Every finding on record at Villa Toscana at Cypress Woods

Based on interview and record review, the facility failed to designate a registered nurse to serve as the DON (Director of Nursing) on a full-time basis for 1 of 1 DON reviewed for DON coverage.The facility failed to have a full-time DON from 06/24/2026 to 07/08/2026.This failure could place residents at risk of lack of nursing administrative oversight that only the DON can provide. During an interview on 07/08/26 at 9:00 AM, the Administrator stated the former DON, who was an RN, accepted a corporate position, was currently in training but had returned every now and then over the past 2 weeks (06/24/26 to 07/08/26) to finish some work. The Administrator stated the facility's two ADONs, who were LVNs, were assigned to the DON duties until the newly hired DON begins work at the end of July 2026. The Administrator stated there was currently no interim DON.During an interview on 07/08/26 at 4:30 PM, the Administrator stated he did not have a waiver for DON requirements. The Administrator stated he did not document the number of hours the former DON worked over the last 2 weeks (06/24/26 to 07/08/26), but she stepped in two times a week. The Administrator stated the former DON worked maybe half a day on 07/03/26 and 07/07/26. The Administrator stated that he had not designated an RN to serve as DON and if needed he would designate one of the staff RNs until the new DON arrives.Record review of the facility's document titled Job Description for the Director of Nursing dated 2014 read in part: The following is a non-exhaustive criterion that relates to the job of a Director of Nursing, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for Director of Nursing and are related to the functions that are essential to the job of a Director of Nursing. Knowledge Base: Registered Nurse with required state licensure.Working knowledge of nursing home regulations. Accountable for nursing compliance, excellence, and delivery of resident care services in adherence with The Company, local, state, and federal regulations.Manage nursing staff through appropriate hiring, training, evaluation, assignment, and delegation of duties, within budget and resident census guidelines. Augment floor staffing if needed .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 2 of 4 (LVN A, CNA B) staff members reviewed for food service safety.The facility failed to ensure LVN A and CNA B's hands were washed or sanitized before and between serving residents their meals during breakfast in the secured unit.This failure placed the residents at risk for cross contamination, foodborne illness, and transmission of infectious organisms.Findings included:During an observation on 05/06/2026 at 9:31am in the secured unit CNA B did not wash or sanitize their hands before serving a resident's breakfast, between serving consecutive residents, or while moving back and forth between the residents and the meal trays. At 9:41am LVN Adid not wash or sanitize her hands after assisting a resident and completing an assessment. LVN A then brought the resident to the dining room, removed her gloves, received the resident's breakfast plate, and immediately began assisting with feeding. There were 8 residents in the secured unit's dining room during breakfast.During an interview on 05/06/2026 at 9:58am with LVN A she stated that she washes her hands before handling trays and afterward. She stated that the reason she wears gloves is the food can be sticky and she would sanitize her hands if she were unable to wash them. LVN A stated that she was unsure where she was required to sanitize between trays. When LVN A was asked about the observation of putting on the gloves, assessing a resident, holding the resident's hand to assist with walking to the secured unit's dining room and then assisting the resident with feedings, she acknowledged that not sanitizing could place residents at risk for infection, viral diseases, and contamination.During an interview on 05/06/2026 at 10:20 am with CNA B she stated that they usually have small hand sanitizer bottles available, but none were present un in the area. She stated that the meal service time becomes very busy, and tasks are expected to be completed quickly to keep the residents from being served cold food. She stated when she was going back and forth between rooms and passing out trays, she didn't use hand sanitizer because she was rushing to make sure all residents received their breakfast. CNA B stated that staff are supposed to wash or sanitize their hands between passing trays, and that the risk of not doing so is the spread of germs.During an interview on 05/06/2026 at 6:22pm with the DON she stated the expectation for hand hygiene is to sanitize hands before receiving a tray and again after placing the tray down, and before touching another tray. She stated that hand sanitizer can is available at the nurse's station and that pocket sized sanitizers could also be used, though she was unsure whether the company provides them, but there is also hand sanitizer in each resident's room. The DON stated the risk of not sanitizing if is the spread of infection. She also stated that gloves are not a substitute for handwashing and are intended for single use only.Record review of the facility's policy for 'Fundamentals pf of Infection Control Precautions' undated read. A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. Before and after eating or handling food (hand washing with soap and water); Before and after assisting a resident with meals; After removing gloves or aprons; and Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident)

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident 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 1 of 6 (Resident #7) residents reviewed for comprehensive assessments.The facility failed to revise Resident #7's care plan with intervention after completing an elopement assessment when the resident scored high risk for eloping.This failure could result in the care plans not reflecting the residents' status, needs, and interventions and the potential to lead to unmet needs, inconsistent care, and avoidable decline.Findings include:During an interview on 05/06/2026 at 10:20am with CNA B she stated that Resident #7 attempted to elope from the facility approximately two weeks ago and was located at the front of the building in her wheelchair, still on the facility property, by a member of the dietary staff. She stated that she did not know the name of the dietary staff member at this time. CNA B stated that Resident #7 has not been on the secured unit long and has not attempted to leave since being placed in the unit.Record review of Resident #7's undated face sheet revealed a [AGE] year-old female who admitted into the facility on [DATE] and readmitted on [DATE]. She had diagnoses of dementia (a condition that affects memory and thinking), cerebrovascular disease (problems with blood flow in the brain), lack of coordination (difficulty controlling body movements), seizures (episodes of abnormal electrical activity in the brain), anxiety (feelings of worry or nervousness), dysphagia (trouble swallowing), depression (a mood disorder that causes sadness or loss of interest), difficulty in walking (problems with mobility), and cognitive communication deficit (trouble understanding or expressing information due to thinking or memory problems).Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed she had BIMS score of 04 out of 15 which indicated significant difficulty with memory, decision-making, and understanding of their surroundings. Resident #7 had no impairment in upper or lower extremities and used a wheelchair for mobility. Resident #7's functional abilities were scored as 03 out of 06 for partial/moderate assistance, which indicated the helper does less than half the effort when it comes to sitting to stand, walk 10 feet, and chair/bed to-chair transfer.Record review of Resident #7's Elopement Risk assessment dated [DATE] revealed a score of 23, which indicated a high risk for elopement completed by the ADON. The assessment revealed Resident #7 was able to propel self, was not on the secured unit, moderately impaired- decisions poor; cues/supervision required, one or more attempts to leave facility in the last year, does not recognize stop lights, physical needs, precautions when crossing the streets, and knows location of current residence. Elopement Risk assessment dated for 04/14/2026 revealed a score of 27, which indicated a high risk for elopement completed by the DON. The assessment revealed Resident #7 was able to propel self, was on the secured unit, moderately impaired- decisions poor; cues/supervision required, one or more attempts to leave facility in the last week, does not recognize stop lights, physical needs, precautions when crossing the streets, and knows location of current residence. Additional information noted included Resident #7 exited the building this morning and was able to be redirected. Elopement Risk assessment dated for 04/20/2026 revealed a score of 27, which indicated a high risk for elopement completed by the DON. The assessment revealed Resident #7 was able to propel self, was on the secured unit, moderately impaired- decisions poor; cues/supervision required, one or more attempts to leave facility in the last week, does not recognize stop lights, physical needs, precautions when crossing the streets, and knows location of current residence.Record review of Resident #7's Physician Orders active and discontinued as of 5/06/2026 revealed Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to DEPRESSION, OXcarbazepine Oral Tablet 300 MG (Oxcarbazepine) Give 1 tablet by mouth two times a day for seizure, Apixaban Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for Atrial Fibrillation, and LORazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 4 hours as needed for Anxiety for 14 Days and was ordered and started on 04/13/2026.Record review of Resident #7's Care Plan initiated on 04/14/2026 revealed the focus read an actual elopement or elopement attempt. Resident was confused and wandered outside the facility unattended. The interventions read, assess/record/report to the doctor risk factors for potential elopement such as: Resident's elopement or attempted elopement, Wandering, Repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital,. 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. The care plan did not indicate any focus or interventions from the elopement risk Assessment on 10/31/2025 when Resident #7 scored 23, which indicated a high-risk elopement. On 04/29/2026 the focus read Resident #7 had recent transition to the secure unit and maybe at risk for increased confusion and social isolation. The interventions read, including Activity staff, will invite, encourage, and remind Resident #7 daily to attend structured group activities appropriate for residents with dementia (e.g., reminiscence, music therapy, sensory stimulation, simple games). Activity staff will provide escort and/or hand-over-hand assistance as needed to support safe attendance and ease transition within the secure unit. Activity staff will utilize consistent daily routine and familiar programming to promote comfort and reduce confusion. Activity staff will provide simple instructions, cueing, redirection, and reassurance during activities to enhance participation and reduce anxiety. Activity staff will provide alternate 1:1 sensory or calming interventions when Resident #7 declines group participation.During an interview on 05/06/2026 at 4:37pm with Dietary Staff she stated that when she arrived at approximately 5:30am on 04/14/2026 she saw Resident #7 in the center parking lot. She stated her headlights illuminated Resident #7, and when she asked where she was going, Resident #7 replied she was going to see her mom. The Dietary Staff stated she redirected Resident #7 and told her she would help her find a ride, and Resident #7 then allowed the Dietary Staff to push her back into the facility in the wheelchair, though she was initially resisting returning inside. The Dietary Staff stated Resident #7 did not state how long she had been outside, and she did not believe the resident had been out for long. She stated Resident #7 did not appear agitated. She stated when they re-entered the building, a nurse called Resident #7's name and she appeared to be relieved that someone recognized her. The Dietary Staff stated that she believed the door alarm was sounding when they came back inside and stated she did not see a wander guard on the resident's leg.During an interview on 05/06/2026 at 5:42pm with the ADON she stated she had been made aware of the incident during the morning meeting on 04/14/2026. She reported the resident had been placed on 1:1 supervision until she was transferred to the secured unit. She stated the resident was able to self propel her wheelchair well and often stated she wanted to go home. She stated Resident #7 would typically wake up around 5:00 a.m., saying she had to go, and staff would get her up. The ADON stated the facility did not use Wander Guards and she was unsure why. She explained that the elopement risk scoring system stopped asking additional questions if the resident was able to self propel. She stated the scoring was based on the questions answered, and residents on the secured unit were prompted with additional items. She stated Resident #7 was confused and often said she needed to get ready for her children. She stated Resident #7 scored the resident a 4 for impairment, noting the resident sometimes required cues for tasks such as changing clothes. She stated elopement risk assessments were completed quarterly or with a change in condition, and she believed the ADONs were responsible for updating them. She stated that an elopement risk score of 23 would be considered high risk because higher scores indicated greater risk. She stated there should have been interventions in place and that staff should have informed the DON when the first assessment was completed with a high score. She stated Resident #7 would frequently get up and said she needed to leave, and the risk occurred when Resident #7 exited the door.During an interview on 05/06/2026 at 6:22pm with the DON she had been informed that the resident was found outside in the walkway under the patio after the door alarm sounded. She stated an elopement assessment had been completed, Resident #7 scored over 11, and the team decided to place Resident #7 on the secured unit. She stated the incident was classified as an elopement attempt, explaining that an attempt involved going out the door, while an elopement meant leaving facility property; Resident #7 had remained on property, so it was not reportable at that time. The DON stated that for the 10/31/25 assessment, Resident #7's elopement risk score of 23 should have triggered care plan interventions, as higher scores indicated greater risk. She explained that interventions should have addressed wandering, walking without purpose, and elopement behaviors, which involved exit seeking and leaving the building. She stated it would have been ADON's responsibility to update the care plan.The facility policy for 'Comprehensive Care Planning' undated read.Comprehensive Care PlanningThe facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. The facility will address these areas and will document the assessment of these risks, weaknesses or needs in the medical record and determine whether to develop a care plan and interventions to address the area. If the decision to proceed with care planning is made, the interdisciplinary team (IDT), in conjunction with the resident and/or resident's representative, if applicable, will develop and implement the comprehensive care plan and describe how the facility will address the resident's goals, preferences, strengths, weaknesses, and needs.

Based on observation, interview and record review the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 8 of 32 residents (Residents #1, #6, #7, #8, #9, #11, #14 and #15) reviewed for hydration. The facility failed to ensure Residents #1, #6, #7, #8, #9, #11, #14 and #15 were offered the minimum quantity of fluids daily to maintain hydration on 03/17/2026 and 03/18/2026. This failure could place residents at risk of dehydration.Findings include: 1. Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included end stage renal (kidney) disease, altered mental status, bipolar disorder (mood disorder), metabolic encephalopathy (brain dysfunction caused by an underlying medical problem), thrombocytopenia (low blood platelet count), congestive heart failure (failure of the heart to circulate blood effectively), restlessness, and agitation, dysphagia (trouble swallowing), muscle weakness, abnormal posture, and cognitive communication deficit (communication problems resulting from cognitive impairment). Record review of the admission MDS for Resident #1, dated 02/07/2026, reflected a BIMS score of 06, which indicated severe cognitive impairment. Resident #1 required set up or clean up assistance with eating and drinking and was completely dependent on staff for transfers from his bed to his chair. Record review of Resident #1's care plan, dated 02/04/2026, reflected the following: Focus: The resident has potential fluid deficit r/t dialysis.Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgorInterventions: Encourage fluids during med pass and with each care intervention. Encourage the resident to drink fluids of choice. Ensure the resident has fluids in reach. Inform the nurse if the resident is refusing to drink fluids. Record review of Resident #1's meal tickets reflected he received 24 ounces of fluids across his breakfast, lunch, and dinner trays. Observation and interview on 03/17/2026 at 10:27 AM revealed Resident #1 sitting up in his bed with an empty bedside table in front of him. There was a 32-ounce, lidded, handled cup filled with water with a straw in it on his windowsill, out of reach. He stated he could not have gotten up to reach the cup of water. He stated the water was not fresh and he did not know when it had been refilled. His skin and lips did not exhibit signs of dehydration. Observation and interview on 03/17/2026 at 01:10 PM revealed Resident #1 sitting in front of his lunch tray in his bed. He drank the one 8-ounce glass of red punch that was on his meal tray and was eating the ice within. He stated he would drink more if he had more to drink. There were no other drinks on his meal tray. Observation on 03/18/2026 at 06:40 AM revealed Resident #1 had no water accessible to him at his bedside. The 32-ounce pitcher was still sitting on his windowsill in the same place and had the same level of water that it contained the previous day. 2. Record review of Resident #6's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hypocalcemia (low blood calcium), hyperosmolality and hypernatremia (elevated sodium caused primarily by water deficit), lack of coordination, repeated falls, muscle weakness, contracture (permanent shortening and tightening of muscle fibers that reduces flexibility and function), muscle wasting and atrophy (loss of muscular strength due to disuse), chronic kidney disease, Parkinson's disease (progressive neurological disorder that affects movement), and ataxic gait (unsteady, poorly coordinated walking pattern caused by neurological dysfunction). Record review of Resident #6's quarterly MDS, dated [DATE], reflected a BIMS score of 05, which indicated severe cognitive impairment. It also reflected he required partial to moderate assistance with eating and drinking and was completely dependent on staff for transfers from his bed to his chair. Record review of Resident #6's care plan, dated 02/13/2026, reflected the following: Focus: The resident has potential fluid deficit r/t poor memory.Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgorInterventions: Encourage the resident to drink fluids of choice. Ensure the resident has fluids in reach. Inform the nurse if the resident is refusing to drink fluids. Record review of Resident #6's meal tickets reflected he received 28 ounces of fluids across his breakfast, lunch, and dinner trays. Observation on 03/17/2026 at 09:28 AM revealed Resident #6 lying asleep in his bed, which had a scoop mattress, was in low position, and had fall mats on either side. There was no cup of water within reach on his side of the room. Observation on 03/17/2026 at 03:12 PM revealed Resident #6 was sitting up in his wheelchair. There was no cup of water available in his room. He did not respond to efforts to interview him. His skin and lips did not exhibit signs of dehydration. Observation on 03/18/2026 at 07:18 AM revealed Resident #6 lying asleep in his bed in the low position with fall mats on either side. There was still no cup of water within reach on his side of the room. 3. Record review of Resident #7's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included ataxia (a neurological condition leading to poor muscle control and lack of coordination), cognitive communication deficit (communication problems resulting from cognitive impairment), dysarthria and anarthria (damage to the brain causing lack of control to the muscles that allow speech), mild protein-calorie malnutrition (an individual does not receive enough protein to maintain adequate nutrition), dementia, depression, and muscle weakness. Record review of Resident #7's quarterly MDS, dated [DATE], reflected a BIMS score of 07, which indicated severe cognitive impairment. Resident #7 required supervision or touching assistance with eating and drinking and was completely dependent on staff for transfers from his bed to his chair. Record review of Resident #7's care plan, dated 02/19/2026, reflected the following: Focus: The resident has potential fluid deficit related to low intake.Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgorInterventions: Encourage the resident to drink fluids of choice. Ensure the resident has fluids in reach. Inform the nurse if the resident is refusing to drink fluids. Record review of Resident #7's meal tickets reflected he received 28 ounces of fluids across his breakfast, lunch, and dinner trays. Observation on 03/17/2026 at 09:34 AM revealed Resident #7 sat in his bed in his room having breakfast. There was one 4-ounce cup of orange juice and one 4-ounce cup of milk on his breakfast tray. He was eating on his own. There was no drinking water in his room. He waved hello but did not respond to efforts to interview him. His skin and lips did not exhibit signs of dehydration. Observation on 03/18/2026 at 06:50 AM revealed Resident #7 was asleep in his room with no drinking water on his side of the room. 4. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (paralysis on one side of the body) following cerebrovascular disease (disease related to lack of blood flow to the brain), cognitive communication deficit (communication problems resulting from cognitive impairment), muscle weakness, muscle wasting and atrophy (loss of muscular strength due to disuse), moderate protein-calorie malnutrition (an individual does not receive enough protein to maintain adequate nutrition), and lack of coordination. Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score of 07, which indicated severe cognitive impairment. It Resident #8 required supervision or touching assistance with eating and drinking and was completely dependent on staff for transfers from her bed to her chair. Record review of Resident #8's care plan, dated 03/16/2026, reflected the following: Focus: The resident has potential fluid deficit r/t memory loss.Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgorInterventions: Encourage the resident to drink fluids of choice. Ensure the resident has fluids in reach. Inform the nurse if the resident is refusing to drink fluids. Record review of Resident #8's meal tickets reflected he received 28 ounces of fluids across his breakfast, lunch, and dinner trays. Observation and interview on 03/17/2026 at 09:15 AM revealed Resident #8 sat in her bed. She stated she was waiting for breakfast. Her bedside table was in reach, but there was no drinking water or fluids on it. Her breakfast was served ten minutes later with a 4-ounce cup of orange juice and two 4-ounce cups of milk on the tray. Her skin and lips did not exhibit signs of dehydration. Observation on 03/18/2026 at 07:03 PM revealed Resident #8 sat in her bed. She had an empty medicine cup on her bedside table and, when asked if she had anything to drink, asked the state surveyor to fill the cup with water. There were no other fluids available to her within reach. There was a 16-oounce disposable water bottle on the shelf behind her bed, but she could not reach the bottle. 5. Record review of Resident #9's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included unspecified head injury, muscle weakness, ataxic gait (unsteady, poorly coordinated walking pattern caused by neurological dysfunction), lack of coordination, cognitive communication deficit (communication problems resulting from cognitive impairment), aphasia following cerebrovascular disease (language disorder after a stroke), muscle wasting and atrophy (loss of muscular strength due to disuse), weakness, depression, anxiety disorder, and type two diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar). Record review of Resident #9's quarterly MDS, dated [DATE], reflected a BIMS score of 05, which indicated severe cognitive impairment. Resident #9 was independent with eating and drinking and was completely dependent on staff for transfers from his bed to his chair. Record review of Resident #9's care plan, dated 02/19/2026, reflected the following: Focus: The resident has potential fluid deficit do (sic) to dementa (sic).Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgorInterventions: Encourage the resident to drink fluids of choice. Ensure the resident has fluids in reach. Inform the nurse if the resident is refusing to drink fluids. Record review of Resident #9's meal tickets reflected he received 28 ounces of fluids across his breakfast, lunch, and dinner trays. Observation on 03/17/2026 at 09:18 AM revealed Resident #9 laid in his bed, asleep, and no drinking water or other fluids was on his side of the room. His skin and lips did not exhibit signs of dehydration. Observation on 03/18/2026 at 07:00 AM revealed Resident #9 was asleep in his bed with no water on his bedside table, dresser, or anywhere else on his side of the room. 6. Record review of Resident #11's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included depression, senile degeneration of brain, anxiety disorder, muscle weakness, lack of coordination, ataxic gait (unsteady, poorly coordinated walking pattern caused by neurological dysfunction), cognitive communication deficit (communication problems resulting from cognitive impairment), and moderate protein-calorie malnutrition (an individual does not receive enough protein to maintain adequate nutrition). Record review of Resident #11's quarterly MDS, dated [DATE], reflected a BIMS score of 05, which indicated severe cognitive impairment. Resident #11's required set up and clean up assistance with eating and drinking and partial to moderate assistance from staff for transfers from his bed to his chair. Record review of Resident #11's care plan, dated 12/18/2025, reflected the following: Focus: The resident has an ADL self-performance deficit.Goal: The resident will maintain or improve current level of ADL functionInterventions: Eating requires staff X 1 Record review of Resident #11's meal tickets reflected he received 24 ounces of fluids across his breakfast, lunch, and dinner trays. Observation on 03/17/2026 at 09:11 AM revealed Resident #11 was seated in his wheelchair in his room. He had no drinking water or fluids accessible to him in his room. When asked if he had any water or was thirsty, he shrugged and did not engage verbally. His skin and lips did not exhibit signs of dehydration. Observation on 03/18/2026 at 07:19 AM revealed Resident #11 was asleep in his bed and had no water or fluids accessible on his side of the room. 7. Record review of Resident #14's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease, muscle weakness, muscle wasting and atrophy (loss of muscular strength due to disuse), difficulty in walking, ataxic gait (unsteady, poorly coordinated walking pattern caused by neurological dysfunction), repeated falls, depression, anxiety disorder, frontotemporal neurocognitive disorder (progressive brain disorder that affects the frontal and temporal lobe of the brain), cognitive communication deficit (communication problems resulting from cognitive impairment), and lack of coordination. Record review of Resident #14's quarterly MDS, dated [DATE], reflected a BIMS score of 07, which indicated severe cognitive impairment. Resident #14 was independent with eating and drinking and required supervision or touching assistance of staff for transfers from her bed to her chair. Record review of Resident #14's care plan, dated 02/03/2026, reflected the following: Focus: The resident has potential fluid deficit r/t memory loss.Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgorInterventions: Encourage the resident to drink fluids of choice. Ensure the resident has fluids in reach. Inform the nurse if the resident is refusing to drink fluids. Record review of Resident #14's meal tickets reflected he received 32 ounces of fluids across his breakfast, lunch, and dinner trays. Observation and interview on 03/18/2026 at 06:44 AM revealed Resident #14 laid in her bed with no drinking water or fluids available to her within reach. When asked if she was thirsty, she stated, Yeah some water would be nice. She then stated she might have some next to her bed and struggled to look around at her bedside table, which was not in reach and did not have any drinks on it. Her skin and lips did not exhibit signs of dehydration. 8. Record review of Resident #15's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included senile degeneration of brain, abnormalities of gait and mobility, lack of coordination, moderate protein-calorie malnutrition (an individual does not receive enough protein to maintain adequate nutrition), depression, anxiety disorder, muscle weakness, and cognitive communication deficit (communication problems resulting from cognitive impairment). Record review of Resident #15's quarterly MDS, dated [DATE], reflected a BIMS score of 02, which indicated severe cognitive impairment. Resident #15 required partial to moderate assistance with eating and drinking and was completely dependent on staff for transfers from her bed to her chair. Record review of Resident #15's care plan, dated 12/18/2025, reflected the following: Focus: The resident has potential fluid deficit r/t dementia.Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgorInterventions: Encourage the resident to drink fluids of choice. Ensure the resident has fluids in reach. Record review of Resident #15's meal tickets reflected she received 28 ounces of fluids across his breakfast, lunch, and dinner trays. Observation on 03/17/2026 at 09:06 AM revealed Resident #15 was in bed with no drinking water or fluids in reach. She did not respond to efforts to interview her. Her skin and lips did not exhibit signs of dehydration. Observation on 03/18/2026 at 07:04 AM revealed Resident #15 lying in bed asleep with no drinking water or fluids visible in her room. Observation on 03/18/2026 at 07:30 AM revealed an ice chest on the 200-hall which contained an inch of water and a few ice cubes floating in it. There was a water dispenser filled with ice water and lemon and disposable foam cups beside it. Observation on 03/18/2026 at 10:27 AM revealed the ice chest was closed into a nutrition room on the 200-hall. It still only had an inch of water in it, and the ice that was within at 07:30 AM had melted or been removed. During an interview on 03/18/2026 at 07:35 AM, CNA E stated she was not sure who was supposed to fill the ice chest. She stated she guessed someone would fill the ice chest after breakfast that day and that would be when they passed around fresh water to all the residents in their rooms. She stated the ice machine on their side of the building (serving the 100, 200, and 300 halls) was broken so they had to go to the other side of the building to get ice. She stated residents could always get water if they were up and could get water themselves, because there was a dispenser of ice water at the nurse's station filled by the dietary department every shift. She stated residents who could not get up on their own could ask for water. She stated residents who forgot to ask for water were reminded to drink. She stated she did not refill any of the water cups on her hall the previous day and did not know why there had not been fresh water passed on the 200 and 300 hall the previous day. During an interview on 03/19/2026 at 10:45 AM, the LD stated she reviewed lab results and observed meals being served at the facility once per quarter and had not noticed any issues that would make her think the residents were not receiving enough fluids. She stated the standard quantity of fluids that should have been offered to each resident per day was 1900 cc, which equaled 64 ounces. She stated the minimum quantity of fluids she would expect to be offered, even to someone with fluid restrictions or receiving hemodialysis (a life-saving treatment for kidney failure that removes waste from the blood), was a liter and a half, which equaled 50 ounces. She stated the amount of fluids ordered on the facility menu were not her decision, but the facility used a food ordering company that had their own dietitians who produced the menus. She stated if some residents were only receiving 4 ounces of fluids at breakfast and 8 ounces at lunch and dinner, the nursing department would have to offer fluids consistently to ensure residents did not become dehydrated. She stated milk and coffee also contained fluids that would prevent dehydration and should be included in daily totals. During an interview on 03/19/2026 at 01:16 PM, RN D stated she worked PRN but was usually on the 200 hall when she worked. She stated she did monitor for compliance with hydration requirements by offering water every single time she entered the resident's rooms. She stated she frequently offered water for those who were not able to drink water on their own, and she ensured there was ice and fresh water for all residents. She stated the fresh water was to be passed every shift at the beginning of the shift. She stated she could not explain why some residents were not seen with fresh water on 03/17/2026 and 03/18/2026, as she had not been working. She stated if she saw the conditions on the hall like that, she would have made sure water was given to every resident. She stated all the residents had fresh water on her hall that morning. She stated with the meal service and the medication administration, there would be no way the residents would go without any water for an entire day. She stated it was important to stay hydrated for wound healing and to prevent infections. During an interview on 03/19/2026 at 02:30 PM, CNA E stated the procedure for passing water was when the ice chest was filled with ice, the aides went around filling pitchers with water every two hours just like they did when they checked the residents for incontinent care or other needs. She stated on the first day of the investigation, which was 03/17/2026, there was no ice in the ice chest. She stated she did not know who was supposed to fill the ice chest, but she and her fellow aides kept waiting for someone to fill the ice chest so they could start passing fresh water. CNA E stated they usually placed the tables close to the resident beds. She stated there were two days that went by where nobody filled the ice chest or made the fresh cups available to residents, but someone had finally gotten them ice that morning and they passed water as usual. CNA E stated the cups were small on the meal trays, and she did not know why the meal trays did not also have cups of water on them as well as juice and milk. She stated there were several residents who would probably like to have additional fluids with their meals. She stated she thought it would also help if there was a set schedule for who should fill the ice chest and when. She stated the possible negative outcome of a resident not receiving fluids was they could become dehydrated, weak, and sick. During an interview on 03/19/2026 at 02:40 PM, ADON B stated the expectation was the aides or nursing staff passed fresh water every shift. She stated she had done in-services on it and would probably need to add a specific time that it was done each shift if it was not being done every day. She stated she monitored for compliance with hydration rounds by making her own rounds. She stated she was on the hall more than she was in her office watching to make sure residents received the care they needed. She stated there was ice, clean scoops, and fresh cups available on the halls every day, but for the past two days the nursing staff had not ensured the residents were receiving their fresh ice water. She stated she found the ice chest that morning (03/19/2026) in the nutrition room, dirty and in need of fresh ice. She stated she did not have a specific staff member responsible for cleaning the ice chests and scoops each shift, as she had no reason to think it was not being done prior to this week. She stated the residents may not have received fresh ice water on 03/17/2026 and 03/18/2026, based on the state of the ice chest. She stated they talked to their nursing staff about the importance of hydration. She stated the residents who ate in the dining room received a cup of juice, tea, or punch as well as were offered a cup of water. She stated many of those residents accepted a cup of ice water at meals. She stated she did not know why a cup of ice water was not placed on the meal trays that came to the halls. She stated she tried to get the dietary department to do that, but it had not happened so far. She stated if a resident did not receive enough fluids, it could lead to dehydration, UTI, and dry skin. An attempted interview was made on 03/19/2026 at 02:42 PM with CNA F by telephone was unsuccessful. A voicemail was left but not returned as of 03/25/2026. During an interview on 03/19/2026 at 03:12 PM, the DON stated she had been out for two weeks and had just returned on 03/18/2026. She stated the procedure was supposed to be that there was an ice chest for each nurse's station and the nursing staff was to pass fresh ice water each shift. She stated she interpreted at the beginning of each shift. She stated no specific staff was assigned to refill the ice chest in particular, but the night shift was assigned the job of washing the ice scoops and ice chest. She stated she noticed meal trays did not have cups of water on them. She stated residents were receiving fluids through medication administration and the juice, milk, and coffee they received at and between meal times. She stated there were no residents in the facility on fluid restrictions. She stated ice water needed to be offered to residents every shift, whether they drank it or not. She stated this issue had not been identified by the facility QAPI program as a quality deficiency, but the observations made during the survey were not consistent with her expectations. She stated she monitored for compliance with hydration protocols through doing rounds and monitoring labs and infections. She stated the potential negative impacts of not providing adequate hydration were dehydration and UTI. During an interview on 03/19/2026 at 03:58 PM, the MD stated her recommendation would be the least amount of fluid any resident was offered each day was 1500 cc, equivalent to 50 ounces. She stated she had no reason to be concerned that residents at the facility were not receiving enough fluids. During an interview on 03/19/2026 at 04:03 PM, the ADM stated there should have been hydration carts going out on the halls for the residents to have the opportunity to receive ice and water. He stated he monitored through visual and morning rounds and being observant of surroundings. He stated the potential negative impact of the residents not receiving water at the bedside was dehydration. Record review of in-services from 2025 and 2026 reflected one in-service related to hydration, titled Night Shift Responsibilities and including instruction to pass ice and water each shift. Record review of the facility's, undated, policy titled Hydration reflected the following: GoalsThe resident will maintain adequate hydrationThe resident will not experience skin breakdown related to hydration status.Vital signs will remain within a normal paraFluid intake is monitorThe resident will not demonstrate signs or symptoms of dehydration.2.Staff should offer hydration, unless contraindicated, at the following intervals. 1. Direct care interaction with the resident in the residence room [ROOM NUMBER]. Prior to, during, and following meals 3. During a medication pass 4. During activities3. The facility may utilize fine dining programs to encourage fluids prior to, during and following meals. The facility may use education and encouragement to increase fluid intake with intermittent direct care duties. Freshwater will be maintained at bedside when not con indicated. The facility may implement a hydration card system designed to offer appropriate fluids every shift to residents except where contraindicated. Alternative treatment approaches may include use of popsicles, gelatin, and other similar non-fluid foods as recommended by the dietitian.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 12 residents (Resident #1) reviewed for accommodations of needs. The facility failed to ensure Resident #1 had a call button that he could use with his contracted hands. This failure could place residents at risk of not having their needs met.Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included end stage renal (kidney) disease, altered mental status, bipolar disorder (mood disorder), metabolic encephalopathy (brain dysfunction caused by an underlying medical problem), thrombocytopenia (low blood platelet count), congestive heart failure (failure of the heart to circulate blood effectively), restlessness and agitation, dysphagia (trouble swallowing), muscle weakness, abnormal posture, and cognitive communication deficit (communication problems resulting from cognitive impairment). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 06, which indicated severe cognitive impairment. It also reflected he had no limitations on his range of motion on his upper extremities. Record review of Resident #1's care plan, dated 02/04/2026, reflected the following: Focus: The resident has an ADL Self Care Performance DeficitGoal: The resident will maintain or improve current level of function in (Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date.Intervention: Encourage the resident to use bell to call for assistance.Focus: The resident is risk for fallsGoal: The resident will be free of falls through the review date.Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation on 03/17/2026 at 09:12 AM revealed a loud male voice yelling Nurse! Nurse! from Resident #1's room. After the second time the yelling occurred, ADON A walked to the room. The person yelling was Resident #1. He had a call button within reach, but he had not used it. Both his left and right hands were contracted (permanent shortening or tightening of the tendons, muscles, and skin that restricts movement). During an interview and observation on 03/17/2026 at 10:27 AM, Resident #1 stated he knew how to press his call button, but he had a hard time doing it with his hands. He demonstrated he could pick up the call button with his right hand and use a left finger to press the button, but it took extreme effort and concentration. Observation on 03/17/2026 at 12:56 PM revealed Resident #1 yelled Nurse! Nurse!, and a medication aide went into his room to assist. Observation on 03/18/2026 at 06:50 AM revealed Resident #1 yelled Nurse! Nurse!, and CNAs E and F went into his room to assist him. Observation on 03/18/2026 at 06:55 AM revealed CNA F asked LVN H to obtain a flat call button for Resident #1 so he could more easily use it and stop yelling in the hall. Observation on 03/19/2026 at 10:21 AM revealed Resident #1 still had the standard call button and no flat button. He stated he would have liked a flat call button and would have used it if he had one he could more easily press. During an interview on 03/19/2026 at 02:30 PM, CNA E stated she worked at the facility for three months, and she always worked on the hall where Resident #1 lived. She stated Resident #1 could not use a call button, and she and her fellow aide had notified the nurse on the hall the day prior (03/18/2026) that he was not able to use his call button and needed a flat button to accommodate his contracted hands. She stated she thought he would use a flat button more often and would not have to scream into the hallway. Attempted interview on 03/19/2026 at 02:42 PM with CNA F by telephone was unsuccessful. A voicemail was left but not returned as of 03/25/2026. During an interview on 03/19/2026 at 03:26 PM, the DON stated Resident #1 had been in the facility before for short-term care but had only just returned recently. She stated any aide or nurse could enter things into the electronic work order system, and they were trained to do so. She stated she could not remember how recently the nursing staff were trained to enter requests into the work order system, but it had been a long time. She stated a potential negative outcome was their needs were not met and they could reach for something and fall. During an interview on 03/19/2026 at 04:03 PM, the ADM stated his expectations were that a call button that accommodated Resident #1's needs would be provided for him right away. He stated they had an extra one on another hall and traded it for Resident #1's call button. He stated he did not know, if the request had been entered into the electronic work order system, he just wanted to get the right device for the resident right away. Record review of the facility's, undated, policy titled Resident Rights reflected the following:The resident has a right to a dignified existence, self-determination, and communication with and access to persons and service services inside and outside the facility, including those specified in this policy.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.Respect and dignity - the resident has a right to be treated with respect and dignity, including:3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so what endanger the health or safety of the resident or other residents.

Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 32 residents (Resident #2) reviewed for activities of daily living. The facility failed to ensure Resident #2 was checked for and provided with incontinence care from 09:10 AM to 03:30 PM on 03/17/2026. This failure could place residents at risk of discomfort, embarrassment, and skin breakdown.Findings include: Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (area of death in the brain), cognitive communication deficit (communication problems resulting from cognitive impairment), lack of coordination, overactive bladder, and dementia (a general term for a decline in mental ability-such as memory, language, and problem-solving-severe enough to interfere with daily life). Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 07, which indicated a severe cognitive impairment. It also reflected she was completely dependent on staff assistance with toileting hygiene. Record review of Resident #2's care plan, dated 03/18/2026, reflected the following: Focus: The resident has bowel incontinence.Goal: The resident will not have any complications r/t bowel incontinence.Intervention: Check resident every two hours and assist with toileting as needed,Focus: The resident has an ADL Self Care Performance Deficit.Goal: The resident will maintain or improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date.Intervention: Toilet use: requires staff x2 for assistance.Focus: The resident has bladder incontinenceGoal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date.Intervention: Activities: notify nursing if incontinent during activities. Incontinent care often and apply moisture barrier after each episode. Record review of Resident #2's toileting hygiene/incontinent care tasks, dated 03/17/2026, reflected she was provided incontinent care at 12:17 AM and 08:56 PM. There was no care recorded for the day shift 6 AM to 2 PM. Observation on 03/17/2026 at 09:15 AM revealed Resident #2 was seated at a table in the living room (common area near the nurse's station) eating her breakfast. During observation and interview on 03/17/2026 at 10:21 AM revealed Resident #2 was in the doorway of her room. She stated her brief had not been changed since she got out of bed. She stated she did not know what time that was. When asked if she felt wet or uncomfortable, she smiled and did not answer. Observation on 03/17/2026 at 11:21 AM revealed Resident #2 in the living room participating in a music activity. Observation on 03/17/2026 at 01:18 PM revealed Resident #2 in the living room receiving her lunch. She was still in the same clothing she had been wearing at 09:15 AM. Observation on 03/18/2026 of an automated electronic surveillance video, dated 03/17/2026, revealed Resident #2's camera did not activate between the hours of 09:10 AM and 03:30 PM. It activated when she was brought to her room and provided incontinent care at 03:30 PM. During an interview on 03/18/2026 at 03:37 PM, the FM for Resident #2 stated they monitored the automated electronic surveillance for Resident #2 and did not see Resident #2 return to her room for incontinent care until 03:30 PM, when the FM called the nurse's station to request the staff provide incontinent care. The FM stated they did not remember who they spoke to at that time. The FM stated they had to call the nurse's station again that day (03/18/2026) at lunchtime to request incontinent care be provided to Resident #2. During an interview on 03/19/2026 at 01:16 PM, RN D stated the aides on the hall should have checked residents every two to three hours and changed them as needed. She stated had she been at the facility on 03/17/2026 when Resident #2 was not checked/changed for six hours, that would not meet her expectation. She stated she was not working that day. She stated the possible negative impact of not being changed for six hours was a skin issue, UTI, or rash. During an interview on 03/19/2026 at 02:10 PM, CNA E stated they checked and changed residents every two hours. She stated some residents got up at breakfast and spent the whole day in the living room. She stated she checked on her residents throughout the day in the living room, and if they needed to be changed then she brought them back to be changed. CNA E stated CNA F was assigned to Resident #2 on 03/17/2026, and she (CNA E) had not provided her care. CNA E stated it was possible they might forget to check on a resident in the living room and change them if they got busy, but it was unlikely. She stated if residents were not changed frequently, they could get pressure sores. During an interview on 03/19/2026 at 03:30 PM, the DON stated she expected residents to be checked and changed every two to three hours. She stated Resident #2 waiting from 09:00 AM to 03:00 PM was inconsistent with her expectations and the staff should have rounded more frequently. She stated she monitored for compliance by being in the facility and making rounds. She stated staff were able to check the wetness gauge on the brief itself to find out if residents needed to be changed without completely undressing them and interrupting their activities in the living room. She stated the potential negative impact of being left sitting in a wet or soiled brief was skin breakdown and infections such as UTIs. She stated she provided training to staff about providing incontinent care every two-three hours within the last two months but did not know exactly when. During an interview on 03/19/2026 at 04:03 PM, the ADM stated facility staff were mandated to check on residents and provide incontinent care if needed. He stated six hours was too long for them to wait to check and change any incontinent resident. He stated the potential negative impact of not being provided incontinent care for six hours, depended on what the resident was sitting in during that time. Record review of the facility's policy, dated 05/11/2022 and titled Perineal Care, reflected the following:An incontinent resident of urine and/or bowel should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible.It is essential that residents using various devices, absorbent products, external collection, devices, etc., be checked and changed as needed on a schedule based upon the residence, avoiding pattern, professional, standards of practice, and the manufacturers recommendations.

Based on observation, interview, and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and clinical records. A. One of 12 residents (Resident #1) on 300 Hall had his personal health information left on the unlocked computer screen on LVN A's nursing cart. This failure could result in Resident #1's personal information being exposed to unauthorized individuals. This problem had the potential to affect all 24 residents in care of LVN A on 11/13/2025.The findings included:Record review of Resident #1's face sheet, dated 11/14/2025, revealed a 55-years-old male admitted on [DATE]. Resident's #1's diagnoses included intestinal obstruction unspecified (a medical condition where food or stool cannot pass through the small or large intestine, but the specific cause is not yet known or categorized), malignant neoplasm of colon (a cancerous tumor in the large intestine that can invade nearby tissues or spread to other parts of the body), ileostomy status (opening in the abdomen to divert waste from the small intestine), essential hypertension (high blood pressure that has no identifiable cause), mild intellectual disabilities (characterized by a slower-than-normal development in conceptual, social, and practical skills, typically with an IQ (Intelligence Quotient) range of 50-69).Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment suggesting that the individual needs additional support and monitoring. Observation on 11/13/2025 at 10:15 a.m. revealed the nursing cart of LVN A was positioned near room [ROOM NUMBER] unattended. It was locked but the computer screen was open with Resident #1's clinical information in Point Click Care (computer program) displayed on the screen. This confidential information was opened for anyone such as visitors or other residents to see. LVN A came back to the nursing cart at 10:19 a.m.During an interview on 11/13/2025 at 10:21 a.m. with LVN A, she stated that she just stepped away for a few minutes to get some additional supplies. She stated that she received HIPAA training (Health Insurance Portability and Accountability Act which protects sensitive patient health information from disclosure without consent) at time of hire and annually. She said that she is responsible for closing the computer screen and locking the nursing cart when she steps away. She stated that leaving a computer without minimizing the computer screen can lead to exposing residents' private medical information to non-authorized personnel or public. During an interview on 11/13/2025 at 5:56 p.m. DON revealed the policy was that the computer on the medication cart should be minimized when the nurse or medication aide are not using the computer. She said the nurse or the medication aide using the computer are responsible for minimizing the screen. She said if the screen was not minimized someone could have unauthorized access. She said the ADON and the DON monitor to ensure the screens are closed. She said they monitor through observation rounds. She said she did not know why the screen was left open on the nursing cart.During interview on 11/14/2025 at 12:55 p.m. with ADM revealed all staff were trained on HIPAA at the time of hire by signing acknowledgements, and at least annually after that. He stated that everybody is responsible for maintaining privacy of residents' information and if a computer screen is open and information is exposed that can cause a privacy breach of residents' personal and medical information. Record review of facility's staff educational course script, undated, revealed that HIPAA 101 - protecting private health information is any data that can identify a patient such as names, addresses, birth dates, medical record numbers, and other personal details. Digital best practice interacts with email and devices using strict security measures that protect private health information at every step: (2). Lock or log off devices when stepping away.Record review of staff in-services, dated 11/13/2025, revealed 12 nursing staff were in serviced on nurse/med aide cart protocol Carts are to be locked, and screens are to be closed when not in front of cart. No earlier dated staff in-services were available for review. Record review of HR - Personnel Handbook, dated 9/20/2019, revealed information on Confidentiality/HIPAA Regulation: The Privacy Policy reflects practices that have been adopted by the facility to protect patients' privacy and security in relation to their Protected Health Information as defined under HIPAA regulation. It is the duty and responsibility of each staff person associated with this facility to be fully familiar with Privacy Policy and to comply with the requirements detailed within it. The Privacy Policy is available to all facility employees for review at any time and may be obtained by requesting a copy from the Privacy Officer.

Based on interview, observations and record review, the facility failed to ensure that the residents were free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the residents' medical symptoms for 3 of 28 residents observed for restraints/bed rails. The facility failed to ensure that bedrails were not used on the side of Residents #2, Resident #3 and Resident #4's bed without the resident having been evaluated for the medical need. This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need. Findings included:Record review of Resident #4's face sheet revealed an [AGE] year-old woman admitted to the facility on [DATE]. Record review of Resident #4's orders dated 11/13/2025 revealed, Resident #4 did not have orders for the bedrails. An observation was conducted on 11/13/2025 at 1:08PM of Resident #4 which revealed both side bed rails were up on her bed. Record review of Resident #3's face sheet revealed a [AGE] year-old woman admitted to the facility on [DATE]. Record review of Resident #3's orders dated 11/13/2025 revealed, Resident #3 did not have orders for the bedrails. An observation was conducted on 11/13/2025 at 2:20PM of Resident #3 laying in the bed with two bed rails raised. Resident #3's bed was in high position at the time of the observation. Resident #3 stated the bed rails have always been on the bed. Record review of Resident #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #2's orders dated 11/13/2025 revealed, Resident #2 did not have orders for the bedrails. An observation was conducted on 11/13/2025 at 5:45PM of Resident #2 laying in the bed with two bed rails raised. An interview was conducted on 11/13/2025 at 5:45PM with Resident #3 who stated she does not know why there are bed rails on her bed. Resident #3 stated it was not her choice to have the rails placed on her bed. An interview was conducted on 11/13/2025 at 6:00p.m. with Resident #3's RP who stated that the bed rails were not from personal request but because when Resident #3 first arrived at the facility she kept falling. RP stated that the facility put the bed rails up to prevent Resident #3 from falling out of bed. RP stated that the bed rails are usually locked up most of the time unless staff are changing Resident #3's brief. An observation was conducted on 11/13/2025 at 5:46p.m., which revealed Resident #2 was trying to get out of his bed. Resident #2 was hollering and saying he needed help getting out of bed. Resident #2 had his feet on the ground and was not able to use the bedrails to reposition himself. An interview with Resident #2 at 5:47p.m., revealed Resident #2 was not interviewable. An interview was conducted on 11/13/2025 at 5:16pm with LVN A which revealed she had been trained on restraints. She said she only knows how to have the bed rails down when the patient is in bed. She said example of restraints is having someone tied down and restricting someone from getting out of the bed. She said she does not know the policy for the bed rails here. She said staff do not need to have doctor orders for bed rails. She said the bed rails help stop falls, and some use as assistance for turning. She said the bed rails are used to help the resident from falling. She said she does not know of any resident being hurt on the bed rails. She said she had not noticed a decline in the residents with bed rails. Said she does not consider the bed rails a restraint. She said they use the bed rails if they are on the beds when the resident is in the bed. An interview was conducted on 11/13/2025 at 5:40pm with the DON which revealed the facility is a free restraint facility and they try not to use restraints. She said some examples of restraints are lap bands, hand mitts or a table put on their chair, and full 4 side rails are restraints. She said the policy was bed rails are used to assist the resident to turn side to side, the resident could use the rails to hold onto when getting out of bed. The DON said the benefit is to provide independence for the resident, and risks are entrapment, and sliding between the bed rails. The DON said they do not have to have a doctor's order for the bed rails. The DON said there had been some bruises and skin tears due to the bed rails. She said she did not remember what residents did or when the residents sustained the bruises and skin tears. She said she was not sure how long ago that was. The DON said she did not know of any residents who had a decline due to the bedrails being used The DON said the assessment had the reason the bed rails were being used on each resident. During an interview on 11/13/2025 at 5:55p.m. with LVN C revealed he had not been trained on restraints. He said that the policy on restraints was that the facility had to have a doctor's order to use the bed rails. He said the family requests the doctor order and they do an assessment to see if the resident qualify to use the bedrails. He said he was unsure if he had been trained on the bed rails at the facility. He said he thinks he just had on the job training. He said the bed rails are up for some of the residents because the bed rails decrease the risk of injury. He said he is unsure how long the bed rails stay up. An observation was conducted on 11/13/2025 at 8:45PM which revealed 28 residents including Resident #2, Resident #3 and Resident #4 had bed rails up and in use on the residents beds while the residents were sleeping. An interview was conducted on 11/14/2025 at 10:26 AM. with CNA A who stated the benefits of bed rails are that they could prevent residents from falling out of bed at night. An interview was conducted on 11/14/2025 at 10:26AM with CNA B who revealed that bed rails could cause residents who are cognitively impaired to feel trapped in bed. An interview was conducted on 11/14/2025 at 10:41AM with RN B who stated bedrails can be restraints and the facility should have doctor's order to have them installed. RN B stated that bed rails can hurt residents if they try to climb out of bed. An interview was conducted on 11/14/2025 at 11:57AM the NP stated that all beds at the facility should have bed rails on them. The NP stated that he had not assessed residents for bed rails when at the facility, but the facility does not need a doctor order for bed rails. The NP stated he does not know how many residents have bed rails on the beds. The NP stated the risk of using bed rails is that they could be perceived as restraints. The NP stated that whenever a patient had bed rails all around the bed the resident would be locked in, resulting in the resident not being able to get out of bed, which would be considered a restraint. The NP stated he is not aware of any residents being injured while using bedrails. An interview was conducted on 11/14/2025 at 1:00PM with the ADM. The ADM stated that the facility is a restraint reduction facility, but they use bed rails. The ADM stated that residents need to have assessments done for bed rails. He stated that the facility does not use bed rails, they use assist bars. Record review of policy titled Bed Rails not dated revealed the following information: The facility will utilize bed rails for those residents that use them for bed mobility. The facility will attempt to use appropriate alternative prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use and maintenance of bed rails including but not limited to the following elements: Assess the resident for risk of entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Prior to using a bed rail, the resident will be assessed to ensure the proper rail is utilized for the resident's need. The resident and/or resident representative will provide consent for the use of rails prior to installation.

Based on observation, interviews, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain mobility, and good foot health.The facility failed to ensure toenails are trimmed regularly and free from abnormal nail conditions and ingrown toenails for 2 of 6 residents (Resident #5 and Resident #6) reviewed for foot care.This failure could place residents at risk of infection, pain, injury and altered gait.Finding included: Record review of Resident # 5's face sheet dated 11/14/2025 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident # 5 had diagnoses that included encephalopathy (any disorder that affects the brain's function or structure leading to altered mental function), osteoporosis (disease that weakens the bones and make them more likely to break), muscle weakness, abnormalities of gait or mobility, ataxic gait (impaired balance or coordination due to damage to the brain, nerves or muscles), dementia (memory, thinking, difficulty), pain in left lower leg, difficulty in walking, lack of coordination, cognitive communication deficit (problems with communication), adult neglect or abandonment (Observed pattern of unmet needs), and anxiety (feeling of uneasiness or worry). Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 5 indicating severe cognitive impairment. The MDS also revealed Resident #5 was partial/moderate assist with personal care, dressing and putting on/off footwear. Record review of Resident # 5's care plan dated 7/25/2025 revealed resident had an ADL self-care performance deficit. Interventions were BATHING: Check nail length and trim and clean on bath day and as necessary.Record review of Resident # 6's face sheet dated 11/13/2025 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), cognitive communication deficit (problems with communication), muscle weakness, difficulty in walking, lack of coordination, vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), parkinsonism (syndrome characterized by tremors and postural instability), chronic pain, visual loss-both eyes. Record review of Resident #6's quarterly MDS dated [DATE] revealed Resident #6 had a BIMS score of 4 indicating severe cognitive impairment. The MDS also revealed Resident #6 required supervision/touching assistance with personal care, dressing and putting on/off footwear.Record review of Resident # 6's care plan dated 2/13/2025 revealed that the resident had an ADL self-care deficit related to dementia (memory, thinking, difficulty). Interventions were BATHING: assist time one staff.Observation of Resident #5 on 11/13/2025 at 12:09 p.m., revealed she was standing at her door, waiting for her lunch to be served. She was wearing blue non-slip socks, with no shoes. Observation of Resident #6 on 11/13/2025 at 12:13 p.m., revealed . Resident #6's toenails were about 1inch long, yellowish on both feet. Resident #6's toenails were curved downward and some of them were digging into her skin. Her toenail on big toe was thick and brittle. Observation of Resident #5 on 11/14/2025 at 8:58 a.m., revealed she was walking in the hallway of the secure care unit. Resident #5 was wearing no-slip blue socks, but she did not have shoes on. Resident#5 went to her room and removed her socks, while sitting in her bed. Resident #5's toenails were yellow colored, thick and about an inch long ; both her big toenails were curved toward the other toenails while the rest of the toenails were curved toward the big toe. Her feet were very dry with flaky skin. During an interview with Resident #5 on 11/14/2025 at 8:59a.m., she said If they just would give me a nail clipper or scissors, I would cut these toenails myself. She said that her toenails hurt sometimes, and she could not wear any shoes .Observation of Resident #6 on 11/14/2025 at 9:15 a.m., revealed Resident #6 had about an inch long , yellowish toenails on both feet. Resident #6's toenails were curved downward and some of them were digging into her skin. Her toenail on big toe was thick and brittle. Attempted interview with Resident #6 on 11/14/2025 at 9:17a.m., revealed she was not interviewable.During an Interview with CNA C on 11/13/2025 at 3:38p.m., she stated that the staff in the secure care unit was not touching residents' toenails. She said the podiatrist would come to the unit and provide toenail care. She said the staff reported to the nurse if any resident needed foot care. She said not trimming resident's nails can cause discomfort, pain, and infection. She did not know why Resident #5 and Resident #6's toenails had not been cut or referred to the podiatrist. During an Interview with the DON on 11/13/2025 at 5:28p.m., she stated the podiatrist saw the residents every 62 to 90 days. She said staff were to report if a resident had long toenails to a nurse. She said not cutting long toenails could cause the resident to have an ingrown toenail and could be painful to treat. She said she did not know why Resident #5 and Resident #6 did not have their toenails cut by the podiatrist. During an interview with the SW on 11/14/25 at 12:02 p.m., he stated that he orchestrates the podiatry clinics for the facility. He said the facility just hired a new podiatry group. He said the new podiatry group had been to the facility twice. He said that he sends all required residents' information to the podiatrist. He said then the podiatrist would come to the facility and provides toenail care to the residents on the list. He said the last time the new podiatrist was at the facility was on October 23rd. He said staff were expected to provide residents who were not diabetic toenail care. He said staff should do toenail care when the resident is given a shower. He said if staff did not provide toenail care to the residents it could cause the resident pain and potentially infection. He did not know why staff had not cut Resident #5 and Resident #6's toenails. During an interview with the ADM on 11/14/2025 at 1:00p.m, he stated residents' toenail care was important because if staff let them get too long it could cause discomfort, injuries, and scratching. He also said many residents are nonverbal, so it was the facility's responsibility to do a head-to-toe assessment and refer them to physicians. He did not know who was supposed to do residents' toenails. He said he did not know why Resident #5 and Resident #6 did not have nail care. Record review of ADL Nail Care Policy dated 3/10/2000 revealed Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails all occur in the elderly with some frequency. Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions. The resident will be free from infection. Should be performed according to the resident centered plan of care.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Residents #8) reviewed for pharmacy services.The facility failed to ensure RN A checked the pharmacy delivery before signing off that medication delivered was correct. The medication RN A signed for could not be located.These failures could result in residents not receiving their medications as ordered and have adverse effects due to the medications not being administered. Findings Included:An interview was conducted on 11/13/2025 at 4:21PM with LVN B who reported being employed at the facility for 3 weeks. LVN B stated that all LVNs complete audits of the MC which should be done daily. LVN B stated that loose medications on the bottom of the MC could be from when LVNs popped the medication and the medications fell. LVN B stated that loose medications that have been found at the bottom of MCs could potentially been considered a medication error. LVN B stated that loose medications at the bottom of the MC could negatively affect residents by potential drug interactions and could cause a resident to go without their medication. LVN B stated this could have meant that the residents did not receive their medications as prescribed. LVN B described the 2 loose pills as potentially an antipsychotic and melatonin. An interview was conducted on 11/13/2025 at 4:31PM with LVN C who reported being employed at the facility for 9 years. LVN C stated that MCs should be audited by the LVNs regularly. LVN C stated that loose medications at the bottom of the MC could negatively affect residents by the potential for shortages of the medication and/or the residents not receiving their full dose of medications as prescribed. LVN C stated that the LVNs and RNs should verify medications received at the facility from the pharmacy, which includes they should look at the prescription card and compare it with the order slip that they had received. LVN C stated that medications received should not be misplaced. An interview was conducted on 11/13/2025 at 5:25PM with LVN D who reported being employed at the facility for 3 weeks. LVN D stated she had never verified medications that had been sent to the facility through the pharmacy. LVN D stated that if the medication delivered was a controlled medication, they are to get the controlled medication and write down the date and time received and put it in the lock box. LVN D stated if it was a reordered medication they would place the medication back into the resident's file. LVN D stated if the MTs or LVNs were to log onto the computer, it would say that the medication order had arrived. LVN D also stated that misplacing medications could negatively affect a resident by the medication would not be available to the resident if they needed it. An interview was conducted on 11/13/2025 at 5:40PM with the DON who revealed the nurse told her that she got the package of medication but did not confirm what was in the bag. She said she did not remember who opened the package. The DON said the hospice nurse came the next day asking for the medication and the facility could not find it. The DON said whoever opened the medication should have verified the medication was there. The DON said it should have been done when the medication came in that way if a medication was not in the bag they would know. It was hard to prove the facility did not get the medication when the nurse signed for it and did not look at it. The DON revealed she had been trained on medication storage. She said the training covered narcotic storage, and storing medication in the carts. She said she does not remember the last time she had that training. She said she would have to review the policy for loose medications in the medication cart, but they should not be in the cart. She said the nurse or the medication aide are responsible for ensuring there are no loose pills in the cart. If there are loose pills in the cart it could affect the resident by the resident possibly not getting their medication. She said the ADON monitors and so does the pharmacist. She said they monitor by doing cart checks. She said she did not know why there were loose pills on the medication carts. An interview was attempted on 11/14/2025 at 11:45AM with RN A. An interview was attempted on 11/14/2025 at 11:48AM with the pharmacist of the hospice company that provided the medications to RN A. An interview was conducted on 11/14/2025 at 1:00PM with the ADM who reported he had worked at the facility for 11 months. The ADM stated the DON, ADON and nursing staff are responsible for MC audits. The ADM stated that if there were medications at the bottom of the MC, then there could be possibility that the resident did not receive the medication. The ADM stated that the policy for receiving medication is that the staff should not allow medications into the facility unless they have seen it, counted it, and signed off for it. The ADM stated if staff members signed for medication, and the medication could no longer be found, it could mean the residents did not receive it. The ADM stated that during the investigation, it was determined that the RN that signed off on the medication delivery passed her UA testing and had her own prescription for benzodiazepines. The ADM stated the RN had ultimately been suspended pending investigation. Record review of investigation record revealed that RN A had signed off on an unknown prescription delivery with Rx #327042 on 06/03/2025. Record review of a signed handwritten letter dated 06/04/2025, revealed RN A had received medications for the resident on 06/03/2025 at approximately 7:30PM. RN A wrote that the medications received were Ativan, Morphine Haldol, total comfort kit. RN A wrote that she had stored the medications in the narcotic lock box. Record review of policy titled PCU027-Medication Storage in the Facility dated 2025 revealed the following:1. Medication and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel or members lawfully authorized to administer medications. a. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. Medication storage areas are kept clean, well lit, and free of clutter.

Based on observation, interview, and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 1 (medication cart #1) of 2 medication carts reviewed for medication storage. The facility failed to ensure that MC #1 did not have unidentifiable medications in the bottom of the MC drawer. This failure could result in residents not receiving their medications as ordered and have adverse effects due to the medications not being administered. Findings included: An observation and audit conducted on 11/13/2025 at 4:21PM revealed Med Cart #1 which was stationed on the 500-hall, contained loose medications at the bottom of drawer #2. The observation revealed that 2 unidentifiable pills were under the blister packs. An interview was conducted on 11/13/2025 at 4:21PM with LVN B who reported being employed at the facility for 3 weeks. LVN B stated that all LVNs complete audits of the MC which should be done daily. LVN B stated that loose medications on the bottom of the MC could be from when LVNs popped the medication and the medications fell. LVN B stated that loose medications that have been found at the bottom of MCs could potentially been considered a medication error. LVN B stated that loose medications at the bottom of the MC could negatively affect residents by potential drug interactions and could cause a resident to go without their medication. LVN B stated this could have meant that the residents did not receive their medications as prescribed. LVN B described the 2 loose pills as potentially an antipsychotic and melatonin. An interview was conducted on 11/13/2025 at 4:31PM with LVN C who reported being employed at the facility for 9 years. LVN C stated that MCs should be audited by the LVNs regularly. LVN C stated that loose medications at the bottom of the MC could negatively affect residents by the potential for shortages of the medication and/or the residents not receiving their full dose of medications as prescribed. LVN C stated that the LVNs and RNs should verify medications received at the facility from the pharmacy, which includes they should look at the prescription card and compare it with the order slip that they had received. LVN C stated that medications received should not be misplaced. An interview was conducted on 11/13/2025 at 5:25PM with LVN D who reported being employed at the facility for 3 weeks. LVN D stated she had never verified medications that had been sent to the facility through the pharmacy. LVN D stated that if the medication delivered was a controlled medication, they are to get the controlled medication and write down the date and time received and put it in the lock box. LVN D stated if it was a reordered medication they would place the medication back into the resident's file. LVN D stated if the MTs or LVNs were to log onto the computer, it would say that the medication order had arrived. LVN D also stated that misplacing medications could negatively affect a resident by the medication would not be available to the resident if they needed it. An interview was conducted on 11/13/2025 at 5:40PM with the DON revealed she had been trained on medication storage. She said the training covered narcotic storage, and storing medication in the carts. She said she does not remember the last time she had that training. She said she would have to review the policy for loose medications in the medication cart, but they should not be in the cart. She said the nurse or the medication aide are responsible for ensuring there are no loose pills in the cart. If there are loose pills in the cart it could affect the resident by the resident possibly not getting their medication. She said the ADON monitors and so does the pharmacist. She said they monitor by doing cart checks. She said she did not know why there were loose pills on the medication carts. An interview was conducted on 11/14/2025 at 1:00PM with the ADM who reported he had worked at the facility for 11 months. The ADM stated the DON, ADON and nursing staff are responsible for MC audits. The ADM stated that if there were medications at the bottom of the MC, then there could be possibility that the resident did not receive the medication. Record review of policy titled PCU027-Medication Storage in the Facility dated 2025 revealed the following:1. Medication and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel or members lawfully authorized to administer medications. a. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. Medication storage areas are kept clean, well lit, and free of clutter.

Based on observations, interviews and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 18.52% based on 5 errors out of 27 opportunities, which involved three (Resident #26, Resident #37, and Resident #77) of seven residents reviewed for medication errors. 1. The facility failed to ensure that Resident 26's Ferrous Sulfate 300 (60 Fe) mg/5ml and Calcium-Vitamin D 600-200 mg were available at the time of observation and administered as ordered. 2. The facility failed to ensure that Resident 37's Glucosamine HCL 500 mg was available at the time of observation and administered as ordered. 3. The facility failed to ensure that Resident 77's Fish Oil 1000 mg was administered correctly as Resident 77 was administered Fish Oil 1200 mg. The facility failed to ensure that Resident 77's Super B-Complex Oral Tablet (B-Complex w/Biotin & Folic Acid) was administered correctly. Resident 77 was administered Vitamin B-Complex and Folic Acid 400 mcg in place of the Super B-Complex Oral Tablet (B-Complex w/Biotin & Folic Acid). These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, per physician orders. Findings include: Record Review of Resident #26's face sheet dated 2/25/25, revealed resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Aftercare Following Joint Replacement Surgery, Unspecified Osteoarthritis, Vascular Dementia, Age-Related Osteoporosis, Vitamin Deficiency, and Alzheimer's Disease. Record Review of Resident #37's face sheet dated 2/25/25, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease (Narrowing of Peripheral Blood Vessels), Diabetes Mellitus, and Dementia. Record Review of Resident #77's face sheet dated 2/25/25, revealed resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Cerebral Atherosclerosis (Plaque Build-Up in the Brain), Unspecified Dementia, Mixed Hyperlipidemia (High Cholesterol), Spondylosis (Degenerative Changes in the Spine) and Other Intervertebral Disc Degeneration. Record Review of Resident #26's Order Summary Report dated 2/26/25 revealed Calcium-Vitamin D Tablet 600-200 mg with start date of 9/30/24 and Ferrous Sulfate Oral Solution (60 Fe) mg/5 ml with start date of 9/26/24. Record Review of Resident #27's Order Summary Report dated 2/26/25 revealed Glucosamine HCL 500 mg with start date of 12/19/24. Record Review of Resident #77's Orders Summary Report dated 2/26/25 revealed Fish Oil Capsule 1000 mg with start date of12/28/24 and Super B-Complex Oral Tablet (B-Complex w/Biotin & Folic Acid) with start date of 12/28/24. Record Review of order printed 2/25/25 at 9:52 a.m. revealed on 2/25/25 at 9:49 new order for Resident #26 for Ferrous Sulfate Oral Solution (Ferrous Sulfate) Give 7.5 ml by mouth two times a day. Record Review of order printed 2/25/25 at 9:57 a.m. revealed on 2/25/25 at 9:54 new order for Resident #26 for Calcium 600+D3 Oral Tablet 600-10 mg-mcg (Calcium Carbonate-Cholecalciferol) Give 1 tablet by mouth one time a day for supplements Calcium D3-600 mg/10mcg. Record Review of order printed 2/25/25 at 10:01 a.m. revealed on 2/25/25 at 10:00 a.m. new order for Resident #37 for Glucosamine Sulfate Oral Tablet (Glucosamine Sulfate) Give 1000 mg by mouth one time a day for supplement. Observation on 2/25/25 at 8:44 a.m. revealed that Glucosamine 500 mg was not administered to Resident #37 as ordered. Observation and Interview with MA G on 2/25/25 at 8:44 a.m. revealed that MA G was unable to find Glucosamine 500 mg tablets on medication cart but was had Glucosamine 1000 mg tablets on medication cart. MA G said she would hold the Glucosamine since she did not have the correct dosage and would notify the nurse. Observation on 2/25/25 at 9:03 a.m. revealed that Ferrous Sulfate 300 (60 Fe) mg/5ml and Calcium-Vitamin D 600-200 mg was not administered to Resident #26 as was ordered. Observation and Interview of MA G on 2/25/25 at 9:03 a.m. revealed that MA G was unable to find medication bottles for Ferrous Sulfate 300 (60 Fe) mg/5 ml and Calcium-Vitamin D 600-200 mg on the medication cart. MA G said she would hold the Ferrous Sulfate and Calcium-Vitamin D since the medications and would notify the nurse. Observation on 2/25/25 at 9:15 a.m. revealed that MA G notified LVN G that she was unable to administer Glucosamine to Resident #37, and Ferrous Sulfate and Calcium-Vitamin D 600-200 mg to Resident #26. Observation on 2/25/25 at 10:22 a.m. revealed that Fish Oil 1200 mg, Folic Acid 400 mcg, and Vitamin B-Complex was administered to Resident #77. During interview with MA H on 2/25/25 at 10:22 a.m., MA H said that he was administering Folic Acid for Super B-Complex Oral Tablet (B-Complex w/Biotin & Folic Acid) per resident's MAR. During interview with the DON on 2/25/25 at 12:45 p.m., the DON said that the ADONs and the DON were usually the ones who will check medication orders to make sure the orders match the over the counter medications that the facility carries and will call the doctor to get updated orders. The DON said that the nurses can contact the doctor to fix the medications orders as well if needed. The DON said that if a medication was not available for medication pass then it would be an ineffective medication pass and the effect on the resident would depend on what the medication was for. During interview with MA G on 2/25/25 at 1:36 p.m., MA G said that the orders had been obtained for Glucosamine for Resident #37, and Ferrous Sulfate and Calcium-Vitamin D 600-200 mg to Resident #26. MA G provided surveyor with copies of the orders. During interview with LVN G on 2/25/25 at 1:39 p.m., LVN G said that if a medication was not available at time of medication pass then she would check if the medication was in the automated medication delivery system or the stock. LVN G said if the medication was not available then she would notify the resident's doctor. LVN G said that if a medication was not in stock at time of medication pass then the resident could have a change in condition and she would have to monitor the resident, document, and notify the resident's doctor. During interview with ADON A on 2/26/25 at 9:13 a.m., ADON A said that if they do not have an OTC medication in stock then the pharmacy can supply. ADON A said that she would check with the doctor first and see if the order can be changed if needed. ADON A said that if an OTC medication was not available during medication pass then it could lead to complications. During interview with ADON B on 2/26/25 at 1:15 p.m., ADON B said that if an OTC medication was not available then it would depend on the medication for the effect and gave the example if a resident did not receive iron, then the resident's iron levels would continue to be low. During an observation and interview with MA H on 2/28/25 at 11:22 a.m., MA H showed surveyor the bottle that he uses to administer Fish Oil to Resident #77 and the bottle was labeled as Fish Oil 1200 mg. MA H also said that he gave Folic Acid and Vitamin B Complex for the order of Super B-Complex Oral Tablet (B-Complex w/Biotin & Folic Acid). Record Review of facility's policy Medication Administration Procedures with revised date of 10/25/17 revealed that the 10 rights of medication should always be adhered to which includes the right medication and the right dose.

Based on observations, interviews and record review, the facility failed to ensure that all drugs and biologicals used in the facility must include the expiration date when applicable for five out of five residents (Resident #20, Resident #81, Resident #35, Resident #2, and Resident #299) reviewed for expired medication. The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma and other causes of high pressure inside the eye) were labeled with expiration date for Resident #20, Resident #81, Resident #35, Resident #2, and Resident #299. This failure could place residents at risk of not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications. Findings include: Record Review of Resident 20's face sheet dated [DATE], revealed resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including Paroxysmal Atrial Fibrillation (Irregular Heartbeat), Unspecified Glaucoma (Eye Condition that damages the Optic Nerve), Unspecified Amblyopia (Lazy Eye) of the left eye, and Blindness Right Eye Category 3. Record Review of Resident 20's Orders Summary Report dated [DATE] revealed order for Xalatan Ophthalmic Solution 0.005% (Latanoprost) with start date of [DATE]. Record Review of Resident 20's MAR printed [DATE] revealed resident had Latanoprost eyes drops administered on ,d+[DATE]-[DATE]. Record Review of Resident 81's face sheet dated [DATE] revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Other Sequelae Following Unspecified Cerebrovascular Disease (Aftereffect of a Stroke), Essential Hypertension (High Blood Pressure) and Liver Disease. Record Review of Resident 81's Orders Summary Report dated [DATE] revealed order for Latanoprost Ophthalmic Solution 0.005% (Latanoprost) with start date of [DATE]. Record Review of Resident 81's MAR printed [DATE] revealed resident had Latanoprost eyes drops administered on ,d+[DATE]-[DATE]. Record Review of Resident 35's face sheet dated [DATE] revealed resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia and Essential Hypertension (High Blood Pressure). Record Review of Resident 35's Orders Summary Report dated [DATE] revealed order for Latanoprost PF Ophthalmic Solution 0.005% (Latanoprost) with start date of [DATE]. Record Review of Resident 35's MAR printed [DATE] revealed resident had Latanoprost eyes drops administered on ,d+[DATE]-[DATE]. Record Review of Resident 2's face sheet dated [DATE] revealed resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including Acute on Chronic Systolic (Congestive) Heart Failure, Primary Open-Angle Glaucoma (Eye Condition that damages the Optic Nerve) and Legal Blindness. Record Review of Resident 2's Orders Summary Report dated [DATE] revealed order for Latanoprost Ophthalmic Solution 0.005% (Latanoprost) with start date of [DATE]. Record Review of Resident 2's MAR printed [DATE] revealed resident had Latanoprost eyes drops administered on ,d+[DATE]-[DATE]. Record Review of Resident 299's face sheet dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (Condition in which Brain Function is Disturbed), Unspecified Dementia and Essential Hypertension (High Blood Pressure). Record Review of Resident 299's Orders Summary Report dated [DATE] revealed order for Latanoprost Ophthalmic Solution 0.005% (Latanoprost) with start date of [DATE]. Record Review of Resident 299's MAR printed [DATE] revealed resident had Latanoprost eyes drops administered on ,d+[DATE]-[DATE]. Observation on [DATE] at 9:22 a.m. of ,d+[DATE] Hallway Medication Aide Medication Cart revealed that Latanoprost eye drops for Resident #20, Resident #81, Resident #35, and Resident #2 were not labeled with an open or expiration date. Resident #2's Latanoprost eye drops had a sticker that said, discard 42 days after opening. Observation on [DATE] at 9:45 a.m. of 100 Hallway Medication Aide Medication Cart revealed that Latanoprost eye drops for Resident #299 was not labeled with an open or expiration date. Resident #299's Latanoprost eye drops were not opened but was being stored at room temperature in the medication cart. During interview on [DATE] at 9:45 a.m., MA H said eye drops should be dated when they were opened. MA H said that residents could have negative effects if they were given eye drops that were expired because the open date was not documented. During interview on [DATE] at 12:45 p.m., the DON said that she did not know the policy by memory regarding medications being dated when opened but she would find out. The DON said that if an expired eye drop was given to the resident, then the medication might not be as effective. During interview on [DATE] at 1:39 p.m., LVN G said that eye drops should be dated when they were opened. LVN G said that an effect of eye drops not being dated when opened was that staff would not know if the eye drops were expired or when they were opened. LVN G said that a resident could experience a change in condition if they received expired eye drops. During interview on [DATE] at 9:13 a.m., ADON A said that eye drops should be dated when they were opened. ADON A said that if eye drops were given past their use by date, then it could cause burning sensation in the resident's eyes or infection. During interview on [DATE] at 1:15 p.m., ADON B said that eye drops should be labeled when they were opened. ADON B said that if a resident was given eye drops past their use by date, then the resident could have a reaction. Record Review of facility's Recommended Medication Storage policy with revised date of ,d+[DATE] revealed that Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. XALATAN (LANTANOPROST) OPHTHALMIC DROPS Refrigerate until initial use. Expires 6 weeks (42 days) when stored at room temperature. Refrigerated Xalatan remains effective up to expiration date on bottle.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation. -The facility failed to label, and date left over foods items in 1 of 1 walk in-cooler in the kitchen. -The facility failed to ensure that expired food products were not stored in the food pantry (dry goods area). These failures could place residents at risk for food-borne illness and food contamination. The findings include: Observation and interview with the Dietary Manager on [DATE] at 10:15AM, revealed- The cooler in the kitchen had the following expired food products: - sour cream half container of 5 Ibs dated best by -[DATE] Cottage cheese 3Ibs container half use dated best by -[DATE]. Half container of pimento cheese dated best by [DATE]. Observation of the dry good storage area revealed the following:. -6 one quart of high calorie protein supplements dated used by [DATE]. -,d+[DATE]oz containers of chipotle dated used by [DATE]. 8 oz bottle of imitation coconut extract dated used by [DATE]. During an interview with the Dietary Manager on [DATE] at 10:40 AM, she said all food items out of original containers should be labeled and dated. She said the dairy products dated best by dates can still be used but she would not use them if the product smelled bad. During an interview with facility's Cooperate Dietitian on [DATE] at 2:00PM, she said the used by date and best by dates were used interchangeably in the company's policy and procedure for food storage. She said the Dietary Manager can determine when to use used by and best by dates. Record review of facility policy titled Dietary, service policy& procedure Manual 2012 read in parts- All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: 4. Open packages of food are stored in closed containers with covers or in sealed and dated as to when opened. 6. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality

Based on interviews and record review, the facility failed to provide pharmaceutical services to meet the needs of 1 (Resident #300) of 6 residents reviewed for pharmacy services. The facility failed to ensure that medications were administered to Resident #300 on 3/6/2024 when she was admitted to the facility. This failure could place residents at risk of not having appropriate therapeutic effects from prescribed medications. Findings include: Record Review of Resident 300's face sheet dated 2/28/25, revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Vascular Dementia (Dementia caused from impaired blood flow to the brain), Anxiety, Restlessness and Agitation. Record Review of Resident 300's Discharge-Summary - V3 dated 4/9/24 at 9:36 a.m. revealed Resident 300 was admitted to the facility on [DATE] and discharged on [DATE]. Resident 300 was not admitted to the facility at the time of the investigation and was unable to be observed or interviewed due to having history of Alzheimer's Disease. Record review of Resident's 300's admission MDS dated [DATE] revealed a BIMS score of 7 that suggests severe cognitive impairment. Record Review of Resident 300's Admission Nurse Note v12 - V 8 dated 3/6/24 revealed admitted and time of 3/6/24 at 4:25 p.m. Record Review of Resident 300's March MAR revealed that no medications were administered on 3/6/2024. Resident 300 should have received evening doses of Buspirone HCL 10 mg three times a day for anxiety disorder, Mirtazapine 15 mg at bedtime and Depakote Oral Tablet Delayed Release 125 mg - 3 tablets one time a day that should have been scheduled at 5 p.m. Record Review of Resident 300's doctor's progress noted dated 3/7/24 revealed that Resident #300 arrived last night and missed her evening medicines. Record Review of Resident 300's Order Summary Report with active orders as of 3/8/24 revealed medication orders with order date of 3/6/24 of: Depakote for restlessness and agitation, Effexor XR 75 mg for generalized anxiety disorder, Mirtazapine 15 mg by mouth at bedtime for depression. Buspirone HCl 10 mg by mouth three times a day for anxiety disordered with order date of 3/7/24. Record Review of Resident 300's Progress Notes revealed order for Mirtazapine entered at 3/7/24 at 1:02 a.m. by LVN H that revealed LVN H was working overnight 3/6/24. During interview on 2/28/25 at 11:26 a.m. with the DON, the DON said that she would have been the ADON during March of 2024 for Resident #300. The DON said that if a resident was admitted past 4 p.m. she would not have been at the facility, but she would have checked the resident's medication orders the next day. The DON said that the charge nurse is who is responsible for the medications to be given and she could not say what happened regarding Resident #300 not receiving her medications on 3/6/24. The DON said that psychiatric, blood pressure and antibiotics were examples of medications that should be given even if a resident was admitted in the evening. During interview on 2/28/25 at 12:15 p.m. with the DON, the DON said that medications can be obtained from the emergency kit or the automated medication dispensing system. The DON said that medications can be obtained from the pharmacy overnight if needed. The DON said that resident medications should be started in the evening unless there were extenuating circumstances. Surveyor left message for LVN H on 2/28/25 at 12:38 p.m. to follow up if she had any further information why Resident #300 would not have gotten medications on 3/6/24. During interview on 2/28/25 at 12:47 p.m. with Administrator A, Administrator A said it was the expectation that residents will get their medications if the medication was in hand and have consent if needed. Administrator A said they can obtain medication from the automated medication dispensing system if needed or the pharmacy but that may take more time depending on the situation. During interview on 2/28/25 at 2:58 p.m. with Administrator B, Administrator B said she just started work at the facility in February 2024. Administrator B said she could not remember any information regarding Resident #300. Record Review of facility's policy Medication Administration Procedures with revised date of 10/25/17 stated Defining the schedules for administering medications: Maximize the effectiveness (optimal therapeutic effect) of the medication. The policy also stated all orders are presumed to be administered on the first scheduled medication time following their arrival at the facility through the normal pharmacy delivery process. The policy also stated that the 10 rights of medication should always be adhered to which included the right time.

Based on observations, interviews and record reviews, the facility failed to ensure residents were free from abuse for 4 (CR #1 and Resident #2, and Resident #6 and Resident #7) of 6 residents. The facility failed to protect Resident #6 from being slapped by CR#1 resulting in CR#1 being grabbed by Resident #7 on 1/26/24 at 9:15 am. The facility failed to supervise CR#1, who was on 1:1 supervision, when CR#1 hit Resident #2 on 1/26/24 at approximately 5:30 p.m. This failure placed residents at risk of harm and injury. Findings included: Resident #6 Record review of Resident #6's face sheet dated 1/26/24 revealed Resident #6 was an [AGE] year old female resident who admitted on [DATE]. Diagnosis included hypertensive heart disease, muscle wasting and atrophy, heart failure, difficulty walking, and anxiety. Record review of Resident #6's Nurse Event note dated 1/26/24 at 15:26 (3:26 p.m.) revealed Resident #6 said another resident came over to her and tried to hit her in the eye and she pushed her away. Record review of Resident #6's Staff assessment dated revealed resident seen today to insure well-being to disagreement with peers. She is at baseline. Does not recall any occurrence of concern. Staff will continue to monitor. This writer will as well on rounds. Record review of Resident #6's progress note dated 1/26/24 at 14:05 (2:05 p.m) revealed CNA informed this nurse that they heard a loud noise coming from the hallway, upon arrival one of the resident's had another resident by the arm and was trying to force her out of the dining room and tried to close the door on the CNAs. Once they entered the dining room they asked Resident #6 what happened and she told them that CR#1 slapped her in the face. Upon my investigation when I asked Resident #6 what happened she said that resident tried to poke her in the eye and she pushed her away. No redness noted. Progress note completed by LVN B. In an interview on 2/7/25 at 9:13 am with Resident #6 she stated she vaguely remembers being slapped. She said it was someone being real stupid and then then she was dumb enough to get close. She said she threatened them real well and someoene even said she would get her back. She was hurting a little bit but figured it was her own fault. She tries to be be nice to people. She doesn't remember where she was hit. She can't remember if it was a resident or staff. She thinks it was a resident. The staff are very good here and not abusive. She doesn't' remember if Resident #7 pushed someone. She said hes a good man and its not fair to put him in it. Resident #7 Record review of Resident #7's face sheet dated 1/26/24 revealed Resident #7 is an [AGE] year old male that was admitted to the facility on [DATE]. Diagnosis included difficulty walking, hyperlipidemia, anxiety, and depression. Record review of Resident #7's progress note dated 1/26/24 at 14:18 (2:18 p.m.) revealed CNA informed this nurse that they heard a loud noise coming from the hallway, upon arrival Resident #7grabbed resident by the arm and was trying to force her out of the dining room and tried to close the door on CNAs. Once they entered the dining room they asked another resident what happened and she told them that CR#1 slapped her in the face. Upon my investigation when I asked Resident #6 what happened she said that resident tried to poke her in the eye and that she pushed her away, no redness noted. Note completed by LVN B. Record review of Resident #7's Staff assessment dated [DATE] at 11:52 am revealed resident seen today to insure well-being 2nd to disagreement with peers. He is at baseline, does not recall any occurrence of concern. Staff will continue to monitor. This writer will as well on rounds. Unknown who completed document. Record review of Resident #7's Nurse's event Note dated 1/26/24 at 14:37 (2:37 p.m.) revealed resident grabbed another resident arm and tried to push her out of the dining room. Completed by LVN B. In an interview on 2/7/25 at 9:12 a.m. with Resident #7 he said he's been here a long time. He said he goes here a long time. When asked about the incident and he just kept saying he's been here a long time. Record review of the CNA E written statement revealed on 1/26/24 around 9:15 am, myself and other CNA's were near the nurse station and heard CR#1 yelling and I heard 2 smacking sounds. We ran to lock unit and I saw Resident #7 holing CR#1's arm and pushing her out of the room and slamming the door closed. Resident #6 said that CR#1 slapped her. Residents were separated and nurse, DON and administrator were notified. Record review of CNA C's written statement dated 1/26/24 revealed at approximately 9:15 am myself and another CAN were near the nurses station and heard loud smacking noises and yelling coming from the lock unit. We immediately ran to the unit upon entering the unit we observed Resident #7 shoving Cr#1 out of the room. HE then slammed the door shut on CNA face. When we entered the room Resident #6 was holding her face and said CR#1 slapped the shit out of her. We then separated all the residents and informed the nurse in charge. In an interview on 2/6/25 at 2:24 p.m with CNA C she said CR#1 does not ring a bell in her memory. She hasn't worked on secured unit in forever. She doesn't remember the incident. She said she had been trained on a/n/e while she was here and she knew the abuse coordinator is the administrator and she would report a/n/e if she witnessed it. Record review of CNA A's written statement dated 1/26/24 at 9:15 am revealed I was giving patient care when everything transpired. In an interview on 2/6/25 at 2:38 p.m. with CNA A, she said she can't recall the incident. She said If you have a written statement then that's what it was. She can't remember it right now because its been so long. She didn't work other parts of the building. She said she was probably on the unit but was in a room. If its wrote then that's what it is. She had been trained on a/ne and completed inservices. Record review of CNA B's written statement dated 1/26/24 revealed I was in a room giving patient care I did not witness the incident with CR#1 On 2/7/15 at 9:50 am a telephone call was placed to CNA B. No vm set up. CR#1 Record review of CR#1's face sheet dated 2/7/2025 revealed she was a [AGE] year-old female resident at the time of the incident. CR#1's original admission date is 11/7/2022. Diagnoses included Alzheimer's, Bipolar, Dementia, restlessness and agitation, and Anxiety. CR#1 was discharged on 1/26/24. Record review of CR#1's Quarterly MDS dated [DATE] revealed CR#1 was severely cognitively impaired . Record review of CR#1's undated Care plan revealed CR#1 required anti-psychotic medication for dx of bipolar disorder, current episode manic severe with psychotic features. CR#1 had potential to demonstrate physical behaviors, poor impulse control, she hit another resident. Staff should assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Give the resident as many choices as possible about care and activities. Monitor/document/report to MD of danger to self and others. Staff to do UA to rule out UTI. Staff to watch resident one on one. Date initiated 9/12/23. Record review of CR#1's progress notes revealed Resident slapped another resident. Note was completed by LVN A on 1/26/24 at 18:13 (6:13 p.m.). Record review of Event Nurses' Note dated 1/26/24 at 18:16 (7:16 pm) revealed CR#1 very anxious noted picking up tables and chair, no grimacing noted. CR#1 noted very anxious and packing and noted slapping another resident. Document completed by LVN A. Record review of CR#1's Progress Note dated 1/26/24 at 10:03 am, revealed CNA informed this nurse that they heard a loud noise coming from the hallway, upon arrival one of the resident's had a resident by the arm and was trying to force out of the dining room and tried to close the door on the CNA's. Once they entered the dining room they asked another resident what happened and she told them that CR#1 slapped her [Resident #6] in the face. Upon my investigation when I asked Resident #6 what happened she said that resident tried to poke her in the eye and that she pushed her away. No redness noted to Resident #6's face. No bruises or redness noted to CR#1's arm. No c/o voice. Progress note completed by LVN B Record review of CR#1's Staff assessment dated [DATE] at 17:35 (5:35 p.m.) revealed Resident has become volatile. Impression: Psychosis. Staffed with provider who directed Inpatient psychiatric care for further evaluation and stableingation (stabilization) There was not any note of who completed the assessment. Record review of CR#1's Discharge summary dated [DATE] at 22:30 (10:20 p.m.) completed by LVN A revealed CR#1 had behaviors noted, slapping another resident, order to send CR#1 to [behavioral hospital] for eval and treat. Resident #2 Record review of Resident #2's Face sheet dated 2/7/25 revealed Resident #2 is an [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included generalized anxiety disorder, acute kidney failure, type 2 diabetes, muscle weakness, schizophrenia, and Alzheimer's disease. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 3 indicating severely cognitively impaired. Record review of Resident #2's undated Care plan revealed Resident #2 had a potential for being afraid due to another resident hit her. Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Record review of Resident #2's progress notes revealed this writer was making rounds when the CNA came to inform of incident upon coming to the dining room. During dinner resident was sitting at the table with her [family member], when this writer was told that another resident had slapped Resident #2, upon assessment no redness to resident's face, resident was calm no complaints of pain. Effective date was 1/26/24 at 17:30 (5:50 pm) completed by LVN A. Record review of Event Nurse's note completed by LVN A on 1/26/24 at 18:00 (6pm) revealed Resident #2 was sitting for dinner at table with her [family member] when another resident slapped her. No complaints of pain verbalized. No injury noted. Resident #2 unable to state what occurred but stated not in pain and calm. No distress noted. Record review of Facility's Provider Investigation Report revealed on 1/26/24 at 5:30 p.m. in the memory care unit CR#1 slapped Resident #2 in the Dining room during dinner. LVN B completed assessment and Resident #2 had on injury or redness to face. Resident #2 had no pain and was calm. Resident Safety maintained; CR#1 maintained on 1:1; Physical and Mental Assessment provided; Psyche Consult for all residents involved; Trauma Informed Assessment; Staff /Resident's interviews initiated; In-service Abuse/Neglect initiated; AD HOC QAPI held. It is noted that on 1/26/2024 at approximately 5:30 pm, Resident #2 was eating dinner with other residents and visiting with her [family member]. CR#1 initially came into the dining room and tried to flip the table over. CNA stopped her from flipping table. CR#1 then, on her way out, stopped and slapped Resident #2 across the face. No redness or injury noted. Note: This is the 2nd incident today with CR#1 slapping another resident. Maintain Resident Safety by monitoring; Continue 1:1 supervision. CR#1 sent out for behavioral eval and treatment. In an interview and observation on 2/6/25 at 9:35 a.m. with Resident #2, she said she didn't remember being hit or slapped by any other resident. Resident #2 was observed in her bed eating breakfast. She did not have any skin bruising, tears or other concerns for her skin. She said she feels fine when she was asked if she felt safe. In an interview on 2/5/25 at 12:30 p.m. with the DON , she said CR#1 had an episode of slapping people and she remembered Resident #2 just happened to be sitting there. She doesn't remember if family was there. The incident with Resident #2 was the second incident that day. In an interview on 2/6/25 at 11:16 a.m. with Family Member she said she was in the memory care unit sitting at a table with Resident #2. She said there were two tables, her and Resident #2 were sitting at one table, and another resident (CR#1) was lifting the other table and she was trying to turn the table over. Resident #2 was sitting at the table and then the lady (CR#1) slapped her on the face, and she (Family Member) screamed and said, She slapped my mama!. There were not any staff in the room when this happened. It didn't take a long time for staff to come. The incident happened during meal time and this happened in the second room with the tables, during lunch or dinner. She said that staff came to see what happened and staff just looked at her and said, Are you fine Resident #2? Resident #2 said yes. When CR#1 slapped Resident #2, Family Member started hollering and staff came in and took CR#1 out of the room. She did not know which staff. Record review of Provider investigation report revealed written statement from Family Member dated 1/29/24 One Friday the 26 of January, [CR#1] came in and [Resident #2] was eating dinner with other and she tried to turn the table over, then the CNA had her to stop. Then as she was walking out touching and messing with others she slapped [Resident #2] and I held [Resident #2] and told her to stop and I called for help. The CNA came in and got her. [sic] In a telephone interview on 2/6/25 at 2:38 p.m. with CNA A, she said she used to work at the facility as a CNA. She cannot recall the incident. She said if surveyor had a written statement then that's what it was. She can't remember the incident right now because it was so long ago. She said she didn't work other parts of the building and she was probably on the secured unit but was in another resident's room. Record review of Provider investigation report revealed there was not a written statement from CNA A. Telephone attempts were made on 2/6/25 at 9:50 a.m. to CNA B. No voicemail box was set up. CNA B never called back. Record review of Provider investigation report revealed written statement from CNA B dated 1/26/24 revealed I was passing hall trays at the time of the incident, I did not witness anything. In an interview on 2/6/25 at 2:44 p.m. with LVN A, she stated she worked the secured unit all the time. She was familiar with Resident #2 and CR#1. She said she worked in the evening. She was not sure about the morning incident, she didn't witness the morning incident. She doesn't know who was working that day. She stated that when CR#1 had bad days, there were a few incidences. There were a couple residents that don't like the other person. CR#1 had a few people that she didn't really like. She said they would notify family, administrator, DON, and separate residents when an incident occurs between residents. She said they would do interventions. They would watch them. She stated when a resident is placed on 1:1, that means staff would be right there with resident. She said the nurses really don't do 1:1 monitoring, but they try to help out. She said it would be hard on locked unit to do 1:1 monitoring. She stated when CR#1 had incidences she was placed on 1:1. She confirmed that she signed the 1:1 Sheet for CR#1 (dated 1/26/2024). She said she didn't see CR#1 slap a resident that evening. She said she wouldn't leave the 1:1. She said she can't remember everything but she is pretty sure she didn't leave CR#1's side on 1/26/2024. She said a resident slapping another resident is considered abuse. In an interview on 2/7/25 at 9:57 a.m. with the DON, she stated she vaguely remembers the incident in the morning with CR#1. She said that morning was the first episode of CR #1 hitting someone. She stated that standard protocol during resident-to-resident incident was that the staff would separate residents, call MD and get orders and notify family. She said the facility may have put CR#1 on 1:1, but she wasn't 100% sure. She said 1:1 protocol can last as little as 8 hours or until medications are received or 2 to 3 days. She stated 1:1 supervision means an employee is always with resident. If a staff needs to take a break, the other employee will step in. The DON reviewed and confirmed that the initials on the 1:1 monitoring sheet belonged to the Assistant Business Office Manager. The DON stated she was not aware that a staff was not with CR#1 at the time CR#1 hit Resident #2 on that same day (1/26/2024), later that evening (5:30 p.m.). She said CR #1 was on 1:1 supervision when she hit the second resident later that same day (1/26/2024), but even if staff was with CR#1 on the 1:1 supervision, there was not a guarantee that Resident #2 would not have been hit if someone was with her 1:1. During passing of trays the expectation was that staff should still be with their 1:1 resident.In an interview on 2/7/25 at 10:09 a.m. with the Assistant Business Office Manager she confirmed that she signed off on the 1:1 monitoring sheet. She stated CR#1 was acting out and having behaviors so the DON and Administrator asked her to sit with CR#1. She thought the behavior was CR#1 was hitting other residents. She said she was 1:1 with her for CR#1. She said she didn't know who took over 1:1 Supervision when she left. She said she told LVN A she was leaving. When she left, someone else would've taken over. During the time she was on 1:1 monitoring with CR#1 she would walk with her and then sit a little. CR#1 was agitated. She didn't have any injuries. She didn't see her hit anyone. In an interview on 2/7/25 at 10:09 a.m. with the Assistant Business Office Manager she confirmed that she signed off on the 1:1 monitoring sheet and was providing 1:1 care for CR #1 on 1/26/2024, after she hit a resident that morning. She stated CR#1 was acting out and having behaviors so the DON and Administrator asked her to sit with CR#1. She thought the behavior was CR#1 was hitting other residents. She said she was 1:1 with her for CR#1. She said she didn't know who took over 1:1 Supervision when she left. She said she told LVN A she was leaving. When she left, someone else would have taken over. During the time she was on 1:1 monitoring with CR#1 she would walk with her and then sit a little. CR#1 was agitated. She didn't have any injuries. She didn't see her hit anyone. In a telephone interview on 2/7/25 at 10:26 a.m. with the former Administrator he stated that he does not recall if CR#1 was on 1:1. He referred to the DON. He said it was his normal protocol to place residents on 1:1 to ensure safety. He cannot say whether or for sure if it did or did not happen. He said he didn't remember a whole lot about it. Record review of the Monitoring Chart dated 1/26/24 revealed Frequency of Monitoring 1:1 for CR#1. The Assistant Business Office Manager initialed from 1330 through 1430 (1:30 p.m. through 2:30 p.m.). The Monitoring chart revealed LVN A signed off as monitoring CR#1 on 1:1 supervision from 1400 (2pm) through 2230 (10:30 p.m.). Record review of the Facility's undated Event Reporting Policy revealed in part 8. Interventions: Include and care plan any required interventions or supervision to help prevent further occurrence of the event . Record reveiw of the facility's abuse policy dated March 2018 revealed residents have the right to be free from abuse.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 Residents (Resident #3, #4 and #5 ) observed for infection control, in that: MA A failed to sanitize blood pressure cuff after each use for Resident #3, and Resident #5 MA A failed to use proper hand hygiene while passing medications to Resident #3, Resident #4, and Resident #5. MA A failed to maintain a clean work space/med cart while passing medications to Resident #3, Resident #4 and Resident #5. These failures place residents at risk of cross contamination and infections. Findings included: Resident #3 Record review of Resident #3's face sheet dated 2/7/25 revealed Resident #3 was a [AGE] year old female resident who admitted on [DATE]. Diagnoses included chronic kidney disease, type 2 diabetes, hypertension and dementia. Record review of Resident #3's physician's orders dated 8/5/24 revealed Lisinopril Oral Tablet 20 MG (Lisinopril), Give 20 mg by mouth one time a day for HTN HOLD, FOR spb less than 110 dbp less than 60 or HR <60. Resident #4 Record review of Resident #4's face sheet dated 2/7/25 revealed Resident #4 is a [AGE] year old female who admitted on [DATE]. Some Diagnoses included Dementia, anxiety disorder, ataxic gait (abnormal walking pattern by uncoordination and instability), hyperlipidemia (high levels of fat in blood), and osteoporosis . Record review of Resident #4's physician's orders dated 10/28/24 revealed may crush meds or open capsules PRN. Record review of Resident #5's face sheet dated 2/7/25 revealed Resident #5 is a [AGE] year old female resident who admitted to the facility on [DATE]. Diagnoses included Encephalopathy (disturbance of brain function causing memory loss), epilepsy (seizure disorder), hypertension (high blood pressure), Dementia, and hyperlipidemia. Record review of Resident #5's physician's orders dated 3/27/24 amLODIPine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth two times a day for HTN hold for SBP < 100 or pulse < 60. Observation and interview on 2/6/25 at 9:39 a.m. revealed MA A had a box of food on the med cart and he was eating with the blood pressure cuff and thermometer next to the food. There was a cup of pudding on the car without a lid or cover on top. MA A stated he said he was eating breakfast. He said he just had a bite to see how it tasted. He said a staff just brought it to him and he was not intending to eat it. MA A then placed the food in the bottom drawer of the med cart. Observation of medication pass on 2/6/25 at 9:40 revealed MA A placed the blood pressure cuff on Resident #3's wrist and took blood pressure without sanitizing his hands, cart or blood pressure cuff after eating his breakfast. MA A administered medications to Resident #3 without wearing gloves, washing hands, or sanitizing his hands or cart. Without washing or sanitizing hands, MA A then pulled Resident #4's medications out of the cart and set them on top of the cart. MA A crushed medications and when pouring the crushed medications in the cup some fell on the cart. MA A then brushed the medication off the cart onto the floor with his hand. MA A used the bed remote which was on the floor and adjusted Resident #4's bed. MA A administered medications to Resident #4. MA A then put on gloves but did not wash or sanitize hands or cart. MA A proceeded to grab the blood pressure cuff, closed the bathroom door and proceeded to check Resident #5's blood pressure. MA A did not sanitize the blood pressure cuff. MA A kept gloves on and dug in his pocket for keys, dropped something on the floor and picked it up and put it back in his pocket and then pulled and prepped medications. MA A adjusted Resident #5's bed with the remote that was on the floor and administered medications. MA A then removed and discarded gloves and then used hand sanitizer from the cart to sanitize his hands. In an interview on 2/6/25 at 10:10 am with MA A, he stated that he normally sanitized the cart before he started meds and then when he finished passing medications. MA A said ideally he should sanitize cart in between each resident, but he didn't today because none of the other residents touched the cart. MA A said he would agree that he should have sanitized his cart after he was eating on it. MA A said he should wash his hands after each resident. MA A said he did wash his hands after each resident. MA A then said that he didn't wash his hands or sanitize because he didn't touch the residents. MA A said he only sanitized one time because he touched a bed rail. He said the blood pressure cuff should be sanitized after every use. He said he didn't do it because he just missed it. When MA A was asked about the crushed meds getting on the cart if he should brush them off, he said he didn't honestly realize he did that. MA A stated the risk to the residents for not sanitizing or using proper hand hygiene is cross contamination. MA A said he didn't wash or sanitize hands after eating because he thought he had gloves on while eating . In an interview on 2/7/25 at 9:57 am with the DON, she said absolutely not there should not be food on the med cart. She said staff should not store food on the med cart. She said MA A should have done all three, sanitize hands, wash hands, and sanitize cart. She said MA A should sanitize blood pressure cuff between each use. MA A should wash his hands or sanitize hands between each person. She said the risk to residents is passing infection. Record review of the facilities Fundamentals of Infection Control Precautions policy dated 3/2024 revealed in relevant part Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: Before and after eating or handling food (hand washing with soap and water); Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); After handling soiled equipment or utensils; After removing gloves or aprons. Record review of the facilities Medication Administration Procedures dated 2003 revealed in relevant part The medication cart and surrounding work area must be always clean.

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 5 residents (Resident #1) reviewed for call lights. The facility failed to have a call light within reach for Resident #1 to call for assistance. This failure could place residents at risk for a delay in care and services. Findings included: Record review of Resident #1's face sheet dated 1/28/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: wrist drop-right wrist (weakness of the muscles that control wrist extension, resulting in the inability to lift the hand or extend the wrist properly), muscle weakness, lack of coordination, muscle wasting, hemiplegia (almost complete paralysis of one side, including loss of movement), and hemiparesis (partial weakness or reduced strength on one side but not complete paralysis) affecting left non-dominant, type 2 diabetes (group of diseases that affect how the body uses blood sugar), and anemia (reduced red blood cells.). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 of 15 which indicated she was cognitively intact. Further review revealed Resident #1 needed partial to moderate assistance with ADLs (Section GG - roll left and right - partial/moderate assistance, toileting hygiene - partial/moderate assistance), (Section H - Urinary and Bowel continence - frequently incontinent) which required at least one staff assistance. Record review of Resident #1's care plan initiated on 4/10/2024 revealed Resident #1 had risk for falls related to hemiplegia/hemiparesis. An intervention was to ensure Resident #1's call light was within reach. Resident #1 had an ADL self-care deficit related to inability to perform activities of daily living independently. Goal was to maintain toilet use and personal hygiene. Intervention required extensive assistance of one staff. During an observation and interview on 1/28/2025 at 9:19 a.m., revealed Resident #1's manual call bell was on her bedside dresser. The dresser was on Resident #1's right side. Resident #1 said she was soaking wet. She said she was very uncomfortable and frustrated because she was not able to find her call bell. She said it was normally on her tray table. Resident #1 asked the state surveyor if she could find her call light, and the state surveyor pointed to the dresser. She said she was not able to reach it. She said the call light system was not working and she was given a manual bell to ring and call for assistance. She said the staff came into her room at approximately 3:00 a.m. when a blood draw was attempted. She said she had been saturated with urine for over an hour. During an observation and interview on 1/28/2025 at 9:23 a.m. there was no visible staff on the hall. At 9:24 a.m. CNA A was walking down the hall with a cart and picking up breakfast trays. The state surveyor asked if there was another staff member available to assist Resident #1. CNA A said she was not sure. During an interview on 1/28/2025 at 9:27 a.m., CNA A said she was picking up breakfast trays. She said there was another CNA A that helped on the hall but was on another hall. CNA A said she did not go in and check on Resident #1 or check if she needed an incontinent change. She said she had not checked if Resident 1's call bell was in reach. She said CNAs and nurses were responsible and supposed to ensure the call bell was in a resident's reach. She said she started her shift at 6:00 a.m. this morning. She said she opened Resident #1's door, but assumed she was asleep and had not been back to the room. She said because the call light system was out, we were supposed to check on residents every 15-minute checks. She said she went to the door but had not gone into the room . In a further interview and observation on 1/28/2025 at 9:30 a.m., with Resident #1 to CNA A said she was saturated with urine. CNA A said did you use your call light. Resident #1 said she could not find it. CNA A said I can come back after I finish picking up trays. Resident #1 said I would rather not wait. CNA A said I can come back after I finish the trays and give you a shower. Resident #1 said she wanted to be changed now. CNA said she last checked on Resident #1 when she completed her initial rounds at approximately 6:40 a.m., after she came on shift. When CNA A said she did not want to wake up Resident #1 at 6:40 a.m., Resident #1 said she was not sitting up, but she heard CNA A open the door. Resident #1 said no other staff had come in the room and asked if she needed any assistance or made sure her call bell was within her reach. CNA A showed Resident #1's soaked brief that was in a plastic bag after she was changed. CNA A said the blue line down the middle of the brief, indicated it was soiled. She said although [Resident #1] was a heavy wetter, the brief was soaked and had leaked out onto her clothing. She said this could cause the resident discomfort. During an interview on 1/28/2025 at 9:40 a.m., LVN A (sitting at nurse's station) said he had not seen Resident #1. He said he rounded on two other halls. He said LVN B was the nurse for the 600 hall. He said his shift started at 6:00 a.m. During an interview on 1/28/2025 at 9:50 a.m., LVN B said she arrived late for her shift at 6:00 a.m. and LVN A completed shift change. She said she made rounds between 6:30 a.m. and 7:00 a.m. She said she peeked in the door. She said she saw Resident #1 from the room door and verified the resident was in the bed. She said it was the nurses and CNAs responsibility to ensure call bells were within the residents' reach. She said the resident was at risk of not receiving care if they were not able to reach the call bell or notify staff. She said she had been trained to check on residents every 15 minutes and document on a log placed at the nurse's station. During an interview on 1/28/2025 at 10:39 a.m., CNA B said she worked the 6:00 a.m. - 2:00 p.m. shift. She said she had been trained to make room checks every 15 minutes because the call light system was not working. She said she had not been in Resident #1's room since she placed her meal tray on her table at approximately 8:30 a.m. CNA B said she did not check where Resident #1's call bell was within reach. She said she did not check because she was focused on getting breakfast trays delivered. She said CNAs and nurses were responsible for ensuring the call bells were within the residents' reach. She said the resident was at risk for not receiving care or assistance. During an interview on 1/28/2028 at 11:38 a.m., RN A said the call bell should be placed within a resident's reach and on their dominant side. She said if a call bell was out of reach, a resident would not be able to call for help or for assistance. She said the CNAs and nurses were responsible for ensuring the call bells were in place. She said staff should check residents every 15 minutes, because the call light system was currently not working. She said staff had been in-serviced on the 15 minutes rounding. She said the DON and the ADON were responsible for ensuring rounds were completed. During an interview on 1/28/2028 at 11:48 a.m., the DON said CNAs and nurses were responsible for ensuring the call bells were in place. She said the also completed Champion Rounds by department head to ensure residents needs were met. She said the Activities Dir. was the department head for the 600 hall. She said if the call bell was not in place, the resident is at risk their needs not met and could reach too far and fall. She said staff should walk and do rounds to ensure the call lights were in place. During an interview on 1/28/2025 at 2:56 p.m., Activity Dir. said she completed the champion that included Resident #1's room. She said she brought Resident #1's mail approximately 9:05 a.m. She said she did not stay in the room long because this state surveyor was in the room with CNA A. She said she picked up a piece of trash. She said she did not check Resident #1's call light. She said she had not been in Resident #1's room before she delivered the mail . Record review of the facility's policy on Perineal Care Female (revised 12/8/2009) read in part the following, e. Always replace call signal and needed items within resident's reach . Record review of the facility policy Resident Rights (not dated) revealed the following in part: The resident has a right to a dignified existence, self-determination . including those specified in this policy. Respect and dignity - The resident has a right to be treated with respect and dignity, including . 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs .

Based on observation, interviews, and record review, the facility failed to ensure residents who are unable to carry out the activities of daily living received the necessary services to maintain grooming and personal hygiene care for 1 (Resident #1) of five residents reviewed for ADL care. -The facility failed to ensure Resident #1 was provided timely incontinent care. These failures could place residents who required ADL care at risk of not receiving personal care and services. Findings included: Record review of Resident #1's face sheet dated 1/28/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: wrist drop-right wrist (weakness of the muscles that control wrist extension, resulting in the inability to lift the hand or extend the wrist properly), muscle weakness, lack of coordination, muscle wasting, hemiplegia (almost complete paralysis of one side, including loss of movement), and hemiparesis (partial weakness or reduced strength on one side but not complete paralysis) affecting left non-dominant, type 2 diabetes (group of diseases that affect how the body uses blood sugar), and anemia (reduced red blood cells.). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 of 15 which indicated she was cognitively intact. Further review revealed Resident #1 needed partial to moderate assistance with ADLs (Section GG - roll left and right - partial/moderate assistance, toileting hygiene - partial/moderate assistance), (Section H - Urinary and Bowel continence - frequently incontinent) which required at least one staff assistance. Record review of Resident #1's care plan initiated on 4/10/2024 revealed Resident #1 had risk for falls related to hemiplegia/hemiparesis. An intervention was to ensure Resident #1's call light was within reach. Resident #1 had an ADL self-care deficit related to inability to perform activities of daily living independently. Goal was to maintain toilet use and personal hygiene. Intervention required extensive assistance of one staff. During an observation and interview on 1/28/2025 at 9:19 a.m., revealed Resident #1's manual call bell was on her bedside dresser. The dresser was on Resident #1's right side. Resident #1 said she was soaking wet. Resident #1 was wet with urine from front to back, and her bed sheets and temporary bed pad was soaked. She said she was very uncomfortable and frustrated. She said had been saturated with urine for over an hour. During an observation and interview on 1/28/2025 at 9:23 a.m. there was no visible staff on the hall. At 9:24 a.m. a CNA A was walking down the hall with a cart and picking up breakfast trays. Surveyor asked was there another staff available to assist Resident #1. CNA A said she was not sure. During an interview on 1/28/2025 at 9:27 a.m., CNA A said she was picking up breakfast trays. She said there was another CNA that helped on the hall but was on another hall. CNA A said she did not go in and check on Resident #1 or check if she needed an incontinent change. She said she started her shift at 6:00 a.m. this morning. She said she open Resident #1's door approximately at 6:40 a.m., but assumed she was asleep and had not been back to the room. She said she had helped in the dining room and assisted with feeding residentsShe said because the call light system was out, we were supposed to check on residents every 15-minute checks. She said she thought CNA B had checked on the resident since she was in the dining room. She said the resident can go without being helped if staff does not round. In a further interview and observation on 1/28/2025 at 9:30 a.m., with Resident #1 to CNA A said she was saturated with urine. CNA A said did you use your call light? Resident #1 said she could not find it. CNA A said I can come back after I finished picking up trays. Resident #1 said I would rather not wait. CNA A said I can come back after I finish the trays and give you a shower. Resident #1 said she wanted to be changed Now. CNA A completed the Resident #1 incontinent change and came out of the room. This surveyor asked to see the saturated brief. CNA A said the brief was heavily saturated. She said the blue line down the middle of the brief indicated the brief was wet. She said Resident #1's clothing had to be changed because it was wet from urine. CNA A said she assisted residents in the dining room with feeding and had not been back to check on Resident #1. During an interview on 1/28/2025 at 9:50 a.m., LVN B said she arrived late for her shift at 6:00 a.m. and LVN A completed shift change. She said she made rounds between 6:30 a.m. and 7:00 a.m. She said she peeked in the door. She said she saw Resident #1 from the room door and verified the resident was in the bed. She said she was not aware Resident #1 was soiled. He said the resident is at risk of not receiving incontinent care which could result in skin breakdown. She said she had been trained to check on residents every 15 minutes and documents on a log placed at the nurse's station . During an interview on 1/28/2025 at 10:39 a.m., CNA B said she worked the 6:00 a.m. - 2:00 p.m. shift. She said she had been trained to make room checks every 15 minutes because the call light system is not working. She said she had not been in Resident #1's room since she placed her meal tray on her table at approximately 8:30 a.m. She said Resident #1 wanted coffee. CNA B said she did not check where Resident #1's call bell was within reach. She said she did not check because she was focused on getting breakfast trays delivered. She said cnas and nurses were responsible for ensuring the residents' incontinent changes were completed timely. She said the resident was at risk for skin breakdown . During an interview on 1/28/2028 at 11:48 a.m., DON said cnas and nurses were responsible for ensuring resident had timely incontinent changes. She said a residents' call bell should be within reach so that the resident can call for assistance. She said saturated briefs could lead to skin breakdown if not changed timely. She said she was not sure why Resident #1 had not been changed timely. She said staff were trained on rounding every 15 minutes because the call system was not working and call bells were being used. Record review of the facility's policy on Perineal Care Female (revised 12/8/2009) read in part the following , . d. Provide for resident's comfort . e. Always replace call signal and needed items within resident's reach . Record review of the facility policy Resident Rights (not dated) revealed the following in part: The resident has a right to a dignified existence, .including those specified in the this policy. Respect and dignity - The resident has a right to be treated with respect and dignity, including . 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs .

Based on observation, record reviews, and interviews, the facility failed to ensure a resident's environment remained as free of accidents and hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for transfers in that: - CNA A failed to provide incontinence care with another staff member when Resident #1 required assistance of 2 staff, which resulted in the resident rolling off the bed on 8/19/24, sustaining a right femur fracture, and requiring surgery. An Immediate Jeopardy (IJ) was identified on 9/30/24. The IJ template was provided to the facility on [DATE] at 2:46p.m. While the IJ was removed on 10/1/24 at 2:50p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm, with the potential for minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for falling out of bed, injuries, and hospitalization . Findings included: Record review of Resident #1's undated face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of aftercare following joint replacement surgery, cognitive communication deficit, muscle weakness, vascular dementia, osteoporosis, displaced fracture of lower end of right femur, right artificial knee joint, difficulty in walking, type 2 diabetes, and Alzheimer's disease. Record review of Resident #1's Annual MDS assessment dated [DATE] indicated a BIMS was unable to be performed due to her medical conditions. The resident was severely impaired with cognitive skills for daily decision making and never/rarely made decisions. She was dependent (staff does all the work and resident does none of the work. Or resident requires 2 or more staff members) with all ADLs. The resident was always incontinent of bowel and bladder. The MDS indicated she had a hip and knee replacement. The MDS did not have Resident #1's fall on it. Record review of Resident #1's care plan dated 9/13/24 revealed a Focus: The resident is at risk for falls r/t unaware of safety needs with an actual fall (Initiated: 2/23/21, Revised: 9/17/24). Goal: The resident will be free of falls through the review date. The resident will not sustain serious injury through the review date (Initiated: 2/23/21, Revised: 9/15/24, Target: 12/13/24). Interventions: Resident with actual fall during care. Resident rolled and was guided to the floor mat by CNA A. Resident sent to the hospital (Initiated: 8/19/24). Focus: The resident had a fracture after a fall (Initiated: 7/16/21, Revised: 9/17/24). Goal: Resident's surgical incision will heal without s/sx of infection or breakdown by review date (Initiated: 9/17/24, Revised: 9/17/24, Target: 12/13/24). Interventions: Change surgical incision dressing as per order and PRN (Initiated: 9/17/24). Focus: Resident has an ADL self-care performance deficit. Goal: Resident will demonstrate the appropriate use of adaptive devices to increase ability in bed mobility through the review date (Initiated: 12/22/23, Revised: 9/15/24, Target: 12/13/24). Interventions: Bed Mobility: requires staff x2 for assistance (Initiated: 12/22/21). Record review of Resident #1' s undated Kardex (information about how to care for the resident in the EMR), indicated she required 2 staff assistance for bed mobility. Record review of Resident #1's nursing note dated 8/19/24 at 6:55am, revealed the resident rolled off the bed and on to the floor while CNA A performed bed side care. Record review of Resident #1's fall-risk assessment dated [DATE] at 6:57am, indicated she was a high fall risk. Record review of Resident #1's nursing note dated 8/19/24 at 9:04am, indicated there was a new order for an x-ray for her right knee and right leg r/t pain and the fall. Record review of Resident #1's fall nurses note dated 8/19/24 at 10:46pm, indicated she had bruises to her BLE that were blue/purple. Record review of Resident #1's SBAR dated 8/19/24 at 10:56pm, indicated she had a fracture of the distal shaft (part of her femur by her knee) of her right femur and MD O ordered her to be sent to the ER. Record review of Resident #1's hospital records dated 8/20/24 at 1:03pm, indicated she had a comminuted (broken in 3 or more places) right femoral (thigh bone) fracture extending along the medial lateral (inside and outside) margins of the femoral component (part of the thigh bone that goes into the knee) of the knee arthroplasty (knee replacement). Record review of Resident #1's hospital records dated 8/21/24 at 11:51am, indicated she would need surgery for her right femur fracture, along with revision of her right knee arthroplasty (knee replacement). Record review of Resident #1's hospital records dated 8/25/24 at 10:28am, indicated the resident had a right open reduction internal fixation (repairing fractured bone using plates, screws or rods to stabilize the bone) of her femur on 8/22/24. During an interview on 9/29/24 at 12:26pm, Resident #1's family member said she had fallen out of bed twice in the last month and 10 times in the last year. He said it always happened early in the morning or late at night. He said Resident #1 was non-verbal and bedbound and the last time she fell was when a staff member was changing her and she rolled out of bed onto the floor. During an interview on 9/29/24 at 2:18pm, LVN B said he observed Resident #1 on her back on the floor, next to her bed, on 8/19/24. He said there was 1 CNA who had provided care and he thought the resident was a 1-person assist. During an interview and observation on 9/29/24 at 3:25pm, Resident #1 was laying on her back in bed. The bed was in the lowest position. Resident #1 said she was not having any pain at that time. During an interview on 9/29/24 at 3:35pm, CNA C said the way she knew if a resident was a 2-person assist, was based on the need of the resident, the weight, and the experience of the CNA. She said if a resident had to be a 2-person assist it would be listed in the POC/Kardex. She was not sure if Resident #1 was a 2-person assist. During an interview on 9/29/24 at 3:40pm, CNA D said if a resident was a fall risk and/or a 2-person assist it would be noted in their POC/Kardex. She said Resident #1 was a 2-person assist and she would never change her without another person because the resident could fall. During an interview on 9/29/24 at 3:48pm, CNA E said if a resident is a fall risk and their mobility status, would be on their Kardex. She said if a resident was a 2-person assist and there were not 2 CNAs, then a nurse or some other staff member could assist. She said if only 1 person assists a resident when they need 2 people, they could fall. During an interview on 10/2/24 at 3:15pm, CNA A said Resident #1 rolled off the bed when she turned her away from her during incontinence care. She said at the time, she thought the resident was a 1-person assist and did not know the resident was a 2-person assist. She said she knew to look at the Kardex for mobility and transfer information, but she never thought to look, and it was a mistake. Record review of the facility's policy titled Safe Patient Handling dated 12/30/05 indicated: The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safe transfer, repositioning and resident movement. Nurses will identify residents in need of transfer, repositioning, or movement assistance. Nurses will assess the risks associated with lifting, transferring, repositioning or movement assistance. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling. Resident will be evaluated on admission and as needed for alternative means of lifting, transferring, repositioning and other movement to minimize risk of injury. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury. Facility staff will report to supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff. Nursing will request therapy disciplines to evaluate resident ability to assist and amount of assistance needed with lifting, repositioning, transferring or mobility. An Immediate Jeopardy (IJ) was identified on 9/30/24. The IJ template was provided to the facility on [DATE] at 2:46pm. The Plan of Removal was accepted on 9/30/24 at 6:09pm. The plan of removal reflected the following: Interventions: A head-to-toe assessment on resident #1 was completed as of 9/30/24. No additional injuries or complaints of pain were noted. Bilateral grab bars were installed on the bed for resident #1 to assist with turning and repositioning on 9/30/24. As of 9/30/24, The Administrator and DON was 1:1 in-serviced by the Regional Compliance Nurse on 9/30/24 on the topics below. Then CNA A was in-serviced 1:1 by the DON on the following topics below: Completion date 9/30/24. o Following the Kardex in [EMR system] for required assistance with bed mobility. How t o locate the Kardex and determine the staff needed for bed mobility and other ADLS. o Abuse and Neglect (failure to provide the proper number of staff for bed mobility could result in neglect). o Fall Prevention Policy This in-service will include reporting to the charge nurse immediately if a resident suffers a fall, has an accident, or is found on the floor or if CNA must assist a resident to the floor. If the charge nurse is not available, staff will report to the DON immediately. o Safe Handling- the resident will be positioned in the center of bed prior to be turned for care. The other staff member will be positioned on the other side of the bed to prevent the resident from rolling off the bed. o Notification of change in condition- if a resident reports pain or suspected injury, the charge nurse, DON, and/or Physician will be notified. As of 9/30/24 head to toe skin assessments were initiated on all residents in the facility by the DON/ADON/Tx Nurse for any injuries and/or fractures. No additional issues were found. Completion date will be 10/1/24. On 9/30/24, all residents in the facility were assessed and evaluated for assistance with bed mobility by the DON/ADON and Director of Rehab. On 9/30/24, all resident care plans were reviewed for accuracy of assistance needed for bed mobility by Regional Compliance Nurse, DON, and ADON. No issues were identified. The medical director was notified of the immediate jeopardy on 9/30/24 by the Administrator. Ad hoc QAPI was held with the Medical Director and facility interdisciplinary team on 9/30/24 to discuss the immediate jeopardy and subsequent plan of removal. In-services: The DON and ADON then initiated in-servicing all nursing staff on the following topics below as of 9/30/24. All staff not present will not be allowed to assume their duties until in-serviced.?All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to start of their assignment. o Following the Kardex in Point Click Care for required assistance with bed mobility. How to locate the Kardex and determine the staff needed for bed mobility and other ADLS. o Abuse and Neglect (failure to provide the proper number of staff for ADLs could result in neglect). o Fall Prevention Policy This in-service will include reporting to the charge nurse immediately if a resident suffers a fall, has an accident, or is found on the floor or if CNA must assist a resident to the floor. If the charge nurse is not available, staff will report to the DON immediately. o Safe Handling- the resident will be positioned in the center of bed prior to be turned. The other staff member will be positioned on the other side of the bed to prevent the resident from rolling off the bed. o Notification of change in condition- if a resident reports pain or suspected injury, the charge nurse, DON, and/or Physician will be notified. On 10/1/24 a monitoring visit was conducted to ensure the facility was following its POR. The visit revealed: Record review of Resident #1's skin assessment performed by the DON on 9/30/24 at 3:18pm, indicated bruising was found on the R hand, L hand, and R 1st and 2nd toe. Resident #1 had a healed incision to her L and R knee, a rash under both breasts, and an abrasion to the L and R thigh. Record review of Resident #1's bed rail assessment performed by the DON on 9/30/24 at 4:10pm, indicated bilateral 1/3 rails would be used for turning side to side and holding herself to one side. Record review of Resident #1's bed rail consent from the [family member] on 9/30/24 at 4:11pm, indicated it was for bilateral 1/3 partial rails. Record review of in-services dated 9/30/24 given to the ADM by the Regional Compliance Nurse, reflected Notification of Fall/Injury to Regional Compliance Nurse: To ensure she reaches out to the Compliance Nurse to go over falls/injuries to ensure policies/procedures are being followed accurately and timely, Following the Kardex in [EMR system] for Required Assistance with Bed Mobility, How to Locate the Kardex and Determine Staff Needed for Bed Mobility and Other ADLs, ANE, Fall Prevention Policy, Safe Handling, and Notification of Change in Condition. Record review of in-services dated 9/30/24 given to the DON by the Regional Compliance Nurse, reflected Notification of Fall/Injury to Regional Compliance Nurse: To ensure she reaches out to the Compliance Nurse to go over falls/injuries to ensure policies/procedures are being followed accurately and timely, Following the Kardex in [EMR] for Required Assistance with Bed Mobility, How to Locate the Kardex and Determine Staff Needed for Bed Mobility and Other ADLs, ANE, Fall Prevention Policy, Safe Handling, and Notification of Change in Condition. Record review of in-services dated 9/30/24 given to CNA A by the DON reflected, Following the Kardex, ANE, Fall Prevention Policy, Safe Handling, and Notification of Change. Record review of head-to-toe skin assessments dated 9/30/24 performed by the DON/ADON/Treatment Nurse, reflected all 87 resident assessments were completed on 10/1/24. 2 residents were found with new skin issues. 1 resident had new skin tears to Bil knees and R shin. The other resident had new rashes to her lower back and the back of her Bil knees. Record review of assistance with bed mobility dated 9/30/24 assessed by the DON/ADON and Director of Rehab, reflected no new residents were found with mobility concerns, and no changes needed to occur with the current mobility of residents. Record review of care plans dated 9/30/24 assessed by the Regional Compliance Nurse, DON, and ADON, reflected no issues found with any care plans. Record review revealed the Medical Director was notified of the IJ on 9/30/24 by the ADM. Record review of the Ad Hoc QAPI meeting dated 9/30/24 reflected the Medical Director, ADM, DON, ADON, SW, Dietary Manager, Activities Director, Maintenance Supervisor, Director of Rehab, and all other appropriate members were in attendance. Record review of in-services dated 9/30/24 to all nursing staff, reflected the Kardex, ANE, Fall Prevention, Safe Handling, and Notification of Change in Condition. As of 9:30am on 10/1/24 100% of the nursing staff had completed in-services either in person or over the phone. During an interview on 10/1/24 at 11:39am with the ADM, she said she received in-services on ANE, Reporting, Kardex, Fall Prevention, Safe Handling, and COC. She received in-services on what COC means. She received in-services on ANE and the different types of abuse which were: physical, mental, sexual, and misappropriation. She said if she were to see any ANE she investigated, suspended the staff member, and reported to her superiors. She said the Kardex was the resident's plan of Care and had their mobility, assistance, skin issues, and diets on it. The ADM said she was in-serviced on falls and interventions like, fall mats and non-slip footwear. Safe handling was also in-serviced which was 2 person transfers, pulling the resident towards yourself when changing. COC was vomiting, coffee ground emesis, blood in the stool, or change in mobility. If the ADM were to see a COC, she would notify the DON. During an interview on 10/1/24 at 11:32am with the DON she said she received in-services on mechanical lift transfers, and gait belt transfers, ANE and the different types like, physical, mental, misappropriation, neglect, and sexual. She said if she were to see any ANE she would report to the Abuse Coordinator (ADM). She received in-services on how to use the Kardex and what was on it like, mobility, fall prevention, and ADLs. She also was in-serviced on fall prevention and who to notify and Safe Patient Handling, which was having 1 person on each side of the bed and centering the resident in the bed. COC in-services were also given which could be pain, injury, bruises, or anything changed from baseline. If there was a COC staff were to notify the Charge Nurse or herself. During an interview on 10/1/24 at12:42pm with CNA A she said she received in-services on notification of changes, the Kardex, mechanical lifts, ANE, Fall Prevention, and Safe Handling. She said safe handling was positioning the resident in the center of the bed and having 1 person on each side of the bed when changing a resident. She said the Kardex had toileting, and information you need to take care of the resident like, transferring. She said the different types of ANE were physical, mental, and sexual. She said she would report to the ADM (Abuse Coordinator). She said if a resident was falling and was guided to the floor, it was still a fall. CNA A said she would report to a fall to the Charge Nurse, and if she was not available then the DON. During an interview on 10/1/24 at 10:02am with CNA F she said she received in-services on mechanical lifts, who to call when there was a fall, following the Kardex, abuse/neglect, safety handling, and fall prevention. She said the different types of ANE were physical, mental, sexual, and misappropriation. If she were to witness any she would report to the DON/ADM (Abuse Coordinator). She said safe handling was always having 2 people to assist the resident if they required it and having the resident in the center of the bed during care. She said she would report a fall/COC to the Charge Nurse/DON. CNA F said the Kardex had the resident's diet, how many staff members it took to transfer/take care of the resident, and any information needed to take care of a resident. During an interview on 10/1/24 at 10:10am with CNA G she said she had in-services on fall prevention, transfers, ANE, 2-person transfers, positioning, notification of change, safe handling, and the Kardex. She said the Kardex had information on how to transfer residents or if they were a 2-person assist, their mobility, how to take care of them, and their ADLs. She said the different types of ANE were verbal, physical, mental, misappropriation, and isolation. She would report to the ADM (Abuse Coordinator) if she ever saw any. CNA G said she would report a fall to the Charge Nurse immediately or the DON. She said safe handling was ensuring the resident was positioned properly in bed, ensuring the resident was centered in bed, pulling the resident towards you before turning, and making sure there was a second person to help. If she noticed a COC, she would notify the Charge Nurse. During an interview on 10/1/24 at 10:22am with CNA H she said she received in-services on gait belts, transferring, mechanical lifts, fall prevention, COC, who to report to, Kardex, ANE, and safe handling. She said the Kardex had information about if the resident required 2 person transfers, their mobility, diet, and how to take care of the resident. She said the different types of ANE were physical, verbal, sexual, seclusion, and misappropriation. If she were ever to see any ANE she would report to the ADM (Abuse Coordinator). She said safe handling was using 2-persons if needed and positioning the resident correctly in bed. If she saw a COC, she would notify the Charge Nurse or the DON. If she found a resident who had fallen, she would not move the resident, and get the nurse/DON. During an interview on 10/1/24 at 10:30am CNA I said she had in-services on the Kardex, transfers, ANE, reporting falls to the Abuse Coordinator, and safe handling. She said safe handling was positioning the resident in the center of the bed when providing care, pulling them towards you, and having 2 people assist. The Kardex: had information on how many people it took to transfer, how they ate, their mobility, toileting, and ADLs. She said the different types of ANE were physical, mental, exploitation, and neglect. She said she would report to the nurse, ADON, and ADM (Abuse Coordinator) if she were ever to see any ANE. If she saw a fall she would get the nurse, would not move the resident, and would get the DON if the Charge Nurse was not available. She said a COC was something different on the skin, pain, seeing something that was different from baseline, or not eating. She would notify the nurse/DON. During an interview on 10/1/24 at 11:00am CNA J said she received in-services on transfers, mechanical lifts, gait belts, ANE, turning/positioning, 2-person assist, COC, and the Kardex. She said the Kardex had information about how many people were needed for turning/mobility, and ADLs. She said examples of ANE were physical, mental, verbal, sexual, neglect, and misappropriation. If she were to see ANE she would inform the Charge Nurse/ADM (Abuse Coordinator). If she were to witness a fall, she would notify the nurse and would not move the resident because they could have broken bones. She said a guided fall was still a fall. She said safe handling was putting the resident in the middle of the bed, having 2 people, making sure there was enough room to turn the resident, and always using 2 people with mechanical lifts. She said if she noticed a COC, she would notify the Charge Nurse/DON. A COC could be redness, bruising, skin tear, rash, bed sore, or a change in mood. During an interview on 10/1/24 at 11:04am Med Aide K said she had in-services on mechanical lifts, transfers, 2-person assist, safe handling, ANE, the Kardex, and COC. She said safe handling was having 2 people assisting the resident, having the resident in the center of the bed, and having the resident face you when turning them. She said the different types of ANE were physical, verbal, and neglect. If she saw any ANE she would notify the Abuse Coordinator (ADM). The Kardex had information on it like the resident's mobility, their amount of assistance needed, and ADLs. She said a COC could be pain or not urinating and she would notify the Charge Nurse or the DON. During an interview on 10/1/24 at 11:17am CNA L said she had in-services on fall prevention, transferring, person assist, the Kardex, ANE, and safe handling. She said the Kardex had information about the resident's transferring assistance, mobility, and ADLs. She said examples of ANE were physical, mental, verbal, and sexual. If she were to see ANE she would report to the Charge Nurse, the DON, and the Abuse Coordinator (ADM). She said if she had a resident who had fallen, she would notify the nurse and would not move the resident. If the nurse was not available, she would notify the DON. She said safe handling was taking a second person or nurse to change the resident and pulling the resident toward you. A COC could be skin tears, bruising, or anything out of the normal and she would report it to the Charge Nurse and the DON. During an observation on 10/1/24 at 1:46pm Resident #1 was asleep on her back in bed. The bed was in the lowest position and there were bil side rails up on the bed. During an interview on 10/1/24 at 2:00pm LVN B said he had in-services on ANE, transferring residents, mechanical lifts, 1-2 person assists, COC, the Kardex, fall prevention, and safe handling. He said the different types of ANE were physical, verbal, mental, and misappropriation. He said he would report ANE to the Abuse Coordinator (ADM). He said the Kardex was a care plan for each resident, and had transferring, and ADLs on it. He said safe handling was having 1 person on each side of the bed during resident care, positioning yourself and the resident safely, and turning the resident towards yourself if alone. A COC was any change from baseline like, confusion, or agitation. He would notify the MD and perform an SBAR. If a resident were to fall, he would assess the resident on the spot, get vitals, and notify the MD. He said he would start neuro checks if the fall was unwitnessed and continue even when the resident comes back from the hospital. During an interview on 10/1/24 at 2:14pm LVN M said she received in-services on transfers with Hoyer lifts and gait belts, ANE, safe handling, the Kardex, COC, Falls, and ANE. If a resident had a COC, she would notify the DON and the CNAs notify her. If a resident had a fall, she would notify the DON and the ADM. She said examples of ANE were physical, emotional, misappropriation, mental, sexual, neglect and she would report it to the DON and ADM (Abuse Coordinator). She said the Kardex had the resident's transfer status, mobility, and ADLs. She said safe handling was having 1 person on each side of the bed and rolling the resident toward you. During an interview and observation on 10/1/24 at 2:32pm CNA N and CNA F were observed performing incontinence care on a resident who was a 2 person assist. The resident was centered in the bed. CNA F pulled the resident toward her and then turned her toward CNA N. When the resident was clean, the resident was pulled toward CNA N and turned toward CNA F. After the resident was finished, she was centered back in the bed. The CNAs explained the process during the procedure and the resident remained safe the whole time. An Immediate Jeopardy (IJ) was identified on 9/30/24. The IJ template was provided to the facility on [DATE] at 2:46pm. While the Regional Nurse Consultant was notified the IJ was removed on 10/1/24 at 2:50pm, the facility remained out of compliance at a severity of no actual harm with the potential for minimal harm, that is not immediate jeopardy with a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent elopement for two of seven residents (Resident #4 and Resident #5) reviewed for accident hazards and supervision. -The facility failed to ensure Resident #4 had adequate supervision on 4/5/2024 and 4/30/2024 which allowed her to elope from the facility's memory care unit. -The facility failed to ensure Resident #5 had adequate supervision on 4/30/2024 which allowed her to elope from the facility's memory care unit at a different time from Resident #4. -The facility failed to ensure the memory care unit's secured doors remained secured on 4/5/2024 and 4/30/2024 allowing two residents to elope. The noncompliance was identified as PNC and the Administrator was given the I.J. Templae on 8/9/24 at 2:15 p.m. The IJ began on 4/5/2024 and ended on 4/30/2024. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of serious injury or harm. Findings include: Resident #4 Record review of Resident #4's face sheet revealed an [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included lack of coordination, dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), malnutrition (a condition that occurs when a person's intake of energy and nutrients is deficient, excessive, or imbalanced), anxiety disorder (mental health conditions that cause excessive fear, worry, and other feelings of dread and uneasiness), TIA (medical emergency that occurs when blood flow to the brain is temporarily disrupted, causing a lack of oxygen to the brain), difficulty walking, restlessness and agitation, and adjustment disorder (condition in which a person has an unhealthy or excessive emotional or behavioral reaction to a stressful event or life change within three months of it happening). Record review of Resident #4's admission MDS dated [DATE] with an ARD of 4/14/2024 revealed a BIMS score of 8 indicating significant cognitive impairment. The MDS documented she had no potential indicators of psychosis, behaviors affecting others, or rejection of care. Per the MDS, Resident #4 had wandering behaviors daily during the review period. The MDS revealed she had an impairment of one lower extremity, and she used a walker for mobility. The MDS documented she required supervision or assistance with all ADL's except eating. Per the MDS, Resident #4 received OT services. Record review of Resident #4's care plan dated 4/18/2024 revealed a focus on her admission to the secure unit due to her dementia diagnosis and elopement risk with interventions including monitoring for possible off unit activities, monitoring for signs of depression, and monitoring and reporting any changes of condition. The care plan documented a focus on her risk of wandering with interventions including distraction from wandering, monitoring and identifying a pattern of wandering, remaining with her when she was exit-seeking, providing her with structured activities, and ensuring she remained on the secure unit. The care plan included a focus on her previous attempts to exit the facility with interventions including assessing and reporting factors leading to her elopement, close supervision, providing structured activities, and remaining with her if she was exit-seeking. Per the care plan, she was found outside the facility and returned with no injuries. Record review of Resident #4's nurse's note dated 4/5/2024 revealed she had been found outside the facility on the street leading away from the facility at approximately 7:45 PM. The note documented she was provided with food and water, and she was assessed. Per the note, Resident #4 said she was looking for her family member but was unable to find her. Record review of the facility's Provider Investigation Report (PIR) dated 4/12/2024 for Intake ID 495508 revealed Resident #4 had eloped from the facility shortly after 6:00 PM on 4/5/2024. The PIR documented the nurse on duty had last had contact with Resident at approximately 6:00 PM on 4/5/2024. Per the PIR, at approximately 7:45 PM on 4/5/2024 a staff member from an adjacent business called the facility and reported Resident #4 had been found walking on the street near the facility, walking towards a major thoroughfare. The PIR revealed the staff member from the adjacent business was able to coax Resident #4 into the staff member's car and bring her back to the facility. The report documented the facility had an outside vendor and staff ensure all doors were working properly after the incident. Interview on 8/9/2024 at 2:14 PM with the Admin, who said her expectations for a resident elopement were that staff would complete an internal and external search of the facility and call a code orange. The Admin said she expected that staff would search further from the facility to the major thoroughfare approximately a half mile away. The Admin said she expected that when staff heard a door alarm sound the staff would immediately go to the door, visually assess the outdoor area near the door, ensure no one exited the facility, inform the charge nurse, and the charge nurse would complete a headcount. The Admin said during a power outage, all staff were required to go to a specific door until the power returned or the backup generator provided power to the doors, and they were manually reset. The Admin said the plastic covers were installed over the emergency door release buttons near the two nurses' station after the incidents in April, the emergency door release button cover had been installed on the emergency door release in the memory care unit prior to her onboarding, the facility had one reset button for all the doors near the nurse's station on the skilled nursing side of the building and would be installing another one near the nurses' station on the long term care side so staff could reset from each side of the facility. Record review of Resident #4's nurse's note dated 4/30/2024 revealed that the staff was unable to find her on the hall or other halls at approximately 8:46 PM. The note documented the DON at the time was notified that Resident #4 was missing. Record review of Resident #4's behavior note dated 5/20/2024 revealed she was exit-seeking. The note documented she said she wanted to leave, and the facility was holding her against her will. Per the note, Resident #4 picked up a trash can, hit the window with the can, pulled a staff member's hair, and punched a staff member. Record review of Resident #4's nursing note dated 7/19/2024 revealed she was pounding on the door in the secure unit attempting to leave. Record review of Resident #4's elopement risk assessment dated [DATE] revealed she was an elopement risk. Record review of Resident #4's elopement risk assessment dated [DATE] revealed she was an elopement risk. Record review of Resident #4's elopement risk assessment dated [DATE] revealed she was an elopement risk. Observation on 7/5/2024 at 2:35 PM revealed Resident #4 was in the activity room of the memory care unit engaged with other residents. Observation on 8/9/2024 at 9:54 AM revealed Resident #4 was in her bed sleeping. Resident #4 appeared dressed and appropriately groomed. Resident #5 Record review of Resident #5's face sheet dated 7/5/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included encephalopathy (any disease, disorder, or damage that affects the structure or function of the brain), epilepsy (chronic neurological disorder of the brain that causes people to have recurrent, unprovoked seizures more than twenty-four hours apart), difficulty walking, dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), brief psychotic disorder (psychotic condition that begins suddenly and lasts for at least one day but less than one month), generalized anxiety disorder (mental health condition that causes excessive, persistent, and unrealistic worry about everyday events and situations), adjustment disorder (condition that occurs when an individual has an emotional or behavioral reaction to a stressful event or life change that is considered unhealthy or excessive), and kidney failure (occurs when the kidneys are unable to function properly and remove waste and extra water from the blood, or maintain the body's chemical balance). Record review of Resident #5's quarterly MDS dated [DATE] with an ARD of 4/22/2024 revealed no BIMS was completed as she was unable to complete the interview. The MDS documented she had inattention and disorganized thinking. Per the MDS, Resident #5 had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering behaviors. The MDS revealed she had no impairments of her upper or lower extremities, and she used a walker for mobility. The MDS documented she required supervision or assistance with all ADL's except eating. The MDS revealed she received OT services. Record review of Resident #5's care plan dated 4/1/2024 revealed a focus on her risk of wandering with interventions including a fall risk assessment, distracting her form wandering, identifying a pattern of wandering, remaining with her when she was exit-seeking, and providing her with structured activities. The care plan documented a focus on her elopement risk with interventions including ensuring she resided on the secure unit, assessing for potential elopement causes, providing structured activities, and distracting her. Per the care plan she was found out of the secured unit and returned on an unknown date. Record review of Resident #5's nurse's note dated 4/30/2024 at 9:04 PM revealed a CNA could not locate her on the secure unit. The note documented she was not found on the secure or other units. Per the note, the DON at the time was notified Resident #5 could not be located. Record review of the facility's Provider Investigation Report (PIR) dated 5/9/2024 for Intake ID 501268 revealed Resident #4 and Resident #5 had eloped from the facility on 4/30/2024 sometime before the dinner service. The PIR documented a CNA had searched the memory care unit for the residents and was unable to locate them prior to dinner service. Per the PIR, the CNA informed the nurse the residents were missing. The PIR revealed that at 6:38 PM the residents were located, returned to the facility, assessed, and no injuries were identified. The PIR revealed the facility placed plastic covers over the door release buttons throughout the facility and no further elopements had occurred after that time. Interview on 8/9/2024 at 2:14 PM with the Admin, who said her expectations for a resident elopement were that staff would complete an internal and external search of the facility and call a code orange. The Admin said she expected that staff would search further from the facility to the major thoroughfare approximately a half mile away. The Admin said she expected that when staff heard a door alarm sound the staff would immediately go to the door, visually assess the outdoor area near the door, ensure no one exited the facility, inform the charge nurse, and the charge nurse would complete a headcount. The Admin said during a power outage, all staff were required to go to a specific door until the power returned or the backup generator provided power to the doors, and they were manually reset. The Admin said the plastic covers were installed over the emergency door release buttons near the two nurses' station after the incidents in April, the emergency door release button cover had been installed on the emergency door release in the memory care unit prior to her onboarding, the facility had one reset button for all the doors near the nurse's station on the skilled nursing side of the building and would be installing another one near the nurses' station on the long term care side so staff could reset from each side of the facility. Record review of Resident #5's elopement risk assessment dated [DATE] revealed she was an elopement risk. Record review of Resident #5's elopement risk assessment dated [DATE] revealed she was an elopement risk. Observation on 7/5/2024 at 2:36 PM revealed Resident #5 was in the activity room with other residents and engaged. Observation on 8/9/2024 revealed Resident #5 was walking in the hall. Resident #5 appeared dressed and appropriately groomed. Observation on 7/5/2024 at 12:49 PM revealed a doorbell had to be pressed to enter the facility. The door was locked and there was keypad near the door to open it. A sign was on the door with a telephone number to call if no one answered the door. Observation on 7/5/2024 at 1:19 PM revealed the exterior doors on the 300 and 600 halls were locked and unable to be opened without using the push bar. The doors had a keypad near them to allow exit. Both doors had a sign that said an alarm would sound if they were opened without the code. Observation on 7/5/2024 at 1:24 revealed the door to the interior courtyard was unlocked and able to be opened. The courtyard was surrounded on all sides by the facility. There were three exits to the courtyard from the facility, but no exit to the exterior of the facility. Video cameras were observed on the courtyard. There was no manner to exit the courtyard to the exterior of the facility. Observation on 7/5/2024 at 1:26 PM revealed the memory care unit was secured with a keypad to enter and exit. On the memory care unit were two CNA's, a nurse, and a hospitality aid. There was an emergency exit at the end of the memory care unit hall, but the door was locked and unable to be opened. The door had a push bar and an alarm if opened. Interview on 7/5/2024 at 2:02 PM with the DON, who said the facility did not have a policy specific to rounding. The DON said the facility's elopement risk residents were on the secure unit. Interview on 7/5/2024 at 4:08 PM with CNA A, who said she had been employed for three years. CNA A said her primary duties as a CNA were to ensure the residents were groomed, showered, and provided with incontinence care, making the beds, and supervising the residents. CNA A said she completed her rounds hourly most times, but at least every two hours. CNA A said there was no specific policy related to rounds, but the expected practice was to complete rounds at least every two hours. CNA A said when she completed rounds, she checked the residents to determine if they required incontinence care, looked to make sure no residents had fallen, and made sure all the residents were on the hall. CNA A said the staff were required to complete a headcount every fifteen minutes on the secure unit. CNA A said after completing the head count, the staff had to sign that it was completed. CNA A said the DON kept the documentation for the headcounts. CNA A said the facility had completed the headcounts since she had been employed. CNA A said she was not present when Resident #4 eloped on 4/5/2024, when Resident #4 and Resident #5 eloped on 4/30/2024. CNA A said the residents may have eloped through the door from the memory care unit to the rest of the facility if it was not closed completely, but she did not know for sure as she was not at the facility for any of those elopements. CNA A said if a resident eloped the staff were trained to inform the nurse immediately and then begin searching for the resident. CNA A said she did not recall the most recent date the facility provided in-service training related to elopement risk of residents. CNA A the staff were to redirect or distract Resident #4 and Resident #5 if they were near the door to the memory care unit. CNA A said she did not know of any other elopements between 4/1/2024 and 7/5/2024. CNA A said she was required to provide written statements for incidents at the facility including elopements, falls, and other injuries. CNA A said she had never been asked to provide a false statement for any incident by the facility. CNA A said the facility was well prepared to mitigate elopement behaviors on the memory care unit as the door was locked and there were three staff for the unit. CNA A said there were two CNA's and one hospitality staff assigned to the unit daily. Interview on 7/5/2024 at 4:22 PM with RN B, who said that was her first shift on the memory care unit and she had been employed by the facility for one week. RN B said CNA's were expected to complete rounds at least every two hours, and more often when needed. RN B said the CNA's were expected to ensure the residents did not require incontinence care, were present, and not walking into other residents' rooms. RN B said the CNA's were expected to be out on the floor with the residents as often as was possible. RN B said if a resident was identified as missing, the staff were to look through the hall, in the resident rooms, the closets, and the restrooms. RN B said if the resident could not be located on the hall, the staff throughout the facility would begin searching for the resident, staff would begin searching the grounds of the facility, the DON and law enforcement would be notified, and staff would begin searching the areas near the facility both on foot and in cars. RN B said since she had been at the facility there had not been any elopements she was aware of. RN B said nurses also completed their rounds every two hours and ensured all residents were accounted for. Interview on 7/5/2024 at 4:40 PM with RN C, who said she had worked at the facility for six years. RN C said her primary duties included acting as the charge nurse, ensuring all residents were rounded on, ensuring the CNA's knew the plan of care for the residents, charting, administering medications, providing G-tube care and medications, providing the injected medications to all residents, and ensuring all residents at the facility were safe and properly cared for. RN C said the CNA's were expected to round every two hours. RN C said during the CNA rounds, they were expected to ensure the resident's safety, determine if any residents required incontinence care, ensured all residents had water near them, and ensured the residents were accounted for. RN C said if a resident was determined to be missing, CNA's were expected to notify the nurse and the staff would check the hall. RN C said if the resident was not located on the hall, all the staff would look for the resident on all the halls and the grounds of the facility. RN C said because of the alarms on all the doors of the facility, residents should not be able to elope out of the facility, but they may follow a family out when the family left. RN C said the door alarms had not worked in the past. RN C said when the door alarms did not work the staff would conduct fifteen-minute rounds to ensure all residents were accounted for and log the rounds. RN C said the most recent time the doors were not working was after the inclement weather that interrupted electricity in Houston. Interview on 7/5/2024 at 5:11 PM with the DON, who said she had been employed since 6/17/2024, had been employed prior to that time as well, but not been employed by the facility during the month of April 2024. The DON said the steps taken to ensure residents are unable to elope included securing the doors, reinforcing the lock on the gate of the memory care unit's exterior area, and updating the locks on the doors to not disengage with power outages. The DON said there had been no elopements at the facility since her return on 6/17/2024. The DON said Resident #4 and Resident #5 may have exited by following a visitor out of the memory care unit, but she was unsure how those elopements occurred. The DON said the codes to enter the building and the memory care unit have been recently updated to ensure visitors do not know the codes and cannot accidentally allow residents to leave. The DON said she expected CNA's and nurses to round at least every two hours. The DON said she was unsure if staff in the memory care unit completed headcounts every fifteen minutes. The DON said the facility had taken steps to ensure elopements did not occur including monitoring the doors, monitoring when visitors entered and exited the memory care unit, and redirecting residents away from the doors at all times. The DON said some of the memory care unit residents ate in the dining hall with other residents, but at least one CNA and one hospitality aide monitored them when they were not in the memory care unit. Interview on 7/5/2024 at 5:45 PM with the Admin, who said her primary duties were to manage the overall operation of the facility. The Admin said on 4/5/2024 Resident #4 went to the business in the building behind the facility. The Admin said the secretary for the other business called the facility and a nurse brought Resident #4 back to the facility. The Admin said she was unsure how Resident #4 got out of the facility, but she believed it was by staff or a resident accidentally pressing an emergency door release button on the wall throughout the facility which released all the doors allowing her to elope. The Admin said when one of the emergency release buttons is pressed all the doors in the facility are released. The Admin said Resident #4 was found in the roundabout leading from the facility to a major thoroughfare and by a hospital parking lot. The Admin said Resident #4 often wants to go home but she cannot due to her diagnoses and needs. The Admin said Resident #4 must have been walking quickly to be found at the roundabout. The Admin said she was unsure how long Resident #4 was out of the facility on 4/5/2024. The Admin said 4/5/2024 was Resident #4's first day at the facility. The Admin said after the incident, all residents were assessed for an elopement risk, and Resident #4 was provided with increased supervision. The Admin said on 4/30/2024 Resident #4 and Resident #5 were able to elope from the facility. The Admin said she was unsure how the residents were able to exit through the backdoor of the memory care unit and through the normally locked gate. The Admin said the gate could not be unlocked by a resident. The Admin said the gate may have been unlocked by the lawncare agency contracted with the facility. The Admin said since the incidents on 4/5/2024 and 4/30/2024 the facility had the alarm contractor review the facility's needs and risks. The Admin said the release buttons had a protective cover placed over them to ensure no accidental releases occurred. The Admin said the facility was also installing a reset button to automatically relock any doors opened with the emergency release buttons. The Admin said if the power goes out in the facility the doors automatically release and have to be reset. The Admin said the staff have been provided training to ensure that any time the electricity was to go out the staff immediately check and reset the doors. The Admin said the facility was monitoring the doors weekly to ensure there were no further incidents. The Admin said the facility had also added a third staff to the memory care unit which now consisted of two CNA's, a hospitality aide, and a nurse. The Admin said there had been no other concerns in the memory care unit since that time. Interview on 8/8/2024 at 11:09 AM with the Maintenance Director, who said he had been employed for four years. The Maintenance Director said his primary duties included overall facility maintenance of any needs and repairs for the facility. The Maintenance Director said the residents had eloped on 4/5/2024 and 4/30/2024 by following staff and/or visitors out of the memory care unit. The Maintenance Director said on 4/05/2024 Resident #4 eloped from the facility through the back door of the memory care unit. The Maintenance Director said the back door may not have been secured when Resident #4 eloped on 4/5/2024 because when the facility's power surges or goes out the doors disengage. The Maintenance Director said when that occurred staff had to reset the doors. The Maintenance Director said when the facility's generator was engaged due to lack of power the doors disengage and the staff have to reset the system. The Maintenance Director said the facility had the same system currently, but staff were provided with an in-service training related to resetting and checking all exit doors in the event of a power outage or surge. The Maintenance Director said the cover over the emergency door release button had been in place in the memory care unit since it was converted from long term care to memory care multiple years ago. The Maintenance Director said the covers over the other two emergency door release buttons were installed in May of 2024. The Maintenance Director said the emergency door release button could have been the cause of the elopements if someone had accidentally pressed the button. The Maintenance Director said he assisted in presenting the in-service trainings. The Maintenance Director said to his knowledge all staff have received the training. The Maintenance Director said he did not know how long the residents were outside the facility on 4/5/2024 or 4/30/2024. The Maintenance Director said he had made adjustments to the doors to increase the speed at which they close and relock if the release bar is pressed. The Maintenance Director said there had been no more elopements since the door adjustments and cover over the emergency door release buttons were installed. Interview on 8/8/2024 at 1:11 PM with LVN D, she said she had been employed since April 2024 and worked primarily on the memory care unit. LVN D said she was not in the building when Residents #4 and #5 eloped on 4/30/2024. LVN D said she was informed that two residents were able to elope. LVN D said since that time the facility had routine meetings and in-service related to resident supervision and elopements. LVN D said the facility had conducted rounds every fifteen minutes on the secure unit until 8/5/2024. LVN D said the staff in the memory care unit completed two security checks on the front and back doors of the unit each shift. LVN D said the staff were alert for any alarm sounds indicating a door on the memory care unit had become unlocked. LVN D said all the facility's staff were trained where to go if the power went out during a shift. LVN D said she was trained that if power went out the facility's doors became unlocked. LVN D said the staff were trained to go to the doors and secure them to ensure residents did not exit, and nurses would conduct a head count to ensure no residents were unaccounted for, and additional staff would monitor the outdoor area of the facility to ensure no residents had left when the power was out. LVN D said since 4/30/2024 no residents had eloped, and the facility was secure at all times. LVN D said during in-service trainings related to elopement, he was trained that if the power went out or there was a power surge at the facility staff were immediately to go to the doors, nurses were expected to complete a headcount, and staff that reached the doors first were to complete visual inspection of the area around the door to ensure no residents had eloped prior to the staff reaching the doors. LVN D said the staff had to demonstrate their understanding of the information to the DON. LVN D said the doors had an alarm which would chirp if the doors became unlocked. LVN D said if the staff heard a door alarm sound or chirp, the staff were to go to the door immediately, complete a visual assessment of the area around the door to ensure no residents had eloped, and reset the alarm. LVN D said the staff were also expected to attempt to identify any residents or visitors who may have caused the alarm to sound so they could be reeducated on the door alarms. Interview on 8/9/2024 at 1:20 PM with CNA E, who said she had been employed for one year. CNA E said her primary duties included assisting residents with ADL's and everyday care. CNA E said she typically work on all halls, and did not have a specific hall she was assigned to. CNA E said would assist in the memory care unit, but it was not her typical assignment. CNA E said when she worked in the memory care unit she was expected to supervise the residents and ensure they did not get out of the secured doors from the unit. CNA E said she had recently received in-service training related to resident abuse, neglect, and exploitation, and resident elopements. CNA E said during the resident elopement in-service training she was informed that if a door alarm sounded in the facility, all CNA staff went to a door and stood by it until the all clear was called and the system was reset. CNA E said she was also informed that if the power went out at the facility the doors unlocked. CNA E said during the in-service training she was instructed that if there was a power outage at the facility the CNA's were to go to all the doors and gates of the facility until the all clear was sounded and the door locks were reset with the return of power or the backup generator and someone pressed the reset button. CNA E said the nurses completed a headcount while the CNA's remained by the doors. CNA E said if a specific door alarm sounded staff went to that door, went outside the door and conducted a visual assessment of the area around the door to ensure there were no residents outside . CNA E said she was not present when Residents #4 and #5 had eloped in April of 2024, but she was informed it occurred. CNA E said since the residents were able to elope in April of 2024, the facility had installed plastic covers over the emergency door release buttons near the two nurses' stations. CNA E said there had been a cover over the emergency release button in the memory care unit since she had been employed. Interview on 8/9/2024 at 1:27 PM with LVN F, who said she had been employed for seven years. LVN F said her primary duties included medication administration, monitoring the residents, g-tube care, monitoring residents for any changes of condition, and making notifications of resident needs to the physicians and families. LVN F said she primarily worked on the 200-Hall and 300-Hall. LVN F said she had recent in-service training related to resident abuse, neglect, and exploitation, rounding, and resident elopements. LVN F said during the elopement in-service trainings she was instructed that if a resident was determined to be missing staff were to visually observe all residents, conduct head counts, and check the perimeter of the facility for the resident. LVN F said she was also informed that if the facility lost power for any reason the doors unlocked. LVN F said during the in-service training staff were informed that the CNA's were each assigned to a specific door to ensure no residents could elope. LVN F said another staff was assigned to press the reset button to reset the doors when the power was restored or if the backup generator was providing power. LVN F said she was trained that if the facility's power flickered staff must check each door and ensure no residents had eloped. LVN F said the staff were to complete a visual assessment outside the door to ensure there were no residents outside. LVN F said if staff heard a door alarm sound, the staff were instructed to assess the exterior near the door, complete a headcount, and monitor the door until it was reset. LVN F said if staff could not locate a resident the staff called a code orange. LVN F said the nurses completed a head count, the CNA's searched each room, restroom, closet, shower room, or other area accessible to residents, and additional staff searched the exterior of the facility to a perimeter of approximately one mile. Interview on 8/9/2024 at 1:36 PM with CNA G, who said she had been employed for one year. CNA [TRUNCATED]

Based on record review and interview, the facility failed to immediately consult with resident physician and notify the resident representative when there was a significant change in the resident's physical or mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 17 residents (CR#1) reviewed for notification of change. The facility failed to notify CR#1's physician when she had an unwitnessed fall sustaining an injury and bleeding from her head. The facility failed to notify CR#1's representative party (RP) when CR#1 had an unwitnessed fall sustaining an injury and bleeding from her head. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:00 p.m. The IJ template was provided to the facility at that time. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures place residents at risk of delayed treatment causing additional injury, pain, and death. Findings include: Record review of CR#1's face sheet dated [DATE] revealed that she was a [AGE] year-old female that was originally admitted to facility on [DATE]. She had the diagnoses of Alzheimer's Disease, Cellulitis of lower left limb, repeated falls, hypertension, Major Depressive disorder, anxiety disorder, and insomnia. Record review of CR#1's Quarterly MDS assessment, dated [DATE] revealed CR#1 could not complete BIMS due to cognitive impairment. MDS completed by staff, which indicated CR#1 had memory problems and was severely impaired cognitively. CR#1 did exhibit behavioral symptoms of wandering and required supervision and two-person physical assist for ADLs. Record review of CR#1 MDS also revealed that code for four was used to signify a significant change in status when CR#1 had a fall. Record review of CR #1's care plan dated [DATE] indicated she had impaired communication, evidenced by: slurred speech, rarely/never understood. Interventions include administer medications as ordered, engage the resident in simple structured activities that avoid overly demanding tasks. CR#1 was also care planned for falls. Interventions to prevent falls was for CR#1 to wear appropriate footwear, helmet and walk on even flooring. Record review of CR#1's nurses note dated [DATE] written by RN A read in part, Resident was found by CNA at 4:47am to have sustained a small gash or laceration to her right upper brow. She was awake and alert. Wound was cleaned and dressed, resident medicated for pain and continued anxiety. BP ,d+[DATE], HR 106. Resident is resting quietly in bed now. Record review of CR#1's hospital record dated [DATE] revealed that CR#1 was examined in the emergency room and was found to have crepitus (friction between bone and cartilage or fractured bone) in the left face and neck and arms, chest and abdomen. The patient had left pneumothorax (air leaks into space between lungs and chest wall- caused by blunt or penetrating chest injury or lung disease), pneumomediastinum (air is present in the mediastinum-caused by trauma) left sided pneumoperitoneum (air or gas in abdominal cavity), subcutaneous emphysema rib fracture (emphysema caused by injury). In recored review of CR#1 nurses note dated [DATE] revealed that CR# 1 was sent to the hospital because of swelling to her face and neck. The facility nursing staff did notify all pertinent parties and they were given orders to give CR#1 Benadryl and to send CR#1 to the Hospital for further evaluation. In an interview on [DATE] at 5:05pm with CR #1's responsible party, she said she was not notified the CR#1 had an injury on [DATE]. The RP indicated she was not made aware of the incident until [DATE]. In an interview on [DATE] at 8:25am with CNA A, she said that CR#1 was in her room on the fall mat bleeding from her head. CNA A said that RN A was notified, and RN A assessed and cleaned CR#1's laceration and CR#1 was put back in bed. In an interview on [DATE] at 6:01pm RN A said she was notified by staff that CR#1 was in her room on the floor. RN A said she went into CR#1's room, and she noticed that CR#1 had an injury to her right upper eyebrow. RN A said that she cleaned and dressed the injury. RN A said that she administered 0.5ml of morphine to CR#1 for pain. RN A said that she took CR#1's vital signs and performed neuro checks on CR#1. RN A said that she sent a text message to the facility phone informing administration of CR#1's fall. She said that she did not know that she had to call the DON, RP, and the NP. Record review of CR#1's clinical file on [DATE] revealed that neuro checks had not been conducted on CR#1. Also, during this review it revealed that RN A did not notify the facility's DON, Administrator, NP, nor did she notify CR#1's RP. Neuro checks should have been conducted after the resident had fallen and the checks should have been done every 15min to 30min or as necessary until the resident was sent out to the hospital. In an interview on [DATE] at 6:32pm with DON she said she was not aware of CR#1 had an injury on [DATE]. The DON said that she did not receive a call from RN A on [DATE] that an injury had occurred involving CR#1. The DON said that RN A did not follow facility policy of notifying pertinent parties of injuries involving residents. The DON said that RN A should have called the DON, Administrator, NP, and the RP. The DON said the nurses are to report any issues that occurred over their shift or the previous shift during the morning meeting. She said without notifying the pertinent parties, it did not give them the chance to intervene or assist with the residents' care. Record review the facility policy titled Notifying the Physician of Change in status dated [DATE], states that the Nursing staff should call the DON, Administrator, NP, and the RP when there is a change in condition regarding a resident. And if the Physician does not return the call within a reasonable time the Nurse should call the Physician a second time. If still there is no response from the Physician, the nurse must contact the Medical Director and if it is and emergency the Nurse should call an ambulance service. The Nurse then must document this in the resident clinical records and the Nurse reports any issues that occurred over their shift to the oncoming shift. In an interview on [DATE] at 9:56am with the facility's NP she said she was not notified that CR#1 had an injury to her head on [DATE]. She said that if she had been notified, she would have given RN A an order to perform neuro checks and to have CR#1 transported to the hospital for further evaluation. Record review of the facility's policy regarding to Change in Status date ,d+[DATE] read in part, The facility utilizes the INTERACT tool, Change in Condition-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's condition requires immediate notification of the physician or non-immediate/Report on the Next Workday notification of the physician. Record review of CR#1 progress note dated [DATE] after another fall regarding CR#1revealed that the facility's Medical Director noted that he explained to CR#1 Power of Attorney, that if CR#1 continues to have multiple falls at this rate, she will likely suffer a significant trauma and death. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:00 p.m. The IJ template was provided to the facility at that time. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. The Plan of Removal was accepted on [DATE]. Record review of In-Service training attendance roster dated [DATE] revealed that RN A was in serviced on the following Abuse Neglect, Incident Reporting, Change in Condition, Event Notification, 72-hour report, How to notify Director of Nursing, Doctor, Responsible party, and Neuro Checks. Immediate Actions: o o As of [DATE] resident CR#1 was transferred to the hospital for evaluation. o o RN-A was provided 1 on 1 education by Assistant Director of Nursing (ADON) on [DATE] and again by the DON on [DATE] regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Facility Plan to ensure compliance: o o Abuse & Neglect policy was reviewed and in-serviced on [DATE], the Compliance Nurse provided in-service with DON and ADON. DON/ADON will in-service Charge Nurses to ensure compliance for this policy and procedure. Will be in-serviced as needed thereafter. o o Compliance Nurse in-serviced DON and ADON's on Event note completion and Neuro check policy [DATE]. DON/ADON in-serviced Charge Nurses on neuro checks(neuro checks are to be initiated if a resident hits their head or had an un-witnessed fall) and Event note completion. In-services will be completed for the next 3 months, then as needed thereafter. o o Notifying Physician on change in status policy that includes falls with head injury or other serious o injury was reviewed & in-serviced on [DATE], the Compliance Nurse in-serviced DON and ADON. The DON/ADON in-serviced Charge Nurses to ensure .compliance for this policy & procedure. In-services will be completed for the next 3 months, then as needed thereafter. The Regional Compliance Nurse visited the facility [DATE] to review all audits and provide additional training as needed regarding Abuse & Neglect, Neuro checks, Notifying Physician on change in status, and process of reporting changes to oncoming shift nurses. The Administrator also received in-service training on these topics on [DATE]. Audits completed: Event (incident) notes for the last 3 months were audited to ensure neuro checks were initiated and completed per policy. Progress notes were audited using Realtime software to ensure all events (incidents) resulting in a gash or laceration had the appropriate follow-up/treatment. o Notifying oncoming Nurse on change on any resident injury or changes that include falls or injury during change of shift report process reviewed, the Compliance Nurse in-serviced DON and ADON. The DON/ADON in-service Charge Nurses to ensure compliance for this policy & procedures In-services will be completed for the next 3 months, then as needed thereafter. o Nurses were in-serviced on notifying the DON of any falls resulting in injury or any other serious injury immediately by the DON/ADON on [DATE]. o All nurses not in-serviced on [DATE] will be in-serviced prior to their next shift. o The Medical Director was notified by the Administrator on [DATE] at 12:46pm on the immediate jeopardy citation. o An AD HOC QAPI meeting was held on [DATE] by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Monitoring: o The DON / designee will monitor Real Time clinical software and/or the PCC Dashboard for clinical alerts for any resident change of condition including falls, head injuries, other serious injuries, or changes of condition 5 days per week (Monday through Friday) to ensure physician/NP were notified. Monitoring began [DATE] and will continue x 4 weeks and weekly thereafter. o The DON and/or designee will monitor fall events 5 days a week (Monday through Friday) to ensure neuro checks and assessments were initiated for all falls. Monitoring began [DATE] and will continue x 4 weeks or until the administrator determines substantial compliance has been achieved and maintained. o Falls will be reviewed in the morning meeting for proper documentation/assessment and follow up. This plan will be reviewed monthly at QAPI for the next three months. The Immediate Jeopardy for Villa Toscana at Cypress Woods was lowered on [DATE] at 2:02pm. Monitoring of the facility's POR Record review of the facilities in services dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that four nurses RN-B, LVN-A, LVN-B ,LVN-C, three CNA , CNA- B, CNA-C, CNA-D and the Physical therapy department were in serviced on the 2p-10p shift. In an interview with the DON and ADON on [DATE] revealed that they had conducted and revived In-Services on the information listed below: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report Record review of the facility's in services dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that two nurses, two CNA and the house keeping department were in serviced on the 6a-2p shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report Record review of the facility's in services dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that two nurses, two CNA and the house keeping department were in serviced on the 10p-6a shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report The facility was notified that the IJ was lowered on [DATE] at 2:02pm, however, the facility remaiend out of compliance at a scote of isolated and a severity level of actual harm that is not immediate jeopardy due to the facilities needing to evaluate teh effectiveness of the corrective systems.

Based on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 resident of 17 residents (CR #1) reviewed for quality of care. The facility failed to notify CR#1's physician when she had an unwitnessed fall sustaining an injury and bleeding from her head. The facility failed to complete neuro checks, monitor, and send CR#1 to hospital for treatment after CR#1 had an unwitnessed fall sustaining an injury and bleeding from her head. An Immediate Jeopardy (IJ) was identified on 08/25/2022 at 2:00 p.m. The IJ template was provided to the facility at that time. While the IJ was removed on 08/29/2022, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk of further injury, pain and delayed medical treatment. Findings include: Record review of CR#1 face sheet on 08/09/23 at 10:30am revealed that she was a [AGE] year-old white female that was originally admitted to facility on 07/16/21. She has the diagnoses of Alzheimer, Cellulitis of lower left limb, repeated falls, hypertension, Major Depressive disorder, anxiety disorder, and insomnia. Record review of CR#1's Quarterly MDS, dated [DATE] revealed CR#1 could not complete BIMS due to cognitive impairment. MDS completed by staff, which indicated CR#1 had memory problems and was severely impaired cognitively. CR#1 did exhibit behavioral symptoms of wandering and required supervision and two-person physical assist for ADLs. Record review of CR #1's care plan dated 05/19/23 indicated she had impaired communication, evidenced by: slurred speech, rarely/never understood. Interventions include administer medications as ordered, engage the resident in simple structured activities that avoid overly demanding tasks. Record review of CR#1's hospital record dated 08/03/23 revealed that CR#1 was examined in the emergency room and was found to have crepitus (friction between bone and cartilage or fractured bone) in the left face and neck and arms, chest and abdomen. The patient had left pneumothorax (air leaks into space between lungs and chest wall- caused by blunt or penetrating chest injury or lung disease), pneumomediastinum (air is present in the mediastinum-caused by trauma) left sided pneumoperitoneum (air or gas in abdominal cavity), subcutaneous emphysema rib fracture (emphysema caused by injury). In record review of CR#1 nurses note dated 08/03/23 revealed that CR# 1 was sent to the hospital because of swelling to her face and neck. The facility nursing staff did notify all pertinent parties and they were given orders to give CR#1 Benadryl and to send CR#1 to the Hospital for further evaluation. In an interview on 08/09/23 at 8:25am with CNA A, she said that CR#1 was in her room on the fall mat bleeding from her head. CNA A said that RN A was notified, and RN A assessed and cleaned CR#1 laceration and CR#1 was put back in bed. In an interview with RN-A on 08/08/23 at 5:53pm she stated that facility staff notified her that CR#1 was in her room on the floor bleeding from her head. RN-A said that she took CR#1 vitals and she cleaned and dressed the injury. She gave CR#1 medication for pain and CR#1 was placed back in bed. RN-A said that she sent a text message to the facility phone regarding the incident. RN-A stated that she did not notify the facility NP. When RN-A was asked why she didn't notify the NP she said that she sent a message to the facility phone. She said she did not have the number for the DON, nor the NP. RN-A was asked why she didn't perform neuro checks on CR#1 and she stated that she did do neuro checks but she did not know how to save it in the system. Record review of CR#1's nurses note dated 08/01/20223 written by RN A read in part, Resident was found by CNA's to have sustained a small gash or laceration to her right upper brow. She was awake and alert. Wound was cleaned and dressed, resident medicated for pain and continued anxiety. BP 128/82, HR 106. Resident is resting quietly in bed now. In an interview on 8/08/23 at 6:01pm RN A said she was notified by staff that CR#1 was in her room on the floor. RN A said she went into CR#1's room, and she noticed that CR#1 had an injury to her right upper eyebrow. RN A said that she cleaned and dressed the injury. RN A said that she administered 0.5ml of morphine to CR#1 for pain. RN A said that she took CR#1 vital signs and performed neuro checks on CR#1. However, upon record review of RN A nurses' notes it revealed that no neuro checks had been conducted on CR#1. Also, during this review of RN, A nurses' notes it revealed that RN A did not notify the facilities' DON, Administrator, NP, nor did she notify CR#1's RP. In an interview on 08/08/22 at 6:32pm with DON she said she was not aware of CR#1 had an injury on 08/01/23. The DON said that she did not receive a call from RN A on 08/01/23 that an injury had occurred involving CR#1. The DON said that RN A did not follow facility policy of notify pertinent parties of injuries involving residents. The DON said that RN A should have called the DON, Administrator, NP, and the RP. The DON said the nurses are to report any issues that occurred over their shift or the previous shift during the morning meeting. She said without notifying the pertinent parties, it doesn't give them the chance to intervene or assist with the residents' care. DON stated that by RNA not contacting the NP and getting an order to send CR#1 at greater risk of harm. DON also stated that she could not confirm that RN A conducted neuro checks. In an interview on 08/09/23 at 9:56am with the facilities NP she said she was not notified that CR#1 had an injury to her head on 08/01/23. She said that if she had been notified, she would have given RN A an order to perform neuro checks and to have CR#1 transported to the hospital for further evaluation. NP stated that by not informing medical staff of the head injury could put the resident a risk for serious injury. Record review of the facilities policy regarding to Change in Status date 03/2011 read in part, The facility utilizes the INTERACT tool, Change in Condition-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's condition requires immediate notification of the physician or non-immediate/Report on the Next Workday notification of the physician. Record review of CR#1 progress note on 08/26/23 at 11:30am dated 05/25/23 revealed that the facilities Medical Director noted that he explained to CR#1 Power of Attorney, if CR#1 continues at this rate, she will likely suffer a significant trauma and death. In an interview on 08/26/23 at 11:45am with the DON she was asked if she knew that the Medical Director had informed CR#1 Power of Attorney that if CR#1 continues at this rate, she will likely suffer a significant trauma and death. The DON said that she was aware of the conversation, because she and the Medical Director felt that hospice was the best course of action for CR#1. An Immediate Jeopardy (IJ) was identified on 08/25/2022 at 2:00 p.m. The IJ template was provided to the facility at that time. While the IJ was removed on 08/29/2022, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. The Plan of Removal was accepted on 08/27/23. Immediate Actions: o o As of 8/2/23 resident CR#1 was transferred to the hospital for evaluation. o o RN-A was provided 1 on 1 education by Assistant Director of Nursing (ADON) on 8/8/23 and again by the DON on 8/26/23 regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Facility Plan to ensure compliance: o o Abuse & Neglect policy was reviewed and in-serviced on 8/25/23, the Compliance Nurse provided in-service with DON and ADON. DON/ADON will in-service Charge Nurses to ensure compliance for this policy and procedure. Will be in-serviced as needed thereafter. o o Compliance Nurse in-serviced DON and ADON's on Event note completion and Neuro check policy 8/25/23. DON/ADON in-serviced Charge Nurses on neuro checks(neuro checks are to be initiated if a resident hits their head or had an un-witnessed fall) and Event note completion. In-services will be completed for the next 3 months, then as needed thereafter. o o Notifying Physician on change in status policy that includes falls with head injury or other serious o injury was reviewed & in-serviced on 8/25/23, the Compliance Nurse in-serviced DON and ADON. The DON/ADON in-serviced Charge Nurses to ensure .compliance for this policy & procedure. In-services will be completed for the next 3 months, then as needed thereafter. The Regional Compliance Nurse visited the facility 8/25/23 to review all audits and provide additional training as needed regarding Abuse & Neglect, Neuro checks, Notifying Physician on change in status, and process of reporting changes to oncoming shift nurses. The Administrator also received in-service training on these topics on 8/25/23. Audits completed: Event (incident) notes for the last 3 months were audited to ensure neuro checks were initiated and completed per policy. Progress notes were audited using Realtime software to ensure all events (incidents) resulting in a gash or laceration had the appropriate follow-up/treatment. o Notifying oncoming Nurse on change on any resident injury or changes that include falls or injury during change of shift report process reviewed, the Compliance Nurse in-serviced DON and ADON. The DON/ADON in-service Charge Nurses to ensure compliance for this policy & procedures In-services will be completed for the next 3 months, then as needed thereafter. o Nurses were in-serviced on notifying the DON of any falls resulting in injury or any other serious injury immediately by the DON/ADON on 8/25/23. o All nurses not in-serviced on 8/25/23 will be in-serviced prior to their next shift. o The Medical Director was notified by the Administrator on 8/25/23 at 12:46pm on the immediate jeopardy citation. o An AD HOC QAPI meeting was held on 8/25/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Monitoring: o The DON / designee will monitor Real Time clinical software and/or the PCC Dashboard for clinical alerts for any resident change of condition including falls, head injuries, other serious injuries, or changes of condition 5 days per week (Monday through Friday) to ensure physician/NP were notified. Monitoring began 8/25/23 and will continue x 4 weeks and weekly thereafter. o The DON and/or designee will monitor fall events 5 days a week (Monday through Friday) to ensure neuro checks and assessments were initiated for all falls. Monitoring began 8/25/23 and will continue x 4 weeks or until the administrator determines substantial compliance has been achieved and maintained. o Falls will be reviewed in the morning meeting for proper documentation/assessment and follow up. This plan will be reviewed monthly at QAPI for the next three months. Monitoring of the facilities POR Record review of the facilities in services on 08/27/23 at 3:10pm revealed that four nurses, three CNA and the Physical therapy department were in serviced on the 2p-10p shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report Record review of the facilities in services on 08/28/23 at 11:00am revealed that two nurses, two CNA and the house keeping department were in serviced on the 6a-2p shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report Record review of the facilities in services on 08/29/23 at 9:00am revealed that two nurses, two CNA and the house keeping department were in serviced on the 10p-6a shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report The facility was notified that the IJ was lowered on 08/29/23 at 2:02pm, however, the facility remaiend out of compliance at a scote of isolated and a severity level of actual harm that is not immediate jeopardy due to the facilities needing to evaluate teh effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two of 18 residents (CR #2 and Resident #16) reviewed for quality of care. -The facility failed to consult the physician promptly and monitor CR #2's change of condition. CR #2's extremely low blood sugar was not reported promptly to the physician nor was the physician updated when CR #2 continued to be unresponsive throughout the day. Twelve hours after being found in a hypoglycemic state, CR #2 was transported to the hospital where she was intubated, placed on a ventilator and remained unconscious. -The facility failed to assess and consult the physician timely concerning Resident #16's newly identified pain to her right hip after a mechanical lift transfer from wheelchair to bed. Resident #16 was self-restricted to bed for six days do to pain that went unreported to her physician. These failures resulted in an identification of and Immediate Jeopardy (IJ) on 7/10/2019. While the IJ was removed on 7/17/2019 the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. These failures affected two resident and placed residents at risk of delay in medical treatment, infections, [MEDICAL CONDITION], hospitalization s or death. Findings Include: CR #2 Record review of CR #2's Face Sheet dated 6/28/19 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review revealed that CR #2's did not have a MDS to review. She was admitted on [DATE]. She was sent to the hospital on [DATE] and did not return to the facility. Record review of CR #2's Doctor Progress Note dated 6/21/19 revealed her [DIAGNOSES REDACTED]. Record review of CR #2's care plan dated 6/20/19 revealed a care area/problem of Diabetes Mellitus. The interventions were: -Fasting blood sugar via glucometer as ordered -Labs as ordered, report results to MD -Observe for signs and symptoms of [MEDICAL CONDITION] such as blood sugar more than 180 mg/dL, fatigue (weak, tired feeling), blurred vision, headaches, increased thirst, trouble concentrating, frequent urination, weight loss. Notify provider per order -Observe for signs and symptoms of [DIAGNOSES REDACTED] such as shakiness, nervousness or anxiety, irritability or impatience, confusion, rapid heartbeat, lightheadedness or dizziness, nausea, sleepiness, blurred vision, tingling or numbness in lips or coordination, [MEDICAL CONDITION], unconsciousness. Treat per hypoglycemic protocol -Sliding scale insulin coverage as ordered -Therapeutic diet as ordered. Record review of CR #2's physician order's read in part . [MEDICATION NAME] 1 mg Solution for injection of ([MEDICATION NAME]) 1 recon soln inject as needed low blood sugar. Blood glucose check. Administer if blood is less than 60 and resident is unresponsive . MD call. Record review of CR #2's medication administration record (MAR) dated 6/28/19 read in part Finger Hypoglycemic Can complete if high blood sugar or symptomatic if <60 or >400 call MD Blood Glucose Check Check . stick blood sugar/ Accuchek . 1 stick . stick as needed Hyper/ medication for [MEDICATION NAME]was given on 6/21/19 at 5:00 p.m. The MAR revealed on 6/22/19 a X which the MAR key indicates an X is for medication that was not given. The MAR does not have a section to record daily blood sugar levels. Daily blood sugar levels are not documented on the MAR. The initials BG indicates blood glucose checks on the key for the MAR, but CR #2's record did not have a place to record the blood glucose levels. Record review of CR #2's facility nurses' notes read: 6/22/19 at 6:50 a.m. written by RN L revealed she observed the patient asleep in bed, unresponsive to name, breathing bilateral pedal pulse 2+, radial pulses palpable, drooling from the mouth with dark brown secretions, heart rate 101, blood pressure 152/87. Respirations 20, afebrile. Blood sugar reading lo, administered 1mg of [MEDICATION NAME] inner muscular at 7:00 am to right thigh. Rechecked blood sugar 5 minutes later and it was 37, then blood sugar at 7:38 a.m. it was 54 and administered another 1mg of [MEDICATION NAME] inner muscular. Doctor was notified and gave orders to start D5W at a rate of 80 cc/hour and call Physician A back in 50 minutes. In an interview on 6/28/19 at 1:27 p.m. with RN L she said she had been working for the facility since (MONTH) 2019 on the 6 a.m. to 2 p.m. shift. She said she had orientation training that was a broad overview. She said there was some training on the floor for a few days and then she was on her own to work the floor. She said she made frequent rounds, answered call bells and followed doctors' orders. She said on Saturday, 6/22/19, she made room rounds and found CR #2 was not responsive at 6:50 a.m. She said she could not give the resident anything by mouth. She said the resident was drooling and unresponsive. She said she took the blood sugar level and the glucometer read lo twice. She gave 1 mg of [MEDICATION NAME] and she said the first number (blood sugar) reading was 37. She said she gave another 1 mg of [MEDICATION NAME] and CR #2's blood sugar went up to 54 around 7:38 a.m She said she then notified Physician A, the on-call physician. She said Physician A said to start an IV of D5W and call back in 50 minutes. She said she did hang the D5W. She said CR #2 was not alert. RN L said giving the [MEDICATION NAME] first and then calling the doctor is just a standing order. She said she used her nursing judgment and facility protocol when she decided to call the doctor. She said she called and notified the on-call nurse or the DON. She said the doctor's orders were to give 45 cc and call back in 50 minutes. She said she called the doctor back twice and no one called her back. She said there were no further notes than what she put into the system. She said between 10 a.m. and 2 p.m. CR #2 was getting the IV fluids (D5W). She said she did shift change around 2 p.m. She said the next day she learned the resident was sent out. She said CR #2 was not able to talk to her. She said the resident was mumbling and somewhat answering to her name after the [MEDICATION NAME]. She said she did not contact anyone else other than the doctor. She said she tried calling the number on file and the number was not working for the family. RN L said she called the on-call nurse for that weekend. She said the glucometer reading had never read lo. She said her protocol was to get the doctor's orders and follow them. She said the protocol when a resident had a change in condition was to notify the on-call nurse. She said she left a message for the DON on the resident's status. Interview on 6/28/19 at 1:59 p.m. with the DON said she came in the building on 6/22/19 between 4-5 p.m. She said she was not aware of CR #2's morning status with the low blood sugar. She said she did not remember about the 6 a.m. to 2 p.m. nurse calling. She said RN J asked her to come to CR #2's room because the resident was nonresponsive. She said RN J told her the resident had low sugar. The DON said she told RN J and LVN P to call 911. The DON said her only involvement was that she attended to the resident before EMS arrived. She said if the resident was not waking up then we needed to send her out to the ER. She said she would have wanted RN L to call 911 that morning if the resident was in the same condition as that evening. She said she felt CR #2 needed to be sent out the ER if she was not responding. Interview on 6/28/19 at 2:39 p.m. with RN J said she had worked for the facility for 2 months. She confirmed she worked on 6/22/19 on the 2 p.m. -10 p.m. shift. She said she did shift change with RN L who told her that night RN A said CR #2's blood sugar was low overnight. She could not remember when she went to first check on CR #2. She said when she did check on her that the resident was not responsive and she checked her blood sugar and it was 38. She said CR #2 was drooling and sweaty. She said she gave the [MEDICATION NAME] but called for assistance. She called the on-call doctor but did not receive a call back. She said the DON and LVN P came. She said the DON told them to call 911. She said she remembered the D5W that was hung was at 45 cc/hour. Interview on 6/28/19 at 2:57 p.m. with RN J said her main concern was the reading of 38 for CR #2's blood sugar. She said she tried once to call the doctor but did not get a call back and did not wait for the response. She said she tried to contact the family but the voicemail was full. She said she used the option to leave a text message. She described CR #2 as being in critical condition and was not responding. She said LVN P gave the [MEDICATION NAME] and she called 911. She said when 911 arrived the last blood sugar reading was 68. She said CR #2 was gasping for air when EMS was taking her out. She said she had another emergency and was behind on passing her medications and that was why she was not able to follow up with the doctor and document until the next day (6/23/19). She said she tried calling the on-call NP for Physician B but did not reach the NP and missed the return call because she was busy with other emergencies. She said RN A had given report to RN L earlier and said CR #2 was having fluctuating blood sugar readings from the night before. Interview on 6/28/19 at 3:36 p.m. with the Administrator said on Saturday (6/22/19) she received a call from the DON that CR #2 was sent to the hospital. Then on Sunday she received a call from the RN on duty that CR #2's family member had not been notified. She said then CR #2's family member called her about not being notified. The Administrator said the DON said she had called the Resident's family member. The number that the facility had for the RP turned out to be the resident's own phone. She said nurses were expected to call and notify the family, DON, and physician/on-call physician. She said her expectation was to call the physician and follow physician orders. She said they had 31 insulin dependent residents at the facility. Interview on 6/28/19 at 5:24 p.m. with the DON said she did not get a call about CR #2 until she was in the building around 4 p.m. Observation on 6/28/19 at 9:50 a.m. of CR #2 at the local hospital revealed the resident was intubated (had a tube inserted in her windpipe) and was on a ventilator in the intensive care unit. She was not responsive. Interview on 6/28/19 at 9:53 a.m. with the Hospital Nurse said CR #2 was intubated and was not being sedated. The Hospital Nurse said CR #2 was not opening her eyes or waking up. She said CR #2's status currently is global hypoxic ischemic. She explained that hypoxic was lack of oxygen to the brain. Record review of CR #2's emergency medical services report dated 6/22/19 7:25 p.m. read in part, .was called to the nursing home for a patient who was unresponsive and had low BGL (Blood Glucose Level). Upon arrival, the patient was found lying in bed. She had snoring respirations. Pt (Patient) had GCS (Glasgow Coma Scale) of 3 (unresponsive). An IV (intravenous) had been established in her left hand and D5 ([MEDICATION NAME] 5%) administered at 45 ml per hour starting at 1230 (12:30 p.m.). When asked why the IV staff stated that she had low blood sugar and was dehydrated when she was checked at that time. Staff were poor historians and could not tell what the BGL was and stated that she was sleeping at the time. Staff did not know when the patient was last seen normal. The patient was moved to the stretcher. Interview on 7/8/19 at 7:25 a.m. with Physician C (not CR #2's PCP) he said staff usually notify the doctor when a resident's blood sugar is less than 70 or over 400. He said for low blood sugar they usually give D50 or [MEDICATION NAME]. He said they normally do that once or twice. If the resident could not take anything by mouth, then send them out. He said if it is that serious, he would not mind if the nurse just sent the resident out. He said if the doctor cannot get back in a timely manner, like 30 minutes, then they want the staff to send the resident out and not wait on the doctor. Interview on 7/8/19 at 8:13 a.m. with RN D said if a resident was not responsive to a sternal rub, then they call 911. She said they check blood sugar and if there is no reading, if it is below 60, she said she needed to stay in compliance with the doctor. She said she was trained to call the doctor. She said if a glucometer is reading lo then that is a non-detectable blood sugar level, so you would use your nursing judgement. She said if a blood sugar was reading low she would need to be getting that person out of there and not waste time. Interview on 7/8/19 at 11:09 a.m. with the DON she said nurses were supposed to document the blood sugars. She said if the blood sugars were reading low and the resident was not responsive, she would expect the nurse to call the doctor immediately or send the patient out to the ER. She said staff were trained to call the doctor or on-call. She said RN L should have called earlier, even though she had a standing order for [MEDICATION NAME]. She said the glucometers were calibrated every night. She said the nurse should take the verbal order and put the new order into the computer system. She said the information should be put in before they leave the shift. Nurses should document on their notes or the MAR blood sugar readings and vitals. Telephone Interview on 7/8/19 at 12:08 p.m. RN L said initially CR #2 had blood sugars around 38 then 57 at around 7 a.m. She said the resident did not eat all day. She said CR #2 could not eat or swallow. She said she called Physician A and D5W was ordered. She said she had inconsistencies to the order of 80 cc or 45 cc. She said 80 cc was a typo in her notes. She said around 11:30 a.m. the blood sugar was around 78. She said the resident was not able to get out of the bed. She said the resident could answer to her name but was lethargic. RN L did not take CR #2's vitals throughout the day. She said she did not document the exact orders but should have put them into the computer. She said she should monitor residents with change in condition every 30-45 minutes. Interview on 7/8/19 at 1:10 pm with LVN P, she said RN J called her to help with CR #2. She said the DON was there and they walked to the resident's room. She said the DON asked how long had CR#2 been like that. LVN P said RN J was not sure but when she was making her rounds she found the resident lethargic and drooling. She said her blood sugar was 38 and there was a IV of D5W at 45 cc per hour hanging. LVN P said RN J did not have [MEDICATION NAME] at her station so she had to use hers. She said it was used up from earlier in the morning on the resident. She said she gave CR #2 the [MEDICATION NAME]. She said the DON said to call the doctor directly. She said CR #2 was on oxygen. She could not remember if the resident was alert. She said it was around 7:00 p.m. when 911 was called. RN J said she attempted to call CR#2's responsible party but the number was not able to leave a voicemail. It was later found out that the number listed was the resident's phone, but was listed as the resident's spouse's phone number. Interview on 7/8/19 via phone at 9:58 a.m. with Pharmacy Rep. said that they replace the e-kits weekly and the facility can request used items by fax. He said there has been no fax from the facility to replace [MEDICATION NAME] on or after 6/22/19. Telephone Interview on 7/8/19 at 2:09 p.m. with on-call physician, Physician A said he received report that CR #2 had a blood sugar level around 42, but could not remember exactly. He said there were orders to give [MEDICATION NAME] and D5W and told them to call after 15 minutes. He said he did not get a call back from the facility. He said the RN that called did not mention the resident had brown secretions from her mouth. Physician A said he ordered 100 cc per hour and ordered [MEDICATION NAME] to be given. He said the RN did say she had given1 mg of [MEDICATION NAME] and then gave another 1 mg dose. He said the RN never called back and he was not able to instruct her further. Interview on 7/8/19 at 2:47 pm with RN J said on 6/22/19 she did shift change with RN L for about 20 minutes. She said after she started rounds and she got to CR #2 between 3 and 4 p.m. She said she put in a late entry note when documenting on CR #2. She said the computer systems sometimes were not accurate on the times when putting in information. She said she checked CR #2 vitals and her blood sugar was 38. She said her oxygen saturation was between 70 and 80. She said she grabbed the oxygen and put it on CR #2. She said she looked for [MEDICATION NAME] and found an empty packet. She said she asked for help and LVN P, who had to get the [MEDICATION NAME] from the long term side of the building, which was at the opposite far end of the building, and she administered it. She called 911 and they arrived in 3-5 minutes. she said they checked glucose and vitals. She said she advised EMS that [MEDICATION NAME] was just given. RN J said she was not sure if CR #2 was diabetic. She said she tried to call one phone number and could not leave a voicemail because it was full. Interview on 7/9/19 at 8:25 a.m. with CR #2's family member, she said CR #2 remained on a ventilator and had not regained consciousness. Family member said CR #2 had dinner with her family member on 6/21/19 in the evening. The family member said CR #2 ate well and walked her family member to the door. Family member said CR #2 's blood sugar was controlled, no major drops in blood sugar reported. The family member said CR #2 was recently diagnosed with [REDACTED]. Interview on 7/9/19 at 9:40 a.m. with RN A said she had worked for the facility for 4 years. RN A said she worked 10 p.m. - 6 a.m. - (MONTH) 21, 2019. She said CR #2 was a recent admission. She said the resident had a witnessed fall and was sent to the hospital late on 6/20/19 and returned around 3 a.m. on 6/21/19. She said CR #2 returned from the hospital with no injuries. RN A said CR #2 came to the nurse's station requesting [MEDICATION NAME] and [MEDICATION NAME]. RN A said the resident went back to the room and she last communicated with the resident about 3 a. m. RN A said the resident continued to sleep as of 6 a.m. RN A said she gave report to RN L around 6 a.m. She said RN L started checking CR #2 's blood sugar and it was low. She said RN L gave CR #2 [MEDICATION NAME]. RN A said she remembered CR #2 was breathing, not alert, unable to awake, and sluggish. RN A said RN L told her CR #2's blood sugar was 38 and 54. She said CR #2 was a new admission and they did not know her that well. She said CR #2 had a snack late Friday night and all reports said she was lively and talked to everyone. RN A described CR #2 as really active. RN A said after the blood sugar level of 54 she left. RN A said she thought RN L gave two [MEDICATION NAME] injections to CR #2 . RN A said if the resident was not waking up then you send them to the hospital. If blood sugar was low, make notifications after sending the resident out to the hospital. Interview on 7/9/19 at 10:17 a.m. with CNA FF said she worked 6 a.m. - 2 p.m. on 6/22/19 and assisted CR #2 . CNA FF said the resident was lying in bed. CNA FF said she saw RN L and RN A with the resident around 6 a.m. and they were taking vitals. CNA FF said she noticed the resident was not like she was the day before which was alert. She said she checked on the resident every two hours. She said she changed CR #2's brief once and then the second time she saw that RN L was finishing up the IV the resident had after 12 p.m. - 12:30 p.m. She said she tried to give the resident a food tray but CR #2 would not open her eyes. She said the resident did not eat throughout her shift. She said the resident made no sounds. CNA FF said she saw the resident with clear drool around her mouth. She said she continued to check on her through her shift. She said she changed her 1st brief in the morning between 9 am -10 a.m. She said she was not able to rouse CR#2. She said she let RN L know about the residents condition and the RN L said she was aware. CNA FF said she asked RN L what was wrong with CR #2 and RN L said her sugar was down. CNA FF said CR #2 did not come into the facility like that. CNA FF said CR #2 was up walking around talking, went to dining room, and snacking. She said she left that Friday (6/21) and CR #2 was asked was there anything to do and asked about activities. CNA FF said on the second brief change the resident was wet and so the sheets were changed. CNA FF said as she had put on the brief and was putting the resident's gown on, the resident had soaked through her brief again. CNA FF said she told RN L about the change. She said she checked CR #2 after lunch time and she did not need to be changed but her condition was still the same, non-responsive. Resident #16 Record review of Resident #16's face sheet dated 6/20/19 revealed an [AGE] year-old female admitted on [DATE] and re-admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #16's quarterly MDS dated [DATE] revealed a BIMS score of 12 moderately cognitively impaired. The resident needed a mechanical lift for transfers and extensive assist with transfers between surfaces. Record review of Resident #16's care plan dated 6/20/19 read in part . she was immobile and needed maximum help with bed mobility and transfers . Interventions . provide appropriate level of assistance to promote safety of resident . The resident has pain in the right and left knees . Interventions . administer pain medication as ordered, assess pain (location, severity, type of pain, precipitating factors, and relief factors using the pain assessment form), and notify physician of any changes in level of frequency of pain . Record review of Resident #16's Medication Administration Record (MAR) for (MONTH) 2019 revealed an order for [REDACTED]. The documentation indicated she received [MEDICATION NAME] 50 mg on: - 6/14/19 time unknown for pain of 5 location right knee, - 6/14/19 time unknown for pain of 6 for generalized pain. - 6/15/19 time unknown for pain 8 location right knee, - 6/15/19 time unknown, for pain of 6 location legs. - 6/16/19 time unknown, for pain 8 location right hip. - 6/18/19 time unknown, pain of 6 for generalized pain, - 6/18/19 time unknown, pain of 8 location right hip, - 6/18/19 time unknown, pain 8, location generalized. - 6/19/19 time unknown, pain of 8 for right hip pain. Observation and Interview on 6/19/19 at 3:07 p.m. of incontinence care provided by CNA DD to Resident #16. When Resident #16 was rolled to her left side she had facial grimacing, screamed out, and moaned in pain, saying her right hip hurt. Resident #16 said the pain started on 6/14/19 after she was transferred from her wheelchair back to bed and the CNA was to tell the nurse about her pain. She said nothing unusual happened during the transfer. She said she had not gotten up out of bed since 6/14/19 because of the pain in her hip and was afraid it would worsen with movement. Resident #16 said she had told the nurses, but was unsure of the nurses' names. She said the nurses gave her a pain pill, but she still had a lot of pain with movement. While CNA DD was performing care for Resident #16 she said that the pain was new in her right hip and CNA DD told Resident #16 she would notify the floor nurse of her pain complaint after she completed the care and that she needed pain medication. Interview on 6/20/19 at 9:36 a.m. with Resident #16, she said the night nurse, name unknown, came and talked with her about her right hip pain. She said the nurse did not look at her hip but did tell her the doctor would be notified of the new pain. She said she did not give her any pain medication at that time. Interview on 6/20/19 at 9:42 a.m. with RN B and the ADON, who said they were not aware of any complaints of pain from Resident #16. She said there was no report from the night nurse about Resident #16. RN B said the resident had frequent right knee pain that radiated throughout her leg. She said she would assess the resident and notify the physician if there were changes. ADON said she would check into the resident's paperwork to see about any changes. Interview on 6/20/19 at 11:02 a.m. with CNA DD, she said she had told LVN K on 6/19/19 around 4:00 p.m. about Resident #16's pain to right hip when CNA DD moved the resident in bed. CNA DD said LVN K was going to check on Resident #16 in the evening of 6/19/19. CNA DD said she did not follow-up with either LVN K or Resident #16 about the pain. Interview on 6/20/19 at 3:19 p.m. with LVN K, said she was aware Resident #16 had pain yesterday because she heard the resident screaming out in pain and the resident had also told her she was in pain in the right hip. She said CNA DD had also notified her of Resident #16's complaint of pain to right hip. LVN K said she gave Resident #16 a [MEDICATION NAME] and passed the information onto the next shift nurse if the pain continued for possible stronger pain pill. She said she did not contact the doctor related to Resident #16's right hip pain. Interview on 6/20/19 at 2:46 p.m. with RN B, she said she assessed Resident #16 for right hip pain and notified the doctor. She said the doctor ordered an x-ray of the right hip. She said the x-ray order was called into the company but the company had not arrived to do the x-ray at that time. She said she had given the resident [MEDICATION NAME] for pain during the day shift because of hip and knee pain. Interview on 6/20/19 at 12:42 p.m. with the DON, she said she expected the CNA's to report through the computer (P[NAME]) if there was a change in status, or verbally reported to the charge nurse to follow-up with the resident. She said if a resident had a possible change she expected the nurse to stop their task, and check on the resident and do a pain assessment if necessary. The DON said she expected the nurses to notify the doctor of changes and follow the orders that were given. She said the nurse should document on a change of status form in the resident's chart, nurses note, and pain assessment in the chart. She said if a resident had a change in pain that would be considered a change in condition. She said the change should be reported on the 24-hour report along with verbal report to the next shift. She said she was not aware that Resident #16 had pain in her right hip. She said it was not documented on the 24-hour report. Record review of facility policy Change in a Resident's Condition or Status date revised (MONTH) 2007 read in part . 1. The nurse supervisor/ charge nurse will notify the resident's attending physician or on-call physician when there has been: . d. A significant change in the resident's physical/ emotional mental condition . e. A need to alter the resident's medical treatment significantly . 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 . 6. The nurse Supervisor/ Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status . The facility Administrator, Director of Nursing and Regional Director of Operations were notified on 7/10/2019 at 5:27 p.m. that an IJ situation had been identified due to the above failures. A plan of removal was requested at that time. On 7/12/19 a revised Plan of Removal was accepted. The following is a plan of removal to the IJ called 07.10.19 at 5:22 PM for the facility's alleged violation of Neglect, and Quality of Care, relating to CR #2. Notification of IJ status was made by the Administrator to the Medical Director, on 07.10.19 at 6:10 PM. The Medical Director has made themselves available to the team as needed. As of 7.10.19, there are currently 46 diabetics in the facility and 29 have orders for [MEDICATION NAME]. All residents have orders for Glucose orally. Facility clinical leadership conducted a [MEDICATION NAME] audit on 06.28.19 and the E-kits were refilled at that time. The [MEDICATION NAME] was again audited on 07.10.2019 and no additional [MEDICATION NAME] was needed. Facility clinical leadership conducted an 100% audit of the presence of [MEDICATION NAME] orders on 7.10.19. No new order changes were needed. Facility clinical leadership conducted 100% audit of diabetics to ensure insulin orders have hi/lo parameters established for hyper/[DIAGNOSES REDACTED]. Nursing aides were trained starting on 07.10.19, through review and proven competency tested in the form of a quiz. This included instructions on: o Stop and Watch with Interact 4.0. The Stop and Watch Early Warning sign tool is a tool within the InterAct Program for C.N.A use which provides regular evaluation and recognition of changes in residents/patients' condition. Also instructs reporting changes to licensed nurses. o Stop and Watch Early Warning Tool instructions: If you have identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can S: Seems different than usual T: Talks or communicates less O: Overall needs more help P: Pain - new or worsening; Participated less in activities A: Ate less N: No bowel movement in 3 days; or diarrhea D: Drank Less W: Weight change; swollen legs or feet A: Agitated or nervous more than usual T: Tired, weak, confused, or drowsy C: Change in skin color or condition H: Help with walking, transferring, toileting more than usual o Use of Stop and Watch Early Warning Sign tool to be completed if resident, in dining room or in room dining complete less than 25% of their meal. The Stop and Watch Early Warning Sign tool is then given to the Charge Nurse for identification of those residents at high risk for [DIAGNOSES REDACTED] related to decreased intake. The Plan of Care Devices (part of the E.H.R.) are to also be updated with meal intake. Licensed Nurses received additional training, through review and proven competency testing in the form of a quiz on Change of Condition through InterAct 4.0 Program utilizing Change of Condition. o The INTERACT quality improvement program is designed to improve the early identification, evaluation, management, documentation, and communication about acute changes in condition of residents in nursing homes, assisted living facilities and home health care. The fundamental goal of INTERACT is to improve care; its strategies and tools will help reduce the frequency of potentially preventable transfers to the acute hospital and related complications that lead to increased health care costs. The program includes evidence-based and expert-recommended tools, strategies to implement them, and related educational resources. The INTERACT tools are meant to be integrated into every-day care and be incorporated into Villa Toscana's quality improvement program. Licensed Nurses, on 7/10/2019 were in-serviced on Diabetes management and the following: o InterAct 4.0 (see description and purpose above) and Change of Condition in Collain (Electronic Medical Records). o When to notify the DON, Physician and Family o Escalation process if attending physician does not respond timely. o Arkray (TRUNCATED)

Based on observation, interview, and record review the facility failed to provide the right to be free from neglect to one of two residents with a [MEDICAL CONDITION] (Resident #71) who were reviewed for neglect. -The facility failed to have a system in place to train and supervise residents who chose to provide self-suctioning and care to their [MEDICAL CONDITION]. Resident #71 did not receive training or supervision from the Respiratory Therapist or Nursing staff when he performed suctioning to his [MEDICAL CONDITION]. Resident #71 developed a respiratory infection which required antibiotic therapy. -The facility failed to have a system in place that provided a resident, with a [MEDICAL CONDITION], emergency supplies/equipment at the bedside. Resident #71 was not provided an ambu bag or replacement inner cannula for his [MEDICAL CONDITION] in case of a respiratory emergency. These failures resulted in an identification of and Immediate Jeopardy (IJ) on 7/10/2019. While the IJ was removed on 7/17/2019 the facility remained out of compliance at a severity of actual harm that is not an imediate jeopardy with a scope identified as isolated. These failures affected one resident and placed him at risk of [MEDICAL CONDITION], inability of staff to perform emergency care, infections, hospitalization or death. Findings include: Resident #71 Record review of Resident #71's face sheet revealed he was a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #71's significant change MDS dated [DATE] revealed a BIMS score of 0 - indicating severe cognitive impairment. He was totally dependent on one staff for eating, totally dependent on two staff for dressing, toilet use, and personal hygiene. He needed [MEDICAL CONDITION] care. Resident #71 was re-evaluated by the SW on 7/10/19 and his revised BIMS score was between 8 and 11, indicating moderate cognitive impairment. Record review of Resident #71's care plan printed on 6/20/19 read in part, . Care area/problem: [MEDICAL CONDITION] (06/19/2019:updated) . evidence by: [MEDICAL CONDITION] needed secretion (05/01/19: onset) . [MEDICAL CONDITION] time per day (05/01/19: onset) . Interventions . suction PRN and as ordered (05/01/19:onset) . Record review of Resident #71's Physician orders [REDACTED]. [MEDICAL CONDITION] needed secretion . start date 5/1/19 . [MEDICAL CONDITION] time per day . start date 5/1/19 . Record review of Resident #71's MAR for (MONTH) 2019 revealed an H was documented [MEDICAL CONDITION] on 6/17/19 at 9:00 a.m. The H indicated on-hold. There was no documentation [MEDICAL CONDITION] on 6/18/19 to 6/20/19. Observation and Interview on 6/17/19 at 12:58 p.m. of Resident #71, he pointed at [MEDICAL CONDITION] and said no one had suctioned him for since yesterday because the suction machine was not working. He said he needed to be suctioned. Resident #71 placed the yanker in his mouth to demonstrate to the Surveyor that it was not suctioning. Observation and Interview on 6/17/19 at 1:25 p.m. of Resident #71 with MDS B, she entered the resident's room and acknowledged there was no suction coming from the machine. She said she would get Resident #71's nurse. Observation and Interview on 6/17/19 at 1:27 p.m. with RN L, she entered Resident #71's room and checked the suction machine. The machine was on but was not providing suction. She said she would get the resident another saline bottle and mentioned that she was working by herself on the rehab unit. RN L continued to say that there was some type of leak going on with the suction machine and she would have to call respiratory to fix it. She said a respiratory staff was supposed to be on site, but she would page them. Observation on 6/17/19 at 1:38 p.m. of Resident #71's room revealed there was no ambu bag present or a replacement inner cannula [MEDICAL CONDITION]. Interview with DON on 7/12/19 at 9:00 a.m. said central supply is responsible for emergency/ respiratory supplies for [MEDICAL CONDITION]. She said the charge nurse should have notified central supply. She said the charge nurse should have made sure Resident #71's emergency supplies were in his room. She said the night nurse checked the crash cart and the emergency supplies for residents who had a [MEDICAL CONDITION]. She said the respiratory therapist should check the equipment and set it up initially. The DON said the Respiratory Therapist [MEDICAL CONDITION] for Resident #71 on trach's and keeping them sanitary. Interview on 6/17/19 at the same time with RN L, she said Resident #71 had recently gotten off hospice services and hospice removed [MEDICAL CONDITION] supplies from the resident's room. She said she did not see the ambu bag in the room. She said the facility had to provide Resident #71 with emergency equipment. She said she normally suctioned him 2-3 times per day during her 8-hour shift. She said the resident also liked to suction himself. Interview on 6/17/19 at 3:23 p.m. with the Respiratory Therapist, she said she had not been in Resident 71's room to see him yet. She said she did not provide care for Hospice patients. She said she did not know Resident #71 was discharged from hospice care. She said she would stock resident rooms with the [MEDICAL CONDITION] upon admission. Record review of Resident #71's respiratory therapist note dated 6/17/19 at 4:38 p.m. and written by the RT read in part, . RT received consult to eval and treat. Resident's POA recently revoked his hospice services . RT introduced them self and informed resident why they were there, and resident refused to let RT touch [MEDICAL CONDITION]. RT noted the inner cannula was not in place, but the resident refused to let the RT put an inner cannula in trach. Ambu bag at bedside with [MEDICAL CONDITION]. Interview on 6/20/19 at 12:28 p.m. with the DON, she said the facility normally stored the ambu bags on the crash cart. She said there was also a respiratory therapist on site. Interview on 6/20/19 at 1:24 p.m. with RN L, she [MEDICAL CONDITION] had to have an ambu bag in the room in case of an emergency such as respiratory distress. She said Resident #71 did not have an ambu bag in his room on Monday (6/17/19) and she could not find one on the crash cart. She said she had to page the Respiratory Therapist who found two ambu bags in the supply room. She also said that on Monday (6/17/19) there was a malfunction with Resident #71's suctioning machine. She said everything was set up, but it would not suction. She said they fixed the machine the dame day due to the survyeor intervention. Interview and Observation on 7/9/19 at 12:10 p.m. with LVN T, he said he had no recent training on [MEDICAL CONDITION] care. The LVN said that was the first time he had worked with Resident #71. He said he received a report Resident #71 was noncompliant with [MEDICAL CONDITION] care, no changes in lung sounds or secretions. LVN T said [MEDICAL CONDITION] care should be documented on the TAR. Record review and Interview at the same time on 7/9/19 with LVN T, he could not find anywhere on the TAR for nurses to document Resident #71's [MEDICAL CONDITION] care. He said he did Resident #71's [MEDICAL CONDITION] care around 8:30 a.m. and at that time his lung sounds were wheezy and showed the surveyor he had documented in the TAR under comments. He said he did not notify the DON, physician or RT of Resident #71's lung sounds being wheezy. LVN T said Resident #71 did not have an inner cannula in his [MEDICAL CONDITION]. He said Resident #71 did not want the inner cannula in his trach. Interview on 7/9/19 at 11:01 p.m. with RT, she said she comes to the facility as needed or if facility staff, physician or nurse practitioner call her to come in and see a resident. She said typically the facility would call her when [MEDICAL CONDITION] was admitted to assess the resident and set the resident up with supplies. She said she was not aware of any lung sound or secretion color changes for Resident #71. She had seen the resident on 6/17/19, 6/18/19 and 6/21/19 and she instructed the resident not to suction himself. She said she explained to the resident that suctioning is supposed to be a sterile technique and using the yaunker was not sterile. RT said she asked the floor nurses to document Resident #71's noncompliance, refusal of inner cannula and self-care of trach. Observation and interview on 7/9/19 at 12:23 p.m. with Resident #71, he whispered that he does his [MEDICAL CONDITION] because the nurses do not assist him. The resident mouthed he does not like using the inner cannula because he would get short of breath and he did his own suctioning. Resident #71 demonstrated how he suctioned his trach. He picked up the suction catheter from the floor, turned on the machine, then placed the suction tubing close to [MEDICAL CONDITION]. He shook his head no when questioned if he had ever been trained on self-care of trach. Interview on 7/9/19 at 12:39 p.m. with Physician C, he said he remembered the nurses had told him that Resident #71 would remove his inner cannula. He said he was not aware Resident #71 suctioned his own trach. He said the facility had not reported any lung sound or sputum changes for Resident #71. He said he would have liked to have been aware if the resident had a sputum or lung sound change. He said he would call his NP who was at the facility to assess Resident #71. Interview on 7/9/19 at 1:36 p.m. with the DON, she said the NP assessed Resident #71 and ordered an antibiotic, chest x-ray, and a sputum culture. She said she was not aware nurses were documenting in different tabs of the computer program regarding resident concerns or resident changes in the nurse notes. Interview on 7/10/19 at 5:04 p.m. with the RT, she said she attempted to [MEDICAL CONDITION] on Resident #71, but he refused her and nursing assistance. She said he was only able to suction around [MEDICAL CONDITION] and that was not sanitary either. She said she had replaced the inner cannula for Resident #71 but he could remove it himself. She said she had tried to figure out why Resident #71 would not use his inner cannula. She said she had explained to him that with the inner cannula he would have less secretions. Record review of the facility's [MEDICAL CONDITION] Care policy dated (MONTH) 2007 read in part, . Miscellaneous . 7. A replacement [MEDICAL CONDITION] must be available at the bedside at all times . 8. A suction machine . must be available at the bedside at all times . The facility Administrator, Director of Nursing and Regional Director of Operations were notified on 7/10/2019 at 5:27 p.m. that an IJ situation had been identified due to the above failures. A plan of removal was requested at that time. On 7/12/19 a revised Plan of Removal was accepted. The following is a plan of removal to the IJ called 07.10.19 at 5:22 PM for the facility's alleged violation of Neglect, and Quality of Care, relating to Resident #71. Notification of IJ status was made by the Administrator to the Medical Director, on 07.10.19 at 6:10 PM. The Medical Director has made themselves available to the team as needed . Nursing aides were trained starting on 07.10.19, through review and proven competency tested in the form of a quiz. This included instructions on: o Stop and Watch with Interact 4.0. The Stop and Watch Early Warning sign tool is a tool within the InterAct Program for C.N.A use which provides regular evaluation and recognition of changes in residents/patients' condition. Also instructs reporting changes to licensed nurses. o Stop and Watch Early Warning Tool instructions: If you have identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can S: Seems different than usual T: Talks or communicates less O: Overall needs more help P: Pain - new or worsening; Participated less in activities A: Ate less N: No bowel movement in 3 days; or diarrhea D: Drank Less W: Weight change; swollen legs or feet A: Agitated or nervous more than usual T: Tired, weak, confused, or drowsy C: Change in skin color or condition H: Help with walking, transferring, toileting more than usual . Licensed Nurses received additional training, through review and proven competency testing in the form of a quiz on Change of Condition through InterAct 4.0 Program utilizing Change of Condition. o The INTERACT quality improvement program is designed to improve the early identification, evaluation, management, documentation, and communication about acute changes in condition of residents in nursing homes, assisted living facilities and home health care. The fundamental goal of INTERACT is to improve care; its strategies and tools will help reduce the frequency of potentially preventable transfers to the acute hospital and related complications that lead to increased health care costs. The program includes evidence-based and expert-recommended tools, strategies to implement them, and related educational resources. The INTERACT tools are meant to be integrated into every-day care and be incorporated into Villa Toscana's quality improvement program. Licensed Nurses, on 7/10/2019 were in-serviced on Diabetes management and the following: o InterAct 4.0 (see description and purpose above) and Change of Condition in Collain (Electronic Medical Records). o When to notify the DON, Physician and Family o Escalation process if attending physician does not respond timely . When to notify administrative staff (defined as DON/designee) of changes of condition . QA of Change in Condition to be presented to QAPI for a period of three months, or until substantial compliance achieved . Nursing leadership checked the supplies and suction equipment placed at Resident #71 bedside on 06.28.19. Respiratory therapist provided list of supplies [MEDICAL CONDITION] to be checked by charge nurses shift to shift. To be documented on MAR. Back up supplies on emergency cart. Resident #71 received reinforced training by the Respiratory Therapist on the same date regarding the need for their inner cannula to remain in place and the need to not use the 14Fr catheter to self-suction without the inner cannula. Resident #71 was also educated to allow staff to provide and/or supervise [MEDICAL CONDITION] care. Resident #71 remains non-compliant with teaching and plan of care for [MEDICAL CONDITION] and enteral feeding. Resident's physician was notified on 7/11/19. No new orders received Licensed nurses received respiratory training by the Respiratory Therapist starting on 6/8/2019 and continuing through 7/11/2019. Remedial training will continue to assure sustained competencies. Respiratory therapist provided training to licensed nurses through review and proven competency testing in the form of return demonstration on the following regarding: o required supplies and equipment required to be available at bedside at all times. o Placement of a daily check list with initials to assure bedside supplies are available. Licensed nurse is responsible for checklist. o [MEDICAL CONDITION] care including suctioning and cannula care o Emergency cart supplies placed on e-kit. On 07.10.19, the Social Worker evaluated Resident #71 and noted their BIMs to be 8-11. Resident #71 was again educated by the Respiratory Therapist regarding the need for their inner cannula to remain in place and the need to not use the 14Fr catheter to self-suction without the inner cannula. Resident #71 was also educated to allow staff to provide and/or supervise [MEDICAL CONDITION] care. His care plan was reviewed and updated on his personal preferences and his non-compliance with treatment plan for [MEDICAL CONDITION] care and enteral feeding. Resident #71 remains non-compliant with teaching and plan of care for [MEDICAL CONDITION] and enteral feeding. The physician was notified. Note per RT on 7/20/2019 at 4:51 PM indicated .resident refuses inner cannula and drainage dressing . Per interview with RT, she confirmed that no further teaching can be completed without causing trauma as an inner cannula must be in place. Therefore, no further teaching was completed, except to inform patient of the importance of the inner cannula. This patient is well known by the RT and she had stated he most often refuses [MEDICAL CONDITION] or inner cannula. There is one other resident, Resident #3, who has a trach. Their equipment was checked to ensure it was in working order on 07.10.19. Their care plan was also reviewed and updated on personal preferences. QA of [MEDICAL CONDITION] and suction equipment is at the bedside and in working order to be presented to QAPI for a period of three months, or until substantial compliance achieved . Resident #71's care plan was reviewed and updated to reflect his preferences and continued non-compliance with enteral feeding schedule to maintain his caloric needs . On 7.11.19 a care plan meeting had been scheduled with Resident #71 and family member, as well as the care team and physician. However, due to residents' family member unavailability, the care plan meeting has been reschedule for Monday (MONTH) 15, 2019. This is to discuss the following: o The need to use the inner cannula of the trach o The need to have the inner cannula in place prior to using the 14Fr suction catheter o The need to allow staff to suction and witness [MEDICAL CONDITION] care o The need to not remove the feeding from the PEG enteral to prevent weight loss and feeling of being hungry o Discussion of hours of time the enteral feeding needs to occur to prevent nausea and/or vomiting o Plans regarding hospice o Resident #71 wishes and desires and their response regarding the topics discussed in the meeting o Nurses notes and RT notes have refusals documented 6/17/2019 @ 02:49PM, 4/17/2019 @4:25 PM, 6/18/2019 @ 03:24PM, 6/18/2019 @ 5:12PM 7/9/2019@727PM, 7/10/2019 @ 451PM, 7/11/2019 @ 7:57 PM, 7/12/2019 @ 1019 AM Monitoring visits were conducted on (MONTH) 13, 14, 15, 16, and 17, 2019 by surveyors. They interviewed 4 RNs, 4 LVNs, 3 CNAs, 1 Housekeeper, over 2 facility working shifts, Respiratory Therapist, and administrative staff on audits of [MEDICATION NAME], diabetic resident doctor orders with parameters, in-service training on Stop and Watch, Resident Change of Condition, Diabetes Management, respiratory training by the Respiratory Therapist, respiratory supplies at the resident bedside and on the crash cart, weight monitoring, and care plans. Interview and observation of Resident #71 on 7/15/19 at 3:22 p.m. revealed he was lying in bed; [MEDICAL CONDITION] and supplies were noted to be at bedside and additional emergency supplies were noted on the table in Resident #71's room. When asked if he was still doing his own suctioning, Resident #71 said no. Record review of Resident #71's lab revealed a sputum culture was collected on 7/10/19 at 1:20 p.m. and revealed heavy growth of carbapenem resistant pseudomonas aeruginosa isolated and light growth of yeast isolated. Record review of Resident #71's physician orders [REDACTED].>Interview with the SW on 7/15/19 at 4:17 p.m., she said Resident #71 had a care plan meeting with the IDT and his family via phone. She said the RT said she would speak to the MD about reducing the size of the cannula per Resident #71's request. She also said Resident #71 agreed to not suction himself anymore. Interview with LVN R on 7/16/19 at 9:20 a.m., he said Resident #71 continues to [MEDICAL CONDITION] at times but is no longer attempting to suction himself. Interview with Resident #71 on 7/16/19 at 10:22 a.m., he said he didn't [MEDICAL CONDITION] at this time and wanted to sleep because he had a restless night and bad morning. When asked if he was suctioning himself he said, no. Interview with the RT on 7/17/19 at 9:46 a.m. regarding training staff, she said she reviewed all annual training and new hire training in regard to trachs and O2. She said she provided demonstration on a mannequin and had staff provide return demonstration on the mannequin for suctioning and suction techniques, listening for breath sounds,[MEDICAL CONDITION] and replacing disposable inner cannulas. Observation [MEDICAL CONDITION] by the RT and LVN R with Resident #71 on 7/17/19 at 9:59 a.m. revealed no concerns. Record review of the Training In-service form dated 7/8/19 revealed training was provided by the RT on the following: - Oxygen therapy, continuous - Oxygen therapy, cylinder set up - Pulse Oximetry - Medication Administration, aerosol therapy - Medication Administration, metered dose inhalers - Incentive Spirometry - Suctioning, artificial airway - Suctioning, oral - Suctioning, nasotracheal - [MEDICAL CONDITION] care - Sputum Specimen, obtaining of - Ventilator set-up/check On 7/17/19 at 10:47 a.m. the Administrator, DON and Regional Nurse were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not an immediate threat with a scope identified as isolated. The facility was continuing to monitor the Plan of Removal for effectiveness

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for two of three residents (Resident #71 and #132) reviewed for enteral feedings. -The facility failed to follow the Registered Dietitian's recommendations and the physician's administration rate and hold times ordered for Resident #71's enteral feedings. The physician increased Resident #71's enteral feedings twice within four days without the nursing staff implementing either of the increases and the feedings were held longer than the physician ordered hold times. Resident #71 experienced a significant weight loss of 14.7% in 30 days. -The facility failed to administer Resident #132's enteral feedings per the physician's orders [REDACTED]. These failures resulted in an identification of and Immediate Jeopardy (IJ) on 7/10/2019. While the IJ was removed on 7/17/2019 the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. These failures affected two residents and placed them at risk of significant weight loss, hunger, pain, malnutrition, hospitalization or death. Findings include: Resident #71 Record review of Resident #71's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #71's Consolidated Order printed on 6/20/19 read in part for start date 5/1/19 . Pe[DEVICE] placement every shift by aspiration and auscultation prior to medication administration, bolus feedings and/or water flushes .Pe[DEVICE] flush 30 cubic centimeter PEG Tube every shift water before and after medications, use 15 cc water flush in between each medication administered . Pe[DEVICE] Residual cubic centimeter feeding tube every shift check residual q shift. Hold if greater than 100cc, hold feeding and notify MD . Record review of Resident #71's Consolidated Order printed on 6/20/19 read in part for start date 6/18/19 . Fibersource HN 0.05 gram-1.2 kcal/ml liquid for tube feed (nutritional supplement/[MEDICATION NAME]/fructooligosaccharides/fiber) 85 milliliter PEG Tube every 8 hours for 22 hrs hold feed from 12 noon-2pm . Record review of Resident #71's significant change in status MDS assessment dated [DATE] revealed a BIMS score of 0 - indicating severe cognitive impairment. He was totally dependent on one staff for eating, and totally dependent on two or more staff for dressing, toilet use, and personal hygiene. His weight was recorded at 146 pounds. He received 51% or more of his nutrition through tube feeding and 501 cc or more of fluid by the feeding tube. Resident #71 was re-evaluated by the SW on 7/10/19 and his revised BIMS score was between 8 and 11, indicating moderate cognitive impairment. Record review of Resident #71's care plan printed on 6/20/2019 read in part, .Altered Nutritional Status (05/01/2019: onset) related to admission status: recent weight loss (05/01/19: onset) . Evidence by: . BMI <21 (05/10/19: onset) .Significant weight loss (05/10/19: onset) .Medical diagnosis (05/10/19 : onset) . .Interventions: Dietitian referral as indicated (05/01/19: onset) . Monitor oral intake of food and fluid (05/02/19: onset) . Altered Nutritional Status: Enteral Feeding Monitor (05/01/2019: onset) related to dysphagia/swallowing difficulty (06/17/19: onset) .chewing difficulty (06/17/19: onset) .Inability to consume adequate food (06/17/19: onset) .Inability to consume adequate fluids (06/17/19: onset) . Evidence by: BMI <21 (06/17/19: onset) . Significant weight loss (06/17/19: onset) . Resident has inadequate nutrition infusion (06/17/19: onset) . Record review of Resident #71's weight log read in part, .5/02/2019: 150 pounds . 5/21/2019: 145 pounds . 6/05/2019: 146.2 pounds . Resident #l71's height was recorded as 6'4. Record review of the Weight Variance Report dated (MONTH) 2019 and written by the Dietician read in part, .(Resident #71) 128 pounds . -14.7% weight loss in 30 days . Comments: This weight was confirmed 6/14/19 by a reweigh as reported by ADON (but was not in EMR). RDN increased rate of TF 6/17/19. Follow monthly . Record review of Resident #71's Nutrition Therapy assessment dated [DATE] and written by the Consultant Dietician read in part, . Enteral feeding including water flushes provides: ml Total Fluid 1430 ml total for enteral feed + 87 + 255 = 2555 PO intake and / or Enteral feeding meets estimated nutrient needs: No % of estimated needs met from enteral feeding = 75% . Medication and Physical Examination: Oral condition: Missing teeth/unfit dentures, dysphagia/swallowing difficulty . Skin condition: pressure area, 6/14/19 wound report: stage 2 right heel (blister) 3 x 3 x 0.1 . Comments: Resident can communicate with writing. He is able to write out his comments, requests, etc. Nutrition Diagnosis: [REDACTED]. Related to: dysphagia/swallowing difficulty, limited mobility, increased needs for wound care, inability to consume adequate food, inability to consume adequate fluids, edentulous/missing teeth, current medical condition, current enteral feeding orders. As evidenced by: BMI < normal range, significant weight loss, presence of pressure ulcers, enteral feeding does not meet estimated needs, documented need for enteral feeding . Intervention: change enteral feeding, change fluid flush as ordered, Vitamin C . Goals: Resident will gain at least 1 - 2 pounds per week, resident's wounds will show evidence of healing, resident will have no further skin breakdown, resident will have no S/S dehydration, resident will tolerate enteral feeding without complications . Comments: Per nurse, resident is off hospice services as he wanted therapy. Nurse also reported resident was tolerating enteral nutrition well with no N/V or constipation. Current reported weight (by ADON and by resident) is 128 pounds reflecting a 14.7% unplanned weight loss. This reported weight was taken twice, two different days. Current estimated needs and new order for enteral feeding should stop weight loss and begin weight gain. If he does tolerate new feeding rate, can increase if needed to improve rate of weight gain . Plan: .change order to Fibersource HN at goal rate 85/hour x 22 hours (hold 12p-2p) for 2244 kcal, 101 g protein, 1511 cc water . Record review of Resident #71's Physician orders [REDACTED].Fibersource HN 0.05-gram-1.2 kcal/ml liquid for tube feed . 85 milliliter PEG tube every 8 hours for 22 hours hold feed from 12 noon - 2 p.m., start date 6/18/19. Record review of Resident #71's eMAR dated 6/1/2019 - 6/20/2019 read in part, .Fibersource HN 0.05 gram - 1.2 kcal/ml liquid for tube feed . 55 liquid [DEVICE] every hour . start date 5/21/19, end date: 6/14/19 . . Fibersource HN 0.05 gram - 1.2 kcal/ml liquid for tube feed . 65 liquid [DEVICE] every hour . start date 6/14/19, end date: 6/17/19 . . Fibersource HN 0.05 gram - 1.2 kcal/ml liquid for tube feed . 85 liquid [DEVICE] every hour . start date 6/18/19 . Observation on 6/17/19 at 3:25 p.m. of Resident #71, he was lying in a long bed awake. Fibersource HN 1.2 kcal/ml was running at a rate of 55 cc/hr. The bag was labeled as hung on 6/17/19 at 5:00 a.m. with a rate of 58 cc/hr. Observation and interview on 6/18/19 at 10:30 a.m. of Resident #71, Fibersource HN 1.2 kcal/ml was running at a rate of 55 cc/hr. The bag was labeled as hung on 6/18/19 at 4:00 a.m. with a rate of 55 cc/hr. Resident #71 said the facility was supposed to go up on the calories, so he could gain weight. Resident # 71 wrote on a notebook paper that he has lost 40 pounds since he's been here and he's :starving to death. Resident wrote that he just stays hungry all of the time. Observation on 6/18/19 between 1:22 p.m. and 4:14 p.m. revealed Resident #71's feeding was off. There was approximately 650 cc of feeding remaining in the bag. Interview on 6/18/19 at 4:20 p.m. with RN J, she said her shift started at 2 p.m. and Resident #71 was on a 2-hour feeding hold. She said she was unsure if the morning nurse allowed Resident #71 to have a 2-hour rest. She said she would hang a new formula bag and connect Resident #71 to the feeding. Observation on 6/18/19 at 4:51 p.m. of Resident #71, Fibersource HN was hanging and running at a rate of 55 cc/hr. It was labeled as hung on 6/18/19 at 4:00 p.m. Observation and Interview on 6/18/19 at 4:58 p.m. with RN J, she said Resident #71's feeding administration rate was ordered for 55 cc/hr. RN J looked at Resident #71's physician's orders [REDACTED]. Continued observation revealed the Dietitian appeared on the hall. RN J, the Dietitian, and Surveyor went into Resident #71's room and observed his feeding running at a rate of 55 cc/hr. The Dietitian told RN J that Resident #71's feeding rate was changed to 85 cc/hr yesterday (6/17/19). The Dietitian said she may not have reported the information to the nurse prior to leaving the facility. RN J said she was unaware of the rate change because the morning nurse (RN L) did not report anything to her during shift change. RN J said she normally received information about order changes during shift change. She said whoever made the change was responsible for passing the information on to the next shift. She said she could have checked the physician's orders [REDACTED]. She said the facility recently changed over to a new electronic system and she had not received training on it. She said the new feeding order was also not listed on the eMAR. She said she would correct Resident #71's rate. Interview on 6/20/2019 at 9:29 a.m. with the MD, he said Resident #71 had been in the facility for about a month or less. He said due to his [DIAGNOSES REDACTED]. He said in the long run the administration rate would not make a difference but an order is an order. Interview on 6/20/19 at 10:34 a.m. with Resident #71, he said he weighed 128 pounds last week. Interview on 6/20/19 at 10:42 a.m. with RN L, she said on the previous Friday (6/14/19) the Dietitian was in the facility and mentioned that she may increase Resident #71's rate because he needed more caloric intake to increase his weight. RN L said she left work on Friday, was off for two days and returned on Monday. She said on Monday no staff reported a change in rate during shift report and she was not aware that Resident #71's administration rate had changed. She said she normally finds out when orders have changed during shift report. She said she could have checked the eMAR to confirm the rate. Observation and Interview on 6/20/19 at 10:48 a.m. of Resident #71, a physical therapist weighed Resident #71 on a scale while he was sitting in his wheelchair. The physical therapist said the total weight (the resident and wheelchair) was 175.2 pounds, the wheelchair weighed 52.8 pounds, Resident #71's calculated weight was 122.4 pounds. Resident #71 said at that time that he had lost an additional 6 pounds. Resident #132 Record review of Resident #132's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #132's baseline care plan dated 6/14/19 read in part, .cognition/communication/vision: decision making skills -independent . Record review of Resident #132's Nutrition Therapy assessment dated [DATE] and written by Dietitian B read in part, . Nutritional orders . Diet order: Diet-NPO . Enteral feeding -continuous -[MEDICATION NAME] 1.5, 35 cc/hour x 20 hours . Height & Weight .Current Weight (lbs): 119 . BMI: 17.6 . Usual body weight: 124 per resident . Nutritional Lab Results . Date: 06/01/2019 . Comments .K 3.3 L, glucose 125 H, BUN 5 L, creatinine. 0.53 L, hb 9.2 L, hct 28.4 L . Intake/Estimated Nutritional needs . Calories: .1941 calories . Kcal : Enteral feeding or [MEDICATION NAME] feeding provides: 1050 calories . PO intake and/or enteral feeding and/or [MEDICATION NAME] feeding meets estimated nutrient needs: No . Nutrition Diagnosis . Problem: -Resident has swallowing difficulty, -resident is underweight, . -resident has inadequate nutrients from enteral nutrition . As evidenced by - BMI < normal range, -other labs, -enteral feeding does not meet estimated needs . Intervention . Change enteral feeding . Goals . Resident will gain at least 1 -2 pounds per week . Comments: Feeding changed to 65 cc/hour x 20 hours per day. This will provide 1950 calories .feeding order change meets residents calorie, protein, and fluid needs . Record review of Resident #132's Physician orders [REDACTED].[MEDICATION NAME] 1.5 cal 0.07 gram - 1.5 kcal/ml liquid for tube feed . 65 milliliter/ hour [DEVICE] every am pm shift . Peg tube feeding off at 12 pm - 2 pm, start date 6/17/19 . Observations on 6/17/19 at 3:38 p.m., 6/18/19 at 10:26 a.m., 6/18/19 at 1:24 p.m., 6/18/19 at 2:46 p.m., and 6/18/19 at 4:45 p.m. revealed Resident #132 was lying in bed. He was receiving [MEDICATION NAME] 1.5 cal at a rate of 35 cc/hr. Observation and Interview on 6/18/19 at 5:15 p.m. with RN J, she said she was not aware Resident #132's feeding rate had changed. RN J looked at Resident #132's Physician orders [REDACTED]. She said she had not received any information during shift change (from RN L). RN J and the Surveyor went to Resident #132's room and observed his [MEDICATION NAME] 1.5 cal running at a rate of 35 cc/hr. She said she would correct the rate. Interview on 6/19/19 at 5:07 p.m. with the DON, she said the nurses should have verified the correct rate by looking at the Physician orders [REDACTED]. Interview on 6/20/19 at 10:42 a.m. with RN L, she said Resident #132 was new to the facility and she was not sure about his feeding orders. Record review of the facility's Enteral Nutrition policy dated (MONTH) 2007 read in part, .Adequate nutritional support through enteral feeding will be provided to residents unable to consume adequate nutritional intake by mouth .Initial orders 1. A Dietitian will assess residents who are dependent on tube feeding, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feeding . The facility Administrator, Director of Nursing and Regional Director of Operations were notified on 7/10/2019 at 5:27 p.m. that an IJ situation had been identified due to the above failures. A plan of removal was requested at that time. On 7/12/19 a revised Plan of Removal was accepted. The following is a plan of removal to the IJ called 07.10.19 at 5:22 PM for the facility's alleged violation of Neglect, and Quality of Care, relating to Resident #71. Notification of IJ status was made by the Administrator to the Medical Director, on 07.10.19 at 6:10 PM. The Medical Director has made themselves available to the team as needed . Nursing aides were trained starting on 07.10.19, through review and proven competency tested in the form of a quiz. This included instructions on: o Stop and Watch with Interact 4.0. The Stop and Watch Early Warning sign tool is a tool within the InterAct Program for C.N.A use which provides regular evaluation and recognition of changes in residents/patients' condition. Also instructs reporting changes to licensed nurses. o Stop and Watch Early Warning Tool instructions: If you have identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can S: Seems different than usual T: Talks or communicates less O: Overall needs more help P: Pain - new or worsening; Participated less in activities A: Ate less N: No bowel movement in 3 days; or diarrhea D: Drank Less W: Weight change; swollen legs or feet A: Agitated or nervous more than usual T: Tired, weak, confused, or drowsy C: Change in skin color or condition H: Help with walking, transferring, toileting more than usual o Use of Stop and Watch Early Warning Sign tool to be completed if resident, in dining room or in room dining complete less than 25% of their meal. The Stop and Watch Early Warning Sign tool is then given to the Charge Nurse for identification of those residents at high risk for [DIAGNOSES REDACTED] related to decreased intake. The Plan of Care Devices (part of the E.H.R.) are to also be updated with meal intake. Licensed Nurses received additional training, through review and proven competency testing in the form of a quiz on Change of Condition through InterAct 4.0 Program utilizing Change of Condition. o The INTERACT quality improvement program is designed to improve the early identification, evaluation, management, documentation, and communication about acute changes in condition of residents in nursing homes, assisted living facilities and home health care. The fundamental goal of INTERACT is to improve care; its strategies and tools will help reduce the frequency of potentially preventable transfers to the acute hospital and related complications that lead to increased health care costs. The program includes evidence-based and expert-recommended tools, strategies to implement them, and related educational resources. The INTERACT tools are meant to be integrated into every-day care and be incorporated into Villa Toscana's quality improvement program . Licensed Nurses, on 7/10/2019 were in-serviced on Diabetes management and the following: o InterAct 4.0 (see description and purpose above) and Change of Condition in Collain (Electronic Medical Records). o When to notify the DON, Physician and Family o Escalation process if attending physician does not respond timely . When to notify administrative staff (defined as DON/designee) of changes of condition . Each morning in the clinical meeting blood sugars, interventions, Change of Condition and the results of the [MEDICATION NAME] audits for medications needed will be discussed . QA of Change in Condition to be presented to QAPI for a period of three months, or until substantial compliance achieved . On 07.10.19, the Social Worker evaluated Resident #71 and noted their BIMs to be 8-11 . His care plan was reviewed and updated on his personal preferences and his non-compliance with treatment plan for [MEDICAL CONDITION] care and enteral feeding. Resident #71 remains non-compliant with teaching and plan of care for [MEDICAL CONDITION] and enteral feeding. The physician was notified . Clinical leadership and the Registered Dietician (RD) reviewed all residents with enteral feeding. There are currently 14 residents receiving enteral feeding as of 07.10.19. Residents were weighed on 07.10.19. Any residents with an undesired 3lb. weight change were re-weighed and those with a verified undesired weight change of 3lb. will be monitored through weekly Standards of Care. The RD reviewed rates and caloric needs of enteral feeding residents and made recommendations and changes to rates to meet resident needs. A weight schedule was updated per hall per day of the week to ensure all resident weights are captured. All newly admitted residents will be weighed upon admission. This process began on 7/10/2019 for new admissions and on Monday 7/15 /2019 for new hall schedule. Weights will be monitored during the weekly S[NAME] and new admissions will be reviewed the following morning and weekly for 4 weeks. Resident #71's care plan was reviewed and updated to reflect his preferences and continued non-compliance with enteral feeding schedule to maintain his caloric needs. QA of undesired weight changes to be presented to QAPI for a period of three months, or until substantial compliance achieved. QA of validation of correct enteral feeding orders and rates for a period of three months, or until substantial compliance achieved. On 7.11.19 a care plan meeting had been scheduled with Resident #71 and family member, as well as the care team and physician. However, due to residents' family member unavailability, the care plan meeting has been reschedule for Monday (MONTH) 15, 2019. This is to discuss the following: o The need to use the inner cannula of the trach o The need to have the inner cannula in place prior to using the 14Fr suction catheter o The need to allow staff to suction and witness [MEDICAL CONDITION] care o The need to not remove the feeding from the PEG enteral to prevent weight loss and feeling of being hungry o Discussion of hours of time the enteral feeding needs to occur to prevent nausea and/or vomiting o Plans regarding hospice o Resident #71 wishes and desires and their response regarding the topics discussed in the meeting o Nurses notes and RT notes have refusals documented 6/17/2019 @ 02:49PM, 4/17/2019 @4:25 PM, 6/18/2019 @ 03:24PM, 6/18/2019 @ 5:12PM 7/9/2019@727PM, 7/10/2019 @ 451PM, 7/11/2019 @ 7:57 PM, 7/12/2019 @ 1019 AM Monitoring visits were conducted on (MONTH) 13, 14, 15, 16, and 17, 2019 by surveyors. They interviewed 4 RNs, 4 LVNs, 3 CNAs, 1 Housekeeper, over 2 facility working shifts, the Respiratory Therapist, and administrative staff on audits of [MEDICATION NAME], diabetic resident doctor orders with parameters, in-service training on Stop and Watch, Resident Change of Condition, Diabetes Management, respiratory training by the Respiratory Therapist, respiratory supplies at the resident bedside and on the crash cart, weight monitoring, and care plans. Interview and observation of Resident #71 on 7/15/19 at 3:22 p.m. revealed he was lying in bed; his tube feeding was turned off. Resident #71 said it was his down time. Resident #71 said he was no longer feeling hungry and he thought they had the tube feeding straightened out. Interview with the SW on 7/15/19 at 4:17 p.m., she said Resident #71 had a care plan meeting with the IDT and his family via phone. She said they discussed his non-compliance with the feeding and he requested to be on bolus feedings as he was previously on bolus feedings prior to his admission. She said the DON would be reaching out to the dietitian and the MD about changing to bolus feedings. Interview with LVN R on 7/16/19 at 9:20 a.m., he said Resident #71 continues to disconnect his feeding tube. Observation on 7/16/19 between 9:36 a.m. and 10:17 a.m. revealed three residents had tube feedings hanging with no date or time noted on the bag. Interview with the Administrator and Regional Nurse on 7/16/19 at 11:15 a.m. and they both said they would re-do the tube feeding audits and complete additional in-services. Interview with the Regional Nurse on 7/17/19 at 9:20 a.m. revealed a new audit was completed on residents with tube feedings and additional in-services were completed on the afternoon and evening of 7/16/19 and the morning of 7/17/19. Interview with the DON on 7/17/19 at 9:52 a.m., she said Resident #71 was changed to bolus feedings per his request. Observation of three residents with tube feedings on 7/17/19 between 9:30 a.m. and 10:19 a.m. revealed no concerns. Record review of the Training In-Service Form dated 7/16/19 at 2:45 p.m. revealed the in-service was completed by the Regional Nurse on Principles of Tube Feeding Administration, clarifying orders and following right rate, right resident and right orders. Based on the interviews conducted with the staff, record review of in-services provided to staff, and audits of [MEDICATION NAME], diabetic resident orders,[MEDICAL CONDITION] at bedside, and resident weight records, it was determined that the facility had completed the facility Plan of Removal. On 7/17/19 at 10:47 a.m. the Administrator, DON and Regional Nurse were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not an immediate threat with a scope identified as pattern. The facility was continuing to monitor the Plan of Removal for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care including [MEDICAL CONDITION] care and tracheal suctioning was provided such care consistent with professional standards of practice for one of two residents (Resident #71) reviewed for [MEDICAL CONDITION] care. -The facility failed to have a working suction machine at Resident #71's bedside to suction excretions for the [MEDICAL CONDITION]. The suction machine in Resident #71's bed was not operational. -The facility failed to ensure there was emergency equipment and supplies at the bedside of Resident #71 to use in case of [MEDICAL CONDITION]. There was no ambu bag or replacement inner tracheal cannula in Resident #71's room. These failures resulted in an identification of and Immediate Jeopardy (IJ) on 7/10/2019. While the IJ was removed on 7/17/2019 the facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm with a scope identified as isolated. These failures affected one resident and placed him at risk for respiratory complications, hospitalization , and/or death. Findings include: Resident #71 Record review of Resident #71's face sheet revealed he was a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #71's significant change MDS dated [DATE] revealed a BIMS score of 0 - indicating severe cognitive impairment. He was totally dependent on one staff for eating, totally dependent on two staff for dressing, toilet use, and personal hygiene. He needed [MEDICAL CONDITION] care. Resident #71 was re-evaluated by the SW on 7/10/19 and his revised BIMS score was between 8 and 11, indicating moderate cognitive impairment. Record review of Resident #71's Consolidated Order printed on 6/20/19 read in part for start date 5/1/19 . O2 saturations every morning O2 saturation check . Pe[DEVICE] dressing 1 time per day cleanse site with normal saline pat dry and cover with dry dressing . Pe[DEVICE] placement every shift by aspiration and auscultation prior to medication administration, bolus feedings and/or water flushes .Pe[DEVICE] flush 30 cubic centimeter PEG Tube every shift water before and after medications, use 15 cc water flush in between each medication administered . Pe[DEVICE] Residual cubic centimeter feeding tube every shift check residual q shift. Hold if greater than 100cc, hold feeding and notify MD .[MEDICAL CONDITION] As Needed, as needed secretion **remove and replace disposable inner cannula. Cleanse [MEDICAL CONDITION] with NS. Pat dry apply dressing change ties when soiled . [MEDICAL CONDITION] time per day **Observe for changes in sputum, notify MD of increase viscosity in color of sputum, bloody sputum and increase in sputum production ***Give oral care may suction oral cavity .[MEDICAL CONDITION] every am pm shift (6am-2pm-10pm) Shiley size 6 cuff **Remove and Replace Disposable inner cannula. Cleanse [MEDICAL CONDITION] with NS, pat dry apply dressing. Change ties when soiled . Record review of Resident #71's care plan printed on 6/20/19 read in part, . Care area/problem: [MEDICAL CONDITION] (06/19/2019:updated) . evidence by: [MEDICAL CONDITION] needed secretion (05/01/19: onset) . [MEDICAL CONDITION] time per day (05/01/19: onset) . Interventions . suction PRN and as ordered (05/01/19:onset) . Record review of Resident #71's Physician orders [REDACTED]. [MEDICAL CONDITION] needed secretion . start date 5/1/19 . [MEDICAL CONDITION] time per day . start date 5/1/19 . Record review of Resident #71's MAR for (MONTH) 2019 revealed an H was documented [MEDICAL CONDITION] on 6/17/19 at 9:00 a.m. The H indicated on-hold. There was no documentation [MEDICAL CONDITION] on 6/18/19 to 6/20/19. Record review of Resident #71's respiratory therapist note dated 6/17/19 at 4:38 p.m. and written by the RT read in part, . RT received consult to eval and treat. Resident's POA recently provoked his hospice services . RT introduced them self and informed resident why they were there, and resident refused to let RT touch [MEDICAL CONDITION]. RT noted the inner cannula was not in place, but the resident refused to let the RT put an inner cannula in trach. Ambu bag at bedside with [MEDICAL CONDITION]. Observation and Interview on 6/17/19 at 12:58 p.m. of Resident #71, he pointed at [MEDICAL CONDITION] and said no one had suctioned him for since yesterday because the suction machine was not working. He said he needed to be suctioned. Resident #71 placed the yanker in his mouth to demonstrate to the Surveyor that it was not suctioning. Observation and Interview on 6/17/19 at 1:25 p.m. of Resident #71 with MDS B, she entered the resident's room and acknowledged there was no suction coming from the machine. She said she would get Resident #71's nurse. Observation and Interview on 6/17/19 at 1:27 p.m. with RN L, she entered Resident #71's room and checked the suction machine. The machine was on but was not providing suction. She said she would get the resident another saline bottle for the suction machine and mentioned that she was working by herself on the rehab unit. RN L continued to say that there was some type of leak going on with the suction machine and she would have to call respiratory to fix it. She said a respiratory staff was supposed to be on site, but she would page them. Observation on 6/17/19 at 1:38 p.m. of Resident #71's room revealed there was no ambu bag present. Interview on 6/17/19 at the same time with RN L, she said Resident #71 had recently gotten off hospice services and hospice removed [MEDICAL CONDITION] supplies from the resident's room. She said she did not see the ambu bag in the room. She said the facility had to provide Resident #71 with emergency equipment. She said she normally suctioned him 2-3 times per day during her 8-hour shift. She said the resident also liked to suction himself. Interview on 6/17/19 at 3:23 p.m. with the Respiratory Therapist, she said she had not been in Resident 71's room to see him yet. She said she did not provide care for Hospice patients. She said she did not know Resident #71 was discharged from hospice care. She said she would stock resident rooms with the [MEDICAL CONDITION] upon admission. Interview on 6/20/19 at 12:28 p.m. with the DON, she said the facility normally stored the ambu bags on the crash cart. She said there was also a respiratory therapist on site. Interview on 6/20/19 at 1:24 p.m. with RN L, she [MEDICAL CONDITION] had to have an ambu bag in the room in case of an emergency such as respiratory distress. She said Resident #71 did not have an ambu bag in his room on Monday (6/17/19) and she could not find one on the crash cart. She said she had to page the Respiratory Therapist who found two ambu bags in the supply room. She also said that on Monday (6/17/19) there was a malfunction with Resident #71's suctioning machine. She said everything was set up, but it would not suction. She said they fixed the machine. Record review of the facility's [MEDICAL CONDITION] Care policy dated (MONTH) 2007 read in part, . Miscellaneous . 8. A suction machine . must be available at the bedside at all times . The facility Administrator, Director of Nursing and Regional Director of Operations were notified on 7/10/2019 at 5:27 p.m. that an IJ situation had been identified due to the above failures. A plan of removal was requested at that time. On 7/12/19 a revised Plan of Removal was accepted. The following is a plan of removal to the IJ called 07.10.19 at 5:22 PM for the facility's alleged violation of Neglect, and Quality of Care, relating to Resident #71. Notification of IJ status was made by the Administrator to the Medical Director, on 07.10.19 at 6:10 PM. The Medical Director has made themselves available to the team as needed . Nursing aides were trained starting on 07.10.19, through review and proven competency tested in the form of a quiz. This included instructions on: o Stop and Watch with Interact 4.0. The Stop and Watch Early Warning sign tool is a tool within the InterAct Program for C.N.A use which provides regular evaluation and recognition of changes in residents/patients' condition. Also instructs reporting changes to licensed nurses. o Stop and Watch Early Warning Tool instructions: If you have identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can S: Seems different than usual T: Talks or communicates less O: Overall needs more help P: Pain - new or worsening; Participated less in activities A: Ate less N: No bowel movement in 3 days; or diarrhea D: Drank Less W: Weight change; swollen legs or feet A: Agitated or nervous more than usual T: Tired, weak, confused, or drowsy C: Change in skin color or condition H: Help with walking, transferring, toileting more than usual o Use of Stop and Watch Early Warning Sign tool to be completed if resident, in dining room or in room dining complete less than 25% of their meal. The Stop and Watch Early Warning Sign tool is then given to the Charge Nurse for identification of those residents at high risk for [DIAGNOSES REDACTED] related to decreased intake. The Plan of Care Devices (part of the E.H.R.) are to also be updated with meal intake. Licensed Nurses received additional training, through review and proven competency testing in the form of a quiz on Change of Condition through InterAct 4.0 Program utilizing Change of Condition. o The INTERACT quality improvement program is designed to improve the early identification, evaluation, management, documentation, and communication about acute changes in condition of residents in nursing homes, assisted living facilities and home health care. The fundamental goal of INTERACT is to improve care; its strategies and tools will help reduce the frequency of potentially preventable transfers to the acute hospital and related complications that lead to increased health care costs. The program includes evidence-based and expert-recommended tools, strategies to implement them, and related educational resources. The INTERACT tools are meant to be integrated into every-day care and be incorporated into Villa Toscana's quality improvement program . Licensed Nurses, on 7/10/2019 were in-serviced on Diabetes management and the following: o InterAct 4.0 (see description and purpose above) and Change of Condition in Collain (Electronic Medical Records). o When to notify the DON, Physician and Family . When to notify administrative staff (defined as DON/designee) of changes of condition . QA of Change in Condition to be presented to QAPI for a period of three months, or until substantial compliance achieved . Nursing leadership checked the supplies and suction equipment placed at Resident #71 bedside on 06.28.19. Respiratory therapist provided list of supplies [MEDICAL CONDITION] to be checked by charge nurses shift to shift. To be documented on MAR. Back up supplies on emergency cart. Resident #71 received reinforced training by the Respiratory Therapist on the same date regarding the need for their inner cannula to remain in place and the need to not use the 14Fr catheter to self-suction without the inner cannula. Resident #71 was also educated to allow staff to provide and/or supervise [MEDICAL CONDITION] care. Resident #71 remains non-compliant with teaching and plan of care for [MEDICAL CONDITION] and enteral feeding. Resident's physician was notified on 7/11/19. No new orders received Licensed nurses received respiratory training by the Respiratory Therapist starting on 6/8/2019 and continuing through 7/11/2019. Remedial training will continue to assure sustained competencies. Respiratory therapist provided training to licensed nurses through review and proven competency testing in the form of return demonstration on the following regarding: o required supplies and equipment required to be available at bedside at all times. o Placement of a daily check list with initials to assure bedside supplies are available. Licensed nurse is responsible for checklist. o [MEDICAL CONDITION] care including suctioning and cannula care o Emergency cart supplies placed on e-kit. On 07.10.19, the Social Worker evaluated Resident #71 and noted their BIMs to be 8-11. Resident #71 was again educated by the Respiratory Therapist regarding the need for their inner cannula to remain in place and the need to not use the 14Fr catheter to self-suction without the inner cannula. Resident #71 was also educated to allow staff to provide and/or supervise [MEDICAL CONDITION] care. His care plan was reviewed and updated on his personal preferences and his non-compliance with treatment plan for [MEDICAL CONDITION] care and enteral feeding. Resident #71 remains non-compliant with teaching and plan of care for [MEDICAL CONDITION] and enteral feeding. The physician was notified. Note per RT on 7/20/2019 at 4:51 PM indicated .resident refuses inner cannula and drainage dressing . Per interview with RT, she confirmed that no further teaching can be completed without causing trauma as an inner cannula must be in place. Therefore, no further teaching was completed, except to inform patient of the importance of the inner cannula. This patient is well known by the RT and she had stated he most often refuses [MEDICAL CONDITION] or inner cannula. There is one other resident, Resident #3, who has a trach. Their equipment was checked to ensure it was in working order on 07.10.19. Their care plan was also reviewed and updated on personal preferences. QA of [MEDICAL CONDITION] and suction equipment is at the bedside and in working order to be presented to QAPI for a period of three months, or until substantial compliance achieved . On 7.11.19 a care plan meeting had been scheduled with Resident #71 and family member, as well as the care team and physician. However, due to residents' family member unavailability, the care plan meeting has been reschedule for Monday (MONTH) 15, 2019. This is to discuss the following: o The need to use the inner cannula of the trach o The need to have the inner cannula in place prior to using the 14Fr suction catheter o The need to allow staff to suction and witness [MEDICAL CONDITION] care o The need to not remove the feeding from the PEG enteral to prevent weight loss and feeling of being hungry o Discussion of hours of time the enteral feeding needs to occur to prevent nausea and/or vomiting o Plans regarding hospice o Resident #71 wishes and desires and their response regarding the topics discussed in the meeting o Nurses notes and RT notes have refusals documented 6/17/2019 @ 02:49PM, 4/17/2019 @4:25 PM, 6/18/2019 @ 03:24PM, 6/18/2019 @ 5:12PM 7/9/2019@727PM, 7/10/2019 @ 451PM, 7/11/2019 @ 7:57 PM, 7/12/2019 @ 1019 AM Monitoring visits were conducted on (MONTH) 13, 14, 15, 16, and 17, 2019 by surveyors. They interviewed 4 RNs, 4 LVNs, 3 CNAs, 1 Housekeeper, over 2 facility working shifts, the Respiratory Therapist, and administrative staff on audits of [MEDICATION NAME], diabetic resident doctor orders with parameters, in-service training on Stop and Watch, Resident Change of Condition, Diabetes Management, respiratory training by the Respiratory Therapist, respiratory supplies at the resident bedside and on the crash cart, weight monitoring, and care plans. Interview and observation of Resident #71 on 7/15/19 at 3:22 p.m. revealed he was lying in bed; [MEDICAL CONDITION] and supplies were noted to be at bedside and additional emergency supplies were noted on the table in Resident #71's room. When asked if he was still doing his own suctioning, Resident #71 said no. Record review of Resident #71's lab revealed a sputum culture was collected on 7/10/19 at 1:20 p.m. and revealed heavy growth of carbapenem resistant pseudomonas aeruginosa isolated and light growth of yeast isolated. Record review of Resident #71's physician orders [REDACTED].>Interview with the SW on 7/15/19 at 4:17 p.m., she said Resident #71 had a care plan meeting with the IDT and his family via phone. She said the RT said she would speak to the MD about reducing the size of the cannula per Resident #71's request. She also said Resident #71 agreed to not suction himself anymore. Interview with LVN R on 7/16/19 at 9:20 a.m., he said Resident #71 continues to [MEDICAL CONDITION] at times but is no longer attempting to suction himself. Interview with Resident #71 on 7/16/19 at 10:22 a.m., he said he didn't [MEDICAL CONDITION] at this time and wanted to sleep because he had a restless night and bad morning. When asked if he was suctioning himself he said, no. Interview with the RT on 7/17/19 at 9:46 a.m. regarding training staff, she said she reviewed all annual training and new hire training in regard to trachs and O2. She said she provided demonstration on a mannequin and had staff provide return demonstration on the mannequin for suctioning and suction techniques, listening for breath sounds,[MEDICAL CONDITION] and replacing disposable inner cannulas. Observation [MEDICAL CONDITION] by the RT and LVN R with Resident #71 on 7/17/19 at 9:59 a.m. revealed no concerns. Record review of the Training In-service form dated 7/8/19 revealed training was provided by the RT on the following: - Oxygen therapy, continuous - Oxygen therapy, cylinder set up - Pulse Oximetry - Medication Administration, aerosol therapy - Medication Administration, metered dose inhalers - Incentive Spirometry - Suctioning, artificial airway - Suctioning, oral - Suctioning, nasotracheal - [MEDICAL CONDITION] care - Sputum Specimen, obtaining of - Ventilator set-up/check On 7/17/19 at 10:47 a.m. the Administrator, DON and Regional Nurse were informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm with a scope identified as isolated. The facility was continuing to monitor the Plan of Removal for effectiveness.

Based on observation, interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, in accordance with professional standards of practice for one (Resident #16) of 18 residents reviewed for pain management. -The facility did not assess and effectively treat Resident #16's new complaint of pain pain to her right hip. These failures affected one resident and placed her at risk of increased pain and discomfort. Findings included: Resident #16 Record review of Resident #16's face sheet dated 6/20/19 revealed an [AGE] year-old female admitted on [DATE] and re-admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #16's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating she was moderately cognitively impaired. The resident needed a mechanical lift for transfers and extensive assist with transfers between surfaces. Record review of Resident #16's care plan dated 6/20/19 read in part . she was immobile and needed maximum help with bed mobility and transfers . Interventions . provide appropriate level of assistance to promote safety of resident . The resident has pain in the right and left knees . Interventions . administer pain medication as ordered, assess pain (location, severity, type of pain, precipitating factors, and relief factors using the pain assessment form), and notify physician of any changes in level of frequency of pain . Record review of Resident #16's Medication Administration Record [REDACTED]. The documentation indicated she received [MEDICATION NAME] 50 mg on: - 6/14/19 time unknown for pain of 5 location right knee, - 6/14/19 time unknown for pain of 6 for generalized pain. - 6/15/19 time unknown for pain 8 location right knee, - 6/15/19 time unknown, for pain of 6 location legs. - 6/16/19 time unknown, for pain 8 location right hip. - 6/18/19 time unknown, pain of 6 for generalized pain, - 6/18/19 time unknown, pain of 8 location right hip, - 6/18/19 time unknown, pain 8, location generalized. - 6/19/19 time unknown, pain of 8 for right hip pain. Observation and Interview on 6/19/19 at 3:07 p.m. of incontinence care provided by CNA DD to Resident #16. When Resident #16 was rolled to her left side she displayed grimacing, screamed out, and moaned in pain, saying her right hip hurt, but the aid continued the care. Resident #16 said the pain started on 6/14/19 after she was transferred from her wheelchair back to bed and the CNA was to tell the nurse about her pain. She said nothing unusual happened during the transfer. She said she had not gotten up out of bed since 6/14/19 because of the pain in her hip and was afraid it would worsen with movement. Resident #16 said she had told the nurses, but was unsure of the nurses' names. She said the nurses gave her a pain pill, but she still had a lot of pain with movement. While CNA DD was performing care for Resident #16 she said that the pain was new in her right hip and CNA DD told Resident #16 she would notify the floor nurse of her pain complaint after she completed the care and that she needed pain medication. Interview on 6/20/19 at 9:36 a.m. with Resident #16, she said the night nurse, name unknown, came and talked with her about her right hip pain. She said the nurse did not look at her hip but did tell her the doctor would be notified of the new pain. She said the nurse did not give her any pain medication at that time. Interview on 6/20/19 at 9:42 a.m. with RN B and the ADON, RN B said she was not aware of any complaints of pain from Resident #16. She said there was no report from the night nurse about Resident #16. RN B said the resident had frequent right knee pain that radiated throughout her leg. She said she would assess the resident and notify the physician if there were changes. ADON said she would check into the resident's paperwork to see about any changes. Interview on 6/20/19 at 11:02 a.m. with CNA DD, she said she had told LVN K on 6/19/19 around 4:00 p.m. about Resident #16's pain to right hip when CNA DD moved the resident in bed. CNA DD said LVN K was going to check on Resident #16 in the evening of 6/19/19. CNA DD said she did not follow-up with either LVN K or Resident #16 about the pain. Interview on 6/20/19 at 2:46 p.m. with RN B, she said she assessed Resident #16 for right hip pain and notified the doctor. She said the doctor ordered an x-ray of the right hip. She said the x-ray order was called into the company but the company had not arrived to do the x-ray at that time. She said she had given the resident [MEDICATION NAME] for pain during the day shift because of hip and knee pain. Interview on 6/20/19 at 12:42 p.m. with the DON, she said she expected the CNA's to report through the computer (P[NAME]) if there was a change in status, or verbally reported to the charge nurse to follow-up with the resident. She said if a resident had a possible change she expected the nurse to stop their task, and check on the resident and do a pain assessment if necessary. The DON said she expected the nurses to notify the doctor of changes and follow the orders that were given. She said the nurse should document on a change of status form in the resident's chart, nurses note, and pain assessment in the chart. She said if a resident had a change in pain that would be considered a change in condition. She said the change should be reported on the 24-hour report along with verbal report to the next shift. She said she was not aware that Resident #16 had pain in her right hip. She said it was not documented on the 24-hour report. Interview on 6/20/19 at 3:19 p.m. with LVN K, said she was aware Resident #16 had pain yesterday because she heard the resident screaming out in pain and the resident had also told her she was in pain in the right hip. She said CNA DD had also notified her of Resident #16's complaint of pain to right hip. LVN K said she gave Resident #16 a [MEDICATION NAME] and passed the information onto the next shift nurse if the pain continued for possible stronger pain pill. She said she did not contact the doctor related to Resident #16's right hip pain. Record review of facility policy Change in a Resident's Condition or Status date revised (MONTH) 2007 read in part . 1. The nurse supervisor/ charge nurse will notify the resident's attending physician or on-call physician when there has been: . d. A significant change in the resident's physical/ emotional mental condition . e. A need to alter the resident's medical treatment significantly . 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 . 6. The nurse Supervisor/ Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status . Record review of facility policy for Pain Assessment revised date of (MONTH) 2007 read in part . The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team . 4. Pain will be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident will occur within 2 hours of administration . Steps in procedure: . 2. Ask the resident if he/ she is experiencing pain . Use the pain assessment tool . 3. Assess pain including onset and duration, location, severity, alleviating an aggravating factors, possible causes, and accompanying signs and symptoms . Reporting: . 3. Notify the physician of any unrelieved pain . Monitoring: . 3. The staff will discuss significant changes in levels of comfort with the attending physician who will adjust interventions accordingly .

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (Resident #3) of eight residents reviewed for incontinent care, in that: The facility failed to provide Resident #3 with foley catheter care according to the plan of care. Resident #3's catheter became clogged, abdomen was distended and she demonstrated pain when her lower abdomen was touched. This failure affected one resident and placed three additional residents with catheters at risk of their catheters not being appropriately care for. Findings include: Record review of Resident #3's face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE] with following Diagnosis: [REDACTED]., depression. Record review of Resident #3's MDS dated [DATE], revealed: BIMS score of 00, which indicated Resident #3's cognition was severely impaired. Further review of MDS revealed resident is total care with ADL and two person assist. Record review of Resident #3's Care Plan dated 12/09/17 revealed resident had a urinary catheter related to [MEDICAL CONDITION] and interventions were: Assess for bladder distention, small frequent voids, dribbling, blockage of the catheter and monitor fluid intake and output. Observation on 02/07/18 at 11:10a.m., CNA L was about to transfer Resident #3 from her Geri - chair to bed, when the surveyor noted that the resident's draw sheet and air mattress cover were visibly wrinkled underneath the resident. CNA L was asked to remove the draw sheet from the mattress cover. The mattress cover was observed to be bunched up underneath the resident's lower back, sacral area, and buttocks and a strong urine odor was present. Also noted that resident's foley bag tubing was absent of urine but instead had dried sediment in the tube. Interview on 02/07/18 at 11:15a.m., Wound Care Nurse stated that the air mattress cover should be cleaned and straightened before transferring the resident to bed. She also stated that because Resident #3 had a sacral wound, it was important that the draw sheet and cover be flat underneath the resident. Interview on 02/07/18 at 11:30a.m, DON stated he saw Resident #3's mattress cover and stated that he saw the and wrinkled cover. He stated the mattress should be cleaned and straightened out, and he would start an in-service. During observation and interview on 02/07/18 at 12:15p.m., LVN C stated that she normally did not work on this hall and she didn't know that Resident #3's had a foley. She stated that it was not draining, there was no urine in the bag and she had to call the doctor to get an order to irrigate the foley. LVN C stated that the facility does not keep a record of urine output because there was no order for it. Observation on 02/07/18 at 2:11p.m. of Resident #3's foley care, revealed when LVN C inserted the syringe of water into the port and applied pressure, the water splashed everywhere. She stated that it is clogged at the port site. She said she would notify the doctor and change the foley. She palpated Resident #3's lower abdomen which caused the resident to moan and grimace. LVN C stated that her abdomen was distended and she would call the doctor to have the foley changed. Record review of Resident #3's nursing note by LVN C dated 2/7/18 at 4:30p.m., revealed a doctor's order was received to change the foley and document the urine output every shift. Record review of Resident #3's TAR dated 2/7/18 revealed: Monitor urine output every shift for bladder distension. Observation on 2/8/18 at 7:54a.m., revealed Resident #3's foley bag contained 200mls of normal amber colored urine. Record review of facility policy on catheter care dated 2001 MED-PASS, Inc. (Revised (MONTH) 2007) revealed in general guideline #1: observe the resident's urine level for noticeable increase or decreases. If the level stays the same, or increases rapidly, report to your supervisor. CMS 672 dated 2/8/18 revealed the facility had 4 residents with a catheter.

Based on observation, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services for one (Resident #3) of eight residents reviewed for incontinent care, in that: The facility failed to provide Resident #3 with appropriate foley catheter care. Resident #3's catheter became clogged, abdomen was distended and she demonstrated pain when her lower abdomen was touched. This failure affected one resident and placed three additional residents with catheters at risk of their catheters not being appropriately care for. Findings include: Record review of Resident #3's face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE] with following Diagnosis: [REDACTED]., depression. Record review of Resident #3's MDS dated [DATE], revealed: BIMS score of 00, which indicated Resident #3's cognition was severely impaired. Further review of MDS revealed resident is total care with ADL and two person assist. Record review of Resident #3's Care Plan dated 12/09/17 revealed resident had a urinary catheter related to [MEDICAL CONDITION] and interventions were: Assess for bladder distention, small frequent voids, dribbling, blockage of the catheter and monitor fluid intake and output. Observation on 02/07/18 at 11:10a.m., CNA L was about to transfer Resident #3 from her Geri - chair to bed, when the surveyor noted that the resident's draw sheet and air mattress cover were visibly wrinkled underneath the resident. CNA L was asked to remove the draw sheet from the mattress cover. The mattress cover was observed to be bunched up underneath the resident's lower back, sacral area, and buttocks and a strong urine odor was present. Also noted that resident's foley bag tubing was absent of urine but instead had dried sediment in the tube. Interview on 02/07/18 at 11:15a.m., Wound Care Nurse stated that the air mattress cover should be cleaned and straightened before transferring the resident to bed. She also stated that because Resident #3 had a sacral wound, it was important that the draw sheet and cover be flat underneath the resident. Interview on 02/07/18 at 11:30a.m, DON stated he saw Resident #3's mattress cover and stated that he saw the and wrinkled cover. He stated the mattress should be cleaned and straightened out, and he would start an in-service. During observation and interview on 02/07/18 at 12:15p.m., LVN C stated that she normally did not work on this hall and she didn't know that Resident #3's had a foley. She stated that it was not draining, there was no urine in the bag and she had to call the doctor to get an order to irrigate the foley. LVN C stated that the facility does not keep a record of urine output because there was no order for it. Observation on 02/07/18 at 2:11p.m. of Resident #3's foley care, revealed when LVN C inserted the syringe of water into the port and applied pressure, the water splashed everywhere. She stated that it is clogged at the port site. She said she would notify the doctor and change the foley. She palpated Resident #3's lower abdomen which caused the resident to moan and grimace. LVN C stated that her abdomen was distended and she would call the doctor to have the foley changed. Record review of Resident #3's nursing note by LVN C dated 2/7/18 at 4:30p.m., revealed a doctor's order was received to change the foley and document the urine output every shift. Record review of Resident #3's TAR dated 2/7/18 revealed: Monitor urine output every shift for bladder distension. Observation on 2/8/18 at 7:54a.m., revealed Resident #3's foley bag contained 200mls of normal amber colored urine. Record review of facility policy on catheter care dated 2001 MED-PASS, Inc. (Revised (MONTH) 2007) revealed in general guideline #1: observe the resident's urine level for noticeable increase or decreases. If the level stays the same, or increases rapidly, report to your supervisor. CMS 672 dated 2/8/18 revealed the facility had 4 residents with a catheter.

Based on observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of four residents reviewed for abuse and neglect. CNA #5 inappropriately transferred Resident #1 with the Hoyer Lift. Resident #1 was transferred to a local hospital and an x-ray confirmed a left leg fracture. This failure effected 1 resident and placed 2 other residents on the 200 hall at risk for injury during an improper Hoyer lift transfer. Findings include: Record review of Resident #1's facesheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan dated 7/12/17 revealed that Resident #1 was to be transferred with the Hoyer lift with 2 person assist. Record review of Resident #1's MDS dated [DATE] revealed that Resident #1 required a 2 person transfer. Resident #1 had a BIMS score of 09 indicating moderate cognitive impairment. Observation and interview on 12/19/17 at 7:07 pm revealed Resident #1 sitting in a Geri-chair in her room. The resident was awake, alert, and interviewable. She was sitting in the chair with her legs extended out. Both feet were rotated inward toward each other. When asked if the resident had ever had any leg injuries, Resident #1 stated yes but she could not remember when the injury occurred. Resident #1 stated someone wanted me to do something and I kept telling them I could not do it and then they let me down. Resident #1 stated that someone stayed with her and then helped her off the floor. Interview on 12/19/17 at 8:55 pm, ADON stated that on 9/24/17, CNA #5 transferred Resident #1 from the Geri-chair to the bed. She said the CNA #5 told her during the transfer the resident said ouch and when she looked down, the lower part of Resident #1's left leg was starting to form a bruise. The ADON said she believed the CNA #5 performed the transfer with the Hoyer lift by herself. The ADON said staff were required to use 2 people when using the Hoyer lift to transfer a resident. She said after Resident #1 was assessed, the physician and family member were called, the resident was medicated for pain and transferred to the hospital for x-rays. ADON stated the resident was not admitted to the hospital, but she returned to the facility with the left leg splinted. Record review of the local hospital's Final Report Impression of the left lower leg dated 9/24/17, revealed Resident #1 sustained distal tibial and fibular shaft fractures. Interview on 12/19/17 at 9:40 pm, CNA #5 revealed she was transferring Resident #1 from the Geri-chair to bed using the Hoyer lift. CNA #5 said once she had the resident lifted up in the Hoyer, she was maneuvering Resident #1 around and the resident stated her leg was hurting. CNA #5 stated it was hard to see if anything was wrong with the resident's leg at the time. CNA #5 then told the resident when she got her on the bed, she would check her legs. Once the resident was on the bed, her legs were crossed so CNA #5 uncrossed them by lifting the left leg from over the right leg and placing them apart. She said at that time she could see that the resident legs didn't look right. The surveyor asked CNA #5 what she meant by that and she said she had placed the left leg on a pillow and the leg looked raised, so she ran and got LVN #1. CNA #5 acknowledged she did the transfer with the Hoyer lift alone and should have had another person present to assist with the transfer. CNA #5 stated the reason she performed the transfer alone was that Resident #1 wanted to go to bed and there was not anyone else to assist her. She said the CNA who was working on the hall with her had gone to lunch and she could not find anyone else. Interview on 12/19/17 at 9:57 pm, LVN #1 revealed he was told by CNA #5 that there was something wrong with Resident #1's leg. He went into Resident #1's room to assess the resident and at that time he noticed the resident had suffered an injury. He said the shin of Resident #1's left leg was partially sticking up with a hematoma forming and the leg was starting to swell. At that point he said he believed the leg was broken but he was not sure. He then notified the ADON who called the physician, received the orders for the x-rays, and notified the resident's responsible party. LVN #1 stated Resident #5 had to be transferred to the hospital for the x-rays. LVN #1 said staff were required to use 2 persons in order to transfer a resident using a Hoyer lift. He also said he asked CNA #5 why she did not call for someone to assist her before transferring the resident and she told him because she thought he was busy. Record review of Resident #1's physician orders dated 9/24/17 revealed an order was obtained by the ADON to transfer Resident #1 to the hospital. Record review of Resident #1's medical record revealed that on 9/24/17 at 10:52 pm, Resident #1 was seen in the ED Triage of a local hospital. The chief complaint documented was nursing home possibly injured this patient's left leg. The [DIAGNOSES REDACTED]. The resident was not admitted to the hospital. Interview on 12/21/17 at 9:10 am, LVN #2 revealed there should always be 2 persons whenever a resident is transferred using a Hoyer lift. Interview on 12/21/17 at 9:55 am, WDTRNU revealed that it was required that 2 people assist whenever a resident was transferred using the Hoyer lift. Interview on 12/21/17 at 1:15 pm, DON revealed that CNA #5 had worked for the facility for about a month and she had completed all the training and orientation required before she was allowed to work with residents. He said CNA #5 went to put Resident #1 into bed using the Hoyer lift. Once the CNA had the resident suspended in the air Resident #1 started saying wait, wait, my leg. CNA #5 did not want to leave the resident suspended in the air so she let her down onto the bed and noticed that her leg looked funny. CNA #5 left and got the nurse. DON said that Resident #1 told him that there were 2 people in the room but one of them left. He said there was an investigation and he came to the conclusion that something happened while transferring the resident. The DON acknowledged that it was required that 2 people be used when transferring a resident with the Hoyer lift. Record review of the facility policy titled Lifting Machine, Using a Portable 2001 MED-PASS, Inc. (Revised (MONTH) 2007) revealed the portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, 2 nursing assistants will be required to perform the procedure. CMS 672 dated 12/19/17 listed 3 residents residing on the 200 hall required the use of the Hoyer lift for transferring.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents, hazards, and supervision. CNA #5 failed to follow the plan of care which required 2 persons assist to transfer Resident #1 with the Hoyer Lift. Resident #1 was transferred to a local hospital and an x-ray confirmed a left leg fracture. This failure effected 1 resident and placed 2 other residents on the 200 hall at risk for injury during an improper Hoyer lift transfer. Findings include: Record review of Resident #1's facesheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan dated 7/12/17 revealed that Resident #1 was to be transferred with the Hoyer lift with 2 person assist. Record review of Resident #1's MDS dated [DATE] revealed that Resident #1 required a 2 person transfer. Resident #1 had a BIMS score of 09 indicating moderate cognitive impairment. Observation and interview on 12/19/17 at 7:07 pm revealed Resident #1 sitting in a Geri-chair in her room. The resident was awake, alert, and interviewable. She was sitting in the chair with her legs extended out. Both feet were rotated inward toward each other. When asked if the resident had ever had any leg injuries, Resident #1 stated yes but she could not remember when the injury occurred. Resident #1 stated someone wanted me to do something and I kept telling them I could not do it and then they let me down. Resident #1 stated that someone stayed with her and then helped her off the floor. Interview on 12/19/17 at 8:55 pm, ADON stated that on 9/24/17, CNA #5 transferred Resident #1 from the Geri-chair to the bed. She said the CNA #5 told her during the transfer the resident said ouch and when she looked down, the lower part of Resident #1's left leg was starting to form a bruise. The ADON said she believed the CNA #5 performed the transfer with the Hoyer lift by herself. The ADON said staff were required to use 2 people when using the Hoyer lift to transfer a resident. She said after Resident #1 was assessed, the physician and family member were called, the resident was medicated for pain and transferred to the hospital for x-rays. ADON stated the resident was not admitted to the hospital, but she returned to the facility with the left leg splinted. Record review of the local hospital's Final Report Impression of the left lower leg dated 9/24/17, revealed Resident #1 sustained distal tibial and fibular shaft fractures. Interview on 12/19/17 at 9:40 pm, CNA #5 revealed she was transferring Resident #1 from the Geri-chair to bed using the Hoyer lift. CNA #5 said once she had the resident lifted up in the Hoyer, she was maneuvering Resident #1 around and the resident stated her leg was hurting. CNA #5 stated it was hard to see if anything was wrong with the resident's leg at the time. CNA #5 then told the resident when she got her on the bed, she would check her legs. Once the resident was on the bed, her legs were crossed so CNA #5 uncrossed them by lifting the left leg from over the right leg and placing them apart. She said at that time she could see that the resident legs didn't look right. The surveyor asked CNA #5 what she meant by that and she said she had placed the left leg on a pillow and the leg looked raised, so she ran and got LVN #1. CNA #5 acknowledged she did the transfer with the Hoyer lift alone and should have had another person present to assist with the transfer. CNA #5 stated the reason she performed the transfer alone was that Resident #1 wanted to go to bed and there was not anyone else to assist her. She said the CNA who was working on the hall with her had gone to lunch and she could not find anyone else. Interview on 12/19/17 at 9:57 pm, LVN #1 revealed he was told by CNA #5 that there was something wrong with Resident #1's leg. He went into Resident #1's room to assess the resident and at that time he noticed the resident had suffered an injury. He said the shin of Resident #1's left leg was partially sticking up with a hematoma forming and the leg was starting to swell. At that point he said he believed the leg was broken but he was not sure. He then notified the ADON who called the physician, received the orders for the x-rays, and notified the resident's responsible party. LVN #1 stated Resident #5 had to be transferred to the hospital for the x-rays. LVN #1 said staff were required to use 2 persons in order to transfer a resident using a Hoyer lift. He also said he asked CNA #5 why she did not call for someone to assist her before transferring the resident and she told him because she thought he was busy. Record review of Resident #1's physician orders dated 9/24/17 revealed an order was obtained by the ADON to transfer Resident #1 to the hospital. Record review of Resident #1's medical record revealed that on 9/24/17 at 10:52 pm, Resident #1 was seen in the ED Triage of a local hospital. The chief complaint documented was nursing home possibly injured this patient's left leg. The [DIAGNOSES REDACTED]. The resident was not admitted to the hospital. Interview on 12/21/17 at 9:10 am, LVN #2 revealed there should always be 2 persons whenever a resident is transferred using a Hoyer lift. Interview on 12/21/17 at 9:55 am, WDTRNU revealed that it was required that 2 people assist whenever a resident was transferred using the Hoyer lift. Interview on 12/21/17 at 1:15 pm, DON revealed that CNA #5 had worked for the facility for about a month and she had completed all the training and orientation required before she was allowed to work with residents. He said CNA #5 went to put Resident #1 into bed using the Hoyer lift. Once the CNA had the resident suspended in the air Resident #1 started saying wait, wait, my leg. CNA #5 did not want to leave the resident suspended in the air so she let her down onto the bed and noticed that her leg looked funny. CNA #5 left and got the nurse. DON said that Resident #1 told him that there were 2 people in the room but one of them left. He said there was an investigation and he came to the conclusion that something happened while transferring the resident. The DON acknowledged that it was required that 2 people be used when transferring a resident with the Hoyer lift. Record review of the facility policy titled Lifting Machine, Using a Portable 2001 MED-PASS, Inc. (Revised (MONTH) 2007) revealed the portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, 2 nursing assistants will be required to perform the procedure. CMS 672 dated 12/19/17 listed 3 residents residing on the 200 hall required the use of the Hoyer lift for transferring.

Based on observations, interviews, and record reviews, the facility failed to consult with the resident's physician and notify the responsible party (RP) when a change of condition occurred for two of five residents (CR #1 and CR#2) who were reviewed for changes in conditions. - CR #1's had an identified change in condition of pain to her lower extremities, the physician was not promptly consulted for 4 1/2 hours. - CR #1 had a [MEDICAL CONDITION] hip and her physician was not notified of the findings until 6 hours later. - CR#1 ' s family was not notified by the facility. CR #1's Hospice nurse notified the family 8 hours after a change in condition was identified. - CR#2 had an abnormal chest x-ray and the facility did not consult CR #2's physician for 21 hours. The findings required follow up care. This failure affected two discharged residents who were hospitalized and placed 32 residents on Hall 200 at risk of not having their responsible party, interested family members or physicians aware of a change in their medical condition which could cause extended durations of pain and a delay in medical treatment. Findings include: Intake # 1 and # 6 CR#1 Record review of CR#1 ' s medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Further review revealed she was transferred to the hospital on [DATE] at 11:00 PM. Record review of CR#1 ' s Pain Care Plan, dated 6/10/15, revealed CR#1 was at risk for pain. Interventions included notifying physician or any changes in level or frequency of pain. Record review of CR#1 ' s Quarterly MDS, dated [DATE], revealed she had severe cognitive impairment, had no behaviors, no rejection of care or wandering, and required extensive assistance by two staff for bed mobility, transfers, dressing, and toilet use. She required extensive assistance of one staff for locomotion, eating, personal hygiene, and bathing. Further review revealed she used a wheelchair for mobility, was incontinent of bowel and bladder, had no recent falls, and was receiving hospice care. Interview on 1/15/16 at 1:02 PM, LVN#1 stated she worked 6 AM-2 PM shift. She stated on 1/14/16 at 7:00 AM, CNA #1 requested her to look at CR#1. She stated CR#1 stated both legs were hurting and said my legs don ' t work . She stated she assessed CR#1 by doing range of motion. She stated she failed to take vital signs of CR#1. After her assessment, CNA #1 got her up for breakfast. She further stated she later called the NP to get an order for [REDACTED]. She stated the Hospice Nurse had arrived at the facility and she reported the change of condition to the Hospice Nurse. She stated the Hospice Nurse stated she would notify the family. She stated she did not contact CR#1's family members to notify them of the change of condition. She further stated CR#1 was alert, but was not a good historian due to her advanced dementia. She stated CR#1 could not use a pain scale. She stated she assessed CR#1 ' s pain level to be a 6 or 7/out of 10. She stated it was unusual for CR#1 to complain of pain and to receive pain medications. She further stated when CR#1 was sitting still, she was fine, but if you tried to move her, she had complaints of pain. She stated when she left for the day, she had informed the oncoming nurse (LVN#2) that CR#1 was complaining of leg pain, an x-ray was completed, and was waiting on the results. Record review of LVN#1 Witness Statement, no date, read On the morning of 1/14/15(1/14/16) CNA #1 reported to me that CR#1 was complaining of pain. When I entered the room CR#1 was guarding her right leg. I asked her if she could straighten it out, and she did. I instructed the CNA to get her up if she could tolerate it and she did. NP was notified upon arrival to facility before lunch. I asked if she could give me an order to take x-rays, and she did. X-ray was on site and I told him to hold on I needed him to take an x-ray on CR#1. X-Ray was called in and the tech took the x-ray between 2 pm-3 pm. Tech informed me to call x-ray in STAT and that was done. Hospice nurse was on site to see patient that day. I informed Hospice Nurse about new onset of pain and she informed me that she would call CR#1 family member. Around 2:30 PM CR#1 ' s family member called the nurse ' s station and inquired about why she heard from hospice nurse and not me . Record review of CR#1 ' s Physician Notes, dated 1/14/16, revealed the Nurse Practitioner (NP) was called by nurse to evaluate patient who complains of leg pain and seems not her usual state of self. The NP wrote .Patient does not appear in pain but when I moved R (right) knee she exhibited guarding behaviors and would not let me touch knee again. Under the section titled Functional Status, revealed CR#1 required full assist and supervision and was wheelchair dependent. Her [DIAGNOSES REDACTED]. Record review of CR#1 ' s NP witness statement, dated 1/21/16, the NP wrote .around 11:30 AM when nurse informed me of patient ' s (CR#1) ' s leg pain . I asked nurse to medicate for pain. Nurse administered [MEDICATION NAME] 50 mg at that time. Further review revealed the NP wrote At 10:30 PM nurse reported x-ray results showing left acute hip FX (fracture) and I gave order to transfer patient (CR#1) to ER (emergency room ) for further evaluation. During the call, the phone was taken by family member who introduced herself as a rehab nurse Record review of CR#1 ' s Nurse ' s Notes dated 1/14/16 revealed: 11:53 AM- PRN Administration- [MEDICATION NAME] 50 mg tablet, one tablet by mouth every 8 hours as needed Pain; 2:41 PM- PRN Follow-up- Pain evaluation at 3 or less; 3:12 PM- Patient complains of pain in BLE. Patient given PRN [MEDICATION NAME]. NP notified. New orders to get x-ray of BLE. Hospice nurse notified upon arrival to facility. RP aware. Further review of Nurse ' s Notes dated 1/15/16 at 12:00 AM, LVN#2 wrote Received X-ray result with findings of diffuse osteopenia. Subcapital acute fracture left hip is noted with minimal displacement . NP was notified and ordered to transfer patient to hospital. RP present at the facility at that time requested to send patient to hospital. Report was given to ER charge nurse . Record review of CR#1's MAR, dated 1/14/16, revealed CR#1 received one dose of pain medication [MEDICATION NAME] 50 mg. Further review revealed her pain level was a 6 out of 10 prior to administration, and after administration her pain level decreased to a 1 out of 10. The pain was to her legs. Record review of CR#1 ' s Change in Condition, revealed nurses had electronically documented: -1/14/16 at 3:15 PM, LVN#1 assessed CR#1 ' s pain level to be a 6 to her bilateral lower extremities. -1/15/16 at 12:21 AM, LVN#2 assessed CR#1 ' s pain level to be a 4 to her left hip. Record review of CR#1 ' s X-Ray Final report, dated 1/14/16, revealed CR#1 sustained an acute subcapital fracture left hip. Further review revealed the physician electronically signed the report at 4:44 PM. Further review CR #1's X-Ray Final Report, revealed two different reports date/time stamp of receipt from the fax machine: 1. 1/14/16 at 6:26 PM. There was no indication or documentation this report was reviewed and CR#1's physician or family were notified. 2. 1/14/16 at 9:52 PM. Further review of the report revealed a stamp received. The stamp revealed the NP was notified of the findings at 10:40 PM and CR#1 ' s family was notified at 10:30 PM. Record review of CR#1 ' s family Text message records with Hospice Nurse, revealed: 1/14/16 at 3:47 PM- Hospice Nurse wrote: Talked with (LVN#1) she said (CR#1) was in a ball this am and complaining of pain in legs. Their taking some x-rays to make sure no fracture. I ' ll let you know . Family wrote Ok thanks for letting me know because no one called me . 1/14/16 at 11:22 PM- Family wrote Hi I know it ' s late. I ' m at the facility with (CR#1) and she has an a [MEDICAL CONDITION] hip. Her facility (physician) thinks it ' s best to send her to the ER for further evaluation. An acute left [MEDICAL CONDITION] . Interview on 1/15/16 at 2:05 PM, the contracted X-Ray Company Supervisor stated CR#1 ' s x-ray results were done by the technician at the facility on 1/14/16 at 2:58 PM. The order was changed to Stat at 3:26 PM and was read by the physician on 1/14/16 at 4:44 PM. She stated as soon as the physician electronically signed the reports, the report was automatically faxed to the number they had on file. She stated because the results for CR#1 were abnormal, it was the policy of the company to call and speak to a nurse to ensure they had received the findings. She stated the X-Ray Company attempted to contact the facility on 1/14/16 at 5:00 PM and 9:57 PM- with no success. On 1/15/16, they called at 7:06 AM, 10:38 AM, and 12:02 PM- with no success. At 1:00 PM, the facility was finally able to speak to a nurse. She further stated this was not the first time the company had a problem with getting in touch with the facility. She stated this was an ongoing problem with the facility. Observation on 1/15/16 at 2:30 PM revealed inside the locked medication room (Located near nurse station #1) was a fax machine/copier. The machine was lit red and read toner out . RN#1 took the toner cartridge out of the machine and shook it and faxes began to come out the machine. A total of 72 pages were received. The date/time stamped on the pages began at 1/15/16 at 11:12 AM. No faxes had been received since 11:12 AM (Over 3 hours). Interview on 1/15/16 at 2:30 PM , RN #1 stated the fax machine had been out of toner for two days. She stated she called the pharmacy to ask them to bring a toner cartridge over. She stated the pharmacy stated they would deliver the toner today. Record review of CR#1 ' s Hospital Records revealed: History and Physical, dated 1/21/15 revealed .had x-ray done in the facility for complaint of pain which showed a left hip subcapital fracture. Not sure patient had a fall prior to that or not, no known fall or trauma so the patient was sent to the ER and the patient is admitted for ortho evaluation . Discharge Summary, dated 1/21/16 revealed XXX[AGE] year old female who was admitted after found to have a fracture in skilled facility. Patient was admitted here since the family did not want to return to the same facility. Another issue was for pain control, even though the patient did not need any pain medication for the last 32 hours. Patient denies any significant pain, patient was also mostly in the bed at this time .The new medication is the pain medications [MEDICATION NAME] . Record review of Facility ' s Investigation Report for CR#1, dated 1/21/16 revealed an injury of unknown source on 1/14/16 at 10:30 PM. The Assessment was completed on 1/14/16 at 7:00 AM. Further read patient complained of pain of BLE on 1/14/16. Per nurses statement the patient assessment was conducted and pain medication was refused at that time. At appx 11:30 AM nurse administered 50 mg of [MEDICATION NAME]. Hospice and NP notified at appx 11:30 AM. NP was on site and completed assessment. New orders received to obtain x-ray of BLE. RP (Responsible Party) was notified. Assessment included: pain evaluation noted at a 9, after medication administration pain level was a 3. Blood pressure was 106/68 . X-ray results received subcapital fracture of left hip. NP was notified of X-ray results. Order was received to transfer resident to (hospital. RP notified. Further review revealed CR#1 was transferred to the hospital on [DATE] at 11:27 PM. Under the section titled Provider Action Taken post- investigation read The facility provided transfer education to staff; in-service presented by Therapy department. In-Service on notification of change of condition to responsible party, follow-up lab and x-rays. Interview on 1/21/16 at 2:57 PM, CR#1 ' s family member stated the facility did not contact her to notify her of the change in condition for CR#1. She stated this was not the first communication problem from the facility and on multiple occasions she had tried to call the nurse ' s station after hours and could not reach any staff. She stated the hospice nurse sent her a personal text message on 1/14/16 at 3:45 PM notifying her that CR#1 was found in a ball and was complaining of pain. She stated she thought the facility was responsible for notifying the family and consulting the physician after any incident. She further stated she had not heard anything on the results of CR#1 ' s x-rays and called the facility and spoke to LVN #2 and asked her about the x-ray. She stated LVN#2 reported the x-rays results were not in. She stated at 9:45 PM she drove to the facility to see CR#1. She stated CR#1 screamed out in pain when she touched her. She stated she went to the nurse ' s station to check on the status of the x-ray results and LVN#2 stated there was no toner in the fax machine. CR#1 ' s family member stated she contacted the x-ray company and asked them to send the results to the other fax machine located inside the facility. The other fax machine received the x-ray results at 10:32 PM. She further stated the facility neglected CR#1 because it took them too long to get the results, not medicating her, and for not notifying her in a timely manner. She stated CR#1 was only given pain medication one time and was crying out in pain when she saw CR#1. Interview on 1/25/16 at 5:30 PM, CR#1 ' s Hospice Nurse stated when she came to the facility on [DATE], LVN#1 had reported CR#1 was complaining of leg pain, that they were waiting for x-rays, and had already administered pain medications. She stated that was unusual for CR#1. She stated CR#1 usually complained that she didn ' t feel good or would say I am dying , but would never complain of pain or take medications for pain. She stated for CR#1 to take pain medications, she was really in a lot of pain . She further stated she sent a text message to CR#1 ' s family member to keep her informed. She stated the family member had later notified her of the x-ray result findings. CR#2 Record review of CR#2 ' s medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Further review revealed she was transferred to the hospital on [DATE]. Record review of CR#2 ' s 14 day Scheduled Assessment- MDS, dated [DATE], revealed she was cognitively intact, had no [MEDICAL CONDITION] or behaviors, and required extensive assistance by one staff member for bed mobility, transfers, dressing, toilet use and personal hygiene. Eating, she needed supervision and setup assistance. Record review of CR#2 ' s X-Ray report, dated 1/14/16, revealed a physician read the report at 12:20 PM. The date/time stamp the facility fax machine received the report was 1/15/16 at 11:12 AM. The findings read Right lower lobe infiltrate and right pleural effusion. Pneumonia is suspected. Follow-up exam is recommended. Mild [MEDICAL CONDITION] vascular congestion. The facility fax machine was out of toner and CR#2's results were not printed until 1/15/16 at 2:30 PM. Record review of CR#2 ' s Electronic Nurses Notes revealed multiple late entries: 1/14/16 at 9:59 AM LVN #1 wrote: Patient states her heart is racing and shaking . NP notified immediately . STAT chest x-ray, CBC and BMP. Family notified of resident ' s condition and new orders. 1/15/16 at 6:30 PM (written for 1/14/16) LVN#2 wrote Received BMP and CBC result with BUN 68, Creat 1.5 and WBC 4.4. NP was notified and ordered to repeat BMP every 2 days. (Family) aware . 1/15/16 at 6:48 PM (written for 1/14/16) LVN#2 wrote Patient was observed sliding on the floor. I helped ease her on the floor and call for assistance to put her back in bed . 1/18/16 at 8:59 AM (written for 1/15/16)-LVN #1 wrote Late entry. At 7 am CNA reported that patient has new abrasion on left elbow. Entered room to find small ½ inch abrasion on left elbow. ADON and Wound Care notified. Attempted to call responsible party, no answer . 1/15/16 at 3:40 PM-LVN #1 wrote Late entry. NP notified of chest x-ray results around 9:30 (AM). Awaiting Orders. Further review revealed an addendum with new orders for 500 mg [MEDICATION NAME] daily x 10 days. 1/18/16 at 11:41 AM (written for 1/16/15)- LVN #3 wrote Received X-ray results, mild [MEDICAL CONDITION] vascular congestion is seen, right lower lobe infiltrate is noted, notified NP, new order [MEDICATION NAME] 875-125 mg 1 tab by mouth every 12 hours, RP (responsible party) notified. 1/18/16 at 10:38 AM-LVN #1 wrote CNA presents a stop and watch form for resident stating that the resident doesn ' t seem usual self. Entered the room of resident to find resident sitting upright in wheelchair unable to feed herself as usual. Resident had tremors and appeared lethargic. Resident was asked full name and where she was from and it took resident longer than usual to answer and she was stuttering. Apical pulse checked at 62 manual blood pressure of 118/58, respirations 18, and temp 98.0. Patient has no complaints of pain. NP notified of patients condition, and ordered to transfer patient to the hospital. EMS called for transport. Patient transferred to Hospital. RP notified of patient transfer. Interview on 1/21/16 at 5:11 PM, the Interim DON stated she had worked at the facility for 1 ½ years. She stated she was the interim DON when the previous DON left on 1/14/16. She stated when a resident had any change of condition; she expected the physician and family to be notified right away and no later than during the shift. Concerning pain medication: she expected the administration of pain medications to be done immediately after an assessment and a follow-up to be completed within one hour to ensure the medication was effective. Concerning answering calls and fax machines: she stated the BOM was in charge of answering calls and checking the fax machines. She stated after hours, the nurses were responsible for answering calls and checking the fax machines. She stated the facility had implemented a new policy and procedure to include purchased back-up toner cartridges for each fax machine, and after 5 PM, the calls go to the cordless phones located at the nurse ' s stations. Record review of the facility ' s Acute Condition Changes policy, dated 4/2007 revealed the nursing staff was responsible for contacting the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response within approximately one-half hour or less. This policy did not address notifying family members. Record review of the facility ' s Abuse Prohibition Management Program, no date, read Our facility will not condone resident abuse, neglect or mistreatment . by anyone, including staff members . Further review of the policy defined Neglect as the failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury or harm or death to the resident. The census revealed 32 residents resided on Hall 200.

Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures when a change of condition occurred for two of five residents (CR #1 and CR#2), who were reviewed for neglect. - CR #1's leg pain was not treated for [REDACTED].½ hours. - CR #1's X-Rays revealed a fracture to the left hip. Her physician was not consulted for 6 hours after the results were available, which caused a delay in treatment hospitalization . - CR#2's Chest X-revealed a change of condition. Her physician was not consulted for 21 hours after the results were available, which caused a delay in treatment and hospitalization . - The facility's fax machine was without toner/ink for two days, which delayed the results to be printed by the facility nursing staff. - The Contracted X-Ray company could not reach nursing staff on the telephone for two days to verbally report the abnormal reports to nursing staff. This failure affected two discharged resident who had delayed treatments and required hospitalization and placed 32 residents on Hall 200 at risk of not having their medical needs addressed timely which could cause extended durations of pain and a delay in medical treatments. Findings include: Intake # 1 and # 6 CR#1 Record review of CR#1 ' s medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Further review revealed she was transferred to the hospital on [DATE] at 11:00 PM. Record review of CR#1 ' s Pain Care Plan, dated 6/10/15, revealed CR#1 was at risk for pain. Interventions included notifying physician or any changes in level or frequency of pain. Record review of CR#1 ' s Quarterly MDS, dated [DATE], revealed she had severe cognitive impairment, had no behaviors, no rejection of care or wandering, and required extensive assistance by two staff for bed mobility, transfers, dressing, and toilet use. She required extensive assistance of one staff for locomotion, eating, personal hygiene, and bathing. Further review revealed she used a wheelchair for mobility, was incontinent of bowel and bladder, had no recent falls, and was receiving hospice care. Interview on 1/15/16 at 1:02 PM, LVN#1 stated she worked 6 AM-2 PM shift. She stated on 1/14/16 at 7:00 AM, CNA #1 requested her to look at CR#1. She stated CR#1 stated both legs were hurting and said my legs don ' t work . She stated she assessed CR#1 by doing range of motion. She stated she failed to take vital signs of CR#1. After her assessment, CNA #1 got her up for breakfast. She further stated she later called the NP to get an order for [REDACTED]. She stated the Hospice Nurse had arrived at the facility and she reported the change of condition to the Hospice Nurse. She stated the Hospice Nurse stated she would notify the family. She stated she did not contact CR#1's family members to notify them of the change of condition. She further stated CR#1 was alert, but was not a good historian due to her advanced dementia. She stated CR#1 could not use a pain scale. She stated she assessed CR#1 ' s pain level to be a 6 or 7/out of 10. She stated it was unusual for CR#1 to complain of pain and to receive pain medications. She further stated when CR#1 was sitting still, she was fine, but if you tried to move her, she had complaints of pain. She stated when she left for the day, she had informed the oncoming nurse (LVN#2) that CR#1 was complaining of leg pain, an x-ray was completed, and was waiting on the results. Record review of LVN#1 Witness Statement, no date, read On the morning of 1/14/15(1/14/16) CNA #1 reported to me that CR#1 was complaining of pain. When I entered the room CR#1 was guarding her right leg. I asked her if she could straighten it out, and she did. I instructed the CNA to get her up if she could tolerate it and she did. NP was notified upon arrival to facility before lunch. I asked if she could give me an order to take x-rays, and she did. X-ray was on site and I told him to hold on I needed him to take an x-ray on CR#1. X-Ray was called in and the tech took the x-ray between 2 pm-3 pm. Tech informed me to call x-ray in STAT and that was done. Hospice nurse was on site to see patient that day. I informed Hospice Nurse about new onset of pain and she informed me that she would call CR#1 family member. Around 2:30 PM CR#1 ' s family member called the nurse ' s station and inquired about why she heard from hospice nurse and not me . Record review of CR#1 ' s Physician Notes, dated 1/14/16, revealed the Nurse Practitioner (NP) was called by nurse to evaluate patient who complains of leg pain and seems not her usual state of self. The NP wrote .Patient does not appear in pain but when I moved R (right) knee she exhibited guarding behaviors and would not let me touch knee again. Under the section titled Functional Status, revealed CR#1 required full assist and supervision and was wheelchair dependent. Her [DIAGNOSES REDACTED]. Record review of CR#1 ' s NP witness statement, dated 1/21/16, the NP wrote .around 11:30 AM when nurse informed me of patient ' s (CR#1) ' s leg pain . I asked nurse to medicate for pain. Nurse administered [MEDICATION NAME] 50 mg at that time. Further review revealed the NP wrote At 10:30 PM nurse reported x-ray results showing left acute hip FX (fracture) and I gave order to transfer patient (CR#1) to ER (emergency room ) for further evaluation. During the call, the phone was taken by family member who introduced herself as a rehab nurse Record review of CR#1 ' s Nurse ' s Notes dated 1/14/16 revealed: 11:53 AM- PRN Administration- [MEDICATION NAME] 50 mg tablet, one tablet by mouth every 8 hours as needed Pain; 2:41 PM- PRN Follow-up- Pain evaluation at 3 or less; 3:12 PM- Patient complains of pain in BLE. Patient given PRN [MEDICATION NAME]. NP notified. New orders to get x-ray of BLE. Hospice nurse notified upon arrival to facility. RP aware. Further review of Nurse ' s Notes dated 1/15/16 at 12:00 AM, LVN#2 wrote Received X-ray result with findings of diffuse osteopenia. Subcapital acute fracture left hip is noted with minimal displacement . NP was notified and ordered to transfer patient to hospital. RP present at the facility at that time requested to send patient to hospital. Report was given to ER charge nurse . Record review of CR#1's MAR, dated 1/14/16, revealed CR#1 received one dose of pain medication [MEDICATION NAME] 50 mg. Further review revealed her pain level was a 6 out of 10 prior to administration, and after administration her pain level decreased to a 1 out of 10. The pain was to her legs. Record review of CR#1 ' s Change in Condition, revealed nurses had electronically documented: -1/14/16 at 3:15 PM, LVN#1 assessed CR#1 ' s pain level to be a 6 to her bilateral lower extremities. -1/15/16 at 12:21 AM, LVN#2 assessed CR#1 ' s pain level to be a 4 to her left hip. Record review of CR#1 ' s X-Ray Final report, dated 1/14/16, revealed CR#1 sustained an acute subcapital fracture left hip. Further review revealed the physician electronically signed the report at 4:44 PM. Further review CR #1's X-Ray Final Report, revealed two different reports date/time stamp of receipt from the fax machine: 1. 1/14/16 at 6:26 PM. There was no indication or documentation this report was reviewed and CR#1's physician or family were notified. 2. 1/14/16 at 9:52 PM. Further review of the report revealed a stamp received. The stamp revealed the NP was notified of the findings at 10:40 PM and CR#1 ' s family was notified at 10:30 PM. Record review of CR#1 ' s family Text message records with Hospice Nurse, revealed: 1/14/16 at 3:47 PM- Hospice Nurse wrote: Talked with (LVN#1) she said (CR#1) was in a ball this am and complaining of pain in legs. Their taking some x-rays to make sure no fracture. I ' ll let you know . Family wrote Ok thanks for letting me know because no one called me . 1/14/16 at 11:22 PM- Family wrote Hi I know it ' s late. I ' m at the facility with (CR#1) and she has an a [MEDICAL CONDITION] hip. Her facility (physician) thinks it ' s best to send her to the ER for further evaluation. An acute left [MEDICAL CONDITION] . Interview on 1/15/16 at 2:05 PM, the contracted X-Ray Company Supervisor stated CR#1 ' s x-ray results were done by the technician at the facility on 1/14/16 at 2:58 PM. The order was changed to Stat at 3:26 PM and was read by the physician on 1/14/16 at 4:44 PM. She stated as soon as the physician electronically signed the reports, the report was automatically faxed to the number they had on file. She stated because the results for CR#1 were abnormal, it was the policy of the company to call and speak to a nurse to ensure they had received the findings. She stated the X-Ray Company attempted to contact the facility on 1/14/16 at 5:00 PM and 9:57 PM- with no success. On 1/15/16, they called at 7:06 AM, 10:38 AM, and 12:02 PM- with no success. At 1:00 PM, the facility was finally able to speak to a nurse. She further stated this was not the first time the company had a problem with getting in touch with the facility. She stated this was an ongoing problem with the facility. Observation on 1/15/16 at 2:30 PM revealed inside the locked medication room (Located near nurse station #1) was a fax machine/copier. The machine was lit red and read toner out . RN#1 took the toner cartridge out of the machine and shook it and faxes began to come out the machine. A total of 72 pages were received. The date/time stamped on the pages began at 1/15/16 at 11:12 AM. No faxes had been received since 11:12 AM (Over 3 hours). Interview on 1/15/16 at 2:30 PM , RN #1 stated the fax machine had been out of toner for two days. She stated she called the pharmacy to ask them to bring a toner cartridge over. She stated the pharmacy stated they would deliver the toner today. Record review of CR#1 ' s Hospital Records revealed: History and Physical, dated 1/21/15 revealed .had x-ray done in the facility for complaint of pain which showed a left hip subcapital fracture. Not sure patient had a fall prior to that or not, no known fall or trauma so the patient was sent to the ER and the patient is admitted for ortho evaluation . Discharge Summary, dated 1/21/16 revealed XXX[AGE] year old female who was admitted after found to have a fracture in skilled facility. Patient was admitted here since the family did not want to return to the same facility. Another issue was for pain control, even though the patient did not need any pain medication for the last 32 hours. Patient denies any significant pain, patient was also mostly in the bed at this time .The new medication is the pain medications [MEDICATION NAME] . Record review of Facility ' s Investigation Report for CR#1, dated 1/21/16 revealed an injury of unknown source on 1/14/16 at 10:30 PM. The Assessment was completed on 1/14/16 at 7:00 AM. Further read patient complained of pain of BLE on 1/14/16. Per nurses statement the patient assessment was conducted and pain medication was refused at that time. At appx 11:30 AM nurse administered 50 mg of [MEDICATION NAME]. Hospice and NP notified at appx 11:30 AM. NP was on site and completed assessment. New orders received to obtain x-ray of BLE. RP (Responsible Party) was notified. Assessment included: pain evaluation noted at a 9, after medication administration pain level was a 3. Blood pressure was 106/68 . X-ray results received subcapital fracture of left hip. NP was notified of X-ray results. Order was received to transfer resident to (hospital. RP notified. Further review revealed CR#1 was transferred to the hospital on [DATE] at 11:27 PM. Under the section titled Provider Action Taken post- investigation read The facility provided transfer education to staff; in-service presented by Therapy department. In-Service on notification of change of condition to responsible party, follow-up lab and x-rays. Interview on 1/21/16 at 2:57 PM, CR#1 ' s family member stated the facility did not contact her to notify her of the change in condition for CR#1. She stated this was not the first communication problem from the facility and on multiple occasions she had tried to call the nurse ' s station after hours and could not reach any staff. She stated the hospice nurse sent her a personal text message on 1/14/16 at 3:45 PM notifying her that CR#1 was found in a ball and was complaining of pain. She stated she thought the facility was responsible for notifying the family and consulting the physician after any incident. She further stated she had not heard anything on the results of CR#1 ' s x-rays and called the facility and spoke to LVN #2 and asked her about the x-ray. She stated LVN#2 reported the x-rays results were not in. She stated at 9:45 PM she drove to the facility to see CR#1. She stated CR#1 screamed out in pain when she touched her. She stated she went to the nurse ' s station to check on the status of the x-ray results and LVN#2 stated there was no toner in the fax machine. CR#1 ' s family member stated she contacted the x-ray company and asked them to send the results to the other fax machine located inside the facility. The other fax machine received the x-ray results at 10:32 PM. She further stated the facility neglected CR#1 because it took them too long to get the results, not medicating her, and for not notifying her in a timely manner. She stated CR#1 was only given pain medication one time and was crying out in pain when she saw CR#1. Interview on 1/25/16 at 5:30 PM, CR#1 ' s Hospice Nurse stated when she came to the facility on [DATE], LVN#1 had reported CR#1 was complaining of leg pain, that they were waiting for x-rays, and had already administered pain medications. She stated that was unusual for CR#1. She stated CR#1 usually complained that she didn ' t feel good or would say I am dying , but would never complain of pain or take medications for pain. She stated for CR#1 to take pain medications, she was really in a lot of pain . She further stated she sent a text message to CR#1 ' s family member to keep her informed. She stated the family member had later notified her of the x-ray result findings. CR#2 Record review of CR#2 ' s medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Further review revealed she was transferred to the hospital on [DATE]. Record review of CR#2 ' s 14 day Scheduled Assessment- MDS, dated [DATE], revealed she was cognitively intact, had no [MEDICAL CONDITION] or behaviors, and required extensive assistance by one staff member for bed mobility, transfers, dressing, toilet use and personal hygiene. Eating, she needed supervision and setup assistance. Record review of CR#2 ' s X-Ray report, dated 1/14/16, revealed a physician read the report at 12:20 PM. The date/time stamp the facility fax machine received the report was 1/15/16 at 11:12 AM. The findings read Right lower lobe infiltrate and right pleural effusion. Pneumonia is suspected. Follow-up exam is recommended. Mild [MEDICAL CONDITION] vascular congestion. The facility fax machine was out of toner and CR#2's results were not printed until 1/15/16 at 2:30 PM. Record review of CR#2 ' s Electronic Nurses Notes revealed multiple late entries: 1/14/16 at 9:59 AM LVN #1 wrote: Patient states her heart is racing and shaking . NP notified immediately . STAT chest x-ray, CBC and BMP. Family notified of resident ' s condition and new orders. 1/15/16 at 6:30 PM (written for 1/14/16) LVN#2 wrote Received BMP and CBC result with BUN 68, Creat 1.5 and WBC 4.4. NP was notified and ordered to repeat BMP every 2 days. (Family) aware . 1/15/16 at 6:48 PM (written for 1/14/16) LVN#2 wrote Patient was observed sliding on the floor. I helped ease her on the floor and call for assistance to put her back in bed . 1/18/16 at 8:59 AM (written for 1/15/16)-LVN #1 wrote Late entry. At 7 am CNA reported that patient has new abrasion on left elbow. Entered room to find small ½ inch abrasion on left elbow. ADON and Wound Care notified. Attempted to call responsible party, no answer . 1/15/16 at 3:40 PM-LVN #1 wrote Late entry. NP notified of chest x-ray results around 9:30 (AM). Awaiting Orders. Further review revealed an addendum with new orders for 500 mg [MEDICATION NAME] daily x 10 days. 1/18/16 at 11:41 AM (written for 1/16/15)- LVN #3 wrote Received X-ray results, mild [MEDICAL CONDITION] vascular congestion is seen, right lower lobe infiltrate is noted, notified NP, new order [MEDICATION NAME] 875-125 mg 1 tab by mouth every 12 hours, RP (responsible party) notified. 1/18/16 at 10:38 AM-LVN #1 wrote CNA presents a stop and watch form for resident stating that the resident doesn ' t seem usual self. Entered the room of resident to find resident sitting upright in wheelchair unable to feed herself as usual. Resident had tremors and appeared lethargic. Resident was asked full name and where she was from and it took resident longer than usual to answer and she was stuttering. Apical pulse checked at 62 manual blood pressure of 118/58, respirations 18, and temp 98.0. Patient has no complaints of pain. NP notified of patients condition, and ordered to transfer patient to the hospital. EMS called for transport. Patient transferred to Hospital. RP notified of patient transfer. Interview on 1/21/16 at 5:11 PM, the Interim DON stated she had worked at the facility for 1 ½ years. She stated she was the interim DON when the previous DON left on 1/14/16. She stated when a resident had any change of condition; she expected the physician and family to be notified right away and no later than during the shift. Concerning pain medication: she expected the administration of pain medications to be done immediately after an assessment and a follow-up to be completed within one hour to ensure the medication was effective. Concerning answering calls and fax machines: she stated the BOM was in charge of answering calls and checking the fax machines. She stated after hours, the nurses were responsible for answering calls and checking the fax machines. She stated the facility had implemented a new policy and procedure to include purchased back-up toner cartridges for each fax machine, and after 5 PM, the calls go to the cordless phones located at the nurse ' s stations. Record review of the facility ' s Acute Condition Changes policy, dated 4/2007 revealed the nursing staff was responsible for contacting the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response within approximately one-half hour or less. This policy did not address notifying family members. Record review of the facility ' s Abuse Prohibition Management Program, no date, read Our facility will not condone resident abuse, neglect or mistreatment . by anyone, including staff members . Further review of the policy defined Neglect as the failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury or harm or death to the resident. The census revealed 32 residents resided on Hall 200.

Based on observation, interview, and record review, the facility failed to provide the necessary medical treatments to attain or maintain the highest practicable physical, mental, and psychosocial well-being according to the comprehensive assessment and plan of care for two of two discharged residents (CR #1 and CR #2) assessed for pain management and quality of care. - CR #1's leg pain was not treated for [REDACTED].½ hours. - CR #1's X-Rays revealed a fracture to the left hip. Her physician was not consulted for 6 hours after the results were available, which caused a delay in treatment hospitalization . - CR #1's pain was assessed and did not receive any pain medication for 4 1/2 hours. The resident continued to demonstrate pain when her extremity was moved/touched but did not receive any additional pain medication. CR #1 was transferred to the hospital 16 hours after her initial complaint of pain. - CR#2's Chest X-revealed a change of condition. Her physician was not consulted for 21 hours after the results were available, which caused a delay in treatment and hospitalization . - The facility's fax machine was without toner/ink for two days, which delayed the results to be printed by the facility nursing staff. - The Contracted X-Ray company could not reach nursing staff on the telephone for two days to verbally report the abnormal reports to nursing staff. This failure affected two discharged residents and placed 32 residents who resided on Hall 200 at risk for which could cause a delay in treatment and a decline in their medical, physical, and mental health. Findings include: Intake # 1 and # 6 CR#1 Record review of CR#1 ' s medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Further review revealed she was transferred to the hospital on [DATE] at 11:00 PM. Record review of CR #1 ' s Pain Care Plan, dated 6/10/15, revealed CR#1 was at risk for pain. Interventions included notifying physician or any changes in level or frequency of pain. Record review of CR#1 ' s Quarterly MDS, dated [DATE], revealed she had sever cognitive impairment, had no behaviors, rejection of care, or wandering, and required extensive assistance by two staff for bed mobility, transfers, dressing, and toilet use. She required extensive assistance by one staff for locomotion, eating, personal hygiene, and bathing. Further review revealed she used a wheelchair for mobility, was incontinent of bowel and bladder, had no recent falls, and was receiving hospice care. Interview on 1/15/16 at 1:02 PM, LVN#1 stated she worked 6 AM-2 PM shift. She stated on 1/14/16 at 7:00 AM, CNA #1 requested her to look at CR#1. She stated CR#1 stated both legs were hurting and said my legs don ' t work . She stated she assessed CR#1 by doing range of motion. She stated she failed to take vital signs of CR#1. After her assessment, CNA #1 got her up for breakfast. She further stated she later called the NP to get an order for [REDACTED]. She stated the Hospice Nurse had arrived at the facility and she reported the change of condition to the Hospice Nurse. She stated the Hospice Nurse stated she would notify the family. She stated she did not contact CR#1's family members to notify them of the change of condition. She further stated CR#1 was alert, but was not a good historian due to her advanced dementia. She stated CR#1 could not use a pain scale. She stated she assessed CR#1 ' s pain level to be a 6 or 7/out of 10. She stated it was unusual for CR#1 to complain of pain and to receive pain medications. She further stated when CR#1 was sitting still, she was fine, but if you tried to move her, she had complaints of pain. She stated when she left for the day, she had informed the oncoming nurse (LVN#2) that CR#1 was complaining of leg pain, an x-ray was completed, and was waiting on the results. Record review of LVN#1 Witness Statement, no date, read On the morning of 1/14/15(1/14/16) CNA #1 reported to me that CR#1 was complaining of pain. When I entered the room CR#1 was guarding her right leg. I asked her if she could straighten it out, and she did. I instructed the CNA to get her up if she could tolerate it and she did. NP was notified upon arrival to facility before lunch. I asked if she could give me an order to take x-rays, and she did. X-ray was on site and I told him to hold on I needed him to take an x-ray on CR#1. X-Ray was called in and the tech took the x-ray between 2 pm-3 pm. Tech informed me to call x-ray in STAT and that was done. Hospice nurse was on site to see patient that day. I informed Hospice Nurse about new onset of pain and she informed me that she would call CR#1 family member. Around 2:30 PM CR#1 ' s family member called the nurse ' s station and inquired about why she heard from hospice nurse and not me . Record review of CR#1 ' s Physician Notes, dated 1/14/16, revealed the Nurse Practitioner (NP) was called by nurse to evaluate patient who complains of leg pain and seems not her usual state of self. The NP wrote .Patient does not appear in pain but when I moved R (right) knee she exhibited guarding behaviors and would not let me touch knee again. Under the section titled Functional Status, revealed CR#1 required full assist and supervision and was wheelchair dependent. Her [DIAGNOSES REDACTED]. Record review of CR#1 ' s NP witness statement, dated 1/21/16, the NP wrote .around 11:30 AM when nurse informed me of patient ' s (CR#1) ' s leg pain . I asked nurse to medicate for pain. Nurse administered [MEDICATION NAME] 50 mg at that time. Further review revealed the NP wrote At 10:30 PM nurse reported x-ray results showing left acute hip FX (fracture) and I gave order to transfer patient (CR#1) to ER (emergency room ) for further evaluation. During the call, the phone was taken by family member who introduced herself as a rehab nurse Record review of CR#1 ' s Nurse ' s Notes dated 1/14/16 revealed: 11:53 AM- PRN Administration- [MEDICATION NAME] 50 mg tablet, one tablet by mouth every 8 hours as needed Pain; 2:41 PM- PRN Follow-up- Pain evaluation at 3 or less; 3:12 PM- Patient complains of pain in BLE. Patient given PRN [MEDICATION NAME]. NP notified. New orders to get x-ray of BLE. Hospice nurse notified upon arrival to facility. RP aware. Further review of Nurse ' s Notes dated 1/15/16 at 12:00 AM, LVN#2 wrote Received X-ray result with findings of diffuse osteopenia. Subcapital acute fracture left hip is noted with minimal displacement . NP was notified and ordered to transfer patient to hospital. RP present at the facility at that time requested to send patient to hospital. Report was given to ER charge nurse . Record review of CR#1's MAR, dated 1/14/16, revealed CR#1 received one dose of pain medication [MEDICATION NAME] 50 mg. Further review revealed her pain level was a 6 out of 10 prior to administration, and after administration her pain level decreased to a 1 out of 10. The pain was to her legs. Record review of CR#1 ' s Change in Condition, revealed nurses had electronically documented: -1/14/16 at 3:15 PM, LVN#1 assessed CR#1 ' s pain level to be a 6 to her bilateral lower extremities. -1/15/16 at 12:21 AM, LVN#2 assessed CR#1 ' s pain level to be a 4 to her left hip. Record review of CR#1 ' s X-Ray Final report, dated 1/14/16, revealed CR#1 sustained an acute subcapital fracture left hip. Further review revealed the physician electronically signed the report at 4:44 PM. Further review CR #1's X-Ray Final Report, revealed two different reports date/time stamp of receipt from the fax machine: 1. 1/14/16 at 6:26 PM. There was no indication or documentation this report was reviewed and CR#1's physician or family were notified. 2. 1/14/16 at 9:52 PM. Further review of the report revealed a stamp received. The stamp revealed the NP was notified of the findings at 10:40 PM and CR#1 ' s family was notified at 10:30 PM. Record review of CR#1 ' s family Text message records with Hospice Nurse, revealed: 1/14/16 at 3:47 PM- Hospice Nurse wrote: Talked with (LVN#1) she said (CR#1) was in a ball this am and complaining of pain in legs. Their taking some x-rays to make sure no fracture. I ' ll let you know . Family wrote Ok thanks for letting me know because no one called me . 1/14/16 at 11:22 PM- Family wrote Hi I know it ' s late. I ' m at the facility with (CR#1) and she has an a [MEDICAL CONDITION] hip. Her facility (physician) thinks it ' s best to send her to the ER for further evaluation. An acute left [MEDICAL CONDITION] . Interview on 1/15/16 at 2:05 PM, the contracted X-Ray Company Supervisor stated CR#1 ' s x-ray results were done by the technician at the facility on 1/14/16 at 2:58 PM. The order was changed to Stat at 3:26 PM and was read by the physician on 1/14/16 at 4:44 PM. She stated as soon as the physician electronically signed the reports, the report was automatically faxed to the number they had on file. She stated because the results for CR#1 were abnormal, it was the policy of the company to call and speak to a nurse to ensure they had received the findings. She stated the X-Ray Company attempted to contact the facility on 1/14/16 at 5:00 PM and 9:57 PM- with no success. On 1/15/16, they called at 7:06 AM, 10:38 AM, and 12:02 PM- with no success. At 1:00 PM, the facility was finally able to speak to a nurse. She further stated this was not the first time the company had a problem with getting in touch with the facility. She stated this was an ongoing problem with the facility. Observation on 1/15/16 at 2:30 PM revealed inside the locked medication room (Located near nurse station #1) was a fax machine/copier. The machine was lit red and read toner out . RN#1 took the toner cartridge out of the machine and shook it and faxes began to come out the machine. A total of 72 pages were received. The date/time stamped on the pages began at 1/15/16 at 11:12 AM. No faxes had been received since 11:12 AM (Over 3 hours). Interview on 1/15/16 at 2:30 PM , RN #1 stated the fax machine had been out of toner for two days. She stated she called the pharmacy to ask them to bring a toner cartridge over. She stated the pharmacy stated they would deliver the toner today. Record review of CR#1 ' s Hospital Records revealed: History and Physical, dated 1/21/15 revealed .had x-ray done in the facility for complaint of pain which showed a left hip subcapital fracture. Not sure patient had a fall prior to that or not, no known fall or trauma so the patient was sent to the ER and the patient is admitted for ortho evaluation . Discharge Summary, dated 1/21/16 revealed XXX[AGE] year old female who was admitted after found to have a fracture in skilled facility. Patient was admitted here since the family did not want to return to the same facility. Another issue was for pain control, even though the patient did not need any pain medication for the last 32 hours. Patient denies any significant pain, patient was also mostly in the bed at this time .The new medication is the pain medications [MEDICATION NAME] . Record review of Facility ' s Investigation Report for CR#1, dated 1/21/16 revealed an injury of unknown source on 1/14/16 at 10:30 PM. The Assessment was completed on 1/14/16 at 7:00 AM. Further read patient complained of pain of BLE on 1/14/16. Per nurses statement the patient assessment was conducted and pain medication was refused at that time. At appx 11:30 AM nurse administered 50 mg of [MEDICATION NAME]. Hospice and NP notified at appx 11:30 AM. NP was on site and completed assessment. New orders received to obtain x-ray of BLE. RP (Responsible Party) was notified. Assessment included: pain evaluation noted at a 9, after medication administration pain level was a 3. Blood pressure was 106/68 . X-ray results received subcapital fracture of left hip. NP was notified of X-ray results. Order was received to transfer resident to (hospital. RP notified. Further review revealed CR#1 was transferred to the hospital on [DATE] at 11:27 PM. Under the section titled Provider Action Taken post- investigation read The facility provided transfer education to staff; in-service presented by Therapy department. In-Service on notification of change of condition to responsible party, follow-up lab and x-rays. Interview on 1/21/16 at 2:57 PM, CR#1 ' s family member stated the facility did not contact her to notify her of the change in condition for CR#1. She stated this was not the first communication problem from the facility and on multiple occasions she had tried to call the nurse ' s station after hours and could not reach any staff. She stated the hospice nurse sent her a personal text message on 1/14/16 at 3:45 PM notifying her that CR#1 was found in a ball and was complaining of pain. She stated she thought the facility was responsible for notifying the family and consulting the physician after any incident. She further stated she had not heard anything on the results of CR#1 ' s x-rays and called the facility and spoke to LVN #2 and asked her about the x-ray. She stated LVN#2 reported the x-rays results were not in. She stated at 9:45 PM she drove to the facility to see CR#1. She stated CR#1 screamed out in pain when she touched her. She stated she went to the nurse ' s station to check on the status of the x-ray results and LVN#2 stated there was no toner in the fax machine. CR#1 ' s family member stated she contacted the x-ray company and asked them to send the results to the other fax machine located inside the facility. The other fax machine received the x-ray results at 10:32 PM. She further stated the facility neglected CR#1 because it took them too long to get the results, not medicating her, and for not notifying her in a timely manner. She stated CR#1 was only given pain medication one time and was crying out in pain when she saw CR#1. Interview on 1/25/16 at 5:30 PM, CR#1 ' s Hospice Nurse stated when she came to the facility on [DATE], LVN#1 had reported CR#1 was complaining of leg pain, that they were waiting for x-rays, and had already administered pain medications. She stated that was unusual for CR#1. She stated CR#1 usually complained that she didn ' t feel good or would say I am dying , but would never complain of pain or take medications for pain. She stated for CR#1 to take pain medications, she was really in a lot of pain . She further stated she sent a text message to CR#1 ' s family member to keep her informed. She stated the family member had later notified her of the x-ray result findings. CR#2 Record review of CR#2 ' s medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Further review revealed she was transferred to the hospital on [DATE]. Record review of CR#2 ' s 14 day Scheduled Assessment- MDS, dated [DATE], revealed she was cognitively intact, had no [MEDICAL CONDITION] or behaviors, and required extensive assistance by one staff member for bed mobility, transfers, dressing, toilet use and personal hygiene. Eating, she needed supervision and setup assistance. Record review of CR#2 ' s X-Ray report, dated 1/14/16, revealed a physician read the report at 12:20 PM. The date/time stamp the facility fax machine received the report was 1/15/16 at 11:12 AM. The findings read Right lower lobe infiltrate and right pleural effusion. Pneumonia is suspected. Follow-up exam is recommended. Mild [MEDICAL CONDITION] vascular congestion. The facility fax machine was out of toner and CR#2's results were not printed until 1/15/16 at 2:30 PM. Record review of CR#2 ' s Electronic Nurses Notes revealed multiple late entries: 1/14/16 at 9:59 AM LVN #1 wrote: Patient states her heart is racing and shaking . NP notified immediately . STAT chest x-ray, CBC and BMP. Family notified of resident ' s condition and new orders. 1/15/16 at 6:30 PM (written for 1/14/16) LVN#2 wrote Received BMP and CBC result with BUN 68, Creat 1.5 and WBC 4.4. NP was notified and ordered to repeat BMP every 2 days. (Family) aware . 1/15/16 at 6:48 PM (written for 1/14/16) LVN#2 wrote Patient was observed sliding on the floor. I helped ease her on the floor and call for assistance to put her back in bed . 1/18/16 at 8:59 AM (written for 1/15/16)-LVN #1 wrote Late entry. At 7 am CNA reported that patient has new abrasion on left elbow. Entered room to find small ½ inch abrasion on left elbow. ADON and Wound Care notified. Attempted to call responsible party, no answer . 1/15/16 at 3:40 PM-LVN #1 wrote Late entry. NP notified of chest x-ray results around 9:30 (AM). Awaiting Orders. Further review revealed an addendum with new orders for 500 mg [MEDICATION NAME] daily x 10 days. 1/18/16 at 11:41 AM (written for 1/16/15)- LVN #3 wrote Received X-ray results, mild [MEDICAL CONDITION] vascular congestion is seen, right lower lobe infiltrate is noted, notified NP, new order [MEDICATION NAME] 875-125 mg 1 tab by mouth every 12 hours, RP (responsible party) notified. 1/18/16 at 10:38 AM-LVN #1 wrote CNA presents a stop and watch form for resident stating that the resident doesn ' t seem usual self. Entered the room of resident to find resident sitting upright in wheelchair unable to feed herself as usual. Resident had tremors and appeared lethargic. Resident was asked full name and where she was from and it took resident longer than usual to answer and she was stuttering. Apical pulse checked at 62 manual blood pressure of 118/58, respirations 18, and temp 98.0. Patient has no complaints of pain. NP notified of patients condition, and ordered to transfer patient to the hospital. EMS called for transport. Patient transferred to Hospital. RP notified of patient transfer. Interview on 1/21/16 at 5:11 PM, the Interim DON stated she had worked at the facility for 1 ½ years. She stated she was the interim DON when the previous DON left on 1/14/16. She stated when a resident had any change of condition; she expected the physician and family to be notified right away and no later than during the shift. Concerning pain medication: she expected the administration of pain medications to be done immediately after an assessment and a follow-up to be completed within one hour to ensure the medication was effective. Concerning answering calls and fax machines: she stated the BOM was in charge of answering calls and checking the fax machines. She stated after hours, the nurses were responsible for answering calls and checking the fax machines. She stated the facility had implemented a new policy and procedure to include purchased back-up toner cartridges for each fax machine, and after 5 PM, the calls go to the cordless phones located at the nurse ' s stations. Record review of the facility ' s Acute Condition Changes policy, dated 4/2007 revealed the nursing staff was responsible for contacting the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response within approximately one-half hour or less. This policy did not address notifying family members. Record review of the facility ' s Abuse Prohibition Management Program, no date, read Our facility will not condone resident abuse, neglect or mistreatment . by anyone, including staff members . Further review of the policy defined Neglect as the failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury or harm or death to the resident. The census revealed 32 residents resided on Hall 200.

Based on interview and record review, the facility failed to consult the physician for changes in condition for 2 of 14 residents (Resident #1 and CR#6) reviewed for changes in condition as evidenced by: -Resident #1 had a 14 lb weight loss in 2 months; the physician was not consulted and the family was notified; -Resident #1's physician was not consulted on the continuous episodes of nausea and vomiting - CR #6 was identified as having difficulty chewing and swallowing and the MD and the family was not made aware. -CR #6 pocketed food in her mouth and the MD was not consulted. An IJ was identified on 4/27/15 at 2:30 pm. While the IJ was lowered on 5/1/15 at 2:30 pm the facility remained out of compliance at a scope of pattern and a severity of actual harm because all staff had not been trained on monitoring and the importance of consulting the physician related to resident changes. These deficient practices affected 1 CR, 1 current resident and could place 96 additional residents at risk for not having the appropriate person notified when there was a change in the resident's condition. Complaint # 2 and # 5 Findings include: Resident #1: Record review of the facility face sheet for Resident#1 revealed a [AGE] year old male admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Record review of the Nutrition Therapy Assessment, dated 01/12/2015, for Resident #1 revealed in part: Type of assessment: new admission. - Comments: Resident #1 able to make his needs known, he has concerns with swallowing at this time. Usual Body Weight is 180 but since he has become ill states that he has lost and now is 137 lbs. Current weight is 137.2 lbs. Resident at risk of dehydration due to on altered texture diet. On puree diet. History of [MEDICAL CONDITION] strictures. Goals: Resident will maintain weight, will have no sign and symptoms of dehydration. Record review of the facility's weight records for Resident #1 revealed weights on; -01/10/2015 of 137.2 lbs. -01/16/2015 of 133.8 lbs. -02/04/2015 of 126. 6 lbs. -03/02/2015 of 123.4 lbs. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 was cognitively intact with a BIMS score of 15 out of 15. Resident #1 required extensive assistance of 2 persons for bed mobility and toilet use and extensive assistance of one person for locomotion, dressing, eating, personal hygiene and bathing. The assessment section on swallowing/nutritional status revealed no swallowing disorders and weight was 137 lbs. Resident #1 was assessed with [REDACTED]. Resident was assessed with [REDACTED]. Record review of the consolidated physician orders [REDACTED]. -start date 01/15/2015 end date 03/18/2015 - [MEDICATION NAME] 25 mg tablet, one tablet by mouth as needed for nausea and vomiting. -start date 02/26/2015 end date 04/07/2015 mechanical soft diet. -start date 03/17/2015 end date 04/06/2015 - [MEDICATION NAME] sodium 100 mg tablet, table one tablet by mouth 2 times per day for constipation. Record review of Resident #1's MAR indicated [REDACTED] -2/16/2015 -2/17/2015 (twice) -2/18/2015 -2/19/2015 -2/22/2015 -2/24/2015 -2/25/2015 Record review of the nurse notes for Resident #1 revealed in part: -02/05/2015 at 1:52 pm: Resident weight is 126.6 lbs. continues to refuse pureed diet, drinks fluids. Spoke with wife regarding refusal of meals. Further record review revealed no MD notification. Record review of Resident #1's MAR indicated [REDACTED] -3/5/2015 -3/10/2015 -3/15/2015 -3/17/2015 -3/18/2015 (twice) Record review of Resident #1's ADL record dated March 2015 revealed no documentation of the amount of the resident ' s meal consumption. Record review of Resident #1's Therapy Screen dated 3/5/2015 revealed in part: Per patient and nurse report, Resident #1 has been vomiting and choking on regular diet. Patient was instructed to follow reflux precautions due to complaints of " feeling that food gets stuck in esophagus". Recommend to continue with current diet due to patient complaints. Patient will need medical workup to determine basis for [MEDICAL CONDITION] complaints. Record review of Resident #1's nurses notes and Therapy Screens, dated between 3/5/15 - 3/18/15 (date Resident #1 was transferred to a local hospital), revealed no documentation that Resident #1 received any medical work up related to the [MEDICAL CONDITION] complaint. Record review of the nurse notes for Resident #1 revealed in part: -3/15/2015 completed 3/16/2015 at 12:12 am: Received PRN [MEDICATION NAME] 25 mg for nausea and vomiting times 1, effectively. Resident #1 stated that when he drinks cold water it makes him throw-up. Record review of Resident #1's file revealed a physician order [REDACTED]. Record review of Resident #1's hospital history and physical dated 3/19/2015 at 11:41 p.m. revealed in part: - Date of admission: 3/18/2015. - History of present illness: admitted through ER with persistent nausea, vomiting...He had also significant weight loss recently. - Past medical history: ruptured esophagus. - Assessment and plan: 6. - nausea, vomiting with dehydration. We will start the patient on intravenous fluid and his fluid status needs to be closely monitored and electrolyte needs to be corrected. Record review of Resident #1's discharge summary from the hospital dated 4/6/2015 at 8:59 a.m. revealed in part: Final Diagnoses: [REDACTED]. 2. - [MEDICAL CONDITION] stricture with dysphagia not amenable to dilation in this facility, status [REDACTED]. Pertinent hospital course: Resident #1 admitted with inability to eat, persistent vomiting, weight loss and dysphagia. The patient had significant [MEDICAL CONDITION] stricture, which could not be deflated so the patient was seen by surgeon. The patient is having intermittent bowel movement. Observation on 04/08/2015 at 10:05 p.m. revealed Resident #1 in bed with a tube feeding. In an interview at that time, Resident #1 stated he had arrived from the hospital a couple of days ago. He stated, "I went to the hospital for weight loss because I had been vomiting a lot for long time here. They told me at the hospital that my esophagus was closing. I asked the facility several times to send me to the hospital and they refused". Resident #1 further said that since he had arrived to the facility in January 2015 he had been vomiting and he knew something was happening to him and he had been requesting to be sent to the hospital but the facility had been refusing to send him. In continued interview, he stated " everything I ate or drank, I would vomit, they did not listen to me until at the end when they saw me continuously vomiting and they couldn't controlled it anymore". Resident #1 said " every time I ate or drunk and kept vomiting, I kept telling them that something was wrong with me, to send me to the hospital, but they did not send me until March 2015 and when I arrived at the hospital my weight was already 120 lbs.". In an interview on 4/8/2015 at 2:34 p.m., the DON stated that weight loss is a change in condition and required notification of MD and family. When asked if Resident #1's MD and family were made aware of the weight loss of 10.6 lbs. on 2/5/2015, DON responded as she looked at the computer documentation " I don't see any notes". DON further stated she needed to check on the facility's policy for weights as she was not sure what was considered significant weight loss. In continued interview, the DON stated she did not see any notes for weight loss of Resident #1. She stated, the nurses on the floor were responsible to monitor the weights of the residents and notify the MD of any significant weight changes and notify the responsible party. The DON stated the ADON and DON were responsible to oversee the weight records. When asked if she was aware that Resident #1 had any weight loss, she responded that she was not aware that Resident #1 had any significant weight loss. In continued interview with the DON, she stated that she learned of the vomiting of Resident #1 on 3/16/2015 and said "it was when the facility provided IV hydration". When asked if Resident #1 had been vomiting before, DON stated she was not aware. DON further said if a resident or a family requested to be sent to the hospital, the facility gets orders to send residents to the hospital. When asked if Resident #1 had requested to go to the hospital before, the DON responded "the wife called me and that's when we sent him out because she was concerned for the nausea and vomiting. In an interview on 4/8/15 at 3:30 pm, the DON said, when asked about Resident #1's continuous vomiting and nausea, she thought there had been an order for [REDACTED]. Observation at that time revealed the DON looked through Resident #1's records on the facility computer and stated she could not find any information that the resident had been seen by a DR Doctor. In an interview on 4/8/2015 at 4:15 p.m. with the Dietary Manager A revealed she was not aware that Resident #1 had any weight loss or that he had any episodes of nausea and vomiting. She further said "I knew he had refused meals but not that he had weight loss. She stated "he did not like the texture of his diet". In an interview on 4/8/2015 at 4:45 p.m. LVN B stated she was the unit manager and whenever residents had any change in condition, the MD and the family needs to be notified. LVN B stated that change in condition was anything that is not normal for a resident. In continued interview, LVN B stated she monitors the weights and makes sure nurses notify the MD and family of changes. She stated, "I did not know Resident #1 had any weight loss until he was about to go to the hospital. I asked the nurses about 2 days before Resident #1 went to the hospital to get an order for [REDACTED]. In a phone interview on 4/27/2015 at 10:20 a.m. with NP E revealed that she was not aware that Resident #1 was vomiting every day. She further stated that she remembered that she was called once regarding Resident #1 vomiting, a Tuesday before he went to the hospital. In continued interview, she stated that she remembered that Resident #1's wife was worried about dehydration. CR #6 Record review of the facility face sheet for CR #6 revealed a [AGE] year old female admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. CR #6 was sent to the hospital via Emergency Medical Service by the RP on 4/18/2015 after she was found by the family lethargic and non-responsive. Record review of the consolidated physician orders [REDACTED]. - Dated 3/11/2015 - regular diet and thin liquids. -Dated 4/14/2015 - [MEDICATION NAME] ([MEDICATION NAME]) 15 mg tablet one by mouth at bedtime for Atypical [MEDICAL CONDITION]. Record review of the Nutrition Therapy assessment dated [DATE] and completed by the RD C on 3/30/3015 for CR #6 revealed in part: Type of assessment: new admission. - Nutrition Diagnosis: [REDACTED]. Intervention in part: Monitor oral intake of food and fluid, encourage hydration between meals, with meals. Record review of the admission initial MDS with assessment reference date of 03/18/2015 revealed CR #6 was rarely/never understood and did not complete BIMS evaluation. CR #6 required extensive assistance of 2 persons for bed mobility and transfers and limited assistance of one person for eating. The assessment section on swallowing/nutritional status revealed no swallowing disorders. Record review of CR #6's basic metabolic panel report ( blood test that gives information about the body's electrolyte and fluid balance) dated 3/18/2015 revealed in part: Sodium 141 mEq/L expected range (136-146) BUN (blood urea nitrogen/test that evaluates kidney function) 12 mg/dL (7-25) Creatinine (blood test that measures kidney function) 0.8 mg/dL ( 0.6-1.2) Record review of CR #6's Therapy Screen notes revealed in part: -3/12/2015 "...Screen Type: new admit. -Comments: Swallow screened, CR #6 with no overt clinical sign and symptoms of aspiration. Skilled speech language pathologist services are not warranted at this time, evaluation is not indicated". -3/23/2015 at 1:59 p.m. "....Nursing requested a repeat swallow screen as CR #6 is holding food in mouth. C.N.A in room reports CR #6 will eat food from home (husband brought at a hamburger from outside and CR #6 ate without difficulty). Comments: When pasta was placed in mouth, CR #6 refused to swallow and grimaced, spat food into napkin. Recommend: family bring food from home with clearance from MD to ensure is getting proper nutritional support from by mouth. Will follow up if needed. Speech language pathologist assessment is not indicated as CR #6 most likely presenting with dissatisfaction with current facility meals offered, however swallowing outside foods". -3/30/3015 at 2:56 p.m. "..Comments: CR #6 seen again with meal intake and continued to hold bolus in mouth requiring for clinician to clear oral cavity. CR #6's husband called to bring food from home as C.N.A's report CR #6 does eat when eating preferred foods. Both cell and home called, Mailbox for cell phone is full and home number is no longer in service. Will continued to follow up with family as available". Record review of CR #6's History and Physical dated 3/18/2015 and completed by the MD revealed no information that CR #6 had problems pocketing food in her mouth. Record review of CR#6's meal percentage for March 2015 revealed documentation for only 3/24/2015, 100% and 3/26/2015, 100% during dinner time. Further record review revealed no further documentation of meal intakes for the month of March 2015. In continued record review revealed meal percentages for April 1,2015 to April 15, 2015 ranging from 25% to 50% and from April 15,2015 to April 18, 2015 refusing all breakfast. Further observation revealed no meal percentages for lunch and dinner recorded. Record review of CR #6's nurses notes revealed in part: -3/17/2015 at 10:55 a.m. "..CR #6 would not swallow crushed medication mixed with cranberry juice. CR #6 spit out and found she also had food pocketed in her mouth. Speech evaluation ordered". -3/24/2015 Daily skilled note in part: - "..G.I.: Difficulty chewing". -4/4/2015 at 1:20 p.m. "...CR #6 continues to pocket food. Will continue to monitor". -4/7/2015 Daily skilled note in part: - "..G.I.: Difficulty chewing, difficulty swallowing". -4/14/2015 at 6:53 p.m. "...CR #6 transferred from Rehab unit. Needs encouragement to eat. Ate 25% of dinner. Requires total care with ADL's". -4/15/2015 at 8:48 a.m. "..Received orders for [MEDICATION NAME] 15 mg every hs, phoned husband and received consent to receive medication, also received order for dietary consult". -4/17/2015 at 1:51 p.m. " ..CR #6 lying in bed lethargic, arouse when she is stimulated. Still continue to refuse food, medications. Hydration in place at 50 ml/hr for 3 bags. Record review of CR #6's Change of Condition assessment dated [DATE] at 9:55 p.m. revealed in part: *Situation: Change in cognition status and appetite. This change was observed: Today. -Nursing note: CR #6 is sitting in the wheelchair, lethargic, sleeping. Offered food, CR #6 refused, offered dietary supplement, refused. NP ordered an IV normal saline at 50 ml/hr for 3 bags. * Background: Blood pressure 128/47. Mental status changes: lethargy. Record review of CR #6's care plan initiated 3/11/2015 revealed in part: Care Area/Problem: Altered Nutritional Status related to: Need for assistance/cueing with meals. Further record review revealed no information related to CR #6 pocketing food or problems with chewing or swallowing. In continued record review revealed care plan was not updated at any time with appropriate interventions. Record review of CR #6's hospital history and physical dated 4/18/2015 at 10:38 p.m. revealed in part: -Date of admission: 4/18/2015. - History of present illness: Today, while the family members were visiting CR#6, they noticed that she was less alert and was not responsive. They also noticed severely dry mouth and she had a sacral decubitus ulcer. CR#6 was brought to the emergency room . While in the emergency room , CR#6 was noted to be hypernatremic with sodium of 155. She was in acute [MEDICAL CONDITION] with a BUN of 108 and a creatinine of 3.5. She was also noted to have a urinary tract infection and CT brain revealed new left ischemic infarct that was likely subacute. CR #6 has been admitted for the management of the multiple problems currently going on. -Laboratory data in part: Sodium:155, BUN: 108, Creatinine:3.5 and urinalysis: greater than 200 white blood cells, bacteria many. Skin: sacral decubitus ulcer. -Assessment plan: 1.- Subacute stroke, 2.- [MEDICAL CONDITION], likely multifactorial secondary to the stroke, dehydration, [MEDICAL CONDITION], and urinary tract infection. 3.- Dehydration, 4.- [MEDICAL CONDITION], 5.- Acute [MEDICAL CONDITION], 7.- Urinary tract infection, 8.- Sacral decubitus ulcers. Record review of CR #6's hospital Neurology consultation dated 4/19/2015 at 5:43 p.m. revealed in part: -Reason for consultation: Acute kidney injury and [MEDICAL CONDITION]. General: CR #6 lying in bed, very lethargic. -Assessment and plan: [MEDICAL CONDITION] secondary to free water deficit. -Assessment: 1.- Acute kidney injury, most likely due to prerenal dehydration, possible due to poor oral intake. -Plan: will change the fluids to D 5 ([MEDICATION NAME] 5%) half normal saline at 125 mL an hour. Monitor urine output. Observation on 4/21/2015 at 9:20 a.m. revealed CR #6 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #6 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of DiabeticSource (nutritional formula for patients with Diabetes) and water flush at 200 ml every 4 hours. CR #6 also had an intravenous catheter (catheter that is inserted into a vein) to her right upper arm with D5W (5% [MEDICATION NAME] in water) and half normal saline fluids at 100 ml per hour. In continued observation, CR #6 was noted to have a Foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. In an interview at that time, CR #6 's family member stated on 4/18/2015, they visited CR #6 at the facility and she was found very lethargic and non-responsive by the family members. She further stated that CR #6 had dry saliva around her mouth and that her tongue was very dry as well. The family member stated in the ER they were told that CR #6 was severely dehydrated and had kidney failure due to the dehydration. In an interview on 4/22/2015 at 9:40 a.m. C.N.A. F stated she worked with CR #6 before she was transferred to the hospital on [DATE]. C.N.A. F further said that when CR #6 was moved to the long term side, which was about a week and a half before CR #6 went to the hospital, she would pocket the food in her mouth and would hold it and would not eat. C.N.A F continued saying, when CR #6 started pocketing her food, she would eat one or two spoons, but later, CR #6 would not open her mouth for food or fluids. C.N.A. F further said that CR #6 had barely any output of urine on the drainage Foley catheter bag, and continued saying that it was approx. 100 cc of urine at the end of the shift. In continued interview at that time, C.N.A F was asked if the information about CR #6's oral intake and urine output was reported to the nurses and she replied since she moved to this unit, I would notify the nurses, I would say "CR #6 did not eat or drink" . C.N.A F further said that she remembered CR #6 when she was on the Rehab station. CNA F said "I remember staff would bring her to the dining room, and as I passed by, I would see CR #6 with the tray in front of her uneaten, she would just sit in there and not eat". CNA F stated the procedure to follow when residents do not eat is to report it to the nurses, offer something else to the residents but that CR #6 would not even open her mouth. She further said "I would report it to whoever nurse was there " . In an interview on 4/22/2015 at 9:58 a.m. LVN G stated one C.N.A reported to her that CR #6 was pocketing food in her mouth and that she tried to remove the food and offer a supplement and that CR #6 would not take anything, even the medications. She further said that she reported the information to NP E and who ordered IV fluids and blood work. LVN G continued saying that she asked the speech therapist to evaluate CR #6 and that she was told that CR #6 did not want to swallow. LVN G further said "I believe the pocketing problem was there since CR #6 was on the other unit (the rehab unit)". In an interview on 4/22/2015 at 11:26 a.m. LVN B stated she was the ADON for the long term side and that CR #6 was transferred to the long term side on 4/14/2015. LVN B stated she talked to NP E on 4/16/15, when she came to the building regarding CR #6 because she wasn't sure what the baseline was for CR #6. LVN B reported to NP E that CR #6 was not eating or drinking and would just lie in bed not really responding to staff. LVN B further said that NP E told her that CR #6 was not acting at her baseline. LVN B said, "NP E ordered some fluids, but I did not hear the complete orders given", which were given to LVN G. LVN B continued saying that when CR #6 was moved on 4/14/2015 from the Rehab side, she did not know about the food pocketing problem of CR #6. In continued interview at that time, LVN B stated that changes in resident conditions need to be documented on the change of condition assessment, notify the MD and family and the care plan needed to be updated. LVN B stated, after reviewing CR #6's file on the computer, "the only change of condition assessment was on 4/16/2015". LVN B was then asked if the care plan for CR #6 had been updated since admission with new condition of pocketing food and poor by mouth intake and LVN B responded, as she looked at the computer, "the nurses were supposed to be updating the care plan because those were acute changes in condition, no I don't see it". In an interview on 4/22/2015 at 12:18 p.m. , LVN H stated she provided care to CR #6 while she was on the Rehab side of the facility. She stated she had been made aware of CR #6 pocketing food in her mouth. LVN H stated the care plans for pocketing food should have been updated, but that problem was identified from before me, everybody was aware of that". LVN H further stated that changes in condition assessments are completed in the computer and that the MD and family needed to be notified. In an interview on 4/22/2015 at 12:40 p.m. with DON M revealed that she was the new DON and that she had just started working in the facility. In an interview on 4/22/2015 at 12:50 p.m. with Dietary Manager A stated she was made aware on 4/13/15 that CR #6 had stated declining in her appetite and not eating. Surveyor asked Dietary Manager A if she was made aware of any intervention placed as a result of CR #6's decline and she responded "No ma'am". In an interview on 4/22/2015 at 1:00 p.m. Registered Dietitian stated she did not get to see CR #6 recently because CR #6 went to the hospital and she goes to the facility every other week. She further stated she saw CR #6 on 3/30/2015 and at that time she was made aware that CR #6 had a pressure sore but she was not made aware of any food pocketing or food problems. In a phone interview on 4/24/2015 at 1:25 p.m. RN J, stated she was the ADON for the Rehab side of the facility. RN J further said she was not sure of the eating for CR #6 because she was taken to the dining room for meals. RN J continued saying that she remembered that CR #6 used to pocket food in her mouth but she did not remember how long that had been and she was not made aware that CR #6 was able to eat any food. Surveyor asked RN J if the MD was made aware of the condition and she replied "I was told that the MD was notified, nurses will take care of the change of condition assessments, notifications to the family and the MD and to update any care plans as well". RN J stated she did not know the condition of CR #6 when she was transferred to the long term side because she did not see her. In a phone interview on 4/27/2015 at 10:05 a.m. with NP E stated that she was made aware that CR #6 was pocketing food on her mouth but that she was eating some food. She stated she was not made aware that it was a problem that had affected the resident the whole time. NP E continued saying "my understanding was the speech therapist was following CR #6 all along and if there was a problem, the speech therapist would alert us". In continued interview at that time, NP E stated on 4/15/2015 she was told that CR #6 was eating a little bit and she ordered [MEDICATION NAME] but the resident progressively got worse. NP E stated it was not until 4/16/2015 when she was made aware that CR #6 was not eating and that was when she ordered hydration and blood work but CR #6 was sent to the hospital on [DATE] and was not able to get the blood work. NP E further said that she "kind of" let the MD now about the condition of the residents ( notified them of critical labs and changes of condition), but every Tuesday there was a meeting at the facility and the facility made the MD aware of any conditions the patients have. In an interview on 4/27/2015 at 10:35 a.m. with Speech Therapist K stated that CR #6 was never on her case load because she was not able to follow commands. She stated she saw CR #6 only 3 times and it was mainly to screen her; CR #6 was aware but was not receptive to any type of commands. In continued interview, Speech Therapist K stated she remembered that she recommended a dietary consult and that she told the nurses that if CR #6 continued having problems with pocketing of the food or eating to let her know but the nurses never let her know any further problems with CR #6 "I never heard anything else anymore". She further stated, on 3/30/3015, the last time she saw CR #6, she screened her because she saw her sitting in the therapy room and she recognized her. Speech Therapist K continued saying that the times she saw CR #6 eating, she would only eat a couple of spoons only. In continued observation and interview at that time, Speech Therapist K was asked to show the dietary recommendation that she gave to the nurses. Observation revealed Speech Therapist K looked at the computer and replied "I thought I recommended a dietary consult but I guess I did not write it down. The nurses should know if a patient is not eating, they need to contact the dietitian". Interview on 4/27/2015 at 11:40 a.m. C.N.A L stated she worked with CR #6 and she remembered CR#6 did not eat well. She further stated that when CR #6 first arrived to the facility, she would eat good and that later she declined, "she started pocketing food in her mouth to the point that she would not eat at all". In continued interview, she stated that she reported condition to several nurses "I would tell them, she is pocketing her food, she did not eat today". C.N.A. L further stated "I do not remember when the problem started, but in the beginning CR #6 did not have any problems with eating and then later she declined, she would just put the food on her mouth and would not eat at all". Record review of the undated facility's policy and procedure "Guidelines for notifying Physicians of Clinical Problems" revealed in part: These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. - The following symptoms, signs should prompt immediate notification of the Physician, after an appropriate nursing evaluation. Immediate implies that the Physician should be notified as soon as possible, either by phone or by pager. These situations include: 3.- The following symptoms: b.- unrelieved by measures which have already been prescribed - for example, consistent with criteria - abdominal pain with distension, vomiting; persistent or recurrent nausea and vomiting. Surveyor requested the DON on 4/8/2015 the facility's protocol for weight loss/assessment twice and was not provided. An IJ was identified on 4/27/15 at 2:30 pm. While the IJ was lowered on 5/1/15 at 2:30 pm the facility remained out of compliance at a scope of pattern and a severity of actual harm because all staff had not been trained on monitoring and the importance of consulting the physician related to resident changes. In an interview on 4/28/15 at 3:50 pm the Administrator was asked how did she think this IJ came about, she stated there were a couple of licensed nurses that failed to put necessary interventions in place and the DON at that time was not overseeing the nurses as she should have. The Administrator stated she was not made aware of the resident ' s weight loss and continuing vomiting. A Plan of Removal (POR) for the IJ was initially submitted on 4/28/15. A revised plan was submitted and accepted on 4/29/15 at 2:35 pm. The POR included: 2) Change of Condition · Resident Change of Condition form audit was initiated on 4/27/15 on patients that had a change of condition form completed starting from 4/8/15- to present to ensure physicians were notified of change in patient status and communication to other facility departments as necessary. Initial audit was completed 4/28/15 and continued review of new Change of Conditions will be on-going. The review of change of condition includes reviewing completed form for information regarding the change, communication to physician, review of the situation, background, assessment, recommendations and physician communication/notification of responsible party. 3) Care Plans · During review of Resident Change of Condition form audit started on 4/27/15 care plans were reviewed to ensure problems identified are care planned. Care Plan review to be completed by 4/29/15 for all residents identified having a change of condition and updated as necessary . 4) Facility Policies/Practices/Programs · Effective 4/27/15, the facilities policy and practice will be that it is mandatory for nurses to complete a Change of Condition on residents who present with an abnormal sign/symptom with physician and RP notification. · DON M (or designee} will review daily each completed Change of Condition form to ensure completion and physician/RP notification of the resident's condition. Nurses found not to be in compliance will receive corrective action up to and including termination and further education as appropriate. Daily review of these forms began on 4-28-15. · Beginning on 4/15 at each morning's clinical management meeting completed resident Change of Conditions are reviewed for completeness, Care plans reviewed and updated accordingly, and proper communication to other departments will be followed-up on by DON (or designee} to ensure communication has occurred. Clinical management is attended by Director of Nursing, Assistant Directors of Nursing, MDS Coordinator, Therapy Manager, Dietary Service Manager, Social Services and Administrator. · Beginning 4/28/15, denials in request for trans

Based on observation, interview and record review the facility failed to ensure 2 of 14 residents (Resident #1 and CR #6) reviewed for care provided, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being, as evidenced by: -Resident #1 had a 7.7% weight loss in 1 month (a significant weight loss), and the physician consulted nor was the family was notified; -Resident #1's physician was not consulted on the continuous episodes of nausea and vomiting - CR #6 was identified as having difficulty chewing and swallowing and the MD and the family were not made aware. -CR #6 continued pocketing food in her mouth and the MD was not updated. An IJ was identified on 4/27/15 at 2:30 pm. While the IJ was removed on 5/1/15 at 2:30 pm the facility remained out of compliance at a scope of pattern and a severity of actual harm. These deficient practices affected 1 CR, 1 current resident and could place 96 additional residents residents at risk of not receiving adequate assessments, medical care and services, which could have a negative impact on their health and well-being. Complaint # 2 and # 5 Findings include: Resident #1: Record review of the facility face sheet for Resident#1 revealed a [AGE] year old male admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Record review of the Nutrition Therapy Assessment, dated 01/12/2015, for Resident #1 revealed in part: Type of assessment: new admission. - Comments: Resident #1 able to make his needs known, he has concerns with swallowing at this time. Usual Body Weight is 180 but since he has become ill states that he has lost and now is 137 lbs. Current weight is 137.2 lbs. Resident at risk of dehydration due to on altered texture diet. On puree diet. History of [MEDICAL CONDITION] strictures. Goals: Resident will maintain weight, will have no sign and symptoms of dehydration. Record review of the facility's weight records for Resident #1 revealed weights on; -01/10/2015 of 137.2 lbs. -01/16/2015 of 133.8 lbs. -02/04/2015 of 126. 6 lbs. -03/02/2015 of 123.4 lbs. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 was cognitively intact with a BIMS score of 15 out of 15. Resident #1 required extensive assistance of 2 persons for bed mobility and toilet use and extensive assistance of one person for locomotion, dressing, eating, personal hygiene and bathing. The assessment section on swallowing/nutritional status revealed no swallowing disorders and weight was 137 lbs. Resident #1 was assessed with [REDACTED]. Record review of the consolidated physician orders [REDACTED]. -start date 01/15/2015 end date 03/18/2015 - [MEDICATION NAME] 25 mg tablet, one tablet by mouth as needed for nausea and vomiting. -start date 02/26/2015 end date 04/07/2015 mechanical soft diet. -start date 03/17/2015 end date 04/06/2015 - [MEDICATION NAME] sodium 100 mg tablet, table one tablet by mouth 2 times per day for constipation. Record review of Resident #1's MAR indicated [REDACTED] -2/16/2015 -2/17/2015 (twice) -2/18/2015 -2/19/2015 -2/22/2015 -2/24/2015 -2/25/2015 Record review of Resident #1's MAR indicated [REDACTED] -3/5/2015 -3/10/2015 -3/15/2015 -3/17/2015 -3/18/2015 (twice) Record review of Resident #1's ADL record dated March 2015 revealed no documentation of the amount of the residents meal consumption. Record review of Resident #1's Therapy Screen dated 3/5/2015 revealed in part: Per patient and nurse report, Resident #1 has been vomiting and choking on regular diet. Patient was instructed to follow reflux precautions due to complaints of "feeling that food gets stuck in esophagus". Recommend to continue with current diet due to patient complaints. Patient will need medical workup to determine basis for [MEDICAL CONDITION] complaints. Record review of the nurse notes for Resident #1 revealed in part: -02/05/2015 at 1:52 pm: Resident weight is 126.6 lbs. continues to refuse pureed diet, drinks fluids. Spoke with wife regarding refusal of meals. Further record review revealed no MD notification. -3/15/2015 completed 3/16/2015 at 12:12 am: Received PRN [MEDICATION NAME] 25 mg for nausea and vomiting times 1, effectively. Resident #1 stated that when he drinks cold water it makes him throw-up. Record review of Resident #1's hospital history and physical dated 3/19/2015 at 11:41 p.m. revealed in part:- Date of admission: 3/18/2015. - History of present illness: admitted through ER with persistent nausea, vomiting...He had also significant weight loss recently. - Past medical history: ruptured esophagus. - Assessment and plan: 6.- nausea, vomiting with dehydration. We will start the patient on intravenous fluid and his fluid status needs to be closely monitored and electrolyte needs to be corrected. Record review of Resident #1's discharge summary from the hospital dated 4/6/2015 at 8:59 a.m. revealed in part: Final Diagnoses: [REDACTED]. 2.- [MEDICAL CONDITION] stricture with dysphagia not amenable to dilation in this facility, status [REDACTED]. Pertinent hospital course: Resident #1 admitted with inability to eat, persistent vomiting, weight loss and dysphagia. The patient had significant [MEDICAL CONDITION] stricture, which could not be deflated so the patient was seen by surgeon. In an interview at that time, Resident #1 stated he had arrived from the hospital a couple of days ago. He stated, "I went to the hospital for weight loss because I had been vomiting a lot for long time here. They told me at the hospital that my esophagus was closing. I asked the facility several times to send me to the hospital and they refused". Resident #1 further said that since he arrived at the facility in January 2015 he had been vomiting. He stated he had requested to be sent to the hospital but the facility had refused. In continued interview, he stated "everything I ate or drank, I would vomit, they did not listen to me until at the end when they saw me continuously vomiting and they couldn't controlled it anymore". Resident #1 said "every time I ate or drunk and kept vomiting, I kept telling them that something was wrong with me, to send me to the hospital, but they did not send me until March and when I arrived at the hospital my weight was already 120 lbs". In an interview on 4/8/2015 at 2:34 p.m., the DON stated she was not aware that Resident #1 had any significant weight loss. In continued interview the DON, she stated she had learned of Resident #1's vomiting on 3/16/2015 and "it was when the facility provided IV hydration". When asked if Resident #1 had been vomiting before, DON stated she was not aware. DON further said if a resident or a family requested to be sent to the hospital, the facility would get orders to send residents to the hospital. When asked if Resident #1 had requested to go to the hospital before, the DON responded "the wife called me and that's when we sent him out because she was concerned about the nausea and vomiting." In an interview on 4/8/2015 at 4:15 p.m. Dietary Manager A stated she was not aware that Resident #1 had any weight loss or that he had any episodes of nausea and vomiting. She further said "I knew he had refused meals but not that he had weight loss. She stated "he did not like the texture of his diet". In an interview on 4/8/2015 at 4:45 p.m. LVN B stated she had asked the nurses about 2 days before Resident #1 went to the hospital to get an order for [REDACTED]. In a phone interview on 4/27/2015 at 10:20 a.m. NP E stated she was not aware that Resident #1 was vomiting every day. She further stated that she remembered that she was called once regarding Resident #1 vomiting, a Tuesday before he went to the hospital. In continued interview, she stated that she remembered that Resident #1's wife was worried about dehydration. CR #6 Record review of the facility face sheet for CR #6 revealed a [AGE] year old female admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. CR #6 was sent to the hospital via Emergency Medical Service by the RP on 4/18/2015 after she was found by the family lethargic and non-responsive. Record review of the admission MDS with assessment reference date of 03/18/2015 revealed CR #6 was rarely/never understood and did not complete BIMS evaluation. CR #6 required extensive assistance of 2 persons for bed mobility and transfers and limited assistance of one person for eating. The assessment section on swallowing/nutritional status revealed no swallowing disorders. Record review of CR #6's Therapy Screen notes revealed in part: -3/12/2015 "...Screen Type: new admit. -Comments: Swallow screened, CR #6 with no overt clinical sign and symptoms of aspiration. Skilled speech language pathologist services are not warranted at this time, evaluation is not indicated". -3/23/2015 at 1:59 p.m. "....Nursing requested a repeat swallow screen as CR #6 is holding food in mouth. C.N.A in room reports CR #6 will eat food from home...(without difficulty). Comments: When pasta was placed in mouth, CR #6 refused to swallow and grimaced, spat food into napkin. Recommend: family bring food from home with clearance from MD to ensure is getting proper nutritional support from by mouth. Will follow up if needed. Speech language pathologist assessment is not indicated as CR #6 most likely presenting with dissatisfaction with current facility meals offered, however swallowing outside foods". -3/30/3015 at 2:56 p.m. "..Comments: CR #6 seen again with meal intake and continued to hold bolus in mouth requiring for clinician to clear oral cavity. CR #6's husband called to bring food from home as C.N.A's report CR #6 does eat when eating preferred foods. Record review of CR #6's History and Physical dated 3/18/2015 and completed by the MD revealed no information that CR #6 had problems pocketing food in her mouth. Record review of CR#6's meal percentage for March 2015 revealed documentation for only 3/24/2015, 100% and 3/26/2015, 100% during dinner time. Further record review revealed no further documentation of meal intakes for the month of March 2015. Record review of CR #6's meal percentages for April 1- 15, 2015 revealed the intake ranged from 25% to 50% and from April 15 - 18, 2015 CR #6 refused all breakfast and there was no meal percentages documented for the lunch and dinner meals recorded. Record review of CR #6's nurses notes revealed in part: -3/17/2015 at 10:55 a.m. "..CR #6 would not swallow crushed medication mixed with cranberry juice. CR #6 spit out and found she also had food pocketed in her mouth. Speech evaluation ordered". -3/24/2015 Daily skilled note in part: - "..G.I.: Difficulty chewing". -4/4/2015 at 1:20 p.m "...CR #6 continues to pocket food. Will continue to monitor". -4/7/2015 Daily skilled note in part: - "..G.I.: Difficulty chewing, difficulty swallowing". -4/14/2015 at 6:53 p.m. "...CR #6 transferred from Rehab unit. Needs encouragement to eat. Ate 25% of dinner. Requires total care with ADL's". -4/16/2015 at 6:05 a.m. "...A snack was offered and refused. Less than 25% was consumed at mealtime". -4/16/2015 at 1:02 p.m. "...Refused to eat, offered snack and still do not want it". - 4/16/2015 at 8:48 p.m. "... CR #6 is sitting in wheelchair, lethargic, sleeping. Refused food and dietary supplement. NP E ordered IV for hydration". -4/17/2015 at 1:51 p.m. " ..CR #6 lying in bed lethargic, arouse when she is stimulated. Still continue to refuse food, medications. Hydration in place at 50 ml/hr for 3 bags. Unable to reach the husband " . -4/18/2015 at 1:08 p.m. "...CR #6 refusing meals and supplements, just turns her head away. Has IV fluids". -4/18/2015 at 4:12 p.m. "... phone NP E and made aware of transport of CR #6 to hospital per family request". Record review of CR #6's Change of Condition assessment dated [DATE] at 9:55 p.m. revealed in part: *Situation: Change in cognition status and appetite. This change was observed: Today. -Nursing note: CR #6 is sitting in the wheelchair, lethargic, sleeping. Offered food, CR #6 refused, offered dietary supplement, refused. NP ordered an IV normal saline at 50 ml/hr for 3 bags. * Background: Blood pressure 128/47. Mental status changes: lethargy. Record review of CR #6's care plan initiated 3/11/2015 revealed in part: Care Area/Problem: Altered Nutritional Status related to: Need for assistance/cueing with meals. Further review revealed no information related to CR #6 pocketing food or problems with chewing or swallowing. The care plan was not updated at any time with appropriate interventions. Record review of CR #6's hospital history and physical dated 4/18/2015 at 10:38 p.m. revealed in part: -Date of admission: 4/18/2015. - History of present illness: Today, while the family members were visiting CR#6, they noticed that she was less alert and vas not responsive. They also noticed severely dry mouth and she had a sacral decubitus ulcer. CR#6 was brought to the emergency room . While in the emergency room , CR#6 was noted to be hypernatremic with sodium of 155. She was in acute [MEDICAL CONDITION] with a BUN of 108 and a creatinine of 3.5. She was also noted to have a urinary tract infection and CT brain revealed new left ischemic infarct that was likely subacute. CR #6 has been admitted for the management of the multiple problems currently going on. -Laboratory data in part: Sodium:155, BUN: 108, Creatinine:3.5 and urinalysis: greater than 200 white blood cells, bacteria many. Skin: sacral decubitus ulcer. -Assessment plan: 1.- Subacute stroke, 2.- [MEDICAL CONDITION], likely multifactorial secondary to the stroke, dehydration, [MEDICAL CONDITION], and urinary tract infection. 3.- Dehydration, 4.- [MEDICAL CONDITION], 5.- Acute [MEDICAL CONDITION], 7.- Urinary tract infection, 8.- Sacral decubitus ulcers. Record review of CR #6's hospital Neurology consultation dated 4/19/2015 at 5:43 p.m. revealed in part: -Reason for consultation: Acute kidney injury and [MEDICAL CONDITION]. General: CR #6 lying in bed, very lethargic. -Assessment and plan: [MEDICAL CONDITION] secondary to free water deficit. -Assessment: 1.- Acute kidney injury, most likely due to prerenal dehydration, possible due to poor oral intake. -Plan: will change the fluids to D 5 ([MEDICATION NAME] 5%) half normal saline at 125 mL an hour. Monitor urine output. Observation on 4/21/2015 at 9:20 a.m. revealed CR #6 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #6 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes) and water flush at 200 ml every 4 hours. CR #6 also had an intravenous catheter (catheter that is inserted into a vein) to her right upper arm with D5W (5% [MEDICATION NAME] in water) and half normal saline fluids at 100 ml per hour. In continued observation, CR #6 was noted to have a Foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. In an interview at that time, CR #6 's family member stated on 4/18/2015, they visited CR #6 at the facility and she was found very lethargic and non-responsive by the family members. She further stated that CR #6 had dry saliva around her mouth and that her tongue was very dry as well. The family member stated in the ER they were told that CR #6 was severely dehydrated and had kidney failure due to the dehydration. In an interview on 4/22/2015 at 9:40 a.m. C.N.A. F stated she worked with CR #6 before she was transferred to the hospital on [DATE]. C.N.A. F further said that when CR #6 was moved to the long term side, which was about a week and a half before CR #6 went to the hospital, she would pocket the food in her mouth and would hold it and would not eat. C.N.A F continued saying, when CR #6 started pocketing her food, she would eat one or two spoons, but later, CR #6 would not open her mouth for food or fluids. C.N.A. F further said that CR #6 had barely any output of urine on the drainage Foley catheter bag, and continued saying that it was approx. 100 cc of urine at the end of the shift. In continued interview at that time, C.N.A F stated she would notify the nurses that "CR #6 did not eat or drink". C.N.A F further said that she remembered CR #6 when she was on the Rehab station and said " I remember that staff would bring her to the dining room, and as I passed by, I would see CR #6 with the tray in front of her uneaten, she would just sit in there and not eat". C.N.A F stated the procedure to follow when residents do not eat is to report it to the nurses, offer something else to the residents but that CR #6 would not even open her mouth. She further said " but I would report it to whoever nurse was there " . In an interview on 4/22/2015 at 9:58 a.m. LVN G stated one C.N.A reported to her that CR #6 was pocketing food in her mouth and that she tried to remove the food and offer a supplement and that CR #6 would not take anything, even the medications. She further said that she reported the information to NP E and who ordered IV fluids and blood work. LVN G continued saying that she asked the speech therapist to evaluate CR #6 and that she was told that CR #6 did not want to swallow. LVN G further said "I believe the pocketing problem was there since CR #6 was on the other unit (the rehab unit)". In an interview on 4/22/2015 at 11:26 a.m. LVN B stated she was the ADON for the long term side and that CR #6 was transferred to the long term side on 4/14/2015. LVN B stated she talked to NP E on 4/16/15, when she came to the building regarding CR #6 because she wasn't sure what was the baseline for CR #6. LVN B reported to NP E that CR #6 was not eating or drinking and would just lay in bed not really responding to staff. LVN B further said that NP E told her that CR #6 was not acting at her baseline. LVN B said, "NP E ordered some fluids, but I did not hear the complete orders given", which were given to LVN G. LVN B continued saying that when CR #6 was moved on 4/14/2015 from the Rehab side, she did not know about the food pocketing problem of CR #6. In an interview on 4/22/2015 at 12:18 p.m. , LVN H stated she provided care to CR #6 while she was on the Rehab side of the facility. She stated she had been made aware of CR #6 pocketing food in her mouth. Surveyor asked LVN H if any change of condition assessments were completed on CR #6 related to the pocketing of food in her mouth or if the care plan was updated and LVN H responded "it should had been, but that problem was identified from before me, everybody was aware of that". LVN H further stated that changes in condition assessments are completed in the computer and that the MD and family needed to be notified. In an interview on 4/22/2015 at 12:50 p.m. with Dietary Manager A stated she was made aware on 4/13/15 that CR #6 had stated declining in her appetite and not eating. Dietary Manager A was asked if she was made aware of any intervention in place as a result of CR #6's decline and she responded "No ma'am". In an interview on 4/22/2015 at 1:00 p.m. Registered Dietitian stated she did not get to see CR #6 recently because CR #6 went to the hospital and she goes to the facility every other week. She stated she saw CR #6 on 3/30/2015 and at that time she was made aware that CR #6 had a pressure sore but she was not made aware of any food pocketing or food problems. In a phone interview on 4/24/2015 at 1:25 p.m. RN J stated she was the ADON for the Rehab side of the facility. RN J said she was not sure how was the eating of CR #6 because she was taken to the dining room for meals. RN J continued saying that she remembered that CR #6 used to pocket food in her mouth but do not remember since when and was not made aware if CR #6 was able to eat any food. RN J stated she was told that the MD was notified of CR #6's condition. In continued interview, RN J stated that she did not know the condition of CR #6 when she was transferred to the long term side because she did not see her. In a phone interview on 4/27/2015 at 10:05 a.m. NP E stated she was made aware that CR #6 was pocketing food in her mouth but that she was eating some food. She further stated she was not made aware that it was a problem that was affecting her the whole time she was in the facility. NP E continued saying "my understanding was that the speech therapist was following CR #6 all along and if there was a problem, the speech therapist would alert us". In continued interview, NP E stated that on 4/15/2015 she was told that CR #6 was eating a little bit and she ordered [MEDICATION NAME], but CR #6 progressively got worse. NP E stated it was not until 4/16/2015 when she was made aware that CR #6 was not eating and that was when she ordered hydration and blood work but CR #6 was sent to the hospital on [DATE] and was not able to get the blood work. NP E further said that she "kind of" let the MD now about the condition of the residents (informed of critical labs and change of conditions) but every Tuesday there was a meeting at the facility and the facility made the MD aware of any conditions the patients have. In an interview on 4/27/2015 at 10:35 a.m. Speech Therapist K stated CR #6 was never on her case load because she was not able to follow commands. She stated she saw CR #6 only 3 times, mainly to screen her. She stated CR #6 was aware but was not receptive to any type of commands. In continued interview, Speech Therapist K stated she remembered that she recommended a dietary consult and that she told the nurses that if CR #6 continued having problems with pocketing of the food or eating to let her know but that the nurses never let her know any further problems with CR #6 "I never heard anything else anymore". She further stated that on 3/30/3015, the last time she saw CR #6, she screened her because she saw her sitting in the therapy room and she recognized her. Speech Therapist K continued saying that the times she saw CR #6 eating, she would only eat a couple of spoons only. Surveyor asked Speech Therapist K to show the dietary recommendation that she gave to the nurses. Further observation and interview, as the Speech Therapist K looked at the computer, she replied "I thought I recommended dietary consult but I guess I did not write it down, nurses should know if a patient is not eating, they need to contact the dietitian". Interview on 4/27/2015 at 11:40 a.m. C.N.A L stated she worked with CR #6 and she remembered CR#6 did not eat well. CNA L stated she reported CR #6's condition to several nurses, she stated, "I would tell them, she is pocketing her food, she did not eat today". C.N.A. L further stated "I do not remember when the problem started, but in the beginning CR #6 did not have any problems with eating and then later she declined, she would just put the food on her mouth and would not eat at all". Surveyor requested a copy of the facility protocol for weight loss/assessment, twice, on 4/8/15; however, it was not provided prior to facility exit. Record review of the undated facility's policy and procedure "Guidelines for notifying Physicians of Clinical Problems" revealed in part: These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner...The following symptoms, signs should prompt immediate notification of the Physician...Immediate implies that the Physician should be notified as soon as possible, either by phone or by pager. These situations include...for example, consistent with criteria - abdominal pain with distension, vomiting; persistent or recurrent nausea and vomiting. Record review of facility policy on Abuse Prohibition Management Program, undated, read in part:" ...All residents in a skilled nursing facility have the right to be free from abuse...neglect...Identification:...Neglect. is a deprivation of life's necessitates of food, water,shelter or a failure of an individual to provide services, treatment or care to a resident which causes or could cause mental or physical injury or harm or death to a resident..." An IJ was identified on 4/27/15 at 2:30 pm with the Administrator, DON and Clinical Education Specialist. While the IJ was removed d on 5/1/15 at 2:30 pm the facility remained out of compliance at a scope of pattern and a severity of actual harm. In an interview on 4/28/15 at 3:50 pm the Administrator was asked how did she think this IJ came about, she stated there were a couple of licensed nurses that failed to put necessary interventions in place and the DON at that time was not overseeing the nurses as she should have. The Administrator stated she was not made aware of the residents weight loss and continuing vomiting. A Plan of Removal (POR) for the IJ was initially submitted on 4/28/15. A revised plan was submitted and accepted on 4/29/15 at 2:35 pm. The POR included: 2) Change of Condition · Resident Change of Condition form audit was initiated on 4/27/15 on patients that had a change of condition form completed starting from 4/8/15- to present to ensure physicians were notified of change in patient status and communication to other facility departments as necessary. Initial audit was completed 4/28/15 and continued review of new Change of Conditions will be on-going. The review of change of condition includes reviewing completed form for information regarding the change, communication to physician, review of the situation, background, assessment, recommendations and physician communication/notification of responsible party. 3) Care Plans · During review of Resident Change of Condition form audit started on 4/27/15 care plans were reviewed to ensure problems identified are care planned. Care Plan review to be completed by 4/29/15 for all residents identified having a change of condition and updated as necessary . 4) Facility Policies/Practices/Programs · Effective 4/27/15, the facilities policy and practice will be that it is mandatory for nurses to complete a Change of Condition on residents who present with an abnormal sign/symptom with physician and RP notification. · DON M (or designee} will review daily each completed Change of Condition form to ensure completion and physician/RP notification of the resident's condition. Nurses found not to be in compliance will receive corrective action up to and including termination and further education as appropriate. Daily review of these forms began on 4-28-15. · Beginning on 4/15 at each morning's clinical management meeting completed resident Change of Conditions are reviewed for completeness, Care plans reviewed and updated accordingly, and proper communication to other departments will be followed-up on by DON (or designee} to ensure communication has occurred. Clinical management is attended by Director of Nursing, Assistant Directors of Nursing, MDS Coordinator, Therapy Manager, Dietary Service Manager, Social Services and Administrator. · Beginning 4/28/15, denials in request for transfer to acute care will be escalated to the Medical Director for physician-to-physician review of request. Licensed Nursing staff, Director of Nursing or Administrator will escalate to the Medical Director. · The Interdisciplinary Team will review Changes of Condition at the weekly Standards of Care meeting to ensure that the initiatives set forth in the plan are being met, along with compliance with other applicable facility protocols/communication. The Weekly SOC meeting attendees include; Administrator, DON, ADO's, Dietary Manager, Therapist, Social Services, Wound Care Nurse and MDS Coordinator. The results of the weekly SOC will be forwarded to the QA/PI Committee for review. Standard of Care meetings was revised to include review of resident's change of conditions for the prior week on 4-29-15. 5) Staff Education The following in-services have been initiated by RN P on 4/14/15: Acute Change of Condition. Further education was initiated on 4/27/15 with nursing staff prior to the start of their shift regarding Physician Notification, Acute Change of Condition and Referral process/communication. No licensed nursing staff will be allowed to start their shift until the training is successfully completed. Clinical Managers and MDS Coordinators received in-service regarding Care Plan completion, update and resolve process on 4/28/15. Acute Change of Condition education included: On April 27th RN P initiated educational in¿ services with the Licensed Nursing staff at Villa Toscana at Cypress Woods. The in-services consisted of reviewing the following policies: Acute Condition Changes-Clinical Protocol; Change in a Resident's Condition or Status; Guidelines for Notifying Physicians of Clinical Problems. Verbal lectures, review of facility policies and procedures, handouts with explanation and interactive discussions between the attendees and Clinical Education Specialist took place. In discussion staff the following was included (but not limited to): · Definition of Change of Conditions · Locating and completion of Change of Condition in EHR with pertinent details · Notification of Physician and Responsible Party · Communication between shifts for follow up of change of noted · Monitoring of intervention put in place and notifying physician as needed based on nursing judgement. · Escalating communication to facility Medical Director as needed (unable to reach attending etc.) · Sending communication to registered dietician and therapy for further review of identified concerns. Other training included: · In addition to the above in-services, the following topics will be addressed during the scheduled training's : the importance of documenting all changes of condition on the 24 hr report for shift to shift communication until resolved; the importance of following up with physician regarding previously communicated Change of Conditions if unresolved. Completion of Referral for Therapy or RD notification. · Non-nursing staff including housekeeping, laundry, dietary, administration, maintenance were Inserviced on identifying differences or changes in resident's and were instructed to notify the charge nurse of the changes on 4/24/15 and is on-going. · MDS Coordinators will be in-serviced on 4/28/15 to review hospital documents 30 days prior to facility admission for weight loss; complete care plan and notify ADON of any weight loss history within the last 30 days. · No nurse will be allowed to work until the training discussed above is completed. The training will be completed by RN P or DON M (or designee). The training began on 4/27/15 with the 2-10/6p-6a nurses on duty. Each subsequent shift will receive this training prior to the start of their shift until all nurses have completed the training. In addition, this education will be included in orientation training for all newly hired nurses. The Surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record review of in-service revealed names of nurses who attended the training. Interviews were conducted with nursing staff from the 6 am - 2 pm and 2 pm - 10 pm shifts. These interviews included 3 CNA's; 5 LVN's, 1 RN (12 hour shifts), 2 MA (Medication Aides), 1 COTA (Certified Occupational Therapist Assistant) and 1 Medical Director. Record review of in services revealed topics included: acute condition changes; clinical protocol guidelines for notifying physicians of clinical problems; referral process-communications; change in resident condit

Based on interview and record review the facility failed to implement their policy on neglect for 2 of 14 residents (Resident #1 and CR #6) reviewed for neglect, as evidenced by: -Resident #1 had a 14 lb weight loss in 2 months - Resident #1 experienced continuous episodes of nausea and vomiting -Resident #1's physician was not consulted on the continuous episodes of nausea and vomiting - CR #6 had difficulty chewing and swallowing and the MD and the family were not made aware. -CR #6 pocketed food in her mouth and the MD was not updated. These deficient practices affected 1 CR, 1 current resident and could place 96 additional residents residents at risk for being neglected and a diminished quality of life. Complaint # 2 and # 5 Findings include: Resident #1: Record review of the facility face sheet for Resident#1 revealed a [AGE] year old male admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Record review of the Nutrition Therapy Assessment, dated 01/12/2015, for Resident #1 revealed in part: Type of assessment: new admission. - Comments: Resident #1 able to make his needs known, he has concerns with swallowing at this time. Usual Body Weight is 180 but since he has become ill states that he has lost and now is 137 lbs. Current weight is 137.2 lbs. Resident at risk of dehydration due to on altered texture diet. On puree diet. History of [MEDICAL CONDITION] strictures. Goals: Resident will maintain weight, will have no sign and symptoms of dehydration. Record review of the facility's weight records for Resident #1 revealed weights on; -01/10/2015 of 137.2 lbs. -01/16/2015 of 133.8 lbs. -02/04/2015 of 126. 6 lbs. -03/02/2015 of 123.4 lbs. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 was cognitively intact with a BIMS score of 15 out of 15. Resident #1 required extensive assistance of 2 persons for bed mobility and toilet use and extensive assistance of one person for locomotion, dressing, eating, personal hygiene and bathing. The assessment section on swallowing/nutritional status revealed no swallowing disorders and weight was 137 lbs. Resident #1 was assessed with [REDACTED]. Record review of the consolidated physician orders [REDACTED]. -start date 01/15/2015 end date 03/18/2015 - [MEDICATION NAME] 25 mg tablet, one tablet by mouth as needed for nausea and vomiting. -start date 02/26/2015 end date 04/07/2015 mechanical soft diet. -start date 03/17/2015 end date 04/06/2015 - [MEDICATION NAME] sodium 100 mg tablet, table one tablet by mouth 2 times per day for constipation. Record review of Resident #1's MAR indicated [REDACTED] -2/16/2015 -2/17/2015 (twice) -2/18/2015 -2/19/2015 -2/22/2015 -2/24/2015 -2/25/2015 Record review of Resident #1's MAR indicated [REDACTED] -3/5/2015 -3/10/2015 -3/15/2015 -3/17/2015 -3/18/2015 (twice) Record review of Resident #1's ADL record dated March 2015 revealed no documentation of the amount of the residents meal consumption. Record review of Resident #1's Therapy Screen dated 3/5/2015 revealed in part: Per patient and nurse report, Resident #1 has been vomiting and choking on regular diet. Patient was instructed to follow reflux precautions due to complaints of "feeling that food gets stuck in esophagus". Recommend to continue with current diet due to patient complaints. Patient will need medical workup to determine basis for [MEDICAL CONDITION] complaints. Record review of the nurse notes for Resident #1 revealed in part: -02/05/2015 at 1:52 pm: Resident weight is 126.6 lbs. continues to refuse pureed diet, drinks fluids. Spoke with wife regarding refusal of meals. Further record review revealed no MD notification. -3/15/2015 completed 3/16/2015 at 12:12 am: Received PRN [MEDICATION NAME] 25 mg for nausea and vomiting times 1, effectively. Resident #1 stated that when he drinks cold water it makes him throw-up. Record review of Resident #1's hospital history and physical dated 3/19/2015 at 11:41 p.m. revealed in part:- Date of admission: 3/18/2015. - History of present illness: admitted through ER with persistent nausea, vomiting...He had also significant weight loss recently. - Past medical history: ruptured esophagus. - Assessment and plan: 6.- nausea, vomiting with dehydration. We will start the patient on intravenous fluid and his fluid status needs to be closely monitored and electrolyte needs to be corrected. Record review of Resident #1's discharge summary from the hospital dated 4/6/2015 at 8:59 a.m. revealed in part: Final Diagnoses: [REDACTED]. 2.- [MEDICAL CONDITION] stricture with dysphagia not amenable to dilation in this facility, status [REDACTED]. Pertinent hospital course: Resident #1 admitted with inability to eat, persistent vomiting, weight loss and dysphagia. The patient had significant [MEDICAL CONDITION] stricture, which could not be deflated so the patient was seen by surgeon. In an interview at that time, Resident #1 stated he had arrived from the hospital a couple of days ago. He stated, "I went to the hospital for weight loss because I had been vomiting a lot for long time here. They told me at the hospital that my esophagus was closing. I asked the facility several times to send me to the hospital and they refused". Resident #1 further said that since he arrived at the facility in January 2015 he had been vomiting. He stated he had requested to be sent to the hospital but the facility had refused. In continued interview, he stated "everything I ate or drank, I would vomit, they did not listen to me until at the end when they saw me continuously vomiting and they couldn't controlled it anymore". Resident #1 said "every time I ate or drunk and kept vomiting, I kept telling them that something was wrong with me, to send me to the hospital, but they did not send me until March and when I arrived at the hospital my weight was already 120 lbs". In an interview on 4/8/2015 at 2:34 p.m., the DON stated she was not aware that Resident #1 had any significant weight loss. In continued interview the DON, she stated she had learned of Resident #1's vomiting on 3/16/2015 and "it was when the facility provided IV hydration". When asked if Resident #1 had been vomiting before, DON stated she was not aware. DON further said if a resident or a family requested to be sent to the hospital, the facility would get orders to send residents to the hospital. When asked if Resident #1 had requested to go to the hospital before, the DON responded "the wife called me and that's when we sent him out because she was concerned about the nausea and vomiting." In an interview on 4/8/2015 at 4:15 p.m. Dietary Manager A stated she was not aware that Resident #1 had any weight loss or that he had any episodes of nausea and vomiting. She further said "I knew he had refused meals but not that he had weight loss. She stated "he did not like the texture of his diet". In an interview on 4/8/2015 at 4:45 p.m. LVN B stated she had asked the nurses about 2 days before Resident #1 went to the hospital to get an order for [REDACTED]. In a phone interview on 4/27/2015 at 10:20 a.m. NP E stated she was not aware that Resident #1 was vomiting every day. She further stated that she remembered that she was called once regarding Resident #1 vomiting, a Tuesday before he went to the hospital. In continued interview, she stated that she remembered that Resident #1's wife was worried about dehydration. CR #6 Record review of the facility face sheet for CR #6 revealed a [AGE] year old female admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. CR #6 was sent to the hospital via Emergency Medical Service by the RP on 4/18/2015 after she was found by the family lethargic and non-responsive. Record review of the admission MDS with assessment reference date of 03/18/2015 revealed CR #6 was rarely/never understood and did not complete BIMS evaluation. CR #6 required extensive assistance of 2 persons for bed mobility and transfers and limited assistance of one person for eating. The assessment section on swallowing/nutritional status revealed no swallowing disorders. Record review of CR #6's Therapy Screen notes revealed in part: -3/12/2015 "...Screen Type: new admit. -Comments: Swallow screened, CR #6 with no overt clinical sign and symptoms of aspiration. Skilled speech language pathologist services are not warranted at this time, evaluation is not indicated". -3/23/2015 at 1:59 p.m. "....Nursing requested a repeat swallow screen as CR #6 is holding food in mouth. C.N.A in room reports CR #6 will eat food from home...(without difficulty). Comments: When pasta was placed in mouth, CR #6 refused to swallow and grimaced, spat food into napkin. Recommend: family bring food from home with clearance from MD to ensure is getting proper nutritional support from by mouth. Will follow up if needed. Speech language pathologist assessment is not indicated as CR #6 most likely presenting with dissatisfaction with current facility meals offered, however swallowing outside foods". -3/30/3015 at 2:56 p.m. "..Comments: CR #6 seen again with meal intake and continued to hold bolus in mouth requiring for clinician to clear oral cavity. CR #6's husband called to bring food from home as C.N.A's report CR #6 does eat when eating preferred foods. Record review of CR #6's History and Physical dated 3/18/2015 and completed by the MD revealed no information that CR #6 had problems pocketing food in her mouth. Record review of CR#6's meal percentage for March 2015 revealed documentation for only 3/24/2015, 100% and 3/26/2015, 100% during dinner time. Further record review revealed no further documentation of meal intakes for the month of March 2015. Record review of CR #6's meal percentages for April 1- 15, 2015 revealed the intake ranged from 25% to 50% and from April 15 - 18, 2015 CR #6 refused all breakfast and there was no meal percentages documented for the lunch and dinner meals recorded. Record review of CR #6's nurses notes revealed in part: -3/17/2015 at 10:55 a.m. "..CR #6 would not swallow crushed medication mixed with cranberry juice. CR #6 spit out and found she also had food pocketed in her mouth. Speech evaluation ordered". -3/24/2015 Daily skilled note in part: - "..G.I.: Difficulty chewing". -4/4/2015 at 1:20 p.m "...CR #6 continues to pocket food. Will continue to monitor". -4/7/2015 Daily skilled note in part: - "..G.I.: Difficulty chewing, difficulty swallowing". -4/14/2015 at 6:53 p.m. "...CR #6 transferred from Rehab unit. Needs encouragement to eat. Ate 25% of dinner. Requires total care with ADL's". -4/15/2015 at 8:48 a.m. "..Received orders for [MEDICATION NAME] 15 mg every hs, phoned husband and received consent to receive medication, also received order for dietary consult". -4/16/2015 at 6:05 a.m. "...A snack was offered and refused. Less than 25% was consumed at mealtime". -4/16/2015 at 1:02 p.m. "...Refused to eat, offered snack and still do not want it". - 4/16/2015 at 8:48 p.m. "... CR #6 is sitting in wheelchair, lethargic, sleeping. Refused food and dietary supplement. NP E ordered IV for hydration". -4/17/2015 at 1:51 p.m. " ..CR #6 lying in bed lethargic, arouse when she is stimulated. Still continue to refuse food, medications. Hydration in place at 50 ml/hr for 3 bags. Unable to reach the husband " . -4/18/2015 at 1:08 p.m. "...CR #6 refusing meals and supplements, just turns her head away. Has IV fluids". -4/18/2015 at 4:12 p.m. "... phone NP E and made aware of transport of CR #6 to hospital per family request". Record review of CR #6's Change of Condition assessment dated [DATE] at 9:55 p.m. revealed in part: *Situation: Change in cognition status and appetite. This change was observed: Today. -Nursing note: CR #6 is sitting in the wheelchair, lethargic, sleeping. Offered food, CR #6 refused, offered dietary supplement, refused. NP ordered an IV normal saline at 50 ml/hr for 3 bags. * Background: Blood pressure 128/47. Mental status changes: lethargy. Record review of CR #6's care plan initiated 3/11/2015 revealed in part: Care Area/Problem: Altered Nutritional Status related to: Need for assistance/cueing with meals. Further review revealed no information related to CR #6 pocketing food or problems with chewing or swallowing. The care plan was not updated at any time with appropriate interventions. Record review of CR #6's hospital history and physical dated 4/18/2015 at 10:38 p.m. revealed in part: -Date of admission: 4/18/2015. - History of present illness: Today, while the family members were visiting CR#6, they noticed that she was less alert and vas not responsive. They also noticed severely dry mouth and she had a sacral decubitus ulcer. CR#6 was brought to the emergency room . While in the emergency room , CR#6 was noted to be hypernatremic with sodium of 155. She was in acute [MEDICAL CONDITION] with a BUN of 108 and a creatinine of 3.5. She was also noted to have a urinary tract infection and CT brain revealed new left ischemic infarct that was likely subacute. CR #6 has been admitted for the management of the multiple problems currently going on. -Laboratory data in part: Sodium:155, BUN: 108, Creatinine:3.5 and urinalysis: greater than 200 white blood cells, bacteria many. Skin: sacral decubitus ulcer. -Assessment plan: 1.- Subacute stroke, 2.- [MEDICAL CONDITION], likely multifactorial secondary to the stroke, dehydration, [MEDICAL CONDITION], and urinary tract infection. 3.- Dehydration, 4.- [MEDICAL CONDITION], 5.- Acute [MEDICAL CONDITION], 7.- Urinary tract infection, 8.- Sacral decubitus ulcers. Record review of CR #6's hospital Neurology consultation dated 4/19/2015 at 5:43 p.m. revealed in part: -Reason for consultation: Acute kidney injury and [MEDICAL CONDITION]. General: CR #6 lying in bed, very lethargic. -Assessment and plan: [MEDICAL CONDITION] secondary to free water deficit. -Assessment: 1.- Acute kidney injury, most likely due to prerenal dehydration, possible due to poor oral intake. -Plan: will change the fluids to D 5 ([MEDICATION NAME] 5%) half normal saline at 125 mL an hour. Monitor urine output. Observation on 4/21/2015 at 9:20 a.m. revealed CR #6 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #6 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes) and water flush at 200 ml every 4 hours. CR #6 also had an intravenous catheter (catheter that is inserted into a vein) to her right upper arm with D5W (5% [MEDICATION NAME] in water) and half normal saline fluids at 100 ml per hour. In continued observation, CR #6 was noted to have a Foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. In an interview at that time, CR #6 's family member stated on 4/18/2015, they visited CR #6 at the facility and she was found very lethargic and non-responsive by the family members. She further stated that CR #6 had dry saliva around her mouth and that her tongue was very dry as well. The family member stated in the ER they were told that CR #6 was severely dehydrated and had kidney failure due to the dehydration. In an interview on 4/22/2015 at 9:40 a.m. C.N.A. F stated she worked with CR #6 before she was transferred to the hospital on [DATE]. C.N.A. F further said that when CR #6 was moved to the long term side, which was about a week and a half before CR #6 went to the hospital, she would pocket the food in her mouth and would hold it and would not eat. C.N.A F continued saying, when CR #6 started pocketing her food, she would eat one or two spoons, but later, CR #6 would not open her mouth for food or fluids. C.N.A. F further said that CR #6 had barely any output of urine on the drainage Foley catheter bag, and continued saying that it was approx. 100 cc of urine at the end of the shift. In continued interview at that time, C.N.A F stated she would notify the nurses that "CR #6 did not eat or drink". C.N.A F further said that she remembered CR #6 when she was on the Rehab station and said " I remember that staff would bring her to the dining room, and as I passed by, I would see CR #6 with the tray in front of her uneaten, she would just sit in there and not eat". C.N.A F stated the procedure to follow when residents do not eat is to report it to the nurses, offer something else to the residents but that CR #6 would not even open her mouth. She further said " but I would report it to whoever nurse was there " . In an interview on 4/22/2015 at 9:58 a.m. LVN G stated one C.N.A reported to her that CR #6 was pocketing food in her mouth and that she tried to remove the food and offer a supplement and that CR #6 would not take anything, even the medications. She further said that she reported the information to NP E and who ordered IV fluids and blood work. LVN G continued saying that she asked the speech therapist to evaluate CR #6 and that she was told that CR #6 did not want to swallow. LVN G further said "I believe the pocketing problem was there since CR #6 was on the other unit (the rehab unit)". In an interview on 4/22/2015 at 11:26 a.m. LVN B stated she was the ADON for the long term side and that CR #6 was transferred to the long term side on 4/14/2015. LVN B stated she talked to NP E on 4/16/15, when she came to the building regarding CR #6 because she wasn't sure what was the baseline for CR #6. LVN B reported to NP E that CR #6 was not eating or drinking and would just lay in bed not really responding to staff. LVN B further said that NP E told her that CR #6 was not acting at her baseline. LVN B said, "NP E ordered some fluids, but I did not hear the complete orders given", which were given to LVN G. LVN B continued saying that when CR #6 was moved on 4/14/2015 from the Rehab side, she did not know about the food pocketing problem of CR #6. In an interview on 4/22/2015 at 12:18 p.m. , LVN H stated she provided care to CR #6 while she was on the Rehab side of the facility. She stated she had been made aware of CR #6 pocketing food in her mouth. Surveyor asked LVN H if any change of condition assessments were completed on CR #6 related to the pocketing of food in her mouth or if the care plan was updated and LVN H responded "it should had been, but that problem was identified from before me, everybody was aware of that". LVN H further stated that changes in condition assessments are completed in the computer and that the MD and family needed to be notified. In an interview on 4/22/2015 at 12:50 p.m. with Dietary Manager A stated she was made aware on 4/13/15 that CR #6 had stated declining in her appetite and not eating. Dietary Manager A was asked if she was made aware of any intervention in place as a result of CR #6's decline and she responded "No ma'am". In an interview on 4/22/2015 at 1:00 p.m. Registered Dietitian stated she did not get to see CR #6 recently because CR #6 went to the hospital and she goes to the facility every other week. She stated she saw CR #6 on 3/30/2015 and at that time she was made aware that CR #6 had a pressure sore but she was not made aware of any food pocketing or food problems. In a phone interview on 4/24/2015 at 1:25 p.m. RN J stated she was the ADON for the Rehab side of the facility. RN J said she was not sure how was the eating of CR #6 because she was taken to the dining room for meals. RN J continued saying that she remembered that CR #6 used to pocket food in her mouth but do not remember since when and was not made aware if CR #6 was able to eat any food. RN J stated she was told that the MD was notified of CR #6's condition. In continued interview, RN J stated that she did not know the condition of CR #6 when she was transferred to the long term side because she did not see her. In a phone interview on 4/27/2015 at 10:05 a.m. NP E stated she was made aware that CR #6 was pocketing food in her mouth but that she was eating some food. She further stated she was not made aware that it was a problem that was affecting her the whole time she was in the facility. NP E continued saying "my understanding was that the speech therapist was following CR #6 all along and if there was a problem, the speech therapist would alert us". In continued interview, NP E stated that on 4/15/2015 she was told that CR #6 was eating a little bit and she ordered [MEDICATION NAME], but CR #6 progressively got worse. NP E stated it was not until 4/16/2015 when she was made aware that CR #6 was not eating and that was when she ordered hydration and blood work but CR #6 was sent to the hospital on [DATE] and was not able to get the blood work. NP E further said that she "kind of" let the MD now about the condition of the residents (informed of critical labs and change of conditions) but every Tuesday there was a meeting at the facility and the facility made the MD aware of any conditions the patients have. In an interview on 4/27/2015 at 10:35 a.m. Speech Therapist K stated CR #6 was never on her case load because she was not able to follow commands. She stated she saw CR #6 only 3 times, mainly to screen her. She stated CR #6 was aware but was not receptive to any type of commands. In continued interview, Speech Therapist K stated she remembered that she recommended a dietary consult and that she told the nurses that if CR #6 continued having problems with pocketing of the food or eating to let her know but that the nurses never let her know any further problems with CR #6 "I never heard anything else anymore". She further stated that on 3/30/3015, the last time she saw CR #6, she screened her because she saw her sitting in the therapy room and she recognized her. Speech Therapist K continued saying that the times she saw CR #6 eating, she would only eat a couple of spoons only. Surveyor asked Speech Therapist K to show the dietary recommendation that she gave to the nurses. Further observation and interview, as the Speech Therapist K looked at the computer, she replied "I thought I recommended dietary consult but I guess I did not write it down, nurses should know if a patient is not eating, they need to contact the dietitian". Interview on 4/27/2015 at 11:40 a.m. C.N.A L stated she worked with CR #6 and she remembered CR#6 did not eat well. CNA L stated she reported CR #6's condition to several nurses, she stated, "I would tell them, she is pocketing her food, she did not eat today". C.N.A. L further stated "I do not remember when the problem started, but in the beginning CR #6 did not have any problems with eating and then later she declined, she would just put the food on her mouth and would not eat at all". Surveyor requested a copy of the facility protocol for weight loss/assessment, twice, on 4/8/15; however, it was not provided prior to facility exit. Record review of the undated facility's policy and procedure "Guidelines for notifying Physicians of Clinical Problems" revealed in part: These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner...The following symptoms, signs should prompt immediate notification of the Physician...Immediate implies that the Physician should be notified as soon as possible, either by phone or by pager. These situations include...for example, consistent with criteria - abdominal pain with distension, vomiting; persistent or recurrent nausea and vomiting. Record review of facility policy on Abuse Prohibition Management Program, undated, read in part:" ...All residents in a skilled nursing facility have the right to be free from abuse...neglect...Identification:...Neglect. is a deprivation of life's necessitates of food, water,shelter or a failure of an individual to provide services, treatment or care to a resident which causes or could cause mental or physical injury or harm or death to a resident..." The CMS form 672 revealed a resident census of 97.

Based on interview and record review, the facility failed to follow their written policies and procedures that prohibit the mistreatment, neglect, and abuse of residents for 2 of 14 residents (Resident #1 and CR #6) reviewed for abuse and neglect as evidenced by: -Resident #1 had a 14 lb weight loss in 2 months -Resident #1 experienced continuous episodes of nausea and vomiting -Resident #1's physician was not consulted on the continous episodes of nausea and vomiting - CR #6 had difficulty chewing and swallowing and the MD and the family were not made aware. -CR #6 pocketed food in her mouth and the MD was not updated. These deficient practices affected 1 CR, 1 current resident and could place 96 additional residents residents at risk for being neglected and a diminished quality of life. Complaint # 2 and # 5 Findings include: Record review of facility policy on Abuse Prohibition Management Program, undated, read in part:" ...All residents in a skilled nursing facility have the right to be free from abuse...neglect...Identification:...Neglect. is a deprivation of life's necessitates of food, water,shelter or a failure of an individual to provide services, treatment or care to a resident which causes or could cause mental or physical injury or harm or death to a resident..." Resident #1: Record review of the facility face sheet for Resident#1 revealed a [AGE] year old male admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Record review of the Nutrition Therapy Assessment, dated 01/12/2015, for Resident #1 revealed in part: Type of assessment: new admission. - Comments: Resident #1 able to make his needs known, he has concerns with swallowing at this time. Usual Body Weight is 180 but since he has become ill states that he has lost and now is 137 lbs. Current weight is 137.2 lbs. Resident at risk of dehydration due to on altered texture diet. On puree diet. History of [MEDICAL CONDITION] strictures. Goals: Resident will maintain weight, will have no sign and symptoms of dehydration. Record review of the facility's weight records for Resident #1 revealed weights on; -01/10/2015 of 137.2 lbs. -01/16/2015 of 133.8 lbs. -02/04/2015 of 126. 6 lbs. -03/02/2015 of 123.4 lbs. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 was cognitively intact with a BIMS score of 15 out of 15. Resident #1 required extensive assistance of 2 persons for bed mobility and toilet use and extensive assistance of one person for locomotion, dressing, eating, personal hygiene and bathing. The assessment section on swallowing/nutritional status revealed no swallowing disorders and weight was 137 lbs. Resident #1 was assessed with [REDACTED]. Record review of the consolidated physician orders [REDACTED]. -start date 01/15/2015 end date 03/18/2015 - [MEDICATION NAME] 25 mg tablet, one tablet by mouth as needed for nausea and vomiting. -start date 02/26/2015 end date 04/07/2015 mechanical soft diet. -start date 03/17/2015 end date 04/06/2015 - [MEDICATION NAME] sodium 100 mg tablet, table one tablet by mouth 2 times per day for constipation. Record review of Resident #1's MAR indicated [REDACTED] -2/16/2015 -2/17/2015 (twice) -2/18/2015 -2/19/2015 -2/22/2015 -2/24/2015 -2/25/2015 Record review of Resident #1's MAR indicated [REDACTED] -3/5/2015 -3/10/2015 -3/15/2015 -3/17/2015 -3/18/2015 (twice) Record review of Resident #1's ADL record dated March 2015 revealed no documentation of the amount of the residents meal consumption. Record review of Resident #1's Therapy Screen dated 3/5/2015 revealed in part: Per patient and nurse report, Resident #1 has been vomiting and choking on regular diet. Patient was instructed to follow reflux precautions due to complaints of "feeling that food gets stuck in esophagus". Recommend to continue with current diet due to patient complaints. Patient will need medical workup to determine basis for [MEDICAL CONDITION] complaints. Record review of the nurse notes for Resident #1 revealed in part: -02/05/2015 at 1:52 pm: Resident weight is 126.6 lbs. continues to refuse pureed diet, drinks fluids. Spoke with wife regarding refusal of meals. Further record review revealed no MD notification. -3/15/2015 completed 3/16/2015 at 12:12 am: Received PRN [MEDICATION NAME] 25 mg for nausea and vomiting times 1, effectively. Resident #1 stated that when he drinks cold water it makes him throw-up. Record review of Resident #1's hospital history and physical dated 3/19/2015 at 11:41 p.m. revealed in part:- Date of admission: 3/18/2015. - History of present illness: admitted through ER with persistent nausea, vomiting...He had also significant weight loss recently. - Past medical history: ruptured esophagus. - Assessment and plan: 6.- nausea, vomiting with dehydration. We will start the patient on intravenous fluid and his fluid status needs to be closely monitored and electrolyte needs to be corrected. Record review of Resident #1's discharge summary from the hospital dated 4/6/2015 at 8:59 a.m. revealed in part: Final Diagnoses: [REDACTED]. 2.- [MEDICAL CONDITION] stricture with dysphagia not amenable to dilation in this facility, status [REDACTED]. Pertinent hospital course: Resident #1 admitted with inability to eat, persistent vomiting, weight loss and dysphagia. The patient had significant [MEDICAL CONDITION] stricture, which could not be deflated so the patient was seen by surgeon. In an interview at that time, Resident #1 stated he had arrived from the hospital a couple of days ago. He stated, "I went to the hospital for weight loss because I had been vomiting a lot for long time here. They told me at the hospital that my esophagus was closing. I asked the facility several times to send me to the hospital and they refused". Resident #1 further said that since he arrived at the facility in January 2015 he had been vomiting. He stated he had requested to be sent to the hospital but the facility had refused. In continued interview, he stated "everything I ate or drank, I would vomit, they did not listen to me until at the end when they saw me continuously vomiting and they couldn't controlled it anymore". Resident #1 said "every time I ate or drunk and kept vomiting, I kept telling them that something was wrong with me, to send me to the hospital, but they did not send me until March and when I arrived at the hospital my weight was already 120 lbs". In an interview on 4/8/2015 at 2:34 p.m., the DON stated she was not aware that Resident #1 had any significant weight loss. In continued interview the DON, she stated she had learned of Resident #1's vomiting on 3/16/2015 and "it was when the facility provided IV hydration". When asked if Resident #1 had been vomiting before, DON stated she was not aware. DON further said if a resident or a family requested to be sent to the hospital, the facility would get orders to send residents to the hospital. When asked if Resident #1 had requested to go to the hospital before, the DON responded "the wife called me and that's when we sent him out because she was concerned about the nausea and vomiting." In an interview on 4/8/2015 at 4:15 p.m. Dietary Manager A stated she was not aware that Resident #1 had any weight loss or that he had any episodes of nausea and vomiting. She further said "I knew he had refused meals but not that he had weight loss. She stated "he did not like the texture of his diet". In an interview on 4/8/2015 at 4:45 p.m. LVN B stated she had asked the nurses about 2 days before Resident #1 went to the hospital to get an order for [REDACTED]. In a phone interview on 4/27/2015 at 10:20 a.m. NP E stated she was not aware that Resident #1 was vomiting every day. She further stated that she remembered that she was called once regarding Resident #1 vomiting, a Tuesday before he went to the hospital. In continued interview, she stated that she remembered that Resident #1's wife was worried about dehydration. CR #6 Record review of the facility face sheet for CR #6 revealed a [AGE] year old female admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. CR #6 was sent to the hospital via Emergency Medical Service by the RP on 4/18/2015 after she was found by the family lethargic and non-responsive. Record review of the admission MDS with assessment reference date of 03/18/2015 revealed CR #6 was rarely/never understood and did not complete BIMS evaluation. CR #6 required extensive assistance of 2 persons for bed mobility and transfers and limited assistance of one person for eating. The assessment section on swallowing/nutritional status revealed no swallowing disorders. Record review of CR #6's Therapy Screen notes revealed in part: -3/12/2015 "...Screen Type: new admit. -Comments: Swallow screened, CR #6 with no overt clinical sign and symptoms of aspiration. Skilled speech language pathologist services are not warranted at this time, evaluation is not indicated". -3/23/2015 at 1:59 p.m. "....Nursing requested a repeat swallow screen as CR #6 is holding food in mouth. C.N.A in room reports CR #6 will eat food from home...(without difficulty). Comments: When pasta was placed in mouth, CR #6 refused to swallow and grimaced, spat food into napkin. Recommend: family bring food from home with clearance from MD to ensure is getting proper nutritional support from by mouth. Will follow up if needed. Speech language pathologist assessment is not indicated as CR #6 most likely presenting with dissatisfaction with current facility meals offered, however swallowing outside foods". -3/30/3015 at 2:56 p.m. "..Comments: CR #6 seen again with meal intake and continued to hold bolus in mouth requiring for clinician to clear oral cavity. CR #6's husband called to bring food from home as C.N.A's report CR #6 does eat when eating preferred foods. Record review of CR #6's History and Physical dated 3/18/2015 and completed by the MD revealed no information that CR #6 had problems pocketing food in her mouth. Record review of CR#6's meal percentage for March 2015 revealed documentation for only 3/24/2015, 100% and 3/26/2015, 100% during dinner time. Further record review revealed no further documentation of meal intakes for the month of March 2015. Record review of CR #6's meal percentages for April 1- 15, 2015 revealed the intake ranged from 25% to 50% and from April 15 - 18, 2015 CR #6 refused all breakfast and there was no meal percentages documented for the lunch and dinner meals recorded. Record review of CR #6's nurses notes revealed in part: -3/17/2015 at 10:55 a.m. "..CR #6 would not swallow crushed medication mixed with cranberry juice. CR #6 spit out and found she also had food pocketed in her mouth. Speech evaluation ordered". -3/24/2015 Daily skilled note in part: - "..G.I.: Difficulty chewing". -4/4/2015 at 1:20 p.m "...CR #6 continues to pocket food. Will continue to monitor". -4/7/2015 Daily skilled note in part: - "..G.I.: Difficulty chewing, difficulty swallowing". -4/14/2015 at 6:53 p.m. "...CR #6 transferred from Rehab unit. Needs encouragement to eat. Ate 25% of dinner. Requires total care with ADL's". -4/15/2015 at 8:48 a.m. "..Received orders for [MEDICATION NAME] 15 mg every hs, phoned husband and received consent to receive medication, also received order for dietary consult". -4/16/2015 at 6:05 a.m. "...A snack was offered and refused. Less than 25% was consumed at mealtime". -4/16/2015 at 1:02 p.m. "...Refused to eat, offered snack and still do not want it". - 4/16/2015 at 8:48 p.m. "... CR #6 is sitting in wheelchair, lethargic, sleeping. Refused food and dietary supplement. NP E ordered IV for hydration". -4/17/2015 at 1:51 p.m. " ..CR #6 lying in bed lethargic, arouse when she is stimulated. Still continue to refuse food, medications. Hydration in place at 50 ml/hr for 3 bags. Unable to reach the husband " . -4/18/2015 at 1:08 p.m. "...CR #6 refusing meals and supplements, just turns her head away. Has IV fluids". -4/18/2015 at 4:12 p.m. "... phone NP E and made aware of transport of CR #6 to hospital per family request". Record review of CR #6's Change of Condition assessment dated [DATE] at 9:55 p.m. revealed in part: *Situation: Change in cognition status and appetite. This change was observed: Today. -Nursing note: CR #6 is sitting in the wheelchair, lethargic, sleeping. Offered food, CR #6 refused, offered dietary supplement, refused. NP ordered an IV normal saline at 50 ml/hr for 3 bags. * Background: Blood pressure 128/47. Mental status changes: lethargy. Record review of CR #6's care plan initiated 3/11/2015 revealed in part: Care Area/Problem: Altered Nutritional Status related to: Need for assistance/cueing with meals. Further review revealed no information related to CR #6 pocketing food or problems with chewing or swallowing. The care plan was not updated at any time with appropriate interventions. Record review of CR #6's hospital history and physical dated 4/18/2015 at 10:38 p.m. revealed in part: -Date of admission: 4/18/2015. - History of present illness: Today, while the family members were visiting CR#6, they noticed that she was less alert and vas not responsive. They also noticed severely dry mouth and she had a sacral decubitus ulcer. CR#6 was brought to the emergency room . While in the emergency room , CR#6 was noted to be hypernatremic with sodium of 155. She was in acute [MEDICAL CONDITION] with a BUN of 108 and a creatinine of 3.5. She was also noted to have a urinary tract infection and CT brain revealed new left ischemic infarct that was likely subacute. CR #6 has been admitted for the management of the multiple problems currently going on. -Laboratory data in part: Sodium:155, BUN: 108, Creatinine:3.5 and urinalysis: greater than 200 white blood cells, bacteria many. Skin: sacral decubitus ulcer. -Assessment plan: 1.- Subacute stroke, 2.- [MEDICAL CONDITION], likely multifactorial secondary to the stroke, dehydration, [MEDICAL CONDITION], and urinary tract infection. 3.- Dehydration, 4.- [MEDICAL CONDITION], 5.- Acute [MEDICAL CONDITION], 7.- Urinary tract infection, 8.- Sacral decubitus ulcers. Record review of CR #6's hospital Neurology consultation dated 4/19/2015 at 5:43 p.m. revealed in part: -Reason for consultation: Acute kidney injury and [MEDICAL CONDITION]. General: CR #6 lying in bed, very lethargic. -Assessment and plan: [MEDICAL CONDITION] secondary to free water deficit. -Assessment: 1.- Acute kidney injury, most likely due to prerenal dehydration, possible due to poor oral intake. -Plan: will change the fluids to D 5 ([MEDICATION NAME] 5%) half normal saline at 125 mL an hour. Monitor urine output. Observation on 4/21/2015 at 9:20 a.m. revealed CR #6 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #6 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes) and water flush at 200 ml every 4 hours. CR #6 also had an intravenous catheter (catheter that is inserted into a vein) to her right upper arm with D5W (5% [MEDICATION NAME] in water) and half normal saline fluids at 100 ml per hour. In continued observation, CR #6 was noted to have a Foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. In an interview at that time, CR #6 's family member stated on 4/18/2015, they visited CR #6 at the facility and she was found very lethargic and non-responsive by the family members. She further stated that CR #6 had dry saliva around her mouth and that her tongue was very dry as well. The family member stated in the ER they were told that CR #6 was severely dehydrated and had kidney failure due to the dehydration. In an interview on 4/22/2015 at 9:40 a.m. C.N.A. F stated she worked with CR #6 before she was transferred to the hospital on [DATE]. C.N.A. F further said that when CR #6 was moved to the long term side, which was about a week and a half before CR #6 went to the hospital, she would pocket the food in her mouth and would hold it and would not eat. C.N.A F continued saying, when CR #6 started pocketing her food, she would eat one or two spoons, but later, CR #6 would not open her mouth for food or fluids. C.N.A. F further said that CR #6 had barely any output of urine on the drainage Foley catheter bag, and continued saying that it was approx. 100 cc of urine at the end of the shift. In continued interview at that time, C.N.A F stated she would notify the nurses that "CR #6 did not eat or drink". C.N.A F further said that she remembered CR #6 when she was on the Rehab station and said " I remember that staff would bring her to the dining room, and as I passed by, I would see CR #6 with the tray in front of her uneaten, she would just sit in there and not eat". C.N.A F stated the procedure to follow when residents do not eat is to report it to the nurses, offer something else to the residents but that CR #6 would not even open her mouth. She further said " but I would report it to whoever nurse was there " . In an interview on 4/22/2015 at 9:58 a.m. LVN G stated one C.N.A reported to her that CR #6 was pocketing food in her mouth and that she tried to remove the food and offer a supplement and that CR #6 would not take anything, even the medications. She further said that she reported the information to NP E and who ordered IV fluids and blood work. LVN G continued saying that she asked the speech therapist to evaluate CR #6 and that she was told that CR #6 did not want to swallow. LVN G further said "I believe the pocketing problem was there since CR #6 was on the other unit (the rehab unit)". In an interview on 4/22/2015 at 11:26 a.m. LVN B stated she was the ADON for the long term side and that CR #6 was transferred to the long term side on 4/14/2015. LVN B stated she talked to NP E on 4/16/15, when she came to the building regarding CR #6 because she wasn't sure what was the baseline for CR #6. LVN B reported to NP E that CR #6 was not eating or drinking and would just lay in bed not really responding to staff. LVN B further said that NP E told her that CR #6 was not acting at her baseline. LVN B said, "NP E ordered some fluids, but I did not hear the complete orders given", which were given to LVN G. LVN B continued saying that when CR #6 was moved on 4/14/2015 from the Rehab side, she did not know about the food pocketing problem of CR #6. In an interview on 4/22/2015 at 12:18 p.m. , LVN H stated she provided care to CR #6 while she was on the Rehab side of the facility. She stated she had been made aware of CR #6 pocketing food in her mouth. Surveyor asked LVN H if any change of condition assessments were completed on CR #6 related to the pocketing of food in her mouth or if the care plan was updated and LVN H responded "it should had been, but that problem was identified from before me, everybody was aware of that". LVN H further stated that changes in condition assessments are completed in the computer and that the MD and family needed to be notified. In an interview on 4/22/2015 at 12:50 p.m. with Dietary Manager A stated she was made aware on 4/13/15 that CR #6 had stated declining in her appetite and not eating. Dietary Manager A was asked if she was made aware of any intervention in place as a result of CR #6's decline and she responded "No ma'am". In an interview on 4/22/2015 at 1:00 p.m. Registered Dietitian stated she did not get to see CR #6 recently because CR #6 went to the hospital and she goes to the facility every other week. She stated she saw CR #6 on 3/30/2015 and at that time she was made aware that CR #6 had a pressure sore but she was not made aware of any food pocketing or food problems. In a phone interview on 4/24/2015 at 1:25 p.m. RN J stated she was the ADON for the Rehab side of the facility. RN J said she was not sure how was the eating of CR #6 because she was taken to the dining room for meals. RN J continued saying that she remembered that CR #6 used to pocket food in her mouth but do not remember since when and was not made aware if CR #6 was able to eat any food. RN J stated she was told that the MD was notified of CR #6's condition. In continued interview, RN J stated that she did not know the condition of CR #6 when she was transferred to the long term side because she did not see her. In a phone interview on 4/27/2015 at 10:05 a.m. NP E stated she was made aware that CR #6 was pocketing food in her mouth but that she was eating some food. She further stated she was not made aware that it was a problem that was affecting her the whole time she was in the facility. NP E continued saying "my understanding was that the speech therapist was following CR #6 all along and if there was a problem, the speech therapist would alert us". In continued interview, NP E stated that on 4/15/2015 she was told that CR #6 was eating a little bit and she ordered [MEDICATION NAME], but CR #6 progressively got worse. NP E stated it was not until 4/16/2015 when she was made aware that CR #6 was not eating and that was when she ordered hydration and blood work but CR #6 was sent to the hospital on [DATE] and was not able to get the blood work. NP E further said that she "kind of" let the MD now about the condition of the residents (informed of critical labs and change of conditions) but every Tuesday there was a meeting at the facility and the facility made the MD aware of any conditions the patients have. In an interview on 4/27/2015 at 10:35 a.m. Speech Therapist K stated CR #6 was never on her case load because she was not able to follow commands. She stated she saw CR #6 only 3 times, mainly to screen her. She stated CR #6 was aware but was not receptive to any type of commands. In continued interview, Speech Therapist K stated she remembered that she recommended a dietary consult and that she told the nurses that if CR #6 continued having problems with pocketing of the food or eating to let her know but that the nurses never let her know any further problems with CR #6 "I never heard anything else anymore". She further stated that on 3/30/3015, the last time she saw CR #6, she screened her because she saw her sitting in the therapy room and she recognized her. Speech Therapist K continued saying that the times she saw CR #6 eating, she would only eat a couple of spoons only. Surveyor asked Speech Therapist K to show the dietary recommendation that she gave to the nurses. Further observation and interview, as the Speech Therapist K looked at the computer, she replied "I thought I recommended dietary consult but I guess I did not write it down, nurses should know if a patient is not eating, they need to contact the dietitian". Interview on 4/27/2015 at 11:40 a.m. C.N.A L stated she worked with CR #6 and she remembered CR#6 did not eat well. CNA L stated she reported CR #6's condition to several nurses, she stated, "I would tell them, she is pocketing her food, she did not eat today". C.N.A. L further stated "I do not remember when the problem started, but in the beginning CR #6 did not have any problems with eating and then later she declined, she would just put the food on her mouth and would not eat at all". Surveyor requested a copy of the facility protocol for weight loss/assessment, twice, on 4/8/15; however, it was not provided prior to facility exit. Record review of the undated facility's policy and procedure "Guidelines for notifying Physicians of Clinical Problems" revealed in part: These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner...The following symptoms, signs should prompt immediate notification of the Physician, after an appropriate nursing evaluation. Immediate implies that the Physician should be notified as soon as possible, either by phone or by pager. These situations include...vomiting; persistent or recurrent nausea and vomiting." The CMS form 672 revealed a resident census of 97.

Based on observation, interview and record review, the facility failed to ensure that 1 of 14 residents (CR #6) reviewed for pressure sores that entered the facility without pressure sores did not develop pressure sores after admission as evidenced by: -CR #6 was not provided preventive measure to prevent pressure sores. -CR #6 developed a stage II pressure ulcer which deteriorated to unstageable and increased in size. This failure affected 1 CR and could place 13 current residents with pressure sores at risk for development of new pressure sores, infection and worsening of current pressure sores. Findings were: Intake # 5 Record review of the facility face sheet for CR #6 revealed a [AGE] year old female admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. CR #6 was sent to the hospital via Emergency Medical Service by the RP on 4/18/2015 after she was found by the family lethargic and non-responsive. Record review of the admission pressure ulcer risk - Scale for predicting pressure ulcer risk for CR #6 dated 3/11/2015 revealed a score of 12. An assessment of (10 -12) is high risk. Record review of the admission assessment dated 3/11/2015 revealed CR #6 did not have rashes, redness or any wounds or open areas on her body on admission to the facility. Record review of the admission initial MDS with assessment reference date of 03/18/2015 revealed CR #6 was rarely/never understood and did not complete BIMS evaluation. CR #6 required extensive assistance of 2 persons for bed mobility, transfers and toilet use and extensive assistance of one person for personal hygiene and bathing. CR #6 was always incontinent of both bowel and bladder. Further record review of the initial MDS did not document she had a pressure ulcer or additional assessment that CR #6 was at risk of developing pressure ulcers ;although the scale for predicting pressure ulcer risk for CR dated 3/11/15 assessed her at high risk (12) of developing pressure ulcers. CR #6 was not pressure reducing device for a chair and she was not on a turning /repositioning program. Further record review of the Care Area Assessment revealed CR #6 was identified as being at risk for pressure ulcer. Record review of the Registered Dietitian Nutrition Therapy Assessment documented that the initial assessment was started on 03/12/2015 did not include any preventive or recommendations until after the resident developed a pressure sore and was not completed until 3/30/3015 for CR #6. The recommendations were in part: Type of assessment: new admission. - Nutrition Diagnosis: [REDACTED]. Intervention in part: Monitor oral intake of food and fluid, encourage hydration between meals, with meals. Goals: pressure ulcer will be healed; - pressure ulcer will show signs of improvement. These were implemented after 3/30/15., Record review of the initial care plan dated 3/11/5 did not include any preventive measures to prevent the development of pressure sores. There were no interventions that included keeping her clean and dry and she was not on a turning /repositioning program, or on a pressure relieving mattress or a pressure reducing device for a chair. The initial care plan only identified fragile skin. And the goal was the skin will be free of skin tears, infections, bruises over the next 90 days. The only intervention was lotion to dry skin dated 3/11/15. Record review of the facility skin data assessments for CR #6 dated 3/12/15, 3/19/15 & 3/26/15 did not document any rash, redness, abrasions or pressure sores. However, record review of CR #6's nurse notes dated 3/27/2015 at 4:21 a.m. revealed in part: CR #6 has pressure ulcer on buttocks. Zinc applied, turn every 2 hours. NP notified, husband aware. Wound care nurse N notified to assess on Monday. Record review of nurse ' s notes dated 4/13/2015 revealed at 10:40 a.m. in part: upon wound rounds with wound MD, wound has deteriorated. New orders to treat and Stat blood work ordered. CR #6 moved to an air mattress. Further review of note dated 4/13/15 at 9:36 p.m. revealed in part: Foley catheter 14 French inserted to allow for wound healing per NP E. Record review of nurse ' s note dated 3/30/2015 and completed on 4/18/2015 at 3:51 p.m. by the Wound care Nurse N in part: Late entry received a stop and watch. Upon assessment stage II to buttocks noted. NP E notified, new orders to treat. Daughter and husband notified. Will continued to monitor wound. Record review of the electronic consolidated orders for CR #6 revealed orders in part: - 3/28/2015: Cleanse site every am shift with normal saline, pat dry, and apply zinc to buttocks. - 3/30/3015: Cleanse wound every am shift with normal saline, pat dry apply xeroform (medical dressing that won't stick to wound and has antiseptic and antibacterial qualities) dressing to buttocks and cover with protective dressing for pressure ulcer stage II. - 3/31/2015: multivitamins with minerals one tablet by mouth one time per day for pressure ulcer stage II, Prostat( protein liquid) Sugar free liquid protein 30 ml by mouth 2 times per day for pressure ulcer stage II, Stress tablet with Zinc tablet one tablet by mouth 2 times per day for pressure sore stage II. - 4/13/2015: [MEDICATION NAME] (antibiotic) 100 mg capsule one capsule by mouth 2 times per day for 10 days for pressure ulcer, stage II. - 4/13/2015: Cleanse wound every am shift with normal saline, pat dry apply medi honey (highly absorbent seaweed-based material saturated with manuka honey that is believed to kill germs and speed healing) to buttocks and cover with protective dressing for pressure sore stage II. Record review of CR #6's wound report revealed in part: - 3/30/3015 revealed a facility acquired stage II pressure sore to the right buttock, measuring (length per width) 2.5 x 2.0 c.m. with moderate bloody exudate (fluid that has seeped out). -4/6/2015 - stage II pressure sore to the right buttock, measuring (length per width) 2.5 x 2.0 c.m. with moderate bloody exudate (fluid that has seeped out). Status - unchanged. -4/13/2015 - unstageable pressure sore to the right buttocks, measuring 4.0 x 4.0 c.m. with moderate bloody exudate. Tissue with necrosis - eschar. Status - deteriorated. Record review of CR #6's Change of Condition assessment dated [DATE] at 9:55 p.m. revealed in part: *Situation: Change in cognition status and appetite. This change was observed: Today. -Nursing note: CR #6 is sitting in the wheelchair, lethargic, sleeping. Offered food, CR #6 refused, offered dietary supplement, refused. NP ordered an IV normal saline at 50 ml/hr for 3 bags. * Background: Blood pressure 128/47. Mental status changes: lethargy. Record review of CR #6's nurse notes dated 4/18/2015 at 4:12 p.m. revealed in part: "... phone NP E and made aware of transport of CR #6 to hospital per family request". Record review of CR #6's hospital history and physical dated 4/18/2015 at 10:38 p.m. revealed in part: -Date of admission: 4/18/2015. - History of present illness: Today, while the family members were visiting CR#6, they noticed that she was less alert and vas not responsive. They also noticed severely dry mouth and she had a sacral decubitus ulcer. CR#6 was brought to the emergency room . While in the emergency room , CR#6 was noted to be hypernatremic with sodium of 155. She was in acute [MEDICAL CONDITION] with a BUN of 108 and a creatinine of 3.5. She was also noted to have a urinary tract infection and CT brain revealed new left ischemic infarct that was likely subacute. CR #6 has been admitted for the management of the multiple problems currently going on. -Laboratory data in part: Sodium:155, BUN: 108, Creatinine:3.5 and urinalysis: greater than 200 white blood cells, bacteria many. Skin: sacral decubitus ulcer. -Assessment plan: 1. - Subacute stroke, 2. - [MEDICAL CONDITION], likely multifactorial secondary to the stroke, dehydration, [MEDICAL CONDITION], and urinary tract infection. 3.- Dehydration, 4.- [MEDICAL CONDITION], 5.- Acute [MEDICAL CONDITION], 7.- Urinary tract infection, 8.- Sacral decubitus ulcers. Hospital record review of CR #6's wound evaluation assessment dated [DATE] at 1:20 p.m. revealed in part: Pressure area sacral with a deep tissue injury initially now has open area, stage 2 periphery: Length 6.2 c.m. x Width 8.5 c.m., black thick eschar area inside wound area Length 3.4 c.m. x Width 3.5 c.m to 7.0 c.m. -Appearance: wound base red; wound base yellow; wound base with black eschar; wound base pink; Peri-wound area pink; Wound edges open. -Serosanguineous drainage; scant amount of drainage, no odor. - Frequent turning important to decrease pressure on wound site. -treatment plan: [REDACTED] Record review of CR #6's hospital Infectious disease consultation dated 4/19/2015 at 6:35 p.m. revealed in part: - History of present illness: [AGE] year old female admitted to the hospital with [REDACTED]. She did come in with a Foley that was changed here with urinalysis showing numerous white blood cells. - Physical examination: unstageable sacral decubitus. -Diagnosis: [REDACTED]. Sacral wound, surgical debridement will be considered. Observation on 4/21/2015 at 9:20 a.m. revealed CR #6 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #6 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of DiabeticSource (nutritional formula for patients with Diabetes) AC and water flush at 200 ml every 4 hours. CR #6 also had an intravenous catheter (catheter that is inserted into a vein) to her right upper arm with D5W (5% [MEDICATION NAME] in water) and half normal saline fluids at 100 ml per hour. In continued observation, CR #6 was noted to have a Foley catheter that had approx. 200 cc of clear amber colored urine on the collection drainage bag. Further observation at that time revealed CR #6 with a large open area " inverted C " shape to the sacrum that extended to her bilateral upper buttocks. The black area in the middle of the open area covered approx. 70 % of the wound and the remaining 30% of the wound base was red and surrounding site was red with a small amount of yellow drainage noted. An interview with CR #6 was attempted at that time; however, CR #6 was not interviewable. The resident was not responsive to questions. In an interview on 4/21/2015 at 9:46 a.m. CR #6's family member stated CR #6 was admitted to the nursing facility with her skin intact. The family member stated CR #6 developed a pressure sore within 2 weeks of admission to the facility and the sore got worse quickly because CR #6 was always on her back when she was in bed and spent long hours seated in the wheelchair as well. In continued interview she stated " they never turned her, she was always on her back". In an interview on 4/22/2015 at 9:40 a.m. C.N.A. F stated she worked with CR #6 before she was transferred to the hospital on [DATE]. C.N.A. F further said that when CR #6 was moved to the long term care side, which was about a week and a half before CR #6 went to the hospital, she already had a pressure sore on her buttocks. CNA F stated a few days before CR #6 went to the hospital CR #6 was placed on an air mattress and she did not get out of bed. In continued interview, C.N.A F stated CR #6 would refuse to turn to her sides at times. Record review of CR #6's care plan, last updated 4/18/15, revealed no documentation that CR #6 was care planned for the behavior of refusing to turn. In an interview on 4/22/2015 at 1:15 p.m. Wound care Nurse N stated CR #6 acquired a pressure sore while in the facility. She stated that CR #6 started to change and wasn't as alert as before and started refusing to get out of bed. She stated one day (no date specified) during rounds with the wound MD, it was noted that the pressure sore had gotten worse. She further stated on 4/13/15, the MD changed the treatment and that CR #6 was placed on an air loss mattress. Wound care nurse N stated she did not know what CR #6's appetite was like previously, but believed something was happening to her and continued saying "she had a pocketing of food problem, something was happening to her that made her pressure sore deteriorate". When asked if the MD was notified of those changes, she responded she was not sure. In continued interview, wound care nurse N stated that the last time she saw the pressure sore of CR #6, on 4/13/15; it measured approx. 4.0 x 4.0 c.m. When asked if she was aware of the Braden scale score of CR #6 upon admission, she responded that she knew CR #6 was at high risk to develop pressure sores and those residents who were high risk for pressure sores were placed on a turning schedule program and given vitamins. Wound care nurse N further said while observing reviewing the care plan of CR #6 " she was put on a turning schedule on 4/1/2015". When asked why CR #6 was not placed on a turning and repositioning program prior to 4/1/15, Wound care nurse N did not respond. The wound care Nurse N said she was responsible for completing the the weekly assessments. Record review of the facility policy and procedure, revised March 2005, with title " Prevention of pressure ulcers " revealed in part: "Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. -General preventive measures: 2. - For a person in bed: a. - change position at least every two hours or more frequently if needed. B. - determine if resident needs a special mattress. 3. - For a person in a chair: a. - change position at least every hour, b. - use foam, gel or air cushion as indicated to relieve pressure..." Facility CMS 672 listed 13 residents with pressure ulcers.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical and mental well-being in accordance with comprehensive assessment for 1 of 6 residents (CR # 3) reviewed for appropriate transfers. CNA A and CNA B noticed something wrong with CR # 3's left leg on 5/15/2012 at around 3:00 PM but the resident was not sent to the hospital until after 8:00 PM on 5/15/2012. CR # 3 was diagnosed with [REDACTED]. This deficient practice affected 1 resident and could possibly place an additional 105 residents at risk for not being sent to a hospital timely resulting in a delay in treatment when injured. Findings Include: Complaint # 2 Record review of CR # 3's medical record revealed that she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of CR # 3's 2/5/2012 admission MDS revealed that the resident was moderately impaired for cognitive patterns. It further revealed that she required extensive assistance with transfers. Record review of CR # 3's undated Resident Status and Care Plan revealed that the resident required assist if 2 person and a Hoyer lift device for locomotion. In an interview with CR # 3's family member on 5/29/2012 at 11:25 AM she said (CR # 3's) pain in her leg was reported to the nurse earlier in the day (5/15/2012) before she (family member) came to the facility. She further stated the resident had complained of pain when she was put back to bed in the nursing home. She said that nothing was done until she (the family member) went to the facility. The family member said (CR # 3) was not acting right on the phone when she spoke to her prior to going to the facility. The family member stated that the resident had gone to another nursing home when she was discharged from the hospital. Record review of the CR # 3's 5/15/2012 nurse's notes read in part: " . . . 3:30 PM -observed pt on bed - alert, (left) knee is a little bit larger than (right) side, warm to touch - pt denied pain but c/o pain at (right) hand - observed no abnormal sign - will continue to monitor. 4:30 PM- pt sleep quietly in bed - c/o pain (right) hand -when nurse asked pt, denied to take medicine . . ." Record review of CR # 3's 5/15/2012 Accident/Incident Report revealed that the incident occurred before the 6:00 PM to 6:00 AM shift and was a fracture/dislocation. The description of the incident read in part: "Nurse notified Pt's knee was swollen. Nurse went to Pt's room (and) hand slightly on leg (and) Pt reacted. When Pt was asked if she was in pain (and) where Pt denied she was in pain . . . " The witness account of the Accident/Incident Report of the event read in part: "CNA notified nurse to check Pt's knee because it was swollen. CNAs stated they notified the AM nurse (and ) that AM nurse went to check the Pt. PM shift nurse went to Pt's room to check on Pt's knee but attention diverted to patients change in mental condition . . ." Record review of CNA B's 5/15/2012 witness statement read in part: "Today at about 3 pm (CNA A, another CNA) asked me (CNA B) to help her put (CR # 3) to bed because she was sleep (sic) in her wheelchair . . . While we were lifting her up in the Hoyer she (CR # 3) said her foot hurt. I asked which foot and she pointed to her left foot. After we got her in the bed . . . (CNA A) went to take off her pants. (CR # 3) started to cry saying her leg hurt. (CR # 3) grap her left leg (sic) . . . We went report it to the Charge Nurse". Record review of CNA A's 5/15/2012 witness statement read in part: "When I came in this afternoon at 3 pm I found (CR # 3) sitting in her chair . . . When we got her in the bed she started saying that her foot was hurting. As we were turning her she started saying that her leg was hurting. I went and told the nurse about what was going on". Record review of an undated, untitled questionnaire completed by CNA A revealed that she had helped transfer CR # 3 during her shift of 2:00 PM to 10:00 PM with the Hoyer lift with assistance. In response to the question, "Did the resident state she was in pain?" she wrote "yes" . In response to the question, "Did your report it?" she documented yes and the question " To whom? " CNA A documented "nurse" . In response to the question, " Did you observe or are you aware of any unusual occurrences that happened with this resident? " she responded in writing, " Yes, she complain whenever you touch her left leg " . In response to the question, Is there any other information we need to know about this resident?" she wrote, "She always complain about pain at the slightly (sic) touch on her left leg. The night of the incident". Record review of a 5/16/2012 untitled questionnaire completed by CNA B revealed that she had helped CNA A transfer CR # 3 with a Hoyer lift. In response to the question, "Did the resident state she was in pain?" she wrote "yes" . In response to the question, "Did your report it?" she documented "yes" and the question "To whom?" CNA B documented "LVN A and RN A". In response to the question, " Did you observe or are you aware of any unusual occurrences that happened with this resident? " she responded in writing, "Yes, her left leg was swollen and she kept fallen (sic) asleep on the phone. She also complained of pain in her left leg". Record review of a undated, untitled questionnaire completed by CNA C revealed that she transferred CR # 3 on 5/15/2012 with a sit to stand lift. In response to the question, "Did the resident state she was in pain?" she wrote "no" . In response to the question, " Did you observe or are you aware of any unusual occurrences that happened with this resident? " she responded in writing, "No". Record review of CR # 3's Hospital # 1 emergency room record revealed that the resident arrived at the emergency roiagnom on [DATE] at 8:28 PM via EMS. The nursing assessment revealed that CR # 3's family member told them that an aide had told her the resident had been gotten out of bed without the lifting sling and swelling was noted to the left leg. Record review of the emergency room physician 5/15/2012 note at 11:24 PM revealed the chief complaint was chest pain that was present but had resolved. The notes read in part: " . . .Patient present after complaining to (family member) of upper chest pain radiating to bilateral shoulder during visit this evening. Per (family member) patient is also more confused than usual, calling the daughter 'mom' , notes history of baseline dementia but states confusion is a lot more severe than usual. (Family member) also noted on arrival that patient's left lower leg appeared swollen and bruised just called NH and was told that patient injured leg but is unsure of the circumstances or when this occurred. Record review of the emergency room physician's physical assessment of CR # 3 revealed lower extremity, " left lower leg contusion, swelling, tenderness noted anteriorly " . The emergency room report further revealed that CR # 3 had ortho fracture care while in the emergency room and a [DIAGNOSES REDACTED]. The emergency room physician notes read in part: " . . .acute confusion on top of chronic dementia may be (secondary to) leg pain and fracture or chest pain . . .". Record review of CR # 3's 5/15/2012 at 10:42 PM x-ray of left leg, Tibia and Fibula report revealed that there were comminuted (according to <http://medical-dictionary.thefreedictionary.com/comminuted+fracture>, comminuted fracture one in which the bone is splintered or crushed) fractures of the proximal (closer to the knee area) tibia and fibula. Observations during the initial tour on 5/30/2012 from 8:30 AM to 9:55 AM of the facility revealed orange dots next to the resident's name with coded instructions for lifting each resident. In a telephone interview with CNA A on 5/31/2012 at 1:20 PM she said that the when she got to work on 5/15/2012 CR # 3 was up in the chair and sleeping. She further stated that she asked the resident if she wanted to go back to bed. CNA A said when she had the help of CNA B to get the resident into the bed. She said the transfer occurred at about 3:00 PM on 5/15/2012. CNA A said when they transferred the resident she complained of her leg hurting. After the resident was in bed and they were repositioning her and getting her clothes off she said the resident complained of her leg and foot hurting. She further stated they told the charge nurse (LVN A) that the resident was complaining of leg and foot pain. In a telephone interview with CNA B on 5/31/2012 at 2:05 PM she said the only interaction she had with CR # 3 on 5/15/2012 was between 2:30 PM and 3:00 PM while assisting CNA A transferring the resident to bed. She further stated the resident just did not seem right and she asked the nurse to check on her twice. CNA B said CR # 3 was " moaning and groaning " in pain when she was put to bed. She further stated she went and told the nurse (LVN A) about the pain. She said CR # 3 "wasn't right, just wasn't right " . CNA B further stated the resident did not normally complain of pain. Record review of CR #3's 06/01/12 nursing notes read in part: "late entry for 05/15/12 3:30 PM. CNA reported that Pt has (left) leg hurting - nurse came on to check - pt in bed - alert, no s/s of distress, assessed both legs that Pt has swollen +1, for bil leg ( history of [MEDICAL CONDITION]) - "Are you hurting now? " nurse asked Pt and pointed at the (left) knee. "No, but my arm hurt." - . . . . No s/s of abnormal color, normal - "Do you want a pain pill for your arm" nurse asked Pt, "no, I am okay", Pt answered and continued to close her eye (sic) quietly lying in bed . . .". Record review of CR #3 06/02/12, nurses notes read late entry for 05/15/12 at 1845 (6:45). Evening shift CNA notified night shift nurse to check on PT's knee. Nurse was outside the patient's room when the (family member) came out of the room asking, "What's wrong with her?" She keeps mentioning, "(Resident and) castor oil over and over again." Nurse came in the room (and) slightly touched Pt's left lower leg and patient made a whimpering sound. . . . "The nurse asked pt if she was in pain (and) pt denied . . . ". In a telephone interview with RN A on 6/4/2012 at 5:20 PM she said the previous nurse (LVN A) for CR # 3 did not tell her about the complaints of pain when she gave her report at shift change. She stated that the CNAs approached her and told her CR # 3 had complained of leg pain and it was swollen. RN A said when she got to the resident's room her (family member) was there and asking what was wrong with (the resident). She further stated the resident's (family member) was in a panic and told her that she had been warned by the doctor if the resident's vital signs increased it was because she was having another stroke. RN A said the resident's (family member) told her to call the doctor and then call an ambulance. She stated when she finished contacting the doctor and the ambulance service she went back to the room the resident's (family member) said that the resident was now having chest pain. RN A said that she did not get a chance to assess CR # 3's leg because her (family member) had the other concerns. She further stated that the CNAs told her they had approached the previous nurse (LVN A) three times to check on CR # 3. In an interview with CNA B on 6/5/2012 at 11:10 AM she said that she went to the day shift nurse (LVN A) twice to report CR # 3's pain. She said that the second time was 3 to 4 minutes after the first time. CNA B said she went back to the nurse the second time because the resident was still in pain. She said the second time she said to (LVN A) I know you are busy but can you stop and check on the resident. She said when the nurse entered the room the resident was no longer moaning. In an interview with CNA A on 6/5/2012 at 11:40 AM she said CR # 3 had pain when she was transferred. She further stated when they completed her care they went and told the nurse about the pain. She said that the only way the resident was complaining of pain was when she was touched. CNA A said she was not in CR # 3's room when LVN A assessed the resident. She further stated that she went to the night shift nurse; RN A to make sure the message had been passed along. In a telephone interview with CR # 3's family member on 6/5/2012 at 12 noon she said that the resident was different after the incident because she cannot get out of bed like she used to because of the big cast. She said she cannot go to church or for a visit. The family member said the resident was having severe pain and having to take quite a bit of pain medication. She stated since she broke her leg she now had to have a catheter which makes her at higher risk for urinary tract infections. The family member said when CR # 3' s leg was touched she would scream (on 5/15/2012). She said the leg was hard and blueish. In an interview with LVN A on 6/5/2012 at 2:45 PM she said when the CNAs went to transfer CR # 3 from the wheelchair to her bed she complained of hurting in her left leg. She said that she did an assessment, touching the leg and the resident told her she was not hurting. LVN A then said that the resident said her arm was hurting. She said that she touched the resident's arm and did not see anything. LVN A said that she saw the resident again at 4:30 and touched her leg again and did not notice anything. She stated at 5:30 PM CR # 3's family member asked why the resident was sleeping so much. She said the resident did not have any pain at that time. LVN A said that she reported to the night nurse that the resident had complained of pain but she did not see any pain. She said that she made sure she told the oncoming nurse. She further stated she did not see any bruising to the leg. She said if a resident complained of pain she would see about getting an x-ray but the resident did not tell her she was having any pain. According to the Administrator the facility census was 105.

Based on observation, interview and record review, the facility failed to to ensure that a resident obtained the optimal care and services, according to their care plan and comprehensive assessment to prevent their decline. 1 of 9 sampled residents reviewed who had a gastrostomy tube (Resident #1) did not have documentation that the physician was notified when Resident #1 was vomiting "bile". 1. The facility nurse's notes for Resident #1 had no documentation that the physician or responsible party had been notified when she had "bile colored" emesis on [DATE]. 2. The facility had no documented assessment for Resident #1 from [DATE] to [DATE] when she died . 3. Resident #1's medical record had no physician telephone orders from [DATE] to [DATE] when the orders read "Release resident to funeral home." All 16 residents with gastrostomy tubes, currently residing in the facility, could be affected by this deficient practice. Not properly documenting on the condition of a resident with a gastrostomy tube when they have a change in condition and history of aspiration could result in aspiration pneumonia, choking and death. Findings include: Complaint # 7 Resident #1. A record review was conducted on [DATE] of Resident #1's closed medical record. Her date of admission to the facility had been [DATE]. She had a recent re-admission from a hospital on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1 was documented to be a "Full Code." Resident #1 had a gastrostomy for all her nourishment and medications. A quarterly MDS assessment dated [DATE] revealed that Resident #1 had been entirely dependent on staff for all her needs. According to this assessment, Resident #1's cognition was coded as "3" (cognitively impaired). A record review was conducted on [DATE] of Resident #1's nurse's notes. On [DATE] at 11:00 PM. RN C documented "Vomited bile colored emesis x 1. Resident placed in high Fowler position." There were no further nurse notes until [DATE]. The nurse notes documented on [DATE] at 10:30 AM read "CNA came to tell me that resident had episode of vomiting. No residual noted from [DEVICE]. Cleaned. " Continued nurse's notes on [DATE] at 1:40 PM read " Called to room. Resident not breathing. Skin warm and dry. No pulse. CPR initiated, 911 called. Crash cart in room. " Nurse notes at 1:50 PM read " EMS here, resumed CPR. " Nurse notes at 1:59 PM read " Pronounced by EMT. Dr. A notified. Funeral home notified per family request. " Nurse notes at 4:00 PM read " Funeral home here to pick up body. " There was no nursing documentation or assessments conducted for Resident #1 for 6 days until her death. Continued review of Resident #1's medical record revealed there were no physician orders from [DATE] until [DATE] when the telephone order read "Body to morgue". An interview was conducted on [DATE] at 4:30 PM with RN B. She stated she did not know why there were no nurse's notes from [DATE] to [DATE] and no physician orders from [DATE] to [DATE]. She stated she would try to find them. RN B stated she had worked with Resident #1 at another facility as her charge nurse. She stated that it was not uncommon for Resident #1 to vomit some of her formula. She stated it had not been brown or smelled like feces. She stated that she had worked the day that Resident #1 died . She stated, " I was called to the code. She had brown emesis." When asked if it could have been feces, RN B stated "Yes." An interview was conducted on [DATE] at 4:45 PM with RN C. When shown the nurse's notes for [DATE] she stated she had been the nurse who had written them. She stated, " I don't know why I didn't document that I called the physician and the family. But I did. I just didn't document it. I should have." She stated she would try to find the nurse's notes between [DATE] and [DATE]. An interview was conducted on [DATE] at 5:25 PM with RN C. She stated "The nurse's 24 hour report should show what was going on with her during that time frame where there was no documentation". RN C stated she would go and get it to show surveyor. A record review was conducted on [DATE] at 5:45 PM of a document with no title that was provided by RN C. She stated it was the Nurse 24 hour report. It had the dates from an unknown month dated 17 through 24. This document was set up for brief documentation to oncoming nurses of the condition of each resident. It had spaces for the ,[DATE] shift, the ,[DATE] shift and the ,[DATE] shifts. On the date 17, only the ,[DATE] shift had any documentation. It read "OK." On the date 18, only the ,[DATE] shift had documented. It read "Peg - HOB up." On the date 19, the ,[DATE] shift nurse documented "OK", and the ,[DATE] shift documented "OK - dressing change done today." On the date 20 only the ,[DATE] shift had any documentation. It read "OK." On the date 21 only the ,[DATE] shift had any documentation. It read " deceased at 1350. " Resident #5's name was printed on the bottom of this document. An interview was conducted on [DATE] at 5:45 PM with RN C. Surveyor brought her attention to the name on the bottom of the document. RN C stated " That Resident ( #5) is not deceased . It was a mistake. They must have put the wrong resident's name down. I know this really belongs to (Resident #1). I don't know why there is not any documentation for that time. Maybe because we chart by exception". An interview was conducted on [DATE] at 6:00 PM with Dr.A. She stated that Resident #1 had been on her service for some time and she was very familiar with her. Dr.A stated that Resident #1 had been at high risk for aspiration pneumonia. When shown the nurse's notes dated [DATE] she stated " I had no idea. They didn't notify me. I am readily accessible to them. They have my cell phone number. I have it with me all the time. They didn't call me." No further assessments or documentation for the time period from [DATE] to [DATE] fpr Resident #1 was provided by the facility at the time of exit. There were 16 residents with gastrostomy tubes according to the facility Form 802.

Based on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy tube was provided appropriate treatment and services to prevent vomiting, aspiration, or infection at the gastrostomy insertion site. 1 of 9 sampled residents (Residents #1) with gastrostomy tubes, had been vomiting and subsequently died . 1. The facility staff failed to notify the physician of Resident #1 vomiting bile on [DATE]. 2. The facility staff failed to properly assess Resident #1 on [DATE] prior to her death. There was no nursing documentation or physician's telephone orders from [DATE] to [DATE] (6 days) when she died . All 16 residents with gastrostomy tubes, currently residing in the facility, could be affected by this deficient practice. Not properly assessing residents with gastrostomy tubes when they have a history of aspiration could result in aspiration pneumonia, choking and death. Findings include: Resident #1 A record review was conducted on [DATE] of Resident #1's closed medical record. Her date of admission to the facility had been [DATE]. She had a recent re-admission from a hospital on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1 was documented to be a "Full Code." Resident #1 had a gastrostomy tube for all her nourishment and medications. A quarterly MDS assessment dated [DATE] revealed that Resident #1 had been entirely dependent on staff for all her needs. According to this assessment, Resident #1's cognition was coded at "3" (cognitively impaired). A record review was conducted on [DATE] of Resident #1's nurse's notes. On [DATE] at 11:00 PM. RN C documented "Vomited bile colored emesis x 1. Resident placed in high Fowler position." There were no further nurse's notes until [DATE]. These nurse's notes documented on [DATE] at 10:30 AM read "CNA came to tell me that resident had episode of vomiting. No residual noted from [DEVICE]. Cleaned." Continued nurse's notes on [DATE] at 1:40 PM read "Called to room. Resident not breathing. Skin warm and dry. No pulse. CPR initiated, 911 called. Crash cart in room." Nurse notes at 1:50 PM read "EMS here, resumed CPR." Nurse notes at 1:59 PM read "Pronounced by EMT. Dr. (A) notified. Funeral home notified per family request." Further review of the nurse's notes dated [DATE] documented at 4:00 PM read " Funeral home here to pick up body." There was no nursing documentation of assessments conducted for Resident #1 for 6 days until her death. Continued review of Resident #1's medical record revealed there were no physician orders from [DATE] until [DATE] when the physician telephone order read " Body to morgue." An interview was conducted on [DATE] at 4:30 PM with RN B. She stated she did not know why there were no nurse's notes from [DATE] to [DATE] and no physician orders from [DATE] to [DATE] for Resident #1. She stated she would try to find them. RN B stated she had worked with Resident #1 at another facility as her charge nurse. She stated that it was not uncommon for Resident #1 to vomit some of her formula. She stated it had not been brown or smelled like feces. She stated that she had worked the day that Resident #1 died . She stated, "I was called to the code. She had brown emesis." When asked if it could have been feces, RN B stated "Yes." An interview was conducted on [DATE] at 4:45 PM with RN C. When shown the nurse notes for [DATE] she stated she had been the nurse who had written them. She stated, "I don't know why I didn't document that I called the physician and the family. I know I called them. I just didn't document it. I should have done." She stated she would try to find the nurse notes between [DATE] and [DATE]. An interview was conducted on [DATE] at 5:25 PM with RN C. She stated that the nurse's 24 hour report should show what was going on with Resident #1 during that time frame where there was no documentation. RN C stated she would go and get it to show surveyor. A record review was conducted on [DATE] at 5:45 PM of a document with no title that was provided by RN C. She stated it was the nurse's 24 hour report. It had the dates from an unknown month dated 17 through 24. This document was set up for brief documentation to oncoming nurses of the condition of each resident. It had spaces for the ,[DATE] shift, the ,[DATE] shift and the ,[DATE] shifts. On date 17, only the ,[DATE] shift had any documentation. It read "OK." On date 18, only the ,[DATE] shift had documented. It read "Peg - HOB up." On date 19, the ,[DATE] shift nurse documented "OK", and the ,[DATE] shift documented "OK - dressing change done today." On date 20 only the ,[DATE] shift had any documentation. It read "OK." On date 21 only the ,[DATE] shift had any documentation. It read "deceased at 1350." Resident #5's name had been written on the bottom of this form. An interview was conducted on [DATE] at 5:45 PM with RN C. Surveyor brought her attention to the name on the bottom of the document. RN C stated "(Resident #5) is not deceased . It was a mistake. They must have put the wrong resident's name down. I know this really belongs to (Resident #1)." An interview was conducted on [DATE] at 6:00 PM with Dr.A. She stated that Resident #1 had been on her service for some time and she was very familiar with her. Dr.A stated that Resident #1 had been at high risk for aspiration pneumonia. When shown the nurse notes dated [DATE] she stated "I had no idea. They didn't notify me. I am readily accessible to them. They have my cell phone number. I have it with me all the time. They didn't call me." A record review was conducted on [DATE] of the facility's Policy and Procedure related to gastrostomy care. This document read, in part "Purpose: the purposes of this procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection .... Steps in the procedure: #8; Assess the stoma site for signs of redness, pain or soreness, swelling, or drainage. Report any of these signs of infection immediately to your supervisor and resident's physician .... #9; If the stoma site has signs of irritation or infection, clean the area several times a day as described above in Steps 2 through 6. If the signs and symptoms persist, notify your supervisor and resident's physician. The facility had 16 residents with gastrostomy tubes according to their Form 802.