (Monday), and 1/17/2025 (Friday). Wound care for right first toe (site 4) was not performed on 1/01/2025 (Wednesday), 1/03/2025 (Friday), 1/06/2025 (Monday), 1/10/2025 (Friday), 1/13/2025 (Monday), and 1/17/2025 (Friday). Record review of Resident #13's treatment administration record for February 2025 revealed: Wound care for right first toe (site 3) was not performed on 2/06/2025. Record review of Resident #13's weekly wound evaluation summary dated 2/20/2025 revealed wound site 3 was healed and no other wounds were present on 2/20/2025. In an observation on 2/25/2025 at 9:39 a.m., Resident #13 was sitting up in his wheelchair in the activities room. Resident #13 had soft heel protection boots on both feet. No dressings or wounds were observed. Resident #13 was nonverbal and unable to interview. 2. Record review of Resident #87's Quarterly MDS assessment dated [DATE] revealed Resident #87 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of malnutrition, muscle wasting and atrophy (loss of muscle mass and strength), and cognitive communication deficit (difficulty communicating). Section C of the MDS assessment revealed Resident #87 had a BIMS score of 03 (indicated severely impaired cognitive skills). Section M of the MDS assessment revealed Resident #87 was at risk for developing pressure ulcers and had two unhealed pressure ulcers. Record review of Resident #87's care plan with a revision date of 1/17/2025 revealed Resident #87 had a pressure ulcer and interventions included to administer treatments as ordered. Record review of Resident #87's physician orders on 2/25/2025 revealed: Wound care for the pressure sore on the sacrum (site 1) was ordered daily from 1/18/2025 to 2/08/2025. Order was discontinued on 2/08/2025. Wound care for the right heel (site 2) was ordered daily from 1/31/2025 to 2/21/2025. Order was changed on 2/21/2025 from daily to Monday, Wednesday, and Friday. Wound care for the deep tissue injury on the left heel was ordered every Monday, Wednesday, and Friday from 1/08/2025 to 1/20/2025. Wound care for the skin tear to the back of the left hand had dressing changes ordered from to 2/19/2025 to 2/24/2025. Order was changed to steri-strips on 2/25/2025. Record review of Resident #87's treatment administration record for January 2025 revealed: Wound care for sacrum (site 1) was not performed on 1/09/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/15/2025, 1/16/2025, 1/18/2025, 1/19/2025, and 1/26/2025. Wound care for the deep tissue injury on the left heel was not performed on 1/13/2025 and 1/15/2025. Record review of Resident #87's treatment administration record for February 2025 revealed: Wound care for pressure sore on sacrum (site 1) was not performed on 2/06/2025, 2/07/2025, and 2/08/2025. Wound care for right heel (site 2) was not performed on 2/01/2025, 2/06/2025, 2/07/2025, 2/08/2025, 2/9/2025, 2/15/2025, and 2/16/2025. Wound care for the skin tear to the back of the left hand was not performed from 2/19/2025 to 2/25/2025. In an observation on 2/25/2025 at 10:12 a.m., Resident #87 was observed sitting in the TV room with a dressing on the back of her left hand. The dressing was dated 2/20/2025 and the edges of the dressing were peeling away from the skin. In an interview on 2/25/2025 at 11:14 a.m., LVN A stated he was the wound care nurse and did all of the wound care for all of the residents unless he was working the floor or not working that day. LVN A stated if he was not available t o do the wound care then the floor nurses were responsible for completing the wound care. LVN A reported if he was doing wound care then he did all of the residents and did not skip any wound care that was ordered. LVN A reported the wound care doctor rounded and assessed all of the wounds on Thursdays. LVN A denied any concerns that wound care was not being performed, and it should be completed as ordered. LVN A stated he had not seen any wound care that had not been done and had not seen any old dressings. LVN A reported the risk of wound care not being performed was that the wounds could get worse or get infected. LVN A was called away to aid other residents before being asked about Resident #87 and Resident #13's wound care. In an observation on 2/25/2025 at 3:54 p.m., Resident #87 was observed resting in bed. Steri-strips were on the back of the left hand where the dressing dated 2/20/2025 was seen previously. No drainage or foul odor was observed from the left hand. The dressing on the right ankle and right heel was dated 2/24/2025 and appeared clean, dry, and intact. Resident #87 was unable to answer questions and just smiled. In an interview on 2/26/2025 at 2:31 p.m., LVN B stated wound care was performed by the wound care nurse, but if she had not seen him by 10 to 11a.m. then she would do the wound care. LVN B stated she knew the wound care still needed to be completed by looking at the treatment administration record. LVN B reported if the wound care was not done then it would not be charted on the treatment record. LVN B also stated if the wound care was done then it would be charted as completed on the treatment record. LVN B reported that all of the floor nurses were able to see the treatment administration record and were able to see if the wound care needed to be completed. LVN B stated the risk to the residents if wound care was not completed was that the size of the wound could increase, and it could increase the risk for infection. LVN B stated the nurse assigned to the resident was responsible to ensure that wound care was performed as ordered. In an interview on 2/26/2025 at 2:57 p.m., ADON C stated the wound care nurse did all the wound care, and if he was not available then the floor nurses were responsible for doing the wound care. ADON C stated the floor nurses were responsible for monitoring that the wound care was completed for their patients. ADON C stated the ADONs would notify the nurses, or the wound care nurse would notify the nurses if they needed to complete wound care for their patients. ADON C reported the risks to the residents if wound care was not completed was that the wounds could get infected, or the resident could become septic. In an interview on 2/26/2025 at 3:22 p.m., the DON stated he had been at the facility for five days and was still learning the processes at this facility. The DON reported the wound care nurse was responsible for performing the wound care but would have to ask the compliance nurse what the process was if the wound care nurse was not available. The DON stated it would be him at some point that was responsible for monitoring if wound care was completed and that he expected it to be completed as ordered. The DON reported the risks to the resident were that the wounds could get infected. Review of the facility's policy titled Skin Integrity Management, with a revision date of October 5, 2016, revealed, 3. Wound care should be performed as ordered by the physician.

Based on observations, interviews, and record review the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 of 7 residents (Resident #88) reviewed for respect and dignity. The facility staff failed to honor Resident #88 ' s request to stay in bed, put on her slippers, and eat breakfast in the dining area instead of staying in bed and eating in her room. The past noncompliance began on 12/16/24 and ended on 12/18/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of diminished quality of life. Findings included: Record review of Resident # 88' s face sheet dated 02/25/25 revealed, admission on 07/30/24. Resident #11 was an [AGE] year-old female diagnosed with Alzheimer's disease, dementia with behavioral disturbance, muscle weakness (no muscle strength), major depressive disorder, and cognitive communication deficit. Record review of Resident # 88' s Quarterly Minimum Data Set (MDS), dated [DATE] revealed that Resident #88 had a BIMS score of 00 signifying the most severe level of cognitive impairment, requiring extensive assistance with daily activities, and was noted to have both physical and verbal behaviors e.g. hitting, kicking, scratching, and screaming at others. Resident #88 required substantial/maximal assistance for putting on/taking off footwear and was found to be independent for walking over 150 feet. Her primary medical condition was notated as progressive neurological conditions. Record review of Resident # 88's Care Plan dated 11/21/24 revealed that under focus The resident has impaired cognitive function/dementia or impaired thought processes with interventions of Communicate with resident/family/caregivers regarding resident's capabilities and needs .Discuss concerns about confusion, disease process nursing home placement with resident/family/caregivers. Under the category Focus, The resident has a communication problem related to cognitive decline, with interventions of Monitor/document for physical/nonverbal indicators of discomfort or distress and follow up as needed .Monitor/document frustration level. Wait 30 seconds before providing additional cares. Record review of a facility investigation of alleged abuse dated 12/22/24 revealed that in a scheduled care plan meeting on 12/17/24, the resident's representative displayed a video to the staff at the care plan meeting that showed LVN G abruptly waking up Resident #88 who appeared to react in surprise to being woken up and then sat up. LVN G then rushed Resident #88 out of bed. Resident #88 could be heard (on the video) protesting and motioning towards her feet and LVN G could be heard telling Resident #88 that she had to get up and go to breakfast. Further review revealed that 1. Associate suspension, and termination in same day to Human Resources office. 2. Head to toe resident assessment as well as skin checks on all residents in the building and safe surveys to be completed on all alert residents. 3. Police report obtained 4. Associates license was referred to the Texas Board of Nursing 5. Re-education 100 percent for all staff in the facility completed 6. Self-report checklist and audits completed 7. Self-Report to Health and Human Resources Commission within 2 hours. 8. Trauma informed care completed with [Resident #88's resident representative]by social worker at this time. 9. All staff who worked with the individual to be interviewed as well. Upon completion of the investigation and review of all the above audits, interventions, interviews, and skin checks noted that there were no other staff or residents who had any concerns with this specific nurse or any other associate in the building. The associate was terminated on 12/18/24 due to the clear video footage showing the inappropriate nature in which he gave the patient care. In an interview on 02/25/25 at 11:13 AM Resident #88's Representative revealed that she had attended a scheduled care plan meeting on 12/17/24 and she had brought/shown a video that she had recorded from Resident #88's room from earlier that same morning. She stated that the video showed LVN G abruptly waking up Resident #88 who appeared to react in surprise to being woken up and then sat up. LVN G then rushed Resident #88 out of bed Resident #88 could be heard (on the video) protesting and motioning towards her feet. LVN G could be heard telling Resident #88 that she had to get up and go to breakfast. She stated that she had explained to several staff members at the facility, many times, that Resident #88 had to be approached quietly and slowly, and that Resident #88 would eventually follow requests if approached in a calm way. She also stated that Resident #88 would get very upset if she was made to walk on the floors in her bare or socked feet and that if shoes/slippers were put on her feet she would cooperate more fully/easily with the Resident Representative or staff. Review of a video submitted by the Resident Representative of Resident #88 showed LVN G abruptly waking up Resident #88 who appeared to react in surprise to being woken up and then sat up. LVN G then rushed Resident #88 out of bed Resident #88 could be heard (on the video) protesting and motioning towards her feet and LVN G could be heard (on the video) telling Resident #88 that she had to get up and go to breakfast. During an interview on 02/25/24 at 12:30 PM with RN H, she stated that she had not been at the care plan meeting with the Resident Representative of Resident #88, but she had witnessed the video. She stated that in the video she remembered LVN G talking loudly [in the video]. She stated that LVN G had turned the light on and woke Resident #88 up with his voice. She stated that LVN G's goal seemed to have been to get Resident #88 up for breakfast. She stated that she thought there may have been a communication problem, and that his limited English/broken/heavy accent and Resident #88 speaking mostly Spanish may have worsened the incident. RN H stated that she had worked with Resident #88 after that incident and saw no change in her behavior. She stated that the facility had asked speech therapy to help train Resident #88 with the use a communication board; but, that Resident #88 did have advanced dementia, so the training was taking some time. During an interview on 02/25/25 at 3:03 PM with the Social Worker she stated Resident #88 was verbal, she was able to speak both English and Spanish, and she was able to generally speak enough to be able to make her needs known or through gestures. She had a BIMS score of 00, she did have a communication board, most residents in the secure unit usually get communication boards. The incident with LVN G was brought up during a care plan meeting, she was the one that advised that we report the incident and then the termination. We received training for ANE/Dementia Care, we did a staff wide in-service for ANE, Customer /Service, Res/Rights, Proper ways to interact with Residents/De-escalation. Human Resources and the ADM came around after to ascertain if the staff remembered the training, they did that to all of the staff more than once a week for nearly a month. Review of in-services Dated 12/18/24 and 12/19/24 revealed the following in-services were conducted and signed by 54 staff members representing 100% of nursing staff: Abuse, Neglect, and Exploitation, Customer/Service, Resident/Rights, Proper ways to interact, and Residents/De-escalation/Interactions. Review of a document entitled Actual/Alleged Abuse Monitoring Dated 12/28/24 to 01/08/25 stated Ask 15-20 staff members per week, situational questions related to Abuse. i.e. What would you do if . Document Date/Time, the staff members name, if they responded correctly, and any corrective action if needed. Note any corrective actions. The document was signed by the DON, the ADON, and the ADM, and documented 27 different staff members were quizzed on the spot for retention of related in-services. Review of Safe Survey of 68 residents, representing the entire resident population that were able to answer questions, and dated 12/17/24 to 12/18/24 and entitled Staff/Resident/Interactions found no negative findings about staff interactions/supervision. Interviews were conducted with 3 RN's, 4 LVN's, and 12 CNA's on 2/25/25 and 2/26/25. All staff were able to recount all in-service topics, stated that they had been monitored/quizzed for retention and understanding of associated in-services, and the monitoring/quizzes had lasted approximately for 1 month after the incident. Staff were able to identify that residents had the right for when they wanted to get out of bed and when they wanted to eat, as well as dressing preferences. Record review of the facility Resident Rights policy dated 11/28/21 revealed, Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of The United States. Respect and Dignity - The resident has a right to be treated with respect and dignity. Self-Determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The resident has a right to choose activities and schedules (including sleeping and waking times) with his or her interests. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure that the comprehensive person-centered care plan was revised to include the services to be furnished to attain or maintain the resident's highest practicable physical well-being as identified in the comprehensive assessment for two (Resident #13 and Resident #22) of five residents reviewed for care plans. 1. The facility failed to revise Resident #13's care plan to address his diagnosis of dehydration and use of intravenous fluids. 2. The facility failed to revise Resident #22's care plan to address her need for a mechanically altered diet and diagnosis of dysphagia. These failures could place residents at risk of not receiving the services needed to attain or maintain their highest practicable physical well-being. Findings included: 1. Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed Resident #13 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dehydration. Section C of the MDS assessment also revealed Resident #13 had severely impaired cognitive skills and was rarely/never understood. Section GG revealed Resident #13 was dependent with eating and required a helper to do all the work. Section O of the MDS assessment revealed Resident #13 had received IV medications. Record review of Resident #13's care plan with a revision date of 1/17/2025 revealed dehydration and intravenous fluids were not addressed in the care plan. Record review of Resident #13's physician orders revealed: On 12/04/2024 monitoring fluids every shift was ordered. On 1/07/2025 normal saline was ordered to be administered intravenously for dehydration. On 2/18/2025 lactated ringers (fluids to treat dehydration) were ordered to be administered intravenously for dehydration. On 2/19/2025 lactated ringers (fluids to treat dehydration) were ordered to be administered intravenously for dehydration. Record review of Resident #13's treatment administration record revealed fluid intake was monitored every shift from 12/01/2024 to current. Record review of Resident #13's progress note dated 12/03/2024 signed by NP E revealed Resident #13 had previously been hospitalized for dehydration, and NP E had ordered lab work and fluid monitoring to prevent future episodes of dehydration. In an observation on 2/25/2025 at 12:25 p.m., a CNA was assisting Resident #13 with eating and drinking. Resident #13 required full assistance and was unable to use arms to assist. In an interview on 2/26/2025 at 2:05 p.m., NP E reported it was difficult to ensure Resident #13 did not become dehydrated because he was unable to communicate. NP E stated she expected the facility to monitor Resident #13's intake and keep him hydrated. NP E stated she ordered labs and IV fluids to ensure he stayed hydrated. NP E reported Resident #13 had previously been hospitalized for dehydration and required the facility to push fluids. NP E stated the risks to residents if they did not receive enough fluids were that they could become dehydrated. In an interview on 2/26/2025 at 2:09 p.m., LVN F reported Resident #13's fluids were monitored by every shift and documented in PCC (electronic charting system). LVN F reported she personally administered fluids to Resident #13 three to four times during her shift and CNAs also gave fluids to residents. LVN F also reported Resident #13 received fluids at mealtimes and was monitored for signs or symptoms of dehydration. LVN F reported signs of dehydration included poor skin turgor and elevated sodium levels on lab work . LVN F was not interviewed concerning care plans. In an interview on 2/26/2025 at 2:39 p.m., MDS D reported she ensured care plans were updated. MDS D stated IV medications and dehydration should be care planned. MDS D stated if care plans were not updated then staff would potentially not know something about the residents' care. In an interview on 2/26/2025 at 3:22 p.m., the DON reported the treatment nurse, the ADONs, the weekend supervisors, the MDS nurse, the compliance nurse, and the DON were responsible for monitoring the care plans. The DON reported intravenous fluids were ordered and administered to Resident #13 for dehydration. The DON stated care plans should include dehydration and if a resident received intravenous fluids. The DON reported the risks to the residents if their care plans were not updated was that staff would not know if the residents were getting the right care. 2. Record review Resident #22's Quarterly MDS dated [DATE] revealed Resident #22 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing). Section C of the MDS revealed Resident #22 had a BIMS score of 03 (indicated severe cognitive impairment), and Section K of the MDS revealed Resident #22 required a mechanically altered diet. Record review Resident #22's care plan with a review date of 2/03/2025 revealed Resident #22's diet and dysphagia were not addressed. Record review of Resident #22's physician order dated 5/22/2024 revealed a mechanical soft texture diet was ordered for Resident #22. In an observation on 2/25/2025 at 12:25 p.m., Resident #22 was sitting in the dining room with a plate of mechanically altered food sitting in front of her. Resident #22 did not cough during observation. In an interview on 2/26/2025 at 2:39 p.m., MDS D reported she ensured care plans were updated. MDS D stated diets should be care planned. MDS D stated if care plans were not updated then staff would potentially not know something about the residents' care. In an interview on 2/26/2025 at 3:22 p.m., the DON reported the treatment nurse, the ADONs, the weekend supervisors, the MDS nurse, the compliance nurse, and the DON were responsible for monitoring the care plans. The DON stated care plans should include diets and diagnoses. The DON reported the risks to the residents if their care plans were not updated was that staff would not know if the residents were getting the right care. Review of the facility's policy titled, Comprehensive Care Planning, undated, revealed The comprehensive care plan will describe the following - the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent incidents and accidents for one resident (Resident #13) of four residents reviewed for possible accident hazards and incidents. The facility failed to provide adequate supervision for Resident #13 on 10/31/2024 after she was placed on one-to-one monitoring. The noncompliance was identified as past noncompliance (PNC) on 10/31/2024 at 7:05 p.m. The facility had corrected the noncompliance on 10/31/2024 immediately following the incident before the state's investigation began. This failure could place residents at risk for possible resident-to-resident altercations and injuries due to lack of supervision. Findings included: Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, depression, muscle wasting and atrophy (loss of muscle mass), and a cognitive communication deficit. The MDS also revealed a BIMS score of 07 (suggested moderately impaired cognition). Record review of Resident #13's care plan revised on 11/06/2024 revealed on 10/26/2024 Resident #13 was placed on one-on-one supervision as an intervention for behaviors. On 10/31/2024 an intervention was added to the care plan that stated nurses were talked to about monitoring and the expectation of one-on-one supervision. Record review of Resident #15's Quarterly MDS assessment dated [DATE] revealed Resident #15 was aan [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and stroke. Record review of nursing progress note dated 10/26/2024 at 7:15 p.m., revealed Resident #13 was placed on one-on-one supervision due to unpredictable behaviors and aggression. Record review of nursing progress note dated 10/27/2024 at 3:21 p.m., revealed Resident #13 remained on one-on-one supervision. Record review of nursing progress note dated 10/28/2024 at 10:58 a.m., revealed Resident #13 remained on one-on-one supervision and required redirection due to multiple attempts to wander into other residents' rooms. Record review of nursing progress note dated 10/29/2024 at 2:00 p.m., revealed Resident #13 remained on one-on-one supervision. Record review of nursing progress note dated 10/30/2024 at 2:00 p.m., revealed Resident #13 remained on one-on-one supervision. Record review of nursing progress note dated 10/31/2024 at 9:36 p.m. by LVN A, revealed LVN A was notified by another nurse that Resident #13 had an altercation with Resident #15 on the 500 hall that did not result in any injuries. Record review of nursing progress note dated 10/31/2024 at 11:03 p.m. by LVN A, revealed Resident #13 was placed on one-on-one supervision. In an interview on 12/02/2024 at 1:51 p.m., LVN A reported Resident #13 was brought back to the nurse's station from the 500 hall on 10/31/2024 after an altercation with another resident. LVN A stated he assessed Resident #13 and there were no injuries. LVN A stated Resident #13 was then placed on one-on-one supervision. In an interview on 12/02/2024 at 2:40 p.m., the former DON stated Resident #13 was supposed to be one-on-one supervision on 10/31/2024 at the time of the incident, but there was a miscommunication. The former DON stated Resident #13 had been at a Halloween party, and the former DON was not sure who was assigned to Resident #13 after that. The former DON reported there was always a dedicated staff member assigned to watch Resident #13, but she did not remember who was assigned to the resident at that time. Record review of resident one-on-one observation assignment sheet was dated from 10/26/2024 to 11/01/2024 and revealed LVN A and LVN B were assigned to Resident #13 from 4:00 p.m. to 10:00 p.m. on 10/31/2024. Signatures were missing on 10/31/2024 for LVN A and LVN B for 4:00 p.m. to 10:00 p.m. In an interview on 12/02/2024 at 2:56 p.m., LVN A reported that Resident #13 was not on one-on-one supervision at the time of the incident on 10/31/2024. LVN A reported that Resident #13 was usually on one-on-one supervision in the mornings, and a dedicated staff member for one-on-one supervision could have prevented the incident. In an interview on 12/02/2024 at 3:27 p.m., LVN C stated on 10/31/2024 Resident #13 had Resident #15's doll and became aggressive when the Resident #15 attempted to retrieve the doll. LVN C stated Resident #13 hit Resident #15 on the shoulder and face with the soft doll. LVN C reported that she immediately intervened, and no injuries had occurred. LVN C stated that there was no bruising or redness, and that Resident #13 was supposed to have a dedicated staff member assigned to provide one-to-one supervision. LVN C reported she did not see LVN A or LVN B with Resident #13 but thought that she had a one-to-one person assigned with her. LVN C stated she did not remember who was with her and that she immediately took Resident #13 back to her nurse's station. LVN C stated the purpose of the one-to-one supervision was to prevent Resident #13 from getting into trouble and to follow Resident #13 around. Record review of the PIR dated 11/06/2024 revealed residents were assessed, and no injuries or pain were noted, and both residents were at their baseline. In an observation on 12/02/2024 at 2:10 p.m., three soft cotton filled baby dolls were in the bed next to Resident #15. The dolls were around one foot long and approximately six inches wide. They were covered in a thick, soft, furry material resembling animal-like doll clothes. In an interview on 12/02/2024 at 4:19 p.m., the ADM reported that Resident #13 was on one-to-one supervision at the time of the incident on 10/31/2024. The ADM stated LVN B was assigned to Resident #13, and Resident #13 got away from LVN B at the time of the incident. The ADM stated Resident #13 was visible by LVN B but not within physical reach. The ADM did not specify how far away from Resident #13 LVN B was, but that it would take a few seconds for LVN B to intervene. The ADM reported that the risk of inadequate supervision was that residents could have been hurt. The ADM reported after this incident that one-on-one training was completed with LVN A and LVN B concerning one-on-one supervision, one-on-one supervision training was also completed with all staff members, and a notification was added to the dashboard of their EMR that notified all staff of any resident that was on one-on-one supervision. The ADM reported that one-to-one supervision meant that the staff member would have no other duties and keep the resident within arm's reach at all times. The ADM also reported that Resident #13 was discharged on [DATE]. In an attempted interview on 12/02/24 at 3:18 p.m., a telephone call was made to LVN B and voicemail left. No return call received. In an interview and observation on 12/02/2024 at 5:22 p.m., the ADM reported that the DON and ADM were responsible for monitoring one-to-one supervision assignments and ensuring the one-on-one observation assignment sheets were completed. The ADM stated after the incident she checked the observation assignment sheets daily (even on the weekends) and would continue to monitor this way in the future. The ADM reported the nurses were responsible for monitoring the one-on-one staff. The ADM stated the notification that was added to the dashboard of their EMR after the incident notified all staff if a resident was placed on one-to-one monitoring. The ADM stated it displayed on the screen and could not be removed. Observed the ADM pull up the EMR dashboard and observed the notifications displayed at the top of the screen. The ADM reported that Resident #13 was discharged to a higher level of care. Record review of the PIR dated 11/06/2024 listed Resident #13's level of supervision was within arm's length. PIR also revealed interventions taken immediately after the incident were that the EMR dashboard was updated to include notification of who was on one-to-one supervision, re-education on the one-to-one process was initiated with staff, and Resident #13 was discharged to a higher level of care. Record review of facility in-service dated 10/31/2024 revealed education titled One on One Education on 1 to 1 policy and procedure was attached to a sheet signed by staff members. In an interview on 12/02/2024 at 11:44 a.m., CNA F stated he received one-to-one training and would know if someone was on one-to-one supervision. CNA F stated he would know because staff would be with the resident and have a sign off sheet. CNA F stated there would also be a notification on PCC. In an interview on 12/02/2024 at 12:02 p.m., LVN E reported she had received training for one-to-one supervision and would know if a resident was on one-to-one supervision because it would say on PCC. LVN E stated a staff member would be assigned to them at all times and a sign off sheet must be completed. In an interview on 12/02/2024 at 1:30 p.m., LVN D reported he received training for one-to-one supervision that consisted of the notification on PCC, staying within arm's reach of the resident at all times, and signing an observation sheet. In an interview on 12/02/2024 at 3:27 p.m., LVN C stated that she had received lots of training for one-to-one supervision. LVN C stated that staff had to always remain next to the resident and sign the sign off sheet. LVN C stated PCC would also tell them if a resident was assigned to one-to-one training. In an interview on 12/02/2024 at 5:34 p.m., LVN G stated if a resident was on one-to-one supervision, then he would be told in report, and it should also tell you on PCC. LVN G stated he would monitor the resident even if another staff member was assigned to them, and the person assigned to the resident must stay next to them until relieved by another staff member. LVN G stated staff could not let the resident wander off, and an in-service for one-to-one monitoring had been completed. Review of facility education titled One on One Education on 1 to 1 policy and Procedure, undated, reflected 2. Staff member must transfer sign in sheet with resident and have that assignment only during the observation. 3. Staff member must transfer sign in sheet to their relief and not leave their post until that member has taken over the patient assignment. 4. Daily review of the sign in sheet to be completed by the DON or designee or administrator or designee.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Residents #11 and #49) of 7 residents reviewed for quality of care. 1. LVN D failed to order xrays for Resident #11 after she fell on [DATE] and complained of right-side pain. The xrays were not completed until the next day 12/17/23 the resident was diagnosed with fractures of the 8th to 10th ribs. 2. The facility failed to assess and document Resident #49's injury to her right ankle on 01/23/24, when therapy heard an audible sound when he attempted to put her shoe back on. On 01/24/24 it was noticed by staff that Resident #49 had swelling and bruising to her right ankle. Resident #49 was diagnosed with a right ankle fracture and underwent surgery. An Immediate Jeopardy was identified on 02/27/24. While the Immediate Jeopardy was removed on 02/28/24, the facility remained out of compliance at a scope of isolated and a severity potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failure could place residents at risk for diminished quality of care. Findings included: Review of Resident #11's MDS assessment revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA (stroke), non-Alzheimer's dementia, repeated falls, cognitive communication deficit, difficulty in walking and unsteadiness on feet. Resident #11 has a BIMS score of 12 indicating her cognition was moderately impaired. She usually understood others and was usually understood by others. The MDS further reflected the resident used a wheelchair for mobility and used the assistance of one person for ambulating. Review of Resident #11's care plan revised on 12/18/23 revealed the resident had a fall and was at risk for further falls due to dementia, language barrier, and poor safety awareness. Interventions included frequent reminders to request assistance from staff prior to transfers, toileting. The care plan further reflected the resident self-transferred without calling for assistance. Review of the facility's Provider Investigation Report for Resident #11 dated 12/18/23 revealed the following: .On 12/16/23 at approximately 9:00 p.m. resident was noted by the nursing staff to have fallen trying to go to the bathroom in her room without assistance. Resident was assessed for injury and neuro checks started, pain medication given and MD, Family notified. Nurse stated she called the former Xray company as the resident was complaining of pain to the right side. The nurse left the community at 10:00 p.m. and the xray was not ordered as she stated no one returned her call. The nurse failed to report to the oncoming shift, but did complete the incident report and medicated the resident. The next morning upon rounds the supervisor spoke to this nurse who returned again for her shift and a stat (immediately) xray was ordered Review of Resident #11's progress noted dated 12/16/23 at 6:45 PM documented by LVN D reflected the following: Resident walked without a W/C to the bathroom and fell to her bottom and back. Room mate informed the nurse. When nurse responded to the bathroom, Resident was sitting at the door leaning at the door post. Speaking in Spanish. Unable to understand, this nurse called CNA Spanish speak to translate. Resident denied hitting head, stated she was ok but admitted her back hurt a little bit. Resident said she was hungry and wanted to be left alone to eat her dinner Review of Resident #11's hospital records dated 12/17/24 revealed the following: .Impression 1.There are nondisplaced fractures of the right eighth through 10th ribs posteriorly. These appear acute. There also old healed bilateral rib fractures, old healed right clavicle fracture, and old healed sternal fracture Observation and interview on 02/06/24 at 12:22 PM, revealed Resident #11 was sitting at the dining room table eating lunch. The resident was wearing a back brace that extended up her back around her neck with a collar. The resident was not able to recall her fall and said she was not in any pain at the time. Interview on 02/07/24 at 1:55 PM, CNA A revealed the day of Resident #11's fall, he was making rounds and heard something, so he went to the resident's room and found her on the floor by the bathroom. CNA A said he went to get the nurse, LVN D, and she assessed Resident #11 and took over from there. The CNA said he did not work with the resident often but was told she had to be closely monitored because she would try to get up without calling for assistance. After Resident #11 was assessed by the nurse she was taken to the nurse's station to be monitored more closely. CNA A further stated he did not recall her being in any pain as he pushed her to the nurse's station. Interview on 02/07/24 at 4:16 PM with LVN D revealed CNA A let her know Resident #11 had fallen. When she entered the resident's room she noticed Resident #11 was sitting in the bathroom so she let RN B know, and called the family and the physician to get orders. LVN D said the resident was not complaining of too much pain and stated she was feeling ok so she went ahead and gave her pain medication. LVN D said she was given orders for xrays and she called the xray company but did not recall if she spoke to anyone. LVN D stated she did not recall what xray company she called and did not recall getting a return phone call. LVN D further stated before she left for the night she had let LVN FF know when he came on for the 10PM-6AM shift. When she returned to work the following morning, 12/17/23, she realized the xrays had not been done, so the xray company was called and they said they would send a technician out to the facility. Interview on 02/07/24 at 2:02 PM with RN B revealed she was getting ready to leave for the night of Resident #11's fall. LVN D told her the resident had fallen and was complaining of pain to her lower back, so RN B told LVN D to call the doctor and get xrays. RN B said she went to see Resident #11 and he was not moaning or grimacing or showing any signs of pain. When RN B left, LVN D was calling the doctor and notifying the family. RN B further stated the next day when she arrived to work, she realized Resident #11 did not get xrays so she called the DON to let her know. The xrays were ordered that morning around 10AM and she called to confirm they had been ordered. RN B said Resident #11 was having some pain, so she was medicated by the nurse and it appeared to be effective. The xray company was taking too long so they decided to send the resident to the hospital to be evaluated. Interview on 02/07/24 at 2:36 PM , with the current xray company revealed they received xray orders from LVN D for Resident #11 on 12/17/23 at 10:00 AM. Interview on 02/07/24 at 2:40 PM, RN C revealed she worked the night of 12/16/23 (10pm to 6am) and she was never told by LVN D that Resident #11 had fallen or that she needed xrays. RN C said the resident slept all night and did not appear to be in pain when she made rounds. RN C said the resident would take herself to the bathroom during the night and there was no concern with Resident #11 that night. Interview on 02/08/24 at 9:48 AM, the DON revealed she was notified on 12/16/23 at 9:46 PM by LVN D, that Resident #11 had fallen and said the resident had not sustained any injuries. The following day, 12/17/23, she got a call from RN B telling her about Resident #11's fall and again said there were no injuries noted but the resident had complained of pain to her back. RN B told her LVN D was supposed to have gotten orders for xrays but when she arrived in the morning, she overheard LVN D asking another nurse how to order xrays. The DON said they switched xray companies about three months prior and all the staff had been inserviced about the new company and all the previous stickers had been taken off the nurse's station and replaced with the new company information. The DON called LVN D and initially LVN D said she called the previous company and said they had not answered. The DON also said she thought LVN D had not contacted the previous company either because she (LVN D) said they had not answered but that company was open 24 hours a day and all LVN D kept saying was it was really busy and I was doing the best I could so the DON said she thought LVN D forgot to call the xray company and lied about calling the xray company and said she had called the previous company. The DON also said she asked LVN D if she had passed on the xray order information to the next shift and again LVN D had not given her a straight answer and maintained she had called the incorrect company. The DON said Resident #11 had been medicated when she expressed pain. The resident returned from the hospital diagnosed with rib fractures and a back brace to be worn while she is up in her wheelchair. 2. Review of Resident #49's face sheet, dated 02/09/24, reflected the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #49's diagnoses included displaced trimalleolar fracture (lower leg sections that form your ankle joint) of right lower leg, subsequent encounter for closed fracture with routine healing encounter for other orthopedic aftercare, unsteady on feet, age-related Osteoporosis without current pathological fracture, pain, muscle wasting and atrophy. Review of Resident #49's MDS Quarterly Assessment, dated 01/31/24, reflected Resident #49 had a BIMs score of 00, indicating severe impairment. The MDS reflected Resident #49 needed some help with self-care and ambulation. Resident #49 was dependent on staff for lower body dressing and taking off and putting on footwear. Resident #49 utilized a walker and wheelchair. Review of Resident #49's Care Plan, reviewed 02/09/24, reflected: Focus: Resident #49 is at risk for falls related to impaired mobility, poor safety awareness. Goal: Prevent a serious fall related injury. Intervention: Anticipate and meet resident's needs, Be sure call light within reach and encourage use, bed lowest position, therapy evaluations as ordered or needed for treatment. Focus: Resident #49 has an Activity of Daily Living self-care performance deficit of fatigue. Goal: Resident will improve current level of function and demonstrate the appropriate use of adaptive devices to increase mobility, transfers, eating, dressing, toilet use and personal hygiene. Intervention: Toilet use and Transferring: requires staff of 1 for assistance, Transfers: The resident is able to weight bear, pivot, use arms to support, take two steps. Review of Resident #49's nurse assessment reflected: there was no documentation on the date of 01/23/24. Review of Resident #49's physical therapy's assessment reflected: there was no documentation on the date of 01/23/24. Record review of Resident #49's x-ray results dated 01/24/24 revealed: Examination of right tibia/fibula, right ankle, Findings: Fracture of the right lower leg. Record review of Resident #49's hospital records dated 01/24/24 revealed resident presents to the emergency department from nursing home due to right ankle swelling/pain. Emergency Medical Services report patient received physical therapy yesterday and upon returning, nurse noticed her right ankle was swollen and painful. Denies head injury or fall. Patient notes pain to right lower extremity. Radiology report indicated: Ankle: fractures and soft tissue about the ankle. Record review of Resident #49's hospital physical therapy evaluation record dated 01/27/24 revealed diagnosis: Patient presents to emergency department from nursing home with ankle swelling - imaging shows right ankle medial and lateral malleoli fractures. Surgery 01/25/24 for open reduction and internal fixation right ankle fracture. Record review of Resident #49's hospital records dated 02/06/24 at 11:30 AM indicated Resident #49 had fractures of the right ankle. Record review of Resident #49's discharge hospital records dated 01/25/24 indicated return to nursing facility, 01/25/24: open reduction and internal fixation right ankle, non weight bearing right lower extremity, use cast guard for shower do not submerge incision keep wound clean and dry, non weightbearing right lower extremity keep cam boot in place at all times. Updated Medications: Acetaminophen (Tylenol Extra Strength) 500 MG every 4 hours as needed. Follow up appointment: orthopedic surgeon, in 1-2 weeks. Record review of Resident #49's medication and treatment administration report for January 2024 indicated she received Tramadol Oral tablet 50 MG. Give 0.5 tablet by mouth two times a day for Pain, revealing she had taken this medication as directed to include dates of January 23, 2024, at 8:00 AM and 5:00 PM, January 24, 2024, 8:00 AM prior to exiting the facility. Review of Resident #49's progress note dated 01/24/24 at 9:03 AM written by LVN H indicated: Note Text: This nurse was notified by CNA this morning to assess resident's right lower leg and ankle. Upon assessment this nurse noticed that the skin was red, and hot to the touch. The foot points to the right when held and resident screams in pain when it is touched. Notified Nurse Practitioner, DON, ADON and Resident Power of Attorney. Received an order for an Xray and Doxycycline. Stat Xray order placed. Resident's right lower leg was wrapped by ADON, and leg elevated on a pillow for comfort. Review of Resident #49's progress note dated 01/24/24 at 9:30 AM, written by LVN H indicated: Note Text: Continued to monitor resident for pain. Resident received scheduled Tramadol for pain. In addition, she was assessed by therapist and iced pack placed on affected area to reduce swelling. Pain administration was effective, resident is calm and resting in bed. Review of Resident #49's progress note dated 01/24/24 at 11:30 AM, written by LVN H indicated: Note Text: Xray done, awaiting results. Review of Resident #49's progress note dated 01/24/24 at 4:15 PM, written by LVN K indicated: Note Text: Transferred to Hospital ER for assessment r/t x-ray results by ambulance service via stretcher. Family Member unavailable by phone but returned call at 4: 20 PM and spoke with ADON on transfer. Review of Resident #49's progress note dated 01/24/24 at 4:33 PM, written by LVN K indicated: Electronic Medication - Administration Note Note Text: Tramadol HCl Oral Tablet 50 MG Give 0.5 tablet by mouth two times a day for PAIN. emergency room Electronic Medication - Administration Note Note Text: Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for infection for 5 Days. emergency room Observation of Resident #49 on 02/06/24 at 12:00 PM, revealed resident was in the dining room with therapy staff, eating with assistance. Resident was observed with a boot on her right foot. Observation and interview of Resident #49 on 02/06/24 12:00P M - 2:20 PM, revealed resident had been seen about the facility in her wheelchair with staff assist. Resident #49 was able to communicate however she was not able to stay on task when asked about her boot, fall, pain or hospital visit. Last observation revealed resident was in her room in bed sleeping. Resident #49 had a wedge under her knees under the blanket. Interview on 02/07/24 at 1:49 PM, LVN I revealed she did work the morning of 01/24/24. LVN I stated she worked on one side of the hall and LVN H worked on the other side with Resident #49. LVN I said if anything were reported from the night before it would have gone to LVN H. According to LVN I, the aide was about to start bed baths with Resident #49 and she noticed something was wrong and asked LVN H and myself to come assess the resident. LVN I said we were both passing medications at that time. LVN I stated her observation of what she remembered the foot was swollen, red and faced the wrong way. According to LVN I Resident #49 was in pain, she was moaning and had facial expressions of pain. LVN H administered something for pain and called the doctor and DON and sent her to the hospital. Resident #49 did have an x-ray completed, and while they waited for results, they kept her leg still and monitored her for pain. Attempted interview on 02/07/24 at 2:00 PM to CNA P was unsuccessful. Interview on 02/07/24 at 2:16 PM, CNA G revealed she was not present during the incident; however, she did not observe resident in pain at any time prior to or on dates 01/23/24 or 01/24/24 on her shifts. CNA G stated Resident #49 was able to stand and pivot prior to the fracture. CNA G stated that she was able to assist with transfers, however now she was a 2 person assist. Resident #49 was capable to communicate if she was in pain and let you know her needs. Interview on 02/07/24 at 2:35 PM, with LVN H revealed she was not in the building when the incident happened. LVN H stated when she entered the facility the next morning on 01/24/24, she was passing medications when the aide notified me there was something wrong with Resident #49's foot. LVN H said when she entered the room, she saw a bruise on the right lower leg. LVN H said when she tried to turn it, it was not stable. At that time, she called LVN I to take a look at it, it was then confirmed there was a problem. LVN H stated she contacted the nurse practitioner, DON, ADON, and family. X-rays were ordered, and they came out that same morning around 11:00 AM. LVN H stated the findings had not returned by the time she left for the day. LVN H stated she had already alerted LVN K to retrieve the results and alert the doctor. LVN H stated Resident #49 was provided Tramadol for pain. LVN H stated she questioned CNA P about the injury, and she was told that she did care for Resident #49 the previous day on 01/23/24 on the morning shift and Resident #49 did not have any injuries or indication of pain. Interview on 02/08/24 at 5:25 PM, the DON revealed she was notified via text by nursing staff, and on her way to morning meeting Director of Rehabilitation expressed to her that we need to look at Resident #49's ankle it was really swollen and did not look right. The DON stated she had not received any reports of her having a fall at this time, and reviewed that she had been working with the Physical Therapist so she sat down with him and he reported he did work with her on 01/23/24. She stated he told her that he was having her to stand and ambulate with the gait belt. The DON said the Physical Therapist reported While standing her knees started acting like they would buckle so he sat her down on the chair. He then helped to put her shoe on, he had to work towards putting on the shoe and while doing so heard a click, (he was concerned when he heard the pop, she did not show any pain or emotion at the time) and he went to get LVN J and together they assessed it and had no concerns with range of motion or pain. The DON stated, as time went on it got swollen and red, she also stated when staff sent her a picture of the injury, she did not know what she was looking at, stated she thought it was an issue of Resident #49 with edema. The DON stated x-ray was ordered, there were findings of a fracture and she was sent to the hospital. Interview on 02/08/24 at 6:29 PM, the Physical Therapist revealed he did work with Resident #49 on the evening of 01/23/24 right before dinner. The Physical Therapist stated it was normal routine for Resident #49 to walk the halls with her walker. The Physical Therapist stated on that visit she only took 4-5 tiny steps and it appeared that her knees were buckling so he assisted her to sit down in the recliner. She was not positioned securely in the chair, so he asked her to assist with repositioning and her reaction was like get your hands off me (but this was normal for her). The Physical Therapist said after she was repositioned in the recliner he looked down and noticed her right shoe had slid off her heel laterally. He said he reached down to slide her shoe back on and her whole foot went back as if it was dislocated, and it made an audible click. He said he looked at her and asked her if she was hurt, and she said no. He then took her through range of motion, and she did not have any reaction to eversion (outward turn) of her right foot, but with inversion (inward turn) of her right foot, she grunted and did indicate something. The PT said he went down to get LVN J to assess. The PT said during the assessment she responded that she was not hurt, or in pain, she was not tender to touch and went through range of motion with LVN J, with the same reactions with both eversion and inversion. Resident #49 had no swelling and with range of motion and her ankle moved normally. There was no deformity. The PT stated, I was thinking it was a sprain or dislocation. After the assessment I transferred her from the recliner to her wheelchair on her left side just to be safe, there were still no complaints of pain. The PT said LVN J stated she would wheel her down to dinner. The PT said, There was no x-ray completed that night that I was aware of, I wished I had found the aide to inform her to transfer Resident #49 from the left side. Physical Therapist revealed he did not complete documentation of his assessment. Interview on 02/08/24 at 6:57 PM, the DON and the Administrator revealed they were not told anything about Resident #49 having any pain with inversion (inward turn) during assessment with Physical Therapist or LVN J. According to the DON and the Administrator after their investigation they were told range of motion, and everything was fine during the assessment. The DON stated she did not know what she was looking at when the morning clinical team sent her the picture, and she thought the picture was showing cellulitis(bacterial infection of the skin), until the Director of Rehabilitation came to morning meeting requesting someone to go down to look at her foot. According to the DON not alerting someone about Resident #49 having pain when her foot was turned inward placed Resident #49 at risk for discomfort and delayed services of care. The DON stated it was the responsibility of both the nursing staff and the Physical Therapist to report any negative findings when it relates to residents in the facility. According to the Administrator it was her expectation that all staff are to report any incidents to her immediately, that everyone in the facility was aware she was the abuse coordinator. The Administrator stated it was also the expectation that the charge nurses are notified immediately so that residents have the proper care. The Administrator stated not doing this could place residents at risk of not having the attention and care they need. Interview on 02/08/24 at 7:20 PM, LVN J revealed she did work on hall 300 where Resident #49 resided. According to LVN J she was not aware of any incident or accident regarding Resident #49. LVN J stated LVN K was on one side of the nursing station and she was on the other. LVN J said she was asked by the Physical Therapist to come to the room to assist him to reposition Resident #49 because she was sitting on the edge of her recliner. She stated the Physical Therapist returned to Resident #49's room, then he came back to the nursing station and asked if she could come back to the room. She stated when she returned to the room Resident #49 was laying back, leaning back in the recliner and I asked how did she get like that and he responded, we were working on taking steps and she got weak. LVN J stated she then said, I did not know she could stand and left the room. According to LVN J, the Physical Therapist did not alert her to any situation, and she did not complete an assessment. LVN J stated she only assisted the Physical Therapist to put Resident #49 back in the recliner because Resident #49 likes to lay back with her feet elevated in the recliner. Interview on 02/09/24 at 10:26 AM, the Director of Rehabilitation revealed on the morning of 01/24/24 around 7:00 AM she went to Resident #49's room to complete speech therapy and noticed her right foot was displaced. The Director of Rehabilitation stated she then brought it to the DON's attention via text and verbally. The Director of Rehabilitation stated they were in Resident #49's room to observe her foot, the resident was in bed, and her foot was uncovered. The Director of Rehabilitation stated she interviewed the Physical Therapist because she knew he worked with her the night before and he was surprised to hear there was something going on with her. The Director of Rehabilitation said she was told by the Physical Therapist that Resident #49 stood up, but she was shaky so as he sat her down, he heard a pop. He and nurse LVN J check her vitals, assessed, touched, completed range of motion on both ankles and legs, she had no pain with up and down but with inward turn of her foot she had a slight jump, (stated she usually had pain in general with movement). According to the Director of Rehabilitation, the Physical Therapist stated at the end of their assessment Resident #49's ankle did not have any signs or symptoms of bruises, discoloration or distress. That it looked in place and they did not notice anything out of place. The Director of Rehabilitation stated it was her expectation for him to have reported that he heard a click to the floor nurse, herself, the DON, and the Administrator. The Director of Rehabilitation stated not doing so placed Resident #49 at risk for delayed care and treatment. Interview on 02/09/24 at 10:39 AM, LVN K revealed she was working on the evening of 01/23/24 and was at the nursing station when the Physical Therapist came to the desk. LVN K stated she overheard LVN J and the Physical Therapist talking about someone's foot however she did not know which resident it was. LVN K stated Resident #49 was her resident that night however neither LVN J nor the Physical Therapist alerted her to any issues or concerns. LVN K stated, I never knew it was about my resident. According to LVN K she was not alerted to any complaints of pain, swelling or discoloration for Resident #49's foot. Interview on 02/09/24 at 11:10 AM, CNA M revealed he did not know exactly when Resident #49 was involved in an incident, but he did work the night of 01/23/24. CNA M stated he did not work directly with Resident #49 but did assist CNA N with transferring her to bed at the end of the night. CNA M stated he did not observe Resident #49 with any swelling or pain. CNA M stated Resident #49 was able to communicate if she was having pain, and she was able to stand and pivot. Interview on 02/09/24 at 11:16 AM, CNA N revealed she did work the night of 01/23/24, and she did recall Resident #49 having a swollen foot. According to CNA N she thought it was something that would just go away and stated that she thought to herself, Resident #49 should be in pain. According to CNA N she assisted Resident #49 to bed, and this was when she observed the swollen right foot. CNA N stated she alerted the nurse on the 10:00 PM- 6:00 AM shift about the swelling. According to CNA N she had been trained to notify nursing staff when residents have bruising or swelling, and not doing so will place them at risk of not having proper care. Interview on 02/09/24 at 11:50 AM, LVN L revealed she did not work with Resident #49, and when she entered the facility, Resident #49 was already transported to the hospital. According to LVN L she was not told about Resident #49 having any bruising or swelling to her ankle. LVN L stated if she would have been told about something like that, she would have asked the aide to show her what she was talking about. LVN L stated she was responsible for completing assessments while working the floor and during her shifts she did not observe Resident #49 with any indications of pain or dislocated limbs. LVN L stated not providing proper care placed residents at risk of abuse and neglect. Review of the facility's policy titled Notifying the Physician of Change in Status dated 03/2013 reflected the following: The nurse should not hesitate to contact the physician in any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the '[change in condition] tool - When to Notify the MD/NP/PA' to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. Review of the facility's policy titled Preventative Strategies to Reduce Fall Risk revised October 2016 reflected the following: .10. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s) An Immediate Jeopardy was identified on 02/27/24. The Administrator and DON were notified of the Immediate Jeopardy on 02/27/24 at 12:15 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 02/27/24 at 4:53 PM and reflected the following: Interventions: An audit was completed by the DON of all x-rays ordered for residents in the last 24hrs to ensure completion, results were obtained in a timely manner, and communicated to the physician. Completed on 2/27/24. No further issues were identified. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the topic that if x-rays or diagnostics will be delayed or not obtained within 4 hours to notify the physician for a possible transfer to the hospital for x-rays/diagnostics. Completed on 2/27/24. During daily stand-up, ADMIN, DON, and DOR will review all reported changes in condition in Point Click Care to ensure x-rays/diagnostics were followed up within 4 hours. Nurses will report any outstanding x-rays/diagnostics during change of shift report, including the time they were ordered in the [resident's electronic record]. DON/ADON/Compliance Nurse will review orders in [resident's electronic record] during daily stand up to ensure continuation of care for changes in condition, to include x-rays/diagnostics, were completed within 4 hours. Nurses will complete SBAR assessment in [resident's electronic record] for all changes in condition reported. The Medical Director was notified of the immediate jeopardy on 2/27/24 by the Administrator. [QAPI] will be completed on 2/27/24 to include the IDT team and Medical Director to discuss the immediate jeopardy and subsequent plan. In-services: The following in-services below were initiated on 2/27/2024 for all direct care staff (Nurses, CNAs, and CMAs) by the DON, ADON, and/or Regional Compliance Nurse, completed 2/27/24. All staff not present for in-service will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior working their floor assignment. o Abuse and Neglect Policy o Fall Prevention Strategies Policy o Notify a charge nurse and DON for any change in condition to include pain, swelling, redness, and popping noises from limbs. o If x-rays or diagnostics will be delayed or not obtained within 4 hours to notify the physician for a possible trans [TRUNCATED]

Based on observation, interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 2 (Resident #11 and #49) of 7 residents reviewed for radiology services. 1. LVN D failed to order xrays for Resident #11 after she fell on [DATE] and complained of right-side pain. The xrays were not completed until the next day 12/17/23 and the resident was diagnosed with fractures of the 8th to 10th ribs. 2. The facility failed to obtain timely radiology services on 01/23/24, after the Physical Therapist reported to the nurse that Resident #49 had an audible sound to her right ankle and was noted to be in an unusual position. The morning of 01/24/24, the resident was noted to have swelling and after xrays were ordered, she was diagnosed with a right ankle fracture and was sent to the hospital where she underwent surgery. An Immediate Jeopardy was identified on 02/27/24. While the Immediate Jeopardy was removed on 02/28/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failures resulted in delayed diagnosis, medical treatment, and hospitalization . Findings included: Review of Resident #11's MDS assessment revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA (stroke), non-Alzheimer's dementia, repeated falls, cognitive communication deficit, difficulty in walking and unsteadiness on feet. Resident #11 has a BIMS score of 12 indicating her cognition was moderately impaired. She usually understood others and was usually understood by others. The MDS further reflected the resident used a wheelchair for mobility and used the assistance of one person for ambulating. Review of Resident #11's care plan revised on 12/18/23 revealed the resident had a fall and was at risk for further falls due to dementia, language barrier, and poor safety awareness. Interventions included frequent reminders to request assistance from staff prior to transfers, toileting. The care plan further reflected the resident self-transferred without calling for assistance. Review of the facility's Provider Investigation Report for Resident #11 dated 12/18/24 revealed the following: .On 12/16/23 at approximately 9:00 p.m. resident was noted by the nursing staff to have fallen trying to go to the bathroom in her room without assistance. Resident was assessed for injury and neuro checks started, pain medication given and MD, Family notified. Nurse stated she called the former Xray company as the resident was complaining of pain to the right side. The nurse left the community at 10:00 p.m. and the xray was not ordered as she stated no one returned her call. The nurse failed to report to the oncoming shift, but did complete the incident report and medicated the resident. The next morning upon rounds the supervisor spoke to this nurse who returned again for her shift and a stat xray was ordered Review of Resident #11's progress noted dated 12/16/23 at 6:45 PM documented by LVN D reflected the following: Resident walked without a W/C to the bathroom and fell to her bottom and back. Room mate informed the nurse. When nurse responded to the bathroom, Resident was sitting at the door leaning at the door post. Speaking in Spanish. Unable to understand, this nurse called CNA Spanish speak to translate. Resident denied hitting head, stated she was ok but admitted her back hurt a little bit. Resident said she was hungry and wanted to be left alone to eat her dinner Review of Resident #11's hospital records dated 12/17/24 revealed the following: .Impression 1.There are nondisplaced fractures of the right eighth through 10th ribs posteriorly. These appear acute. There also old healed bilateral rib fractures, old healed right clavicle fracture, and old healed sternal fracture Observation and interview on 02/06/24 at 12:22 PM, revealed Resident #11 was sitting at the dining room table eating lunch. The resident was wearing a back brace that extended up her back around her neck with a collar. The resident was not able to recall her fall and said she was not in any pain at the time. Interview on 02/07/24 at 1:55 PM, CNA A revealed the day of Resident #11's fall, he was making rounds and heard something, so he went to the resident's room and found her on the floor by the bathroom. CNA A said he went to get the nurse, LVN D, and she assessed Resident #11 and took over from there. The CNA said he did not work with the resident often but was told she had to be closely monitored because she would try to get up without calling for assistance. After Resident #11 was assessed by the nurse she was taken to the nurse's station to be monitored more closely. CNA A further stated he did not recall her being in any pain as he pushed her to the nurse's station. Interview on 02/07/24 at 4:16 PM with LVN D revealed CNA A let her know Resident #11 had fallen. When she entered the resident's room she noticed Resident #11 was sitting in the bathroom so she let RN B know, and called the family and the physician to get orders. LVN D said the resident was not complaining of too much pain and stated she was feeling ok so she went ahead and gave her pain medication. LVN D said she was given orders for xrays and she called the xray company but did not recall if she spoke to anyone. LVN D stated she did not recall what xray company she called and did not recall getting a return phone call. LVN D further stated before she left for the night she had let LVN FF know when he came on for the 10PM-6AM shift. When she returned to work the following morning, 12/17/23, she realized the xrays had not been done, so the xray company was called and they said they would send a technician out to the facility. Attempts to interview LVN FF on 02/08/24 were unsuccessful. Interview on 02/07/24 at 2:02 PM with RN B revealed she was getting ready to leave for the night of Resident #11's fall. LVN D told her the resident had fallen and was complaining of pain to her lower back, so RN B told LVN D to call the doctor and get xrays. RN B said she went to see Resident #11 and was not moaning or grimacing or showing any signs of pain . When RN B left, LVN D was calling the doctor and notifying the family. RN B further stated the next day when she arrived to work, she realized Resident #11 did not get xrays so she called the DON to let her know. The xrays were ordered that morning around 10AM and she called to confirm they had been ordered. RN B said Resident #11 was having some pain, so she was medicated by the nurse and it appeared to be effective. The xray company was taking too long so they decided to send the resident to the hospital to be evaluated. Interview on 02/07/24 at 2:36 PM, with the current xray company revealed they received xray orders from LVN D for Resident #11 on 12/17/23 at 10:00 AM. Interview on 02/07/24 at 2:40 PM, RN C revealed she worked the night of 12/16/23 (10pm to 6am) and she was never told by LVN D that Resident #11 had fallen or that she needed xrays. RN C said the resident slept all night and did not appear to be in pain when she made rounds. RN C said the resident would take herself to the bathroom during the night and there was no concern with Resident #11 that night. Interview on 02/08/24 at 9:48 AM, the DON revealed she was notified on 12/16/23 at 9:46 PM by LVN D, that Resident #11 had fallen and said the resident had not sustained any injuries. The following day, 12/17/23, she got a call from RN B telling her about Resident #11's fall and again said there were no injuries noted but the resident had complained of pain to her back. RN B told her LVN D was supposed to have gotten orders for xrays but when she arrived in the morning, she overheard LVN D asking another nurse how to order xrays. The DON said they switched xray companies about three months prior and all the staff had been inserviced about the new company and all the previous stickers had been taken off the nurse's station and replaced with the new company information. The DON called LVN D and initially LVN D said she called the previous company and said they had not answered. The DON also said she thought LVN D had not contacted the previous company either because she (LVN D) said they had not answered but that company was open 24 hours a day and all LVN D kept saying was it was really busy and I was doing the best I could so the DON said she thought LVN D forgot to call the xray company and lied about calling the xray company and said she had called the previous company. The DON also said she asked LVN D if she had passed on the xray order information to the next shift and again LVN D had not given her a straight answer and maintained she had called the incorrect company. The DON said Resident #11 had been medicated when she expressed pain. The resident returned from the hospital diagnosed with rib fractures and a back brace to be worn while she is up in her wheelchair. 2. Review of Resident #49's face sheet, dated 02/09/24, reflected the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #49's diagnoses included displaced trimalleolar fracture (lower leg sections that form your ankle joint) of right lower leg, subsequent encounter for closed fracture with routine healing encounter for other orthopedic aftercare, unsteady on feet, age-related Osteoporosis without current pathological fracture, pain, muscle wasting and atrophy. Review of Resident #49's MDS Quarterly Assessment, dated 01/31/24, reflected Resident #49 had a BIMs score of 00, indicating severe impairment. The MDS reflected Resident #49 needed some help with self-care and ambulation. Resident #49 was dependent on staff for lower body dressing and taking off and putting on footwear. Resident #49 utilized a walker and wheelchair. Review of Resident #49's Care Plan, reviewed 02/09/24, reflected: Focus: Resident #49 is at risk for falls related to impaired mobility, poor safety awareness. Goal: Prevent a serious fall related injury. Intervention: Anticipate and meet resident's needs, Be sure call light within reach and encourage use, bed lowest position, therapy evaluations as ordered or needed for treatment. Focus: Resident #49 has an Activity of Daily Living self-care performance deficit of fatigue. Goal: Resident will improve current level of function and demonstrate the appropriate use of adaptive devices to increase mobility, transfers, eating, dressing, toilet use and personal hygiene. Intervention: Toilet use and Transferring: requires staff of 1 for assistance, Transfers: The resident is able to weight bear, pivot, use arms to support, take two steps. Review of Resident #49's nurse's assessment reflected: there was no documentation on the date of 01/23/24. Review of Resident #49's physical therapy's assessment reflected: there was no documentation on the date of 01/23/24. Record review of Resident #49's x-ray results dated 01/24/24 revealed: Examination of right tibia/fibula, right ankle, Findings: Fracture of the right lower leg. Record review of Resident #49's hospital records dated 01/24/24 revealed Resident #49 presented to the emergency department from nursing home due to right ankle swelling/pain. Emergency Medical Services report patient received physical therapy yesterday and upon returning, nurse noticed her right ankle was swollen and painful. Denies head injury or fall. Patient notes pain to right lower extremity. Radiology report indicated: Ankle: fractures and soft tissue about the ankle. Record review of Resident #49's hospital physical therapy evaluation record dated 01/27/24 revealed diagnosis: Patient presents to emergency department from nursing home with ankle swelling - imaging shows right ankle medial and lateral malleoli fractures. Surgery 01/25/24 for open reduction and internal fixation right ankle fracture. Record review of Resident #49's hospital records dated 02/06/24 at 11:30 AM indicated Resident #49 had fractures of the right ankle. Record review of Resident #49's discharge hospital records dated 01/25/24 indicated return to nursing facility, 01/25/24: open reduction and internal fixation right ankle, non weight bearing right lower extremity, use cast guard for shower do not submerge incision keep wound clean and dry, non weightbearing right lower extremity keep cam boot in place at all times. Updated Medications: Acetaminophen (Tylenol Extra Strength) 500 MG every 4 hours as needed. Follow up appointment: orthopedic surgeon, in 1-2 weeks. Record review of Resident #49's medication and treatment administration report for January 2024 indicated she received Tramadol Oral tablet 50 MG. Give 0.5 tablet by mouth two times a day for Pain, revealing she had taken this medication as directed to include dates of January 23, 2024, at 8:00 AM and 5:00 PM, January 24, 2024, 8:00 AM prior to exiting the facility. Review of Resident #49's progress note dated 01/24/24 at 9:03 AM written by LVN H indicated: Note Text: This nurse was notified by CNA this morning to assess resident's right lower leg and ankle. Upon assessment this nurse noticed that the skin was red, and hot to the touch. The foot points to the right when held and resident screams in pain when it is touched. Notified Nurse Practitioner, DON, ADON BB and Responsible Party. Received an order for an Xray and Doxycycline. Stat Xray order placed. Resident's right lower leg was wrapped by ADON BB, and leg elevated on a pillow for comfort. Review of Resident #49's progress note dated 01/24/24 at 9:30 AM, written by LVN H indicated: Note Text: Continued to monitor resident for pain. Resident received scheduled Tramadol for pain. In addition, she was assessed by therapist and iced pack placed on affected area to reduce swelling. Pain administration was effective, resident is calm and resting in bed. Review of Resident #49's progress note dated 01/24/24 at 11:30 AM, written by LVN H indicated: Note Text: Xray done, awaiting results. Review of Resident #49's progress note dated 01/24/24 at 4:15 PM, written by LVN K indicated: Note Text: Transferred to Hospital emergency room for assessment related to x-ray results by Ambulance via stretcher. Family Member unavailable by phone but returned call at 4:20 PM and spoke with ADON on transfer. Review of Resident #49's progress note dated 01/24/24 at 4:33 PM, written by LVN K indicated: Electronic Medication - Administration Note Note Text: Tramadol HCl Oral Tablet 50 MG Give 0.5 tablet by mouth two times a day for PAIN. emergency room Electronic Medication - Administration Note Note Text: Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for infection for 5 Days. emergency room Observation of Resident #49 on 02/06/24 at 12:00 PM, revealed resident was in the dining room with therapy staff, eating with assistance. Resident was observed with a boot on her right foot. Observation and interview of Resident #49 on 02/06/24 12:00P M - 2:20 PM, revealed resident had been seen about the facility in her wheelchair with staff assist. Resident #49 was able to communicate however she was not able to stay on task when asked about her boot, fall, pain or hospital visit. Last observation revealed resident was in her room in bed sleeping. Resident #49 had a wedge under her knees under the blanket. Interview on 02/07/24 at 1:49 PM, LVN I revealed she did work the morning of 01/24/24. LVN I stated she worked on one side of the hall and LVN H worked on the other side with Resident #49. LVN I said if anything were reported from the night before it would have gone to LVN H. According to LVN I, the aide was about to start bed baths with Resident #49 and she noticed something was wrong and asked LVN H and myself to come assess the resident. LVN I said we were both passing medications at that time. LVN I stated her observation of what she remembered the foot was swollen, red and faced the wrong way. According to LVN I Resident #49 was in pain, she was moaning and had facial expressions of pain. LVN H administered something for pain and called the doctor and DON and sent her to the hospital. Resident #49 did have an x-ray completed, and while they waited for results, they kept her leg still and monitored her for pain. Attempted interview on 02/07/24 at 2:00 PM to CNA P was unsuccessful. Interview on 02/27/24 at 2:16 PM, with CNA G revealed she was not present during the incident; however, she did not observe resident in pain at any time prior to or on dates 01/23/24 or 01/24/24 on her shifts. CNA G stated Resident #49 was able to stand and pivot prior to the fracture. CNA G stated that she was able to assist with transfers, however now she was a 2 person assist. Resident #49 was capable to communicate if she was in pain and let you know her needs. Interview on 02/07/24 at 2:35 PM, with LVN H revealed she was not in the building when the incident happened. LVN H stated when she entered the facility the next morning on 01/24/24, she was passing medications when the aide notified me there was something wrong with Resident #49's foot. LVN H said when she entered the room, she saw a bruise on the right lower leg. LVN H said when she tried to turn it, it was not stable. At that time, she called LVN I to take a look at it, it was then confirmed there was a problem. LVN H stated she contacted the nurse practitioner, DON, ADON, and family. X-rays were ordered, and they came out that same morning around 11:00 AM. LVN H stated the findings had not returned by the time she left for the day. LVN H stated she had already alerted LVN K to retrieve the results and alert the doctor. LVN H stated Resident #49 was provided Tramadol for pain. LVN H stated she questioned CNA P about the injury, and she was told that she did care for Resident #49 the previous day on 01/23/24 on the morning shift and Resident #49 did not have any injuries or indication of pain. Interview on 02/08/24 at 5:25 PM, the DON revealed she was notified via text by nursing staff, and on her way to morning meeting Director of Rehabilitation expressed to her that we need to look at Resident #49's ankle it was really swollen and did not look right. The DON stated she had not received any reports of her having a fall at this time, and reviewed that she had been working with the Physical Therapist so she sat down with him and he reported he did work with her on 01/23/24. She stated he told her that he was having her to stand and ambulate with the gait belt. The DON said the Physical Therapist reported While standing her knees started acting like they would buckle so he sat her down on the chair. He then helped to put her shoe on, he had to work towards putting on the shoe and while doing so heard a click, (he was concerned when he heard the pop, she did not show any pain or emotion at the time) and he went to get LVN J and together they assessed it and had no concerns with range of motion or pain. The DON stated, as time went on it got swollen and red, she also stated when staff sent her a picture of the injury, she did not know what she was looking at, stated she thought it was an issue of Resident #49 with edema. The DON stated x-ray was ordered, there were findings of a fracture and she was sent to the hospital. Interview on 02/08/24 at 6:29 PM, the Physical Therapist revealed he did work with Resident #49 on the evening of 01/23/24 right before dinner. The Physical Therapist stated it was normal routine for Resident #49 to walk the halls with her walker. The Physical Therapist stated on that visit she only took 4-5 tiny steps and it appeared that her knees were buckling so he assisted her to sit down in the recliner. She was not positioned securely in the chair, so he asked her to assist with repositioning and her reaction was like get your hands off me (but this was normal for her). The Physical Therapist said after she was repositioned in the recliner he looked down and noticed her right shoe had slid off her heel laterally. He said he reached down to slide her shoe back on and her whole foot went back as if it was dislocated, and it made an audible click. He said he looked at her and asked her if she was hurt, and she said no. He then took her through range of motion, and she did not have any reaction to eversion (outward turn) of her right foot, but with inversion (inward turn) of her right foot, she grunted and did indicate something. The PT said he went down to get LVN J to assess. The PT said during the assessment she responded that she was not hurt, or in pain, she was not tender to touch and went through range of motion with LVN J, with the same reactions with both eversion and inversion. Resident #49 had no swelling and with range of motion and her ankle moved normally. There was no deformity. The PT stated, I was thinking it was a sprain or dislocation. After the assessment I transferred her from the recliner to her wheelchair on her left side just to be safe, there were still no complaints of pain. The PT said LVN J stated she would wheel her down to dinner. The PT said, There was no x-ray completed that night that I was aware of, I wished I had found the aide to inform her to transfer Resident #49 from the left side. Physical Therapist revealed he did not complete documentation of his assessment. Interview on 02/08/24 at 6:57 PM, the DON and the Administrator revealed they were not told anything about Resident #49 having any pain with inversion (inward turn) during assessment with Physical Therapist or LVN J. According to the DON and the Administrator after their investigation they were told range of motion, and everything was fine during the assessment. The DON stated she did not know what she was looking at when the morning clinical team sent her the picture, and she thought the picture was showing cellulitis(bacterial infection of the skin), until the Director of Rehabilitation came to morning meeting requesting someone to go down to look at her foot. According to the DON not alerting someone about Resident #49 having pain when her foot was turned inward placed Resident #49 at risk for discomfort and delayed services of care. The DON stated it was the responsibility of both the nursing staff and the Physical Therapist to report any negative findings when it relates to residents in the facility. According to the Administrator it was her expectation that all staff are to report any incidents to her immediately, that everyone in the facility was aware she was the abuse coordinator. The Administrator stated it was also the expectation that the charge nurses are notified immediately so that residents have the proper care. The Administrator stated not doing this could place residents at risk of not having the attention and care they need. Interview on 02/08/24 at 7:20 PM, LVN J revealed she did work on hall 300 where Resident #49 resided. According to LVN J she was not aware of any incident or accident regarding Resident #49. LVN J stated LVN K was on one side of the nursing station and she was on the other. LVN J said she was asked by the Physical Therapist to come to the room to assist him to reposition Resident #49 because she was sitting on the edge of her recliner. She stated the Physical Therapist returned to Resident #49's room, then he came back to the nursing station and asked if she could come back to the room. She stated when she returned to the room Resident #49 was laying back, leaning back in the recliner and I asked how did she get like that and he responded, we were working on taking steps and she got weak. LVN J stated she then said, I did not know she could stand and left the room. According to LVN J, the Physical Therapist did not alert her to any situation, and she did not complete an assessment. LVN J stated she only assisted the Physical Therapist to put Resident #49 back in the recliner because Resident #49 likes to lay back with her feet elevated in the recliner. Interview on 02/09/24 at 10:26 AM, the Director of Rehabilitation revealed on the morning of 01/24/24 around 7:00 AM she went to Resident #49's room to complete speech therapy and noticed her right foot was displaced. The Director of Rehabilitation stated she then brought it to the DON's attention via text and verbally. The Director of Rehabilitation stated they were in Resident #49's room to observe her foot, the resident was in bed, and her foot was uncovered. The Director of Rehabilitation stated she interviewed the Physical Therapist because she knew he worked with her the night before and he was surprised to hear there was something going on with her. The Director of Rehabilitation said she was told by the Physical Therapist that Resident #49 stood up, but she was shaky so as he sat her down, he heard a pop. He and nurse LVN J check her vitals, assessed, touched, completed range of motion on both ankles and legs, she had no pain with up and down but with inward turn of her foot she had a slight jump, (stated she usually had pain in general with movement). According to the Director of Rehabilitation, the Physical Therapist stated at the end of their assessment Resident #49's ankle did not have any signs or symptoms of bruises, discoloration or distress. That it looked in place and they did not notice anything out of place. The Director of Rehabilitation stated it was her expectation for him to have reported that he heard a click to the floor nurse, herself, the DON, and the Administrator. The Director of Rehabilitation stated not doing so placed Resident #49 at risk for delayed care and treatment. Interview on 02/09/24 at 10:39 AM, LVN K revealed she was working on the evening of 01/23/24 and was at the nursing station when the Physical Therapist came to the desk. LVN K stated she overheard LVN J and the Physical Therapist talking about someone's foot however she did not know which resident it was. LVN K stated Resident #49 was her resident that night however neither LVN J nor the Physical Therapist alerted her to any issues or concerns. LVN K stated, I never knew it was about my resident. According to LVN K she was not alerted to any complaints of pain, swelling or discoloration for Resident #49's foot. Interview on 02/09/24 at 11:10 AM, CNA M revealed he did not know exactly when Resident #49 was involved in an incident, but he did work the night of 01/23/24. CNA M stated he did not work directly with Resident #49 but did assist CNA N with transferring her to bed at the end of the night. CNA M stated he did not observe Resident #49 with any swelling or pain. CNA M stated Resident #49 was able to communicate if she was having pain, and she was able to stand and pivot. Interview on 02/09/24 at 11:16 AM, CNA N revealed she did work the night of 01/23/24, and she did recall Resident #49 having a swollen foot. According to CNA N she thought it was something that would just go away and stated that she thought to herself, Resident #49 should be in pain. According to CNA N she assisted Resident #49 to bed, and this was when she observed the swollen right foot. CNA N stated she alerted the nurse on the 10:00 PM- 6:00 AM shift about the swelling. According to CNA N she had been trained to notify nursing staff when residents have bruising or swelling, and not doing so will place them at risk of not having proper care. Interview on 02/09/24 at 11:50 AM, LVN L revealed she did not work with Resident #49, and when she entered the facility, Resident #49 was already transported to the hospital. According to LVN L she was not told about Resident #49 having any bruising or swelling to her ankle. LVN L stated if she would have been told about something like that, she would have asked the aide to show her what she was talking about. LVN L stated she was responsible for completing assessments while working the floor and during her shifts she did not observe Resident #49 with any indications of pain or dislocated limbs. LVN L stated not providing proper care placed residents at risk of abuse and neglect. Request for the facility's radiology policy was made to the Regional Nurse on 02/28/24 at 3:00 PM however, it was stated the facility did not have a specific policy covering radiology. The facility provided Notifying the physician of Change in Status. Review of the facility's policy titled Notifying the Physician of Change in Status dated 03/2013 reflected the following: The nurse should not hesitate to contact the physician in any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the '[change in condition] tool - When to Notify the MD/NP/PA' to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. Review of the facility's policy titled Preventative Strategies to Reduce Fall Risk revised October 2016 reflected the following: .10. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s) An Immediate Jeopardy was identified on 02/27/24. The Administrator and DON were notified of the Immediate Jeopardy on 02/27/24 at 12:15 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 02/27/24 at 4:53 PM and reflected the following: Interventions: An audit was completed by the DON of all x-rays ordered for residents in the last 24hrs to ensure completion, results were obtained in a timely manner, and communicated to the physician. Completed on 2/27/24. No further issues were identified. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the topic that if x-rays or diagnostics will be delayed or not obtained within 4 hours to notify the physician for a possible transfer to the hospital for x-rays/diagnostics. Completed on 2/27/24. During daily stand-up, ADMIN, DON, and DOR will review all reported changes in condition in Point Click Care to ensure x-rays/diagnostics were followed up within 4 hours. Nurses will report any outstanding x-rays/diagnostics during change of shift report, including the time they were ordered in the [resident's electronic record]. DON/ADON/Compliance Nurse will review orders in [resident's electronic record] during daily stand up to ensure continuation of care for changes in condition, to include x-rays/diagnostics, were completed within 4 hours. Nurses will complete SBAR assessment in [resident's electronic record] for all changes in condition reported. The Medical Director was notified of the immediate jeopardy on 2/27/24 by the Administrator. [QAPI] will be completed on 2/27/24 to include the IDT team and Medical Director to discuss the immediate jeopardy and subsequent plan. In-services: The following in-services below were initiated on 2/27/2024 for all direct care staff (Nurses, CNAs, and CMAs) by the DON, ADON, and/or Regional Compliance Nurse, completed 2/27/24. All staff not present for in-service will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-service [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for one (400 Hall medication cart) of four medication carts and stored securely for 1 (Resident #338) of 22 residents reviewed for labeling and storage. 1. The facility failed to ensure insulin pens that were expired were removed from the 400-hall cart. 2. Resident #338 had a tube of Cortisone cream found on a shelf near the window sill, 1 bottle of Visine and a tube of Icy Hot stored at the resident's bedside table not locked in a lock box or secured in the medication cart or medication room. These failures placed residents at risk of receiving medications that were ineffective. due to having expired insulin vial on the cart. Findings included: 1. Observation on [DATE] at 01:36 PM, of the nurse's medication cart used for the hall 400 with RN O revealed, one insulin vial of Humalog Subcutaneous Solution 100 unit/ml vial that had an opening date of [DATE]. Interview on [DATE] at 01:44PM, with RN O revealed it was all nurses' responsibility to check the carts for expired medication. She stated she had checked the cart and noted the insulin was past the expiration date of 28days, she called the pharmacy, and she was told the Humalog vial was good for 42 days. She stated short acting insulins are good for 28 days after being opened. She stated she does not remember notifying the DON. She stated the effects of expired insulin might be that they might not be effective in controlling blood sugars if administered. She stated she had completed training on labeling and storage of insulin. Interview on [DATE] at 10:42AM, the DON revealed, her expectation was for nurses to check for the opening dates. She stated if insulin was given expired it could be less effective and residents blood sugars will not be controlled. The DON stated Humalog insulins vials were good for 28 days after opening then they were to be discarded. She stated the facility does not have the 42 day insulin. She stated she contacted the pharmacy, and she was told they were good for 28 days. She stated she did a training with the staff after she was notified of the expired insulin. She stated she did not remember whether she had done other trainings to staff and no in-service record was presented. 2. Record review of Resident #338's Face Sheet, dated [DATE], revealed the resident was a [AGE] year-old female who was admitted on [DATE]. Resident #30 had diagnoses that included allergic dermatitis (itchy rash) of left lower eyelid, chronic pain, pain in right shoulder, pain in joint, unspecified pain, and generalized osteoarthritis. Review of Resident #338's quaterly MDS assessment dated [DATE] revealed the resident's cognition was moderately impaired with a BIMS score of 9. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care. Date Initiated: [DATE]. Review of Resident #338's care plan, reviewed [DATE], revealed: Resident #338 had a risk for fracture related to osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis through, Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Resident has chronic pain related to history of a compression fracture. Goals: Resident#338's pain level will be at or below their acceptable level as verbalized by the resident; pain or discomfort will be relieved within one hour of receiving pain medications or treatments as ordered by the physician. Intervention: Monitor/record/report to Nurse any signs and symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care. Resident has impaired visual function related to Glaucoma. Goal: Resident will show no decline in visual function. Intervention: Monitor/document/report to the physician the following signs and symptoms of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky pupils, complaints of halos around lights, double vision, tunnel vision, blurred vision, or hazy vision. Review medications for side effects which affect vision. Record review of Resident #338's order summary report dated [DATE] revealed physician's order for: 1. Artificial Tear Solution Instill 2 drop in left eye every 04 hours as needed for discharge. Active [DATE] start [DATE]. 2. Icy Hot Naturals Cream 7.5 % (Menthol (Topical Analgesic)) Apply to shoulders topically every 06 hours as needed for arthritis pain. Active [DATE] start [DATE]. - No orders for Cortisone Cream. Observation and interview on [DATE] at 12:54 PM, revealed Resident #338 with a bottle of Visine (an ocular lubricant that relives burning, irritation, and discomfort caused by dry eyes) and tube of Icy Hot (remedy or medicine that reduces or relieves pain) on her bedside table. There was also a tube of Cortisone cream (used to treat conditions such as arthritis, blood/hormone/immune system disorders, allergic reactions, certain skin, and eye conditions, breathing problems, and certain cancers) on a shelf near windowsill. According to Resident #338 she had them there in case she needed them. She was not able to say when she last used them. Interview with LVN I on [DATE] at 2:34 PM, who was the charge nurse for Hall 300, revealed the facility did not have residents who self-administered medications. She stated residents were not allowed to have medications in their rooms, and residents' families were educated not to leave over-the-counter medications with the residents. LVN I was observed going to Resident #338's room, and stated that she was not aware of any over the counter orders for Resident #338. LVN I stated she would check the orders for Resident #338 and remove the items from her room. LVN I stated residents having medications in their room placed them at risk for misuse of medications, and other residents having access to something they should not. According to LVN I she was not aware of the medications in the room, and that all staff were responsible for monitoring resident rooms for medications since there were no residents allowed to self-administer. LVN I stated the mediations should not have been in the resident's room because it was against their facility policy. Interview on [DATE] at 2:16 PM, CNA G revealed she was not aware of medications in Resident #338's room. CNA G stated she was working with Resident #338 on [DATE] on the morning shift ,d+[DATE] PM and did not recall seeing any medications in the room. CNA G stated if she observed medications in a resident's room, she would report that information to the charge nurse. CNA G stated all medications were to be administered by the medication aide or the charge nurse on the floor. CNA G stated having medications in the room placed residents at risk for them to overuse, overdose, or another resident administering medications incorrectly. Interview on [DATE] at 10:46 AM, the DON revealed residents were not supposed to have medication of any kind in their rooms. The DON stated there were no residents who were able to self-administer medications on their own and without physician order to do so. The DON stated many residents in the facility were very independent and when they were out on pass, they brought medications back in. The DON was not aware of any residents having medications in their room. The DON stated it was the responsibility of the nursing staff to remove any pills, prescriptions, or over-the-counter medications from resident rooms. The DON stated residents having medications in their rooms put them at risk of double medicating, staff not knowing what they are taking, or other residents could get ahold of them. Record review of the facility's current Types and Actions of Insulin policy, dated 2003, reflected the following: Recommended insulin storage. Insulin opened Vials all types 4 weeks not opened Until expiration date on bottle Cartridges: Humalog & Regular opened 4 weeks not opened Until expiration date on bottle Cartridges: NPH and ,d+[DATE] open 1 week not opened Until expiration date on bottle Review of the facility's current, undated Bedside Storage of Medications policy reflected: Bedside medication storage is permitted for sublingual and Inhaled emergency medications and for residents who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility=s interdisciplinary resident assessment team. PROCEDURE: A written order for the bedside storage of medication is placed in the resident=s medical record. The facility interdisciplinary team must assess that the resident is capable of safely self-administering the medication. The assessment must be documented. Bedside storage of medications is indicated on the resident medication administration record (MAR) for the appropriate medications. For residents with bedside emergency medications, bedside medications are stored in a drawer or cabinet that is locked in security, at the resident=s bedside where they are readily available for emergency use or are kept in the resident=s immediate possession when out of the room. In the event such storage poses a hazard to other residents who may wander into the resident=s room, bedside storage may be discontinued. Nursing staff will monitor the availability and utilization of all medications that are self-administered. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary. 44937

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for 2 (Resident #32 and #29) of 8 residents reviewed for physician notification. The facility failed to ensure: 1. LVN B immediately notified Resident #32's physician when Resident #32, who did not have a history of shortness of breath complaints, complained of not being able to breathe and requested two breathing treatments the night of [DATE]. Resident #32 was discovered on [DATE] unresponsive and not breathing. CPR was preformed but she was pronounced dead at the facility on [DATE]. 2. LVN A notified Resident #29's physician when she complained of pain and numbness to both her arms, pain level 9 out of 10 (10 being the worst) and stated that was how she felt the last time she had a stroke. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:36 PM and the ADM, DON, and the RNC were notified. While the IJ was removed on [DATE] at 7:30 PM, the facility remained out of compliance at a scope of isolated at the severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: 1. Review of Resident #32's quarterly MDS dated [DATE] reflected she was a [AGE] year-old woman initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: chronic respiratory failure, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), CHF (long-term condition in which heart cannot pump blood well enough to meet body's needs), dependence on supplemental oxygen, and HTN. Review of her cognition assessment reflected a BIMS of 15 and indicated she was cognitively intact. The prognosis of her health conditions reflected she did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of Resident #32's face sheet dated [DATE] reflected RP #1 was a family member and the POA. Her designated code status was full code and indicated if her heart or respirations stopped (cardiac arrest or respiratory arrest), all resuscitation procedures would be provided to keep her alive. Review of Resident #32's Care Plans dated with admitted [DATE] reflected Resident #32 had chosen a full code status and interventions included following her advanced directive, initiating CPR in the event of unresponsiveness, no pulse, no respirations, and activating 911. She was at risk for SOB due to CHF and COPD and interventions included giving cardiac medications as ordered, monitoring vital signs, and notifying the MD of significant abnormalities, giving bronchodilators as ordered with monitoring and documenting of effectiveness, monitoring for respiratory difficulty, and monitoring for signs of acute respiratory insufficiency such as: anxiety, confusion, restlessness, and SOB at rest. She was on oxygen due to COPD and interventions included monitoring for signs and symptoms of respiratory distress and reporting to the MD: respirations, pulse, oximetry (test to measure the oxygen level/oxygen saturation of the blood), increased heart rate, restlessness, excessive sweating, headaches, lethargy, confusion, atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung), coughing up blood, cough, pleuritic pain (pain in chest or shoulder made worse with breathing), accessory muscle usage (contraction of any muscle other than the diaphragm during inspiration or use of any muscle during expiration indicating labored breathing/respiratory distress), and skin color. Other interventions included an O2 setting of 2LPM via N/C and promoting lung expansion by positioning with proper body alignment and a head of bed elevated 30 degrees if tolerated. Review of Resident #32's Physician's Orders dated [DATE] reflected the following orders: 1. Full Code. Start date [DATE]. 2. Oxygen via N/C at ,d+[DATE] LPM continuous to keep O2 saturation above 92%. If unable to keep O2 saturation above 92%, notify the MD immediately. Start date [DATE]. 3. DuoNeb solution (inhalation solution containing a combination of albuterol and ipratropium, bronchodilators that relax muscles in the airways and increase air flow to the lungs) 3mL orally via nebulizer every 6 hours as needed for SOB. Start date [DATE]. 4. Symbicort (combination of budesonide and formoterol. Budesonide is a corticosteroid that reduces inflammation in the body. Formoterol is a long-acting bronchodilator that relaxes muscles in the airways to improve breathing) 2 puffs inhale orally two times per day for COPD. Start date [DATE]. Review of Resident #32's e-MARs from [DATE] to [DATE] reflected there were not any PRN DuoNeb breathing treatments documented as being administered on any dates. Review of Resident #32's e-MARs from [DATE] to [DATE] reflected she received a PRN DuoNeb breathing treatment on [DATE] at 11:02 PM. The following vital signs were documented: BP ,d+[DATE], pulse 100, RR 16, O2 saturation 92%. There were not any PRN DuoNeb breathing treatments documented on [DATE] or on any other dates. Review of Resident #32's progress notes from [DATE] through [DATE] reflected the following: 1. On [DATE] at 11:02 PM, LVN B administered a DuoNeb breathing treatment for shortness of breath. 2. On [DATE] at 7:22 AM, LVN B documented a note from [DATE] at 5:10 AM which reflected patient was awake most of the night HOB elevated and breathing treatment given per mar well tolerated.@ 12 midnight she requested to sit upright on wheelchair for comfort call light within reach. respiration even unlabored her vitals [BP ,d+[DATE] Pulse 78 02 Saturation 97% Temperature 97.4 ]she was having a conversation with [friend] on the phone and stable continue to monitor. at about 0400am she requested to be put back in bed still texting [friend] on her phone. she was given her early Morning medication per mar well tolerated. patient in a comfortable position HOB elevated call light within reach. The note did not indicate it was a late entry. 3. On [DATE], LVN B documented a breathing treatment was given at 11:02 PM and was effective. The note was created on [DATE] at 4:19 AM, but the time was changed to 5:19 AM. The note did not indicate the reason the time was changed. 4. On [DATE] at 8:46 AM, RN C documented a note from [DATE] at 6:05 AM which reflected, This Nurse went to the resident room to check on her, upon arriving the room resident was in bed lying, tried to wake up the resident but she was unresponsive, and no respiration noted, checked the pulse and fainted pulse noted, came to call my colleagues and went back to the room and recheck the pulse and there was no pulse, CPR initiated and about [6:08 AM] 911 was notified of this incident and immediately the paramedics were in the building and took over with the CPR. obtained CPR 30 compressions via machine followed by two ventilation breaths for more than 30 minutes and the machine continues to show asystole [no heartbeat], at [6:55 AM] resident was pronounced dead. [MD P], Administrator notified. [ADON F] notified the family member [RP #1]. The note did not indicate it was a late entry. 5. On [DATE] at 8:19 AM, ADON F documented a note from [DATE] at 7:05 AM which reflected, At 0705am this nurse called resident [RP #1] and notified him that his [Resident #32] had expired. [RP #1] was hurt & crying while on the phone & just hung up. 0734am he arrived to the facility. The note did not indicate it was a late entry. Review of Resident #32's EHR on [DATE] reflected the last vital signs documented were on [DATE] at 11:02 PM and were BP ,d+[DATE], pulse 100 bpm, RR 16, and O2 saturation 92% (did not reflect whether this was on oxygen or on room air). The last documented temperature was on [DATE] at 11:59 PM and was 97.4 F. Review of the assessment forms in the EHR reflected the last assessment documented was a skin assessment on [DATE]. There were not any change in condition assessments documented from [DATE] through [DATE]. In a telephone interview with RP #1 on [DATE] at 10:44 AM, RP #1 said Resident #32 had been at the facility since 2018. RP #1 said he did not have any concerns regarding Resident #32's care. He said he picked up Resident #32's belongings, including her phone, from the facility on [DATE] and saw that she had made 2 calls to FM #3 on [DATE] at 11 PM. He said he thought Resident #32 made those calls on accident as she was known to pocket dial. He said he had spoken, via telephone, with Resident #32 on [DATE] a little after lunch, and she seemed fine. RP #1 said FM #2 could provide more information on Resident #32's medical conditions and placed her on the phone. FM #2 stated Resident #32 had some issues with her breathing recently. FM #2 said Resident #32 was receiving continuous O2 at 6LPM via the oxygen concentrator and she was able to let the nurses know if she was not feeling well or she would send a text message the DON. She said Resident #32 could express herself very well. She said Resident #32 had daily, routine breathing treatments and she never used the PRN breathing treatments. In a telephone interview on [DATE] at 1:49 PM, FM #2 stated she and RP #1 initially did not have any concerns regarding Resident #32's care but they had been made aware of a voicemail left for FM #3 by Resident #32 on [DATE] and now they had concerns. She said in the voicemail, Resident #32 could be heard asking for help and stating she could not breathe. She said facility staff could be heard in the background. FM #2 said the voicemail could be sent via e-mail for review. In a telephone interview on [DATE] at 10:46 AM, FM #3 said she had a missed call from Resident #32 on [DATE] at 11:24 PM. FM #3 said she spoke with Resident #32 multiple times daily and Resident #32 had never before stated she could not breathe. She said the last time she spoke with Resident #32 was on [DATE] in the evening and they had a normal conversation, which included the resident complaining of how long her call light would be on overnight before anyone came to her room. FM #3 said Resident #32 had COPD and some difficulty breathing was normal for her, but not like she was, on the voicemail. Review of the telephonic voice message sent via email by FM #2 on [DATE] at 2:16 PM reflected the message was 3 minutes long. Further review reflected a person was speaking in a distressed tone and paused several times between words. They said, Oh. Oh Lord. Oh Lord please. God. I can't breathe. God help me. Oh Lord. God help me. Oh. Oh. Oh. I can't breathe. Please. Oh Lord. Oh Lord. God. Please. Oh Lord. Oh God. Oh. Oh. God help me. Oh God help me. God. Please! Put me in my chair, so I can breathe. Oh. God help me. God help me. God. Somebody. Oh. Oh. Oh Lord. [Second person heard speaking; portions inaudible. You, ok? You can't breathe? Resident continued .] Yeah. The white ones on the closet floor. Oh God. I don't know her. In an interview with LVN B on [DATE] at 1:41 PM, she said on [DATE], Resident #32 was awake all night and could not sleep. She said at around 11 PM on [DATE], Resident #32 complained of not being able to breathe and requested a breathing treatment. LVN B said she obtained Resident #32's vital signs and gave her a PRN breathing treatment. LVN B could not remember what the vital signs were for Resident #32. LVN B also stated she could not recall the O2 concentrator setting when Resident #32 said she could not breathe. LVN B said after the breathing treatment, Resident #32 still complained of not being able to breathe and requested to be transferred from her bed to her wheelchair. LVN B said she overheard Resident #32 making calls on her phone. LVN B said at around 4:15 AM ([DATE]), she told the agency CNA to place Resident #32 back in her bed so that she could receive incontinent care, but Resident #32 refused to be placed back in bed because she was having trouble breathing. LVN B said Resident #32 agreed to be placed back in bed only if LVN B gave her another breathing treatment because the previous breathing treatment had helped. LVN B said she administered to Resident #32 the second PRN breathing treatment but did not obtain her vital signs. LVN B said she went to give Resident #32 her morning medication on [DATE] at around 5 AM and Resident #32 requested water and her cough drops. LVN B said she then went back to the nursing station and when the morning nurses arrived, she gave them report. She said RN C left down the hall to check on Resident #32 and came out of the room yelling for a crash cart and yelling code blue (medical emergency, usually cardiac or respiratory arrest). LVN B said she had known Resident #32 for probably [AGE] years and said it was not abnormal for Resident #32 to be up at night on her phone but said Resident #32 slept most nights. LVN B said she assessed Resident #32 prior to administering the breathing treatment at around 11 PM including her vital signs, O2 saturation. LVN B said Resident #32's oxygen saturation was at ,d+[DATE]% and she said her O2 was set to deliver 2LPM to 4LPM. LVN B could not recall the exact setting of the O2 concentrator and said she increased it a little bit. LVN B could not recall exactly what she increased the O2 setting to, but said she increased it to 3 or 4 or so. LVN B said she did not recall if she documented that she assessed Resident #32's lung sounds but said she listened to Resident #32's front left and right upper lung lobes and listened to her back. LVN B said she did not hear any wheezing or crackles (abnormal breath sounds). LVN B said she believed Resident #32's complaints of not being able to breathe were more related to anxiety than respiratory distress. She said there was an agency CNA working with her that night and Resident #32 did not like unknown staff. She said she observed Resident #32 blowing air out through her mouth forcefully and thought Resident #32 was having anxiety. LVN B said Resident #32 also complained of pain but did not get a measure of Resident #32's pain. She said Resident #32 had pain all over, general body pain. LVN B said she could not recall her documented assessment of Resident #32 on [DATE] and [DATE] and said she wrote some stuff in [her chart]; I documented the breathing treatment. LVN B said she had a very fast and long night on [DATE] due to two other residents on the same hall as Resident #32 continually attempting to or getting out of bed and she was afraid they would have a fall. LVN B said she did not recall Resident #32 ever complaining of not being able to breathe or requesting a breathing treatment prior to [DATE]. LVN B said she did not call the doctor to notify him that Resident #32 had complained of not being able to breathe and was requesting PRN breathing treatments because she did not see it as anything out of the ordinary. In an interview with RN C on [DATE] at 1:21 PM, RN C said she normally worked the 6 AM to 2 PM shift on Resident #32's hall and had worked with her at the facility for 2 years. She said Resident #32 had COPD, HTN, and arthritis. She said she normally arrived for her shift prior to 6 AM and on [DATE] at 6:05 AM, she had completed receiving report from LVN B. She said she would have normally started her rounds at one end of the hall at that time, but because LVN B told her during report that Resident #32 had issues overnight, she went directly to her room. RN C said when she entered Resident #32's room, she noticed she was not breathing and was unresponsive. She stated she checked Resident #32's radial pulse (inside wrist), and said the pulse was faint. RN C said Resident #32 was wearing a N/C for O2, but she did not observe the settings of the O2 concentrator. RN C said she left Resident #32's room and went to get LVN B, who was at the nurses' station, and LVN A who was in another hall. She said she asked for the crash cart and one of them brought it to Resident #32's room. RN C said when she returned to Resident #32's room, she re-assessed Resident #32's pulse, first at her wrist and then at her neck. She said she did not feel a pulse and she instructed LVN A and LVN B to start CPR. LVN A was doing compressions and LVN B was doing the breaths with the Ambu bag (hand-held device commonly used to provide positive pressure ventilation to people who are not breathing or not breathing adequately). RN C said she left to call 911 and when she returned, she took over compressions and LVN A left to get the AED. She said once LVN A arrived with the AED, the pads were placed onto Resident #32, the AED analyzed and advised a shock to be given. RN C said one shock was given and then CPR was resumed. She said the paramedics arrived and took over CPR by inserting a tube into Resident #32's mouth, and the Ambu bag was connected to the tube. RN C said the paramedics continued CPR for approximately 30 minutes, but it was ineffective, and Resident #32 was pronounced dead on [DATE] at 6:55 AM. RN C did not recall at what time she called 911 or at what time the paramedics arrived. RN C said in the two years she worked with Resident #32, she had never heard Resident #32 complaining of not being able to breathe or requesting a breathing treatment. RN C said Resident #32 received a routine breathing treatment during the day and she had never administered to Resident #32 the PRN breathing treatment. RN C said LVN B did not tell her during report that Resident #32 complained of not being able to breathe or that she had administered 2 PRN breathing treatments to Resident #32 overnight. RN C said if a resident complained of not being able to breathe and requested a breathing treatment, she would first assess the resident's vital signs, assess their respiration rate, work of breathing, sit them up or elevate the head of the bed, and assess the lung sounds. She said she would complete the assessment prior to and after the breathing treatment. RN C said she would then assess the resident every 30 minutes, and depending on the findings of her assessment, she would use her nursing judgment in determining to notify the MD. RN C said she would also document her assessment in the resident's EHR. In an interview with LVN A on [DATE] at 1:45 PM, LVN A said on [DATE], shortly after 6 AM, she was getting report from the overnight nurse when she heard RN C yell for the crash cart. She said LVN B grabbed the crash cart, and they went into Resident #32's room. She observed RN C check for Resident #32's pulse at her wrist and say she did not have a pulse. She said she was doing compressions, LVN B was providing ventilation with the Ambu bag, and RN C left to call 911. She said RN C took over compression when she returned, and she left to get the AED. She said she placed the pads on Resident #32 and one shock was given prior to the paramedics' arrival. LVN A said she could not recall at what time the paramedics arrived. In an interview with the city police department's communications staff on [DATE] at 10:08 AM, she stated a call was made to 911 from the facility on [DATE] at 6:26 AM. She stated the paramedics arrived at the facility on [DATE] at 6:30 AM. In an interview on [DATE] at 12:00 PM, ADON F said it would be considered a change in condition if a resident complained of not being able to breathe and requested a PRN breathing treatment. ADON F said she would expect a nurse to assess the resident's vital signs, assess their respirations, seeing if the resident had labored breathing, assess their inhalation and expiration, and listen to the resident's lung sounds. ADON F said she would then expect a nurse to document, notify the doctor, and document the conversation with the doctor. In an interview on [DATE] at 11:12 AM, MD P said he was Resident #32's physician. He said he did not receive any phone calls on [DATE] or [DATE] regarding Resident #32. He said Resident #32's COPD was pretty advanced, and she had orders for routine and PRN breathing treatments. MD P said it was his expectation that a nurse would call him if Resident #32 was having difficulty breathing or receiving a PRN breathing treatment. MD P said he knew nurses would have called if Resident #32 was having difficulty breathing and the nurse would have documented that they called him. In an interview on [DATE] at 10:17 AM, MD X said he was the Medical Director. He said it was his expectation a nurse would call the attending physician for a resident's change in condition. Review of the facility's Oxygen Administration dated 2010 reflected, The purpose of this procedure is to provide guidelines for safe oxygen administration . Review the resident's care plan to assess for any special needs of the resident . while the resident is receiving oxygen therapy, assess for the following: signs or symptoms of cyanosis (i.e. blue tone to the skin and mucous membranes); signs or symptoms of hypoxia (i.e. rapid breathing, rapid pulse rate, restlessness, confusion); signs or symptoms of oxygen toxicity (i.e. tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); vital signs; lung sounds . the following should be documented in the resident's medical record: The date and time the procedure was performed . The rate of oxygen flow, route, and rationale . All assessment obtained before, during, and after the procedure Review of the facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, dated 2010, reflected: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway . Obtain a physician's order as needed. Review the resident's care plan, current orders, and diagnoses to determine resident needs. Check the treatment record . If the resident suffers from Chronic Obstructive Pulmonary Disease (COPD), refer to the [COPD] Clinical Protocol in addition to this procedure . Remain with the resident for the treatment. Approximately five minutes after the treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. Monitor for side effects, including rapid pulse, restlessness, nervousness throughout the treatment. Stop the treatment and notify the physician if the pulse increases 20 percent above baseline . Obtain post-treatment pulse, respiratory rate, and lung sounds . The following information should be documented in the resident's medical record. The date, time, and length of treatment . Pulse, respiratory rate and lung sounds before and after the treatment. Pulse during treatment. Amount and characteristics of sputum production . Any adverse effects of the medication and/or treatment and physician notification, if applicable . Notify the physician is the resident experiences adverse effects from the medication. Notify the physician id the pulse rate during treatment increases 20 percent above baseline. Follow any other orders for physician notification pertinent to the resident. Review of the ACEP COPD recommendations accessed on [DATE] at https://www.emergencyphysicians.org/article/know-when-to-go/COPD, reflected: Chronic Obstructive Pulmonary Disease or COPD is a group of long-term inflammatory lung conditions that make it hard to breathe . COPD is one of the most common chronic diseases seen in patients who need emergency care. More than 16 million people in the United States live with COPD, and COPD-related emergencies annually send about 873,000 people to the emergency department, according to the Centers for Disease Control and Prevention (CDC). COPD symptoms can be manageable with regular checkups and care at home that can include healthy behavior changes like quitting smoking, prescription medications or breathing devices. However, flare ups are common. When symptoms appear more suddenly than usual, or become severe or longer lasting, it may be necessary to get medical attention right away. Paying close attention to changes in typical symptoms and knowing when seek help could prevent a medical emergency. People with COPD can have a cough, chest tightness, wheezing or shortness of breath, and heavy amounts of mucus. Call 911 or go to the closest emergency department if you experience: Difficulty breathing or talking. Chest pains. Fever. Racing heartbeat. Fingernails that turn blue or gray (a sign of a low oxygen level in your blood). Recommended treatment is not working, and symptoms are getting worse. Slurred speech, disorientation, confusion, dizziness. Sleepiness and difficulty awakening from sleep. Those with chronic conditions should work with a physician to create a plan to manage their illness that includes an emergency action plan with medication history, important phone numbers, and other information that can be critical to gather before an emergency occurs . 1. Review of Resident #29's face sheet dated [DATE] reflected she was a [AGE] year-old woman initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: epilepsy, diabetes, hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), COPD, HTN, right-sided paralysis after a stroke, cerebral infarction (stroke, [DATE]), and heart failure. Review of Resident #29's quarterly MDS dated [DATE] reflected she had adequate hearing, clear speech, and could make her wants and needs understood. Her BIMS was 13 and indicated she was cognitively intact. She did not have behavioral symptoms such as delusions, hallucinations, physical aggression, or refusals of care. Review of the pain management assessment reflected she did not receive scheduled, or PRN pain medications and she denied pain in the 5 days prior to the assessment. Review of Resident #29's care plans dated [DATE] reflected Resident #29 had one sided paralysis due to a stroke. Her goal was to be free from signs or symptoms of complications of a stroke such DVT (blood clot in a deep vein), contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), aspiration pneumonia (infection caused by food or liquid breathed into the airways or lungs), or dehydration. Interventions included giving medications as ordered by the physician. Monitoring and document side effects and effectiveness. Monitoring vital sings and notifying the MD of significant abnormalities. Resident #29 did not have a care plan for risk of stroke. A record review of Resident #29's progress notes in the EHR revealed a note documented on [DATE] reflected Resident #29 was sent to the ER via 911 on [DATE] due to a low blood pressure, confusion, and slurred speech. The resident was readmitted to the facility on [DATE] with a diagnosis of stroke. In an interview and observation on [DATE] at 8:16 AM, LVN A stated she would need to administer Resident #29's insulin after breakfast. She entered Resident #29's room and Resident #29 was lying in bed with her eyes closed. She had on a N/C which was connected to the O2 concentrator set to deliver 2LPM. She was breathing but was difficult to arouse. LVN A attempted to arouse Resident #29 with loud verbal prompts and physical touch to the resident's left upper arm. The resident did not arouse after approximately 3 minutes and LVN A said she would hold Resident #29's insulin and would instead obtain a set of vital signs. LVN A left the room and promptly returned with a pulse oximeter (device used to measure the O2 saturation of the blood), thermometer, and an automatic wrist BP cuff. LVN A obtained the readings of temperature 97.3 degrees Fahrenheit, pulse 62, O2 saturation 96%, and BP of ,d+[DATE] on her left wrist. LVN A said the BP reading did not seem accurate and placed the cuff to Resident #29's right wrist. Resident #29 aroused when LVN A placed the cuff to her right wrist, and LVN A asked her if she was feeling ok. Resident #29 said she was feeling lousy. LVN A obtained a reading of ,d+[DATE] from the resident's right wrist. LVN A did not clarify what Resident #29 meant by lousy. The HHSC Surveyor intervened and asked Resident #29 what she meant by lousy. Resident #29 stated she had pain to both her arms and to her back, and both her arms were numb. LVN A said she would administer a pain medication to Resident #29 and began to leave the room without completing a pain assessment. The HHSC Surveyor intervened while LVN A was in the room and asked Resident #29 about her pain. Resident #29 the pain in her back was chronic, but stated her pain was at ,d+[DATE], sharp in nature, and said she had only once previously felt this pain when she was having a stroke last month ([DATE]). Resident #29 was very lethargic, and her speech was slurred. She had intermittent tremors to both of her hands. LVN A again told Resident #29 she would go get her a pain pill and left the room. LVN A returned promptly to the room and administered a whole pill with water to Resident #29 and said it was tramadol, and then left the room. In an observation and interview on [DATE] at 8:44 AM, LVN A returned to Resident #29's room and administered insulin to Resident #29's abdomen. LVN A said she did not know if Resident #29 had a history of a stroke, but to her knowledge she did not. LVN A said she believed Resident #29 was displaying attention seeking behaviors. LVN A then left and sat at the nurses' station down the hall. In an interview and observation on [DATE] at 8:50 AM, the HHSC Surveyor intervened and reported to ADON F Resident #29's complaint of pain, statement that that was the way she felt last time she had a stroke, and the BP's obtained by LVN A. ADON F said she would obtain a manual BP and call the MD. ADON F went to the nurses' station and told LVN A to obtain a manual BP on Resident #29. In an observation on [DATE] at 9:01 AM, LVN A entered Resident #29's room and applied the BP cuff to Resident #29's left upper arm. She placed the bell of the stethoscope in the inner fold of the elbow and stated the resident's BP was ,d+[DATE]. ADON F asked LVN A to see if the MD had responded to the electronic text message which had been sent to him earlier. ADON F then attempted to obtain a second manual BP on Resident #29's right upper arm, but the resident began to shake and displayed signs of a seizure. The resident's eyes were open, not blinking, and she was staring but not following objects with her gaze. Both of her arms stiffened and began to shake. This lasted 2 minutes. ADON F said she could not obtain Resident #29's BP because her arms were shaking too much during her seizure; she left the room and said she would go call the MD. The MDS Nurse entered the room during this observation. In an interview on [DATE] at 9:22 AM, the MDS Nurse said she had previously worked directly with Resident #29 but recently took the position of MDS Nurse. The MDS Nurse said Resident #29 had a history of seizures, she had one when she was first admitted in 2017, but she had never observed one of Resident #29's seizures or known Resident #29 to have any more seizures. The MDS Nurse said the tremors to Resident #29's hands were new. The MDS Nurse was not aware if Resident #29 received any medications for seizures, was followed by a neurologist, or if she'd had an EEG (test used to measure electrical impulses in the brain and one of the main diagnostic tests for epilepsy). In an interview on [DATE] at 9:28 AM, ADON F said she had received an order from NP Q to send Resident #29 to the emergency room . In an interview and observation on [DATE] at 9:30 AM, LVN A and ADON F informed Resident #29 her provider had ordered for her to the ER for further evaluation. Resident #29 refused to go to the ER. ADON F said NP Q had given an order for labs if the resident refused to be sent out. Record review Resident #29's physicians orders in the EHR on [DATE] reflected new orders for a CBC, CMP, UA with culture and sensitivity. Record review of Resident #29's progress notes in her EHR on [DATE] reflected a note documented by LVN A on [DATE]

Based on observations, interviews, and records reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #32 and Resident #29) of 8 residents reviewed for quality of care. The facility failed to ensure: 1. Resident #32 was appropriately assessed, monitored, and care plans were followed when Resident #32, who did not have a history of shortness of breath complaints, complained of not being able to breathe and requested two breathing treatments the night of [DATE]. Resident #32 was discovered on [DATE] unresponsive and not breathing. CPR was preformed but she was pronounced dead at the facility on [DATE]. 2. Resident #29 was appropriately assessed and monitored when she complained of pain to both her arms, pain level 9 out of 10 (10 being the worst) and stated that was how she felt the last time she had a stroke. Resident #29 was difficult to rouse, had slurred speech, tremors in her hands, and then had a seizure, and within 1 day, Resident had a second seizure, was sent to the ER, and was diagnosed with a UTI. Resident #29 had a history of strokes, last on [DATE], and several stroke risks such as diabetes, hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), HTN, and heart failure. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:36 PM and the ADM, DON, and the RNC were notified. While the IJ was removed on [DATE] at 7:30 PM, the facility remained out of compliance at a scope of isolated at the severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: 1. Review of Resident #32's quarterly MDS dated [DATE] reflected she was a [AGE] year-old woman initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: chronic respiratory failure, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), CHF (long-term condition in which heart cannot pump blood well enough to meet body's needs), dependence on supplemental oxygen, and HTN. Review of her cognition assessment reflected a BIMS of 15 and indicated she was cognitively intact. The prognosis of her health conditions reflected she did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of Resident #32's face sheet dated [DATE] reflected RP #1 was a family member and the POA. Her designated code status was full code and indicated if her heart or respirations stopped (cardiac arrest or respiratory arrest), all resuscitation procedures would be provided to keep her alive. Review of Resident #32's Care Plans dated with admitted [DATE] reflected Resident #32 had chosen a full code status and interventions included following her advanced directive, initiating CPR in the event of unresponsiveness, no pulse, no respirations, and activating 911. She was at risk for SOB due to CHF and COPD and interventions included giving cardiac medications as ordered, monitoring vital signs, and notifying the MD of significant abnormalities, giving bronchodilators as ordered with monitoring and documenting of effectiveness, monitoring for respiratory difficulty, and monitoring for signs of acute respiratory insufficiency such as: anxiety, confusion, restlessness, and SOB at rest. She was on oxygen due to COPD and interventions included monitoring for signs and symptoms of respiratory distress and reporting to the MD: respirations, pulse, oximetry (test to measure the oxygen level/oxygen saturation of the blood), increased heart rate, restlessness, excessive sweating, headaches, lethargy, confusion, atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung), coughing up blood, cough, pleuritic pain (pain in chest or shoulder made worse with breathing), accessory muscle usage (contraction of any muscle other than the diaphragm during inspiration or use of any muscle during expiration indicating labored breathing/respiratory distress), and skin color. Other interventions included an O2 setting of 2LPM via N/C and promoting lung expansion by positioning with proper body alignment and a head of bed elevated 30 degrees if tolerated. Review of Resident #32's Physician's Orders dated [DATE] reflected the following orders: 1. Full Code. Start date [DATE]. 2. Oxygen via N/C at ,d+[DATE] LPM continuous to keep O2 saturation above 92%. If unable to keep O2 saturation above 92%, notify the MD immediately. Start date [DATE]. 3. DuoNeb solution (inhalation solution containing a combination of albuterol and ipratropium, bronchodilators that relax muscles in the airways and increase air flow to the lungs) 3mL orally via nebulizer every 6 hours as needed for SOB. Start date [DATE]. 4. Symbicort (combination of budesonide and formoterol. Budesonide is a corticosteroid that reduces inflammation in the body. Formoterol is a long-acting bronchodilator that relaxes muscles in the airways to improve breathing) 2 puffs inhale orally two times per day for COPD. Start date [DATE]. Review of Resident #32's e-MARs from [DATE] to [DATE] reflected there were not any PRN DuoNeb breathing treatments documented as being administered on any dates. Review of Resident #32's e-MARs from [DATE] to [DATE] reflected she received a PRN DuoNeb breathing treatment on [DATE] at 11:02 PM. The following vital signs were documented: BP ,d+[DATE], pulse 100, RR 16, O2 saturation 92%. There were not any PRN DuoNeb breathing treatments documented on [DATE] or on any other dates. Review of Resident #32's progress notes from [DATE] through [DATE] reflected the following: 1. On [DATE] at 11:02 PM, LVN B administered a DuoNeb breathing treatment for shortness of breath. 2. On [DATE] at 7:22 AM, LVN B documented a note from [DATE] at 5:10 AM which reflected patient was awake most of the night HOB elevated and breathing treatment given per mar well tolerated.@ 12 midnight she requested to sit upright on wheelchair for comfort call light within reach. respiration even unlabored her vitals [BP ,d+[DATE] Pulse 78 02 Saturation 97% Temperature 97.4 ]she was having a conversation with [friend] on the phone and stable continue to monitor. at about 0400am she requested to be put back in bed still texting [friend] on her phone. she was given her early Morning medication per mar well tolerated. patient in a comfortable position HOB elevated call light within reach. The note did not indicate it was a late entry. 3. On [DATE], LVN B documented a breathing treatment was given at 11:02 PM and was effective. The note was created on [DATE] at 4:19 AM, but the time was changed to 5:19 AM. The note did not indicate the reason the time was changed. 4. On [DATE] at 8:46 AM, RN C documented a note from [DATE] at 6:05 AM which reflected, This Nurse went to the resident room to check on her, upon arriving the room resident was in bed lying, tried to wake up the resident but she was unresponsive, and no respiration noted, checked the pulse and fainted pulse noted, came to call my colleagues and went back to the room and recheck the pulse and there was no pulse, CPR initiated and about [6:08 AM] 911 was notified of this incident and immediately the paramedics were in the building and took over with the CPR. obtained CPR 30 compressions via machine followed by two ventilation breaths for more than 30 minutes and the machine continues to show asystole [no heartbeat], at [6:55 AM] resident was pronounced dead. [MD P], Administrator notified. [ADON F] notified the family member [RP #1]. The note did not indicate it was a late entry. 5. On [DATE] at 8:19 AM, ADON F documented a note from [DATE] at 7:05 AM which reflected, At 0705am this nurse called resident [RP #1] and notified him that his [Resident #32] had expired. [RP #1] was hurt & crying while on the phone & just hung up. 0734am he arrived to the facility. The note did not indicate it was a late entry. Review of Resident #32's EHR on [DATE] reflected the last vital signs documented were on [DATE] at 11:02 PM and were BP ,d+[DATE], pulse 100 bpm, RR 16, and O2 saturation 92% (did not reflect whether this was on oxygen or on room air). The last documented temperature was on [DATE] at 11:59 PM and was 97.4 F. Review of the assessment forms in the EHR reflected the last assessment documented was a skin assessment on [DATE]. There were not any change in condition assessments documented from [DATE] through [DATE]. In a telephone interview with RP #1 on [DATE] at 10:44 AM, RP #1 said Resident #32 had been at the facility since 2018. RP #1 said he did not have any concerns regarding Resident #32's care. He said he picked up Resident #32's belongings, including her phone, from the facility on [DATE] and saw that she had made 2 calls to FM #3 on [DATE] at 11 PM. He said he thought Resident #32 made those calls on accident as she was known to pocket dial. He said he had spoken, via telephone, with Resident #32 on [DATE] a little after lunch, and she seemed fine. RP #1 said FM #2 could provide more information on Resident #32's medical conditions and placed her on the phone. FM #2 stated Resident #32 had some issues with her breathing recently. FM #2 said Resident #32 was receiving continuous O2 at 6LPM via the oxygen concentrator and she was able to let the nurses know if she was not feeling well or she would send a text message the DON. She said Resident #32 could express herself very well. She said Resident #32 had daily, routine breathing treatments and she never used the PRN breathing treatments. In a telephone interview on [DATE] at 1:49 PM, FM #2 stated she and RP #1 initially did not have any concerns regarding Resident #32's care but they had been made aware of a voicemail left for FM #3 by Resident #32 on [DATE] and now they had concerns. She said in the voicemail, Resident #32 could be heard asking for help and stating she could not breathe. She said facility staff could be heard in the background. FM #2 said the voicemail could be sent via e-mail for review. In a telephone interview on [DATE] at 10:46 AM, FM #3 said she had a missed call from Resident #32 on [DATE] at 11:24 PM. FM #3 said she spoke with Resident #32 multiple times daily and Resident #32 had never before stated she could not breathe. She said the last time she spoke with Resident #32 was on [DATE] in the evening and they had a normal conversation, which included the resident complaining of how long her call light would be on overnight before anyone came to her room. FM #3 said Resident #32 had COPD and some difficulty breathing was normal for her, but not like she was, on the voicemail. Review of the telephonic voice message sent via email by FM #2 on [DATE] at 2:16 PM reflected the message was 3 minutes long. Further review reflected a person was speaking in a distressed tone and paused several times between words. They said, Oh. Oh Lord. Oh Lord please. God. I can't breathe. God help me. Oh Lord. God help me. Oh. Oh. Oh. I can't breathe. Please. Oh Lord. Oh Lord. God. Please. Oh Lord. Oh God. Oh. Oh. God help me. Oh God help me. God. Please! Put me in my chair, so I can breathe. Oh. God help me. God help me. God. Somebody. Oh. Oh. Oh Lord. [Second person heard speaking; portions inaudible. You, ok? You can't breathe? Resident continued .] Yeah. The white ones on the closet floor. Oh God. I don't know her. In an interview with LVN B on [DATE] at 1:41 PM, she said on [DATE], Resident #32 was awake all night and could not sleep. She said at around 11 PM on [DATE], Resident #32 complained of not being able to breathe and requested a breathing treatment. LVN B said she obtained Resident #32's vital signs and gave her a PRN breathing treatment. LVN B could not remember what the vital signs were for Resident #32. LVN B also stated she could not recall the O2 concentrator setting when Resident #32 said she could not breathe. LVN B said after the breathing treatment, Resident #32 still complained of not being able to breathe and requested to be transferred from her bed to her wheelchair. LVN B said she overheard Resident #32 making calls on her phone. LVN B said at around 4:15 AM ([DATE]), she told the agency CNA to place Resident #32 back in her bed so that she could receive incontinent care, but Resident #32 refused to be placed back in bed because she was having trouble breathing. LVN B said Resident #32 agreed to be placed back in bed only if LVN B gave her another breathing treatment because the previous breathing treatment had helped. LVN B said she administered to Resident #32 the second PRN breathing treatment but did not obtain her vital signs. LVN B said she went to give Resident #32 her morning medication on [DATE] at around 5 AM and Resident #32 requested water and her cough drops. LVN B said she then went back to the nursing station and when the morning nurses arrived, she gave them report. She said RN C left down the hall to check on Resident #32 and came out of the room yelling for a crash cart and yelling code blue (medical emergency, usually cardiac or respiratory arrest). LVN B said she had known Resident #32 for probably [AGE] years and said it was not abnormal for Resident #32 to be up at night on her phone but said Resident #32 slept most nights. LVN B said she assessed Resident #32 prior to administering the breathing treatment at around 11 PM including her vital signs, O2 saturation. LVN B said Resident #32's oxygen saturation was at ,d+[DATE]% and she said her O2 was set to deliver 2LPM to 4LPM. LVN B could not recall the exact setting of the O2 concentrator and said she increased it a little bit. LVN B could not recall exactly what she increased the O2 setting to, but said she increased it to 3 or 4 or so. LVN B said she did not recall if she documented that she assessed Resident #32's lung sounds but said she listened to Resident #32's front left and right upper lung lobes and listened to her back. LVN B said she did not hear any wheezing or crackles (abnormal breath sounds). LVN B said she believed Resident #32's complaints of not being able to breathe were more related to anxiety than respiratory distress. She said there was an agency CNA working with her that night and Resident #32 did not like unknown staff. She said she observed Resident #32 blowing air out through her mouth forcefully and thought Resident #32 was having anxiety. LVN B said Resident #32 also complained of pain but did not get a measure of Resident #32's pain. She said Resident #32 had pain all over, general body pain. LVN B said she could not recall her documented assessment of Resident #32 on [DATE] and [DATE] and said she wrote some stuff in [her chart]; I documented the breathing treatment. LVN B said she had a very fast and long night on [DATE] due to two other residents on the same hall as Resident #32 continually attempting to or getting out of bed and she was afraid they would have a fall. LVN B said she did not recall Resident #32 ever complaining of not being able to breathe or requesting a breathing treatment prior to [DATE]. LVN B said she did not call the doctor to notify him that Resident #32 had complained of not being able to breathe and was requesting PRN breathing treatments because she did not see it as anything out of the ordinary. In an interview with RN C on [DATE] at 1:21 PM, RN C said she normally worked the 6 AM to 2 PM shift on Resident #32's hall and had worked with her at the facility for 2 years. She said Resident #32 had COPD, HTN, and arthritis. She said she normally arrived for her shift prior to 6 AM and on [DATE] at 6:05 AM, she had completed receiving report from LVN B. She said she would have normally started her rounds at one end of the hall at that time, but because LVN B told her during report that Resident #32 had issues overnight, she went directly to her room. RN C said when she entered Resident #32's room, she noticed she was not breathing and was unresponsive. She stated she checked Resident #32's radial pulse (inside wrist), and said the pulse was faint. RN C said Resident #32 was wearing a N/C for O2, but she did not observe the settings of the O2 concentrator. RN C said she left Resident #32's room and went to get LVN B, who was at the nurses' station, and LVN A who was in another hall. She said she asked for the crash cart and one of them brought it to Resident #32's room. RN C said when she returned to Resident #32's room, she re-assessed Resident #32's pulse, first at her wrist and then at her neck. She said she did not feel a pulse and she instructed LVN A and LVN B to start CPR. LVN A was doing compressions and LVN B was doing the breaths with the Ambu bag (hand-held device commonly used to provide positive pressure ventilation to people who are not breathing or not breathing adequately). RN C said she left to call 911 and when she returned, she took over compressions and LVN A left to get the AED. She said once LVN A arrived with the AED, the pads were placed onto Resident #32, the AED analyzed and advised a shock to be given. RN C said one shock was given and then CPR was resumed. She said the paramedics arrived and took over CPR by inserting a tube into Resident #32's mouth, and the Ambu bag was connected to the tube. RN C said the paramedics continued CPR for approximately 30 minutes, but it was ineffective, and Resident #32 was pronounced dead on [DATE] at 6:55 AM. RN C did not recall at what time she called 911 or at what time the paramedics arrived. RN C said in the two years she worked with Resident #32, she had never heard Resident #32 complaining of not being able to breathe or requesting a breathing treatment. RN C said Resident #32 received a routine breathing treatment during the day and she had never administered to Resident #32 the PRN breathing treatment. RN C said LVN B did not tell her during report that Resident #32 complained of not being able to breathe or that she had administered 2 PRN breathing treatments to Resident #32 overnight. RN C said if a resident complained of not being able to breathe and requested a breathing treatment, she would first assess the resident's vital signs, assess their respiration rate, work of breathing, sit them up or elevate the head of the bed, and assess the lung sounds. She said she would complete the assessment prior to and after the breathing treatment. RN C said she would then assess the resident every 30 minutes, and depending on the findings of her assessment, she would use her nursing judgment in determining to notify the MD. RN C said she would also document her assessment in the resident's EHR. In an interview with LVN A on [DATE] at 1:45 PM, LVN A said on [DATE], shortly after 6 AM, she was getting report from the overnight nurse when she heard RN C yell for the crash cart. She said LVN B grabbed the crash cart, and they went into Resident #32's room. She observed RN C check for Resident #32's pulse at her wrist and say she did not have a pulse. She said she was doing compressions, LVN B was providing ventilation with the Ambu bag, and RN C left to call 911. She said RN C took over compression when she returned, and she left to get the AED. She said she placed the pads on Resident #32 and one shock was given prior to the paramedics' arrival. LVN A said she could not recall at what time the paramedics arrived. In an interview with the city police department's communications staff on [DATE] at 10:08 AM, she stated a call was made to 911 from the facility on [DATE] at 6:26 AM. She stated the paramedics arrived at the facility on [DATE] at 6:30 AM. In an interview on [DATE] at 12:00 PM, ADON F said it would be considered a change in condition if a resident complained of not being able to breathe and requested a PRN breathing treatment. ADON F said she would expect a nurse to assess the resident's vital signs, assess their respirations, seeing if the resident had labored breathing, assess their inhalation and expiration, and listen to the resident's lung sounds. ADON F said she would then expect a nurse to document, notify the doctor, and document the conversation with the doctor. In an interview on [DATE] at 11:12 AM, MD P said he was Resident #32's physician. He said he did not receive any phone calls on [DATE] or [DATE] regarding Resident #32. He said Resident #32's COPD was pretty advanced, and she had orders for routine and PRN breathing treatments. MD P said it was his expectation that a nurse would call him if Resident #32 was having difficulty breathing or receiving a PRN breathing treatment. MD P said he knew nurses would have called if Resident #32 was having difficulty breathing and the nurse would have documented that they called him. In an interview on [DATE] at 10:17 AM, MD X said he was the Medical Director. He said it was his expectation a nurse would call the attending physician for a resident's change in condition. Review of the facility's Oxygen Administration dated 2010 reflected, The purpose of this procedure is to provide guidelines for safe oxygen administration . Review the resident's care plan to assess for any special needs of the resident . while the resident is receiving oxygen therapy, assess for the following: signs or symptoms of cyanosis (i.e. blue tone to the skin and mucous membranes); signs or symptoms of hypoxia (i.e. rapid breathing, rapid pulse rate, restlessness, confusion); signs or symptoms of oxygen toxicity (i.e. tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); vital signs; lung sounds . the following should be documented in the resident's medical record: The date and time the procedure was performed . The rate of oxygen flow, route, and rationale . All assessment obtained before, during, and after the procedure Review of the facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, dated 2010, reflected: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway . Obtain a physician's order as needed. Review the resident's care plan, current orders, and diagnoses to determine resident needs. Check the treatment record . If the resident suffers from Chronic Obstructive Pulmonary Disease (COPD), refer to the [COPD] Clinical Protocol in addition to this procedure . Remain with the resident for the treatment. Approximately five minutes after the treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. Monitor for side effects, including rapid pulse, restlessness, nervousness throughout the treatment. Stop the treatment and notify the physician if the pulse increases 20 percent above baseline . Obtain post-treatment pulse, respiratory rate, and lung sounds . The following information should be documented in the resident's medical record. The date, time, and length of treatment . Pulse, respiratory rate and lung sounds before and after the treatment. Pulse during treatment. Amount and characteristics of sputum production . Any adverse effects of the medication and/or treatment and physician notification, if applicable . Notify the physician is the resident experiences adverse effects from the medication. Notify the physician id the pulse rate during treatment increases 20 percent above baseline. Follow any other orders for physician notification pertinent to the resident. Review of the ACEP COPD recommendations accessed on [DATE] at https://www.emergencyphysicians.org/article/know-when-to-go/COPD, reflected: Chronic Obstructive Pulmonary Disease or COPD is a group of long-term inflammatory lung conditions that make it hard to breathe . COPD is one of the most common chronic diseases seen in patients who need emergency care. More than 16 million people in the United States live with COPD, and COPD-related emergencies annually send about 873,000 people to the emergency department, according to the Centers for Disease Control and Prevention (CDC). COPD symptoms can be manageable with regular checkups and care at home that can include healthy behavior changes like quitting smoking, prescription medications or breathing devices. However, flare ups are common. When symptoms appear more suddenly than usual, or become severe or longer lasting, it may be necessary to get medical attention right away. Paying close attention to changes in typical symptoms and knowing when seek help could prevent a medical emergency. People with COPD can have a cough, chest tightness, wheezing or shortness of breath, and heavy amounts of mucus. Call 911 or go to the closest emergency department if you experience: Difficulty breathing or talking. Chest pains. Fever. Racing heartbeat. Fingernails that turn blue or gray (a sign of a low oxygen level in your blood). Recommended treatment is not working, and symptoms are getting worse. Slurred speech, disorientation, confusion, dizziness. Sleepiness and difficulty awakening from sleep. Those with chronic conditions should work with a physician to create a plan to manage their illness that includes an emergency action plan with medication history, important phone numbers, and other information that can be critical to gather before an emergency occurs . 1. Review of Resident #29's face sheet dated [DATE] reflected she was a [AGE] year-old woman initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: epilepsy, diabetes, hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), COPD, HTN, right-sided paralysis after a stroke, cerebral infarction (stroke, [DATE]), and heart failure. Review of Resident #29's quarterly MDS dated [DATE] reflected she had adequate hearing, clear speech, and could make her wants and needs understood. Her BIMS was 13 and indicated she was cognitively intact. She did not have behavioral symptoms such as delusions, hallucinations, physical aggression, or refusals of care. Review of the pain management assessment reflected she did not receive scheduled, or PRN pain medications and she denied pain in the 5 days prior to the assessment. Review of Resident #29's care plans dated [DATE] reflected Resident #29 had one sided paralysis due to a stroke. Her goal was to be free from signs or symptoms of complications of a stroke such DVT (blood clot in a deep vein), contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), aspiration pneumonia (infection caused by food or liquid breathed into the airways or lungs), or dehydration. Interventions included giving medications as ordered by the physician. Monitoring and document side effects and effectiveness. Monitoring vital sings and notifying the MD of significant abnormalities. Resident #29 did not have a care plan for risk of stroke. A record review of Resident #29's progress notes in the EHR revealed a note documented on [DATE] reflected Resident #29 was sent to the ER via 911 on [DATE] due to a low blood pressure, confusion, and slurred speech. The resident was readmitted to the facility on [DATE] with a diagnosis of stroke. In an interview and observation on [DATE] at 8:16 AM, LVN A stated she would need to administer Resident #29's insulin after breakfast. She entered Resident #29's room and Resident #29 was lying in bed with her eyes closed. She had on a N/C which was connected to the O2 concentrator set to deliver 2LPM. She was breathing but was difficult to arouse. LVN A attempted to arouse Resident #29 with loud verbal prompts and physical touch to the resident's left upper arm. The resident did not arouse after approximately 3 minutes and LVN A said she would hold Resident #29's insulin and would instead obtain a set of vital signs. LVN A left the room and promptly returned with a pulse oximeter (device used to measure the O2 saturation of the blood), thermometer, and an automatic wrist BP cuff. LVN A obtained the readings of temperature 97.3 degrees Fahrenheit, pulse 62, O2 saturation 96%, and BP of ,d+[DATE] on her left wrist. LVN A said the BP reading did not seem accurate and placed the cuff to Resident #29's right wrist. Resident #29 aroused when LVN A placed the cuff to her right wrist, and LVN A asked her if she was feeling ok. Resident #29 said she was feeling lousy. LVN A obtained a reading of ,d+[DATE] from the resident's right wrist. LVN A did not clarify what Resident #29 meant by lousy. The HHSC Surveyor intervened and asked Resident #29 what she meant by lousy. Resident #29 stated she had pain to both her arms and to her back, and both her arms were numb. LVN A said she would administer a pain medication to Resident #29 and began to leave the room without completing a pain assessment. The HHSC Surveyor intervened while LVN A was in the room and asked Resident #29 about her pain. Resident #29 the pain in her back was chronic, but stated her pain was at ,d+[DATE], sharp in nature, and said she had only once previously felt this pain when she was having a stroke last month ([DATE]). Resident #29 was very lethargic, and her speech was slurred. She had intermittent tremors to both of her hands. LVN A again told Resident #29 she would go get her a pain pill and left the room. LVN A returned promptly to the room and administered a whole pill with water to Resident #29 and said it was tramadol, and then left the room. In an observation and interview on [DATE] at 8:44 AM, LVN A returned to Resident #29's room and administered insulin to Resident #29's abdomen. LVN A said she did not know if Resident #29 had a history of a stroke, but to her knowledge she did not. LVN A said she believed Resident #29 was displaying attention seeking behaviors. LVN A then left and sat at the nurses' station down the hall. In an interview and observation on [DATE] at 8:50 AM, the HHSC Surveyor intervened and reported to ADON F Resident #29's complaint of pain, statement that that was the way she felt last time she had a stroke, and the BP's obtained by LVN A. ADON F said she would obtain a manual BP and call the MD. ADON F went to the nurses' station and told LVN A to obtain a manual BP on Resident #29. In an observation on [DATE] at 9:01 AM, LVN A entered Resident #29's room and applied the BP cuff to Resident #29's left upper arm. She placed the bell of the stethoscope in the inner fold of the elbow and stated the resident's BP was ,d+[DATE]. ADON F asked LVN A to see if the MD had responded to the electronic text message which had been sent to him earlier. ADON F then attempted to obtain a second manual BP on Resident #29's right upper arm, but the resident began to shake and displayed signs of a seizure. The resident's eyes were open, not blinking, and she was staring but not following objects with her gaze. Both of her arms stiffened and began to shake. This lasted 2 minutes. ADON F said she could not obtain Resident #29's BP because her arms were shaking too much during her seizure; she left the room and said she would go call the MD. The MDS Nurse entered the room during this observation. In an interview on [DATE] at 9:22 AM, the MDS Nurse said she had previously worked directly with Resident #29 but recently took the position of MDS Nurse. The MDS Nurse said Resident #29 had a history of seizures, she had one when she was first admitted in 2017, but she had never observed one of Resident #29's seizures or known Resident #29 to have any more seizures. The MDS Nurse said the tremors to Resident #29's hands were new. The MDS Nurse was not aware if Resident #29 received any medications for seizures, was followed by a neurologist, or if she'd had an EEG (test used to measure electrical impulses in the brain and one of the main diagnostic tests for epilepsy). In an interview on [DATE] at 9:28 AM, ADON F said she had received an order from NP Q to send Resident #29 to the emergency room . ADON F said she was not aware of Resident #29 ever having a seizure since she had been em [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 3 residents reviewed for quality of care. The facility failed to monitor/assess the pedal pulse for Resident #1 who was known for having diminished blood flow in the left foot. Review of nurses progress notes Resident #1 was discharged to the hospital at the request of the family on 7/24/2022 at 10:50 PM. His admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An IJ was identified on 8/26/2022. While the IJ was removed on 8/27/2022, the facility remained out of compliance at severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of their plan of removal. These failures could place residents with poor circulation in their legs to experience loss of blood flow which could cause serious illness, loss of a limb and death. Findings Included: Record review of Resident #1's face sheet, dated 8/25/2022, revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with a readmission on 7/28/2021. Record review of Transfer/Discharge report dated 8/25/2022, reflected Resident #1 was discharged from facility on 7/24/2022 at 10:50 PM at the request of his family. No chief complaint/reason for transfer was documented. Record review of Resident #1's quarterly MDS dated [DATE] revealed the following active Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Heart failure (inability of the heart to pump enough blood to meet the needs of the body), BIMS of 08 indicative of moderate cognitive impairment. Section E: Rejection of care - Behavior not exhibited. One person assist needed for ADLs, bed mobility, transferring, toileting and personal hygiene. No pressure wounds, ulcerations of the foot or other skin issues identified. Record review of Resident #1's discharge MDS assessment, dated 7/24/2022, reflected he had a BIMS score of 03, indicating severe cognitive impairment. Resident #1 required extensive assistance with bed mobility and ADL's. Resident #1 had one unstageable deep tissue injury to the left heel. Record review of Resident #1's care plan, undated care plan, reflected as of 7/21/2022 [Resident #1] had an arterial ulcer on the lt. foot r/t arterial insufficiency (poor blood flow in the artery carries blood from the heart to the foot) with approaches including Resident #1 was to wear cotton socks and long pants to protect feet. Record Review of Resident #1's Wound Evaluation and Management Summary report dated 6/30/2022 revealed Physician E, assessed Resident #1 finding bilateral pedal pulses with no swelling of the legs or feet. Record Review of Resident #1's Wound Evaluation and Management Summary report dated 7/7/2022 revealed Physician E, assessed Resident #1 finding bilateral pedal pulses with no swelling of the legs or feet. Record Review of Resident #1's Wound Evaluation and Management Summary report dated 7/14/2022 revealed Physician E, assessed Resident #1 finding bilateral pedal pulses with no swelling of the legs or feet. Record Review of Resident #1's Wound Evaluation and Management Summary report dated 7/21/2022 revealed Resident #1 had a new arterial wound of the left foot for at least 1day duration. Foot was cool to touch without [CONDITION(S)] (swelling). Measured as 10 x 10 cm scab present. Posterior Tibial (behind the ankle inner aspect) pulse was non-palpable (unable to feel), Dorsalis Pedis (top of foot) pulse was non-palpable (unable to feel). Assessment was competed by Physician E. Plan of Care included bilateral arterial US (ultrasound) doppler (measures the waveforms caused by the flow of blood) study. Record review of Resident #1's Order Summary Report of Active Orders as of 7/21/2022 reflected: BLE Arterial Doppler (study to look at the flow of blood to the feet). Record review of Resident #1's Radiology Results Report dated 7/22/2022 12:18 PM, revealed .Marked calcified (hardened) and noncalcified (soft) plaque (buildup of fat inside the blood vessels) is seen in the legs, left greater that the right. There is no detectable flow in the DPA (Artery found on the top of the foot) and PTA (artery found behind the ankle bone). Record review of Resident #1's Nurses Progress Notes dated 7/22/2022, revealed the absence of documentation regarding the assessment of the pedal pulses for Resident #1. Record review of Resident #1's Nurses Progress Notes dated 7/23/2022, revealed the absence of documentation regarding the assessment of pedal pulses for Resident #1. Record Review of Resident #1's Nurses Progress Notes dated 7/24/2022, revealed the absence of documentation regarding the assessment of pedal pulses for Resident #1. Record Review Resident #1's Nurses Progress Notes dated 7/24/2022 at 10:50 PM, revealed Resident #1 was discharged to the hospital at the request of the family, no documentation provided regarding the assessment of pedal pulses. In a telephone interview on 8/25/2022 at 11:04 AM, EC #2 stated on 7/24/2022 when she arrived at the facility around 10:30 PM she observed the left leg and left foot of Resident #1 and insisted that he be discharged to the emergency room because of the appearance of his foot. EC #2 description was as follows: The left foot had black areas that looked like gangrene his toes, the top of his foot, to just above the ankle and he had dark reddened/purplish color changes in the leg almost up to the knee. EC #2 does not recall any swelling. EC #2 stated the facility did not call and report any changes in Resident #1's foot or leg. Resident #1 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 8/25/2022 at 1:57 PM LVN B stated she last saw Resident #1 on 7/23/2022. Remembered that the left foot had a purplish/black appearance with a dark reddish/purplish discoloration moving up the left leg. She said she was told his leg had been like this, unable to remember who told her. She did not recall seeing any swelling or s/s of infection, and believed the change was related to poor circulation. She did not check for a pulse on the top of the foot, She stated resident #1 does not like to be touched. In an interview on 8/25/2022 at 2:48 PM, Physician E, stated Resident #1 had a long history of high cholesterol which could cause the poor circulation in the lower legs. Physician E ordered a test to measure the flow of blood to both lower legs on 7/21/2022 after he was unable to feel the pulse on the top of the left foot or behind the ankle. Physician E stated, he was not provided with the results on 7/22/2022 and the resident was sent out on 7/24/2022. There was no reason for them to call on 7/25/2022. Physician E's order did not include instructions for him to be notified with the results. Physician E's expectation of notification, was it depends on the findings. In an interview on 8/25/2022 at 3:26 PM, ADON G, stated He was assigned to work with Physician E and that he did not recall being asked to notify Physician E with the results of the test used to evaluate blood flow for Resident #1. He stated residents with multiple physicians, results were called to the primary and ordering physician. ADON G stated Physician E, should have been notified of the report on 7/22/2022. In a telephone interview on 8/25/2022 at 4:11 PM, LVN I stated Physician H(PCP) was notified on 7/22/2022 with the results because she does not have contact information for Physician E. Physician E is only contacted by ADON G. In an interview on 8/25/2022 at 3:32 PM, Physician H stated when Resident #1 went to the hospital, there was no blood flow to the foot. Physician H expected that the physician who ordered the test would have been notified of the results. In an interview on 8/25/2022 at 4:18 PM, DON stated that all communication with Physician E goes through ADON G. DON would expect that results are provided to the PC (primary care) physician regardless of who ordered the test. DON's rationale was that the PC would be more familiar with the resident. The report of the study was provided to the PC on 7/22/2022 and the PC voiced no concerns. Physician E would be notified the next time he was in for resident rounds (which would have been 7/28/2022). In an interview on 8/26/2022 at 09:30 AM, DON stated nurses routinely check radial (wrist) pulses unless ordered differently by the physician. Neither Physician E nor Physician H wrote orders instructing the staff to check for the pulses on the left foot of Resident #1. In an interview on 8/26/2022 at 10:00 AM, Adm confirmed the facility did not receive an order to check pedal pulses for Resident #1. The facility followed their policy for notifying the primary care physician with the results of the study. Review of Policy dated 2/17/2020 entitled Assessment - Comprehensive stated .assessments will be done .with significant change of condition .procedure #11 Examine the extremities and note.c. Circulation; palpate popliteal (behind the knee) and pedal(foot) pulses The Adm and DON were notified on 8/26/2022 at 12:38 PM that an Immediate Jeopardy was identified on 8/26/2022. The IJ template was provided to the Adm. The facility was asked to provide a Plan of Removal to address the immediate Jeopardy. The facility's POR was accepted on 8/27/2022 at 1:00 PM and reflected the following: All licensed nursing staff including agency will be in-serviced on the following: Notify the ordering physician of lab/diagnostic test in a timely manner upon receiving the results Demonstrate and acknowledge awareness of the location of contact information for residents under the care of the wound care physician DON to audit case load of the wound care physician DON to audit the face sheets of residents under the care of the wound care physician and validate the presence of contact information for the wound care physician. Education of licensed nursing personnel began on 2nd shift on 8/26/2022 and would be completed by 8/27/2022 at 1:00 PM. DON's audit of residents under the care of wound care, identified 8 residents. The face sheets of the 8 residents contain the contact information for the wound care physician. Results of audits will be reviewed by the IDT and reviewed monthly in QAPI until compliance is met. The following interviews, and record reviews were conducted to verify the implementation of the facility's POR and revealed the following: Interviews conducted on 8/27/2022 from 2:00 PM to 7:00 PM and 11:00 PM 10 LVN's and 7 RN's facility nursing staff and agency) revealed comprehension of the in-service training provided. They stated for residents under the care of wound care, the physician is to be notified of the worsening of wounds. When the physician ordered labs or diagnostic studies, the results were to be called to the wound care doctor. Contact information for the wound care doctor was located under the profile tab in the EHR on the face sheet. Residents with wounds on the lower extremities will have pedal pulses assessed weekly. Review of in-service training records dated 8/26/2022 and 8/27/2022 revealed staff received training related to Wound Care Contact. Contact information in the EHR medical professionals Reporting results of labs/diagnostic studies Worsening of a wound Weekly checking of pedal pulses for residents with lower extremity wounds On 8/27/2022 the Adm and DON were informed that while the IJ was lowered on 8/27/2022, the facility remained out of compliance at the severity of actual harm and a scope of isolated due to the facility requiring more time to monitor the plan of removal for effectiveness.

Based on observation, interview, and record review, the facility failed to notify the physician and DON of a significant change in the resident's physical, mental, or psychosocial status for one (Resident #2) of six residents reviewed for change in condition. 1. LVN A failed to notify Resident #2's physician, DON, of a change in condition of respiratory status when the resident experienced a chronic cough on [DATE]. 2. LVN [NAME] failed to notify Resident #2's physician or the DON after the resident continued to experience a chronic cough for four days until instructed by MD N to notify the resident's primary care giver on [DATE]. The resident was admitted to the hospital on [DATE] [MEDICAL CONDITION], fever, and pneumonia with acute respiratory distress and left-side pleural effusion. Resident # 2 expired in the hospital at 6:24 AM on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:15 P.M. While the IJ was lifted on [DATE] at 6:11 P.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at the scope of isolated because the facility was still monitoring the plan of removal. These failures could affect residents by placing them at risk for delay in appropriate treatment, [MEDICAL CONDITION], and death. Findings included: Review of Resident #2's MDS assessment dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with primary [DIAGNOSES REDACTED]. The resident was alert, with cognitive impairment and had a weight of 134 pounds. Review of Resident #2's physician's orders [REDACTED]. times 22 hours . Review of Resident #2's care plan dated [DATE] revealed Resident #2 required alternative nutrition due to dysphagia potential for possible problems due to [DEVICE] placement (tube inserted through the abdomen that delivers nutrition directly to the stomach.). Interventions included to monitor for signs of respiratory distress. The care plan reflected the resident was, At risk for choking and aspiration due to swallowing difficulties, currently NPO, Goal: resident will have no signs or systems of aspiration Review of MD N's progress note for Resident #2, dated [DATE] revealed: (Resident #2) was evaluated in his room .He was cooperative, but his alertness fluctuated. He displayed severe impairment in mental status. He was unable to recall the day of week, date, place, or time .He was unable to hold a pencil .He was observed to be coughing. It was decided to postpone further testing until any possible medical factors for his current presentation were ruled out. Spoke with (MD M) about his status. She was at the facility and evaluated (sic) him. She was ordering a chest x-ray and labs. Review of MD M's progress note dated [DATE] revealed, follow-up cough, altered mental status, .appears confused, having cough, chest congestion, productive cough, symptoms started 2 days back per nursing, also has low grade fever .chest x-ray rule out Pneumonia . Review of Resident #2's physician orders [REDACTED]. Review of Resident #2's Radiology Results dated [DATE] revealed, Impression: consider exclusion of bilateral [MEDICAL CONDITION] metastatic [MEDICAL CONDITION]. Disseminated fungal or bacterial pneumonia is not excluded . Review of Resident #2's hospital record revealed he was admitted to the ER (emergency room ) on [DATE] at 8:23 P.M. with [DIAGNOSES REDACTED].) Date of Discharge: Patient pronounced dead on [DATE] at 6:24 AM. Review of Resident #2's nurse's notes dated [DATE] revealed LVN A did not assess Resident #2's respiratory status on [DATE] and she did not notify the physician or DON of a change of condition. An interview on [DATE] at 8:47 [NAME]M. with MD N revealed she observed Resident #2 continuously coughing during her visit on [DATE]. She stated she reported his coughing to LVN [NAME] She stated LVN A replied, he has a productive cough. MD N returned on [DATE] and Resident #2 was cooperative, but his alertness fluctuated. He was unable to hold a pencil and he was observed to still be coughing. She decided to postpone further testing until his medical condition improved. MD M was at the facility and she spoke with MD M about his status. An interview with MD M on [DATE] at 12:30 PM revealed on [DATE] at appropriately 12:00 PM, MD N approached her while in the facility and informed her of Resident #2's change of status. She immediately assessed him, and he had increased confusion, sweating, coughing and chest congestion. She immediately ordered a chest x-ray, laboratory test and antibiotics. She asked LVN A how long has he had the change in condition the symptoms and since it had been since the resident experienced a change in condition and LVN A replied, two or three days. MD M revealed she had not been notified of the change in condition in his mental or respiratory status. She stated she expected to be notified when there was any change of condition for evaluations and treatment, if necessary. An interview on [DATE] at 3:30 PM with LVN A revealed she worked Monday through Friday. LVN A said she was not aware of Resident #2's cough on [DATE].When asked about his condition on [DATE], she replied, I only see (Resident #2) around 6:00 AM to get his blood sugars and he is asleep. Then I see him again around 11:00 (AM) to flush his feeding tube. I did not notice a change in his condition. Later, (MD N) asked me to go and assess him because he was coughing. She stated she went to his room and asked him to cough. She denied listening to his lungs and stated he was always confused, and that symptom was nothing out of the ordinary. She continued to state that MD M saw Resident #2 on [DATE], ordered a chest x-ray and laboratory work. She called MD M with the x-ray results and the resident was transferred to the hospital. An interview with on [DATE] at 11:55 [NAME]M. with CNA C revealed she believed it was about three or four day before he was transported to the hospital that she reported to LVN A, Resident #2 was coughing and it sounded like mucus in is throat, a fluid like cough, and he did not act like he felt good; just really quite not his usual self. An interview on [DATE] at 10:50 [NAME]M. with the DON revealed she was not aware Resident #2 had been coughing and had not been notified of a change of condition. The DON's expectation was to be notified of all changes of condition with any resident, and the physician and family should also be notified. Review of facility's policy on Change in Resident's Condition, undated, reflected: A significant change in a resident's condition is defined as deterioration or marked improvement in the health, mental, or psychosocial status .The nurse needs to contact the provider for conditions such as below not limited to: 1.significant change in the resident's condition . As a significant change in the resident's condition occurs, the charge nurse will notify the physician and family of the significant change in a timely manner . 2. Documentation regarding the change of condition is documented in the residents record as to date, time, all pertinent observation noted, all unusual information obtained from the complete physical and mental assessment done, and accurate record of all intervention initiated including date and time of notification of physicians and responsible party. The Administrator, DON and Corporate Nurse were notified on [DATE] at 1:15 P.M. that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 6:11 PM and included: .1. Starting on [DATE] the oncoming and outgoing charge nurse will visually make rounds at the end of their shift and document findings. 2. The DON or designee and identified licensed nurse will round on the residents twice every shift. 3. The identified nurse will round on the night shift. 4. The charge nurse will notify the DON, designee, family and physician immediately when there is a change in condition. (LVN A) was interviewed by the Administrator, Director of Nursing and Director of Clinical Operations, and was placed on immediate suspension for failure to assess, document, and report a resident change of condition as reported by (CNA) pending investigation. (Charge Nurse) will be terminated on [DATE]. In-service conducted by the Director of Clinical Operations on [DATE] and [DATE], The in-service included, Failure to Assess, Failure to Notify and Failure to document change in condition. 1.Resident assessment of change in condition 2. Notifying/reporting change of condition immediately to physician, family and Director of Nursing/ADON. 3. Documentation of change in condition. 4.Use of Stop and watch (tool sheet) to notify of change of condition 5.Training on the use of 24-hour report 6. Use of SBAAR (tool sheet) to notify of change of condition Interviews on [DATE] from 9:00 AM till 3:30 PM revealed the ADON, MDS coordinator, LVNs Q, S, U and V and RNs W and X and the DON; and CNAs P, R, E, K, T, and C, representing all three shifts, management, and weekend staff, all had training on a change of condition, who to notify of the change of condition, nurses will note the documenting changes of condition and promptly notifying the family, physician and nursing leadership/DON. Review of the twenty-four-hour report for [DATE] and [DATE] revealed the day shift, evening shift and night shift nurses had documented all changes in resident's conditions and the family, physician and the DON were notified of the changes. Review of the facility's discharge list and room rounds dated [DATE] and [DATE] for all shifts revealed no discharges related to change of condition and residents' changes of condition were documented. In an interview with the Administrator on [DATE] at 10:15 [NAME]M. revealed she revealed she supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting and by meetings, daily, with the DON. She talked with the DON multiple times a day. She understood the IJ occurred due to lack of notification to the physician and family of the significant change in status for the resident, causing a delay in appropriate treatment. Interview with the DON on [DATE] at 1:15 P.M. revealed there was a failure to notify the physician, DON, and family for of the significant respiratory change in condition for Resident #2. The DON stated she was not notified of the significant change in condition for Resident #2. This failure was addressed with in-service and would be evaluated by monitoring the twenty-four-hour reports and making rounds with follow up. While the Administrator was informed the IJ was lifted on [DATE] at 6:11 P.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at the scope of isolated because the facility was still monitoring the plan of removal.

Based on interview and record review the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, for one (Resident#2) of six Residents reviewed for Quality of care. 1. LVN A failed to document and assess Resident #2's respiratory status after being informed by MD N that the resident was experiencing continuous coughing on [DATE]. 2. LVN A failed to notify Resident #2's primary care physician, the DON, and the family of a change in condition of respiratory status when the resident experienced a chronic cough on [DATE] that was reported to her by MD N. 3. LVN A failed to assess Resident #2's condition or notify the DON after being notified again by MD N that Resident #2 was continuing to experience a significant cough on [DATE]. MD N intervened and notified the resident's primary care physician instead. The resident was discharged to the hospital on [DATE] and with [DIAGNOSES REDACTED]. The resident expired in the hospital at 6:24 AM on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:15 P.M. While the IJ was removed on [DATE] at 6:11 P.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at the scope of isolated because the facility was still monitoring the plan of removal. These failures could affect residents by placing them at risk for delay in appropriate treatment, [MEDICAL CONDITION], and death. Findings included: Review of Resident #2's MDS assessment dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with primary [DIAGNOSES REDACTED]. The resident was alert, with cognitive impairment and had a weight of 134 pounds. Review of Resident #2's care plan dated [DATE] revealed Resident #2 required alternative nutrition due to dysphagia potential for possible problems due to [DEVICE] placement (tube inserted through the abdomen that delivers nutrition directly to the stomach.). Interventions included to monitor for signs of respiratory distress. The care plan reflected the resident was, At risk for choking and aspiration due to swallowing difficulties, currently NPO, Goal: resident will have no signs or systems of aspiration. An interview on [DATE] at 8:47 [NAME]M. with MD N revealed she observed Resident #2 continuously coughing during her visit on [DATE]. She stated she reported his coughing to LVN [NAME] She stated LVN A replied, he has a productive cough. MD N returned on [DATE] and Resident #2 was cooperative, but his alertness fluctuated. He was unable to hold a pencil and he was observed to still be coughing. She decided to postpone further testing until his medical condition improved. MD M was at the facility and she spoke with MD M about his status. Review of MD N's progress note for Resident #2, dated [DATE] revealed: (Resident #2) was evaluated in his room .He was cooperative, but his alertness fluctuated. He displayed severe impairment in mental status. He was unable to recall the day of week, date, place, or time .He was unable to hold a pencil .He was observed to be coughing. It was decided to postpone further testing until any possible medical factors for his current presentation were ruled out. Spoke with (MD M) about his status. She was at the facility and evaluated (sic) him. She was ordering a chest x-ray and labs. An interview with MD M on [DATE] at 12:30 PM revealed on [DATE] at appropriately 12:00 PM, MD N approached her while in the facility and informed her of Resident #2's change of status. She immediately assessed him, and he had increased confusion, sweating, coughing and chest congestion. She immediately ordered a chest x-ray, laboratory test and antibiotics. She asked LVN A how long it had been since the resident experienced a change in condition and LVN A replied, two or three days. MD M revealed she had not been notified of the change in condition in his mental or respiratory status. She stated she expected to be notified when there was any change of condition for evaluations and treatment, if necessary. Review of MD M's progress note dated [DATE] revealed, follow-up cough, altered mental status, .appears confused, having cough, chest congestion, productive cough, symptoms started 2 days back per nursing, also has low grade fever .chest x-ray rule out Pneumonia . Review of Resident #2's physician orders [REDACTED]. Review of Resident #2's Radiology Results dated [DATE] revealed, Impression: consider exclusion of bilateral [MEDICAL CONDITION] metastatic [MEDICAL CONDITION]. Disseminated fungal or bacterial pneumonia is not excluded . Review of Resident #2's hospital record revealed he was admitted to the ER (emergency room ) on [DATE] at 8:23 P.M. with [DIAGNOSES REDACTED].) Date of Discharge: Patient pronounced dead on [DATE] at 6:24 AM. Review of Resident #2's nurse's notes dated [DATE] revealed LVN A did not assess Resident #2's respiratory status on [DATE] and she did not notify the physician or family of a change of condition/coughing. An interview on [DATE] at 3:30 PM with LVN A revealed she worked Monday through Friday. LVN A said she was not aware of Resident #2's cough on [DATE]. When asked about his condition on [DATE], she replied, I only see (Resident #2) around 6:00 AM to get his blood sugars and he is asleep. Then I see him again around 11:00 (AM) to flush his feeding tube. I did not notice a change in his condition. Later, (MD N) asked me to go and assess him because he was coughing. She stated she went to his room and asked him to cough. She denied listing to his lungs and stated he was always confused, and that symptom was nothing out of the ordinary. She continued to state that MD M saw Resident #2 on [DATE], ordered a chest x-ray and laboratory work. She called MD M with the x-ray results and the resident was transferred to the hospital. An interview with on [DATE] at 11:55 [NAME]M. with CNA C revealed she believed it was about three or four day before he was transported to the hospital when she had reported to LVN A that, Resident #2 was coughing and it sounded like mucus in is throat, a fluid like cough, and he did not act like he felt good; just really quite not his usual self. An interview on [DATE] at 10:50 [NAME]M. with the DON revealed she was not aware Resident #2 had been coughing and not been notified of a change of condition. The DON's expectation was to be notified of all changes of condition with any resident, and the physician and family should also be notified. Review of facility's undated policy Change in Resident's Condition reflected: undated: A significant change in a resident's condition is defined as deterioration or marked improvement in the health, mental, or psychosocial status .The nurse needs to contact the provider for conditions such as below not limited to: 1. Significant change in the resident's condition . As a significant change in the resident's condition occurs, the charge nurse will notify the physician and family of the significant change in a timely manner . 2. Documentation regarding the change of condition is documented in the residents record as to date, time, all pertinent observation noted, all unusual information obtained from the complete physical and mental assessment done, and accurate record of all intervention initiated including date and time of notification of physicians and responsible party. The Administrator, DON and Corporate Nurse were notified on [DATE] at 1:15 P.M. that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 6:11 PM and included: .1. Starting on [DATE] the oncoming and outgoing charge nurse will visually make rounds at the end of their shift and document findings. 2.The DON or designee and identified licensed nurse will round on the residents twice every shift. 3. The identified nurse will round on the night shift. 4.the charge nurse will notify the DON, designee, family and physician immediately when there is a change in condition. (LVN A) was interviewed by the Administrator, Director of Nursing and Director of Clinical Operations, and was placed on immediate suspension for failure to assess, document, and report a resident change of condition as reported by (CNA) pending investigation. (Charge Nurse) will be terminated on [DATE]. In-service conducted by the Director of Clinical Operations on [DATE] and [DATE], The in-service included, Failure to Assess, Failure to Notify and Failure to document change in condition. 1.Resident assessment of change in condition 2. Notifying/reporting change of condition immediately to physician, family and Director of Nursing/ADON. 3. Documentation of change in condition. 4.Use of Stop and watch (tool sheet) to notify of change of condition 5.Training on the use of 24-hour report 6. Use of SBAAR (tool sheet) to notify of change of condition Interviews on [DATE] from 9:00 AM till 3:30 PM revealed the ADON, MDS coordinator, LVNs Q, S, U and V and RNs W and X and the DON; and CNAs P, R, E, K, T, and C, representing all three shifts, management, and weekend staff, all had training on a change of condition, who to notify of the change of condition, documenting changes of condition and promptly notifying the family, physician and nursing leadership/DON. Review of the twenty-four-hour report for [DATE] and [DATE] revealed the day shift, evening shift and night shift nurses had documented all changes in resident's conditions and the family, physician and the DON were notified of the changes. Review of the facility's discharge list and room rounds dated [DATE] and [DATE] for all shifts revealed no discharges related to change of condition and residents' changes of condition were documented. In an interview with the Administrator on [DATE] at 10:15 [NAME]M. she revealed she supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting and by meetings, daily, with the DON. She talked with the DON multiple times a day. She understood the IJ occurred due to lack of notification to the physician and DON of the significant change in status for the resident, causing a delay in appropriate treatment. Interview with the DON on [DATE] at 1:15 P.M. revealed there was a failure to notify the physician, DON, of the significant respiratory, and failed to assess his respiratory status when there was a change in condition for Resident #2. The DON stated she was not notified of the significant change in condition for Resident #2. This failure was addressed with in-service and would be evaluated by monitoring the twenty-four-hour reports and making rounds with follow up. While the Administrator was informed the IJ was removed on [DATE] at 6:11 P.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at the scope of isolated because the facility was still monitoring the plan of removal.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of seven residents reviewed for accident hazards. 1. The facility failed to implement their elopement/wandering policy which resulted in Resident #1 eloping through his window on 11/19/18 and again on 11/20/18. 2. The facility failed to report Resident #1's elopement from the facility on 11/19/18 due to the resident being found in the parking lot, even though the resident eloped from the secured unit and was severely cognitively impaired. An Immediate Jeopardy (IJ) was determined to have existed from 11/19/18 to 11/26/18. The IJ was lifted on 11/26/18 because the facility had implemented alarms on the windows to prevent Resident # 1 from elopement. While the IJ was lifted on 11/26/18, the facility remained out of compliance at an isolated level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy. Findings included: Review of Resident #1's [DIAGNOSES REDACTED]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Risk of Elopement/Wandering Review, dated 04/18/18, reflected the resident was at risk for elopement/wandering. The section Potential Interventions had no possible interventions listed. Review of Resident #1's quarterly MDS assessment, dated 10/15/18, reflected the resident had severe cognitive impairment with no behaviors directed at others. The MDS described the resident as having wandering behaviors, and he was independently ambulatory, requiring only supervision. Review of the Care Plan, dated 05/10/18, reflected Resident #1 was at risk for elopement and wandering related to a history of wandering and a [DIAGNOSES REDACTED]. Interventions to provide a structured environment and daily activities were included. Review of incident report dated 11/19/18 at 4:15 p.m. reflected Resident #1 was observed wandering into others room. The resident was redirected to his room. The resident was brought in the unit front door, and it was noted the resident was found in a car in the parking lot. Review of the nurse's note for Resident #1, dated 11/19/18 at 4:32 p.m. and written by MDS RN O, reflected Resident #1 was sitting in a staff member's car with his seatbelt on. The resident was assisted from the car and returned to the facility. Assessed the environment of the resident's room and noted the window was open with the screen on the ground. Review of an incident report dated 11/20/19 at 1:36 p.m. and documented by LVN D reflected the LVN went to the resident's room shortly after he finished his meal. She observed the window blinds up and the window open. An outside search was initiated with Resident #1 being located 20 minutes later. Review of the Care Plan, initiated 11/29/18, reflected Resident #1 was an elopement risk/wanderer with history of attempts to leave the facility unattended. Resident #1 left the faciity on [DATE] but had no reference to his elopement on 11/19/18. Interventions included, patient in secured unit with alarm, safety alarm added to windows in patient's room and urine collected for possible urinary tract infection. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: . There were no preferences listed for the activities. Review of the Resident #1's medical record reflected no activity assessment or documented interests to correspond with the care planned interventions which would distract the resident from wandering. Observation of the Resident # 1 revealed he had no wandering behaviors. An interview was attempted but Resident # 1 smiled and did not respond to interview questions. Interview with MDS RN O on 01/22/19 at 12:08 p.m. revealed corporate staff was leaving the facility when she noted a man was in her car. The corporate staff reported to MDS RN O there was a man in her car. MDS RN O said she exited the building, and as she approached the car, she recognized the man as Resident #1. He was in the passenger side of her car with the seatbelt on. She said she was unsure if they anyone knew he was missing, but elopement protocol was not followed which included announcing Code Green over the public announcement system. She said they found the resident at approximately 4:15 p.m., but it was approximately 4:30 p.m. when they returned him to the building because they had difficulty getting him to return to the building. Interview with CNA I on 01/25/19 revealed he had worked on 11/19/18, the day of Resident #1's first elopement. He said he had never been told to keep Resident #1 on one-to-one supervision. CNA, I said he had never completed an elopement/wandering form. Interview with LVN L on 01/23/19 at 3:20 p.m. revealed she did not know Resident #1 was missing on until staff returned him to the building. Interview with CNA K on 01/25/19 at 1:23 p.m. revealed she worked 11/19/18 and 11/20/18, days when Resident #1 eloped through his window. She said she was never told about the resident's first attempt on 11/19/18. The CNA said the staff in the secured unit did not know Resident #1 was missing until the receptionist came to retrieve help to return the resident to the secured unit. CNA K confirmed she was never told to keep Resident #1 on one-to-one supervision, but she was told to complete 30 minute checks on the resident. She did not know what an elopement/wandering form was. Interview with LVN D on 01/23/19 at 1:15 p.m. revealed she was working on 11/20/18 when Resident #1 eloped. LVN D explained Resident #1 had finished his meal early and she told him told him to go to the bathroom, so the resident went toward his room. LVN D went to check on the resident, and when she went to his room she noted the window was open and the screen had been removed, so she knew he had eloped through the window. The key track stop had been removed, and she could see it outside the window. Resident #1 had removed it the night before and eloped through the window; however, the staff replaced it and it had been on the window the morning of 11/20/18. According to the LVN, they had been checking on the resident every ten minutes. A follow-up interview with LVN D on 01/23/19 at 1:49 p.m. revealed the resident was gone approximately 30 minutes before he was returned to the facility. Interview with the DON on 01/22/19 at 9:17 a.m. revealed Resident #1 was on the secure unit at the times of his elopements. The DON said the resident constantly checked the doors on the unit, and he has had attempted to go out the window. Prior to his elopement on 11/20/18, he removed a key track stop by removing a screw which kept the key track lock secure. This device had been placed on the window to keep it from being opened more than four to six inches. By removing the key track stop, Resident #1 was able to open the window, remove the screen and leave the building. Before this incident occurring on 11/20/18, he had been witnessed in the courtyard trying to climb the fence, but he was unsuccessful; however, she had no time or date for the incident. Alarms were placed on his windows the week following the incidents. The day of the 11/20/19 incident, Resident #1 had finished his meal and began wandering through the unit. He went into his room. Following the meal, the aides went into his room and noted the resident was not in his room. She said the resident was located outside of the facility approximately one-half mile away from the facility. Interview with Resident #1's Family Member on 01/22/19 at 1:44 p.m. reflected she had taken the resident out on pass 11/15/18 and 11/17/19, prior to his elopement. The Family Member said following the resident's first elopement, on 11/19/18, the facility provided no intervention for Resident #1 except to replace the key track stop which he had removed on 11/19/18 so he could not open the window fully. The Family member said on 11/20/18, Resident #1 again removed the key track stop and left the facility through the window. She said Resident #1 was issued a letter for immediate discharge, though the Family Member asked the facility if they would give Resident #1 time to settle down again following his visit to his home. The facility refused. She said the letter stated the facility did not have a memory care unit, and they had physician's orders [REDACTED]. The facility did not have an order from the physician, but only a recommendation, and she thought the facility did have a memory care unit and that was where the resident was residing. They had placed alarms on the windows after the second elopement, and he had no more elopements since the alarms were connected. Interview with the SW on 01/23/19 at 12:27 p.m. revealed following Resident #1's elopement 11/20/18, she placed screws in the bottom track of the resident's windows, so they could not be opened. The SW added that she also placed screws in the windows in room [ROOM NUMBER] and room [ROOM NUMBER] as staff reported to her that those were the rooms where he wandered. Review of the floor plan for the facility, dated 05/08/13 reflected seven rooms with windows which opened to the unsecured area outside of the facility. Interview with the Maintenance Director on 01/23/19 at 3:20 p.m. revealed he was on vacation at the time of the Resident #1's elopements. He said he returned the following Monday, 11/26/18, and placed alarms on the windows of the secured unit windows which faced the unsecured area of the premises. Review of the in-service record, dated 11/20/19, was held on elopement drills. Follow-up interview with the DON on 01/25/19 at 1:53 p.m. revealed she had no knowledge of an elopement/monitoring form. 1. The facility failed to implement their elopement/wandering policy which resulted in Resident #1 eloping through his window on 11/19/18 and again on 11/20/18. 2. The facility failed to report Resident #1's elopement from the facility on 11/19/18 due to the resident being found in the parking lot, even though the resident eloped from the secured unit and was severely cognitively impaired. Policy for Elopement/Wandering, undated, revealed it is the policy of this facility that each resident receives adequate supervision and assistance devices to prevent accidents. The procedure includes evaluating the resident for exit seeking risk on admission utilizing the Risk of Elopement/Wandering review. If a resident is evaluated for elopement, complete the Elopement/. monitor form to account for the resident's location every two hours. Initiate the behavior monitoring form with the behavior wandering to monitor the residents wandering behavior. If the resident was actively exit seeking or had eloped from the facility regardless of how the resident exited the facility, implement the One on One Policy and Procedure. If a resident is not able to be located immediately implement the Elopement Policy and Procedure. Review of the policy for One to One Observation, undated, reflected one-to-one supervision required a resident was never out of the sight from the staff. The resident who was on one-to-one supervision should always be accompanied by the staff member, including bathing, showering, shaving and toileting. Observation of all residents (including Resident # 1), interviews with staff, review of physician orders [REDACTED]. An Immediate Jeopardy (IJ) was determined to have existed from 11/19/18 to 11/26/18. The IJ was removed on 11/26/18 because the facility had implemented alarms on the windows to prevent Resident # 1 from elopement. While the IJ was removed on 11/26/18, the facility remained out of compliance at am isolated level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible, for one (Resident #2) of six residents reviewed for weight loss. The facility failed to intervene when Resident #2 had a significant weight loss of 10.9 percent. This failure could affect residents by placing them at risk for delay in appropriate treatment, malnutrition, and dehydration. An IJ was determined to exist from 10/10/18 to 12/31/18. The IJ was removed on 12/31/18 when Resident # 2 was sent to the hospital and no longer resided in the facility. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy. Findings included: Review of Resident #2's MDS discharge assessment dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with primary [DIAGNOSES REDACTED]. The resident was alert, with cognitive impairment. a weight of 134 pounds Review of Residents # 2's weight record revealed: 8/31/18 weight -150.7 lbs., 10/10/18 weight- 136.6 lbs., 12/05/18 weight 134.3 lbs. (10.9 percent change from 8/31/18 to 12/05/18, a 16.4 lb weight Loss) Review of Resident #2's physician's orders [REDACTED]. times 22 hours . Resident #2's MDS 5-day assessment, dated 8/24/18, reflected the resident's weight was 151 pounds. Review of Resident #2's care plan dated 09/14/18 revealed: Resident #2 required alternative nutrition due to dysphagia potential for due to [DEVICE] placement. Goal: resident will have no signs or systems of aspiration. Weigh resident monthly and prn and report significant changes to physician. Review of Resident #2's MD M ordered laboratory test the results reflected: 08/21/18 the CMP results revealed, Total Protein low 5.9, (reference range 6.4-8.9) and, [MEDICATION NAME] low 3.0 (reference range 3.5 -5.7) 08/23/18 the CMP results revealed, Total Protein low 5.8 and [MEDICATION NAME] low 3.0 09/11/18 the CMP results revealed, Total Protein low 5.8, and [MEDICATION NAME] low 3.1 10/30/18 the CMP results revealed, Total Protein low 5.8, and [MEDICATION NAME] low 3.1 12/19/18 the CMP results revealed, Total Protein low 5.7, and [MEDICATION NAME] low 3.2 Review of consultant RD's Nutritional Monitoring Flow sheet reflected: 08/18/19 revealed Recommendations: d/c current TF regimen, start [MEDICATION NAME] at 75 ml/hr. x22 hours . Rational: TF clarification, Initial enteral nutrition assessment completed. 10/15/18 Recommendations: weekly weight x4, Rational: greater than 7.5 percent weight lose . 11/30/18 Recommendations: none, Rational: Quarterly nutrition assessment completed. 12/20/18 Recommendations: none, Rational: greater than 10 percent weight loss . Observation, review and interview on 01/22/19 at 4:11 PM with ADON B of the weight binder at the nurse's station revealed there were no weight sheets in the binder. ADON B asked CNA K where the weight sheets were? LVN Q and the ADON B stated they would look for the weight sheets. They did not know why the weight sheets were not in the binder. An interview on 1/23/18 at 8:45 AM with RD revealed she was aware of Resident#2's weight loss and she had reported the weight loss to the charge nurse, unable to recall which charge nurse, caring for Resident #2 at that time. She stated she did not make any nutritional recommendation related to the weights not being in the weight binder at the nurse's station and not being documented in the nurses' notes, and labs not being entered into the computer system at the time of her visit. She stated she had a meeting with the DON and Administrator on 11/29/18 to address the weights and labs not being available at the time of her visits. An interview with MD M on 01/22/19 at 12:30 PM revealed she was not aware of Resident #2's significant weight loss, and she was not made aware of his abnormal laboratory tests because the facility never notified her. She stated she expected to be notified when there was any change of condition for evaluations and treatment and testing if necessary. An interview on 01/22/19 at 4:15 PM with the DON revealed she was not aware of Resident #2's weight loss. The DON stated she realized there were issues related to weights prior to the surveyor entering the building. The DON stated she implemented a plan to address the issue. She stated CNA K weighed the residents on the first Monday and Tuesday of the month. CNA K reported a weight loss of three pounds or gain of five pounds to the charge nurse. The charge nurse was to notify the physician of the change of weight. There was a weight binder at each nurse's station for weight sheet. The charge nurses were to document the weights in a computer software system. The weights were not being entered correctly and she now entered the weights into the computer system. In (MONTH) (YEAR) the RD reported the weights were not being entered into the software system. In November, the facility had a meeting with the ADM and Clinical District Coordinator and addressed weight management, and the changes had been implemented and the staff was educated and in-services on weight management. Interview on 01/22/19 at 1:15 PM with CNA K revealed she weighed the residents on Monday and Tuesday of each month. She reported the weights to the charge nurses, and the weight sheets were put into a binder at the nurse's station. Interview on 01/22/19 at 3:30 PM with LVN A revealed CNA K weighed residents on Mondays and Tuesdays of each month and the weights were given to the ADON B, and she notified the physician if needed. The weight sheets were put into a binder at the nurse's station Interview on 01/22/19 at 3:55 PM with LVN Q revealed CNA K weighed residents on Mondays and Tuesdays of each month and gives the weight list to the ADON. She would research if the weight was in question and she would have the resident re-weighed, and the nurses were delegated to call the nutritionist and physician, or the ADON would call herself. The weight sheets were put a binder at the nurse's station. An interview on 01/22/19 at 4:05 PM with ADON B, stated I am out of the loop, I don't have anything to do with the resident's weight. An interview on 01/23/19 at 10:00 AM with the Administrator revealed she was not aware of Resident #2's significant weight loss. She stated in (MONTH) 2019 the facility had a meeting with the RD, DON and Clinical District Coordinator to addressed weight management and the changes have been implemented and the staff was educated and in-services on weight management. Review of facility's policy Change in Resident's Condition, undated, reflected: A significant change in a resident's condition is defined as deterioration or marked improvement in the health, mental, or psychosocial status .The nurse needs to contact the provider for conditions such as below not limited to: 1. Significant change in the resident's condition . As a significant change in the resident's condition occurs, the charge nurse will notify the physician and family of the significant change in a timely manner . 2. Documentation regarding the change of condition is documented in the residents record as to date, time, all pertinent observation noted, all unusual information obtained from the complete physical and mental assessment done, and accurate record of all intervention initiated including date and time of notification of physicians and responsible party. Review of the Weight Loss Policy, undated, revealed, It the policy of this center to have residents weighed at admission, readmission, and per physician orders. Weekly weight are completed for an additional 3 weeks (or longer if not stable) on the following: .Significant weight loss of 5 percent or more in 1 month or less. Observation of residents, interview of staff and review of weights, dietary recommendations, physician orders [REDACTED]. An IJ was determined to exist from 10/10/18 to 12/31/18. The IJ was removed on 12/31/18 when Resident # 2 was sent to the hospital and no longer resided in the facility. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for adequate supervision and assistance devices. 1. CNA D failed to follow fall precautions when she did not put the bed in the lowest position or position the fall mat correctly on 09/16/17 for Resident #1.Resident #1's fall on 09/16/17 resulted in a hematoma. 2. The facility failed to follow their Fall Prevention policy and procedure for Resident #1 after he suffered a fall with injury on 9/16/17. 3. The facility failed to implement physical therapist recommended assistive devices to prevent falls for Resident #1 following a fall from his bed on 09/16/17. These failures placed the 26 residents with a history of falls at risk for further falls and injuries. Findings included: Resident #1's Care Plan, dated 04/18/17, reflected the resident was at high risk for falls. The facility approaches to prevent injury related to falls included: 1. Fall risk assessment on admission, re-admission, and quarterly. 2. Evaluation of use of side rails, low bed, or personal alarm. There were no specific fall interventions care-planned for the resident. Resident #1's MDS assessment, dated 07/12/17, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a reentry date of 02/15/17. The resident's [DIAGNOSES REDACTED]. He had no previous falls and required the extensive assistance of two staff for bed mobility and transfers. The resident's cognitive status was moderately impaired. Resident #1's Physician Orders, dated 03/20/17, reflected: 1. Safety Devices= 1/4 side rails up when in bed as an enabler to potentiate independence with bed mobility. Resident #1 did not have a Falls Assessment on admission or following his fall on 09/16/17 available for review in his medical record. Resident #1's Facility Investigation Report, dated 09/20/17, and signed by the DON reflected the resident fell after he attempted to get out of bed by himself on 09/16/17. On 09/17/17 the resident was sent to the hospital for evaluation and a cat scan of the head after facility x-rays completed on 09/16/17 reflected the resident might have a fracture. The hospital evaluation revealed the resident had a small hematoma on his right, frontal scalp. (Bruise with swelling on the resident's forehead). The facility conclusion was that the resident attempted to get out of bed and caused his fall event. Resident #1's Incident Report, dated 09/16/17 at 9:55 p.m., reflected the aide called the nurse because she saw the resident on the floor. When the nurse arrived, the resident was on the floor lying on his right side. The resident was assessed and had a raised area on the right side of his forehead. The report indicated the resident was attempting to self-transfer at the time of the fall. Resident #1's Physician Communication Note, dated 09/16/17, and signed by LVN A, reflected the resident had a skull x-ray series ordered. The x-ray series was negative for fracture. Resident #1's Physical Therapy Evaluation, dated 09/22/17, and signed by PT B, reflected the resident fell out of bed by rolling out due to his wedges not being properly placed. The Resident was referred to skilled physical therapy to improve sitting balance, safety awareness, resident and caregiver education, and strengthening. Physical Therapy Safety Goal- Current Level of Function: The resident and caregivers demonstrate severely impaired safety awareness and require 90% verbal instruction/cues for proper positioning of foot wedges, body wedge, and floor mat to prevent falls. Goal: The caregiver will increase safety awareness to perform proper bed positioning to decrease the risk of falls. To be completed by 10/06/17. Resident #1's Physical Therapy In-service, dated 10/10/17, and signed by PT C reflected the resident was to be positioned in bed with: a wedge to float his heels, a wedge at the right side of his trunk and hip, and the bed was to be lowered with a fall mat in place. CNA D was the only staff listed as in-serviced. Resident #1's Bed B Green form, not dated, received from the DON on 10/16/17 at 4:00 p.m., reflected the resident required placement of wedges while supine and a fall mat to prevent falls. The DON reported the form was posted in the resident's closet for staff to refer to. An observation of Resident #1 on 10/16/17 at 9:30 a.m. revealed he was in the dayroom in his wheelchair. He had a raised area on his right frontal scalp. The resident was non-verbal, but able to respond to questions by blinking his eyes. A series of questions revealed the resident was not able to answer questions appropriately. An interview with LVN F on 10/16/17 at 9:35 a.m. revealed Resident #1 had a history of [REDACTED]. She reported the resident was supposed to have a wedge placed on his right side when he was in bed, but the resident was able to pull the wedge out. She reported the resident would forget he could not walk and would remove the wedge to get out of bed. LVN F reported she thought maybe the resident had pulled out the wedge the night of his fall on 09/16/17. An interview with the MDS Nurse on 10/16/17 at 12:00 p.m. revealed she was responsible for updating the care plans for Resident #1. She stated she still needed to update his care plan related to his fall on 09/16/17 and planned to do it on 10/16/17. The MDS Nurse stated she did not know what measures were in place to prevent his falls and would have to check his care plans. She reported the nurses were responsible for doing a new care plan anytime a resident had a fall. An interview with the DON on 10/16/17 at 12:15 p.m. revealed staff had been in-serviced regarding fall management for all residents after Resident #1 fell on [DATE]. The DON stated the MDS Nurse was responsible for care plan updates and staff nurses were responsible for completing interim care plans when needed. The DON reviewed Resident #1's care plan and was unable to show what specific measures where previously or currently in place for the resident, but did state the resident had a care plan to prevent falls. The DON reported physical therapy services were discontinued for Resident #1 on 10/12/17. An interview with CNA D on 10/16/17 at 12:50 p.m. revealed on 09/16/17 she had checked on Resident #1 at 8:00 p.m. and changed his brief. She reported the fall prevention measures in place for the resident were staff was supposed to put his bed all the way down, raise his side rail, and place his fall mat. CNA D revealed the resident had a foam wedge in his room but she did not use it the night of the fall because she did not know she was supposed to. CNA D stated she had observed the wedge used before when the resident was in bed. CNA D reported she had not received any in-services indicating a wedge was required to prevent falls when the resident was in bed. She stated on the night of his fall, she put his bed all the way down, raised his side rail, and placed his fall mat. She stated she went to lunch and when she returned, she was told the resident had fallen out of bed and the nurse found the resident. CNA D reported she did not think the resident was able to get out of bed by himself, but she was aware the resident had rolled out of bed by himself before. An interview with LVN A on 10/16/17 at 1:10 p.m. revealed when he entered the room of Resident #1 on the night of 09/20/17, the resident was on the floor. He was not on the fall mat because it was folded up close to his head. The bed was not in the lowest position, but his side rail was up. LVN A stated the resident would try to get out of bed by himself when his brief was soiled. An interview with PT B and PT C on 10/16/17 at 1:25 p.m. revealed staff were supposed to put wedges on the right side of Resident #1 to prevent falls out of bed. PT B reported she was told by LVN F that the wedge was not in place at the time of his fall on 09/16/17. PT B stated staff were educated on physical therapy recommendations through in-services, and if an in-service could not be completed, it was given to the ADON or DON to finish. PT C revealed she in-serviced only one staff on the physical therapy recommendations for Resident #1 on 10/10/17, because there was only one staff available. She reported she did not notify the ADON or the DON about the in-service. PT B and PT C stated further in-services and evaluations were not completed because the resident's insurance, Medicaid, denied payment for further physical therapy visits. An observation of Resident #1 on 10/16/17 at 2:30 p.m. revealed he was in bed with his siderail up. The left side of the bed was against the wall. There was a fall mat on the floor, but the bed was not low to the ground. There was a wedge under his legs, but there was not a wedge on his right side. There was not a green sign posted in his room. An interview with CNA G on 10/16/17 at 2:40 p.m. revealed she was assigned to Resident #1. CNA G revealed the resident was supposed to have a wedge placed on his right side, the bed was supposed to be low to the ground, the fall mat was supposed to be on the floor and he was supposed to be positioned on his left side when he was in bed. CNA G stated she did not know why the bed was not lowered at that time, because the bed was able to be lowered. CNA G reported she only placed the wedge on his right side when he was ready to go to sleep, because he would try to remove it otherwise. An interview with the DON on 10/16/17 at 2:15 p.m. and 3:40 p.m. revealed the resident was supposed to have a fall mat and a wedge under his heels to prevent falls out of bed. She reported staff was supposed to complete a fall risk evaluation when a resident was admitted and after a fall, but she could not locate the fall risk assessment for Resident #1. The DON reported the staff were supposed to review the green sheet posted in resident rooms in order to see what measures were in place for the resident to prevent falls. The facility's current Fall Prevention Policy, not dated, reflected the following: A fall risk assessment should be completed within 24 hours of admission .and after each fall. A care plan for fall risk management and injury prevention should be implemented. The facility's, undated Roster/Sample Matrix Form CMS-802, provided by the DON a current on 10/16/17, reflected 26 had a history of [REDACTED].

Based on interview and record review, the facility failed to implement policies and procedures that prohibited neglect for one (Resident #1) of 10 residents reviewed for neglect. 1. LVN F failed to assess Resident #1 at 11:30 AM on [DATE] when CNA I told her the resident was lethargic, unresponsive, and could not get up for her lunch meal. 2. RN C failed to immediately start CPR when she determined Resident #1 was unresponsive and did not have a pulse on 6:30 PM on [DATE]. RN C left Resident #1 in her room and went to get another staff member to assist. CPR was not initiated on Resident #1 until 6:40 PM at [DATE] by LVN E. As a result, Resident #1 was transported to the hospital by the paramedics on [DATE] and expired that same evening in the hospital. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect 64 residents who were full code status, by placing them at risk for not receiving assessments and CPR immediately and further life-saving treatments as desired, which could result in death. Findings Included: Review of Resident #1's face sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was discharged on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Discharge Summary dated [DATE] reflected Resident #1 was discharged to the hospital and expired at the hospital on [DATE]. Review of Resident #1's clinical chart reflected a green sheet stating Resident #1 was full code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning she wanted all life-saving measures to be taken if she was found unresponsive). Review of Resident #1's telephone orders for [DATE] reflected Resident #1 was full code status. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 3 indicating she was severely cognitively impaired. Resident #1 required extensive assistance with most ADLs. Review of Resident #1's nurses' note, dated [DATE] at 11:30 AM by LVN F, indicated CNA I reported Resident #1 was extremely lethargic, which was normal for a resident after [MEDICAL TREATMENT]. CNA I was unable to take Resident #1 to the dining room to eat. LVN F told CNA I to leave the resident in bed and the LVN would get her tube feeding. Note from 11:30 AM to 2:00 PM by LVN F reflected no other concerns noted. Resident #1 remained in bed. No signs/symptoms of distress noted. Hand off to on-coming nurse at 2:00 PM. The nurse's note revealed no evidence of Resident #1's assessment. In an Interview on [DATE] at 11:01 AM, LVN F denied Resident #1 being her resident after 6:00 AM and recalled CNA I telling her after Resident #1 returned from [MEDICAL TREATMENT] that Resident #1 was not coherent, lethargic, and unable to get her out of bed for lunch. LVN F stated she did not go assess Resident #1 and told CNA I Resident #1 would get her tube feeding. LVN F stated she told LVN W to go give Resident #1 her feeding, but did not tell him about Resident #1 being lethargic or unable to go to the dining room for lunch. Review of LVN F's Job description as a Charge Nurse - LVN undated paperwork reflected to assess for and notify physician and other appropriate parties of changes in condition. In an Interview on [DATE] at 11:47 AM CNA I stated she checked on Resident #1 after she got back from [MEDICAL TREATMENT] during the lunch and Resident #1 was lethargic (barely opened her eyes) and would not get up out of bed for lunch. CNA I stated she immediately informed LVN F about Resident #1 being lethargic and not wanting to get up out of bed to eat lunch and LVN F told her we will feed her by her [DEVICE]. CNA I stated LVN F did not get up to go assess Resident #1. CNA I stated she continued checking on her other residents. CNA I stated LVN W was at the nurse's station too but did not acknowledge her so not sure LVN W heard what she said about Resident #1. CNA I stated she should have informed another nurse of Resident #1's change of condition or informed the Weekend RN Supervisor since LVN F did not go assess Resident #1. In an Interview on [DATE] at 11:20 AM, LVN W stated he worked on [DATE] on 200 hall but could not recall who Resident #1 was. He said if he had assessed her, it would have been written down. LVN W stated he was unaware of any change of condition of Resident #1 on [DATE]. Review of Resident #1's Nurse's note dated [DATE] at 6:30 PM by RN C, indicated after bolus feeding, she changed the resident's [DEVICE] (a tube inserted through the abdomen that delivers nutrition directly to the stomach) dressing and noticed Resident #1 stopped breathing. Attempted to arouse Resident #1, patted her cheek, but she (Resident #1) was unresponsive. Sent a CNA to get another nurse to help me . Attempted to find a carotid pulse, radial pulse, apical pulse and vitals, but was unsuccessful . 911 was called at 6:35 PM, and sent for [MEDICATION NAME], Resident #1 was still warm but unresponsive. [MEDICATION NAME] administered. EMS arrived at 6:45 pm and took over resuscitation efforts. 6:55 PM, Resident #1 was resuscitated. 7:00 PM, Resident #1 was taken via stretcher, still unresponsive, to the local hospital ER via EMS. The DON was notified at 6:53 PM, daughter notified at 7:00 PM, ADON notified at 7:08 PM, Administrator notified at 7:15 PM. Physician notified at 7:10 PM. Review of Resident #1's Nurse's noted dated [DATE] by RN C indicated the local hospital called to notify the facility Resident #1 had passed at 7:35 PM. An Interview on [DATE] at 4:50 PM and 6:18 PM RN C stated she had finished Resident #1's [DEVICE] feeding and was finishing up putting a new dressing on Resident #1's [DEVICE] site when she noticed Resident #1's chest was not rising and falling, no breathing and unresponsive. RN C could not recall what specific time she noticed Resident #1 was unresponsive with no pulse. RN C stated she patted Resident #1's face and shoulder but not response. RN C stated she checked Resident #1 for a carotid, radial and apical pulse with no pulse found. RN C stated she put the call light on and went out to the hallway leaving Resident #1 and found Caregiver G in the hallway and asked Caregiver G to go get another nurse. RN C stated she knew Resident #1 was a full code and did not initiate CPR because she needed to go get another staff member to assist her and staff do not always answer call lights in a timely manner. RN C stated LVN E came back asking her what was going on and told LVN E Resident #1 was unresponsive with no pulse. RN C stated LVN E initiated CPR on Resident #1. RN C stated LVN E checked Resident #1's blood sugar which was 52 and was told by LVN E to go get [MEDICATION NAME] for Resident #1's low blood sugar. RN C stated she looked for glucose tablets in the nurse cart and could not find any. RN C stated she brought the back board to LVN E and had to go back out to find the [MEDICATION NAME]. RN C stated she found the [MEDICATION NAME] in the ER kit and put it in Resident #1's right upper thigh. RN C stated she did not do CPR on Resident #1. RN C stated she was CPR certified. An Interview on [DATE] at 4:20 PM LVN E stated Caregiver G came and got her on [DATE] at 6:39 PM when she was finishing up paperwork from an admission and looked at the clock. She stated Caregiver G told her RN C needed her help so she immediately went with Caregiver G down the hall and RN C was outside of Resident #1's room with her back to the room saying patient, patient and RN C was emotionally distraught. LVN E stated she asked RN C what was going on and she told her Resident #1 was unresponsive with no pulse. LVN E stated at about 6:40 PM (10 minutes after Resident #1 was initially found unresponsive with no pulse by RN C) LVN E got to Resident #1 who looked like she was already gone, still warm to the touch, with no pulse and unresponsive and LVN E initiated CPR on Resident #1. LVN E stated she asked RN C to go get [MEDICATION NAME] after Resident #1's blood sugar was checked which was in the 50s. LVN E stated she also asked Caregiver G to go get apple juice to put in Resident #1's peg tube. LVN E stated Caregiver G returned quicker than RN C so she put about ,[DATE] ounces of orange juice via [DEVICE]. LVN E stated she asked RN C where [MEDICATION NAME] was when she returned with the back board and RN C told her it was not in the nurses' cart when she looked so she would have to go get it. LVN E stated she stayed with Resident #1 until EMS arrived and kept sending staff out to get things for her. LVN E stated she did not see RN C give the [MEDICATION NAME]. LVN E stated she did not fill out any nurse's notes on Resident #1 since she was RN C's resident and assumed RN C had written down what happened. An Interview on [DATE] at 2:15 PM CNA H stated RN C ran down the hallway in a panic stating Resident #1 was not responding. I need help. CNA H came into Resident #1's room where Resident #1 was unresponsive and LVN F was doing CPR. CNA H stated he assisted LVN F with the CPR while RN C came in and out of room to call ambulance until EMS arrived. CNA H stated it took multiple nurses to calm RN C down. CNA H stated LVN F stayed in the room the whole time and did recall RN C giving Resident #1 an injection in her thigh. An interview on [DATE] at 8:11 AM CNA J stated RN C was frantic and LVN F started CPR on Resident #1. CNA J stated she called 911 and got the crash cart for LVN F. CNA J stated she assisted with CPR along with LVN F and CNA H on Resident #1. CNA J stated she did recall RN C giving Resident #1 [MEDICATION NAME] in her thigh. CNA J stated the Paramedics arrived, took over CPR and could not get a pulse from Resident #1 so they were on the phone with the physician about to call Resident #1's time of death when they found a weak pulse. CNA J stated they moved her to the gurney and took her to the hospital. An interview on [DATE] at 9:16 AM RN Weekend Supervisor stated he had left the facility for the day after he was notified by LVN F Resident #1 was unresponsive and no pulse, EMS called and was sent to the hospital with a weak pulse. RN Weekend Supervisor stated LVN E told him RN C was very emotional and they could not calm her down after the incident so he stated he called ADON A to go to the facility to check on her. RN Weekend Supervisor stated he was asked by the DON on [DATE] to review the chart the next day and he did noticing there was missing pieces in the documentation so he contacted the DON about it. RN Weekend Supervisor stated he and the DON interviewed RN C finding she had not put in the intervention of giving Resident #1 two sugar packets and an amount of feeding via [DEVICE]. RN Weekend Supervisor stated RN C was suspended due to her emotional status and needed additional training before returning to the floor as a charge nurse. RN Weekend Supervisor stated he was aware RN C did not do CPR but was not aware there was a delay in CPR given to Resident #1. RN Weekend Supervisor stated EMS had gotten a weak pulse per LVN F but found out later the hospital called saying it was her pacemaker and Resident #1 never had a pulse so Resident #1 expired at the hospital. An interview on [DATE] at 10:11 AM ADON A stated she was contacted by the RN Weekend supervisor to check on RN C to see if she was fit to finish her shift that evening after the incident with Resident #1 being unresponsive. ADON A stated she got immediately went to the facility and when she got there RN C was very emotional and broke down near the nurse's station. ADON A stated RN C was determined to continue working so ADON A followed her and became calm after 30 minutes of talking about what happened. ADON A stated RN C had not filled out any nurse notes about the incident and told RN C to write down in the nurse's notes what happened. ADON A stated she left the facility and RN C was thinking clearly again and able to finish her shift. ADON A stated she talked to the DON after she left the facility to let her know RN C was able to finish her shift. ADON A stated they in serviced the nurses on a code blue on [DATE] with scenario of 2 people finding a resident unresponsive. ADON A stated RN C had not been in-serviced yet and had not worked since she completed her shift on 2 pm to 10 pm shift. In an interview on [DATE] at 10:37 AM, the DON stated the RN Weekend Supervisor informed her Resident #1 had coded, was unresponsive and sent to the hospital, so she asked him to review the chart. The DON stated her concerns were about RN C's emotional distress and on Monday [DATE] she interviewed RN C about the incident. The DON stated RN C was suspended on [DATE] due to her emotional distress and had not worked since the incident. The DON stated RN C would need additional training and to shadow other nurses before returning to work on the hall by herself but no training had occurred. The DON stated she did not have concerns about RN C's delay in CPR, and she would peek out the door and get help herself too before initiating CPR. The DON stated due to RN C's emotional state it was better for her to go get help and have someone else do CPR. The DON stated when she interviewed RN C on Monday after the incident did not interview any other staff involved with the incident. The DON stated she had not looked at Resident #1's chart until [DATE]. She further stated after documentation review, she had concerns about LVN F not assessing Resident #1 on the 6:00 AM to 2:00 PM on [DATE] when CNA I told LVN F Resident #1 was sleepy and she could not get her to eat. The DON stated LVN F admitted to not assessing Resident #1 when she was informed of a change of condition and LVN F should have assessed immediately. The DON stated LVN F was suspended on [DATE] for allegation of neglect for failure to assess Resident #1. In an Interview on [DATE] at 12:52 PM, the Administrator stated the facility received a medical records request on Resident #1 from the coroner's office on [DATE]. The Administrator stated the DON had not reviewed the chart herself until [DATE] after the request for medical records. The Administrator stated she would expect RN C to initiate CPR immediately, but due to her being too emotional at the time of the incident, it was better for her to get someone else to initiate the CPR. The Administrator stated RN C was CPR certified and should have known how to handle a code blue. The Administrator stated RN C had not worked since the incident due to her emotional distress but finished her shift on [DATE]. The Administrator stated on [DATE] after discussing with the DON about LVN F not assessing Resident #1 with a change of condition they knew they needed to report it so they did on [DATE]. The Administrator stated LVN F was suspended on [DATE] and will not be coming back to the facility due to her failure to assess Resident #1. Review of LVN F's employee file reflected no termination in her chart. Review of LVN F's timecard in [DATE] reflected she worked from [DATE] to [DATE]. Review of RN C's time card reflected her last day to work was on [DATE] and had not worked since [DATE]. An interview on [DATE] at 3:58 PM the Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions. Review of facility CPR and Basic Life Support policy revised [DATE] reflected under general guidelines, .5. Depending on the underlying cause, the chances of surviving sudden [MEDICAL CONDITION] may be increased if CPR is initiated immediately upon collapse. 9. If an individual is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g. rigor mortis). The Administrator was notified on [DATE] at 1:03 PM that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 6:45 PM and included: Administrator was notified on [DATE] at approximately 1:03 pm of an Immediate Jeopardy for a) Not following CPR policy. As well as the DON interviewed RN C on Monday [DATE] about incident and chart was not reviewed until [DATE]. The following steps are the centers plan to remove the Immediate Jeopardy. 1. On [DATE], Social Service Director and Nurse Managers immediately identified all current residents in the facility that are FULL CODE and ensured a code indicator (green full code form) was placed on the resident's chart. 2. On [DATE] nursing department audit license nurses CPR Certification. All licensed nurses are CPR certified and are available within the facility 24 hours a day. 3. On [DATE] starting inservicing all staff on what to do immediately for a patient needing CPR. (Specifics in training and what they are going over with them) and how they will validate their understanding. Training includes: a. A nurse that is CPR certified will be on each shift of everyday b. Nurse 1 will upon entering the room with possible code will call out code blue in process and start CPR, Nurse 2 will bring the chart to room, when nurse two arrives they will start bagging. Nurse 1 continues chest compressions. CNA 1 will call Code Blue over intercom. CNA 2 will bring the crash cart. CNA 3 will bring the AED. Once AED arrives, Nurse 2 will apply the AED. CNA 2 will record. c. With only one nurse, (Nurse one) the nurse will pull call light cord out of wall (to get attention of staff) and yell Code Blue. Nurse 2 will bring the chart to room, when nurse two arrives they will start bagging. Nurse 1 continues chest compressions. CNA 1 will call Code Blue over intercom. CNA 2 will bring the crash cart. CNA 3 will bring the AED. Once AED arrives, Nurse 2 will apply the AED. CNA 2 will record. d. For the one Agency nurse working through [DATE] he has been inserviced to the building and code process. e. As of [DATE] all residents that are sent to the hospital will have chart reviewed by DON or ADON's f. On staffing schedule a asterisk (*) will be put beside employees that are CPR certified. g. To monitor that the employees know the system for CPR process we will implement a post test to ensure compliance. All staff will be inserviced before working the floor. h. Staff Development Coordinator will be doing the training for staff 4. Mock Code Training each shift (to ensure all staff knows how to handle a code for patients). This will be accomplished by demonstration of mock code blue. a) Review the emergency cart and AED daily b.) Skills Validation Checklist performed by [DATE]st on LVN's and RN's on AED c) New employees will be trained and educated on CPR process for residents d) Social Services Director will maintain accuracy of Code Status in the medical record e) Physician orders [REDACTED]. f) New residents upon admission will be reviewed for Code Status. Orders will be obtained and updated same day as admission. g) all employees will be inserviced and answer will be reviewed to ensure compliance with facility regulations on CPR for residents. Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The center respectfully requests the Immediate Jeopardy be removed with actions initiated on [DATE]. In an interview on [DATE] at 10:00 AM ADON B stated only one nurse on the 6 AM to 2 PM shift had been in serviced so far and were working on in-servicing the rest of the nurses and all nurses were in-serviced at 5 AM this morning for the night shift. Interviews on [DATE] from 5:15 PM to 5:45 PM revealed six of six Charge Nurses on the 2:00 PM to 10:00 PM shift (LVNs L, M, N, O, P and Q) all understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interviews with four of four 6:00 AM to 2:00 PM shift Charge Nurses (LVNs F, R, S and T) from 11:13 AM to 11:22 AM after their facility in-service revealed they understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Interviews on [DATE] from 11:20 AM to 11:24 AM, two of two Charge Nurses (LVN U and V) on the night shift both understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of the facility's list of residents who are DNR updated weekly by Social Worker was up-to-date per chart audit and placed on each crash cart. Record Review of Clinical Records for Resident #2, #3, #4 and #5 reflected the nurses assessed residents when they had a change of condition and initiated CPR immediately on Resident #2 when he stopped breathing until EMS arrived. Record Review on [DATE] of Nurses' CPR certification revealed nurses were CPR certified on all shifts starting 2 PM to 10 PM shift on Friday [DATE] to Sunday [DATE] on all three shifts. On [DATE] at 7:53 AM the ADON B was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The facility Abuse/Neglect policy undated reflected each resident has the right to be free from mistreatment, neglect and misappropriation of property. All allegations, no matter what types of incidents reported will be investigated fully. An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator. Review of facility CPR and Basic Life Support policy revised [DATE] reflected under general guidelines, .5. Depending on the underlying cause, the chances of surviving sudden [MEDICAL CONDITION] may be increased if CPR is initiated immediately upon collapse. 9. If an individual is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g. rigor mortis). The Administrator provided on [DATE] a list of 64 residents with full code status.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibited neglect for one of five investigations reviewed for investigation and reporting protocols. 1. LVN F failed to assess Resident #1 at 11:30 AM on [DATE] when CNA I told her the resident was lethargic, unresponsive, and could not get up for her lunch meal. 2. RN C failed to immediately start CPR when she determined Resident #1 was unresponsive and did not have a pulse on 6:30 PM on [DATE]. RN C left Resident #1 in her room and went to get another staff member to assist. CPR was not initiated on Resident #1 until 6:40 PM at [DATE] by LVN E. As a result, Resident #1 was transported to the hospital by the paramedics on [DATE] and expired that same evening in the hospital. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect 64 residents who were full code status, by placing them at risk for not receiving assessments and CPR immediately and further life-saving treatments as desired, which could result in death. Findings Included: The facility Abuse/Neglect policy undated reflected each resident has the right to be free from mistreatment, neglect and misappropriation of property. All allegations, no matter what types of incidents reported will be investigated fully. An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator. Review of facility CPR and Basic Life Support policy revised [DATE] reflected under general guidelines, .5. Depending on the underlying cause, the chances of surviving sudden [MEDICAL CONDITION] may be increased if CPR is initiated immediately upon collapse. 9. If an individual is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g. rigor mortis). Review of Resident #1's face sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was discharged on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Discharge Summary dated [DATE] reflected Resident #1 was discharged to the hospital and expired at the hospital on [DATE]. Review of Resident #1's clinical chart reflected a green sheet stating Resident #1 was full code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning she wanted all life-saving measures to be taken if she was found unresponsive). Review of Resident #1's telephone orders for [DATE] reflected Resident #1 was full code status. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 3 indicating she was severely cognitively impaired. Resident #1 required extensive assistance with most ADLs. Review of Resident #1's nurses' note, dated [DATE] at 11:30 AM by LVN F, indicated CNA I reported Resident #1 was extremely lethargic, which was normal for a resident after [MEDICAL TREATMENT]. CNA I was unable to take Resident #1 to the dining room to eat. LVN F told CNA I to leave the resident in bed and the LVN would get her tube feeding. Note from 11:30 AM to 2:00 PM by LVN F reflected no other concerns noted. Resident #1 remained in bed. No signs/symptoms of distress noted. Hand off to on-coming nurse at 2:00 PM. The nurse's note revealed no evidence of Resident #1's assessment. In an Interview on [DATE] at 11:01 AM, LVN F denied Resident #1 being her resident after 6:00 AM and recalled CNA I telling her after Resident #1 returned from [MEDICAL TREATMENT] that Resident #1 was not coherent, lethargic, and unable to get her out of bed for lunch. LVN F stated she did not go assess Resident #1 and told CNA I Resident #1 would get her tube feeding. LVN F stated she told LVN W to go give Resident #1 her feeding, but did not tell him about Resident #1 being lethargic or unable to go to the dining room for lunch. Review of LVN F's Job description as a Charge Nurse - LVN undated paperwork reflected to assess for and notify physician and other appropriate parties of changes in condition. In an Interview on [DATE] at 11:47 AM CNA I stated she checked on Resident #1 after she got back from [MEDICAL TREATMENT] during the lunch and Resident #1 was lethargic (barely opened her eyes) and would not get up out of bed for lunch. CNA I stated she immediately informed LVN F about Resident #1 being lethargic and not wanting to get up out of bed to eat lunch and LVN F told her we will feed her by her [DEVICE]. CNA I stated LVN F did not get up to go assess Resident #1. CNA I stated she continued checking on her other residents. CNA I stated LVN W was at the nurse's station too but did not acknowledge her so not sure LVN W heard what she said about Resident #1. CNA I stated she should have informed another nurse of Resident #1's change of condition or informed the Weekend RN Supervisor since LVN F did not go assess Resident #1. In an Interview on [DATE] at 11:20 AM, LVN W stated he worked on [DATE] on 200 hall but could not recall who Resident #1 was. He said if he had assessed her, it would have been written down. LVN W stated he was unaware of any change of condition of Resident #1 on [DATE]. Review of Resident #1's Nurse's note dated [DATE] at 6:30 PM by RN C, indicated after bolus feeding, she changed the resident's [DEVICE] (a tube inserted through the abdomen that delivers nutrition directly to the stomach) dressing and noticed Resident #1 stopped breathing. Attempted to arouse Resident #1, patted her cheek, but she (Resident #1) was unresponsive. Sent a CNA to get another nurse to help me . Attempted to find a carotid pulse, radial pulse, apical pulse and vitals, but was unsuccessful . 911 was called at 6:35 PM, and sent for [MEDICATION NAME], Resident #1 was still warm but unresponsive. [MEDICATION NAME] administered. EMS arrived at 6:45 pm and took over resuscitation efforts. 6:55 PM, Resident #1 was resuscitated. 7:00 PM, Resident #1 was taken via stretcher, still unresponsive, to the local hospital ER via EMS. The DON was notified at 6:53 PM, daughter notified at 7:00 PM, ADON notified at 7:08 PM, Administrator notified at 7:15 PM. Physician notified at 7:10 PM. Review of Resident #1's Nurse's noted dated [DATE] by RN C indicated the local hospital called to notify the facility Resident #1 had passed at 7:35 PM. An Interview on [DATE] at 4:50 PM and 6:18 PM RN C stated she had finished Resident #1's [DEVICE] feeding and was finishing up putting a new dressing on Resident #1's [DEVICE] site when she noticed Resident #1's chest was not rising and falling, no breathing and unresponsive. RN C could not recall what specific time she noticed Resident #1 was unresponsive with no pulse. RN C stated she patted Resident #1's face and shoulder but not response. RN C stated she checked Resident #1 for a carotid, radial and apical pulse with no pulse found. RN C stated she put the call light on and went out to the hallway leaving Resident #1 and found Caregiver G in the hallway and asked Caregiver G to go get another nurse. RN C stated she knew Resident #1 was a full code and did not initiate CPR because she needed to go get another staff member to assist her and staff do not always answer call lights in a timely manner. RN C stated LVN E came back asking her what was going on and told LVN E Resident #1 was unresponsive with no pulse. RN C stated LVN E initiated CPR on Resident #1. RN C stated LVN E checked Resident #1's blood sugar which was 52 and was told by LVN E to go get [MEDICATION NAME] for Resident #1's low blood sugar. RN C stated she looked for glucose tablets in the nurse cart and could not find any. RN C stated she brought the back board to LVN E and had to go back out to find the [MEDICATION NAME]. RN C stated she found the [MEDICATION NAME] in the ER kit and put it in Resident #1's right upper thigh. RN C stated she did not do CPR on Resident #1. RN C stated she was CPR certified. An Interview on [DATE] at 4:20 PM LVN E stated Caregiver G came and got her on [DATE] at 6:39 PM when she was finishing up paperwork from an admission and looked at the clock. She stated Caregiver G told her RN C needed her help so she immediately went with Caregiver G down the hall and RN C was outside of Resident #1's room with her back to the room saying patient, patient and RN C was emotionally distraught. LVN E stated she asked RN C what was going on and she told her Resident #1 was unresponsive with no pulse. LVN E stated at about 6:40 PM (10 minutes after Resident #1 was initially found unresponsive with no pulse by RN C) LVN E got to Resident #1 who looked like she was already gone, still warm to the touch, with no pulse and unresponsive and LVN E initiated CPR on Resident #1. LVN E stated she asked RN C to go get [MEDICATION NAME] after Resident #1's blood sugar was checked which was in the 50s. LVN E stated she also asked Caregiver G to go get apple juice to put in Resident #1's peg tube. LVN E stated Caregiver G returned quicker than RN C so she put about ,[DATE] ounces of orange juice via [DEVICE]. LVN E stated she asked RN C where [MEDICATION NAME] was when she returned with the back board and RN C told her it was not in the nurses' cart when she looked so she would have to go get it. LVN E stated she stayed with Resident #1 until EMS arrived and kept sending staff out to get things for her. LVN E stated she did not see RN C give the [MEDICATION NAME]. LVN E stated she did not fill out any nurse's notes on Resident #1 since she was RN C's resident and assumed RN C had written down what happened. An Interview on [DATE] at 2:15 PM CNA H stated RN C ran down the hallway in a panic stating Resident #1 was not responding. I need help. CNA H came into Resident #1's room where Resident #1 was unresponsive and LVN F was doing CPR. CNA H stated he assisted LVN F with the CPR while RN C came in and out of room to call ambulance until EMS arrived. CNA H stated it took multiple nurses to calm RN C down. CNA H stated LVN F stayed in the room the whole time and did recall RN C giving Resident #1 an injection in her thigh. An interview on [DATE] at 8:11 AM CNA J stated RN C was frantic and LVN F started CPR on Resident #1. CNA J stated she called 911 and got the crash cart for LVN F. CNA J stated she assisted with CPR along with LVN F and CNA H on Resident #1. CNA J stated she did recall RN C giving Resident #1 [MEDICATION NAME] in her thigh. CNA J stated the Paramedics arrived, took over CPR and could not get a pulse from Resident #1 so they were on the phone with the physician about to call Resident #1's time of death when they found a weak pulse. CNA J stated they moved her to the gurney and took her to the hospital. An interview on [DATE] at 9:16 AM RN Weekend Supervisor stated he had left the facility for the day after he was notified by LVN F Resident #1 was unresponsive and no pulse, EMS called and was sent to the hospital with a weak pulse. RN Weekend Supervisor stated LVN E told him RN C was very emotional and they could not calm her down after the incident so he stated he called ADON A to go to the facility to check on her. RN Weekend Supervisor stated he was asked by the DON on [DATE] to review the chart the next day and he did noticing there was missing pieces in the documentation so he contacted the DON about it. RN Weekend Supervisor stated he and the DON interviewed RN C finding she had not put in the intervention of giving Resident #1 two sugar packets and an amount of feeding via [DEVICE]. RN Weekend Supervisor stated RN C was suspended due to her emotional status and needed additional training before returning to the floor as a charge nurse. RN Weekend Supervisor stated he was aware RN C did not do CPR but was not aware there was a delay in CPR given to Resident #1. RN Weekend Supervisor stated EMS had gotten a weak pulse per LVN F but found out later the hospital called saying it was her pacemaker and Resident #1 never had a pulse so Resident #1 expired at the hospital. An interview on [DATE] at 10:11 AM ADON A stated she was contacted by the RN Weekend supervisor to check on RN C to see if she was fit to finish her shift that evening after the incident with Resident #1 being unresponsive. ADON A stated she got immediately went to the facility and when she got there RN C was very emotional and broke down near the nurse's station. ADON A stated RN C was determined to continue working so ADON A followed her and became calm after 30 minutes of talking about what happened. ADON A stated RN C had not filled out any nurse notes about the incident and told RN C to write down in the nurse's notes what happened. ADON A stated she left the facility and RN C was thinking clearly again and able to finish her shift. ADON A stated she talked to the DON after she left the facility to let her know RN C was able to finish her shift. ADON A stated they in serviced the nurses on a code blue on [DATE] with scenario of 2 people finding a resident unresponsive. ADON A stated RN C had not been in-serviced yet and had not worked since she completed her shift on 2 pm to 10 pm shift. In an interview on [DATE] at 10:37 AM, the DON stated the RN Weekend Supervisor informed her Resident #1 had coded, was unresponsive and sent to the hospital, so she asked him to review the chart. The DON stated her concerns were about RN C's emotional distress and on Monday [DATE] she interviewed RN C about the incident. The DON stated RN C was suspended on [DATE] due to her emotional distress and had not worked since the incident. The DON stated RN C would need additional training and to shadow other nurses before returning to work on the hall by herself but no training had occurred. The DON stated she did not have concerns about RN C's delay in CPR, and she would peek out the door and get help herself too before initiating CPR. The DON stated due to RN C's emotional state it was better for her to go get help and have someone else do CPR. The DON stated when she interviewed RN C on Monday after the incident did not interview any other staff involved with the incident. The DON stated she had not looked at Resident #1's chart until [DATE]. She further stated after documentation review, she had concerns about LVN F not assessing Resident #1 on the 6:00 AM to 2:00 PM on [DATE] when CNA I told LVN F Resident #1 was sleepy and she could not get her to eat. The DON stated LVN F admitted to not assessing Resident #1 when she was informed of a change of condition and LVN F should have assessed immediately. The DON stated LVN F was suspended on [DATE] for allegation of neglect for failure to assess Resident #1. In an Interview on [DATE] at 12:52 PM, the Administrator stated the facility received a medical records request on Resident #1 from the coroner's office on [DATE]. The Administrator stated the DON had not reviewed the chart herself until [DATE] after the request for medical records. The Administrator stated she would expect RN C to initiate CPR immediately, but due to her being too emotional at the time of the incident, it was better for her to get someone else to initiate the CPR. The Administrator stated RN C was CPR certified and should have known how to handle a code blue. The Administrator stated RN C had not worked since the incident due to her emotional distress but finished her shift on [DATE]. The Administrator stated on [DATE] after discussing with the DON about LVN F not assessing Resident #1 with a change of condition they knew they needed to report it so they did on [DATE]. The Administrator stated LVN F was suspended on [DATE] and will not be coming back to the facility due to her failure to assess Resident #1. Review of LVN F's employee file reflected no termination in her chart. Review of LVN F's timecard in [DATE] reflected she worked from [DATE] to [DATE]. Review of RN C's time card reflected her last day to work was on [DATE] and had not worked since [DATE]. An interview on [DATE] at 3:58 PM the Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions. Review of facility CPR and Basic Life Support policy revised [DATE] reflected under general guidelines, .5. Depending on the underlying cause, the chances of surviving sudden [MEDICAL CONDITION] may be increased if CPR is initiated immediately upon collapse. 9. If an individual is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g. rigor mortis). The Administrator was notified on [DATE] at 1:03 PM that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 6:45 PM and included: Administrator was notified on [DATE] at approximately 1:03 pm of an Immediate Jeopardy for a) Not following CPR policy. As well as the DON interviewed RN C on Monday [DATE] about incident and chart was not reviewed until [DATE]. The following steps are the centers plan to remove the Immediate Jeopardy. 1. On [DATE], Social Service Director and Nurse Managers immediately identified all current residents in the facility that are FULL CODE and ensured a code indicator (green full code form) was placed on the resident's chart. 2. On [DATE] nursing department audit license nurses CPR Certification. All licensed nurses are CPR certified and are available within the facility 24 hours a day. 3. On [DATE] starting inservicing all staff on what to do immediately for a patient needing CPR. (Specifics in training and what they are going over with them) and how they will validate their understanding. Training includes: a. A nurse that is CPR certified will be on each shift of everyday b. Nurse 1 will upon entering the room with possible code will call out code blue in process and start CPR, Nurse 2 will bring the chart to room, when nurse two arrives they will start bagging. Nurse 1 continues chest compressions. CNA 1 will call Code Blue over intercom. CNA 2 will bring the crash cart. CNA 3 will bring the AED. Once AED arrives, Nurse 2 will apply the AED. CNA 2 will record. c. With only one nurse, (Nurse one) the nurse will pull call light cord out of wall (to get attention of staff) and yell Code Blue. Nurse 2 will bring the chart to room, when nurse two arrives they will start bagging. Nurse 1 continues chest compressions. CNA 1 will call Code Blue over intercom. CNA 2 will bring the crash cart. CNA 3 will bring the AED. Once AED arrives, Nurse 2 will apply the AED. CNA 2 will record. d. For the one Agency nurse working through [DATE] he has been inserviced to the building and code process. e. As of [DATE] all residents that are sent to the hospital will have chart reviewed by DON or ADON's f. On staffing schedule a asterisk (*) will be put beside employees that are CPR certified. g. To monitor that the employees know the system for CPR process we will implement a post test to ensure compliance. All staff will be inserviced before working the floor. h. Staff Development Coordinator will be doing the training for staff 4. Mock Code Training each shift (to ensure all staff knows how to handle a code for patients). This will be accomplished by demonstration of mock code blue. a) Review the emergency cart and AED daily b.) Skills Validation Checklist performed by [DATE]st on LVN's and RN's on AED c) New employees will be trained and educated on CPR process for residents d) Social Services Director will maintain accuracy of Code Status in the medical record e) Physician orders [REDACTED]. f) New residents upon admission will be reviewed for Code Status. Orders will be obtained and updated same day as admission. g) all employees will be inserviced and answer will be reviewed to ensure compliance with facility regulations on CPR for residents. Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The center respectfully requests the Immediate Jeopardy be removed with actions initiated on [DATE]. In an interview on [DATE] at 10:00 AM ADON B stated only one nurse on the 6 AM to 2 PM shift had been in serviced so far and were working on in-servicing the rest of the nurses and all nurses were in-serviced at 5 AM this morning for the night shift. Interviews on [DATE] from 5:15 PM to 5:45 PM revealed six of six Charge Nurses on the 2:00 PM to 10:00 PM shift (LVNs L, M, N, O, P and Q) all understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interviews with four of four 6:00 AM to 2:00 PM shift Charge Nurses (LVNs F, R, S and T) from 11:13 AM to 11:22 AM after their facility in-service revealed they understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Interviews on [DATE] from 11:20 AM to 11:24 AM, two of two Charge Nurses (LVN U and V) on the night shift both understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of the facility's list of residents who are DNR updated weekly by Social Worker was up-to-date per chart audit and placed on each crash cart. Record Review of Clinical Records for Resident #2, #3, #4 and #5 reflected the facility assessed residents when they had a change of condition and initiated CPR immediately on Resident #2 when he stopped breathing until EMS arrived. Record Review on [DATE] of Nurses' CPR certification revealed nurses were CPR certified on all shifts starting 2 PM to 10 PM shift on Friday [DATE] to Sunday [DATE] on all three shifts. On [DATE] at 7:53 AM the ADON B was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The Administrator provided on [DATE] a list of 64 residents with full code status.

Based on interview and record review, the facility failed to provide services which met professional standards of quality for one (Resident #1) of 10 residents reviewed for services meeting professional standards of quality. 1. LVN F failed to assess Resident #1 at 11:30 AM on [DATE] when CNA I told her the resident was lethargic, unresponsive, and could not get up for her lunch meal. 2. RN C failed to immediately start CPR when she determined Resident #1 was unresponsive and did not have a pulse on 6:30 PM on [DATE]. As a result, Resident #1 was transported to the hospital by the paramedics on [DATE] and expired that same evening in the hospital. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect 64 residents who were full code status, by placing them at risk for not receiving assessments and CPR immediately and further life-saving treatments as desired, which could result in death. Findings included: The website: bon.texas.gov (Board of Nurses for the State of Texas) reflected, The decision to initiate CPR for all nurses should be a spontaneous clinical decision and nursing intervention for a client in cardiac or respiratory distress. CPR should not be delayed to review the client's medical record, to determine the client's wishes, or to search for DNR orders. The Licensed Vocational Nurse Scope of Practice, Texas Board of Nursing reflected, the LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes and patient-centered plans of care that are developed in collaboration with patients, their families, and the interdisciplinary health care team. The LVN cannot perform independent assessments as the LVN has a directed scope of practice under supervision. The LVN participates in the nursing process by appraising the individual patient's status or situation at hand. Also known as a focused assessment, this appraisal may be considered a component of a more comprehensive assessment performed by a RN or another appropriate clinical supervisor. Review of Resident #1's face sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was discharged on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Discharge Summary dated [DATE] reflected Resident #1 was discharged to the hospital and expired at the hospital on [DATE]. Review of Resident #1's clinical chart reflected a green sheet stating Resident #1 was full code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning she wanted all life-saving measures to be taken if she was found unresponsive). Review of Resident #1's telephone orders for [DATE] reflected Resident #1 was full code status. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 3 indicating she was severely cognitively impaired. Resident #1 required extensive assistance with most ADLs. Review of Resident #1's nurses' note, dated [DATE] at 11:30 AM by LVN F, indicated CNA I reported Resident #1 was extremely lethargic, which was normal for a resident after [MEDICAL TREATMENT]. CNA I was unable to take Resident #1 to the dining room to eat. LVN F told CNA I to leave the resident in bed and the LVN would get her tube feeding. Note from 11:30 AM to 2:00 PM by LVN F reflected no other concerns noted. Resident #1 remained in bed. No signs/symptoms of distress noted. Hand off to on-coming nurse at 2:00 PM. The nurse's note revealed no evidence of Resident #1's assessment. In an Interview on [DATE] at 11:01 AM, LVN F denied Resident #1 being her resident after 6:00 AM and recalled CNA I telling her after Resident #1 returned from [MEDICAL TREATMENT] that Resident #1 was not coherent, lethargic, and unable to get her out of bed for lunch. LVN F stated she did not go assess Resident #1 and told CNA I Resident #1 would get her tube feeding. LVN F stated she told LVN W to go give Resident #1 her feeding, but did not tell him about Resident #1 being lethargic or unable to go to the dining room for lunch. Review of LVN F's Job description as a Charge Nurse - LVN undated paperwork reflected to assess for and notify physician and other appropriate parties of changes in condition. In an Interview on [DATE] at 11:47 AM CNA I stated she checked on Resident #1 after she got back from [MEDICAL TREATMENT] during the lunch and Resident #1 was lethargic (barely opened her eyes) and would not get up out of bed for lunch. CNA I stated she immediately informed LVN F about Resident #1 being lethargic and not wanting to get up out of bed to eat lunch and LVN F told her we will feed her by her [DEVICE]. CNA I stated LVN F did not get up to go assess Resident #1. CNA I stated she continued checking on her other residents. CNA I stated LVN W was at the nurse's station too but did not acknowledge her so not sure LVN W heard what she said about Resident #1. CNA I stated she should have informed another nurse of Resident #1's change of condition or informed the Weekend RN Supervisor since LVN F did not go assess Resident #1. In an Interview on [DATE] at 11:20 AM, LVN W stated he worked on [DATE] on 200 hall but could not recall who Resident #1 was. He said if he had assessed her, it would have been written down. LVN W stated he was unaware of any change of condition of Resident #1 on [DATE]. Review of Resident #1's Nurse's note dated [DATE] at 6:30 PM by RN C, indicated after bolus feeding, she changed the resident's [DEVICE] (a tube inserted through the abdomen that delivers nutrition directly to the stomach) dressing and noticed Resident #1 stopped breathing. Attempted to arouse Resident #1, patted her cheek, but she (Resident #1) was unresponsive. Sent a CNA to get another nurse to help me . Attempted to find a carotid pulse, radial pulse, apical pulse and vitals, but was unsuccessful . 911 was called at 6:35 PM, and sent for [MEDICATION NAME], Resident #1 was still warm but unresponsive. [MEDICATION NAME] administered. EMS arrived at 6:45 pm and took over resuscitation efforts. 6:55 PM, Resident #1 was resuscitated. 7:00 PM, Resident #1 was taken via stretcher, still unresponsive, to the local hospital ER via EMS. The DON was notified at 6:53 PM, daughter notified at 7:00 PM, ADON notified at 7:08 PM, Administrator notified at 7:15 PM. Physician notified at 7:10 PM. Review of Resident #1's Nurse's noted dated [DATE] by RN C indicated the local hospital called to notify the facility Resident #1 had passed at 7:35 PM. An Interview on [DATE] at 4:50 PM and 6:18 PM RN C stated she had finished Resident #1's [DEVICE] feeding and was finishing up putting a new dressing on Resident #1's [DEVICE] site when she noticed Resident #1's chest was not rising and falling, no breathing and unresponsive. RN C could not recall what specific time she noticed Resident #1 was unresponsive with no pulse. RN C stated she patted Resident #1's face and shoulder but not response. RN C stated she checked Resident #1 for a carotid, radial and apical pulse with no pulse found. RN C stated she put the call light on and went out to the hallway leaving Resident #1 and found Caregiver G in the hallway and asked Caregiver G to go get another nurse. RN C stated she knew Resident #1 was a full code and did not initiate CPR because she needed to go get another staff member to assist her and staff do not always answer call lights in a timely manner. RN C stated LVN E came back asking her what was going on and told LVN E Resident #1 was unresponsive with no pulse. RN C stated LVN E initiated CPR on Resident #1. RN C stated LVN E checked Resident #1's blood sugar which was 52 and was told by LVN E to go get [MEDICATION NAME] for Resident #1's low blood sugar. RN C stated she looked for glucose tablets in the nurse cart and could not find any. RN C stated she brought the back board to LVN E and had to go back out to find the [MEDICATION NAME]. RN C stated she found the [MEDICATION NAME] in the ER kit and put it in Resident #1's right upper thigh. RN C stated she did not do CPR on Resident #1. RN C stated she was CPR certified. An Interview on [DATE] at 4:20 PM LVN E stated Caregiver G came and got her on [DATE] at 6:39 PM when she was finishing up paperwork from an admission and looked at the clock. She stated Caregiver G told her RN C needed her help so she immediately went with Caregiver G down the hall and RN C was outside of Resident #1's room with her back to the room saying patient, patient and RN C was emotionally distraught. LVN E stated she asked RN C what was going on and she told her Resident #1 was unresponsive with no pulse. LVN E stated at about 6:40 PM (10 minutes after Resident #1 was initially found unresponsive with no pulse by RN C) LVN E got to Resident #1 who looked like she was already gone, still warm to the touch, with no pulse and unresponsive and LVN E initiated CPR on Resident #1. LVN E stated she asked RN C to go get [MEDICATION NAME] after Resident #1's blood sugar was checked which was in the 50s. LVN E stated she also asked Caregiver G to go get apple juice to put in Resident #1's peg tube. LVN E stated Caregiver G returned quicker than RN C so she put about ,[DATE] ounces of orange juice via [DEVICE]. LVN E stated she asked RN C where [MEDICATION NAME] was when she returned with the back board and RN C told her it was not in the nurses' cart when she looked so she would have to go get it. LVN E stated she stayed with Resident #1 until EMS arrived and kept sending staff out to get things for her. LVN E stated she did not see RN C give the [MEDICATION NAME]. LVN E stated she did not fill out any nurse's notes on Resident #1 since she was RN C's resident and assumed RN C had written down what happened. An Interview on [DATE] at 2:15 PM CNA H stated RN C ran down the hallway in a panic stating Resident #1 was not responding. I need help. CNA H came into Resident #1's room where Resident #1 was unresponsive and LVN F was doing CPR. CNA H stated he assisted LVN F with the CPR while RN C came in and out of room to call ambulance until EMS arrived. CNA H stated it took multiple nurses to calm RN C down. CNA H stated LVN F stayed in the room the whole time and did recall RN C giving Resident #1 an injection in her thigh. An interview on [DATE] at 8:11 AM CNA J stated RN C was frantic and LVN F started CPR on Resident #1. CNA J stated she called 911 and got the crash cart for LVN F. CNA J stated she assisted with CPR along with LVN F and CNA H on Resident #1. CNA J stated she did recall RN C giving Resident #1 [MEDICATION NAME] in her thigh. CNA J stated the Paramedics arrived, took over CPR and could not get a pulse from Resident #1 so they were on the phone with the physician about to call Resident #1's time of death when they found a weak pulse. CNA J stated they moved her to the gurney and took her to the hospital. An interview on [DATE] at 9:16 AM RN Weekend Supervisor stated he had left the facility for the day after he was notified by LVN F Resident #1 was unresponsive and no pulse, EMS called and was sent to the hospital with a weak pulse. RN Weekend Supervisor stated LVN E told him RN C was very emotional and they could not calm her down after the incident so he stated he called ADON A to go to the facility to check on her. RN Weekend Supervisor stated he was asked by the DON on [DATE] to review the chart the next day and he did noticing there was missing pieces in the documentation so he contacted the DON about it. RN Weekend Supervisor stated he and the DON interviewed RN C finding she had not put in the intervention of giving Resident #1 two sugar packets and an amount of feeding via [DEVICE]. RN Weekend Supervisor stated RN C was suspended due to her emotional status and needed additional training before returning to the floor as a charge nurse. RN Weekend Supervisor stated he was aware RN C did not do CPR but was not aware there was a delay in CPR given to Resident #1. RN Weekend Supervisor stated EMS had gotten a weak pulse per LVN F but found out later the hospital called saying it was her pacemaker and Resident #1 never had a pulse so Resident #1 expired at the hospital. An interview on [DATE] at 10:11 AM ADON A stated she was contacted by the RN Weekend supervisor to check on RN C to see if she was fit to finish her shift that evening after the incident with Resident #1 being unresponsive. ADON A stated she got immediately went to the facility and when she got there RN C was very emotional and broke down near the nurse's station. ADON A stated RN C was determined to continue working so ADON A followed her and became calm after 30 minutes of talking about what happened. ADON A stated RN C had not filled out any nurse notes about the incident and told RN C to write down in the nurse's notes what happened. ADON A stated she left the facility and RN C was thinking clearly again and able to finish her shift. ADON A stated she talked to the DON after she left the facility to let her know RN C was able to finish her shift. ADON A stated they in serviced the nurses on a code blue on [DATE] with scenario of 2 people finding a resident unresponsive. ADON A stated RN C had not been in-serviced yet and had not worked since she completed her shift on 2 pm to 10 pm shift. In an interview on [DATE] at 10:37 AM, the DON stated the RN Weekend Supervisor informed her Resident #1 had coded, was unresponsive and sent to the hospital, so she asked him to review the chart. The DON stated her concerns were about RN C's emotional distress and on Monday [DATE] she interviewed RN C about the incident. The DON stated RN C was suspended on [DATE] due to her emotional distress and had not worked since the incident. The DON stated RN C would need additional training and to shadow other nurses before returning to work on the hall by herself but no training had occurred. The DON stated she did not have concerns about RN C's delay in CPR, and she would peek out the door and get help herself too before initiating CPR. The DON stated due to RN C's emotional state it was better for her to go get help and have someone else do CPR. The DON stated when she interviewed RN C on Monday after the incident did not interview any other staff involved with the incident. The DON stated she had not looked at Resident #1's chart until [DATE]. She further stated after documentation review, she had concerns about LVN F not assessing Resident #1 on the 6:00 AM to 2:00 PM on [DATE] when CNA I told LVN F Resident #1 was sleepy and she could not get her to eat. The DON stated LVN F admitted to not assessing Resident #1 when she was informed of a change of condition and LVN F should have assessed immediately. The DON stated LVN F was suspended on [DATE] for allegation of neglect for failure to assess Resident #1. In an Interview on [DATE] at 12:52 PM, the Administrator stated the facility received a medical records request on Resident #1 from the coroner's office on [DATE]. The Administrator stated the DON had not reviewed the chart herself until [DATE] after the request for medical records. The Administrator stated she would expect RN C to initiate CPR immediately, but due to her being too emotional at the time of the incident, it was better for her to get someone else to initiate the CPR. The Administrator stated RN C was CPR certified and should have known how to handle a code blue. The Administrator stated RN C had not worked since the incident due to her emotional distress but finished her shift on [DATE]. The Administrator stated on [DATE] after discussing with the DON about LVN F not assessing Resident #1 with a change of condition they knew they needed to report it so they did on [DATE]. The Administrator stated LVN F was suspended on [DATE] and will not be coming back to the facility due to her failure to assess Resident #1. Review of LVN F's employee file reflected no termination in her chart. Review of LVN F's timecard in [DATE] reflected she worked from [DATE] to [DATE]. Review of RN C's time card reflected her last day to work was on [DATE] and had not worked since [DATE]. An interview on [DATE] at 3:58 PM the Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions. Review of facility CPR and Basic Life Support policy revised [DATE] reflected under general guidelines, .5. Depending on the underlying cause, the chances of surviving sudden [MEDICAL CONDITION] may be increased if CPR is initiated immediately upon collapse. 9. If an individual is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g. rigor mortis). The Administrator was notified on [DATE] at 1:03 PM that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 6:45 PM and included: Administrator was notified on [DATE] at approximately 1:03 pm of an Immediate Jeopardy for a) Not following CPR policy. As well as the DON interviewed RN C on Monday [DATE] about incident and chart was not reviewed until [DATE]. The following steps are the centers plan to remove the Immediate Jeopardy. 1. On [DATE], Social Service Director and Nurse Managers immediately identified all current residents in the facility that are FULL CODE and ensured a code indicator (green full code form) was placed on the resident's chart. 2. On [DATE] nursing department audit license nurses CPR Certification. All licensed nurses are CPR certified and are available within the facility 24 hours a day. 3. On [DATE] starting inservicing all staff on what to do immediately for a patient needing CPR. (Specifics in training and what they are going over with them) and how they will validate their understanding. Training includes: a. A nurse that is CPR certified will be on each shift of everyday b. Nurse 1 will upon entering the room with possible code will call out code blue in process and start CPR, Nurse 2 will bring the chart to room, when nurse two arrives they will start bagging. Nurse 1 continues chest compressions. CNA 1 will call Code Blue over intercom. CNA 2 will bring the crash cart. CNA 3 will bring the AED. Once AED arrives, Nurse 2 will apply the AED. CNA 2 will record. c. With only one nurse, (Nurse one) the nurse will pull call light cord out of wall (to get attention of staff) and yell Code Blue. Nurse 2 will bring the chart to room, when nurse two arrives they will start bagging. Nurse 1 continues chest compressions. CNA 1 will call Code Blue over intercom. CNA 2 will bring the crash cart. CNA 3 will bring the AED. Once AED arrives, Nurse 2 will apply the AED. CNA 2 will record. d. For the one Agency nurse working through [DATE] he has been inserviced to the building and code process. e. As of [DATE] all residents that are sent to the hospital will have chart reviewed by DON or ADON's f. On staffing schedule a asterisk (*) will be put beside employees that are CPR certified. g. To monitor that the employees know the system for CPR process we will implement a post test to ensure compliance. All staff will be inserviced before working the floor. h. Staff Development Coordinator will be doing the training for staff 4. Mock Code Training each shift (to ensure all staff knows how to handle a code for patients). This will be accomplished by demonstration of mock code blue. a) Review the emergency cart and AED daily b.) Skills Validation Checklist performed by [DATE]st on LVN's and RN's on AED c) New employees will be trained and educated on CPR process for residents d) Social Services Director will maintain accuracy of Code Status in the medical record e) Physician orders [REDACTED]. f) New residents upon admission will be reviewed for Code Status. Orders will be obtained and updated same day as admission. g) all employees will be inserviced and answer will be reviewed to ensure compliance with facility regulations on CPR for residents. Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The center respectfully requests the Immediate Jeopardy be removed with actions initiated on [DATE]. In an interview on [DATE] at 10:00 AM ADON B stated only one nurse on the 6 AM to 2 PM shift had been in serviced so far and were working on in-servicing the rest of the nurses and all nurses were in-serviced at 5 AM this morning for the night shift. Interviews on [DATE] from 5:15 PM to 5:45 PM revealed six of six Charge Nurses on the 2:00 PM to 10:00 PM shift (LVNs L, M, N, O, P and Q) all understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interviews with four of four 6:00 AM to 2:00 PM shift Charge Nurses (LVNs F, R, S and T) from 11:13 AM to 11:22 AM after their facility in-service revealed they understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Interviews on [DATE] from 11:20 AM to 11:24 AM, two of two Charge Nurses (LVN U and V) on the night shift both understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of the facility's list of residents who are DNR updated weekly by Social Worker was up-to-date per chart audit and placed on each crash cart. Record Review of Clinical Records for Resident #2, #3, #4 and #5 reflected the nurses assessed residents when they had a change of condition and initiated CPR immediately on Resident #2 when he stopped breathing until EMS arrived. Record Review on [DATE] of Nurses' CPR certification revealed nurses were CPR certified on all shifts starting 2 PM to 10 PM shift on Friday [DATE] to Sunday [DATE] on all three shifts. On [DATE] at 7:53 AM the ADON B was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The Administrator provided on [DATE] a list of 64 residents with full code status.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of 10 residents reviewed for neglect. 1. LVN F failed to assess Resident #1 at 11:30 AM on [DATE] when CNA I told her the resident was lethargic, unresponsive, and could not get up for her lunch meal. 2. RN C failed to immediately start CPR when she determined Resident #1 was unresponsive and did not have a pulse on 6:30 PM on [DATE]. RN C left Resident #1 in her room and went to get another staff member to assist. CPR was not initiated on Resident #1 until 6:40 PM on [DATE] by LVN E. As a result, Resident #1 was transported to the hospital by the paramedics on [DATE] and expired that same evening in the hospital. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures could affect 64 residents who were full code status, by placing them at risk for not receiving assessments and CPR immediately and further life-saving treatments as desired, which could result in death. Findings included: The website: bon.texas.gov (Board of Nurses for the State of Texas) accessed at 12:00 p.m. on [DATE] reflected, The decision to initiate CPR for all nurses should be a spontaneous clinical decision and nursing intervention for a client in cardiac or respiratory distress. CPR should not be delayed to review the client's medical record, to determine the client's wishes, or to search for DNR orders. Review of Resident #1's face sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was discharged on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Discharge Summary dated [DATE] reflected Resident #1 was discharged to the hospital and expired at the hospital on [DATE]. Review of Resident #1's clinical chart reflected a green sheet stating Resident #1 was full code status. Review of Resident #1's Consolidated Physician order [REDACTED].#1 was full code status (meaning she wanted all life-saving measures to be taken if she was found unresponsive). Review of Resident #1's telephone orders for [DATE] reflected Resident #1 was full code status. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 3 indicating she was severely cognitively impaired. Resident #1 required extensive assistance with most ADLs. Review of Resident #1's nurses' note, dated [DATE] at 11:30 AM by LVN F, indicated CNA I reported Resident #1 was extremely lethargic, which was normal for a resident after [MEDICAL TREATMENT]. CNA I was unable to take Resident #1 to the dining room to eat. LVN F told CNA I to leave the resident in bed and the LVN would get her tube feeding. Note from 11:30 AM to 2:00 PM by LVN F reflected no other concerns noted. Resident #1 remained in bed. No signs/symptoms of distress noted. Hand off to on-coming nurse at 2:00 PM. The nurse's note revealed no evidence of Resident #1's assessment. In an Interview on [DATE] at 11:01 AM, LVN F denied Resident #1 being her resident after 6:00 AM and recalled CNA I telling her after Resident #1 returned from [MEDICAL TREATMENT] that Resident #1 was not coherent, lethargic, and unable to get her out of bed for lunch. LVN F stated she did not go assess Resident #1 and told CNA I Resident #1 would get her tube feeding. LVN F stated she told LVN W to go give Resident #1 her feeding, but did not tell him about Resident #1 being lethargic or unable to go to the dining room for lunch. Review of LVN F's Job description as a Charge Nurse - LVN undated paperwork reflected to assess for and notify physician and other appropriate parties of changes in condition. In an Interview on [DATE] at 11:20 AM, LVN W stated he worked on [DATE] on 200 hall but could not recall who Resident #1 was. He said if he had assessed her, it would have been written down. LVN W stated he was unaware of any change of condition of Resident #1 on [DATE]. Review of Resident #1's Nurse's note dated [DATE] at 6:30 PM by RN C, indicated after bolus feeding, she changed the resident's [DEVICE] (a tube inserted through the abdomen that delivers nutrition directly to the stomach.) dressing and noticed Resident #1 stopped breathing. Attempted to arouse Resident #1, patted her cheek, but she (Resident #1) was unresponsive. Sent a CNA to get another nurse to help me . Attempted to find a carotid pulse, radial pulse, apical pulse and vitals, but was unsuccessful . 911 was called at 6:35 PM, and sent for [MEDICATION NAME], Resident #1 was still warm but unresponsive. [MEDICATION NAME] administered. EMS arrived at 6:45 pm and took over resuscitation efforts. 6:55 PM, Resident #1 was resuscitated. 7:00 PM, Resident #1 was taken via stretcher, still unresponsive, to the local hospital ER via EMS. The DON was notified at 6:53 PM, daughter notified at 7:00 PM, ADON notified at 7:08 PM, Administrator notified at 7:15 PM. Physician notified at 7:10 PM. Review of Resident #1's Nurse's noted dated [DATE] by RN C indicated the local hospital called to notify the facility Resident #1 had passed at 7:35 PM. An Interview on [DATE] at 4:50 PM and 6:18 PM RN C stated she had finished Resident #1's [DEVICE] feeding and was finishing up putting a new dressing on Resident #1's [DEVICE] site when she noticed Resident #1's chest was not rising and falling, no breathing and unresponsive. RN C could not recall what specific time she noticed Resident #1 was unresponsive with no pulse. RN C stated she patted Resident #1's face and shoulder but not response. RN C stated she checked Resident #1 for a carotid, radial and apical pulse with no pulse found. RN C stated she put the call light on and went out to the hallway leaving Resident #1 and found Caregiver G in the hallway and asked Caregiver G to go get another nurse. RN C stated she knew Resident #1 was a full code and did not initiate CPR because she needed to go get another staff member to assist her and staff do not always answer call lights in a timely manner. RN C stated LVN E came back asking her what was going on and told LVN E Resident #1 was unresponsive with no pulse. RN C stated LVN E initiated CPR on Resident #1. RN C stated LVN E checked Resident #1's blood sugar which was 52 and was told by LVN E to go get [MEDICATION NAME] for Resident #1's low blood sugar. RN C stated she looked for glucose tablets in the nurse cart and could not find any. RN C stated she brought the back board to LVN E and had to go back out to find the [MEDICATION NAME]. RN C stated she found the [MEDICATION NAME] in the ER kit and put it in Resident #1's right upper thigh. RN C stated she did not do CPR on Resident #1. RN C stated she was CPR certified. An Interview on [DATE] at 4:20 PM LVN E stated Caregiver G came and got her on [DATE] at 6:39 PM when she was finishing up paperwork from an admission and looked at the clock. She stated Caregiver G told her RN C needed her help so she immediately went with Caregiver G down the hall and RN C was outside of Resident #1's room with her back to the room saying patient, patient and RN C was emotionally distraught. LVN E stated she asked RN C what was going on and she told her Resident #1 was unresponsive with no pulse. LVN E stated at about 6:40 PM (10 minutes after Resident #1 was initially found unresponsive with no pulse by RN C) LVN E got to Resident #1 who looked like she was already gone, still warm to the touch, with no pulse and unresponsive and LVN E initiated CPR on Resident #1. LVN E stated she asked RN C to go get [MEDICATION NAME] after Resident #1's blood sugar was checked which was in the 50s. LVN E stated she also asked Caregiver G to go get apple juice to put in Resident #1's peg tube. LVN E stated Caregiver G returned quicker than RN C so she put about ,[DATE] ounces of orange juice via [DEVICE]. LVN E stated she asked RN C where [MEDICATION NAME] was when she returned with the back board and RN C told her it was not in the nurses' cart when she looked so she would have to go get it. LVN E stated she stayed with Resident #1 until EMS arrived and kept sending staff out to get things for her. LVN E stated she did not see RN C give the [MEDICATION NAME]. LVN E stated she did not fill out any nurse's notes on Resident #1 since she was RN C's resident and assumed RN C had written down what happened. An Interview on [DATE] at 2:15 PM CNA H stated RN C ran down the hallway in a panic stating Resident #1 was not responding. I need help. CNA H came into Resident #1's room where Resident #1 was unresponsive and LVN F was doing CPR. CNA H stated he assisted LVN F with the CPR while RN C came in and out of room to call ambulance until EMS arrived. CNA H stated it took multiple nurses to calm RN C down. CNA H stated LVN F stayed in the room the whole time and did recall RN C giving Resident #1 an injection in her thigh. An interview on [DATE] at 8:11 AM CNA I stated RN C was frantic and LVN F started CPR on Resident #1. CNA I stated she called 911 and got the crash cart for LVN F. CNA I stated she assisted with CPR along with LVN F and CNA on Resident #1. CNA I stated she did recall RN C giving Resident #1 [MEDICATION NAME] in her thigh. CNA I stated the Paramedics arrived, took over CPR and could not get a pulse from Resident #1 so they were on the phone with the physician about to call Resident #1's time of death when they found a weak pulse. CNA I stated they moved her to the gurney and took her to the hospital. An interview on [DATE] at 9:16 AM RN Weekend Supervisor stated he had left the facility for the day after he was notified by LVN F Resident #1 was unresponsive and no pulse, EMS called and was sent to the hospital with a weak pulse. RN Weekend Supervisor stated LVN E told him RN C was very emotional and they could not calm her down after the incident so he stated he called ADON A to go to the facility to check on her. RN Weekend Supervisor stated he was asked by the DON on [DATE] to review the chart the next day and he did noticing there was missing pieces in the documentation so he contacted the DON about it. RN Weekend Supervisor stated he and the DON interviewed RN C finding she had not put in the intervention of giving Resident #1 two sugar packets and an amount of feeding via [DEVICE]. RN Weekend Supervisor stated RN C was suspended due to her emotional status and needed additional training before returning to the floor as a charge nurse. RN Weekend Supervisor stated he was aware RN C did not do CPR but was not aware there was a delay in CPR given to Resident #1. RN Weekend Supervisor stated EMS had gotten a weak pulse per LVN F but found out later the hospital called saying it was her pacemaker and Resident #1 never had a pulse so Resident #1 expired at the hospital. An interview on [DATE] at 10:11 AM ADON A stated she was contacted by the RN Weekend supervisor to check on RN C to see if she was fit to finish her shift that evening after the incident with Resident #1 being unresponsive. ADON A stated she got immediately went to the facility and when she got there RN C was very emotional and broke down near the nurse's station. ADON A stated RN C was determined to continue working so ADON A followed her and became calm after 30 minutes of talking about what happened. ADON A stated RN C had not filled out any nurse notes about the incident and told RN C to write down in the nurse's notes what happened. ADON A stated she left the facility and RN C was thinking clearly again and able to finish her shift. ADON A stated she talked to the DON after she left the facility to let her know RN C was able to finish her shift. ADON A stated they in serviced the nurses on a code blue on [DATE] with scenario of 2 people finding a resident unresponsive. ADON A stated RN C had not been in-serviced yet and had not worked since she completed her shift on 2 pm to 10 pm shift. In an interview on [DATE] at 10:37 AM, the DON stated the RN Weekend Supervisor informed her Resident #1 had coded, was unresponsive and sent to the hospital, so she asked him to review the chart. The DON stated her concerns were about RN C's emotional distress and on Monday [DATE] she interviewed RN C about the incident. The DON stated RN C was suspended on [DATE] due to her emotional distress and had not worked since the incident. The DON stated RN C would need additional training and to shadow other nurses before returning to work on the hall by herself but no training had occurred. The DON stated she did not have concerns about RN C's delay in CPR, and she would peek out the door and get help herself too before initiating CPR. The DON stated due to RN C's emotional state it was better for her to go get help and have someone else do CPR. The DON stated when she interviewed RN C on Monday after the incident did not interview any other staff involved with the incident. The DON stated she had not looked at Resident #1's chart until [DATE]. She further stated after documentation review, she had concerns about LVN F not assessing Resident #1 on the 6:00 AM to 2:00 PM on [DATE] when CNA I told LVN F Resident #1 was sleepy and she could not get her to eat. The DON stated LVN F admitted to not assessing Resident #1 when she was informed of a change of condition and LVN F should have assessed immediately. The DON stated LVN F was suspended on [DATE] for allegation of neglect for failure to assess Resident #1. In an Interview on [DATE] at 12:52 PM, the Administrator stated the facility received a medical records request on Resident #1 from the coroner's office on [DATE]. The Administrator stated the DON had not reviewed the chart herself until [DATE] after the request for medical records. The Administrator stated she would expect RN C to initiate CPR immediately, but due to her being too emotional at the time of the incident, it was better for her to get someone else to initiate the CPR. The Administrator stated RN C was CPR certified and should have known how to handle a code blue. The Administrator stated RN C had not worked since the incident due to her emotional distress but finished her shift on [DATE]. The Administrator stated on [DATE] after discussing with the DON about LVN F not assessing Resident #1 with a change of condition they knew they needed to report it so they did on [DATE]. The Administrator stated LVN F was suspended on [DATE] and will not be coming back to the facility due to her failure to assess Resident #1. Review of LVN F's employee file reflected no termination in her chart. Review of LVN F's timecard in [DATE] reflected she worked from [DATE] to [DATE]. Review of RN C's time card reflected her last day to work was on [DATE] and had not worked since [DATE]. An interview on [DATE] at 3:58 PM the Medical Director stated she expected the nurse to immediately initiate CPR on a resident with full code status when a resident was unresponsive with no pulse. The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ on [DATE], reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions. Review of facility CPR and Basic Life Support policy revised [DATE] reflected under general guidelines, .5. Depending on the underlying cause, the chances of surviving sudden [MEDICAL CONDITION] may be increased if CPR is initiated immediately upon collapse. 9. If an individual is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g. rigor mortis). The Administrator was notified on [DATE] at 1:03 PM that an Immediate Jeopardy situation was identified and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 6:45 PM and included: Administrator was notified on [DATE] at approximately 1:03 pm of an Immediate Jeopardy for a) Not following CPR policy. As well as the DON interviewed RN C on Monday [DATE] about incident and chart was not reviewed until [DATE]. The following steps are the centers plan to remove the Immediate Jeopardy. 1. On [DATE], Social Service Director and Nurse Managers immediately identified all current residents in the facility that are FULL CODE and ensured a code indicator (green full code form) was placed on the resident's chart. 2. On [DATE] nursing department audit license nurses CPR Certification. All licensed nurses are CPR certified and are available within the facility 24 hours a day. 3. On [DATE] starting inservicing all staff on what to do immediately for a patient needing CPR. (Specifics in training and what they are going over with them) and how they will validate their understanding. Training includes: a. A nurse that is CPR certified will be on each shift of everyday b. Nurse 1 will upon entering the room with possible code will call out code blue in process and start CPR, Nurse 2 will bring the chart to room, when nurse two arrives they will start bagging. Nurse 1 continues chest compressions. CNA 1 will call Code Blue over intercom. CNA 2 will bring the crash cart. CNA 3 will bring the AED. Once AED arrives, Nurse 2 will apply the AED. CNA 2 will record. c. With only one nurse, (Nurse one) the nurse will pull call light cord out of wall (to get attention of staff) and yell Code Blue. Nurse 2 will bring the chart to room, when nurse two arrives they will start bagging. Nurse 1 continues chest compressions. CNA 1 will call Code Blue over intercom. CNA 2 will bring the crash cart. CNA 3 will bring the AED. Once AED arrives, Nurse 2 will apply the AED. CNA 2 will record. d. For the one Agency nurse working through [DATE] he has been inserviced to the building and code process. e. As of [DATE] all residents that are sent to the hospital will have chart reviewed by DON or ADON's f. On staffing schedule a asterisk (*) will be put beside employees that are CPR certified. g. To monitor that the employees know the system for CPR process we will implement a post test to ensure compliance. All staff will be inserviced before working the floor. h. Staff Development Coordinator will be doing the training for staff 4. Mock Code Training each shift (to ensure all staff knows how to handle a code for patients). This will be accomplished by demonstration of mock code blue. a) Review the emergency cart and AED daily b.) Skills Validation Checklist performed by [DATE]st on LVN's and RN's on AED c) New employees will be trained and educated on CPR process for residents d) Social Services Director will maintain accuracy of Code Status in the medical record e) Physician orders [REDACTED]. f) New residents upon admission will be reviewed for Code Status. Orders will be obtained and updated same day as admission. g) all employees will be inserviced and answer will be reviewed to ensure compliance with facility regulations on CPR for residents. Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The center respectfully requests the Immediate Jeopardy be removed with actions initiated on [DATE]. In an interview on [DATE] at 10:00 AM ADON B stated only one nurse on the 6 AM to 2 PM shift had been in serviced so far and were working on in-servicing the rest of the nurses and all nurses were in-serviced at 5 AM this morning for the night shift. Interviews on [DATE] from 5:15 PM to 5:45 PM revealed six of six Charge Nurses on the 2:00 PM to 10:00 PM shift (LVNs L, M, N, O, P and Q) all understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse, and had knowledge of their role in a code blue. Interviews with four of four 6:00 AM to 2:00 PM shift Charge Nurses (LVNs F, R, S and T) from 11:13 AM to 11:22 AM after their facility in-service revealed they understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Interviews on [DATE] from 11:20 AM to 11:24 AM, two of two Charge Nurses (LVN U and V) on the night shift both understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse and had knowledge of their role in a code blue. Review of the facility's list of residents who are DNR updated weekly by Social Worker was up-to-date per chart audit and placed on each crash cart. Record Review of Clinical Records for Resident #2, #3, #4 and #5 reflected the facility assessed residents when they had a change of condition and initiated CPR immediately on Resident #2 when he stopped breathing until EMS arrived. Record Review on [DATE] of Nurses' CPR certification revealed nurses were CPR certified on all shifts starting 2 PM to 10 PM shift on Friday [DATE] to Sunday [DATE] on all three shifts. On [DATE] at 7:53 AM the ADON B was informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. The Administrator provided on [DATE] a list of 64 residents with full code status.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician and/or notify the resident's family member when there was a significant change in the resident's physical and/or mental status and a decision to transfer or discharge the resident from the facility for three (Residents #1, #2, and #3) of five residents reviewed for physician consultation. 1. On [DATE], Resident #1 fell and hit his head during a transfer when a gait belt was not used at 10:45 AM. The physician was not notified of the resident's change of condition until 6:00 PM despite: At 2:30 PM, the resident's blood pressure started rising; At 3:00 PM, the resident's blood pressure continued to elevate and the resident's pulse dropped by 20 beats. At 3:30 PM, Resident #1 vomited a large amount of undigested food. The facility left a message for the Nurse Practitioner, which the NP did not respond to. At 5:30 PM, the resident was unresponsive. At 6:00 PM, the resident vomited, and the physician was contacted; At 6:50 PM, 911 was called. The resident was admitted to the hospital and later died . These failures affected Resident #1, who sustained a head injury and a delay in treatment, contributing to the resident's death. 2. On [DATE] at 7:00 AM, Resident #2 began to experience respiratory distress with an abnormal oxygen saturation level of 88%, BP of ,[DATE] and a pulse of 94. The resident reported extreme fatigue. Resident #2 was unable to swallow her medications and spit them out. The physician was not notified. At 9:45 AM, when the resident reported she could not feel anything on her right side, the physician was notified and the resident was sent to the hospital where she remained. 3. Resident #3 was admitted to the facility as post operative for a cardiac triple bypass. On [DATE], she developed an elevated heart rate of 140 and had an oxygen saturation level of 88% at 1:00 AM. The physician was not notified of the resident's change in condition until approximately 9:00 AM (eight hours later) when the resident's heart rate was 136 and irregular. Resident #3 was ordered to go to the hospital, where she was admitted . These failures affected Residents #2 and #3, which resulted in a delay in treatment and the residents' symptoms worsening and being admitted to the hospital, potentially requiring a longer recovery period than necessary. On [DATE] at 10:47 AM, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE] at 4:40 PM, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern" because the facility was still implementing and monitoring the Plan of Removal. These failures could affect the facility's 127 residents in the facility, placing them at risk for not receiving the care and services needed to ensure their safety and a delay in treatment when experiencing a change of condition, resulting in the potential injury and even death. Findings included: The Face Sheet dated [DATE] reflected Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had short term and long term cognitive impairment, and modified independence in decision-making. Resident #1 required the extensive assistance of two persons with bed mobility, transfers, toilet use, personal hygiene and bathing and one person assist with locomotion off and on the unit, dressing and eating. [DIAGNOSES REDACTED]. Review of Resident #1's Itemized ADL Coding Report dated from [DATE] to [DATE] revealed the following: the resident required the assistance of two people for transfers on the following dates: [DATE] [DATE] [DATE] [DATE] [DATE] Resident #1's ADL Plans of Care dated from [DATE] to [DATE] reflected for bathing there was a caution, which reflected assistance was needed for transfers. Resident #1 required the extensive assistance of one person physical assist with bathing. For transfers, the resident required the extensive assistance of one person physical assist for transfers. Special equipment was identified as a gait belt and wheelchair. On [DATE] at 4:25 PM, observation revealed Resident #1 was lying in a hospital bed at a local hospital. His eyes were closed, his color was pale, he was being administered oxygen via nasal cannula and breathing through his mouth. Resident #1 was unresponsive to the surveyor speaking his name. Review of the SBAR (Situation, Background, Assessment, and Request), Physician/NP/PA Communication and Progress Note, dated [DATE], for Resident #1, revealed the nurse documented there was a fall, and an assessment of the resident with regard to head injury. Review of Resident #1's Progress Notes dated [DATE] at 10:45 AM revealed the following: "CNA reported to nurse that resident had fallen backward while in shower stall - CNA ___ (CNA A) had already picked him up transferred him into shower chair showered & groomed him - then - had notified charge nurse -- found resident in shower chair - c/o head hurting found 3 cm red raised area to back of head -- no broken area -- resident alert & explained to nurse what happened & why he fell - area on back of head cleansed (with) soap & H2O patted dry - answering all questions approp. resident very angry (with) (increased) anxiety d/t fall reassured him - complete body check done - MAEW - PEARL - assisted (with) completing dress - resident did not want to go to bed wanted 'coffee' - wheeled resident to dining room & got him coffee - @ 11:15 (AM) / [MEDICATION NAME] 7.5 mg (narcotic [MEDICATION NAME]) po & [MEDICATION NAME] (anti-anxiety) po given -- Neuros (neurological assessments) started & intact." Retrieved on [DATE] from www.Druglib.com regarding Head Injury and Increased Intracranial Pressure - "The respiratory depressant effects of narcotics and their capacity to elevate cerebrospinal fluid pressure may be markedly exaggerated in the presence of head injury, other intracranial [MEDICAL CONDITION] or a preexisting increase in intracranial pressure. Furthermore, narcotics produce adverse reactions which may obscure the clinical course of patients with head injuries." Resident #1's Neurological Evaluation Flow Sheet dated [DATE] reflected neurological checks were conducted every 15 minutes from 10:45 AM until 12:00 PM. Initially Resident #1's BP was slightly elevated at ,[DATE] along with an elevated pulse rate of 92. By 1:30 PM, Resident #1's BP was ,[DATE] with a pulse of 72. The neurological checks, respirations and temperature remained stable. Resident #1's pupils went from being 2 mm in size to 3 mm at 11:30 AM. At 2:30 PM, Resident #1's BP was ,[DATE], with an 18 point increase in the systolic blood pressure and an 11 point increase in the diastolic pressure. At 3:30 PM, Resident #1's systolic BP jumped another 20 points and was ,[DATE]. His pulse rate at that time was 54, a drop of 20 beats per minute from 74. The Neurological Evaluation Flow Sheet reflected the following: 4:00 PM BP ,[DATE] p pulse 56 4:30 PM BP ,[DATE] pulse 54 5:00 PM BP ,[DATE] pulse 54 5:30 PM BP ,[DATE] pulse 65 At 5:00 PM, Resident #1's best motor response was a "6" - which indicated he obeyed commands. At 5:30 PM, Resident #1's best motor response was a "1" - which indicated there was no movement. It remained a "1" for the 6:00 PM and 7:00 PM neuro checks. Resident #1's Progress Notes dated [DATE] reflected the following: At 3:30 PM, Resident #1 was in bed with his eyes closed and was in no distress. His vitals were documented with a BP of ,[DATE] and pulse rate of 54. LVN C documented, "Will continue to monitor." At 4:00 PM, Resident #1 vomited a large amount of undigested food. The Unit Manager was notified. Resident #1's BP was ,[DATE] with a pulse of 54. The NP was called and a message was left. At 5:00 PM, LVN C documented "Still awaiting a return call...." from the NP. Note: Resident #1's BP was ,[DATE]. At 5:30 PM, Resident #1 was "Unresponsive to speech... No movements noted to verbal commands. BP ,[DATE], P - 65, R - 20 Attempted to call ____ (Resident #1's Primary Care Physician's) office. No answer. Will continue to monitor." At 6:00 PM, CNA notified LVN C Resident #1 vomited. The resident had wheezes in the upper lobes of both lungs. Resident #1's oxygen saturation level was 84% on room air and oxygen was started at 2 LPM per nasal canula. (Normal oxygen saturation level is 95 - 100%.) Resident #1's Primary Care Physician was called and an order was received to send the resident to the hospital. At 6:50 PM, another nurse evaluated Resident #1. The resident was unresponsive to a firm sternal rub and voice commands. The second nurse called 911. When Resident #1's soles of his feet were touched, the resident pulled his feet up toward his chest (in a fetal position). "Spastic Hypertonia (muscular tension in spasm) often occurs after a [MEDICAL CONDITION] (TBI) as a result of damage to the [DIAGNOSES REDACTED], cerebellum or mid-brain. The damage affects the reflex centers in the brain, interrupting the flow of messages along various nerve pathways. This disruption of signals can cause changes in muscle tone, movement, sensation and reflex." Retrieved on [DATE] from: <http://main.uab.edu/tbi/show.asp?durki= > On [DATE] at 8:13 AM, LVN B was interviewed on the telephone regarding Resident #1's fall. LVN B told the surveyor on [DATE], at approximately 10:45 AM, CNA A came to the nurses station and informed her Resident #1 had fallen in the shower room. LVN B stated when she went to assess him, Resident #1 told her, "The ___ (S-- of a B----, referring to CNA A) let me fall backward." LVN B said the resident complained of a headache. LVN B added, "___ (CNA A) told me three different times and showed me how (Resident #1) fell ." LVN B further informed the surveyor she assessed the resident whose blood pressure was elevated and the resident had a two cm, red raised area on the back of his head. LVN B stated she obtained Resident #1's vital signs and called the Nurse Practitioner and left a message. When asked if the Nurse Practitioner returned her call, LVN B stated she never did hear from the Nurse Practitioner. The surveyor asked if she called the Nurse Practitioner again or if she called the physician, and she replied she did not. LVN B added she had notified Resident #1's family member about the incident and the resident wanted to talk to his family member. LVN B told the surveyor when she ended her shift, the resident was stable. On [DATE] at 4:36 PM, CNA A was interviewed regarding the incident with Resident #1 when he hit his head. CNA A told the surveyors he (the CNA) was going to give Resident #1 a shower. The CNA took Resident #1 into the shower room and placed him in the shower stall. CNA A stated he had Resident #1 stand and hold onto the grab bars in the shower stall. CNA A said he was holding onto Resident #1's right arm and reaching back for the shower chair when Resident #1 slipped and fell backwards, hitting his head on the shower stall. When the surveyor asked CNA A if the floor was wet, he replied, "Yes." The surveyor then asked if Resident #1 had slippers or socks on, and the CNA replied, "Yes. The resident had on socks." The surveyor then queried if CNA A had use a gait belt during the transfer, and he replied "No," not in the shower room. He did not use a gait belt with Resident #1, because he had not had a problem with the resident before. CNA A said he went and told LVN B, leaving the resident unattended in the shower room. After LVN B checked the resident, she told CNA A to finish up the resident. CNA A dressed Resident #1. CNA A then stated LVN B told him to put Resident #1 in bed, however Resident #1 wanted coffee. CNA A stated, "___ (LVN B) changed her mind and told me to take him to the dining room for coffee." The facility's current policy, One Person Pivot Transfer, (undated) reflected the purpose was to safely get the resident from one surface to another by allowing the resident to participate. "Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot." On [DATE] at 3:59 PM the surveyors, the Unit Manager and the Regional Nurse Consultant went to the shower on the 300 hall where Resident #1 fell . The facility staff was unable to determine how Resident #1 slipped and hit his head. The surveyor observed there were no anti-slip treads on the shower stall floor. On [DATE] at 5:50 PM, the surveyor interviewed LVN C regarding the LVN's assessment of Resident #1. LVN C told the surveyor she assessed him every hour, but when he vomited, she went to the Nurse Manager, who told her to call the physician. LVN C reported she called the NP and left a message. When the surveyor queried whether LVN C had received a call back from the NP, she replied, "No." The surveyor then asked if she called the physician or NP again, and she said she did not call them again until there was a change in Resident #1's mental status. The surveyor asked if LVN C had noticed the change in Resident #1's blood pressure, which was rising. The LVN responded she did not really see the change until his BP went much higher. LVN C added Resident #1 acted like he wanted to throw up. She checked him, put him on oxygen and first she called the NP and then the doctor when she did not get a return call. LVN C stated, "When (Resident #1) became unresponsive, we sent him out 911." [DATE] at 5:49 PM, the surveyor spoke with the Regional Corporate Nurse, who brought in a book entitled INTERACT (Interventions to Reduce Acute Care Transfers) and the SBAR protocol. The Regional Corporate Nurse told the surveyor this program was put in place about a year ago, and the nurses utilized it to help with the assessment of a resident and the guidelines for calling the physician. The Regional Corporate Nurse said the NP attended the inservice regarding the program, but she did not think the Medical Director had ever attended an inservice regarding the system. When the surveyor asked why Resident #1 was not sent to the hospital when the resident experienced a change in condition, they did not respond. They both stated the nurse should have sent the resident out 911 (when the resident presented with a change in condition). Review of the facility's INTERACT tool revealed if the Systolic Blood Pressure is > than 210 or less than 90, the physician should be called immediately. If the resident has sustained a head injury, the tool reflected "... Any head injury with a change in LOC (Loss of Consciousness), mental status, or any focal neurological findings the doctor should be notified." On [DATE] at 9:50 AM, the Primary Care Physician, who was also the facility's Medical Director, was questioned about the SBAR. He stated he was familiar with the SBAR. The surveyor specifically queried the Primary Care Physician about the blood pressure and pulse rate parameters included on the SBAR as to when to notify the physician. As the Primary Care Physician reviewed the SBAR, he stated he would need to make changes in the parameters for blood pressures and pulse rates in regard to head injuries and when to notify the physician. The Primary Care Physician then stated, "The elderly do not have diastolic but systolic [MEDICAL CONDITION]," and he would reset the SBAR parameters. During an interview with the Administrator on [DATE] at 5:50 PM, the surveyor asked why the facility did not report the incident with Resident #1 to DADS, the State agency. The Administrator stated she had discussed the incident with the facility's Regional Corporate Nurse. They determined the incident was not reportable because Resident #1's fall was witnessed and an incident report had been initiated. The Administrator provided the "Guidelines for Reporting Incidents," which the facility followed. One of the guidelines then reviewed by the Administrator and the surveyor was the directive: "The facility must determine if an injury, harm or death of a resident was due to a facility failure to provide services, treatment, or care to a resident." The surveyor pointed out to the Administrator, following Resident #1's fall, the physician was not notified of the resident's change in condition and staff did not respond when his blood pressure increased by 20 points and then when he vomited other than to document the resident would be monitored. On [DATE] at 9:40 AM, the surveyor interviewed the MDS Coordinator, who was providing RN coverage on the day of Resident #1's incident ([DATE]). When asked about Resident #1's assessment, she told the surveyor she was not informed by the facility staff of the resident's fall or the need for an assessment. The MDS Coordinator further stated she had heard about Resident #1's fall, but she was not aware she needed to assess Resident #1. On [DATE] at 4:03 PM, the Primary Care Physician, who was also the facility's Medical Director, was interviewed. The Primary Care Physician stated the facility called him frequently and facility staff would be told to monitor a resident after a fall. However, if the resident started vomiting after a fall then it was "too late." The Primary Care Physician further stated if facility staff could not reach him by phone, "then they can always ship them out 911." Review of Resident #1's hospital's records dated [DATE] revealed the results of a CT Scan. The findings reflected Resident #1 had a large subdural hematoma one the left side of the brain with a 1.6 cm left to right midline shift. There were also samll hemorrhages identified in the left frontal lobe. Medical Decision making reflected Resident #1 had an intracranial bleed and herniation with a poor prognosis. The resident was admitted to the hospital on [DATE]. During a telephone interview on [DATE] at 3:00 PM with the hospital Case Manager, the surveyor was informed the resident had expired on Saturday, [DATE]. 2) The Face Sheet dated [DATE] reflected Resident #2, 81-years-old, was admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #2's MDS assessment dated [DATE] reflected the resident was moderately impaired cognitively for daily decision-making. The MDS assessment reflected the resident required extensive assistance of two plus persons physical assist with bed mobility and transfers. She required the extensive assistance of one person with locomotion, dressing, eating, toilet care, personal hygiene and bathing. Additional [DIAGNOSES REDACTED]. Resident #2's consolidated physician's orders [REDACTED]. [MEDICATION NAME] (antihypertensive) 2.5 mg every 12 hours, hold for S BP less than 120; [MEDICATION NAME] (antihypertensive) 6.25 mg every 12 hours, hold for systolic BP less than 120. Review of Resident #2's Comprehensive Plan of Care dated [DATE] revealed identification of the following problems: Resident takes nine or more medications; ADL functions; [DIAGNOSES REDACTED]. History of Anxiety Incontinence, diarrhea Aspirin as a blood thinner Cognitive Impairment Impaired Communication Decreased mobility, Mobility At risk for falls Hearing deficit [MEDICAL CONDITION] medications Skin breakdown Therapeutic Diet There was no nursing care plan addressing the resident's Hypertension, including interventions to implement when the resident potentially experienced headaches, dizziness, nausea/vomiting, vision problems, generalized weakness and/or episodes of orthostatic [MEDICAL CONDITION]. Resident #2's History and Physical dated [DATE] reflected a past medical history, which included [DIAGNOSES REDACTED]. Resident #2's physician progress notes [REDACTED]. The SBAR Progress Note dated [DATE] at 7:00 AM reflected LVN D documented Resident #2 was complaining of shortness of breath and was wheezing. The physician-ordered Nebulizer treatment was administered. Resident #2's vital signs were BP ,[DATE], pulse 94, respirations 22. The resident had an oxygen saturation level of 88% on room air. Oxygen was administered at a rate of 2 liters per minute per nasal cannula, which brought the resident's saturation level up to 92% (normal is 95 - 100%). Further documentation included Resident #2 was unable to swallow her medications and spit them out. The resident continued to complain of generalized weakness, was tired and was unable to sit in her wheelchair. The resident was assisted to bed, the call light was placed within reach and the resident would continue to be monitored. The SBAR Progress Note dated [DATE] at 9:45 AM reflected the following, which was documented by LVN D. Resident #2 told LVN D she could not feel anything on her right side. LVN D's assessment revealed Resident #2 was unable to hold a cup, could not stand or transfer like she normally could. The Facility Nurse Practitioner was called immediately and LVN D received orders to send Resident #2 to the hospital ER for evaluation and treatment. Resident #2's family member was notified at 10:00 AM, who responded he/she would go to the ER. On the SBAR Progress Note [DATE], below the staff identification legend was a note facility staff reported the issue to the Nurse Practitioner on [DATE] at 10:00 AM. LVN D was interviewed on [DATE] at 8:26 AM regarding Resident #2. LVN D told the surveyor when she entered the resident's room, Resident #2 was complaining of difficulty breathing so she (LVN D) gave her a nebulizer treatment. The resident's blood pressure was already up, and LVN D asked the MA to give Resident #2 her blood pressure medication, but the resident was unable to swallow her pills. When LVN D was asked if she tried to notify the physician or NP at that time about Resident #2, LVN D stated she planned to "just monitor her." The next time the resident called LVN D, she said she could not feel anything on her right side. LVN D stated she thought she called the physician and/or nurse practitioner two times without a response from either. When the surveyor asked LVN D when she called them, she was unable to give specific times of the phone calls. She told the surveyor she had other duties and residents including blood sugars on other residents and she also had to monitor the dining room during breakfast. LVN D added Resident #2's complaints began sometime between 6:30 AM and 7:00 AM. Interview with the Facility Nurse Consultant on [DATE] at approximately 3:00 PM revealed the resident was admitted to the hospital for treatment. 3) Resident #3's Progress Notes dated [DATE] at 6:30 PM reflected Resident #3, a [AGE] year-old female, was admitted to the facility with an admitting [DIAGNOSES REDACTED]. Resident #3's Admission Nursing Evaluation dated [DATE] reflected Resident #3 was admitted to the facility on that date with [DIAGNOSES REDACTED]. Resident #3's BP was ,[DATE] with a pulse rate of 60 beats per minute and respirations of 20. The Evaluation reflected Resident #3's cognitive status was not assessed at that time. The resident required assistance with bed mobility, transfers and dressing. Resident #3 required the assistance of one person with toileting, personal care/hygiene and bathing. The resident was independent with eating. The Evaluation reflected Resident #3 was continent and had no significant skin breakdown. Resident #3's undated Interim Plan of Care identified Orientation to Room, Elopement Risk, Pressure Ulcer Risk, Dehydration Risk, Pressure Ulcers, [MEDICAL CONDITION] Disease, Dental Problems and Nausea/Vomiting as areas to be care planned. Interventions included: turn and reposition, obtain a (anti-pressure) device for the bed/chair, determine likes and dislikes in regard to providing adequate fluids, monitor for signs/symptoms of dehydration and check lung sounds. Resident #3's Daily Skilled Nurses Notes dated [DATE] reflected the resident had no memory problems, and was not impaired for decision-making. The Notes reflected the following at 1:00 AM: "(Resident #3) c/o not (sic) 'feeling bad' O2 concentrator found to not be working. O2 Sat - 88%, P - 140, B/P ,[DATE]. Placed on tank O2@ 2L/min. Will monitor." At !:20 AM, Resident #3's oxygen saturation level was 94%, BP ,[DATE] and respirations were 18. Resident #3 was "Feeling better." There was no further documentation until 7:30 AM. Resident #3's Progress Notes dated [DATE] at 7:30 AM reflected: "In report it was told pt had a restless night with pulse as high as 150 and SOB (with) 02 stat (sic) varying from (upper) 80's to (lower) 90's on 2 liters (of oxygen per) N/C." Assessment reflected no shortness of breath but Resident #3 was awake and confirmed her restlessness. She denied chest pain, but reported minor chest pressure. At that time, the resident's apical pulse was 145 and irregular in pattern. (An apical pulse is measured directly over the heart.) Resident #3's Progress Notes dated [DATE] at 8:30 AM reflected her "...pulse was 136 and still irregular in sound and for this reason cannot obtain a blood pressure. ...Called FNP and awaiting response...." At 9:00 AM, an order was received to send to the ER for evaluation and at 9:30 AM, Resident #3 was discharged and her family member was notified. At 1:00 PM, Resident #3's family member contacted the facility and told them she was planning on seeing Resident #3 in the hospital. The Physician's Telephone Order dated [DATE] reflected to send Resident #3 to the ER, status/post Triple Bypass and for [MEDICAL CONDITION](increased heart rate) and decreased oxygen saturation level. Resident #3's transport service Patient Care Record dated [DATE] reflected the Primary Impression was Cardiac Rhythm Disturbance. At 9:20 AM, the resident's pulse rate was 116 and at 9:30 AM, it was 120. The ECG reflected the resident had [MEDICAL CONDITION] Fibrillation. Medical Necessity reflected, "Admit to Hospital...." Attempts to contact facility staff providing care for Resident #3 were unsuccessful. 4) On [DATE] at approximately 9:00 AM, the surveyor interviewed the Regional Nurse Consultant in regard to Residents #2 and #3, who both experienced a change in condition and the physician/NP were not notified when the change in condition was first detected. The Regional Nurse Consultant did not voice any comments on the notes documenting these incidents, but just looked at them. The surveyor stated a review of the clinical records for two other residents with changes in condition resulted in immediate 911 calls. The surveyor queried the Regional Nurse Consultant in regard to Residents #1, #2 and #3, who experienced changes in condition without immediate 911 calls. The Regional Nurse Consultant referred to the SBAR as an assessment guide, and staff could call 911 if they could not get the physician to return their call. On [DATE] at approximately 9:32 AM, the surveyor interviewed the Facility Nurse Consultant regarding Residents #1, #2 and #3 and their need for emergency care, the facility nurses' assessments and the evaluation of those assessments in obtaining prompt medical care. The Facility Nurse Consultant informed the surveyor the facility had started to inservice the staff the evening of [DATE] in regard to assessments, notifying the physician and calling 911. 5) Review of the facility's current Nursing Services Policy and Procedure Manual 2001 MED-PASS Inc, revised [DATE], revealed : Change in a Resident's Condition or Status. Policy Statement "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On Call Physician when there has been: a. An accident or incident involving the resident; ...d. A significant change in the resident's physical/emotional condition; ...g. A need to transfer the resident to a hospital/treatment center... 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one area of the resident's health status... 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change in the resident's medical/mental condition or status...." 6) Review of the facility's current policy and procedure for the Abuse Prevention Program dated with a revision date of [DATE] revealed the following policy statement: "Our residents have the right to be free from... neglect...." Policy Interpretation and Implementation "...3. Comprehensive policies and procedures have been developed to aid our facility in preventing ...neglect... of our residents. Recognizing Signs and Symptoms of Abuse/Neglect Policy Statement "Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect...." Policy Interpretation and Implementation "...2. 'Neglect' is defined as the failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and sign and symptoms of abuse/neglect that should be promptly reported... ...b. Signs of/Actual Physical Neglect: ...Improper use/administration of medication; Inadequate provision of care; ...Leaving someone unattended who needs supervision...." 7) On [DATE] at 11:06 AM, the Administrator, the Regional Corporate Nurse and the Regional Vice President were notified an IJ had been identified in the area of Resident Behavior/Facility Practice. A Plan of Removal was requested for the IJ. 8) On [DATE] at 4:50 PM, the surveyor interviewed the Administrator regarding the IJ and what policies were put in place to ensure the nursing needs of the residents were being met. The Administrator stated there had been a history in the facility of inconsistent leadership, and she had been at the facility the past four months. She was holding staff accountable for their actions, and there had been a lot of turn over in staff. The Administrator further stated they would continue to inservice staff, follow up with Quality Assurance meetings and resident assessments. She further stated they had developed action plans for areas of concern, especially identifying safe handling of residents, transfers and falls. They planned on doing extensive training with the staff. The Administrator went on to say there were multiple system failures, which she had been hired to address. 9) A Plan of Removal of the IJ was provided by the facility and was accepted on [DATE] at 4:40 PM and reflected the following: (1) The Medical Director was notified by the Regional VP of Operations of the IJ situation on [DATE] at around 1:15 PM. (2) Re-educate all licensed nurses on immediately assessing a resident with noted significant change of condition to include checking blood pressure, pulse, respiration, temperature, oxygen saturation, pain, mental status and

Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures that prohibited neglect for three (Residents #1, #2, and #3) of five residents reviewed for neglect. 1. On [DATE], Resident #1 fell and hit his head during a transfer when a gait belt was not used at 10:45 AM. The physician was not notified of the resident's change of condition until 6:00 PM despite: At 2:30 PM, the resident's blood pressure started rising; At 3:00 PM, the resident's blood pressure continued to elevate and the resident's pulse dropped by 20 beats. At 3:30 PM, Resident #1 vomited a large amount of undigested food. The facility left a message for the Nurse Practitioner, which the NP did not respond to. At 5:30 PM, the resident was unresponsive. At 6:00 PM, the resident vomited, and the physician was contacted; At 6:50 PM, 911 was called. The resident was admitted to the hospital and later died . These failures affected Resident #1, who sustained a head injury and a delay in treatment, contributing to the resident's death. 2. On [DATE] at 7:00 AM, Resident #2 began to experience respiratory distress with an abnormal oxygen saturation level of 88%, BP of ,[DATE] and a pulse of 94. The resident reported extreme fatigue. Resident #2 was unable to swallow her medications and spit them out. The physician was not notified. At 9:45 AM, when the resident reported she could not feel anything on her right side, the physician was notified and the resident was sent to the hospital where she remained. 3. Resident #3 was admitted to the facility as post operative for a cardiac triple bypass. On [DATE], she developed an elevated heart rate of 140 and had an oxygen saturation level of 88% at 1:00 AM. The physician was not notified of the resident's change in condition until approximately 9:00 AM (eight hours later) when the resident's heart rate was 136 and irregular. Resident #3 was ordered to go to the hospital, where she was admitted . These failures affected Residents #2 and #3, which resulted in a delay in treatment and the residents' symptoms worsening and being admitted to the hospital, potentially requiring a longer recovery period than necessary. On [DATE] at 10:47 AM, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE] at 4:40 PM, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern" because the facility was still implementing and monitoring the Plan of Removal. These failures could affect the facility's 127 residents in the facility, placing them at risk for not receiving the care and services needed to ensure their safety and a delay in treatment when experiencing a change of condition, resulting in the potential injury and even death. Findings included: The Face Sheet dated [DATE] reflected Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had short term and long term cognitive impairment, and modified independence in decision-making. Resident #1 required the extensive assistance of two persons with bed mobility, transfers, toilet use, personal hygiene and bathing and one person assist with locomotion off and on the unit, dressing and eating. [DIAGNOSES REDACTED]. Review of Resident #1's Itemized ADL Coding Report dated from [DATE] to [DATE] revealed the following: the resident required the assistance of two people for transfers on the following dates: [DATE] [DATE] [DATE] [DATE] [DATE] Resident #1's ADL Plans of Care dated from [DATE] to [DATE] reflected for bathing there was a caution, which reflected assistance was needed for transfers. Resident #1 required the extensive assistance of one person physical assist with bathing. For transfers, the resident required the extensive assistance of one person physical assist for transfers. Special equipment was identified as a gait belt and wheelchair. On [DATE] at 4:25 PM, observation revealed Resident #1 was lying in a hospital bed at a local hospital. His eyes were closed, his color was pale, he was being administered oxygen via nasal cannula and breathing through his mouth. Resident #1 was unresponsive to the surveyor speaking his name. Review of the SBAR (Situation, Background, Assessment, and Request), Physician/NP/PA Communication and Progress Note, dated [DATE], for Resident #1, revealed the nurse documented there was a fall, and an assessment of the resident with regard to head injury. Review of Resident #1's Progress Notes dated [DATE] at 10:45 AM revealed the following: "CNA reported to nurse that resident had fallen backward while in shower stall - CNA ___ (CNA A) had already picked him up transferred him into shower chair showered & groomed him - then - had notified charge nurse -- found resident in shower chair - c/o head hurting found 3 cm red raised area to back of head -- no broken area -- resident alert & explained to nurse what happened & why he fell - area on back of head cleansed (with) soap & H2O patted dry - answering all questions approp. resident very angry (with) (increased) anxiety d/t fall reassured him - complete body check done - MAEW - PEARL - assisted (with) completing dress - resident did not want to go to bed wanted 'coffee' - wheeled resident to dining room & got him coffee - @ 11:15 (AM) / [MEDICATION NAME] 7.5 mg (narcotic [MEDICATION NAME]) po & [MEDICATION NAME] (anti-anxiety) po given -- Neuros (neurological assessments) started & intact." Retrieved on [DATE] from www.Druglib.com regarding Head Injury and Increased Intracranial Pressure - "The respiratory depressant effects of narcotics and their capacity to elevate cerebrospinal fluid pressure may be markedly exaggerated in the presence of head injury, other intracranial [MEDICAL CONDITION] or a preexisting increase in intracranial pressure. Furthermore, narcotics produce adverse reactions which may obscure the clinical course of patients with head injuries." Resident #1's Neurological Evaluation Flow Sheet dated [DATE] reflected neurological checks were conducted every 15 minutes from 10:45 AM until 12:00 PM. Initially Resident #1's BP was slightly elevated at ,[DATE] along with an elevated pulse rate of 92. By 1:30 PM, Resident #1's BP was ,[DATE] with a pulse of 72. The neurological checks, respirations and temperature remained stable. Resident #1's pupils went from being 2 mm in size to 3 mm at 11:30 AM. At 2:30 PM, Resident #1's BP was ,[DATE], with an 18 point increase in the systolic blood pressure and an 11 point increase in the diastolic pressure. At 3:30 PM, Resident #1's systolic BP jumped another 20 points and was ,[DATE]. His pulse rate at that time was 54, a drop of 20 beats per minute from 74. The Neurological Evaluation Flow Sheet reflected the following: 4:00 PM BP ,[DATE] p pulse 56 4:30 PM BP ,[DATE] pulse 54 5:00 PM BP ,[DATE] pulse 54 5:30 PM BP ,[DATE] pulse 65 At 5:00 PM, Resident #1's best motor response was a "6" - which indicated he obeyed commands. At 5:30 PM, Resident #1's best motor response was a "1" - which indicated there was no movement. It remained a "1" for the 6:00 PM and 7:00 PM neuro checks. Resident #1's Progress Notes dated [DATE] reflected the following: At 3:30 PM, Resident #1 was in bed with his eyes closed and was in no distress. His vitals were documented with a BP of ,[DATE] and pulse rate of 54. LVN C documented, "Will continue to monitor." At 4:00 PM, Resident #1 vomited a large amount of undigested food. The Unit Manager was notified. Resident #1's BP was ,[DATE] with a pulse of 54. The NP was called and a message was left. At 5:00 PM, LVN C documented "Still awaiting a return call...." from the NP. Note: Resident #1's BP was ,[DATE]. At 5:30 PM, Resident #1 was "Unresponsive to speech... No movements noted to verbal commands. BP ,[DATE], P - 65, R - 20 Attempted to call ____ (Resident #1's Primary Care Physician's) office. No answer. Will continue to monitor." At 6:00 PM, CNA notified LVN C Resident #1 vomited. The resident had wheezes in the upper lobes of both lungs. Resident #1's oxygen saturation level was 84% on room air and oxygen was started at 2 LPM per nasal canula. (Normal oxygen saturation level is 95 - 100%.) Resident #1's Primary Care Physician was called and an order was received to send the resident to the hospital. At 6:50 PM, another nurse evaluated Resident #1. The resident was unresponsive to a firm sternal rub and voice commands. The second nurse called 911. When Resident #1's soles of his feet were touched, the resident pulled his feet up toward his chest (in a fetal position). "Spastic Hypertonia (muscular tension in spasm) often occurs after a [MEDICAL CONDITION] (TBI) as a result of damage to the [DIAGNOSES REDACTED], cerebellum or mid-brain. The damage affects the reflex centers in the brain, interrupting the flow of messages along various nerve pathways. This disruption of signals can cause changes in muscle tone, movement, sensation and reflex." Retrieved on [DATE] from: <http://main.uab.edu/tbi/show.asp?durki= > On [DATE] at 8:13 AM, LVN B was interviewed on the telephone regarding Resident #1's fall. LVN B told the surveyor on [DATE], at approximately 10:45 AM, CNA A came to the nurses station and informed her Resident #1 had fallen in the shower room. LVN B stated when she went to assess him, Resident #1 told her, "The ___ (S-- of a B----, referring to CNA A) let me fall backward." LVN B said the resident complained of a headache. LVN B added, "___ (CNA A) told me three different times and showed me how (Resident #1) fell ." LVN B further informed the surveyor she assessed the resident whose blood pressure was elevated and the resident had a two cm, red raised area on the back of his head. LVN B stated she obtained Resident #1's vital signs and called the Nurse Practitioner and left a message. When asked if the Nurse Practitioner returned her call, LVN B stated she never did hear from the Nurse Practitioner. The surveyor asked if she called the Nurse Practitioner again or if she called the physician, and she replied she did not. LVN B added she had notified Resident #1's family member about the incident and the resident wanted to talk to his family member. LVN B told the surveyor when she ended her shift, the resident was stable. On [DATE] at 4:36 PM, CNA A was interviewed regarding the incident with Resident #1 when he hit his head. CNA A told the surveyors he (the CNA) was going to give Resident #1 a shower. The CNA took Resident #1 into the shower room and placed him in the shower stall. CNA A stated he had Resident #1 stand and hold onto the grab bars in the shower stall. CNA A said he was holding onto Resident #1's right arm and reaching back for the shower chair when Resident #1 slipped and fell backwards, hitting his head on the shower stall. When the surveyor asked CNA A if the floor was wet, he replied, "Yes." The surveyor then asked if Resident #1 had slippers or socks on, and the CNA replied, "Yes. The resident had on socks." The surveyor then queried if CNA A had use a gait belt during the transfer, and he replied "No," not in the shower room. He did not use a gait belt with Resident #1, because he had not had a problem with the resident before. CNA A said he went and told LVN B, leaving the resident unattended in the shower room. After LVN B checked the resident, she told CNA A to finish up the resident. CNA A dressed Resident #1. CNA A then stated LVN B told him to put Resident #1 in bed, however Resident #1 wanted coffee. CNA A stated, "___ (LVN B) changed her mind and told me to take him to the dining room for coffee." The facility's current policy, One Person Pivot Transfer, (undated) reflected the purpose was to safely get the resident from one surface to another by allowing the resident to participate. "Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot." On [DATE] at 3:59 PM the surveyors, the Unit Manager and the Regional Nurse Consultant went to the shower on the 300 hall where Resident #1 fell . The facility staff was unable to determine how Resident #1 slipped and hit his head. The surveyor observed there were no anti-slip treads on the shower stall floor. On [DATE] at 5:50 PM, the surveyor interviewed LVN C regarding the LVN's assessment of Resident #1. LVN C told the surveyor she assessed him every hour, but when he vomited, she went to the Nurse Manager, who told her to call the physician. LVN C reported she called the NP and left a message. When the surveyor queried whether LVN C had received a call back from the NP, she replied, "No." The surveyor then asked if she called the physician or NP again, and she said she did not call them again until there was a change in Resident #1's mental status. The surveyor asked if LVN C had noticed the change in Resident #1's blood pressure, which was rising. The LVN responded she did not really see the change until his BP went much higher. LVN C added Resident #1 acted like he wanted to throw up. She checked him, put him on oxygen and first she called the NP and then the doctor when she did not get a return call. LVN C stated, "When (Resident #1) became unresponsive, we sent him out 911." [DATE] at 5:49 PM, the surveyor spoke with the Regional Corporate Nurse, who brought in a book entitled INTERACT (Interventions to Reduce Acute Care Transfers) and the SBAR protocol. The Regional Corporate Nurse told the surveyor this program was put in place about a year ago, and the nurses utilized it to help with the assessment of a resident and the guidelines for calling the physician. The Regional Corporate Nurse said the NP attended the inservice regarding the program, but she did not think the Medical Director had ever attended an inservice regarding the system. When the surveyor asked why Resident #1 was not sent to the hospital when the resident experienced a change in condition, they did not respond. They both stated the nurse should have sent the resident out 911 (when the resident presented with a change in condition). Review of the facility's INTERACT tool revealed if the Systolic Blood Pressure is > than 210 or less than 90, the physician should be called immediately. If the resident has sustained a head injury, the tool reflected "... Any head injury with a change in LOC (Loss of Consciousness), mental status, or any focal neurological findings the doctor should be notified." On [DATE] at 9:50 AM, the Primary Care Physician, who was also the facility's Medical Director, was questioned about the SBAR. He stated he was familiar with the SBAR. The surveyor specifically queried the Primary Care Physician about the blood pressure and pulse rate parameters included on the SBAR as to when to notify the physician. As the Primary Care Physician reviewed the SBAR, he stated he would need to make changes in the parameters for blood pressures and pulse rates in regard to head injuries and when to notify the physician. The Primary Care Physician then stated, "The elderly do not have diastolic but systolic [MEDICAL CONDITION]," and he would reset the SBAR parameters. During an interview with the Administrator on [DATE] at 5:50 PM, the surveyor asked why the facility did not report the incident with Resident #1 to DADS, the State agency. The Administrator stated she had discussed the incident with the facility's Regional Corporate Nurse. They determined the incident was not reportable because Resident #1's fall was witnessed and an incident report had been initiated. The Administrator provided the "Guidelines for Reporting Incidents," which the facility followed. One of the guidelines then reviewed by the Administrator and the surveyor was the directive: "The facility must determine if an injury, harm or death of a resident was due to a facility failure to provide services, treatment, or care to a resident." The surveyor pointed out to the Administrator, following Resident #1's fall, the physician was not notified of the resident's change in condition and staff did not respond when his blood pressure increased by 20 points and then when he vomited other than to document the resident would be monitored. On [DATE] at 9:40 AM, the surveyor interviewed the MDS Coordinator, who was providing RN coverage on the day of Resident #1's incident ([DATE]). When asked about Resident #1's assessment, she told the surveyor she was not informed by the facility staff of the resident's fall or the need for an assessment. The MDS Coordinator further stated she had heard about Resident #1's fall, but she was not aware she needed to assess Resident #1. On [DATE] at 4:03 PM, the Primary Care Physician, who was also the facility's Medical Director, was interviewed. The Primary Care Physician stated the facility called him frequently and facility staff would be told to monitor a resident after a fall. However, if the resident started vomiting after a fall then it was "too late." The Primary Care Physician further stated if facility staff could not reach him by phone, "then they can always ship them out 911." Review of Resident #1's hospital's records dated [DATE] revealed the results of a CT Scan. The findings reflected Resident #1 had a large subdural hematoma one the left side of the brain with a 1.6 cm left to right midline shift. There were also samll hemorrhages identified in the left frontal lobe. Medical Decision making reflected Resident #1 had an intracranial bleed and herniation with a poor prognosis. The resident was admitted to the hospital on [DATE]. During a telephone interview on [DATE] at 3:00 PM with the hospital Case Manager, the surveyor was informed the resident had expired on Saturday, [DATE]. 2) The Face Sheet dated [DATE] reflected Resident #2, 81-years-old, was admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #2's MDS assessment dated [DATE] reflected the resident was moderately impaired cognitively for daily decision-making. The MDS assessment reflected the resident required extensive assistance of two plus persons physical assist with bed mobility and transfers. She required the extensive assistance of one person with locomotion, dressing, eating, toilet care, personal hygiene and bathing. Additional [DIAGNOSES REDACTED]. Resident #2's consolidated physician's orders [REDACTED]. [MEDICATION NAME] (antihypertensive) 2.5 mg every 12 hours, hold for S BP less than 120; [MEDICATION NAME] (antihypertensive) 6.25 mg every 12 hours, hold for systolic BP less than 120. Review of Resident #2's Comprehensive Plan of Care dated [DATE] revealed identification of the following problems: Resident takes nine or more medications; ADL functions; [DIAGNOSES REDACTED]. History of Anxiety Incontinence, diarrhea Aspirin as a blood thinner Cognitive Impairment Impaired Communication Decreased mobility, Mobility At risk for falls Hearing deficit [MEDICAL CONDITION] medications Skin breakdown Therapeutic Diet There was no nursing care plan addressing the resident's Hypertension, including interventions to implement when the resident potentially experienced headaches, dizziness, nausea/vomiting, vision problems, generalized weakness and/or episodes of orthostatic [MEDICAL CONDITION]. Resident #2's History and Physical dated [DATE] reflected a past medical history, which included [DIAGNOSES REDACTED]. Resident #2's physician progress notes [REDACTED]. The SBAR Progress Note dated [DATE] at 7:00 AM reflected LVN D documented Resident #2 was complaining of shortness of breath and was wheezing. The physician-ordered Nebulizer treatment was administered. Resident #2's vital signs were BP ,[DATE], pulse 94, respirations 22. The resident had an oxygen saturation level of 88% on room air. Oxygen was administered at a rate of 2 liters per minute per nasal cannula, which brought the resident's saturation level up to 92% (normal is 95 - 100%). Further documentation included Resident #2 was unable to swallow her medications and spit them out. The resident continued to complain of generalized weakness, was tired and was unable to sit in her wheelchair. The resident was assisted to bed, the call light was placed within reach and the resident would continue to be monitored. The SBAR Progress Note dated [DATE] at 9:45 AM reflected the following, which was documented by LVN D. Resident #2 told LVN D she could not feel anything on her right side. LVN D's assessment revealed Resident #2 was unable to hold a cup, could not stand or transfer like she normally could. The Facility Nurse Practitioner was called immediately and LVN D received orders to send Resident #2 to the hospital ER for evaluation and treatment. Resident #2's family member was notified at 10:00 AM, who responded he/she would go to the ER. On the SBAR Progress Note [DATE], below the staff identification legend was a note facility staff reported the issue to the Nurse Practitioner on [DATE] at 10:00 AM. LVN D was interviewed on [DATE] at 8:26 AM regarding Resident #2. LVN D told the surveyor when she entered the resident's room, Resident #2 was complaining of difficulty breathing so she (LVN D) gave her a nebulizer treatment. The resident's blood pressure was already up, and LVN D asked the MA to give Resident #2 her blood pressure medication, but the resident was unable to swallow her pills. When LVN D was asked if she tried to notify the physician or NP at that time about Resident #2, LVN D stated she planned to "just monitor her." The next time the resident called LVN D, she said she could not feel anything on her right side. LVN D stated she thought she called the physician and/or nurse practitioner two times without a response from either. When the surveyor asked LVN D when she called them, she was unable to give specific times of the phone calls. She told the surveyor she had other duties and residents including blood sugars on other residents and she also had to monitor the dining room during breakfast. LVN D added Resident #2's complaints began sometime between 6:30 AM and 7:00 AM. Interview with the Facility Nurse Consultant on [DATE] at approximately 3:00 PM revealed the resident was admitted to the hospital for treatment. 3) Resident #3's Progress Notes dated [DATE] at 6:30 PM reflected Resident #3, a [AGE] year-old female, was admitted to the facility with an admitting [DIAGNOSES REDACTED]. Resident #3's Admission Nursing Evaluation dated [DATE] reflected Resident #3 was admitted to the facility on that date with [DIAGNOSES REDACTED]. Resident #3's BP was ,[DATE] with a pulse rate of 60 beats per minute and respirations of 20. The Evaluation reflected Resident #3's cognitive status was not assessed at that time. The resident required assistance with bed mobility, transfers and dressing. Resident #3 required the assistance of one person with toileting, personal care/hygiene and bathing. The resident was independent with eating. The Evaluation reflected Resident #3 was continent and had no significant skin breakdown. Resident #3's undated Interim Plan of Care identified Orientation to Room, Elopement Risk, Pressure Ulcer Risk, Dehydration Risk, Pressure Ulcers, [MEDICAL CONDITION] Disease, Dental Problems and Nausea/Vomiting as areas to be care planned. Interventions included: turn and reposition, obtain a (anti-pressure) device for the bed/chair, determine likes and dislikes in regard to providing adequate fluids, monitor for signs/symptoms of dehydration and check lung sounds. Resident #3's Daily Skilled Nurses Notes dated [DATE] reflected the resident had no memory problems, and was not impaired for decision-making. The Notes reflected the following at 1:00 AM: "(Resident #3) c/o not (sic) 'feeling bad' O2 concentrator found to not be working. O2 Sat - 88%, P - 140, B/P ,[DATE]. Placed on tank O2@ 2L/min. Will monitor." At !:20 AM, Resident #3's oxygen saturation level was 94%, BP ,[DATE] and respirations were 18. Resident #3 was "Feeling better." There was no further documentation until 7:30 AM. Resident #3's Progress Notes dated [DATE] at 7:30 AM reflected: "In report it was told pt had a restless night with pulse as high as 150 and SOB (with) 02 stat (sic) varying from (upper) 80's to (lower) 90's on 2 liters (of oxygen per) N/C." Assessment reflected no shortness of breath but Resident #3 was awake and confirmed her restlessness. She denied chest pain, but reported minor chest pressure. At that time, the resident's apical pulse was 145 and irregular in pattern. (An apical pulse is measured directly over the heart.) Resident #3's Progress Notes dated [DATE] at 8:30 AM reflected her "...pulse was 136 and still irregular in sound and for this reason cannot obtain a blood pressure. ...Called FNP and awaiting response...." At 9:00 AM, an order was received to send to the ER for evaluation and at 9:30 AM, Resident #3 was discharged and her family member was notified. At 1:00 PM, Resident #3's family member contacted the facility and told them she was planning on seeing Resident #3 in the hospital. The Physician's Telephone Order dated [DATE] reflected to send Resident #3 to the ER, status/post Triple Bypass and for [MEDICAL CONDITION](increased heart rate) and decreased oxygen saturation level. Resident #3's transport service Patient Care Record dated [DATE] reflected the Primary Impression was Cardiac Rhythm Disturbance. At 9:20 AM, the resident's pulse rate was 116 and at 9:30 AM, it was 120. The ECG reflected the resident had [MEDICAL CONDITION] Fibrillation. Medical Necessity reflected, "Admit to Hospital...." Attempts to contact facility staff providing care for Resident #3 were unsuccessful. 4) On [DATE] at approximately 9:00 AM, the surveyor interviewed the Regional Nurse Consultant in regard to Residents #2 and #3, who both experienced a change in condition and the physician/NP were not notified when the change in condition was first detected. The Regional Nurse Consultant did not voice any comments on the notes documenting these incidents, but just looked at them. The surveyor stated a review of the clinical records for two other residents with changes in condition resulted in immediate 911 calls. The surveyor queried the Regional Nurse Consultant in regard to Residents #1, #2 and #3, who experienced changes in condition without immediate 911 calls. The Regional Nurse Consultant referred to the SBAR as an assessment guide, and staff could call 911 if they could not get the physician to return their call. On [DATE] at approximately 9:32 AM, the surveyor interviewed the Facility Nurse Consultant regarding Residents #1, #2 and #3 and their need for emergency care, the facility nurses' assessments and the evaluation of those assessments in obtaining prompt medical care. The Facility Nurse Consultant informed the surveyor the facility had started to inservice the staff the evening of [DATE] in regard to assessments, notifying the physician and calling 911. 5) Review of the facility's current Nursing Services Policy and Procedure Manual 2001 MED-PASS Inc, revised [DATE], revealed : Change in a Resident's Condition or Status. Policy Statement "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On Call Physician when there has been: a. An accident or incident involving the resident; ...d. A significant change in the resident's physical/emotional condition; ...g. A need to transfer the resident to a hospital/treatment center... 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one area of the resident's health status... 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change in the resident's medical/mental condition or status...." 6) Review of the facility's current policy and procedure for the Abuse Prevention Program dated with a revision date of [DATE] revealed the following policy statement: "Our residents have the right to be free from... neglect...." Policy Interpretation and Implementation "...3. Comprehensive policies and procedures have been developed to aid our facility in preventing ...neglect... of our residents. Recognizing Signs and Symptoms of Abuse/Neglect Policy Statement "Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect...." Policy Interpretation and Implementation "...2. 'Neglect' is defined as the failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and sign and symptoms of abuse/neglect that should be promptly reported... ...b. Signs of/Actual Physical Neglect: ...Improper use/administration of medication; Inadequate provision of care; ...Leaving someone unattended who needs supervision...." 7) On [DATE] at 11:06 AM, the Administrator, the Regional Corporate Nurse and the Regional Vice President were notified an IJ had been identified in the area of Resident Behavior/Facility Practice. A Plan of Removal was requested for the IJ. 8) On [DATE] at 4:50 PM, the surveyor interviewed the Administrator regarding the IJ and what policies were put in place to ensure the nursing needs of the residents were being met. The Administrator stated there had been a history in the facility of inconsistent leadership, and she had been at the facility the past four months. She was holding staff accountable for their actions, and there had been a lot of turn over in staff. The Administrator further stated they would continue to inservice staff, follow up with Quality Assurance meetings and resident assessments. She further stated they had developed action plans for areas of concern, especially identifying safe handling of residents, transfers and falls. They planned on doing extensive training with the staff. The Administrator went on to say there were multiple system failures, which she had been hired to address. 9) A Plan of Removal of the IJ was provided by the facility and was accepted on [DATE] at 4:40 PM and reflected the following: (1) The Medical Director was notified by the Regional VP of Operations of the IJ situation on [DATE] at around 1:15 PM. (2) Re-educate all licensed nurses on immediately assessing a resident with noted significant change of condition to include checking blood pressure, pulse, respiration, temperature, oxygen saturation, pain, mental status and range of motion and immediately notifying the physician and family regarding abnormal assessment. A competency based test will be given to each licensed nurse. The Nursing Services Policy a

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures that prohibited neglect for three (Residents #1, #2, and #3) of five residents reviewed for neglect. 1. On [DATE], Resident #1 fell and hit his head during a transfer when a gait belt was not used at 10:45 AM. The physician was not notified of the resident's change of condition until 6:00 PM despite: At 2:30 PM, the resident's blood pressure started rising; At 3:00 PM, the resident's blood pressure continued to elevate and the resident's pulse dropped by 20 beats. At 3:30 PM, Resident #1 vomited a large amount of undigested food. The facility left a message for the Nurse Practitioner, which the NP did not respond to. At 5:30 PM, the resident was unresponsive. At 6:00 PM, the resident vomited, and the physician was contacted; At 6:50 PM, 911 was called. The resident was admitted to the hospital and later died . These failures affected Resident #1, who sustained a head injury and a delay in treatment, contributing to the resident's death. 2. On [DATE] at 7:00 AM, Resident #2 began to experience respiratory distress with an abnormal oxygen saturation level of 88%, BP of ,[DATE] and a pulse of 94. The resident reported extreme fatigue. Resident #2 was unable to swallow her medications and spit them out. The physician was not notified. At 9:45 AM, when the resident reported she could not feel anything on her right side, the physician was notified and the resident was sent to the hospital where she remained. 3. Resident #3 was admitted to the facility as post operative for a cardiac triple bypass. On [DATE], she developed an elevated heart rate of 140 and had an oxygen saturation level of 88% at 1:00 AM. The physician was not notified of the resident's change in condition until approximately 9:00 AM (eight hours later) when the resident's heart rate was 136 and irregular. Resident #3 was ordered to go to the hospital, where she was admitted . These failures affected Residents #2 and #3, which resulted in a delay in treatment and the residents' symptoms worsening and being admitted to the hospital, potentially requiring a longer recovery period than necessary. On [DATE] at 10:47 AM, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE] at 4:40 PM, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern" because the facility was still implementing and monitoring the Plan of Removal. These failures could affect the facility's 127 residents in the facility, placing them at risk for not receiving the care and services needed to ensure their safety and a delay in treatment when experiencing a change of condition, resulting in the potential injury and even death. Findings included: 1) Review of the facility's current policy and procedure for the Abuse Prevention Program dated with a revision date of [DATE] revealed the following policy statement: "Our residents have the right to be free from... neglect...." Policy Interpretation and Implementation "...3. Comprehensive policies and procedures have been developed to aid our facility in preventing ...neglect... of our residents. Recognizing Signs and Symptoms of Abuse/Neglect Policy Statement "Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect...." Policy Interpretation and Implementation "...2. 'Neglect' is defined as the failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and sign and symptoms of abuse/neglect that should be promptly reported... ...b. Signs of/Actual Physical Neglect: ...Improper use/administration of medication; Inadequate provision of care; ...Leaving someone unattended who needs supervision...." 2) The Face Sheet dated [DATE] reflected Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had short term and long term cognitive impairment, and modified independence in decision-making. Resident #1 required the extensive assistance of two persons with bed mobility, transfers, toilet use, personal hygiene and bathing and one person assist with locomotion off and on the unit, dressing and eating. [DIAGNOSES REDACTED]. Review of Resident #1's Itemized ADL Coding Report dated from [DATE] to [DATE] revealed the following: the resident required the assistance of two people for transfers on the following dates: [DATE] [DATE] [DATE] [DATE] [DATE] Resident #1's ADL Plans of Care dated from [DATE] to [DATE] reflected for bathing there was a caution, which reflected assistance was needed for transfers. Resident #1 required the extensive assistance of one person physical assist with bathing. For transfers, the resident required the extensive assistance of one person physical assist for transfers. Special equipment was identified as a gait belt and wheelchair. On [DATE] at 4:25 PM, observation revealed Resident #1 was lying in a hospital bed at a local hospital. His eyes were closed, his color was pale, he was being administered oxygen via nasal cannula and breathing through his mouth. Resident #1 was unresponsive to the surveyor speaking his name. Review of the SBAR (Situation, Background, Assessment, and Request), Physician/NP/PA Communication and Progress Note, dated [DATE], for Resident #1, revealed the nurse documented there was a fall, and an assessment of the resident with regard to head injury. Review of Resident #1's Progress Notes dated [DATE] at 10:45 AM revealed the following: "CNA reported to nurse that resident had fallen backward while in shower stall - CNA ___ (CNA A) had already picked him up transferred him into shower chair showered & groomed him - then - had notified charge nurse -- found resident in shower chair - c/o head hurting found 3 cm red raised area to back of head -- no broken area -- resident alert & explained to nurse what happened & why he fell - area on back of head cleansed (with) soap & H2O patted dry - answering all questions approp. resident very angry (with) (increased) anxiety d/t fall reassured him - complete body check done - MAEW - PEARL - assisted (with) completing dress - resident did not want to go to bed wanted 'coffee' - wheeled resident to dining room & got him coffee - @ 11:15 (AM) / [MEDICATION NAME] 7.5 mg (narcotic [MEDICATION NAME]) po & [MEDICATION NAME] (anti-anxiety) po given -- Neuros (neurological assessments) started & intact." Retrieved on [DATE] from www.Druglib.com regarding Head Injury and Increased Intracranial Pressure - "The respiratory depressant effects of narcotics and their capacity to elevate cerebrospinal fluid pressure may be markedly exaggerated in the presence of head injury, other intracranial [MEDICAL CONDITION] or a preexisting increase in intracranial pressure. Furthermore, narcotics produce adverse reactions which may obscure the clinical course of patients with head injuries." Resident #1's Neurological Evaluation Flow Sheet dated [DATE] reflected neurological checks were conducted every 15 minutes from 10:45 AM until 12:00 PM. Initially Resident #1's BP was slightly elevated at ,[DATE] along with an elevated pulse rate of 92. By 1:30 PM, Resident #1's BP was ,[DATE] with a pulse of 72. The neurological checks, respirations and temperature remained stable. Resident #1's pupils went from being 2 mm in size to 3 mm at 11:30 AM. At 2:30 PM, Resident #1's BP was ,[DATE], with an 18 point increase in the systolic blood pressure and an 11 point increase in the diastolic pressure. At 3:30 PM, Resident #1's systolic BP jumped another 20 points and was ,[DATE]. His pulse rate at that time was 54, a drop of 20 beats per minute from 74. The Neurological Evaluation Flow Sheet reflected the following: 4:00 PM BP ,[DATE] p pulse 56 4:30 PM BP ,[DATE] pulse 54 5:00 PM BP ,[DATE] pulse 54 5:30 PM BP ,[DATE] pulse 65 At 5:00 PM, Resident #1's best motor response was a "6" - which indicated he obeyed commands. At 5:30 PM, Resident #1's best motor response was a "1" - which indicated there was no movement. It remained a "1" for the 6:00 PM and 7:00 PM neuro checks. Resident #1's Progress Notes dated [DATE] reflected the following: At 3:30 PM, Resident #1 was in bed with his eyes closed and was in no distress. His vitals were documented with a BP of ,[DATE] and pulse rate of 54. LVN C documented, "Will continue to monitor." At 4:00 PM, Resident #1 vomited a large amount of undigested food. The Unit Manager was notified. Resident #1's BP was ,[DATE] with a pulse of 54. The NP was called and a message was left. At 5:00 PM, LVN C documented "Still awaiting a return call...." from the NP. Note: Resident #1's BP was ,[DATE]. At 5:30 PM, Resident #1 was "Unresponsive to speech... No movements noted to verbal commands. BP ,[DATE], P - 65, R - 20 Attempted to call ____ (Resident #1's Primary Care Physician's) office. No answer. Will continue to monitor." At 6:00 PM, CNA notified LVN C Resident #1 vomited. The resident had wheezes in the upper lobes of both lungs. Resident #1's oxygen saturation level was 84% on room air and oxygen was started at 2 LPM per nasal canula. (Normal oxygen saturation level is 95 - 100%.) Resident #1's Primary Care Physician was called and an order was received to send the resident to the hospital. At 6:50 PM, another nurse evaluated Resident #1. The resident was unresponsive to a firm sternal rub and voice commands. The second nurse called 911. When Resident #1's soles of his feet were touched, the resident pulled his feet up toward his chest (in a fetal position). "Spastic Hypertonia (muscular tension in spasm) often occurs after a [MEDICAL CONDITION] (TBI) as a result of damage to the [DIAGNOSES REDACTED], cerebellum or mid-brain. The damage affects the reflex centers in the brain, interrupting the flow of messages along various nerve pathways. This disruption of signals can cause changes in muscle tone, movement, sensation and reflex." Retrieved on [DATE] from: <http://main.uab.edu/tbi/show.asp?durki= > On [DATE] at 8:13 AM, LVN B was interviewed on the telephone regarding Resident #1's fall. LVN B told the surveyor on [DATE], at approximately 10:45 AM, CNA A came to the nurses station and informed her Resident #1 had fallen in the shower room. LVN B stated when she went to assess him, Resident #1 told her, "The ___ (S-- of a B----, referring to CNA A) let me fall backward." LVN B said the resident complained of a headache. LVN B added, "___ (CNA A) told me three different times and showed me how (Resident #1) fell ." LVN B further informed the surveyor she assessed the resident whose blood pressure was elevated and the resident had a two cm, red raised area on the back of his head. LVN B stated she obtained Resident #1's vital signs and called the Nurse Practitioner and left a message. When asked if the Nurse Practitioner returned her call, LVN B stated she never did hear from the Nurse Practitioner. The surveyor asked if she called the Nurse Practitioner again or if she called the physician, and she replied she did not. LVN B added she had notified Resident #1's family member about the incident and the resident wanted to talk to his family member. LVN B told the surveyor when she ended her shift, the resident was stable. On [DATE] at 4:36 PM, CNA A was interviewed regarding the incident with Resident #1 when he hit his head. CNA A told the surveyors he (the CNA) was going to give Resident #1 a shower. The CNA took Resident #1 into the shower room and placed him in the shower stall. CNA A stated he had Resident #1 stand and hold onto the grab bars in the shower stall. CNA A said he was holding onto Resident #1's right arm and reaching back for the shower chair when Resident #1 slipped and fell backwards, hitting his head on the shower stall. When the surveyor asked CNA A if the floor was wet, he replied, "Yes." The surveyor then asked if Resident #1 had slippers or socks on, and the CNA replied, "Yes. The resident had on socks." The surveyor then queried if CNA A had use a gait belt during the transfer, and he replied "No," not in the shower room. He did not use a gait belt with Resident #1, because he had not had a problem with the resident before. CNA A said he went and told LVN B, leaving the resident unattended in the shower room. After LVN B checked the resident, she told CNA A to finish up the resident. CNA A dressed Resident #1. CNA A then stated LVN B told him to put Resident #1 in bed, however Resident #1 wanted coffee. CNA A stated, "___ (LVN B) changed her mind and told me to take him to the dining room for coffee." The facility's current policy, One Person Pivot Transfer, (undated) reflected the purpose was to safely get the resident from one surface to another by allowing the resident to participate. "Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot." On [DATE] at 3:59 PM the surveyors, the Unit Manager and the Regional Nurse Consultant went to the shower on the 300 hall where Resident #1 fell . The facility staff was unable to determine how Resident #1 slipped and hit his head. The surveyor observed there were no anti-slip treads on the shower stall floor. On [DATE] at 5:50 PM, the surveyor interviewed LVN C regarding the LVN's assessment of Resident #1. LVN C told the surveyor she assessed him every hour, but when he vomited, she went to the Nurse Manager, who told her to call the physician. LVN C reported she called the NP and left a message. When the surveyor queried whether LVN C had received a call back from the NP, she replied, "No." The surveyor then asked if she called the physician or NP again, and she said she did not call them again until there was a change in Resident #1's mental status. The surveyor asked if LVN C had noticed the change in Resident #1's blood pressure, which was rising. The LVN responded she did not really see the change until his BP went much higher. LVN C added Resident #1 acted like he wanted to throw up. She checked him, put him on oxygen and first she called the NP and then the doctor when she did not get a return call. LVN C stated, "When (Resident #1) became unresponsive, we sent him out 911." [DATE] at 5:49 PM, the surveyor spoke with the Regional Corporate Nurse, who brought in a book entitled INTERACT (Interventions to Reduce Acute Care Transfers) and the SBAR protocol. The Regional Corporate Nurse told the surveyor this program was put in place about a year ago, and the nurses utilized it to help with the assessment of a resident and the guidelines for calling the physician. The Regional Corporate Nurse said the NP attended the inservice regarding the program, but she did not think the Medical Director had ever attended an inservice regarding the system. When the surveyor asked why Resident #1 was not sent to the hospital when the resident experienced a change in condition, they did not respond. They both stated the nurse should have sent the resident out 911 (when the resident presented with a change in condition). Review of the facility's INTERACT tool revealed if the Systolic Blood Pressure is > than 210 or less than 90, the physician should be called immediately. If the resident has sustained a head injury, the tool reflected "... Any head injury with a change in LOC (Loss of Consciousness), mental status, or any focal neurological findings the doctor should be notified." On [DATE] at 9:50 AM, the Primary Care Physician, who was also the facility's Medical Director, was questioned about the SBAR. He stated he was familiar with the SBAR. The surveyor specifically queried the Primary Care Physician about the blood pressure and pulse rate parameters included on the SBAR as to when to notify the physician. As the Primary Care Physician reviewed the SBAR, he stated he would need to make changes in the parameters for blood pressures and pulse rates in regard to head injuries and when to notify the physician. The Primary Care Physician then stated, "The elderly do not have diastolic but systolic [MEDICAL CONDITION]," and he would reset the SBAR parameters. During an interview with the Administrator on [DATE] at 5:50 PM, the surveyor asked why the facility did not report the incident with Resident #1 to DADS, the State agency. The Administrator stated she had discussed the incident with the facility's Regional Corporate Nurse. They determined the incident was not reportable because Resident #1's fall was witnessed and an incident report had been initiated. The Administrator provided the "Guidelines for Reporting Incidents," which the facility followed. One of the guidelines then reviewed by the Administrator and the surveyor was the directive: "The facility must determine if an injury, harm or death of a resident was due to a facility failure to provide services, treatment, or care to a resident." The surveyor pointed out to the Administrator, following Resident #1's fall, the physician was not notified of the resident's change in condition and staff did not respond when his blood pressure increased by 20 points and then when he vomited other than to document the resident would be monitored. On [DATE] at 9:40 AM, the surveyor interviewed the MDS Coordinator, who was providing RN coverage on the day of Resident #1's incident ([DATE]). When asked about Resident #1's assessment, she told the surveyor she was not informed by the facility staff of the resident's fall or the need for an assessment. The MDS Coordinator further stated she had heard about Resident #1's fall, but she was not aware she needed to assess Resident #1. On [DATE] at 4:03 PM, the Primary Care Physician, who was also the facility's Medical Director, was interviewed. The Primary Care Physician stated the facility called him frequently and facility staff would be told to monitor a resident after a fall. However, if the resident started vomiting after a fall then it was "too late." The Primary Care Physician further stated if facility staff could not reach him by phone, "then they can always ship them out 911." Review of Resident #1's hospital's records dated [DATE] revealed the results of a CT Scan. The findings reflected Resident #1 had a large subdural hematoma one the left side of the brain with a 1.6 cm left to right midline shift. There were also samll hemorrhages identified in the left frontal lobe. Medical Decision making reflected Resident #1 had an intracranial bleed and herniation with a poor prognosis. The resident was admitted to the hospital on [DATE]. During a telephone interview on [DATE] at 3:00 PM with the hospital Case Manager, the surveyor was informed the resident had expired on Saturday, [DATE]. 3) The Face Sheet dated [DATE] reflected Resident #2, 81-years-old, was admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #2's MDS assessment dated [DATE] reflected the resident was moderately impaired cognitively for daily decision-making. The MDS assessment reflected the resident required extensive assistance of two plus persons physical assist with bed mobility and transfers. She required the extensive assistance of one person with locomotion, dressing, eating, toilet care, personal hygiene and bathing. Additional [DIAGNOSES REDACTED]. Resident #2's consolidated physician's orders [REDACTED]. [MEDICATION NAME] (antihypertensive) 2.5 mg every 12 hours, hold for S BP less than 120; [MEDICATION NAME] (antihypertensive) 6.25 mg every 12 hours, hold for systolic BP less than 120. Review of Resident #2's Comprehensive Plan of Care dated [DATE] revealed identification of the following problems: Resident takes nine or more medications; ADL functions; [DIAGNOSES REDACTED]. History of Anxiety Incontinence, diarrhea Aspirin as a blood thinner Cognitive Impairment Impaired Communication Decreased mobility, Mobility At risk for falls Hearing deficit [MEDICAL CONDITION] medications Skin breakdown Therapeutic Diet There was no nursing care plan addressing the resident's Hypertension, including interventions to implement when the resident potentially experienced headaches, dizziness, nausea/vomiting, vision problems, generalized weakness and/or episodes of orthostatic [MEDICAL CONDITION]. Resident #2's History and Physical dated [DATE] reflected a past medical history, which included [DIAGNOSES REDACTED]. Resident #2's physician progress notes [REDACTED]. The SBAR Progress Note dated [DATE] at 7:00 AM reflected LVN D documented Resident #2 was complaining of shortness of breath and was wheezing. The physician-ordered Nebulizer treatment was administered. Resident #2's vital signs were BP ,[DATE], pulse 94, respirations 22. The resident had an oxygen saturation level of 88% on room air. Oxygen was administered at a rate of 2 liters per minute per nasal cannula, which brought the resident's saturation level up to 92% (normal is 95 - 100%). Further documentation included Resident #2 was unable to swallow her medications and spit them out. The resident continued to complain of generalized weakness, was tired and was unable to sit in her wheelchair. The resident was assisted to bed, the call light was placed within reach and the resident would continue to be monitored. The SBAR Progress Note dated [DATE] at 9:45 AM reflected the following, which was documented by LVN D. Resident #2 told LVN D she could not feel anything on her right side. LVN D's assessment revealed Resident #2 was unable to hold a cup, could not stand or transfer like she normally could. The Facility Nurse Practitioner was called immediately and LVN D received orders to send Resident #2 to the hospital ER for evaluation and treatment. Resident #2's family member was notified at 10:00 AM, who responded he/she would go to the ER. On the SBAR Progress Note [DATE], below the staff identification legend was a note facility staff reported the issue to the Nurse Practitioner on [DATE] at 10:00 AM. LVN D was interviewed on [DATE] at 8:26 AM regarding Resident #2. LVN D told the surveyor when she entered the resident's room, Resident #2 was complaining of difficulty breathing so she (LVN D) gave her a nebulizer treatment. The resident's blood pressure was already up, and LVN D asked the MA to give Resident #2 her blood pressure medication, but the resident was unable to swallow her pills. When LVN D was asked if she tried to notify the physician or NP at that time about Resident #2, LVN D stated she planned to "just monitor her." The next time the resident called LVN D, she said she could not feel anything on her right side. LVN D stated she thought she called the physician and/or nurse practitioner two times without a response from either. When the surveyor asked LVN D when she called them, she was unable to give specific times of the phone calls. She told the surveyor she had other duties and residents including blood sugars on other residents and she also had to monitor the dining room during breakfast. LVN D added Resident #2's complaints began sometime between 6:30 AM and 7:00 AM. Interview with the Facility Nurse Consultant on [DATE] at approximately 3:00 PM revealed the resident was admitted to the hospital for treatment. 4) Resident #3's Progress Notes dated [DATE] at 6:30 PM reflected Resident #3, a [AGE] year-old female, was admitted to the facility with an admitting [DIAGNOSES REDACTED]. Resident #3's Admission Nursing Evaluation dated [DATE] reflected Resident #3 was admitted to the facility on that date with [DIAGNOSES REDACTED]. Resident #3's BP was ,[DATE] with a pulse rate of 60 beats per minute and respirations of 20. The Evaluation reflected Resident #3's cognitive status was not assessed at that time. The resident required assistance with bed mobility, transfers and dressing. Resident #3 required the assistance of one person with toileting, personal care/hygiene and bathing. The resident was independent with eating. The Evaluation reflected Resident #3 was continent and had no significant skin breakdown. Resident #3's undated Interim Plan of Care identified Orientation to Room, Elopement Risk, Pressure Ulcer Risk, Dehydration Risk, Pressure Ulcers, [MEDICAL CONDITION] Disease, Dental Problems and Nausea/Vomiting as areas to be care planned. Interventions included: turn and reposition, obtain a (anti-pressure) device for the bed/chair, determine likes and dislikes in regard to providing adequate fluids, monitor for signs/symptoms of dehydration and check lung sounds. Resident #3's Daily Skilled Nurses Notes dated [DATE] reflected the resident had no memory problems, and was not impaired for decision-making. The Notes reflected the following at 1:00 AM: "(Resident #3) c/o not (sic) 'feeling bad' O2 concentrator found to not be working. O2 Sat - 88%, P - 140, B/P ,[DATE]. Placed on tank O2@ 2L/min. Will monitor." At !:20 AM, Resident #3's oxygen saturation level was 94%, BP ,[DATE] and respirations were 18. Resident #3 was "Feeling better." There was no further documentation until 7:30 AM. Resident #3's Progress Notes dated [DATE] at 7:30 AM reflected: "In report it was told pt had a restless night with pulse as high as 150 and SOB (with) 02 stat (sic) varying from (upper) 80's to (lower) 90's on 2 liters (of oxygen per) N/C." Assessment reflected no shortness of breath but Resident #3 was awake and confirmed her restlessness. She denied chest pain, but reported minor chest pressure. At that time, the resident's apical pulse was 145 and irregular in pattern. (An apical pulse is measured directly over the heart.) Resident #3's Progress Notes dated [DATE] at 8:30 AM reflected her "...pulse was 136 and still irregular in sound and for this reason cannot obtain a blood pressure. ...Called FNP and awaiting response...." At 9:00 AM, an order was received to send to the ER for evaluation and at 9:30 AM, Resident #3 was discharged and her family member was notified. At 1:00 PM, Resident #3's family member contacted the facility and told them she was planning on seeing Resident #3 in the hospital. The Physician's Telephone Order dated [DATE] reflected to send Resident #3 to the ER, status/post Triple Bypass and for [MEDICAL CONDITION](increased heart rate) and decreased oxygen saturation level. Resident #3's transport service Patient Care Record dated [DATE] reflected the Primary Impression was Cardiac Rhythm Disturbance. At 9:20 AM, the resident's pulse rate was 116 and at 9:30 AM, it was 120. The ECG reflected the resident had [MEDICAL CONDITION] Fibrillation. Medical Necessity reflected, "Admit to Hospital...." Attempts to contact facility staff providing care for Resident #3 were unsuccessful. 5) On [DATE] at approximately 9:00 AM, the surveyor interviewed the Regional Nurse Consultant in regard to Residents #2 and #3, who both experienced a change in condition and the physician/NP were not notified when the change in condition was first detected. The Regional Nurse Consultant did not voice any comments on the notes documenting these incidents, but just looked at them. The surveyor stated a review of the clinical records for two other residents with changes in condition resulted in immediate 911 calls. The surveyor queried the Regional Nurse Consultant in regard to Residents #1, #2 and #3, who experienced changes in condition without immediate 911 calls. The Regional Nurse Consultant referred to the SBAR as an assessment guide, and staff could call 911 if they could not get the physician to return their call. On [DATE] at approximately 9:32 AM, the surveyor interviewed the Facility Nurse Consultant regarding Residents #1, #2 and #3 and their need for emergency care, the facility nurses' assessments and the evaluation of those assessments in obtaining prompt medical care. The Facility Nurse Consultant informed the surveyor the facility had started to inservice the staff the evening of [DATE] in regard to assessments, notifying the physician and calling 911. 6) Review of the facility's current Nursing Services Policy and Procedure Manual 2001 MED-PASS Inc, revised [DATE], revealed : Change in a Resident's Condition or Status. Policy Statement "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On Call Physician when there has been: a. An accident or incident involving the resident; ...d. A significant change in the resident's physical/emotional condition; ...g. A need to transfer the resident to a hospital/treatment center... 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one area of the resident's health status... 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change in the resident's medical/mental condition or status...." 7) On [DATE] at 11:06 AM, the Administrator, the Regional Corporate Nurse and the Regional Vice President were notified an IJ had been identified in the area of Resident Behavior/Facility Practice. A Plan of Removal was requested for the IJ. 8) On [DATE] at 4:50 PM, the surveyor interviewed the Administrator regarding the IJ and what policies were put in place to ensure the nursing needs of the residents were being met. The Administrator stated there had been a history in the facility of inconsistent leadership, and she had been at the facility the past four months. She was holding staff accountable for their actions, and there had been a lot of turn over in staff. The Administrator further stated they would continue to inservice staff, follow up with Quality Assurance meetings and resident assessments. She further stated they had developed action plans for areas of concern, especially identifying safe handling of residents, transfers and falls. They planned on doing extensive training with the staff. The Administrator went on to say there were multiple system failures, which she had been hired to address. 9) A Plan of Removal of the IJ was provided by the facility and was accepted on [DATE] at 4:40 PM and reflected the following: (1) The Medical Director was notified by the Regional VP of Operations of the IJ situation on [DATE] at around 1:15 PM. (2) Re-educate all licensed nurses on immediately assessing a resident with noted significant change of condition to include checking blood pressure, pulse, respiration, temperature, oxygen saturation, pain, mental status and range of motion and immediately notifying the physician and family regarding abnormal assessment. A competency based test will be given to each licensed nurse. The Nursing

Based on observation, interview and record review, the facility failed to ensure three (Residents #1, #2 and #3) of five residents reviewed for quality of care each received and the facility provided the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care when there was a significant change in their condition. 1. On [DATE], Resident #1 fell and hit his head during a transfer when a gait belt was not used at 10:45 AM. The physician was not notified of the resident's change of condition until 6:00 PM despite: At 2:30 PM, the resident's blood pressure started rising; At 3:00 PM, the resident's blood pressure continued to elevate and the resident's pulse dropped by 20 beats. At 3:30 PM, Resident #1 vomited a large amount of undigested food. The facility left a message for the Nurse Practitioner, which the NP did not respond to. At 5:30 PM, the resident was unresponsive. At 6:00 PM, the resident vomited, and the physician was contacted; At 6:50 PM, 911 was called. The resident was admitted to the hospital and later died . These failures affected Resident #1, who sustained a head injury and a delay in treatment, contributing to the resident's death. 2. On [DATE] at 7:00 AM, Resident #2 began to experience respiratory distress with an abnormal oxygen saturation level of 88%, BP of ,[DATE] and a pulse of 94. The resident reported extreme fatigue. Resident #2 was unable to swallow her medications and spit them out. The physician was not notified. At 9:45 AM, when the resident reported she could not feel anything on her right side, the physician was notified and the resident was sent to the hospital where she remained. 3. Resident #3 was admitted to the facility as post operative for a cardiac triple bypass. On [DATE], she developed an elevated heart rate of 140 and had an oxygen saturation level of 88% at 1:00 AM. The physician was not notified of the resident's change in condition until approximately 9:00 AM (eight hours later) when the resident's heart rate was 136 and irregular. Resident #3 was ordered to go to the hospital, where she was admitted . These failures affected Residents #2 and #3, which resulted in a delay in treatment and the residents' symptoms worsening and being admitted to the hospital, potentially requiring a longer recovery period than necessary. On [DATE] at 10:47 AM, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE] at 4:40 PM, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern" because the facility was still implementing and monitoring the Plan of Removal. These failures could affect the facility's 127 residents in the facility, placing them at risk for not receiving the care and services needed to ensure their safety and a delay in treatment when experiencing a change of condition, resulting in the potential injury and even death. Findings included: The Face Sheet dated [DATE] reflected Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 had short term and long term cognitive impairment, and modified independence in decision-making. Resident #1 required the extensive assistance of two persons with bed mobility, transfers, toilet use, personal hygiene and bathing and one person assist with locomotion off and on the unit, dressing and eating. [DIAGNOSES REDACTED]. Review of Resident #1's Itemized ADL Coding Report dated from [DATE] to [DATE] revealed the following: the resident required the assistance of two people for transfers on the following dates: [DATE] [DATE] [DATE] [DATE] [DATE] Resident #1's ADL Plans of Care dated from [DATE] to [DATE] reflected for bathing there was a caution, which reflected assistance was needed for transfers. Resident #1 required the extensive assistance of one person physical assist with bathing. For transfers, the resident required the extensive assistance of one person physical assist for transfers. Special equipment was identified as a gait belt and wheelchair. On [DATE] at 4:25 PM, observation revealed Resident #1 was lying in a hospital bed at a local hospital. His eyes were closed, his color was pale, he was being administered oxygen via nasal cannula and breathing through his mouth. Resident #1 was unresponsive to the surveyor speaking his name. Review of the SBAR (Situation, Background, Assessment, and Request), Physician/NP/PA Communication and Progress Note, dated [DATE], for Resident #1, revealed the nurse documented there was a fall, and an assessment of the resident with regard to head injury. Review of Resident #1's Progress Notes dated [DATE] at 10:45 AM revealed the following: "CNA reported to nurse that resident had fallen backward while in shower stall - CNA ___ (CNA A) had already picked him up transferred him into shower chair showered & groomed him - then - had notified charge nurse -- found resident in shower chair - c/o head hurting found 3 cm red raised area to back of head -- no broken area -- resident alert & explained to nurse what happened & why he fell - area on back of head cleansed (with) soap & H2O patted dry - answering all questions approp. resident very angry (with) (increased) anxiety d/t fall reassured him - complete body check done - MAEW - PEARL - assisted (with) completing dress - resident did not want to go to bed wanted 'coffee' - wheeled resident to dining room & got him coffee - @ 11:15 (AM) / [MEDICATION NAME] 7.5 mg (narcotic [MEDICATION NAME]) po & [MEDICATION NAME] (anti-anxiety) po given -- Neuros (neurological assessments) started & intact." Retrieved on [DATE] from www.Druglib.com regarding Head Injury and Increased Intracranial Pressure - "The respiratory depressant effects of narcotics and their capacity to elevate cerebrospinal fluid pressure may be markedly exaggerated in the presence of head injury, other intracranial [MEDICAL CONDITION] or a preexisting increase in intracranial pressure. Furthermore, narcotics produce adverse reactions which may obscure the clinical course of patients with head injuries." Resident #1's Neurological Evaluation Flow Sheet dated [DATE] reflected neurological checks were conducted every 15 minutes from 10:45 AM until 12:00 PM. Initially Resident #1's BP was slightly elevated at ,[DATE] along with an elevated pulse rate of 92. By 1:30 PM, Resident #1's BP was ,[DATE] with a pulse of 72. The neurological checks, respirations and temperature remained stable. Resident #1's pupils went from being 2 mm in size to 3 mm at 11:30 AM. At 2:30 PM, Resident #1's BP was ,[DATE], with an 18 point increase in the systolic blood pressure and an 11 point increase in the diastolic pressure. At 3:30 PM, Resident #1's systolic BP jumped another 20 points and was ,[DATE]. His pulse rate at that time was 54, a drop of 20 beats per minute from 74. The Neurological Evaluation Flow Sheet reflected the following: 4:00 PM BP ,[DATE] p pulse 56 4:30 PM BP ,[DATE] pulse 54 5:00 PM BP ,[DATE] pulse 54 5:30 PM BP ,[DATE] pulse 65 At 5:00 PM, Resident #1's best motor response was a "6" - which indicated he obeyed commands. At 5:30 PM, Resident #1's best motor response was a "1" - which indicated there was no movement. It remained a "1" for the 6:00 PM and 7:00 PM neuro checks. Resident #1's Progress Notes dated [DATE] reflected the following: At 3:30 PM, Resident #1 was in bed with his eyes closed and was in no distress. His vitals were documented with a BP of ,[DATE] and pulse rate of 54. LVN C documented, "Will continue to monitor." At 4:00 PM, Resident #1 vomited a large amount of undigested food. The Unit Manager was notified. Resident #1's BP was ,[DATE] with a pulse of 54. The NP was called and a message was left. At 5:00 PM, LVN C documented "Still awaiting a return call...." from the NP. Note: Resident #1's BP was ,[DATE]. At 5:30 PM, Resident #1 was "Unresponsive to speech... No movements noted to verbal commands. BP ,[DATE], P - 65, R - 20 Attempted to call ____ (Resident #1's Primary Care Physician's) office. No answer. Will continue to monitor." At 6:00 PM, CNA notified LVN C Resident #1 vomited. The resident had wheezes in the upper lobes of both lungs. Resident #1's oxygen saturation level was 84% on room air and oxygen was started at 2 LPM per nasal canula. (Normal oxygen saturation level is 95 - 100%.) Resident #1's Primary Care Physician was called and an order was received to send the resident to the hospital. At 6:50 PM, another nurse evaluated Resident #1. The resident was unresponsive to a firm sternal rub and voice commands. The second nurse called 911. When Resident #1's soles of his feet were touched, the resident pulled his feet up toward his chest (in a fetal position). "Spastic Hypertonia (muscular tension in spasm) often occurs after a [MEDICAL CONDITION] (TBI) as a result of damage to the [DIAGNOSES REDACTED], cerebellum or mid-brain. The damage affects the reflex centers in the brain, interrupting the flow of messages along various nerve pathways. This disruption of signals can cause changes in muscle tone, movement, sensation and reflex." Retrieved on [DATE] from: <http://main.uab.edu/tbi/show.asp?durki= > On [DATE] at 8:13 AM, LVN B was interviewed on the telephone regarding Resident #1's fall. LVN B told the surveyor on [DATE], at approximately 10:45 AM, CNA A came to the nurses station and informed her Resident #1 had fallen in the shower room. LVN B stated when she went to assess him, Resident #1 told her, "The ___ (S-- of a B----, referring to CNA A) let me fall backward." LVN B said the resident complained of a headache. LVN B added, "___ (CNA A) told me three different times and showed me how (Resident #1) fell ." LVN B further informed the surveyor she assessed the resident whose blood pressure was elevated and the resident had a two cm, red raised area on the back of his head. LVN B stated she obtained Resident #1's vital signs and called the Nurse Practitioner and left a message. When asked if the Nurse Practitioner returned her call, LVN B stated she never did hear from the Nurse Practitioner. The surveyor asked if she called the Nurse Practitioner again or if she called the physician, and she replied she did not. LVN B added she had notified Resident #1's family member about the incident and the resident wanted to talk to his family member. LVN B told the surveyor when she ended her shift, the resident was stable. On [DATE] at 4:36 PM, CNA A was interviewed regarding the incident with Resident #1 when he hit his head. CNA A told the surveyors he (the CNA) was going to give Resident #1 a shower. The CNA took Resident #1 into the shower room and placed him in the shower stall. CNA A stated he had Resident #1 stand and hold onto the grab bars in the shower stall. CNA A said he was holding onto Resident #1's right arm and reaching back for the shower chair when Resident #1 slipped and fell backwards, hitting his head on the shower stall. When the surveyor asked CNA A if the floor was wet, he replied, "Yes." The surveyor then asked if Resident #1 had slippers or socks on, and the CNA replied, "Yes. The resident had on socks." The surveyor then queried if CNA A had use a gait belt during the transfer, and he replied "No," not in the shower room. He did not use a gait belt with Resident #1, because he had not had a problem with the resident before. CNA A said he went and told LVN B, leaving the resident unattended in the shower room. After LVN B checked the resident, she told CNA A to finish up the resident. CNA A dressed Resident #1. CNA A then stated LVN B told him to put Resident #1 in bed, however Resident #1 wanted coffee. CNA A stated, "___ (LVN B) changed her mind and told me to take him to the dining room for coffee." The facility's current policy, One Person Pivot Transfer, (undated) reflected the purpose was to safely get the resident from one surface to another by allowing the resident to participate. "Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot." On [DATE] at 3:59 PM the surveyors, the Unit Manager and the Regional Nurse Consultant went to the shower on the 300 hall where Resident #1 fell . The facility staff was unable to determine how Resident #1 slipped and hit his head. The surveyor observed there were no anti-slip treads on the shower stall floor. On [DATE] at 5:50 PM, the surveyor interviewed LVN C regarding the LVN's assessment of Resident #1. LVN C told the surveyor she assessed him every hour, but when he vomited, she went to the Nurse Manager, who told her to call the physician. LVN C reported she called the NP and left a message. When the surveyor queried whether LVN C had received a call back from the NP, she replied, "No." The surveyor then asked if she called the physician or NP again, and she said she did not call them again until there was a change in Resident #1's mental status. The surveyor asked if LVN C had noticed the change in Resident #1's blood pressure, which was rising. The LVN responded she did not really see the change until his BP went much higher. LVN C added Resident #1 acted like he wanted to throw up. She checked him, put him on oxygen and first she called the NP and then the doctor when she did not get a return call. LVN C stated, "When (Resident #1) became unresponsive, we sent him out 911." [DATE] at 5:49 PM, the surveyor spoke with the Regional Corporate Nurse, who brought in a book entitled INTERACT (Interventions to Reduce Acute Care Transfers) and the SBAR protocol. The Regional Corporate Nurse told the surveyor this program was put in place about a year ago, and the nurses utilized it to help with the assessment of a resident and the guidelines for calling the physician. The Regional Corporate Nurse said the NP attended the inservice regarding the program, but she did not think the Medical Director had ever attended an inservice regarding the system. When the surveyor asked why Resident #1 was not sent to the hospital when the resident experienced a change in condition, they did not respond. They both stated the nurse should have sent the resident out 911 (when the resident presented with a change in condition). Review of the facility's INTERACT tool revealed if the Systolic Blood Pressure is > than 210 or less than 90, the physician should be called immediately. If the resident has sustained a head injury, the tool reflected "... Any head injury with a change in LOC (Loss of Consciousness), mental status, or any focal neurological findings the doctor should be notified." On [DATE] at 9:50 AM, the Primary Care Physician, who was also the facility's Medical Director, was questioned about the SBAR. He stated he was familiar with the SBAR. The surveyor specifically queried the Primary Care Physician about the blood pressure and pulse rate parameters included on the SBAR as to when to notify the physician. As the Primary Care Physician reviewed the SBAR, he stated he would need to make changes in the parameters for blood pressures and pulse rates in regard to head injuries and when to notify the physician. The Primary Care Physician then stated, "The elderly do not have diastolic but systolic [MEDICAL CONDITION]," and he would reset the SBAR parameters. During an interview with the Administrator on [DATE] at 5:50 PM, the surveyor pointed out to the Administrator, following Resident #1's fall, the physician was not notified of the resident's change in condition and staff did not respond when his blood pressure increased by 20 points and then when he vomited other than to document the resident would be monitored. The Administrator had no response. On [DATE] at 9:40 AM, the surveyor interviewed the MDS Coordinator, who was providing RN coverage on the day of Resident #1's incident ([DATE]). When asked about Resident #1's assessment, she told the surveyor she was not informed by the facility staff of the resident's fall or the need for an assessment. The MDS Coordinator further stated she had heard about Resident #1's fall, but she was not aware she needed to assess Resident #1. On [DATE] at 4:03 PM, the Primary Care Physician, who was also the facility's Medical Director, was interviewed. The Primary Care Physician stated the facility called him frequently and facility staff would be told to monitor a resident after a fall. However, if the resident started vomiting after a fall then it was "too late." The Primary Care Physician further stated if facility staff could not reach him by phone, "then they can always ship them out 911." Review of Resident #1's hospital's records dated [DATE] revealed the results of a CT Scan. The findings reflected Resident #1 had a large subdural hematoma one the left side of the brain with a 1.6 cm left to right midline shift. There were also samll hemorrhages identified in the left frontal lobe. Medical Decision making reflected Resident #1 had an intracranial bleed and herniation with a poor prognosis. The resident was admitted to the hospital on [DATE]. During a telephone interview on [DATE] at 3:00 PM with the hospital Case Manager, the surveyor was informed the resident had expired on Saturday, [DATE]. 2) The Face Sheet dated [DATE] reflected Resident #2, 81-years-old, was admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #2's MDS assessment dated [DATE] reflected the resident was moderately impaired cognitively for daily decision-making. The MDS assessment reflected the resident required extensive assistance of two plus persons physical assist with bed mobility and transfers. She required the extensive assistance of one person with locomotion, dressing, eating, toilet care, personal hygiene and bathing. Additional [DIAGNOSES REDACTED]. Resident #2's consolidated physician's orders [REDACTED]. [MEDICATION NAME] (antihypertensive) 2.5 mg every 12 hours, hold for S BP less than 120; [MEDICATION NAME] (antihypertensive) 6.25 mg every 12 hours, hold for systolic BP less than 120. Review of Resident #2's Comprehensive Plan of Care dated [DATE] revealed identification of the following problems: Resident takes nine or more medications; ADL functions; [DIAGNOSES REDACTED]. History of Anxiety Incontinence, diarrhea Aspirin as a blood thinner Cognitive Impairment Impaired Communication Decreased mobility, Mobility At risk for falls Hearing deficit [MEDICAL CONDITION] medications Skin breakdown Therapeutic Diet There was no nursing care plan addressing the resident's Hypertension, including interventions to implement when the resident potentially experienced headaches, dizziness, nausea/vomiting, vision problems, generalized weakness and/or episodes of orthostatic [MEDICAL CONDITION]. Resident #2's History and Physical dated [DATE] reflected a past medical history, which included [DIAGNOSES REDACTED]. Resident #2's physician progress notes [REDACTED]. The SBAR Progress Note dated [DATE] at 7:00 AM reflected LVN D documented Resident #2 was complaining of shortness of breath and was wheezing. The physician-ordered Nebulizer treatment was administered. Resident #2's vital signs were BP ,[DATE], pulse 94, respirations 22. The resident had an oxygen saturation level of 88% on room air. Oxygen was administered at a rate of 2 liters per minute per nasal cannula, which brought the resident's saturation level up to 92% (normal is 95 - 100%). Further documentation included Resident #2 was unable to swallow her medications and spit them out. The resident continued to complain of generalized weakness, was tired and was unable to sit in her wheelchair. The resident was assisted to bed, the call light was placed within reach and the resident would continue to be monitored. The SBAR Progress Note dated [DATE] at 9:45 AM reflected the following, which was documented by LVN D. Resident #2 told LVN D she could not feel anything on her right side. LVN D's assessment revealed Resident #2 was unable to hold a cup, could not stand or transfer like she normally could. The Facility Nurse Practitioner was called immediately and LVN D received orders to send Resident #2 to the hospital ER for evaluation and treatment. Resident #2's family member was notified at 10:00 AM, who responded he/she would go to the ER. On the SBAR Progress Note [DATE], below the staff identification legend was a note facility staff reported the issue to the Nurse Practitioner on [DATE] at 10:00 AM. LVN D was interviewed on [DATE] at 8:26 AM regarding Resident #2. LVN D told the surveyor when she entered the resident's room, Resident #2 was complaining of difficulty breathing so she (LVN D) gave her a nebulizer treatment. The resident's blood pressure was already up, and LVN D asked the MA to give Resident #2 her blood pressure medication, but the resident was unable to swallow her pills. When LVN D was asked if she tried to notify the physician or NP at that time about Resident #2, LVN D stated she planned to "just monitor her." The next time the resident called LVN D, she said she could not feel anything on her right side. LVN D stated she thought she called the physician and/or nurse practitioner two times without a response from either. When the surveyor asked LVN D when she called them, she was unable to give specific times of the phone calls. She told the surveyor she had other duties and residents including blood sugars on other residents and she also had to monitor the dining room during breakfast. LVN D added Resident #2's complaints began sometime between 6:30 AM and 7:00 AM. Interview with the Facility Nurse Consultant on [DATE] at approximately 3:00 PM revealed the resident was admitted to the hospital for treatment. 3) Resident #3's Progress Notes dated [DATE] at 6:30 PM reflected Resident #3, a [AGE] year-old female, was admitted to the facility with an admitting [DIAGNOSES REDACTED]. Resident #3's Admission Nursing Evaluation dated [DATE] reflected Resident #3 was admitted to the facility on that date with [DIAGNOSES REDACTED]. Resident #3's BP was ,[DATE] with a pulse rate of 60 beats per minute and respirations of 20. The Evaluation reflected Resident #3's cognitive status was not assessed at that time. The resident required assistance with bed mobility, transfers and dressing. Resident #3 required the assistance of one person with toileting, personal care/hygiene and bathing. The resident was independent with eating. The Evaluation reflected Resident #3 was continent and had no significant skin breakdown. Resident #3's undated Interim Plan of Care identified Orientation to Room, Elopement Risk, Pressure Ulcer Risk, Dehydration Risk, Pressure Ulcers, [MEDICAL CONDITION] Disease, Dental Problems and Nausea/Vomiting as areas to be care planned. Interventions included: turn and reposition, obtain a (anti-pressure) device for the bed/chair, determine likes and dislikes in regard to providing adequate fluids, monitor for signs/symptoms of dehydration and check lung sounds. Resident #3's Daily Skilled Nurses Notes dated [DATE] reflected the resident had no memory problems, and was not impaired for decision-making. The Notes reflected the following at 1:00 AM: "(Resident #3) c/o not (sic) 'feeling bad' O2 concentrator found to not be working. O2 Sat - 88%, P - 140, B/P ,[DATE]. Placed on tank O2@ 2L/min. Will monitor." At !:20 AM, Resident #3's oxygen saturation level was 94%, BP ,[DATE] and respirations were 18. Resident #3 was "Feeling better." There was no further documentation until 7:30 AM. Resident #3's Progress Notes dated [DATE] at 7:30 AM reflected: "In report it was told pt had a restless night with pulse as high as 150 and SOB (with) 02 stat (sic) varying from (upper) 80's to (lower) 90's on 2 liters (of oxygen per) N/C." Assessment reflected no shortness of breath but Resident #3 was awake and confirmed her restlessness. She denied chest pain, but reported minor chest pressure. At that time, the resident's apical pulse was 145 and irregular in pattern. (An apical pulse is measured directly over the heart.) Resident #3's Progress Notes dated [DATE] at 8:30 AM reflected her "...pulse was 136 and still irregular in sound and for this reason cannot obtain a blood pressure. ...Called FNP and awaiting response...." At 9:00 AM, an order was received to send to the ER for evaluation and at 9:30 AM, Resident #3 was discharged and her family member was notified. At 1:00 PM, Resident #3's family member contacted the facility and told them she was planning on seeing Resident #3 in the hospital. The Physician's Telephone Order dated [DATE] reflected to send Resident #3 to the ER, status/post Triple Bypass and for [MEDICAL CONDITION](increased heart rate) and decreased oxygen saturation level. Resident #3's transport service Patient Care Record dated [DATE] reflected the Primary Impression was Cardiac Rhythm Disturbance. At 9:20 AM, the resident's pulse rate was 116 and at 9:30 AM, it was 120. The ECG reflected the resident had [MEDICAL CONDITION] Fibrillation. Medical Necessity reflected, "Admit to Hospital...." Attempts to contact facility staff providing care for Resident #3 were unsuccessful. 4) On [DATE] at approximately 9:00 AM, the surveyor interviewed the Regional Nurse Consultant in regard to Residents #2 and #3, who both experienced a change in condition and the physician/NP were not notified when the change in condition was first detected. The Regional Nurse Consultant did not voice any comments on the notes documenting these incidents, but just looked at them. The surveyor stated a review of the clinical records for two other residents with changes in condition resulted in immediate 911 calls. The surveyor queried the Regional Nurse Consultant in regard to Residents #1, #2 and #3, who experienced changes in condition without immediate 911 calls. The Regional Nurse Consultant referred to the SBAR as an assessment guide, and staff could call 911 if they could not get the physician to return their call. On [DATE] at approximately 9:32 AM, the surveyor interviewed the Facility Nurse Consultant regarding Residents #1, #2 and #3 and their need for emergency care, the facility nurses' assessments and the evaluation of those assessments in obtaining prompt medical care. The Facility Nurse Consultant informed the surveyor the facility had started to inservice the staff the evening of [DATE] in regard to assessments, notifying the physician and calling 911. 5) Review of the facility's current Nursing Services Policy and Procedure Manual 2001 MED-PASS Inc, revised [DATE], revealed : Change in a Resident's Condition or Status. Policy Statement "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On Call Physician when there has been: a. An accident or incident involving the resident; ...d. A significant change in the resident's physical/emotional condition; ...g. A need to transfer the resident to a hospital/treatment center... 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one area of the resident's health status... 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change in the resident's medical/mental condition or status...." 6) On [DATE] at 11:06 AM, the Administrator, the Regional Corporate Nurse and the Regional Vice President were notified an IJ had been identified in the area of Resident Behavior/Facility Practice. A Plan of Removal was requested for the IJ. 7) On [DATE] at 4:50 PM, the surveyor interviewed the Administrator regarding the IJ and what policies were put in place to ensure the nursing needs of the residents were being met. The Administrator stated there had been a history in the facility of inconsistent leadership, and she had been at the facility the past four months. She was holding staff accountable for their actions, and there had been a lot of turn over in staff. The Administrator further stated they would continue to inservice staff, follow up with Quality Assurance meetings and resident assessments. She further stated they had developed action plans for areas of concern, especially identifying safe handling of residents, transfers and falls. They planned on doing extensive training with the staff. The Administrator went on to say there were multiple system failures, which she had been hired to address. 8) A Plan of Removal of the IJ was provided by the facility and was accepted on [DATE] at 4:40 PM and reflected the following: (1) The Medical Director was notified by the Regional VP of Operations of the IJ situation on [DATE] at around 1:15 PM. (2) Re-educate all licensed nurses on immediately assessing a resident with noted significant change of condition to include checking blood pressure, pulse, respiration, temperature, oxygen saturation, pain, mental status and range of motion and immediately notifying the physician and family regarding abnormal assessment. A competency based test will be given to each licensed nurse. The Nursing Services Policy and Procedure entitled "Acute Condition Changes - Clinical Protocol" will be included in the above education, which is a current policy of the facility. Review of the failure to assess and timely notify the physician of the assessment changes resulted in the SBAR (Situation Background Assessment and Request) no longer being utilized by the facility effective [DATE]. Review of neglect in regard to the failure to assess and respond timely to the assessment will also be included in the education. (2) Any resident with a significant change of condition will be discussed in the daily morning meeting, which is attended by the Administrator, DON or other designee, ADON, and the Unit Managers. Physician notification and responsible party notification will be reviewed for compliance. (3) Each nurse will be re-educated and provide competence based testing regarding the policy and procedures to follow during a medical emergency. (4) All of the nursing departments will be educated (licensed nurses, MAs and CNAs) regarding the resident's ADL plan of care and proper transfers in which gait belts are utilized. Each staff member will be checked regarding their proficiency in the transfer of a resident. (5) The Plan of Care of a resident will be driven by the MDS assessment and the current need of the resident. The IDT (Inter Disciplinary Team) will collect and gather data from the MDS assessment and the Care Area Triggers, and will further assess the resident's needs prior to making a plan of care. If there is a change in the resident's ADL status, the IDT team will assess and update the care plan. Any changes will be addressed in the morn

Based on observation, interview and record review, it was determined the facility failed to immediately consult with the resident's physician for one (Resident #3) of 11 residents reviewed when a significant change in the resident's physical status was identified. Resident #3 had a [DEVICE] for nutrition intake. On 01/22/11 at 7:00 a.m., the tube was found out of the resident with the bulb inflated. There was no physician's order to reinsert the tube. Without first consulting with the physician, LVN F attempted to reinsert the tube. On her second attempt, LVN F reinserted the tube and began using the tube by delivering formula and medications through the tube. Resident #3 was sent to the hospital on [DATE] at 6:20 p.m. due to abdominal pain and malfunction of the [DEVICE]. The resident was diagnosed with [REDACTED]. The [DEVICE] had to be surgically replaced. These failures could affect the 22 residents in the facility with [DEVICE]s, including Resident #3, and placed them at risk for developing malfunctioning [DEVICE]s that could lead to life threatening complications, including severe infections, aspiration, and hospitalization for reinsertion of their [DEVICE]s. Findings included: 1) Resident #3 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on 01/27/11 at 8:29 a.m. with an unidentified staff member revealed Resident #3 was in the hospital. Review of a nurse's note dated 01/20/11 at 3:15 a.m., authored by LVN F, for Resident #3, revealed, "...Resident voiced pain to abdomen...." Review of a Physician/NP/PA Communication and Progress Note dated 01/22/11 at 7:00 a.m. for Resident #3 completed by LVN F revealed: "7:00 a.m. Went in to visit resident. Resident place hand to stomach and was removing cover. Noted [DEVICE] out (with) bulb. Attempted to replace [DEVICE] was unsuccessful. (FNP) notified and stated 'to get [DEVICE] in.' Retried and [DEVICE] replaced at this time...swollen and tender to touch ... 11:30 a.m. Family called voicing pt (patient) complained of pain to GTube site...notified (FNP)...New order may apply ice pack to GTube site PRN for pain... 2:00 p.m. [MEDICATION NAME] AC [MEDICATION NAME] given...Placement (checked)... 4:30 p.m. Resident sitting up in w/c at bedside. Resident said, 'look.' Noted clothing wet to GTube site. Noted copious amount of drainage to lower part of stoma. Drainage smelt of feeding. Notified (DON) at 12:30 p.m. of stoma site and reported to continue to monitor...Received okay to send (Resident #3) to (hospital) for eval (evaluation)... 6:20 p.m. ...transport to (hospital)...." Review of a Physician's telephone order dated 01/22/11 at 11:00 a.m. for Resident #3 revealed "Reinsert [DEVICE]." Review of a Physician's telephone order dated 01/22/11 at 11:30 a.m. for Resident #3 revealed, "May apply ice pack to [DEVICE] site PRN for pain." Review of a Physician's telephone order dated 01/22/11 at 4:30 p.m. for Resident #3 revealed, "May send to (hospital) ER for eval." Review of a Transfer Form dated 01/22/11 for Resident #3 revealed she was transferred to a local hospital ER for "leaking GTube...redness, hard edge to stoma site and GTube leaking.... " Review of a Grievance Report dated 01/23/11 for Resident #3 revealed, "1) [DEVICE] pulled out & family expressed concerns...." Review of a Blood Culture (from a local hospital) dated 01/22/11 for Resident #3 revealed after 19 hours, the blood was positive for Gram Positive Cocci. Review of an abdominal wound culture (from a local hospital) collected on 01/23/11 for Resident #3 revealed the final result was [MEDICAL CONDITION] Resistant Staph [MEDICAL CONDITION]." Review of an Operative Report dated 01/24/11 from a local hospital for Resident #3 revealed, "Procedure: Esophagogastroduodenoscopy and placement of feeding Gastrostomy tube. Indications for Procedure: Dysfunctional displaced Gastrostomy tube...." Interview on 01/27/11 at 12:21 p.m. with CNA G revealed she observed Resident #3's [DEVICE] site with drainage at least three days before she went to the hospital on [DATE]. CNA G stated she reported this to LVN E. On the day Resident #3 went to the hospital, CNA G stated she observed a piece of gauze with blood on it at the site of the [DEVICE]. CNA G stated she was not in Resident #3's room when the nurse attempted to reinsert the [DEVICE]. Interview on 01/27/11 at 12:30 p.m. with LVN E revealed she observed Resident #3's [DEVICE] was inflamed on 01/21/11. She stated at that time there was no drainage. LVN E stated she left a note in "the book" asking the FNP to look at it. LVN E stated the FNP came to the facility on Monday, Wednesday, and Friday, and was very good about reading "the book." When asked if the FNP came to the facility on [DATE], LVN E stated she was not sure. LVN E stated she did not call the physician about Resident #3's [DEVICE] site on 01/21/11. LVN E stated when she arrived for her shift on Monday (01/24/11) she was informed Resident #3's [DEVICE] had come out and the resident was sent to the hospital for complication of the [DEVICE]. When asked if she had ever reinserted a [DEVICE] in the facility, LVN E stated she would find someone who knew how to do it. She added she had never had to do it. Telephone interview on 01/27/11 at 2:30 p.m. with LVN F revealed she observed Resident #3 on 01/22/11 early in the morning on her shift. The [DEVICE] was completely out of resident with the bulb still inflated. She stated she had the 10:00 p.m. - 6:00 a.m. nurse look at it with her. LVN F stated she and the 10:00 p.m. - 6:00 a.m. nurse attempted to re-insert the [DEVICE] but met resistance. They were unsuccessful with the reinsertion. LVN F stated she notified the FNP by telephone and was told to, "Get it in!" LVN F stated the 10:00 p.m. - 6:00 a.m. nurse went back to the room with her, and they re-inserted the [DEVICE] successfully at that time. LVN F stated she did not meet resistance on the second attempt. She stated that once the [DEVICE] was in, she checked placement and obtained [MEDICAL CONDITION] juices with the syringe. LVN F stated she informed the DON about the incident and was told to monitor the site. LVN F stated she gave the [MEDICATION NAME] at 10:00 a.m. without difficulty. LVN F stated around 11:30 a.m., the family was reporting Resident #3 was complaining of pain to the [DEVICE] site and [MEDICATION NAME] was administered for pain. LVN F stated she notified the FNP that the resident was having pain. The FNP told her to apply ice to the site. LVN F stated she gave the [MEDICATION NAME] at 2:00 p.m. without difficulty. LVN F stated at 3:00 p.m. she administered the [MEDICATION NAME] without any problem. She stated she entered the room at 4:30 p.m. and noticed the [DEVICE] had leaked copious amounts of formula. The DON and the FNP were notified and orders were obtained to send the resident to the hospital. When asked if she had reinserted a [DEVICE] before, LVN F stated she had, and she felt comfortable doing it. When asked if she had any training or if her skills had been validated, she revealed she had been checked off on reinserting a [DEVICE]. LVN F stated the night nurse (another LVN) had trained her to reinsert [DEVICE]s. She was not able to recall if she had any additional training on reinserting [DEVICE]s. During the end of day meeting on 01/27/11 at 3:00 p.m. with the ADM and the DON, documentation of training for LVNs reinserting [DEVICE]s was requested for LVN F, LVN H and LVN I. Review of the Nurse Proficiency Checklist for "Tube Feeding by Gravity" and by "Pump" provided by the DON on 01/28/11 revealed: LVN F was checked on 05/04/10, LVN H on 04/08/10 and LVN I on 10/12/10. There was no documentation regarding reinsertion of a [DEVICE]. On 01/28/11 at 2:06 p.m., the DON revealed she was notified of Resident #3's [DEVICE] coming out and had instructed the nurses to monitor the site. The DON stated she was not aware of the attempt to reinsert the [DEVICE] prior to notifying the physician. She stated she was under the impression the physician was notified, an order was obtained and then the [DEVICE] was reinserted. The ADM entered the conference room at that time and was informed of the incident with Resident #3's [DEVICE] being reinserted without an order by LVN F. Interview on 01/28/11 at 3:30 p.m. with the FNP revealed she was notified on 01/22/11 of Resident #3's [DEVICE] being out of the resident with the bulb inflated. She also understood the nurse was able to reinsert it. The FNP revealed she was called after the tube was reinserted told the area was reddened. She stated she gave orders to send Resident #3 to the hospital. When asked if she instructed the nurse to "Get it in," (reinsert the [DEVICE]) the FNP stated she would NEVER tell a nurse to do anything like that. The FNP stated the [DEVICE] was already reinserted, according to the nurse, when she received the first telephone call. When the surveyor informed the FNP no training had been provided to the nursing staff to reinsert the [DEVICE]s, the FNP stated she was under the impression nursing home staff were trained to reinsert [DEVICE]s. A Discharge Summary (from a local hospital) dated 01/28/11 for Resident #3 from a local hospital reflected, "...Discharge Diagnoses: [REDACTED]. Staff states that they replaced it and once they replaced it the tube was leaking right around the tube and she had increased pain, all tube feedings were stopped. She was sent to the Emergency Department for medical management...." Review of a Patient Discharge Med Instruction sheet (from a local hospital) dated 01/28/11, signed by the FNP, for Resident #3 revealed, "...(cannot replace [DEVICE] in future)...." Telephone interview with Dr. J on 01/31/11 at 1:00 p.m. revealed he had not been aware of what had gone on with Resident #3 ' s [DEVICE], other than she was sent to the hospital, and it was replaced. When the surveyor informed Dr. J of the [DEVICE] being reinserted by staff that had not been trained to reinsert a [DEVICE], he stated the GI doctors had stated, if the [DEVICE] came out, they wanted a [DEVICE] or Foley catheter reinserted to keep the tract open. Dr. J added the [DEVICE] should not be used after it was replaced temporarily. Interview on 01/31/11 at 2:14 p.m., the ADM revealed LVN F had been suspended pending an investigation as to whether or not she followed policy by reinserting the [DEVICE]. When queried regarding lack of notification of the physician by LVN E, the ADM stated he would check in to it. Review of a facility policy entitled, "Change in a Resident's Condition or Status," dated April 2007, provided by the DON as the current policy, revealed, "...1) The nurse supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there had been:...d. A significant change in the resident's physical...condition; e. A need to alter the resident's medical treatment significantly... 2) A 'significant change' in condition is a decline...in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions...." Review of a facility policy entitled, "Changing a Gastrostomy Tube," dated September 2004, provided by the DON as the current policy, revealed, "...1) Verify that there is a physicians' order for this procedure...." 2) Review of a Position Statement from the Texas Board of Nursing website, www.http://www.bon.state.tx.us/practice/position.html#15.2415.24, obtained on 02/07/11, Nurses Engaging In Reinsertion of Permanently Placed Feeding Tubes, revealed: The Board approved curriculum for both vocational nurses...does not provide graduates with sufficient instruction to ascertain that a nurse has the necessary knowledge, skills and ability to re-insert and determine correct placement of a permanently placed feeding tube (such as a Gastrostomy or Jejunostomy tubes). The Board does allow LVNs...to expand their practice beyond the basic educational preparation through post-licensure continuing education and training for certain tasks and procedures...Orders should be obtained from the patient's physician regarding re-insertion guidelines...The nurse who accepts an assignment to engage in care and/or replacement of permanently placed feeding tubes is responsible to adhere to the NPA and Board rules, particularly ?217.11, Standards of Nursing Practice, as well as any other standards or rules applicable to the nurse's practice setting...Additional standards in Rule 217.11 that may be applicable when a nurse chooses to engage in replacement of a permanently placed feeding tube include (but are not limited to): ? (1)(D) "Accurately and completely report and document: (i) ..client status....(ii) nursing care rendered...(iii) physician, dentist or podiatrist orders...(iv) administration of medications and treatments....(v) client response(s)...," ? (1)(G) "Obtain instruction and supervision as necessary when implementing nursing procedures or practices..." Regardless of facility policy or physicians' orders, the nurse always has a duty to maintain the safety of the patient (Reference 217.11(1)(B) above); this standard has previously been upheld in a landmark case (Lunsford vs. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App. -- Austin 1983). (Adopted 01/2005)(Reviewed - 01/2010) 3) The CMS-672 dated 01/27/11 and provided by the DON on 01/27/11 revealed there were 22 residents with [DEVICE]s, and the census was 135.

Based on observation, interview and record review, it was determined the facility failed to ensure services provided by one (LVN F) of 32 LVNs employed at the facility met professional standards of quality for one (Resident #3) of 11 residents reviewed. LVN F was not trained to insert [DEVICE]s. On 01/22/11 Resident #3's [DEVICE] was found out of the resident with the bulb inflated. LVN F attempted to reinsert the tube without first contacting the physician for an order. On her second attempt, LVN F reinserted the tube and began using the tube by delivering formula and medications through the tube without getting an x-ray for placement verification. The facility failed to ensure LVN F was trained and skills validated on the proper procedure for the reinsertion of [DEVICE]s. Resident #3 was sent to the hospital on [DATE] at 6:20 p.m. due to abdominal pain and malfunction of the [DEVICE]. The resident was diagnosed with [REDACTED]. The [DEVICE] had to be surgically replaced. These failures could affect the 22 residents in the facility with [DEVICE]s, including Resident #3, and placed them at risk for developing malfunctioning [DEVICE]s that could lead to life threatening complications, including severe infections, aspiration, and hospitalization for reinsertion of their [DEVICE]s. Findings included: 1) Review of a Position Statement from the Texas Board of Nursing website, www.http://www.bon.state.tx.us/practice/position.html#15.2415.24, obtained on 02/07/11, Nurses Engaging In Reinsertion of Permanently Placed Feeding Tubes, revealed: The Board approved curriculum for both vocational nurses...does not provide graduates with sufficient instruction to ascertain that a nurse has the necessary knowledge, skills and ability to re-insert and determine correct placement of a permanently placed feeding tube (such as a Gastrostomy or Jejunostomy tubes). The Board does allow LVNs...to expand their practice beyond the basic educational preparation through post-licensure continuing education and training for certain tasks and procedures. One of the main considerations in determining whether or not a nurse should consider re-insertion of a Gastrostomy, Jejunostomy or similar feeding tube is how long the original tube was in place before becoming dislodged. Though sources vary, most give a range of 8-12 weeks for maturation/healing of the fistulous tract and stoma formation. The method of initial insertion (surgical, endoscopy, or radiographic guidance) may impact the length of healing. Orders should be obtained from the patient's physician regarding re-insertion guidelines. It is the opinion of the Board that LVNs...should not engage in the reinsertion of a permanently placed feeding tube through an established tract until the LVN...successfully completes a competency validation course congruent with prevailing nursing practice standards. Training should provide instruction on the nursing knowledge and skills applicable to tube replacement and verification of correct and incorrect placement. The Board of Nursing (BON) does not define nor set qualifications for competency validation courses; however, inclusion of the following factors is encouraged: 1. The nurse should complete training designed specifically for the type or types of permanent feeding tubes the nurse may need to replace, including overall patient assessment, verification of proper tube placement, and assessment of the tube insertion site. 2. A registered nurse or a physician who has the necessary expertise with regard to the specific feeding tube provides supervision during the training process. 3. The nurse demonstrates competency in all appropriate aspects (knowledge, decision-making, and psycho-motor skills) of performing the procedure. 4. The patient has an established tract. The established tract is not determined by the nurse. 5. The facility has resources available to develop an educational program for initial instruction of LVNs...as well as for ongoing competency validation. 6. Documentation of each nurse's initial education and ongoing competency validation should be maintained by the nurse and/or the employer in accordance with facility policies. 7. Regardless of training, policies and procedures of the facility must also permit the nurse to engage in the procedure. The nurse who accepts an assignment to engage in care and/or replacement of permanently placed feeding tubes is responsible to adhere to the NPA and Board rules, particularly ?217.11, Standards of Nursing Practice, as well as any other standards or rules applicable to the nurse's practice setting. Two standards applicable in all practice scenarios include: ? ?217.11(1)(B) "implement measures to promote a safe environment for clients and others;" and ? ?217.11(1)(T) "accept only those assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability." Additional standards in Rule 217.11 that may be applicable when a nurse chooses to engage in replacement of a permanently placed feeding tube include (but are not limited to): ? (1)(D) "Accurately and completely report and document: (i) ..client status....(ii) nursing care rendered...(iii) physician, dentist or podiatrist orders...(iv) administration of medications and treatments....(v) client response(s)...," ? (1)(G) "Obtain instruction and supervision as necessary when implementing nursing procedures or practices," ? (1)(H) "Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations," ? (1)(R) "Be responsible for one's own continuing competence in nursing practice and individual professional growth." ? Standards specific to LVNs may be found in ?217.11(2); standards specific to RNs may be found in ?217.11(3). Regardless of facility policy or physicians' orders, the nurse always has a duty to maintain the safety of the patient (Reference 217.11(1)(B) above); this standard has previously been upheld in a landmark case (Lunsford vs. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App. -- Austin 1983). (Adopted January 2005)(Reviewed - January 2010) 2) Resident #3 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on 01/27/11 at 8:29 a.m. with an unidentified staff member revealed Resident #3 was in the hospital. Review of a nurse's note dated 01/20/11 at 3:15 a.m., authored by LVN F, for Resident #3, revealed, "...Resident voiced pain to abdomen...." Review of a Physician/NP/PA Communication and Progress Note dated 01/22/11 at 7:00 a.m. for Resident #3 completed by LVN F revealed: "7:00 a.m. Went in to visit resident. Resident place hand to stomach and was removing cover. Noted [DEVICE] out (with) bulb. Attempted to replace [DEVICE] was unsuccessful. (FNP) notified and stated 'to get [DEVICE] in.' Retried and [DEVICE] replaced at this time...swollen and tender to touch ... 11:30 a.m. Family called voicing pt (patient) complained of pain to GTube site...notified (FNP)...New order may apply ice pack to GTube site PRN for pain... 2:00 p.m. [MEDICATION NAME] AC [MEDICATION NAME] given...Placement (checked)... 4:30 p.m. Resident sitting up in w/c at bedside. Resident said, 'look.' Noted clothing wet to GTube site. Noted copious amount of drainage to lower part of stoma. Drainage smelt of feeding. Notified (DON) at 12:30 p.m. of stoma site and reported to continue to monitor...Received okay to send (Resident #3) to (hospital) for eval (evaluation)... 6:20 p.m. ...transport to (hospital)...." Review of a Physician's telephone order dated 01/22/11 at 11:00 a.m. for Resident #3 revealed "Reinsert [DEVICE]." Review of a Physician's telephone order dated 01/22/11 at 11:30 a.m. for Resident #3 revealed, "May apply ice pack to [DEVICE] site PRN for pain." Review of a Physician's telephone order dated 01/22/11 at 4:30 p.m. for Resident #3 revealed, "May send to (hospital) ER for eval." Review of a Transfer Form dated 01/22/11 for Resident #3 revealed she was transferred to a local hospital ER for "leaking GTube...redness, hard edge to stoma site and GTube leaking.... " Review of a Grievance Report dated 01/23/11 for Resident #3 revealed, "1) [DEVICE] pulled out & family expressed concerns...." Review of a Blood Culture (from a local hospital) dated 01/22/11 for Resident #3 revealed after 19 hours, the blood was positive for Gram Positive Cocci. Review of an abdominal wound culture (from a local hospital) collected on 01/23/11 for Resident #3 revealed the final result was [MEDICAL CONDITION] Resistant Staph [MEDICAL CONDITION]." Review of an Operative Report dated 01/24/11 from a local hospital for Resident #3 revealed, "Procedure: Esophagogastroduodenoscopy and placement of feeding Gastrostomy tube. Indications for Procedure: Dysfunctional displaced Gastrostomy tube...." Interview on 01/27/11 at 12:21 p.m. with CNA G revealed she observed Resident #3's [DEVICE] site with drainage at least three days before she went to the hospital on [DATE]. CNA G stated she reported this to LVN E. On the day Resident #3 went to the hospital, CNA G stated she observed a piece of gauze with blood on it at the site of the [DEVICE]. CNA G stated she was not in Resident #3's room when the nurse attempted to reinsert the [DEVICE]. Interview on 01/27/11 at 12:30 p.m. with LVN E revealed she observed Resident #3's [DEVICE] was inflamed on 01/21/11. She stated at that time there was no drainage. LVN E stated she left a note in "the book" asking the FNP to look at it. LVN E stated the FNP came to the facility on Monday, Wednesday, and Friday, and was very good about reading "the book." When asked if the FNP came to the facility on [DATE], LVN E stated she was not sure. LVN E stated she did not call the physician about Resident #3's [DEVICE] site on 01/21/11. LVN E stated when she arrived for her shift on Monday (01/24/11) she was informed Resident #3's [DEVICE] had come out and the resident was sent to the hospital for complication of the [DEVICE]. When asked if she had ever reinserted a [DEVICE] in the facility, LVN E stated she would find someone who knew how to do it. She added she had never had to do it. Telephone interview on 01/27/11 at 2:30 p.m. with LVN F revealed she observed Resident #3 on 01/22/11 early in the morning on her shift. The [DEVICE] was completely out of resident with the bulb still inflated. She stated she had the 10:00 p.m. - 6:00 a.m. nurse look at it with her. LVN F stated she and the 10:00 p.m. - 6:00 a.m. nurse attempted to re-insert the [DEVICE] but met resistance. They were unsuccessful with the reinsertion. LVN F stated she notified the FNP by telephone and was told to, "Get it in!" LVN F stated the 10:00 p.m. - 6:00 a.m. nurse went back to the room with her, and they re-inserted the [DEVICE] successfully at that time. LVN F stated she did not meet resistance on the second attempt. She stated that once the [DEVICE] was in, she checked placement and obtained [MEDICAL CONDITION] juices with the syringe. LVN F stated she informed the DON about the incident and was told to monitor the site. LVN F stated she gave the [MEDICATION NAME] at 10:00 a.m. without difficulty. LVN F stated around 11:30 a.m., the family was reporting Resident #3 was complaining of pain to the [DEVICE] site and [MEDICATION NAME] was administered for pain. LVN F stated she notified the FNP that the resident was having pain. The FNP told her to apply ice to the site. LVN F stated she gave the [MEDICATION NAME] at 2:00 p.m. without difficulty. LVN F stated at 3:00 p.m. she administered the [MEDICATION NAME] without any problem. She stated she entered the room at 4:30 p.m. and noticed the [DEVICE] had leaked copious amounts of formula. The DON and the FNP were notified and orders were obtained to send the resident to the hospital. When asked if she had reinserted a [DEVICE] before, LVN F stated she had, and she felt comfortable doing it. When asked if she had any training or if her skills had been validated, she revealed she had been checked off on reinserting a [DEVICE]. LVN F stated the night nurse (another LVN) had trained her to reinsert [DEVICE]s. She was not able to recall if she had any additional training on reinserting [DEVICE]s. During the end of day meeting on 01/27/11 at 3:00 p.m. with the ADM and the DON, documentation of training for LVNs reinserting [DEVICE]s was requested for LVN F, LVN H and LVN I. Review of the Nurse Proficiency Checklist for "Tube Feeding by Gravity" and by "Pump" provided by the DON on 01/28/11 revealed: LVN F was checked on 05/04/10, LVN H on 04/08/10 and LVN I on 10/12/10. There was no documentation regarding reinsertion of a [DEVICE]. On 01/28/11 at 2:06 p.m., the DON revealed she was notified of Resident #3's [DEVICE] coming out and had instructed the nurses to monitor the site. The DON stated she was not aware of the attempt to reinsert the [DEVICE] prior to notifying the physician. She stated she was under the impression the physician was notified, an order was obtained and then the [DEVICE] was reinserted. The ADM entered the conference room at that time and was informed of the incident with Resident #3's [DEVICE] being reinserted without an order by LVN F. Interview on 01/28/11 at 3:30 p.m. with the FNP revealed she was notified on 01/22/11 of Resident #3's [DEVICE] being out of the resident with the bulb inflated. She also understood the nurse was able to reinsert it. The FNP revealed she was called after the tube was reinserted told the area was reddened. She stated she gave orders to send Resident #3 to the hospital. When asked if she instructed the nurse to "Get it in," (reinsert the [DEVICE]) the FNP stated she would NEVER tell a nurse to do anything like that. The FNP stated the [DEVICE] was already reinserted, according to the nurse, when she received the first telephone call. When the surveyor informed the FNP no training had been provided to the nursing staff to reinsert the [DEVICE]s, the FNP stated she was under the impression nursing home staff were trained to reinsert [DEVICE]s. A Discharge Summary (from a local hospital) dated 01/28/11 for Resident #3 from a local hospital reflected, "...Discharge Diagnoses: [REDACTED]. Staff states that they replaced it and once they replaced it the tube was leaking right around the tube and she had increased pain, all tube feedings were stopped. She was sent to the Emergency Department for medical management...." Review of a Patient Discharge Med Instruction sheet (from a local hospital) dated 01/28/11, signed by the FNP, for Resident #3 revealed, "...(cannot replace [DEVICE] in future)...." Telephone interview with Dr. J on 01/31/11 at 1:00 p.m. revealed he had not been aware of what had gone on with Resident #3 ' s [DEVICE], other than she was sent to the hospital, and it was replaced. When the surveyor informed Dr. J of the [DEVICE] being reinserted by staff that had not been trained to reinsert a [DEVICE], he stated the GI doctors had stated, if the [DEVICE] came out, they wanted a [DEVICE] or Foley catheter reinserted to keep the tract open. Dr. J added the [DEVICE] should not be used after it was replaced temporarily. Interview on 01/31/11 at 2:14 p.m., the ADM revealed LVN F had been suspended pending an investigation as to whether or not she followed policy by reinserting the [DEVICE]. When queried regarding lack of notification of the physician by LVN E, the ADM stated he would check in to it. Review of a facility policy entitled, "Change in a Resident's Condition or Status," dated April 2007, provided by the DON as the current policy, revealed, "...1) The nurse supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there had been:...d. A significant change in the resident's physical...condition; e. A need to alter the resident's medical treatment significantly... 2) A 'significant change' in condition is a decline...in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions...." Review of a facility policy entitled, "Changing a Gastrostomy Tube," dated September 2004, provided by the DON as the current policy, revealed, "...1) Verify that there is a physicians' order for this procedure...." 3) "The most dreaded complication of [DEVICE] replacement is misplacement of the tube into the peritoneal cavity. Starting tube feeds into the peritoneum often leads to serious morbidity and mortality. This complication can be avoided by obtaining a verification study (x-ray) prior to using the tube." (Retrieved at http://emedicine.medscape.com/article/ 9-treatment on 03/03/11) The CMS-672 (Resident Census and Conditions of Residents) dated 01/27/11 and provided by the DON reflected there were 22 residents with [DEVICE]s. The census was 135. Review of a list of employees dated 01/27/11, provided by the DON, revealed there were 32 LVNs currently employed at the facility.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #1) of four residents reviewed for pressure ulcers received the necessary care and services to prevent the development of new pressure ulcers and to promote healing of an existing pressure ulcers. Resident #1 was admitted to the facility on [DATE] and assessed with [REDACTED]. The facility failed to 1. Perform skin assessments which were complete and accurate; 2. Provide pressure ulcer care using a clean technique adequately to prevent the potential for infection in the pressure ulcer through cross-contamination and to promote healing; 3. Coordinate care of the resident's pressure ulcer through communication with other staff and appropriate care planning including notifying the physician to ensure the resident was receiving the appropriate treatment to aid in healing of the pressure ulcer; and 4. Turn and reposition the resident to relieve pressure on the sacrum. On [DATE] after surveyor inquiry, a newly developed Stage 2 pressure ulcer was identified on the resident's right ischial (buttock). In addition, the Stage 4 on the resident's coccyx increased in size from 9.0 cm x 11.0 cm x 4.5 cm to 12 cm x 14 cm x (no depth measured) on [DATE]. The pressure ulcer had also developed a strong odor (sign of infection). These failures likely caused Resident #1 to develop a new pressure ulcer and deterioration and delayed healing of the existing pressure ulcers. Resident #1 was hospitalized on [DATE] for wound care. These failures could affect the facility's 23 residents currently identified with pressure ulcers and placed them at risk for the development of more pressure ulcers, and deterioration and delayed healing of existing pressure ulcers. Findings included: 1) Resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Admission Intake Report dated [DATE] provided by the hospital to the facility reflected Resident #1 was alert and oriented to person, place and time, had a [MEDICAL CONDITION] on his left lower abdomen and a gastrostomy-jejunostomy tube (a tube with an outlet into the stomach and an outlet into the small intestine); received [MEDICAL TREATMENT] three times a week; had multiple non-healing wounds; and was on full isolation [MEDICAL CONDITION]. The facility Admission assessment dated [DATE] reflected Resident #1's medical [DIAGNOSES REDACTED]. Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #2 was not cognitively impaired but required extensive or total assistance from staff for all ADLs. The MDS assessment reflected Resident #2 had pain daily and was on a scheduled pain medication regimen. During initial tour on [DATE] at 7:55 a.m., Resident #1 was lying on his back in bed. The bed had on an air mattress and the head of the bed was elevated in a Semi-Fowler's (30 degree angle) position. Resident #1 was receiving oxygen via a nasal cannula at 2 liters/minute. [MEDICATION NAME] formula was infusing at 70 ml/hour via his J-tube (jejunostomy outlet). Also, a large, dried, brown-colored stained ring was observed on the right side of the bottom sheet. The surveyor requested to check the resident's skin. LVN A and an unidentified CNA assisted the resident on to his right side. Resident #1 was observed to have a sacral wound dressing dated [DATE] that covered his entire sacral area. The resident was leaking yellow, liquid feces from his rectum onto his buttocks and the sacral wound dressing was saturated with the liquid feces. The thick cloth incontinent pad under the resident was saturated and stained with feces. Below the wound dressing on his lower right buttock was an uncovered, shallow, open pressure ulcer with a red wound bed. LVN A revealed that pressure ulcer was new; she was not aware of it was there. LVN A stated Resident #1 frequently leaked liquid feces from his rectum, and she did not understand why, since he had a [MEDICAL CONDITION] for bowel elimination. When queried if the physician was aware of the rectal leakage, LVN A stated she assumed the physician knew, because his FNP visited the facility every week to see his residents. LVN A stated she had not notified the resident's physician. LVN A described the resident's covered sacral pressure ulcer as a large Stage 4. LVN A was asked if the pressure ulcer had worsened or improved since the resident's admission. LVN A stated she was not sure, because the 2:00 p.m. to 10:00 p.m. shift charge nurse was assigned to do the resident's treatment on his sacrum; therefore, she (LVN A) had not observed the pressure ulcer. LVN A revealed she was responsible for doing the wound treatments on the resident's legs. LVN A explained that the resident had a Stage 3 pressure ulcer on his left lower leg. She stated she did not know if it had gotten worse. She did not know what Stage it was on admission. LVN A said she knew the resident had the pressure ulcers before he was admitted to the facility except for the new pressure ulcer just discovered. At this time a dressing was observed on the resident's right thigh. On [DATE] at 8:50 a.m. (55 minutes after the initial observation of Resident #1) CNA B and CNA C entered Resident #1's room. The resident was still lying in bed on the soiled sheet stained with the same large brown ring. His G-J tube site was draining copious amounts of a yellow/bloody-colored mucus-textured substance. When asked why the resident had not been cleaned up, the CNAs stated the student nurses training in the facility were assigned to care for the resident that morning, and they thought the students had cleaned him up. During the observation, LVN A entered the room and revealed the facility did not have a treatment nurse. She stated she and the evening shift nurse provided wound care for Resident #1. LVN A explained the evening shift nurse did the treatments on the resident's sacral ulcer and she did the treatments on his lateral left lower leg, upper right and left anterior thigh ulcers. LVN A revealed the pressure ulcers on the resident's thighs were Stage 3's and his coccyx wound was a Stage 4. LVN A explained that Resident #1 had only resided on her hall for approximately one and a half weeks. LVN A revealed Resident #1 was admitted with the pressure ulcers. She was unaware if the ulcers had improved or worsened since his admission since she had not seen any progress notes on the ulcers. At this time, the surveyors requested to look at the resident's sacral wound. CNA B and CNA C put gloves on and assisted Resident #1 to roll onto his right side. A stream of yellow colored liquid feces was observed again oozing from the resident's rectum. The sacral dressing was non-occlusive (loose/dislodged) and saturated with a yellow and brownish colored substance. The dressing was removed to reveal a large pressure ulcer with full tissue thickness loss. Slough (moist dead tissue) and exposed bone were observed with undermining. LVN A then used her gloved hand and pressed (re-attached) the dressing against the wound. CNA B cleaned the resident's buttock crease with several moistened wipes. CNA B did not clean the resident's left buttock, his groin, and perineal area. Next, CNA B rolled the soiled sheet and incontinent pad next to the resident's buttocks. Wearing the same contaminated gloves she placed a clean sheet and incontinent pad on the bed next to the resident's buttocks. CNA B and CNA C rolled the resident over the linens onto his left side. CNA C pulled the clean sheet and incontinent pad from underneath the resident's buttocks and secured the sheet on the bed. CNA C did not clean the resident's right buttock, groin area, or perineal area. CNA B and CNA C rolled Resident #1 onto his back. While still wearing her contaminated gloves, CNA B placed a clean sheet over the resident and adjusted his pillow and oxygen tubing. Resident #1 was again positioned on his back in a Semi-Fowler's position. Last, CNA B removed her gloves and discarded them in the trashcan. CNA B was observed to leave Resident #1's room without washing her hands. Review of Resident #1's Admission Wound Pressure Report dated [DATE] revealed: ? One coccyx wound (no staging provided) measuring 9.0 cm x 11.0 cm x 4.5 cm and depth with 7.0 cm undermining (over hanging skin edges at margin) and tunneling; ? Two left lower lateral (outside portion) leg pressure ulcers - one Stage 2 measuring 7.0 cm x 2.3 cm, and one 4.0 cm x 2.0 cm ulcer that was not staged; ? One left anterior (front/top) thigh Stage 3 pressure ulcer measured 3.2 cm x 1.9 cm; One right anterior thigh Stage 3 pressure ulcer measured 7.2 cm x 2.0 cm. A review of Resident #1's entire clinical record revealed no other pressure ulcer assessments. On [DATE] at 7:47 a.m. LVN A was asked for any pressure ulcer assessments for Resident #1. LVN A stated there were no pressure ulcer sheets in the resident's record. Then, LVN A completed a Wound Treatment & Progress Record form and provided it to the surveyor. Review of the Wound Treatment & Progress Record provided by LVN A and dated [DATE] revealed the following data: A) Stage 4 sacrum/buttock: size 9.0 cm x 14.0 cm; (admitted [DATE] with pressure ulcer). B) Stage 2 right ischial buttock (newly discovered by surveyor): size 1.0 cm x 0.5 cm x 0.2 cm. Treatment: New order to clean with normal saline; apply hydrogel, non-stick dressing, and [MEDICATION NAME] tape. C) Left lower leg, size 20.0 cm x 6.0 cm. D) Right thigh, size 7.0 cm x 2.0 cm. E) Left thigh, size 1.5 cm x 0.1 cm. There was no documentation of: ? Depth - extent of any undermining (over-hanging skin edges over the base of the pressure ulcer), or tunneling depth; ? Exudates - color, odor and approximate amount; ? Wound bed - its color, type of tissue, evidence of healing granulation tissue or necrosis (slough or eschar); ? Description of wound edges and surrounding tissue (example, rolled edges, hardness/indurations and maceration). During an interview on [DATE] at 7:40 a.m. with LVN A regarding Resident #1's pressure ulcers, LVN A revealed she wrote a note on [DATE] to the physician requesting an order for [REDACTED]. Two other nurses had told her about the odor. LVN A stated she also requested the Wound Vac because it was a large Stage 4 pressure ulcer that drained. LVN A was queried as to why she or the other nurses had not notified the physician of the resident's condition. LVN A stated the physician's Nurse Practitioner visited the resident every Wednesday and would see the note she (LVN A) wrote in the doctor's book. LVN A revealed the nurse practitioner happened not to come to the facility that Wednesday, so there was no response to the message. LVN A stated the resident's physician was never notified. Review of "The Physician's Book" (messages from the nurses to the physician and nurse practitioner) revealed on [DATE] a written message regarding a strong odor from Resident #1's sacral pressure ulcer. The nurse requested an order for [REDACTED]. On [DATE] at 8:10 a.m. RN D revealed she was the Unit Manager on the hall where Resident #1 resided. RN D revealed she had not observed the resident's pressure ulcers and did not know what the ulcers looked like or what Stage they were. RN D stated she did not know if his pressure ulcers had improved or worsened since his admission to the facility. RN D explained that Resident #1 had transferred to her unit approximately one and a half week's ago. RN D stated the resident's wound treatment sheets were not transferred with his record. RN D stated she had not observed the pressure ulcers because the LVN charge nurses were the treatment nurses. RN D revealed new skin assessments had not been done and wound treatment progress notes had not been initiated. RN D also revealed she had not received a verbal report from the resident's former nurse regarding his pressure ulcers. RN D explained when residents transferred to a different room on a different hall; the same treatments were continued and documented on the TAR. RN D was queried as to how she or staff would know the size of a wound, what a wound looked like, and if the wound had improved or worsened if staff had not reviewed the previous wound sheets. RN D stated that without the records, staff would not know. RN D revealed the LVN charge nurse was responsible for making sure wound treatment progress reports were completed and wounds were followed closely to prevent worsening of wounds. RN D stated she was responsible for following-up and making sure the treatment sheets were completed and reviewed. On [DATE] at 1:45 p.m. an interview with the DON revealed Resident #1 had [MEDICAL CONDITION] infection and was being treated with the antibiotic [MEDICATION NAME]. When asked if the resident had seen a wound specialist, the DON said the resident had not, but the facility was looking into providing one. The DON stated there was nothing that could be done for the resident's sacral wound. "All we can do is keep it clean and dry." The DON provided Wound Pressure Reports that reflected the following documentation (measurements in cm): ? [DATE] - worsened in size and measured 11.7 x 10.2 x 4.9 with 8.3 undermining and 50% tan colored slough; ? [DATE] - slightly improved in size measuring 9.4 x 9.5 x 5; ? [DATE] - 9.7 x 7.2 x 4.8; ? [DATE] - 10.0 x 6.4 x 4.3; ? [DATE] - 9.4 x 7.0 x 4.3; ? [DATE] - 9.4 x 7.9 x 4.5; ? [DATE], 9.8 x 6.8 x 4.3; The record indicated the sacral (coccyx) pressure ulcer was a Stage 4 upon admission. The DON's weekly Skin Report notes to the corporate office sent weekly reflected Resident #1's Stage 4 coccyx pressure ulcer measurements (in cm) on the following: ? [DATE] - 11 x 10 x 5.2, worse; ? [DATE] - 11.0 x 10.0 x 5.2; ? [DATE] - 12.0 x 11.0 x 6.2; ? [DATE] - 12.4 x 11.0 x 6.4; ? [DATE] - 13.2 x 11.8 x 6.6; and ? [DATE] - (no measurements). The DON's weekly Skin Report notes for Resident #1's left lateral leg reflected: ? [DATE] - two pressure ulcers, one measured 11.0 x 3.0 with eschar/slough (unstageable) and a Stage 2 measured 2.1 x 0.1; ? [DATE] - two pressure ulcers, one measured 11 x 4 with eschar/slough and a Stage 2 measured 1.8 x 0.8 x 0.1; ? [DATE] - two pressure ulcers, one measured 11 x 4.3 still unstageable and the other (no stage documented) measured 1.6 x 0.6 x 0.1; ? [DATE] - two pressure ulcers, one unstageable measured 11 x 4.4 with yellow colored slough and the other measured 1.4 x 0.5 x 0.1 (not staged); ? [DATE] - two pressure ulcers, one measured 11.5 x 4.9 x 0.1 with 4.0 cm of yellow colored slough in upper center. The other measured 1.3 x 1.0 x 0.1 (not staged); ? [DATE] - now one Stage 3 pressure ulcer measuring 20.0 x 6.0 with eschar and drainage (worsened since admission). The DON's weekly Skin Report notes for Resident #1's right and left medial thigh pressure ulcer reflected: ? [DATE] - right thigh 0.6 x 2.6 x 0.1, left thigh 2.3 x 1.0 x 0.1; ? [DATE] - right thigh 0.5 x 2.0 x 0.1, left thigh 2.3 x 1.0 x 0.1; ? [DATE] - right thigh 0.5 x 1.8 x 0.1, left thigh 2.2 x 1.0 x 0.1; ? [DATE] - right thigh 0.4 x 1.4 x 0.1, left thigh 2.1 x 1.0 x 0.1; ? [DATE] - right thigh 3.0 x 1.5 x 0.1, left thigh 2.5 x 1.1 x 0.1; ? [DATE] - right thigh Stage 2 (no measurements), left thigh Stage 3 (no measurements); and ? [DATE] - right thigh 7.0 x 2.0, left thigh 1.5 x 1.0. Resident #1's consolidated Physician order [REDACTED]. 1) Stage 4 sacral pressure ulcer; clean with normal saline, pat dry, apply Hydrogel, apply [MEDICATION NAME] Plus to entire wound bed, pack loosely with 4x4 gauze moistened with Hydrogel and cover with dry dressing daily and prn (when necessary) dislodgement. 2) Left lower lateral leg; clean with normal saline, pat dry, apply Hydrogel and cover with collagen then [MEDICATION NAME], wrap with Kerlix, and change everyday. There were not treatment order changes since [DATE]. A review of Resident #1's Care Plan dated [DATE] revealed, "Approaches - skin concerns, pressure ulcers, 1) Perform treatments as ordered, if no improvement x (times) 2 weeks report to M.D. 2) Monitor areas for increase breakdown, s/s of infection report to M.D ... 5) Keep M.D. informed of resident's progress. 6) Assess skin weekly and record findings in clinical record." On [DATE] at 3:20 p.m. an interview with FNP K was conducted to discuss Resident #1's pressure ulcer. FNP K revealed she did not think a Wound Vac would work on Resident #1's sacral wound because it would cover his rectum. FNP K stated she could possibly transfer Resident #1 to the hospital to receive TPN (nutrition given intravenously) and have a wound doctor assess Resident #1's sacral wound. FNP K was asked if she was aware Resident #1's pressure ulcer treatments had not been changed since it was ordered [DATE]. FNP K stated, "No, I might try a medication to slough the wound." On [DATE] at 1:00 p.m. an interview with Resident #1's physician, Dr. J revealed he could not remember the last time he observed the resident's sacral pressure ulcer. When queried about when he last discussed Resident #1 with his FNP, Dr. J revealed he talked with FNP on [DATE] (after surveyor inquiries) when it was decided to admit the resident to the hospital. The physician stated he could not remember when he last discussed the status of Resident #1's sacral pressure ulcer with his FNP prior to [DATE]. The physician did reveal he was aware Resident #1 had a Stage 4 pressure ulcer on his coccyx. The physician asked what constituted a pressure ulcer as "non-healing." The physician answered by stating the resident had the pressure ulcer a long time before he was admitted to the facility. When asked about the resident's continued diarrhea from the rectum, the physician revealed he was aware the resident had a [MEDICAL CONDITION]. He indicated the [MEDICAL CONDITION] was placed to protect the sacral pressure ulcer from fecal contamination. He was unaware that the resident had yellow liquid feces oozing from his rectum onto his wound dressing. The physician also revealed the facility told him they were getting a wound care doctor to care for Resident #1's ulcer. He did not understand why that had not happened. On [DATE] at 1:28 p.m. an interview with the DON revealed she was not aware if the information provided to her on the weekly Skin Report notes was placed in the Treatment Book on the units. The DON stated the weekly Skin Report notes were for her knowledge and she filed them. "They are just my work sheets so I know what's going on." The DON also revealed the charge nurses were assigned to do weekly skin check rounds on the 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. shifts every week. Skin problems found should be documented on the anatomy figure form and placed in the treatment book. Measurements should be documented on the flow sheets with one sheet per wound on the Wound Treatment and Progress Record and monitored weekly. The DON stated she was not sure if they were done or not. When queried about Resident #1's wound treatment sheets not being transferred with the resident to his new unit, she stated, "I heard that." Physician's Telephone Orders dated [DATE] reflected Resident #1 was to be sent to the ER. A review of hospital physician's orders [REDACTED]. Review of List Patient Notes, dated [DATE] for Resident #1 from a local hospital revealed, "...1) Stage 4 sacral PU (pressure ulcer), 12 cm x 12 cm x ,[DATE] cm with ,[DATE] cm undermining from ,[DATE] o'clock, odiferous (with odor) with moderate serous exudate...." The National Pressure Ulcer Adversary Panel and guidelines retrieved on [DATE] at www.ncbi.nlm.nih.gov/bookshelf/br.fcgibook=hsahcpr&part=A5393PressureUlcers[DATE] <http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgibook=hsahcpr&part=A5393PressureUlcers[DATE]> reflected, " Pressure ulcers should be uniformly described to facilitate communication among staff and to ensure adequate monitoring of the progress toward healing ...To monitor progress or deterioration of the lesion, the examiner must accurately measure the length, width, and depth of the ulcer and describe sinus tracts, tunneling, undermining, necrotic tissue, exudate, and the presence or absence of granulation tissue and [MEDICATION NAME] ...Reassess pressure ulcers at least weekly ...If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted ...to determine the adequacy of the treatment plan, it is essential to monitor pressure ulcers at consistent intervals. Assessments and documentation should be carried out at least weekly, unless there is evidence of deterioration, in which case both the pressure ulcer and the patient's overall management must be reassessed immediately...." The CMS-672 dated [DATE], provided by the DON revealed there were 23 residents with pressure ulcers with 14 developed in-house. The census was 135.

Based on observation, interview and record review, it was determined the facility failed to ensure two (Residents #1 and #3) of eleven residents reviewed with gastrostomy feeding tubes received the appropriate treatment and services to prevent malfunctioning of their [DEVICE]s. 1) Resident #1 was discharged from the hospital on [DATE] after a having a [DEVICE] replaced due to leakage around the old tube. Upon readmission to the facility, the physician ordered the placement of an abdominal binder to prevent displacement of this new tube. The facility failed to follow the physician's orders and the resident was sent back to the hospital on [DATE], because the [DEVICE] was again not working. 2) Resident #3 had a [DEVICE] for nutrition intake. On 01/22/11 at 7:00 a.m., the tube was found out of the resident. There was no physician's order to reinsert the tube. Without first contacting the physician, LVN F attempted to reinsert the tube. On her second attempt, LVN F reinserted the tube and began using the tube with the delivery of formula and medications. The facility failed to ensure LVN F was trained and skills validated on the proper procedure for the reinsertion of [DEVICE]s. Resident #3 was sent to the hospital on [DATE] at 6:20 p.m. due to abdominal pain and malfunction of the [DEVICE]. The resident was diagnosed with [REDACTED]. The [DEVICE] had to be surgically replaced. These failures could affect the 22 residents in the facility with [DEVICE]s, including Residents #1 and #3, and placed them at risk for developing malfunctioning [DEVICE]s that could lead to life threatening complications, including severe infections as well as hospitalization for reinsertion of their [DEVICE]s. Findings included: 1) Resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Admission Intake Report dated 09/29/10 provided by the hospital to the facility reflected Resident #1 was alert and oriented to person, place and time, had a [MEDICAL CONDITION] on his left lower abdomen and a gastrostomy-jejunostomy tube (a tube with an outlet into the stomach and an outlet into the small intestine); received [MEDICAL TREATMENT] three times a week; had multiple non-healing wounds; and was on full isolation [MEDICAL CONDITION]. The facility Admission Assessment, dated 09/30/10, reflected Resident #1's medical [DIAGNOSES REDACTED]. Resident #1's quarterly MDS assessment, dated 12/22/10, reflected Resident #1 was not cognitively impaired but required extensive or total assistance from staff for all ADLs. The MDS assessment reflected Resident #1 had pain daily and was on a scheduled pain medication regimen. During initial tour on 01/27/11 at 7:55 a.m., Resident #1 was lying on his back in bed. The bed had on an air mattress and the head of the bed was elevated in a Semi-Fowler's (30 degree angle) position. Resident #1 was receiving oxygen via a nasal cannula at 2 liters/minute. [MEDICATION NAME] formula was infusing at 70 ml/hour via his J-tube (jejunostomy outlet). LVN A revealed Resident #1 was transferred to and from the hospital the prior day after having his G-J tube replaced. LVN A said his [DEVICE] was replaced due to it constantly leaking. At that time, Resident #1 was observed to have copious amounts of mucus-textured, yellow-colored drainage from his G-J tube site. An abdominal binder was observed underneath the resident but not around the abdomen nor over the resident's tube site. Two towels around the G-J tube site to catch the drainage were saturated. LVN A stated she just finished administering Resident #1's medications via the [DEVICE]. The skin surrounding the tube site, approximately one-inch in diameter, was bright red in color. Resident #1 complained the area was tender and painful when touched. There was also a large, dried, brown-colored stain, on the right side of the bottom sheet. Resident #1's physician's post gastrostomy orders dated 01/26/11, reflected: 1. Keep head of bed up at all times. 2. Abdominal binder loosely placed to prevent inadvertent displacement of [DEVICE] for 2 weeks. 3. Use G tube for meds today (01/26/11) with 30 ml saline flushes. 4. Start tube feeding at original rate (70 ml) per hour on 01/26/11 at 2:00 p.m. via J-tube. 5. Flush J-tube with normal saline 60 ml every 8 hours. Use more flushes if resistance noted. 6. Do not use J-tube for meds ever. 7. Use J-tube only for formula feedings. On 01/27/11 at 8:50 a.m. (55 minutes after the initial observation of Resident #1) CNA B and CNA C entered Resident #1's room. The resident was still lying in bed on the soiled sheet stained with the same large brown ring. His G-J tube site was draining copious amounts of a yellow/bloody-colored mucus-textured substance. When asked why the resident had not been cleaned up, the CNAs stated the student nurses training in the facility were assigned to care for the resident that morning, and they thought the students had cleaned him up. At that time, LVN A and RN D entered Resident #1's room. RN D stated the resident was transferred to the hospital the prior day (01/26/11) to have his tube replaced. RN D said his tube had been leaking since Monday, 01/24/11. LVN A then revealed Resident #1's tube site did not start leaking again until she poured his medications through his tube that morning. The resident's abdominal binder was again observed underneath him and not secured over his abdomen. LVN A said she could not keep his [DEVICE] site clean, because it kept oozing. The skin around the resident's [DEVICE] site was observed to be inflamed and there was a small ulceration below the tube site. LVN A then placed a 4 x 4 gauze pad around Resident #1's [DEVICE] site. The surveyor queried LVN A if there was a physician's order for the abdominal binder. LVN A stated there was not a physician's order for the abdominal binder. The surveyor informed LVN A the resident had an order for [REDACTED]. LVN A said she had not had time to look at the order. When asked if the new order was passed on to her in report, LVN A said, "No." On 01/31/11 at 1:00 p.m., during an interview with Resident #1's physician, Dr. J, the surveyor queried the physician why an abdominal binder was ordered for the resident after his [DEVICE] replacement. The physician revealed the binder was to keep the tube from coming out due to the resident's fresh stoma. Dr. J stated, "Better to put a binder on." Review of Resident #1's MAR for January 2011 revealed the resident's J-tube was flushed with 60 ml of saline every six hours instead of the new physician order (01/26/11) for every eight hours. Physician's Telephone Orders dated 01/28/11 reflected an order to send Resident #1 to the ER. A hospital Physician's Order Sheet for Resident #1, dated 01/29/11 reflected to attach his [DEVICE] to suction (to empty the stomach). The hospital [MEDICATION NAME] Consultation Report dated 01/30/11 reflected Resident #1's [DEVICE] was dysfunctional, because it did not fit snugly into the anterior abdominal wall. The Report reflected Gastroparesis (delayed emptying of food) allowed [MEDICAL CONDITION] contents to leak from the loosely fitting PEG (refers to the method of placement of [DEVICE]). A review of Resident #1's hospital Physician's Order Sheet dated 01/31/11 revealed to apply [MEDICATION NAME] cream to his skin around his [DEVICE] site for infection. Review of List Patient Notes dated 02/01/11 for Resident #1 from a local hospital revealed, "...3) [DEVICE] site - Cleaned with N/S, large area of peri-tubular yeast present with erythemia and diffuse satellite [MEDICAL CONDITION]." 2) Resident #3 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on 01/27/11 at 8:29 a.m. with an unidentified staff member revealed Resident #3 was in the hospital. Review of a nurse's note dated 01/20/11 at 3:15 a.m., authored by LVN F, for Resident #3, revealed, "...Resident voiced pain to abdomen...." Review of a Physician/NP/PA Communication and Progress Note dated 01/22/11 at 7:00 a.m. for Resident #3 completed by LVN F revealed: "7:00 a.m. Went in to visit resident. Resident place hand to stomach and was removing cover. Noted [DEVICE] out (with) bulb. Attempted to replace [DEVICE] was unsuccessful. (FNP) notified and stated 'to get [DEVICE] in.' Retried and [DEVICE] replaced at this time...swollen and tender to touch ... 11:30 a.m. Family called voicing pt (patient) complained of pain to GTube site...notified (FNP)...New order may apply ice pack to GTube site PRN for pain... 2:00 p.m. [MEDICATION NAME] AC [MEDICATION NAME] given...Placement (checked)... 4:30 p.m. Resident sitting up in w/c at bedside. Resident said, 'look.' Noted clothing wet to GTube site. Noted copious amount of drainage to lower part of stoma. Drainage smelt of feeding. Notified (DON) at 12:30 p.m. of stoma site and reported to continue to monitor...Received okay to send (Resident #3) to (hospital) for eval (evaluation)... 6:20 p.m. ...transport to (hospital)...." Review of a Physician's telephone order dated 01/22/11 at 11:00 a.m. for Resident #3 revealed "Reinsert [DEVICE]." Review of a Physician's telephone order dated 01/22/11 at 11:30 a.m. for Resident #3 revealed, "May apply ice pack to [DEVICE] site PRN for pain." Review of a Physician's telephone order dated 01/22/11 at 4:30 p.m. for Resident #3 revealed, "May send to (hospital) ER for eval." Review of a Transfer Form dated 01/22/11 for Resident #3 revealed she was transferred to a local hospital ER for "leaking GTube...redness, hard edge to stoma site and GTube leaking.... " Review of a Grievance Report dated 01/23/11 for Resident #3 revealed, "1) [DEVICE] pulled out & family expressed concerns...." Review of a Blood Culture (from a local hospital) dated 01/22/11 for Resident #3 revealed after 19 hours, the blood was positive for Gram Positive Cocci. Review of an abdominal wound culture (from a local hospital) collected on 01/23/11 for Resident #3 revealed the final result was [MEDICAL CONDITION] Resistant Staph [MEDICAL CONDITION]." Review of an Operative Report dated 01/24/11 from a local hospital for Resident #3 revealed, "Procedure: Esophagogastroduodenoscopy and placement of feeding Gastrostomy tube. Indications for Procedure: Dysfunctional displaced Gastrostomy tube...." Interview on 01/27/11 at 12:21 p.m. with CNA G revealed she observed Resident #3's [DEVICE] site with drainage at least three days before she went to the hospital on [DATE]. CNA G stated she reported this to LVN E. On the day Resident #3 went to the hospital, CNA G stated she observed a piece of gauze with blood on it at the site of the [DEVICE]. CNA G stated she was not in Resident #3's room when the nurse attempted to reinsert the [DEVICE]. Interview on 01/27/11 at 12:30 p.m. with LVN E revealed she observed Resident #3's [DEVICE] was inflamed on 01/21/11. She stated at that time there was no drainage. LVN E stated she left a note in "the book" asking the FNP to look at it. LVN E stated the FNP came to the facility on Monday, Wednesday, and Friday, and was very good about reading "the book." When asked if the FNP came to the facility on [DATE], LVN E stated she was not sure. LVN E stated she did not call the physician about Resident #3's [DEVICE] site on 01/21/11. LVN E stated when she arrived for her shift on Monday (01/24/11) she was informed Resident #3's [DEVICE] had come out and the resident was sent to the hospital for complication of the [DEVICE]. When asked if she had ever reinserted a [DEVICE] in the facility, LVN E stated she would find someone who knew how to do it. She added she had never had to do it. Telephone interview on 01/27/11 at 2:30 p.m. with LVN F revealed she observed Resident #3 on 01/22/11 early in the morning on her shift. The [DEVICE] was completely out of resident with the bulb still inflated. She stated she had the 10:00 p.m. - 6:00 a.m. nurse look at it with her. LVN F stated she and the 10:00 p.m. - 6:00 a.m. nurse attempted to re-insert the [DEVICE] but met resistance. They were unsuccessful with the reinsertion. LVN F stated she notified the FNP by telephone and was told to, "Get it in!" LVN F stated the 10:00 p.m. - 6:00 a.m. nurse went back to the room with her, and they re-inserted the [DEVICE] successfully at that time. LVN F stated she did not meet resistance on the second attempt. She stated that once the [DEVICE] was in, she checked placement and obtained [MEDICAL CONDITION] juices with the syringe. LVN F stated she informed the DON about the incident and was told to monitor the site. LVN F stated she gave the [MEDICATION NAME] at 10:00 a.m. without difficulty. LVN F stated around 11:30 a.m., the family was reporting Resident #3 was complaining of pain to the [DEVICE] site and [MEDICATION NAME] was administered for pain. LVN F stated she notified the FNP that the resident was having pain. The FNP told her to apply ice to the site. LVN F stated she gave the [MEDICATION NAME] at 2:00 p.m. without difficulty. LVN F stated at 3:00 p.m. she administered the [MEDICATION NAME] without any problem. She stated she entered the room at 4:30 p.m. and noticed the [DEVICE] had leaked copious amounts of formula. The DON and the FNP were notified and orders were obtained to send the resident to the hospital. When asked if she had reinserted a [DEVICE] before, LVN F stated she had, and she felt comfortable doing it. When asked if she had any training or if her skills had been validated, she revealed she had been checked off on reinserting a [DEVICE]. LVN F stated the night nurse (another LVN) had trained her to reinsert [DEVICE]s. She was not able to recall if she had any additional training on reinserting [DEVICE]s. During the end of day meeting on 01/27/11 at 3:00 p.m. with the ADM and the DON, documentation of training for LVNs reinserting [DEVICE]s was requested for LVN F, LVN H and LVN I. Review of the Nurse Proficiency Checklist for "Tube Feeding by Gravity" and by "Pump" provided by the DON on 01/28/11 revealed: LVN F was checked on 05/04/10, LVN H on 04/08/10 and LVN I on 10/12/10. There was no documentation regarding reinsertion of a [DEVICE]. On 01/28/11 at 2:06 p.m., the DON revealed she was notified of Resident #3's [DEVICE] coming out and had instructed the nurses to monitor the site. The DON stated she was not aware of the attempt to reinsert the [DEVICE] prior to notifying the physician. She stated she was under the impression the physician was notified, an order was obtained and then the [DEVICE] was reinserted. The ADM entered the conference room at that time and was informed of the incident with Resident #3's [DEVICE] being reinserted without an order by LVN F. Interview on 01/28/11 at 3:30 p.m. with the FNP revealed she was notified on 01/22/11 of Resident #3's [DEVICE] being out of the resident with the bulb inflated. She also understood the nurse was able to reinsert it. The FNP revealed she was called after the tube was reinserted told the area was reddened. She stated she gave orders to send Resident #3 to the hospital. When asked if she instructed the nurse to "Get it in," (reinsert the [DEVICE]) the FNP stated she would NEVER tell a nurse to do anything like that. The FNP stated the [DEVICE] was already reinserted, according to the nurse, when she received the first telephone call. When the surveyor informed the FNP no training had been provided to the nursing staff to reinsert the [DEVICE]s, the FNP stated she was under the impression nursing home staff were trained to reinsert [DEVICE]s. A Discharge Summary (from a local hospital) dated 01/28/11 for Resident #3 from a local hospital reflected, "...Discharge Diagnoses: [REDACTED]. Staff states that they replaced it and once they replaced it the tube was leaking right around the tube and she had increased pain, all tube feedings were stopped. She was sent to the Emergency Department for medical management...." Review of a Patient Discharge Med Instruction sheet (from a local hospital) dated 01/28/11, signed by the FNP, for Resident #3 revealed, "...(cannot replace [DEVICE] in future)...." Telephone interview with Dr. J on 01/31/11 at 1:00 p.m. revealed he had not been aware of what had gone on with Resident #3's [DEVICE], other than she was sent to the hospital, and it was replaced. When the surveyor informed Dr. J of the [DEVICE] being reinserted by staff that had not been trained to reinsert a [DEVICE], he stated the GI doctors had stated, if the [DEVICE] came out, they wanted a [DEVICE] or Foley catheter reinserted to keep the tract open. Dr. J added the [DEVICE] should not be used after it was replaced temporarily. Interview on 01/31/11 at 2:14 p.m., the ADM revealed LVN F had been suspended pending an investigation as to whether or not she followed policy by reinserting the [DEVICE]. When queried regarding lack of notification of the physician by LVN E, the ADM stated he would check in to it. Review of a facility policy entitled, "Change in a Resident's Condition or Status," dated April 2007, provided by the DON as the current policy, revealed, "...1) The nurse supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there had been:...d. A significant change in the resident's physical...condition; e. A need to alter the resident's medical treatment significantly... 2) A 'significant change' in condition is a decline...in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions...." Review of a facility policy entitled, "Changing a Gastrostomy Tube," dated September 2004, provided by the DON as the current policy, revealed, "...1) Verify that there is a physicians' order for this procedure...." Review of a Position Statement from the Texas Board of Nursing website, www.http://www.bon.state.tx.us/practice/position.html#15.2415.24, retrieved on 02/07/11, Nurses Engaging In Reinsertion of Permanently Placed Feeding Tubes, revealed: The Board approved curriculum for both vocational nurses...does not provide graduates with sufficient instruction to ascertain that a nurse has the necessary knowledge, skills and ability to re-insert and determine correct placement of a permanently placed feeding tube (such as a Gastrostomy or Jejunostomy tubes). The Board does allow LVNs...to expand their practice beyond the basic educational preparation through post-licensure continuing education and training for certain tasks and procedures. One of the main considerations in determining whether or not a nurse should consider re-insertion of a Gastrostomy, Jejunostomy or similar feeding tube is how long the original tube was in place before becoming dislodged. Though sources vary, most give a range of 8-12 weeks for maturation/healing of the fistulous tract and stoma formation. The method of initial insertion (surgical, endoscopy, or radiographic guidance) may impact the length of healing. Orders should be obtained from the patient's physician regarding re-insertion guidelines. It is the opinion of the Board that LVNs...should not engage in the reinsertion of a permanently placed feeding tube through an established tract until the LVN...successfully completes a competency validation course congruent with prevailing nursing practice standards. Training should provide instruction on the nursing knowledge and skills applicable to tube replacement and verification of correct and incorrect placement. The Board of Nursing (BON) does not define nor set qualifications for competency validation courses; however, inclusion of the following factors is encouraged: 1. The nurse should complete training designed specifically for the type or types of permanent feeding tubes the nurse may need to replace, including overall patient assessment, verification of proper tube placement, and assessment of the tube insertion site. 2. A registered nurse or a physician who has the necessary expertise with regard to the specific feeding tube provides supervision during the training process. 3. The nurse demonstrates competency in all appropriate aspects (knowledge, decision-making, and psycho-motor skills) of performing the procedure. 4. The patient has an established tract. The established tract is not determined by the nurse. 5. The facility has resources available to develop an educational program for initial instruction of LVNs...as well as for ongoing competency validation. 6. Documentation of each nurse's initial education and ongoing competency validation should be maintained by the nurse and/or the employer in accordance with facility policies. 7. Regardless of training, policies and procedures of the facility must also permit the nurse to engage in the procedure. The nurse who accepts an assignment to engage in care and/or replacement of permanently placed feeding tubes is responsible to adhere to the NPA and Board rules, particularly ?217.11, Standards of Nursing Practice, as well as any other standards or rules applicable to the nurse's practice setting. Two standards applicable in all practice scenarios include: ? ?217.11(1)(B) "implement measures to promote a safe environment for clients and others;" and ? ?217.11(1)(T) "accept only those assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability." Additional standards in Rule 217.11 that may be applicable when a nurse chooses to engage in replacement of a permanently placed feeding tube include (but are not limited to): ? (1)(D) "Accurately and completely report and document: (i) ..client status....(ii) nursing care rendered...(iii) physician, dentist or podiatrist orders...(iv) administration of medications and treatments....(v) client response(s)...," ? (1)(G) "Obtain instruction and supervision as necessary when implementing nursing procedures or practices," ? (1)(H) "Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations," ? (1)(R) "Be responsible for one's own continuing competence in nursing practice and individual professional growth." ? Standards specific to LVNs may be found in ?217.11(2); standards specific to RNs may be found in ?217.11(3). Regardless of facility policy or physicians' orders, the nurse always has a duty to maintain the safety of the patient (Reference 217.11(1)(B) above); this standard has previously been upheld in a landmark case (Lunsford vs. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App. -- Austin 1983). (Adopted January 2005)(Reviewed - January 2010) 3) "The most dreaded complication of [DEVICE] replacement is misplacement of the tube into the peritoneal cavity. Starting tube feeds into the peritoneum often leads to serious morbidity and mortality. This complication can be avoided by obtaining a verification study (x-ray) prior to using the tube." (Retrieved at http://emedicine.medscape.com/article/ 9-treatment on 03/03/11) The CMS-672 (Resident Census and Conditions of Residents) dated 01/27/11 and provided by the DON reflected there were 22 residents with [DEVICE]s. The census was 135. Review of a list of employees dated 01/27/11, provided by the DON, revealed there were 32 LVNs currently employed at the facility.