Every finding on record at Village Healthcare and Rehabilitation

Based on observations, interviews, and record reviews 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 need that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's care plan included his preference for warm wipes during peri-care. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.Findings included: Record review of Resident #1's admission record, dated 08/17/26, reflected [AGE] year-old male with an admission date of 04/16/26. His relevant diagnoses included Alzheimer's disease (a progressive brain disorder and the most common cause of dementia), dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life), cognitive communication deficit (a breakdown in communication caused by impaired thinking process), and resistance with personal care. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 04, which indicated his cognition was severely impaired. Record review of Resident #1's quarterly care plan, dated 04/17/26, reflected:Focus: Impaired coping. Date initiated/created 07/13/26. Interventions: Provide assistance with ADLs as needed. Date initiated 07/13/26. There was no mention of using warm wipes listed on the care plan. During an observation on 08/17/26 at 10:15 a.m., revealed Resident #1's room, a wipe warmer was observed on his bedside drawer. During an observation and interview on 08/17/26 at 10:56 a.m., Resident #1 was observed sitting on his wheelchair and was not interviewable. During an interview on 08/17/26 at 11:04 a.m., CNA A said she was assigned to Resident #1's hall. She said Resident #1 had dementia which caused him to become aggressive at times. She said Resident #1 preferred warm wipes during peri care and was a known practice amongst hall 100's CNA's and nursing staff. CNA A said Resident #1 would resist and become physically aggressive when cold wipes were used during peri care. She said for that reason, his family member provided a wipe warmer several months ago to be used during peri care. CNA A said a negative outcome to Resident #1 if cold wipes were used during peri care would be him resisting care and get physically aggressive.During an interview on 08/17/26 at 11:28 a.m., CNA B said she was assigned to Resident #1's hall. She said Resident #1 had dementia. She said Resident #1 preferred warm wipes during peri care. She said if cold wipes were used on Resident #1 during peri care, he would resist care and become agitated. She said Resident #1's family member had provided a wipe warmer to ensure CNAs used warm wipes during peri care. She said she had not informed Resident #1's Charge Nurse about his preference because it was a known practice to use warm wipes on Resident #1 during peri care. CNA B was not able to use say if Resident #1's preference of warm wipes during peri care was not care planned.During an interview on 08/17/26 at 11:45 a.m., LVN C said he was assigned to Resident #1's hall. He said Resident #1 was usually quiet and required frequent monitoring. LVN C said Resident #1 would freak out when cold wipes were used during peri care. He said Resident #1's family member had provided a wipe warmer to use during peri care. He said CNAs and Nursing staff in Resident #1's hall used warm wipes during peri care. LVN C said he had not informed his ADON or DON of Resident #1's preferred warm wipes during peri. LVN C was not able to say what negative outcome to Resident #1 not having his care plan include his preference of warm wipes during peri care. He said, it's something that is already known between CNAs and Nursing staff.During an observation on 08/17/26 at 1:35 p.m., CNA A and CNA B were observed performing peri care behind Resident #1's privacy curtain. Resident #1 was asked per permission to perform peri care and throughout the procedure, both CNA A and CNA B were heard explaining each step and asking Resident #1 if he was ok. CNA A was heard telling Resident #1 they were going to use warm wipes and had him feel the wipes before being used.During an interview and observation on 08/17/26 at 2:21 p.m., the MDS-RN was observed as she reviewed Resident #1's electronic medical record and said his care plan did not include his preference of warm wipes during peri care. She said the only way she would know of a change in Resident #1's condition was if his CNA reported it to his charge nurse. The Charge nurse would then communicate the change to either the ADON or DON. She said the ADON or DON also had the option of going directly to her or during their morning meetings it would be discussed. The MDS-RN said a negative outcome to Resident #1 not having his care plan include he preferred warm wipes during peri care could be direct care staff would not know and could trigger behaviors.During an interview and observation on 08/17/26 at 2:32 p.m., the ADON said Resident #1 had a diagnosis of dementia. She said Resident #1 preferred warm wipes during peri care. She said Resident #1 would not let the CNAs perform peri care if the wipes were cold. The ADON said it was a known practice amongst the direct care staff in Resident #1's hall. She said Resident #1's family member had provided a wipe warmer to ensure warm wipes were used during peri care. The ADON was observed as she reviewed Resident #1's electronic medical record and said I can't find where his preference of warm wipes during peri care was care planned. She said she had not informed the DON or MDS of Resident #1's preference of warm wipes during peri care due to miscommunication. She said a negative outcome to Resident #1 not having his care plan indicate that he preferred warm wipes during peri care would be that whoever performed peri care would not know and trigger him to refuse care.During an interview on 08/17/26 at 4:00 p.m., the DON said Resident #1 had dementia and at times had behaviors. She said Resident #1 exhibited behaviors whether cold or warm wipes were used during peri care. She said Resident #1's family member was the one that preferred the warm wipes, not him. The DON was not able to say if there were any negative outcomes to Resident #1 care plan did not include his preference of warm wipes during peri care.Record review of the facility's Comprehensive Person-Centered Care Planning policy revised 04/2025, reflected:Policy: It is a policy of this facility that the interdisciplinary team shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and time frames to meet residents medical and nursing home and cycle needs are identified in the assessment.Procedure: 6.The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessment.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 2 (Resident #40 and Resident #28) of 2 residents reviewed for enteral feeding: 1. The facility failed to ensure LVN A checked gastric residual prior to medication administration for Resident #40 and Resident #28 on 06/03/2026. 2. The facility failed to ensure LVN A flushed water via gravity through the G-tube prior to mediation administration for Resident #40 on 06/03/2026. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications, resident discomfort, tube damage, and decline in health. 1. Record review of Resident #40's face sheet, dated 06/03/2026, revealed a [AGE] year-old female with an original admission date of 04/04/2025, and a current admission date of 08/11/2025. Pertinent diagnoses included Gastrostomy (feeding tube; a surgical procedure in which an opening is created through the abdominal wall directly into the stomach), Chronic Kidney Disease, and Type 2 Diabetes Mellitus. Record review of Resident #40's MDS assessment, dated 04/10/2026, revealed he scored a 3 on his BIMS which reflected severely cognitively impaired. Section K0520 Nutritional Approaches marked for Feeding tube. Record review of Resident #40's care plan revealed the resident required a feeding tube related to swallowing problem. Interventions: Check for gastric contents/residual volume. Resident #40 dependent with tube feeding and water flushes. Record review of Resident #40's Order Summary Report dated 06/03/2026 revealed the following: Check Gastric residual prior to each bolus feeding/flushing/medication administration with order date 08/11/2025. Flush (feeding) tube with 30-50 ml (cc) of water before and after administration of medication pass every shift related to gastrostomy with order date 6/18/25 and no end date. Observation on 06/03/2026 at 3:20 p.m., revealed Resident #40 lying in bed with head of the bed elevated. Observed LVN A immediately poured 30mls of water to flush the G-tube without checking for residual. LVN A waited for the water to flow down via gravity in the barrel, but the water did not move. He then proceeded to attach the plunger and forcefully pushed the water through the tube. Due to the amount of force applied, water seeped out of the tube before immediately flowing through. 2.Record review of Resident #28's face sheet, dated 12/19/2025, revealed a [AGE] year-old male with an admission date of 12/19/2025. Pertinent diagnoses included Gastrostomy (feeding tube; a surgical procedure in which an opening is created through the abdominal wall directly into the stomach), Heart Failure, and Type 2 Diabetes Mellitus. Record review of Resident #28's MDS assessment, dated 03/23/2026, revealed he scored a 10 on his BIMS which reflected moderately cognitively impaired. Section K0520 Nutritional Approaches marked for Feeding tube. Record review of Resident #28's care plan revealed the resident required a feeding tube related to Dysphagia (swallowing problem). Interventions: Check for gastric contents/residual volume. Dependent with tube feeding and water flushes. Record review of Resident #28's Order Summary Report dated 06/03/2026 revealed the following: Check Gastric residual prior to each bolus feeding/flushing/medication administration with order date 12/19/2025. Flush (feeding) tube with 30-50 mls of water before and after administration of medication pass every shift related to gastrostomy with order date 12/19/2025 and no end date. Observation on 06/03/2026 at 3:02 p.m., revealed Resident #28 lying in bed with head of the bed elevated. Observed LVN A immediately poured 30mls of water to flush the G-tube without checking for residual. In an interview on 06/03/2026 at 3:38 p.m., LVN A stated that he forgot to check for residual prior to flushing the G-tube with water. He stated that he knew he was supposed to check for residuals, but he became nervous and did not do it this time. LVN A stated that checking residuals was important to ensure that the stomach was not too full or obstructed and to ensure that everything was functioning properly. He stated that if excessive residual had been present, he would have notified the physician immediately. LVN A stated that failure to check residuals could have resulted in a negative outcome for the resident including paralytic ileus (temporary paralysis of the intestinal muscles). LVN A further stated that the proper process for flushing water through G-tube was to allow it via gravity. However, if the tube was clogged, light pressure could be applied to flush it. He stated that he did not think that he had applied excessive pressure. LVN A stated that applying too much pressure could cause trauma to the stomach. In an interview on 06/03/2026 at 3:53 p.m., the ADON stated that staff were trained to check for residual prior to medication administration via G-tube. She stated that they were trained upon hire and thereafter on an as needed basis. The ADON stated that it was important to check for residual prior to medication administration to ensure the residents' stomach was not too full and to reduce the risk of aspiration. The ADON further stated that staff should not apply pressure when performing water flushes through G-tube. She stated that force should not be used because of a balloon inside the G-tube that could rupture. The ADON stated that staff should not force water boluses or medications through the tube. Staff were trained to stop the procedure, attempt to unclog the G-tube and then restart the process from the beginning. The nurse stated that the negative outcome of forcing fluids or medications through the tube could include rupture of the internal balloon or the external portion of the tube, which could require G-tube replacement. In an interview on 06/03/2026 at 4:05 p.m., the DON stated that staff were instructed to check for residual prior to medication administration via G-tube. She stated that if residual was greater than 150-200mls, staff were to hold the medications and notify the physician for further orders. The DON stated that if a resident had a large amount of residual, it indicated that the stomach was too full and could place the resident at risk for aspiration. The DON further stated that if the G-tube became clogged, staff were trained to stop the procedure and notify the physician and us. The staff should not continue with medication administration. The DON stated that the flushing process should be performed via gravity. She stated that applying force could cause the tubing or the internal balloon inside the resident to rupture. The DON stated that skill check offs were completed by her, the ADON, and outside resource personnel as needed. Record review of the facility's Medication Administration via Feeding Tube dated April 2025 revealed: Policy: It is the policy of this facility to ensure that medications administered via feeding tue are administered safely and accurately. A physician's order is required for the administration of any mediation via feeding tube Procedure 14. Administer prescribed medication. Pour the liquified medication into the syringe and allow to flow by gravity int the tube- never force fluid into the tube. Notify supervisor if problems are encountered. Rinse medication cup with water or prescribed diluent and administer to assure administration of the complete dose of medication.

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #40 and Resident #28) of 6 residents reviewed for infection control practices. 1.The facility failed to ensure LVN A performed hand hygiene before and after medication administration via G-Tube for Resident #40 and Resident #28 on 06/03/2026. 2.The facility failed to ensure LVN A cleaned the syringe after using it for medication administration for Resident #28 on 06/03/2026. These failures could place residents at risk for healthcare associated cross-contamination and the spread of infection. 1.Record review of Resident #40's face sheet, dated 06/03/2026, revealed a [AGE] year-old female with an original admission date of 04/04/2025, and a current admission date of 08/11/2025. Pertinent diagnoses included Gastrostomy (feeding tube; a surgical procedure in which an opening is created through the abdominal wall directly into the stomach), Chronic Kidney Disease, and Type 2 Diabetes Mellitus. Record review of Resident #40's MDS assessment, dated 04/10/2026, revealed he scored a 3 on his BIMS which reflected severely cognitively impaired. Record review of Resident #40's Order Summary Report dated 06/03/2026 revealed the following: Rinse Syringe after each use with order date 08/11/2025. During an observation conducted on 06/03/2026 at 3:02 p.m., LVN A was observed putting on gloves without washing hands and proceeded to administer medications via G-tube to Resident #40. Observed LVN A complete procedure, remove gloves and did not wash hands. 2. Record review of Resident #28's face sheet, dated 12/19/2025, revealed a [AGE] year-old male with an admission date of 12/19/2025. Pertinent diagnoses included Gastrostomy (feeding tube; a surgical procedure in which an opening is created through the abdominal wall directly into the stomach), Heart Failure, and Type 2 Diabetes Mellitus. Record review of Resident #28's MDS assessment, dated 03/23/2026, revealed he scored a 10 on his BIMS which reflected moderately cognitively impaired. During an observation conducted on 06/03/2026 at 3:20 p.m., LVN A was observed putting gloves without washing hands and proceeded to administer medications via G-tube to Resident #28. Observed LVN A complete the medication administration via G-tube and he then placed the syringe back in the bag without cleaning it. Observed LVN A remove gloves and did not wash hands. In an interview on 06/03/2026 at 3:38 p.m., LVN A stated that he forgot to wash his hands prior to donning gloves and after he was done with medication administration via G-tube because he was nervous. He stated that he was expected to wash hands before and after procedure. LVN A further stated that failure to not wash hands before and after care poses risks for cross-contamination and infection. LVN A stated that he forgot to clean the syringe after use because he got nervous. He stated that he was supposed to clean it to get rid of medication residue and germs. In an interview on 06/03/2026 at 3:53 p.m., the ADON stated that staff were trained to wash hands before and after G-tube medication administration. She stated that it was required to prevent the spread of infection. The ADON stated that infection control was their number one priority. She stated that LVN A was supposed to rinse the syringe after being used due to residual could be left and there would be a possiblitiy of overmedicating the resident. The ADON stated an infection control in-service was done about one to two weeks ago. In an interview on 06/03/2026 at 4:05 p.m., the DON stated that staff were required to wash hands before and after medication administration to prevent the spread of infection. She stated that staff were instructed to clean the syringe after it has been used to prevent cross contamination. The DON stated that infection control in-services were done on a monthly basis. Record review of the facility's Infection Prevention and Control Program dated April 2025 revealed: Policy The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Scope of the Infection Control and Prevention Program: 2. Process Surveillance is the review of practices by staff directly related to resident care a. Hand hygiene e. Infection control practices during the provision of resident care and treatments. Record review of the facility's Medication Administration via Feeding Tube dated April 2025 revealed: Procedure 3. Wash hands thoroughly and put on gloves. Guidelines 7. Clean syringe until all residue is removed and store in protective container labeled with residents name and date. Replace syringe per facility protocol.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #28) of 6 residents reviewed for pharmacy services. The facility failed to ensure LVN A administered medications in accordance with accepted standards of practice when he administered a delayed release medication via G-tube for Resident #28 on 06/03/2026. This failure could place residents at risk for adverse outcomes and potentially affect the medications effectiveness. Record review of Resident #28's face sheet, dated 12/19/2025, revealed a [AGE] year-old male with an admission date of 12/19/2025. Pertinent diagnoses included Gastrostomy (feeding tube; a surgical procedure in which an opening is created through the abdominal wall directly into the stomach) and Gastroesophageal Reflux Disease (a chronic digestive condition where stomach acid or bile repeatedly flows back into the esophagus). Record review of Resident #28's MDS assessment, dated 03/23/2026, revealed he scored a 10 on his BIMS which reflected moderately cognitively impaired. Record review of Resident #28's care plan revealed the resident has GERD. Interventions: Give medications as ordered. Monitor/document side effects and effectiveness. Record review of Resident #28's Order Summary Report dated 06/03/2026 revealed the following: Lansoprazole 15mg capsule delayed release, give one capsule via PEG-tube two times a day for GERD with order start date 03/23/2026. Observation on 06/03/2026 at 3:02 p.m., revealed Resident #28 lying in bed with head of the bed elevated. Observed LVN A remove one Lansoprazole 15mg capsule DR from the blister pack, opened the capsule and mixed contents in 10mls of water. LVN A then proceeded to administer the medication through the G-tube via gravity. In an interview on 06/03/2026 at 3:38 p.m., LVN A stated that delayed release medications were designed to be released gradually throughout the day. He stated that they should not be administered via G-tube due to the protective coating on medication. LVN A stated that he had not realized Resident #28's Lansoprazole medication was delayed release. He stated delayed release medications were intended to prevent all the medication from being released at once. LVN A stated that administering the medication via G-tube could cause an adverse reaction to the resident. In an interview on 06/03/2026 at 4:05 p.m., the DON stated that delayed release medications should not be administered via G-tube. She stated that staff should not open delayed release capsules, and that medication should instead be provided in a tablet form. The DON stated that delayed release medications were designed to dissolve over a longer period of time rather than immediately in the stomach. She stated that they try to change them to a regular tablet. The DON stated that a delayed release capsule should not be opened. She stated that a potential negative outcome of administering a delayed release medication via G-tube was that the resident may not receive the intended therapeutic effect of the medication depending on the condition being treated and may not adequately resolve the residents' symptoms. Record review of the facility's policy titled Pharmacy Services dated April 2025 revealed, Purpose The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, that are consistent with current standards of practice, and that meet state and federal requirements. Procedure Develop, implement, evaluate, and revise (as necessary) the procedures of the provision of all aspects of pharmaceutical services (including procedures that assure the accurate acquiring, labeling, storage, receiving, dispensing, and administering of drugs and biologicals). 12. Other Services may include: Recommending type of medication delivery system Identify facility educational and informational needs about medications.

Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan by the interdisciplinary team, for 1 of 6 residents (Resident #10) reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #10's care plan to reflect he no longer had a bilateral toenail fungal infection.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.Findings included:Record review of Resident #10's face sheet, dated 06/03/26, reflected an [AGE] year-old male, admitted on [DATE], diagnoses included: unspecified complications of amputation stump, peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping), atherosclerotic heart disease (hardening of arteries from plaque limiting blood flow to the heart muscle), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), acute kidney failure (condition that affects the kidneys' ability to filter waste from the blood), cirrhosis of the liver (advanced scarring of the liver and decline in its function), generalized weakness, lack of coordination, and hypertension (high blood pressure). Record review of Resident #10's MDS assessment, dated 03/24/26, reflected a BIMS score of 15, indicating intact cognition. Record review of Resident #10's care plan, dated 06/03/26, reflected [Resident #10] was at risk for self-care performance deficit related to generalized weakness, lack of coordination, and left/right BKA status-post amputation surgery. Date initiated: 03/24/26. [Resident #10] had a potential fluid deficit related to bilateral toenail fungal infection. Date initiated: 10/21/25. Record review of Resident #10's order summary, dated 06/03/26, reflected no physician's orders for toenail fungal infection. During an interview and observation, on 06/02/26 at 9:30 AM, Resident #10 stated he was doing well and had no issues. Resident #10 stated he did not have feet as they were amputated, but he did not remember when they were amputated. Resident #10 stated the nurses took care of the amputations and other skin issues. Resident #10 stated the amputations were healed and he declined to show his legs. Resident #10 was observed with no visible bruising, skin tears, or injury noted to his skin. During an interview, on 06/04/26 at 9:15 AM, the ADON stated the MDS nurse developed when they completed the MDS assessments and the IDT updated care plans as needed. The ADON stated Resident #10 had the left BKA last year, but she was not sure what date. The ADON stated Resident #10 had the right BKA in March 2026. The ADON stated Resident #10's care plan should have been updated to resolve the toenail fungal infection and remove it from the care plan since he no longer had toenails. The ADON stated there was no negative outcome for Resident #10 as he no longer had any physician's orders for the toenail fungal infection. The ADON stated it was important for the care plan to be revised to ensure all staff were aware of how to care for the residents' current needs. During an interview, on 06/04/26 at 9:30 AM, the MDS Nurse stated Resident #10 had the left BKA first, but she was not sure what date. The MDS Nurse stated Resident #10 was sent back to the hospital in March 2026 and had the right BKA. The MDS Nurse stated she updated the care plans when they do the MDS assessments and as needed when there were changes for the resident. The MDS Nurse stated since Resident #10 was not out of the facility for more than 30 days, they updated his care plan when he returned on 03/23/26, instead of initiating a new care plan. The MDS Nurse stated the toenail fungal infection should have been removed from Resident #10's care plan when he returned. The MDS Nurse stated Resident #10 had no negative outcome as he did not have any orders for the toenail infection. The MDS Nurse stated it was important for the care plan to be updated accurately to ensure everyone was aware of the resident's current needs and how to care for him. During an interview, on 06/04/26 at 9:45 AM, the DON stated care plans were updated by the IDT. The DON stated Resident #10 had the left BKA on 11/28/25 and the right BKA on 3/12/26. The DON stated Resident #10 returned to the facility on 3/23/26 and his care plan should have been updated to resolve the toenail fungal infection. The DON stated there was no negative outcome or risk of injury for Resident #10 as his orders for the toenail infection were discontinued. The DON stated it was important for the care plan to be revised to ensure there was an accurate plan of care. Record review of the facility's Comprehensive Person-Centered Care Planning policy, dated January 2022, reflected - Policy: It is the policy of this facility that the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment.6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on interviews, observations and record review, the facility failed to ensure the resident had the right to personal privacy during medical treatment for 1 (Resident #28) of 6 Residents reviewed for Privacy. The facility failed to ensure LVN A closed the door, the curtain, or the window blinds during medication administration via Gastrostomy Tube for Resident #28 on 06/03/2026. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment. During an observation on 06/03/2026 at 3:20 p.m., LVN A kept the door, the curtain, and the blinds open while administering medications via G-tube (a soft, flexible tube into the stomach to deliver liquid nutrition, fluids, and medications directly to the digestive tract) to Resident #28. In an interview on 06/03/2026 at 3:38 p.m., LVN A stated that he forgot to close the door, the curtain and the blinds while administering medications to Resident #28 because he got nervous. LVN A stated that he should have closed the blinds, the curtain, and the door to provide the resident with privacy. LVN A stated that he had been trained in resident dignity and privacy. In an interview on 06/03/2026 at 3:53 p.m., the ADON stated that staff should close the door, pull the curtain, and close the blinds to provide privacy when administering medications. She stated that this was important to provide privacy. The ADON stated that the staff were trained upon hired and had skill check offs. In an interview on 06/03/2026 at 4:05 p.m., the DON stated that LVN A should have closed the door, the curtain, and the blinds prior to administering medications to Resident #28. She stated that the staff should provide privacy when providing care. The DON stated that staff were trained annually and as needed. Record review of the facility's policy, Medication Administration via Feeding Tube review date April 2025 revealed, Procedure: 4. Screen resident for Privacy Record review of the facility's policy, Dignity and Respect review date October 2015 revealed, PROCEDURES: 4. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by. People not involved in the care of the Resident shall not be present without the resident's consent while they are being examined or treated. 5. Privacy of a Residents body shall be maintained during toileting, bathing and other activities of personal hygiene, except when staff assistance is needed for the Residents' safety. HIGHLIGHTS: Dignity and respect, daily activity schedules, privacy, care and treatments, reporting violations and grievances.

Based on interview and record review, the facility failed to ensure there was a valid reason for discharge and a resident's physician order for discharge was documented when a discharge was conducted for four Residents (R #4, R #5, R #6, and R #7) of seven Residents whose discharge orders were reviewed, in that: The facilty failed to document a reason for discharge and a physician's discharge order for Resident's #4, #5, #6, and #7 prior to discharge. This failure could place residents at risk of diminished continuity of care and unsafe and/or improper discharges. The findings include:Resident #4In a record review of R #4's Face Sheet dated 11/04/25 documented an [AGE] year-old female initially admitted on [DATE] and discharged on07/11/25 with the diagnoses of: Vascular Dementia (a type of dementia caused by damage to the blood vessels in the brain), Delusional Disorders (a type of serious mental illness called a psychotic disorder the inability to tell what is real from what is imagined), Mood Disorder (A group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood), and Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions). Record review of R 4#'s care plan dated 07/16/25 revealed resident has an elopement risk and wanderer related to impaired safety awareness, resident wanders aimlessly. Intervention included distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Potential for a behavior problem potential for mood problem secondary to moods disorder administer medications as ordered. Monitor and document for side effects and effectiveness. Record review of R #4's discharged Minimum Data Set (MDS) dated [DATE] revealed she had a brief interview of mental status score of 0-severe cognitive impairment difficulty with attention, orientation, and memory. R #4 mood interview revealed she had presented symptoms of depression, no interest in activities, trouble concentrating, with a frequency of 7 to 10 days. R #4 had behaviors of rejecting care and needed supervised assistance completing ADL's. Health conditions revealed she had two or more falls with no injury observed. The active discharge plan was occurring for the resident to return to the community indicated yes. A referral was made to the Local Contact Agency. Record review of R #4's Progress notes dated 07/11/25 revealed Resident scheduled to be transferred to a new facility the nurse practitioner and responsible party were made aware. Discharge instructions given to the nurse at the new facility, voiced understanding, medications sent with patient picked up by their transportation via wheelchair. R #4's discharge note revealed reason for discharging as just Transferring to new facility. Record review of R #4's physician orders dated 07/11/25 revealed no documentation of the discharged ordered by the physician the endangerment of the safety or health of R #4.Record review of R#4's clinical record from 06/13/25 to 07/11/25 revealed there was no reason for discharge documented. In an interview on 11/05/25 at 8:45 A.M., FM #1 of R #4 stated the facility told the family on the same day of the transfer the reason why R#4 was being transferred. The facility staff member stated because the facility had to start remolding the next day. FM #1 stated she went the next day no remolding was being done. FM #1 stated she also went to the facility a week later and saw another resident was in of R #4's room, and all residents were eating in the dining room of the locked unit. FM #1 stated she was not given a choice of what facilities R #4 could go. FM #1 stated another FM #2 was there and witnessed the staff coming into the room removing things from the room and putting them in a trash bag. FM #1 stated FM #3 then arrived at the time the facility was putting R #4 in the van and transferring her. FM #1 stated no paperwork was given to anyone to sign and no instructions were given, not anything. Resident #5Record review of R #5's Face Sheet dated 07/11/25 documented an [AGE] year-old female initially admitted on [DATE] and discharge date of 07/11/25 with the diagnoses of Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions), Dementia (A group of thinking an social symptoms that interferes with daily functioning),Muscle weakness, and Cognitive communication deficit(a communication challenge resulting from impaired thinking skills like attention, memory, and problem-solving, rather than a language or speech problem). Record review of R #5's discharge MDS dated [DATE] revealed a BIMS score of 3. R #5 mood was depressed with little interest or pleasure in doing things. No behaviors of wandering took were presented or frequent. R#5's functional abilities reveal supervision need in areas of personal hygiene and in some areas was independent like transferring to shower or toilet. R#5 had history of falls with no injury. The active discharge plan was occurring for the resident to return to the community indicated yes. A referral was made to the Local Contact Agency. Record review of R #5's care plan dated 07/17/25 revealed care areas as follows: * Potential for a psychosocial well-being problem related to disease process of dementia. Intervention included take time to answer questions and to help verbalize feelings, perceptions, and fears. *R#5 is at risk for elopement risk/wanderer related to impaired safety awareness. Intervention included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. *R#5 is an antipsychotic medication related to agitation. Document episodes of behavior and side effects. Record review of R 5#'s Physician's orders dated 05/01/25 to 07/11/25 reveal no order which stated a discharge based on the endangerment of the safety or health of individuals in the facility was documented. Record review of R #5 's progress notes dated 06/04/2025 to 07/05/25 revealed on 07/11/2025 discharge instructions given to a nurse at the new facility, voiced understanding, medications sent with patient picked up by their transportation via wheelchair. R#5 discharge note revealed reason for discharging as just Transferring to new facility. Resident #6 Record review of Resident#6 face sheet revealed an [AGE] year-old female initially admitted on [DATE], with diagnosis of Dementia (A group of thinking an social symptoms that interferes with daily functioning), Epilepsy (a chronic neurological disorder characterized by recurrent seizures, which are sudden, uncontrolled electrical discharges in the brain). Record review of R #6's Care Plan date 07/16/25 revealed the following care areas:* Elopement risk/wanderer related to disoriented place. Intervention included Distract resident from wandering by offering participation in activities pleasant diversions, structured activities, food, conversation, and television. *The resident is Dependent on staff for activities, cognitive stimulation, social interaction, related to Cognitive deficits, Physical Limitations walks around the memory care unit with supervision. Record review of R 6#'s Comprehensive MDS assessment dated [DATE] revealed a BIMS Score of 11 indicated moderate cognitive impairment. R #6's mood interview revealed R#6 was feeling depressed with little interest in doing things. R #6's the behavior of wandering occurred for 1 to 3 days. Record review of Resident #6's Physician's orders dated 04/19/25 to 07/11/25 revealed no physician's order for discharge or reason for discharge. Record review of R #6's progress notes dated 07/02/25 to 08/02/25 revealed the following: * 07/11/25 at 10:21 A.M. written by RN B indicated Resident #6 was discharged , instructions given to the nurse at the new facility, voiced understanding, medications sent with patient picked up by their transportation via wheelchair. The resident is being discharged due to another facility. Record review of R #6's progress notes dated 07/02/25 to 08/02/25 revealed the following: * 07/11/25 at written by RN B at 10:21 A.M. indicated Resident #6 was discharged , instructions given to the nurse at the new facility, voiced understanding, medications sent with patient picked up by their transportation via wheelchair. The resident is being discharged due to another facility. Resident #7 5. Record review of Resident #7's face sheet, dated 11/05/2025, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Pertinent diagnoses included Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), Delusional Disorder (a serious mental illness characterized by the presence of one or more persistent delusions which last for at least one month, without significant impairment in functioning) and Hypertensive Heart Disease and Chronic Kidney Disease (closely interconnected conditions, where unmanaged high blood pressure could lead to heart complications and worsen kidney function). Record review of Resident #7's care plan, initiated 01/04/2022, revealed an initial care plan for wishing to remain long-term, which included established a pre-discharge plan with resident, family/caregivers and evaluate progress and revise plan as needed, but there were no revisions on care plan or interventions to include planned discharge with resident, family/caregivers, as well as no interventions to include the RP or family was notified of planned discharge. Record review of Resident #7's discharge MDS, dated [DATE], revealed a BIMS score of 09, which indicated moderately impaired cognition. MDS also revealed Resident #7 had a planned discharge (MDS section A0310.G) to another skilled nursing facility (MDS section A2105). Record review of Resident #7's physician orders revealed no orders for transfer or discharge. Record review of Resident #7's discharge note, dated 07/11/2025, revealed planned discharge for 07/11/2025 for transferring to another facility. In an interview on 11/04/25 at 3:30 P.M., LVN C stated the nurse in charge of the unit was responsible for getting the discharged papers ready ensuring all steps have been completed and have the resident's responsible party sign to discharge from the resident from facility. LVN C stated the nurse was to prepare the resident's transfer sheets, get medications ready to be sent to facility if meds belong to the resident, call giving report to new facility, give transfer sheet to responsible party, educate responsible party of medications if resident is going home. The resident or responsible party should have a choice of where the resident wants to go. The resident or family should be told where the resident is going if facility-initiated transfer. LVN C stated the only reason he knew the residents were discharged from the locked unit was the remolding of the unit. LVN C stated he did not know how much time the resident or resident representative was to be given before transfer. LVN C did not know who the nurse was that discharged the residents for why the medical record for each resident discharged on 07/11/25 did not show the physician's order documented for discharge. In an interview on 01/04/25 at 4:30 P.M.with DON she stated the discharged in the unit we had decided to do some remodeling and would have numerous people coming in and out of the locked unit which increase the risk of a wandering resident eloping. The DON stated the unit was closed and all residents were moved. The social worker called RP's the day before the unit closed. The DON stated she did not know if the facility had a policy and procedure for discharge notices. The DON stated the alarms on the windows were being replaced so no elopement could take place in the lock unit. The windows would open, and the alarm would not sound off at times. The DON stated the facility never had a resident elope because the windows were locked. The DON stated the social worker sent an email to ombudsman to notify her of the residents' move to another facility. The DON stated the charge nurse is responsible for medication, instructions for the medications were packed, discharge instructions, and sign the discharge. The DON stated all the families were given a choice of two other facility here Mc [NAME]. The DON stated, No body was moved that was not notified. The [NAME] stated the facility nursing staff do not care plan a discharge to another facility or home and usually starts with the order from the Physician. The DON stated the facility sent out 7 residents from the facility locked unit to other facility locked unit. The [NAME] stated some residents did come back and were notified that the remodel was complete. The DON stated no mold had been removed or anything else to medically harm the resident's health. The DON doesn't know if Resident #4 was notified. The DON stated market was notifying the residents of unit opening. The DON stated No type of training for discharging residents are available because every discharge is so different. In an interview on 11-04-2 at 5:41 the ADON stated she had the position of social services until the middle of August of 2025. The ADON stated she got the list of wanders and made the calls to the family members but could not remember if she had documentation about the calls. The ADON stated the residents were all sent to a choice of two facilities. The ADON could not remember if some residents left the day of the phone call or were notified of the transfer the day of transfer to the new facility . The ADON stated a 48-hour last coverage date insurance notice was the only notice she knew to give to the resident she knew what the time frame was for a discharge. The ADON stated she usually only handled resident insurance discharges and did not know how long the advance notice was. The ADON stated she received training for discharge for short term, and resident insurance discharges. The ADON stated care planning meetings are done for a resident or RP about discharges and usually starts with the physician ordering the discharge. The ADON stated the discharge started at admission, she would send notification to ombudsman monthly of all discharges. The ADON stated the RP signature for a resident transfer or discharges. The ADON stated she was not sure if the nurse had all the paperwork ready to RP at the time of discharge. The DON stated they knew about the remolding 30 days in advance but did not know exactly when the remolding was to begin. The ADON stated the staff only got two day notice of when the remolding was to begin. In an interview with the administrator 11/5/25 at 10:06 AM he stated all transfers were made via telephone for the 07/11/25 transfers out of the locked unit The administrator stated the process of discharge began when the physician orders the discharge, then the SW notifies family by phone not in written form. The administrator stated the care plan is documented by RN SW or DON would ensure the care plan of discharge. The administrator stated there should be an MDS as well The administrator stated the residents' RPs were called with two choices of where to go and told their family members the resident was being moved. The administrator stated not sure why residents face sheet transfer discharge orders were not documented. The administrator stated the residents in the locked unit stayed if the facility did not contact the family and made them aware of the transfer. The administrator stated typically, a discharged resident's family will be notified by phone. The administrator stated the administrator stated the SW notified families of the residents of the facility transfer always by phone.Record Review of the facility's Discharge policy and procedure dated 12/2023 revealed It is the policy of this Facility and not be transferred or discharged unless the discharge or transferred unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation of resident representative to ensure safe and orderly transfers or discharges from the facility for 5 of 5 residents (Resident #2, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for transfer and discharge. The facility failed to notify the residents and their responsible parties of the transfers or discharges with the reasons for the move in writing in a language and manner they understand. This failure placed residents at risk of not receiving an advocate who could inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .The findings included: 1. Record review of Resident #2's face sheet, dated 11/05/2025, revealed a [AGE] year-old female re-admitted to the facility on [DATE]. Pertinent diagnoses included Type 2 Diabetes (a chronic condition which affects how your body metabolizes sugar, or glucose, leading to high blood sugar levels and various health complications), Myocardial Infarction (commonly known as a heart attack, occurs when blood flow to a part of the heart muscle was blocked, leading to tissue damage), Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), Hallucinations (perception of having seen, heard, touched, tasted or smelled something which wasn't actually there), and Paranoid Personality Disorder (a mental health condition characterized by a pervasive pattern of distrust and suspicion of others, often without sufficient reason). Record review of Resident #2's annual MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderately impaired cognition. Resident #2's discharge MDS, dated [DATE], revealed Resident #2 had an unplanned discharge (MDS section A0310) to a short-term general hospital (MDS section A2105) with an acute change in mental status (MDS section C1310). Section Q of the MDS discharge assessment, dated 10/24/2025, Section A0310. F. indicated discharge assessment with return anticipated; G. indicated unplanned discharge. Section A2105 Discharge status indicated Resident #2 discharged to a short-term general hospital. Section Q0400 indicated no discharge planning. Record review of Resident #2's care plan, dated 09/30/2025, revealed Resident #2 had Delirium or an acute confusional episode related to hallucinations and paranoia. The facility attempted to send Resident #2 to the emergency room for evaluation and treatment, but the resident refused. The care plan dated 10/23/2025 revealed Resident #2 was paranoid and thought kitchen staff were looking in her window, poisoning her, and raping her. Resident #2 refused to go to the emergency room and refused counseling services. Interventions included discussing concerns, fears, and/or issues with family or caregivers, and caregiver to provide opportunity for positive interaction. Resident #2 continued to refuse medications and recommendations from the physician. There was a care plan for pre-discharge that was established on 09/01/2024, but that care plan had not been revised since 09/04/2024. Record review of Resident #2's progress note, dated 10/24/2025, revealed Resident #2 was transferred to the ER on [DATE] via stretcher due to hallucinations, delusions, and paranoia which began on 10/20/2025. Progress note also revealed the RP was notified. Record review of Resident #2's physician orders, dated 10/24/2025, revealed Resident #2 was transferred to the ER for medical clearance with section 28. In an interview on 11/05/2025 at 4:53 PM, Resident #2's family member stated they were not told their family member was getting transferred or discharged until it happened. They stated the SW was supposed to call them back regarding all the details of where their family member went, and when their family member would get to return, but no one ever called them back. They also stated they were never given any written discharge or transfer notifications or paperwork regarding their family member. 2. Record review of Resident #4's face sheet, dated 11/0420/25, revealed an [AGE] year-old female initially admitted on [DATE]. Pertinent diagnoses included Vascular Dementia (a type of dementia caused by damage to the blood vessels in the brain), Delusional Disorders (a type of serious mental illness called a psychotic disorder the inability to tell what is real from what is imagined), Mood Disorder (A group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood), and Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions). Record review of Resident #4's progress note, dated 07/11/2025, revealed Resident #4 was scheduled to be transferred to a new facility, and the nurse practitioner and responsible party were made aware. Discharge instructions were given to the nurse at the new facility, and medications were sent with Resident #4. Resident #4's discharge note revealed the reason for discharging was transferring to local nursing home. Record review of Resident #4's care plan, dated 07/16/2025, revealed Resident #4 had an elopement and wandering risk related to impaired safety awareness, and resident wandered aimlessly. Interventions included distracting the residents from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Resident #4 had potential for a behavior problem and potential for mood problems secondary to mood disorder; administer Resident #4's medications as ordered, as well as monitor and document for side effects and effectiveness. No documentation of a discharge care plan or order from the physician. Record review of Resident #4's physician orders revealed no orders for transfer or discharge. Record review of Resident #4's discharge note, dated 07/11/2025, revealed planned discharge for 07/11/2025 for transferring to another facility. 3. Record review of Resident #5's face sheet, dated 11/05/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Pertinent diagnoses included Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning). Record review of Resident #5's care plan, dated 04/11/2025, revealed an initial care plan for wishing to remain long-term with interventions which included established a pre-discharge plan with resident, family/caregivers and evaluate progress and revise plan as needed, but there were no revisions on the care plan or interventions to include planned discharge with resident, family/caregivers, as well as no interventions to include the RP or family was notified of planned discharge. Record review of Resident #5's discharge MDS, dated [DATE], revealed a BIMS score of 03, which indicated severely impaired cognition. MDS also revealed Resident #5 had a planned discharge (MDS section A0310.G) to another skilled nursing facility (MDS section A2105). Record review of Resident #5's physician orders revealed no orders for transfer or discharge. Record review of Resident #5's discharge note, dated 07/11/2025, revealed planned discharge for 07/11/2025 for transferring to another facility. 4. Record review of Resident #6's face sheet, dated 11/05/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Pertinent diagnoses included Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), Type 2 Diabetes (a chronic condition which affects how your body metabolizes sugar (glucose), leading to high blood sugar levels and various health complications) and Epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain). Record review of Resident #6's care plan, dated 04/21/2025, revealed an initial care plan for wishing to be discharged to home or another facility which included established a pre-discharge plan with resident, family/caregivers and evaluate progress and revise plan as needed, but there were no revisions to the care plan or interventions to include planned discharge with resident, family/caregivers, as well as no interventions to include the RP or family was notified of planned discharge. Record review of Resident #6's discharge MDS, dated [DATE], revealed a BIMS score of 11, which indicated moderately impaired cognition. MDS also revealed Resident #6 had a planned discharge (MDS section A0310.G) to another skilled nursing facility (MDS section A2105). Record review of Resident #6's physician orders revealed no orders for transfer or discharge. Record review of Resident #6's discharge note, dated 07/11/2025, revealed planned discharge for 07/11/2025 for transferring to another facility. In an interview on 11/05/25 at 3:30 PM, a family member for both Resident #5 and Resident #6, who were related, stated only a verbal notification via the telephone was received on 07/11/2025, which was the date both residents were discharged and transferred to another facility. The family member stated they were not given a choice of where the residents were to be placed and was never given any kind of discharge notice or education in writing. 5. Record review of Resident #7's face sheet, dated 11/05/2025, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Pertinent diagnoses included Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), Delusional Disorder (a serious mental illness characterized by the presence of one or more persistent delusions which last for at least one month, without significant impairment in functioning) and Hypertensive Heart Disease and Chronic Kidney Disease (closely interconnected conditions, where unmanaged high blood pressure could lead to heart complications and worsen kidney function). Record review of Resident #7's care plan, initiated 01/04/2022, revealed an initial care plan for wishing to remain long-term, which included established a pre-discharge plan with resident, family/caregivers and evaluate progress and revise plan as needed, but there were no revisions on care plan or interventions to include planned discharge with resident, family/caregivers, as well as no interventions to include the RP or family was notified of planned discharge. Record review of Resident #7's discharge MDS, dated [DATE], revealed a BIMS score of 09, which indicated moderately impaired cognition. MDS also revealed Resident #7 had a planned discharge (MDS section A0310.G) to another skilled nursing facility (MDS section A2105). Record review of Resident #7's physician orders revealed no orders for transfer or discharge. Record review of Resident #7's discharge note, dated 07/11/2025, revealed planned discharge for 07/11/2025 for transferring to another facility. In an interview on 11/04/2025 at 4:15 PM, the Ombudsman stated she received discharge logs monthly from the facility, but the facility was not consistent with sending the logs. She stated the discharge logs consisted of resident names, discharge date s, discharge locations, and name of RP notified. The reason for discharge was vague and did not typically list any detailed information. In an interview on 11/04/25 at 5:42 PM, the ADON stated she worked as social services until the end of July 2025, then moved into the ADON role. She stated all her discharge and transfer notifications with the RPs were done verbally via telephone. She stated she never sent any written discharge or transfer notifications to the residents, families, or RPs. In an interview on 11/05/2025 at 11:01 AM, the Administrator stated these residents had not been given 30 day notice as one of the residents was transferred out due to mental health issues, and the other residents were transferred out due to they needed to be placed in a facility with a locked unit as they were starting construction such as painting and fixing window alarms on the locked unit at their facility. In an interview on 11/05/2025 at 11:27 AM, the DON stated the SW (or the social services nurse) was the one who discussed with residents, families, or RPs via telephone to let them know their loved one was being transferred or discharged from the facility. The DON also stated no written discharge or transfer notifications were given to the residents, the families, or their RPs regarding any of these discharges or transfers because it was not something the facility did and was not part of the facility's process or policy. In an interview on 11/05/2025 at 4:05 PM, RN-B stated he gave some discharging residents, as well as the receiving facility, paperwork which included their medications and how they were to be transferred but did not give or send the RPs any discharge or transfer notifications or paperwork. Record review of the facility's Transfer and Discharge Policy, Revised 12/2023, revealed Facility initiated transfer or discharge - A transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. 2. If the resident (and/or their representative) exercises their right to appeal a transfer or discharge notice, the facility shall not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility shall document the danger that failure to transfer, or discharge would pose. A refusal to readmit the resident to the facility is considered a discharge, and the requirements of 42 CRF Section 483.15 in terms of documentation, notice before transfer, and orientation for transfer/discharge apply. S483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. S483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

Based on observations, interviews, and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance while providing care for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed when CNA B did not provide Resident #1 adequate supervision while providing incontinent care on [DATE] at around 11:50 AM, which led to Resident #1 falling from his bed, resulting in a traumatic intracranial hemorrhage (brain bleed). The non-compliance was identified as past non-compliance. The Immediate jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This deficient practice has the potential to affect all residents in the building by causing resident injuries, such as falls, fractures, and even death due to improper supervision. The findings included: Record review of Resident #1's face sheet dated [DATE] reflected an [AGE] year-old male with an original admission date of [DATE]. His relevant diagnoses included: unspecified dementia, syncope (fainting) and collapse, anxiety disorder, atrial fibrillation (abnormal heart rhythm), and adult failure to thrive. Record review of Resident #1's care plan dated [DATE] reflected Resident #1 required one staff assistance for toileting and one staff assistance for bed mobility to reposition and turn in bed. Resident #1 had mobility bars (x2) to aide in easy turning and repositioning while in bed. Record review of Resident #1's fall risk evaluation dated [DATE] reflected Resident #1 was at a high risk for falls with a score of 15 (indicated high risk). Record review of Resident #1's MDS dated [DATE] reflected Resident #1 had a catheter for urinary continence and was always incontinent for bowel continence. Resident #1 was dependent for toileting hygiene and roll left/right. Resident #1 had a BIMS score of 00 with severe cognitive impairment. Record review of Resident #1's skin evaluation dated [DATE] reflected Resident #1 noted with swelling to left side of forehead, with open area size 0.4x0.4x0.3 cm, small amount of sanguineous drainage, purple discoloration present. Left lateral side of head noted with open laceration size 1.3x0.2x0.4 cm, moderate amount of sanguineous drainage, slight purple discoloration surrounding laceration. Left anterior shoulder with skin abrasion, size 1x1x0.1 cm, small amount of sanguineous drainage, no swelling noted. Left forearm noted with abrasion, size 2x1x0.1 cm, small amount of sanguineous drainage, no swelling noted. Open areas were cleansed with normal saline and gauze, pat dry with gauze, covered with gauze and secured with tape. Resident tolerated well. Record review of Resident #1's hospital records dated [DATE] reflected Resident #1 was diagnosed with a traumatic intracranial hemorrhage. Family did not want further treatment. Family decided on palliative care. In an interview on [DATE] at 9:40 AM, CNA B said on [DATE] she was going to provide incontinent care for Resident #1. CNA B said Resident #1 was on his side, facing towards the wall, and she was standing behind him. CNA B said she did not remember if she moved him onto his side or if he was already positioned that way when she entered the room. CNA B said Resident #1 was able to move in bed. CNA B added that she was interrupted by CNA C who came into the room, called CNA B's name to ask for assistance with another resident. CNA B said she turned momentarily to respond and when she turned back, Resident #1 had already rolled off the bed and to the floor. CNA B added that although she was standing next to the bed she was not holding on to the resident or else he would not have fallen. CNA B said she turned her head quickly but it happened very fast, in a second, and she was not able to prevent Resident #1 from falling off the bed. CNA B said CNA C heard the fall and she told CNA C to call the nurse right away. CNA B said she stayed with Resident #1 until LVN A arrived to assess him. CNA B said she was in-serviced on falls, incontinent care, and safety before and after the fall on [DATE]. CNA B said they were told to not leave the resident alone with the bed high, to be careful, and to pay attention to the resident. In an interview on [DATE] at 10:00 AM, CNA C said she entered Resident #1's room on [DATE] to inform CNA B, who was performing incontinent care for Resident #1, that she needed help with another resident. CNA C said the curtain was closed for Resident #1's privacy, but CNA B opened the curtain a bit and CNA B told CNA C that okay, she would go help her right now. CNA C said CNA B was standing right next to Resident #1's bed, CNA B did not move away from the bed, and the curtain was not far from the bed. CNA C said CNA B just quickly told her okay and closed the curtain. CNA C said she did not see how Resident #1 was positioned in the bed. CNA C said she turned towards the door to exit the room when she heard a noise. CNA C said CNA B told her Resident #1 fell and to call the nurse. CNA C said she immediately notified LVN A and LVN A went to Resident #1's room. CNA C said she was in-serviced before and after the fall on [DATE] and was told to focus on what they are doing for peri care or other tasks. In an interview on [DATE] at 10:30 AM, LVN A said he was notified by CNA C that Resident #1 had fallen so he went to his room to assess. LVN A said when he walked in, Resident #1 was lying on the floor on his left side and CNA B was kneeling next to him. LVN A said CNA B reported she was attending to Resident #1 on the bed when CNA C called her from the doorway so CNA B turned around to answer CNA C. LVN A said CNA B said when she turned back, Resident #1 was on the floor. LVN A said he and RN B completed a head to toe assessment and noted Resident #1 with a raised area to the left temporal side with minimal bleeding that was controlled. LVN A said he followed the protocol and notified the MD and RP . LVN A said Resident #1 was sent out to the hospital for further evaluation and treatment. LVN A said he was familiar with Resident #1 and knew he was fidgety at times and was able to move in bed. LVN A said he was in-serviced on falls, abuse/neglect, safe transfers, and incontinent care before and after the fall on [DATE]. LVN A said when they in-serviced them on peri care and other tasks, they were instructed to focus on the task at hand. LVN A said the staff could have focused on Resident #1 and not turned away from him. In an interview on [DATE] at 11:15 AM, RN B said he was called to Resident #1's on [DATE] for a fall. RN B said Resident #1 was in bed, awake, but not in distress. RN B said he assessed Resident #1's skin, cleansed the affected areas, and placed a temporary dressing. RN B said Resident #1 was immediately sent out to the hospital. RN B said he noted the details of the injuries in his documentation and recalled the injuries were on Resident #1's left side. RN B said he was in-serviced on falls, abuse/neglect, incontinent care, and safety, before and after the fall on [DATE]. In an interview on [DATE] at 5:25 PM, the DON said on [DATE], she was notified Resident #1 had fallen. The DON said when she walked towards Resident #1's room, the ambulance had arrived to transfer him to the hospital. The DON said CNA B explained that she was providing incontinent care and when CNA C called for her, CNA B turned quickly to answer CNA C, and when CNA B turned back, Resident #1 had fallen and was on the floor. The DON said CNA B explained it happened fast and she could not prevent Resident #1 from falling. The DON said Resident #1 was 1 person assist for incontinent care and bed mobility as Resident #1 could help move. The DON said Resident #1 had a raised area on his forehead with a small laceration, first aid was provided, and he was sent out to the hospital for further evaluation. The DON said the hospital diagnosed Resident #1 with a traumatic intracranial hemorrhage and the family opted out of surgical interventions. The DON said Resident #1 returned on [DATE] under palliative care and he expired on [DATE]. The DON said they in-serviced all staff on falls, abuse/neglect, safety to prevent falls, transfers, change of condition, and how to find information on the Kardex (documentation system with the plan of care information). The DON said they reviewed all residents' charts to ensure the bed mobility and ADL status reflected in the plan of care. The DON said interdisciplinary team or an assigned staff monitored the staff by conducting random spot checks of information and observed staff providing care. In an interview on [DATE] at 5:45 PM, the Administrator said on [DATE], he was notified that Resident #1 had fallen. The Administrator said he spoke to CNA B who explained that she was providing incontinent care for Resident #1 when CNA C called her name and said she needed help. The Administrator said CNA B explained she turned to tell CNA C she would be right there and when she turned back, Resident #1 was on the floor. The Administrator said they interviewed staff and investigated the fall. The Administrator said they in-serviced all staff on abuse/neglect, falls, safety, change of condition, and the Kardex. The Administrator said they reviewed all residents' Kardex information which included their level of care needs and they did not identify any errors. The Administrator said they had a QAPI meeting and followed the plan in place which included ongoing in-services/education, resident assessments, and random spot checks of knowledge with staff. The facility had corrected the noncompliance before the survey began as followed: Record review of the following interventions put into place: 1. Record review of Resident #1's change of condition form dated [DATE] reflected Resident #1 had a left raised temporal area with a laceration, decreased level of consciousness, and MD gave new orders to send resident to the hospital for evaluation and treatment. 2. Record review of Resident #1's skin evaluation dated [DATE] reflected injury details. 3. Record review of Resident #1's neurological checks dated [DATE] reflected Resident #1 was checked at 11:50 AM. For the next check, Resident #1 was noted to be at the hospital. 4. Record review of Resident #1's fall risk evaluation dated [DATE] reflected Resident #1 had a score of 16 - high risk. 5. Record review of Resident #1's pain evaluation dated [DATE] reflected Resident #1 was not able to be interviewed and showed no indications of pain. 6. Record review of in-service education dated [DATE]-[DATE] reflected direct care staff, including CNA B, were in-serviced on falls, safety, abuse and neglect, and the care information. 7. Record review of validation test and questionnaires dated [DATE]-[DATE] reflected all staff were quizzed on abuse/neglect, falls, and assistance types. 8. Record review of validation of knowledge - dated [DATE] for week 1 with 5 staff - dated [DATE] for week 2 with 5 staff - dated [DATE] for week 3 with 5 staff - dated [DATE] for week 4 with 5 staff 9. Record review of investigation dated [DATE] reflected Resident #1's fall was on [DATE]. Incident Summary noted: Resident #1 sustained a witnessed fall while receiving peri care by CNA B. Upon charge nurse entering Resident #1's room, Resident #1 noted lying on his left side next to the bed with CNA B by his side. Resident #1 was noted with a raised area to left temporal head with abrasions and moderate bleeding. Resident #1 was awake with eyes open and in no apparent distress. MD/RP made aware immediately and Resident #1 was sent to the hospital per MD orders. As per CNA B's interview, fall attributed to Resident #1 abruptly rolling to right side of bed and CNA B unable to brace his fall. No evidence of emotional distress and no signs of abuse/neglect during this incident. Bleeding and raised area to head was related to witnessed fall and Resident #1 used anticoagulant therapy as per MD orders. 10. Record review of the Kardex dated [DATE] reflected 100% current residents' information reviewed to ensure bed mobility and ADL status was reflecting on POC. No other current residents were identified with potential for injury. 11. Record review of new admissions dated [DATE] reflected new admissions reviewed and care plan initiated/updated appropriately for residents, including Resident #1's readmission on [DATE]. 12. Record review of the QAPI meeting dated [DATE] reflected fall during ADL care. The team met with the medical director. Goal: Staff would be knowledgeable of safety during ADL care according to established criteria and decrease in falls. Interviews with other CNAs/nurses revealed they were in-serviced on falls, safety, bed mobility, incontinent care, abuse/neglect, and level of care/Kardex information. On the following dates and times: [DATE] at 1:50 PM, CNA A [DATE] at 1:30 PM, CNA D [DATE] at 1:40 PM, CNA E [DATE] at 1:50 PM, LVN B [DATE] at 2:05 PM, CNA F [DATE] at 2:15 PM, CNA G [DATE] at 2:45 PM, CNA H [DATE] at 3:00 PM, CNA I [DATE] at 3:10 PM, CNA J [DATE] at 3:20 PM, CNA K [DATE] at 3:30 PM, CNA L [DATE] at 3:50 PM, CNA M [DATE] at 5:15 PM, RN A [DATE] at 10:45 PM, CNA N [DATE] at 10:55 PM, LVN C [DATE] at 11:10 PM, LVN D [DATE] at 11:25 PM, CNA O [DATE] at 11:35 PM, CNA P Two observations of bed mobility/transfers on [DATE] at 4:15 PM and 4:30 PM completed by CNAs with other residents revealed no other concerns regarding bed mobility or transfers. Record review of facility's policy titled Fall Management System, Quality of Care with revision date [DATE] revealed, it is the policy of this facility to provide a safe environment that remains as free of accident hazards as possible.

Based on interviews and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of 10 residents (Resident #1) reviewed for accidents and hazards. The facility failed to provide adequate supervision to prevent Resident #1 from falling from bed, fracturing her right humerus. The non-compliance was identified as past non-compliance. The Immediate threat began on 11/06/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. This deficient practice has the potential to affect all residents in the building by causing resident injuries, such as falls, fractures, and even death due to improper supervision. Findings included: Record review of Resident #1's admission record reflected she was a [AGE] year-old female with an admitted [DATE]. Her relevant diagnoses included cerebral infraction (is a condition where brain tissue dies due to insufficient blood flow, leading to a lack of oxygen and nutrients) and morbid obesity. Resident #1's cognition was moderately impaired. Record review of Resident #1 care plan dated 10/3/2019 revealed Resident #1 was a two person assist for toileting. Record review of Resident #1 MDS dated [DATE] revealed Resident#1 was always incontinent to bowel and bladder. Section GG revealed Resident#1 was dependent 2 persons assist to toileting hygiene. In an interview on 04/9/25 at 2:40 pm, CNA A said she knew Resident #1 was a two person assist for incontinent care but still decided to do it on her own on 11/06/2024. CNA A said that she did not want to wait because it was lunch time. CNA A said while she performed incontinent care to Resident #1 on 11/6/24, CNA A turned Resident #1 to her right side and she slipped off the bed and landed on the floor. CNA A said that she started yelling for help and CNA B arrived to assist. CNA A said as soon as CNA B arrived, she went out to look for a nurse. CNA A said she and CNA B stayed with Resident #1 while she was being assessed by RN C. CNA A said 11/06/2024 was not the first time she had performed incontinent care to Resident #1 by herself. CNA A said that on 11/13/24 she had beed inserviced on the following topics abuse and neglect, Kardex use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. CNA A said she was reeducated on the types of abuse and neglect and to follow the plan of care. In an interview on 4/9/2025 at 2:50 pm, CNA B said that she heard CNA A screaming and she went into Resident #1 room. CNA B said she saw Resident#1 on the floor. CNA B said that she stayed with resident while CNA A went to inform RN C. In an interview on 04/09/2025 at 3:00 pm, RN C said after he assessed Resident#1, Resident #1 complained of right shoulder pain. RN C said that it took 4 therapists to transfer Resident #1 back to her bed. RN C said that he immediately called NP and got stat orders for x-rays to right shoulder and right hip. RN C said that x-rays results showed Resident #1 had sustained an acute displaced fracture to the right distal humerus. In an interview on 4/9/25 at 4:40 pm Physical Therapy Director said Resident #1 was dependent 2 person assist for all activities of daily living prior to and after the incident. In an interview on 04/09/2025 at 3:30 pm, the DON said she had been informed Resident #1 had fallen while she was being repositioned. The DON said that she had interviewed CNA A. The DON said CNA A told her that she was repositioning Resident #1 and resident slipped out of bed. During an interview on 04/10/2025 the Administrator said the DON informed him of Resident #1's fall. The Administrator stated he spoke with the RN C and CNA A during the investigation. The Administrator said CNA A told him she was performing care on Resident #1. He stated CNA A was not terminated at that time. He said she was terminated at another time for insubordination. Records show CNA A was terminated on 03/13/2025. The Administrator stated they did in-servicing on abuse/neglect, bed mobility, transfers, and falls. He stated they also went through all the resident's charts to ensure whether they were one or two person assists and ensured all CNAs were able to locate the assists on the Kardex. The Administrator stated they also reported the incident to State. Interview on 4/10/24 at 2:40 pm, the DON said they monitor CNAs by doing frequent observations, in services on how to access the Kardex, and print out the Kardex to see if it matches section GG and update as needed. The facility had corrected the noncompliance before the survey began. Record review of the following interventions put into place: 7. Head to toe assessment completed on 11/06/2024. Record review dated 11/6/24 of resident assessment revealed Resident #1 was complaining of right shoulder pain. Resident #1 was not able to move right arm due to pain. 8. Pain assessment was completed, and pain medication was administered. Record Review dated 11/6/24 of resident pain assessment revealed Resident #1 was assessed on 11/6/24 and pain medication was administered on 11/6/24 at 12:20 pm. 9. Record review dated 11/6/25 revealed FNP was notified, and he ordered stat x-rays. X rays to right shoulder and right hip were done on 11/6/24 and were reported to FNP on 11/7/24. 10. Record review dated 11/7/24 of Resident #1 revealed Resident #1 was transferred to the local hospital for further evaluation. 11. Random residents were selected for the safety survey, no negative findings. Resident #3, Resident #4, Resident #5 and Resident #6. 12. Record review dated 11/6/24 revealed All staff were in-serviced on date of incident abuse and neglect, Kardex use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. 13. Record review dated 11/13/24 revealed CNA A have been inserviced ont he following topics abuse and neglect, Kardex use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. 7. Interviews with other CNA's revealed they were aware of where to find the resident's level of care and not to deviate from plan. 4/8/2025 at 1:54 pm, CNA N 4/8/2025 at 3:00 pm, CMA AA 4/8/2025 at 3:15 pm, CNA F 4/8/2025 at 3:24 pm, LVN CC 4/8/2025 at 6:00 pm, RN O 4/8/2025 at 6:10 pm, CNA DD 4/9/2025 at 10:03 am, LVN EE 4/9/2025 at 2:43 pm, CNA M 4/8/2025 at 2:50 pm, CNA BB 4/9/2025 at 2:50 pm, CNA B 4/9/1025 at 3:00 pm, RN C 4/9/2025 at 4:21 pm, CNA K 4/9/2025 at 4:30 pm, CNA L Record review of facility's policy titled Quality of care with revision date 6/2023 revealed, it is the policy of this facility to create a safe environment for the resident.

Based on interview and record reviews the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 10 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. CNA A attempted to provide Resident #1 care at bed side by herself knowing that Resident #1 required two person assistance for all activities, which lead to Resident #1 falling off the bed and sustaining a right humerus fracture. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/06/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. The facility was informed about the past non-compliance on 4/10/25 at 3:55 pm. This failure could place residents at risk of neglect . Findings included: Record review of Resident #1's admission record reflected she was a [AGE] year-old female with an admitted [DATE]. Her relevant diagnoses included cerebral infraction (is a condition where brain tissue dies due to insufficient blood flow, leading to a lack of oxygen and nutrients) and morbid obesity. Resident #1's cognition was moderately impaired. Record review of Resident #1 care plan dated 10/3/2019 revealed Resident #1 was a two person assist for toileting. Record review of Resident #1 MDS dated [DATE] revealed Resident#1 was always incontinent to bowel and bladder. Section GG revealed Resident#1 was dependent 2 persons assist to toileting hygiene. In an interview on 04/9/25 at 2:40 pm, CNA A said she knew Resident #1 was a two person assist for incontinent care but still decided to do it on her own on 11/06/2024. CNA A said that she did not want to wait because it was lunch time. CNA A said while she performed incontinent care to Resident #1 on 11/6/24, CNA A turned Resident #1 to her right side and she slipped off the bed and landed on the floor. CNA A said that she started yelling for help and CNA B arrived to assist. CNA A said as soon as CNA B arrived, she went out to look for a nurse. CNA A said she and CNA B stayed with Resident #1 while she was being assessed by RN C. CNA A said 11/06/2024 was not the first time she had performed incontinent care to Resident #1 by herself. In an interview on 4/9/2025 at 2:50 pm, CNA B said that she heard CNA A screaming and she went into Resident #1 room. CNA B said she saw Resident#1 on the floor. CNA B said that she stayed with resident while CNA A went to inform RN C. CNA B said that she checked the Kardex to know how many assist each resident needed, and asked the nurse. In an interview on 04/09/2025 at 3:00 pm, RN C said after he assessed Resident#1, Resident #1 complained of right shoulder pain. RN C said that it took 4 therapists to transfer Resident #1 back to her bed. RN C said that he immediately called NP and got stat orders for x-rays to right shoulder and right hip. RN C said that x-rays results showed Resident #1 had sustained an acute displaced fracture to the right distal humerus ( a bone break where the broken pieces have moved out of alignment with each other, resulting in a gap between the fragments). In an interview on 4/9/25 at 4:40 pm Physical Therapy Director said Resident #1 was dependent 2 person assist for all activities of daily living prior to and after the incident. In an interview on 04/09/2025 at 3:30 pm, the DON said she had been informed Resident #1 had fallen while she was being repositioned. The DON said that she had interviewed CNA A. The DON said CNA A told her that she was repositioning Resident #1 and resident slipped out of bed. During an interview on 04/10/2025 at 3:00 pm, the Administrator said the DON informed him of Resident #1's fall. The Administrator stated he spoke with RN C and CNA A during the investigation. The Administrator said CNA A told him she was performing care on Resident #1. He stated CNA A was not terminated at that time. He said she was terminated at another time for insubordination. Records show CNA A was terminated on 03/13/2025. The Administrator stated they did in-servicing on abuse/neglect, bed mobility, transfers, and falls. He stated they also went through all the resident's charts to ensure whether they were one or two person assists and ensured all CNAs were able to locate the assists on the Kardex (a copy of the care plan focused on the amount of assist each resident needed). The Administrator stated they also reported the incident to State. Interview on 4/10/24 at 2:40 pm, the DON said they monitor CNAs by doing frequent observations, in services on how to access the Kardex, and print out the Kardex to see if it matches section GG and update as needed. The facility had corrected the noncompliance before the survey began. Record review of the following interventions put into place: 1. Head to toe assessment completed on 11/06/2024. Record review dated 11/6/24 of resident assessment revealed Resident #1 was complaining of right shoulder pain. Resident #1 was not able to move right arm due to pain. 2. Pain assessment was completed, and pain medication was administered. Record Review dated 11/6/24 of resident pain assessment revealed Resident #1 was assessed on 11/6/24 and pain medication was administered on 11/6/24 at 12:20 pm. 3. Record review dated 11/6/25 revealed FNP was notified, and he ordered stat x-rays. X rays to right shoulder and right hip were done on 11/6/24 and were reported to FNP on 11/7/24. 4. Record review dated 11/7/24 of Resident #1 revealed Resident #1 was transferred to the local hospital for further evaluation. 5. Random residents were selected for the safety survey, no negative findings. Resident #3, Resident #4, Resident #5 and Resident #6. 6. Record review dated 11/6/24 revealed All staff were in-serviced on date of incident abuse and neglect, Kardex use to determine bed mobility and transfer, fall prevention, and demonstration of Point Click Care and Plan Of Care. 7. Interviews with other CNA's revealed they were aware of where to find the resident's level of care and not to deviate from plan. 8. Pain assessment was completed, and pain medication was administered. Record Review dated 11/6/24 of resident pain assessment revealed Resident #1 was assessed on 11/6/24 and pain medication was administered on 11/6/24 at 12:20 pm. 9. Record review dated 11/6/25 revealed FNP was notified, and he ordered stat x-rays. X rays to right shoulder and right hip were done on 11/6/24 and were reported to FNP on 11/7/24. 10. Record review dated 11/7/24 of Resident #1 revealed Resident #1 was transferred to the local hospital for further evaluation. 11. Random residents were selected for the safety survey, no negative findings. Resident #3, Resident #4, Resident #5 and Resident #6. 12. Record review dated 11/6/24 revealed All staff were in-serviced on date of incident abuse and neglect, Kardex use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. 13. Record review dated 11/13/24 revealed CNA A have been inserviced ont he following topics abuse and neglect, Kardex use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. 4/8/2025 at 1:54 pm, CNA N 4/8/2025 at 3:00 pm, CMA AA 4/8/2025 at 3:15 pm, CNA F 4/8/2025 at 3:24 pm, LVN CC 4/8/2025 at 6:00 pm, RN O 4/8/2025 at 6:10 pm, CNA DD 4/9/2025 at 10:03 am, LVN EE 4/9/2025 at 2:43 pm, CNA P 4/8/2025 at 2:50 pm, CNA BB 4/9/2025 at 2:50 pm, CNA B 4/9/1025 at 3:00 pm, RN C 4/9/2025 at 4:21 pm, CNA FF 4/9/2025 at 4:30 pm, CNA L Record review of facility's policy titled freedom from abuse, neglect, exploitation revealed: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by state and federal laws.

Based on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 5 residents (Resident #2) reviewed for PASRR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. Findings included: Record review of Resident #2's face sheet, dated 04/09/25, revealed a [AGE] year-old male originally admitted [DATE], and most recent admitted [DATE]. His diagnoses included Cerebral Palsy (lifelong brain disorder caused by non-progressive brain damage during prenatal, neonatal, or early infant period that affects movement, balance, and posture), muscle weakness, DM (diabetes mellitus where the body either doesn't produce enough insulin or can't effectively use the insulin it produces leading to high blood sugar levels) and hypertension (high blood pressure). Record review of Resident #2's Quarterly MDS assessment, dated 03/29/25, revealed a BIMS score of 09, indicating moderately impaired cognition. The MDS assessment also revealed Resident #2 had impairment to an upper and lower extremity on one side and utilized a wheelchair, as well as Resident #2 was dependent in shower/bathe self, lower body dressing, putting on/taking off footwear, needed substantial/maximal assistance with toileting hygiene and personal hygiene. Record review of Resident #2's undated care plan revealed resident was a positive PASSR for IDD/CP Date Initiated: 10/06/2022 Revision on: 07/31/2024. It also revealed W/C purchased through PASSR services and if discharged equipment to follow Resident #2 currently use a loaner custom w/c due to request for new w/c denied secondary to last w/c was not over 5 years therapy to continue to request for w/c Date Initiated: 10/06/2022 Revision on: 03/30/2025. Record review of Resident #2's PASRR evaluation, dated 04/20/23, revealed resident had an intellectual disability which manifested before the age of 18, and she had a developmental disability other than the intellectual disability that manifested before the age of 22. Specialized service recommendations included: self-monitoring and coordinating treatments; self-help with ADLs such as toileting, grooming, dressing, and eating; and independent living skills such as cleaning, shopping, and money management, laundry, accessibility within the community. Record review of Resident #2's progress notes revealed progress notes concerning IDT meetings or PASRR updates for dates 05/17/24 through 02/10/25 in which they notified the HHS PASRR Program Specialist that specialized services had been completed and needs met, or that needs and services were no longer warranted or needed. Record review of Resident #47's PASRR PCSP, dated 02/10/25, revealed the quarterly meeting was held. New requests will be done for CMWC, habilitative, OT and PT. In an interview via email on 04/09/25 at 9:47 AM with the HHSC PASSR Unit Program Specialist, she wrote, I sent an email to the DON and the Administrator on 1/28/2025. I was not told why they did not do it. The IDT meeting was 5/17/2024. The NF has 20 business days from this meeting date to initiate the service that was recommended/documented for this resident. The 26 Texas Administrative Code (TAC), Chapter 554, Subchapter BB, section S554.2704(i)(7), a nursing facility must initiate nursing facility specialized services within 20 business days following the date that the services are agreed to in the IDT meeting. Currently, your nursing facility is out of compliance as per this TAC Rule. (HHSC PASSR Unit Program Specialist, personal communication, 4/9/2025). In an interview on 4/9/25 at 2:00 pm MDS K said they conducted the IDT meeting, and therapy took over the initiation of the NFSS to initiate the request for PASRR specialized service of Resident #2's customized manual wheelchair. He said he submitted information to PASSR regarding recommendations such as independent living skills within the 20-day time frame. He said therapy takes over initiating requests for items dealing with PT, OT, ST and/or wheelchairs. He said the DOR took over NFSS. He said as soon as they get an alert on the online portal, they should initiate it right away. In an interview on 4/9/25 at 2:16 pm the DOR said she was aware now about the requirement of submitting the NFSS request 20 days from IDT. She said she became aware of the requirement from the DME company. She said they helped and guided her through the process. She said she had not received any emails from PASSR HHSC. She said she started this position in February of 2025, so she was not sure if the former DOR was receiving those emails. She said the facility provided Resident #2 with a customized wheelchair. His insurance denied the request because it had not been more than 5 years since his last customized wheelchair. She said she scheduled an IDT meeting for this Friday, 4/11/25 to review continuation of therapy services and the CMWC. In an interview on 4/9/25 at 3:42 pm the DON said that she found out a couple of days ago that a new meeting was being set up so they could re-initiate the NFSS and restart the 20 days. She said the prior DOR did not work longer than 6 months and the current DOR was new to the process since she started working this past February. The DON said she never received an email from HHSC PASRR. She said she did receive an email from quality monitoring that a visit was going to be done, but not from HHSC PASRR. She said the DOR and MDS were responsible for logging on and ensuring all the information required was placed onto the online portal. She said she was not sure what happened and was not sure what training the current DOR received from the prior DOR, but LVN/MDS was very involved, and he assisted with that. The DON said it was a collaboration between therapy and MDS. She said therapy usually took over the online portal entrance when it dealt with customized wheelchairs. She was not sure where the problem occurred. She said when she worked MDS, they logged into Simple to see the alert and recalls she was required to log onto the portal within 20 days. In an interview on 4/10/25 at 10:30 am with the Administrator, he said when they had the IDT meeting for Resident #2 and recommended the WC, the request was then submitted on simple. He said it was his understanding they did complete the process. He said he feels there was a misunderstanding on the time frame, but the resident never went without the services. He said they provided him with the customized manual wheelchair Resident #2 required as a loaner. He said normally, the DOR will conduct evaluations for therapy, coordinate with DME, then DOR will submit for services and complete follow ups. He said as the administrator, he oversees and supervises MDS and PASRR services, so ultimately it was his responsibility to ensure the submission of the NFSS (Nursing Facility Specialized Services) request on the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. The administrator said he was responsible for ensuring the requests were being submitted and follow ups being done to make sure they were meeting the requests. He said he looked into this specific case once it was brought to his attention, and it was not submitted within the 20-day time frame. He said their new DOR has initiated an IDT meeting this Friday, 4/11/25, and he will ensure the 20-day time frame was met. Record review of the facility's undated PASRR policy reflected: Policy: It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. Procedures: 2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR. 3. Social Services shall contact the appropriate State Agency for referral of specialized care and services the resident may require.

Based on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for, 1 of 1 resident (Resident # 63) observed for infection control issues in that: CNA B reused wipes when she cleansed the perineal area and did not sanitize hands between glove changes. This deficient practice could place residents at risk for infection due to improper hand sanitizing and incontinent care practices. The findings were: Record review of Resident #63's electronic face sheet dated 04/10/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis DM (diabetes mellitus where the body either does not produce enough insulin or cannot effectively use the insulin it produces leading to high blood sugar levels), unsteadiness on feet, muscle weakness, muscle wasting and atrophy (decrease in size or wasting away of muscle), and lack of coordination. Record review of Resident #63's undated comprehensive person-centered care plan reflected she had an ADL self-care and mobility performance deficit. Date Initiated: 09/01/2024. Revision on: 10/08/2024. Toilet hygiene: requires substantial/maximal assistance of one staff member to assist with task. Record review of Resident #63's Quarterly MDS dated [DATE] reflected she required substantial/maximal assistance with self-care of toileting hygiene and was always bladder and bowel incontinent. During an incontinent care observation for Resident #63, on 4/10/24 at 8:30 AM., CNA B performed incontinent care on Resident #63. CNA B performed hand washing for the appropriate amount of time prior to starting perineal care. CNA B donned (put on) clean gloves. CNA B grabbed a couple of wipes to clean the vaginal area, wiped horizontal above pubic area, then wiped downward from front to back of the labia working outwards towards both thighs, then wiped down the center of the urethral area, separated labia, folded over wipes, then wiped down the center over the urethral area. CNA B used the same side of the wipes throughout the entire process, folding over and using the same wipes to clean the urethral area. CNA B changed gloves. CNA B grabbed a couple of wipes, wiped the buttocks area, folded over the wipes, and then wiped the rectum using the same wipes. CNA B changed gloves. CNA B performed hand washing for the appropriate amount of time at the end of providing care. CNA B did not sanitize hands between glove changes throughout the whole procedure. In an interview on 4/10/25 at 8:58 AM, CNA B said every time she changed gloves, she should sanitize her hands, but she noticed she did not have sanitizer in her pocket, so she could not do it. She said she knows she should sanitize and usually always did. CNA B said she remembered at school she was able to use the four corners technique. She said she forgot it was when using a washcloth, not when using wipes. CNA B said about a week ago they did a hand hygiene in-service for washing hands and how to use wipes. She said she knew to use one wipe per swipe and discard, she just forgot. In an interview on 4/10/25 at 9:29 AM CNA L said they must clean hands before, during and after patient care. She said every time she changes gloves, she must sanitize her hands. She said she must always be sure when using wipes, to use one wipe per swipe, it does not matter how many wipes she used. CNA when they were in-serviced on hand hygiene they were told they must sanitize between glove changes and always hand hygiene before and after care. She said they were reminded daily throughout the week. In an interview on 4/10/25 at 9:50 am CNA M said she was involved in training CNAs in incontinent care. She said they do in-services for hand hygiene and incontinent care monthly and PRN. She said they have staff meetings once a week and go over incontinent care. She said the CNAs know they must hand sanitize or wash hands before entering and leaving a room. She said anytime they change gloves and when going from dirty to clean, they must hand sanitize. She said they were instructed to use one swipe per wipe and then must throw the wipe away. She said if they do not it could cause a UTI. She said they get checked off upon hire and throughout the year as often as can. In an interview on 4/10/25 at 10:00 AM DON said she was involved in the hand hygiene/incontinent care training. She said she had training at least once a month and as needed. She said they do random check offs on hand hygiene. She said incontinent care check offs were done upon hire, annually and randomly as needed. She said staff were instructed to hand hygiene before and after incontinent care and between glove changes during incontinent care. She said they should always use wipes cleaning from front to back. They should always use a wipe and then discard and grab another and discard. They should always discard after using a wipe once. She said not sanitizing between glove changes or discarding gloves could cause cross contamination or an infection. Record review of the Skills Checklist - Perineal Care for CNA B dated 02/19/25 reflected: Perineal Care Procedure . A. Female Procedure: . 1. Separated labia cleaning downward from front to back using a clean part of cloth with each stroke . Record review of facility's undated Perineal Care policy and procedure reflected: Policy: It is the policy of this facility to: . Prevent skin irritation or infection to perineal area . Procedures: . 4. Wash hands properly. Supplies: Disposable wipes . Hand sanitizer . Female - without catheter . 4. Cleanse pubic area, including upper, inner aspect of both thighs and frontal portion of perineum. A. Use long strokes from the most anterior down to the base of the labia. (Wash from the cleanest area to the dirtiest area.) B. After each stroke, use a new disposable wipe. 8. Wash perennial area thoroughly, with each stroke beginning at the base of the labia and extending up over the buttocks. A. Use a new disposable wipe after each stroke. For all variations, complete procedure as follows: . Wash hands properly Record review of facility's Hand Washing policy and procedure - Nursing Clinical, revised 10/2023 reflected: Policy: It is the policy of this facility to cleanse hands to prevent transmission of possible infections material and to provide clean, health environment for residents and staff. Purpose: Hand washing is generally considered the most important single procedure for preventing nosocomial infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects. Although antiseptics and other hand washing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the hand washing technique followed. Waterless handwashing products 1. Some situations require hand washing in areas where sinks are not readily available. In these limited circumstances, waterless hand washing products may be used.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 3 medication carts (medication cart located in 200 hallway) reviewed for medication storage and labeling. The facility failed to ensure that all insulin in medication cart in 200 hallway were not past their expiration date. The facility's failure could result in residents receiving medications at their best therapeutic level. The findings included: During an observation on 04/8/25 at 04:10 PM the medication cart on 200 hallway revealed 1 insulin vial passed the 28th day, opened date was 3/9/2025. During an interview on 04/8/25 at 02:40 PM LVN I stated residents could get adverse reactions if expired medications were given to the residents. LVN I stated insulins need to be discarded after 30 days from the opening date. LVN A stated expired insulin was not as potent as it supposed to be. During an interview on 04/8/25 at 03:57 PM LVN J stated the insulin vials needed to be discarded in the sharps container and the vials were good for 30 days after the opened date. LVN J stated if given to a resident after the 30 days, the insulin could cause an adverse reaction, or the insulin would not work as it is supposed to. During an interview on 04/8/25 at 04:30 PM the ADON stated the insulin must be discarded after 28 days from the opened date. The ADON also stated the charge nurse of each hallway had to make sure the insulin was not expired, and it was not appropriate to give expired insulin to residents because it could cause an adverse reaction. During an interview with on 04/9/25 at 04:10 PM the DON stated the insulins were good for 28 days after the insulins were open. The DON stated that the insulin would not be as effective and could cause adverse effects to the resident. Record review of policy titled Medication Storage Limits with revision date of April 2023 revealed: It is the policy of this facility to store medications in a safe manner. All medications are to be stored according to facility policy unless the consultant pharmacist for the facility has approved an exception based on resident safety and pharmaceutical products integrity. Insulin vials: At room temperature for 30 days. Record review of Novolog pamphlet titled novolog insulin aspart injection with revision date of 02/2023 revealed: 16.2 Recommended storage: 10milliliters multiple-dose vial in use (opened), do not use after the 28 days.

Based on interview and record review the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #78) of 33 residents whose records were reviewed for pharmacy services. The facility failed to ensure Resident #78 was not prescribed an antipsychotic (Aripiprazole) without appropriate diagnosis for its use. This deficient practice could place residents without a proper diagnosis for taking antipsychotic medications at risk for receiving unnecessary medications. The findings were: Record review of Resident #78's admission record, revealed he was a [AGE] year old male, admitted to the facility on [DATE], with diagnoses of heart disease, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Physician Order dated 03/11/2025, ARIPiprazole Oral Tablet 20 MG (Aripiprazole) Give 1 tablet enterally at bedtime for Dementia w/ behavioral disturbance. Start 03/11/2025 1706 (05:06 p.m.) Record review of March 2025 MAR and April 2025 MAR revealed Resident #78 received ARIPiprazole Oral Tablet 20 MG (Aripiprazole) Give 1 tablet enterally at bedtime for Dementia w/ behavioral disturbance at bedtime from 03/11/2025 through 04/06/25. Record review of Resident #78's comprehensive person-centered care plan dated 03/12/2025 revealed FOCUS: o Resident #78 requires the use of Psychotropic medications use r/t Disease process (dementia with behaviors) Date Initiated: 03/12/2025 Created on: 03/12/2025 . And FOCUS: o Resident #78 requires the use of Anti psychotic medication (ARIPiprazole Oral Tablet) r/t Dementia with behaviors Date Initiated: 03/12/2025 Created on: 03/12/2025 Revision on: 03/12/2025 . Record review of Resident #78's Medicare 5 Day MDS assessment dated [DATE], revealed Resident #78 had a BIMS of 00 which indicated his cognition was severely impaired. Resident #78 had adequate hearing and staff could usually understand him and he was usually able to understand. Resident #78 was always incontinent of bladder and bowels. In an interview on 04/09/25 at 01:53 PM CNA E stated Resident #78 was not a difficult resident (no behaviors). She said he was very nice and easy (to work with). In an interview on 04/09/25 at 01:53 PM CNA D stated Resident #78 was a nice resident and she had no problems with him. CNA D stated resident had no behaviors. In an interview on 04/09/25 at 01:54 PM CNA F stated Resident #78 had no behaviors and was not a difficult resident. In an interview on 04/09/25 at 01:55 PM RN C stated Resident #78 was very polite. RN C stated he had not experienced any behaviors with Resident #78. In an interview on 04/10/25 at 04:10 PM RN G stated the admission nurse was the one who usually put the orders in for newly admitted residents. RN G stated the admission nurse would also reconcile the medications with the doctor. RN G stated ADON H would reconcile the antipsychotics and psychotropics. RN G stated the ADON H would also get the consents (for psychotropics and antipsychotics) from the resident or RP. In an interview on 04/10/25 at 04:20 PM ADON H stated she was usually the one who puts the antipsychotics in the computer. She said if she would see an admission where a resident had an antipsychotic, she would contact psych or hospice to notify that an antipsychotic could not have the diagnosis as dementia. ADON H stated she knew that was not accepted. In an interview on 04/10/25 at 04:45 PM the DON stated the admitting nurse was the one who put the medication orders in the computer. The DON stated ADON H was the one who reviewed the antipsychotics and psychotropics (before putting the medication orders in the computer). In an interview on 04/10/25 at 05:10 PM the Administrator stated Resident #78 had come in from another facility with the antipsychotic with dementia diagnosis and he knew that was not allowed. Record review of facility's Psychotropic Policy, date implemented 05/2007 Revision/Review Date(s): 12/2019; 2/2022; 12/2023, revealed: Policy: It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medications shall not be administered for the purpose of discipline or convenience. Based on a comprehensive assessment, the facility will ensure that: -Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; -Residents do not receive psychotropic drugs pursuant to an as needed (PRN) order unless medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; - PRN orders for psychotropic drugs are limited to 14 days. Except for PRN orders for anti-psychotic medications, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN psychotropic med order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order; -PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Definitions Psychotropic Medication: The Centers for Medicare and Medicaid Services (CMS) defines a psychotropic medication as any drug that affects brain activities associated with mental processes and behavior. This category includes medications in the categories of antipsychotics, anti-depressants, anti-anxiety, and hypnotics .

Based on interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded in the MDS for a fall with major injury on 1/30/25. This failure could place residents at risk of receiving care and services to meet their needs. The findings included: Record review of Resident #1's face sheet dated 3/5/2025 reflected Resident #1 was admitted on [DATE] and she was [AGE] years old. Resident #1 had diagnoses of muscle weakness, unsteadiness on feet, other abnormalities of gait and mobility, and dementia (a progressive decline in cognitive functions, such as memory, thinking, problem-solving and decision-making). Record review of Resident #1's comprehensive care plan dated 1/24/25 reflected: Resident #1 had an actual fall with major injury, poor balance, and unsteady gait. She was sent to the ER for an evaluation and returned with a right rib fracture. Date Initiated: 01/30/2025. Record review of Provider Investigation Report revealed the facility reported the fall incident of Resident #1 to HHSC on 1/31/25. The resident was sent out to the ER for x-rays. The ER reported to the facility the resident had right rib fractures. A safety survey was conducted. Staff were in-serviced on abuse, neglect, and falls. Record review of Resident #1's Discharge MDS dated [DATE] revealed: 1 fall since Admission/Entry or Reentry or Prior MDS Assessment with no injury. During an interview on 3/4/25 at 3:20 pm, LVN B said he completed the head-to-toe assessment after the fall. She did have a fall but did not recall the actual date. He said he heard a thump, and when he checked on the resident, she was getting herself back in bed. When LVN B asked Resident #1 what she was doing prior to the fall, Resident #1 said she was trying to unlock the door at the bottom. He said they did not know what she meant by that. He said when he felt the back of her head, she complained of pain. He stated they called the on-call provider, and he gave the order to send to the ER for further evaluation. He said we did not lock the doors on the residents. He said they would provide Resident #1 repeated reminders to use the call light and to use her walker, but she would not remember. He said he did not remember the interventions provided for that fall, but Resident #1 had at one point 1:1 redirecting, providing snacks, bed low position, and floor mats. He said he did frequent rounding for his residents. He said he recalled receiving in-services for abuse, neglect, and exploitation, and for falls . During an interview on 3/5/25 at 3:15 pm, MDS A said when she ran her Risk Assessment report, it showed Resident #1 had a fall but did not have an injury at the time of the incident. She said she went based on that report. She said Resident #1 was later sent out to the hospital, where they found the fractures. She said the fall with injury should have been updated and coded accurately on the MDS once they learned about the fractures. She said she just missed it. She said if the MDS was not documented accurately, the information that gets automatically transferred to other facilities would be inaccurate. The accepting facility would not be aware that Resident #1 had a prior fall with major injury, and it could cause more injury or harm to the Resident if not communicated. She said she modified the assessment and fixed the issue once she reviewed the documentation from the hospital. During an interview on 3/5/25 at 4:00 pm, the DON said Resident #1 had an unwitnessed fall on 1/30/25, and she was complaining of pain to the head. The DON said due to the fall being unwitnessed, the MD sent her to the hospital for a CT scan. She said in-services were conducted for abuse, neglect, and exploitation which included injury of unknown origin. She said a falls in- service was also conducted once we ensured it was a fall. She said depending on what was involved with a fall, we included transfer training or get the therapist involved. She said Resident #1's fall happened due to self-transferring at night. She said Resident #1 understood when we instructed her on the use of the call light for assistance with transfers, but she would not remember to use the call light due to her diagnosis of dementia, bipolar, and schizophrenia. She said fall in-services were done any time there was an incident, a change of condition that involved an injury, or for a fall and included the reason of what happened to try and improve on the care. The DON said the Risk Assessment report showed no injury due to the head CT scan results were negative for injury, and the initial complaint was related to pain to the head. She said the fall with major injury should have been caught and coded accurately on the MDS. She said the outcome of the coding did not affect the care Resident #1 received when she returned to the facility because the care plan was being followed to provide her care and the MD was aware of her status. During an interview on 3/5/25 at 5:10 pm, the Administrator said Resident #1 had a fall and was sent out to the hospital where they found she had rib fractures. He said we want to ensure our facility was accurate in our reporting for the MDS. He said the fall was reported, we just forgot to include it involved an injury. He said he felt it would not affect the care Resident #1 needed for the fall. He said it was more a technical error. Record review of CMS's RAI Version 3.0 Manual dated 10/2024 reflected section: J1800: Any falls since admission/entry or reentry or Prior to Assessment . Steps for Assessment . 3. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. Coding instructions: Code 1, yes if the resident has fallen since the last assessment. Continue to number of falls since admission/entry or reentry or prior to assessment. J1900: Any falls since admission/entry or reentry or Prior to Assessment. Coding instructions for J1900C: Code 1, one: if the resident had one major injurious fall since admission/entry or reentry prior assessment . Coding Tip If the level of injury directly related to a fall that occurred during the look-back period is identified after the ARD and is at a different injury level than what was originally coded on an assessment that was submitted to the Internet Quality Improvement and Evaluations System (iQIES), the assessment must be modified to update the level of injury that occurred with that fall. Definitions . Major Injury Includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.

Based on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 4 residents (Resident #73, Resident #305) reviewed for accuracy of records. 1. The facility failed to accurately document Resident #73's blood sugar level on 01/24/2024 at 3:51 p.m. 2. The facility failed to accurately document Resident #305's blood sugar level on 01/21/2024 at 4:41 p.m. These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury. The Findings included: 1. Record review of Resident #73's face sheet reflected a [AGE] year-old female with an admitted [DATE]. Her relevant diagnoses included: respiratory failure, type 2 diabetes mellitus, Parkinson's disease, urinary tract infection, hypertension, gastrostomy (surgical incision into the stomach), pneumonia, cognitive communication deficit and tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck). Record review of Resident #73's comprehensive care plan reflected Resident #73 had diabetes mellitus and was at risk of complications, date initiated 01/02/2024. Interventions: diabetes medication as ordered by doctor, monitor/document/report to MD PRN for s/sx of hypoglycemia. Record review of Resident #73's physician's order dated 01/01/2024 reflected if blood sugar via fingerstick is above 350 mg/dl or below 60 mg/dl then call MD. Record review of Resident #73's weights and vitals in the facility's electronic health records system reflected a blood sugar reading of 32.0 mg/dl on 01/24/2024 at 3:51 p.m., recorded by Staff A. Record review of Resident #73's progress notes on 01/24/2024 did not reflect any documentation related to her blood sugar reading of 32 mg/dl. An observation of Resident #73 on 01/24/2024 at 10:03 a.m. was observed asleep, bed set to lowest position, call light within reach, tracheostomy, and oxygen via trach. During an attemted interview on 01/24/2024 at 10: 05 a.m., Resident #73 was not able to answer any questions. 2. Record review of Resident #305's face sheet reflected a [AGE] year-old female with an admitted [DATE]. Her relevant diagnoses included: type 2 diabetes mellitus, obesity, hyperlipidemia ( a condition that incorporates various genetic and acquired disorders that describe elevated lipid levels within the human body), hypertension (High pressure in the arteries , vessels that carry blood from the heart to the rest of the body), and absence of right foot. Record review of Resident #305's MDS admission assessment dated [DATE] reflected a BIMS score of 15 (cognitively intact) and an active diagnosis of diabetes mellitus. Record review of Resident #305's physician's order dated 01/09/2024 reflected BS checks BID and PRN. Notify MD if BS is less than 60 or greater than 350. Record review of Resident #305's weights and vitals on PCC reflected a blood sugar reading of 361.0 mg/dl on 01/21/2024 at 4:41 p.m., recorded by Staff A. Record review of Resident #305's progress notes on 01/21/2024 did not reflect any documentation related to her blood sugar reading of 361 mg/dl at 4:41 p.m. An observation on 01/23/2024 at 10:25 a.m. Resident #305 was observed lying in bed, dressed in her own personal clothing, bed set to lowest position, and call light within reach. An interview on 01/23/2024 at 10:27 a.m., Resident #305 said she was satisfied with the care she was receiving at facility. She said she was admitted to facility to receive physical therapy after right foot was amputated. She said her vitals had been normal since she was admitted . An interview on 01/24/2024 at 3:45 p.m., Staff A said Resident #305's blood sugar had been within normal range since being admitted . She said she did not remember entering a blood sugar reading of 361 mg/dl on 01/21/2024 for Resident #305. She said, I am going to be honest with you, on 01/21/2024, I was having a bad day. She said she was there when resident kept crying and she was under a lot of stress. Staff A said she made a mistake when entering Resident #305's blood sugar reading on PCC under weights and vitals. Staff A said the correct sugar level reading was 261 and not 361 mg/dl. She said she did not do a change of condition or notified MD because a blood sugar reading of 261 mg/dl was within normal range for Resident #305. Staff A said there were no negative outcome because it was just a documentation error. An interview on 01/25/2024 at 3:15 p.m., Staff A said she did not remember Resident #73's blood sugar on 01/24/2024 being 32 mg/dl. While being interviewed, Staff A checked Resident #73's weights and vitals on PCC and said she made a mistake when she documented a blood sugar level of 32 mg/dl on 01/24/2024. Staff A said the correct blood sugar reading was 132 mg/dl and not 32 mg/dl, she said she must have forgotten to enter the 1. Staff A said she did not do a change of condition, notified MD because in her mind, she knew [Resident #73's] blood sugar level was 132 mg/dl and was within her normal range. Staff A said no negative outcome for Resident #73 because it was just a documentation error. In an interview on 01/26/2024 at 2:00 p.m., the DON said the correct blood sugar reading for Resident #73 was 132 mg/dl on 01/24/2024 at 3:51 p.m. and 261 mg/dl for Resident #305 on 01/21/2024. The DON said Staff A had entered an incorrect reading for both residents on PCC. She said their MD was not notified and no change of condition was done because it was only a documentation error. The DON said no negative effects on Resident #73 or Resident #305 due to the documentation error. Record review of facility's policy on Documenting and Charting (no date) reflected: Policy: It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. Procedures: 23. Vital signs: A. Date and time vital signs taken. B. Any deviations from the resident's normal pattern. D. Date and time physician was notified, as well as the physician's response. E. All pertinent observations.

Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 3 of 12 residents (Resident #1, #2, #3) reviewed for oxygen in that: 1.Resident #1 's oxygen was administered at 1.5 Liters Per Minute instead of 3 Liters Per Minute via nasal cannula as ordered by the physician. 2.Resident #2's oxygen was administered at 4 Liters Per Minute instead of 2 Liters Per Minute via nasal cannula as ordered by the physician. 3. Resident #'3's oxygen was administered at 3.5 Liters Per Minute instead of 3 Liters Per Minute via nasal cannula as ordered by the physician. This deficient practice placed 12 residents who received oxygen continuously and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. The findings were: 1.Record review of Resident #1's electronic face sheet dated 1/05/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and original admitted [DATE]. His diagnoses included Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in your body), Chronic Obstructive Pulmonary Disease with Acute Exacerbation (a sudden worsening in a chronic lung disease that causes air flow limitation), Benign Prostatic Hyperplasia (enlarged Prostate) without Lower Urinary Tract Symptoms, Heart Failure Unspecified, Type 2 Diabetes Mellitus with Unspecified Complications, Primary Hypertension (high blood pressure), Pure Hypercholesterolemia (high cholesterol) Unspecified, Depression Unspecified, Muscle Weakness, Dysphagia (difficulty swallowing). Record review of Resident #1's quarterly MDS assessment, dated 12/07/23 a BIMS score of 11, indicating Resident #1 was moderately cognitive impairment. Record review of Resident #1's comprehensive person-centered care plan, date initiated 4/28/23 reflected Focus Resident #1 has COPD, respiratory failure with hypoxia. At risk for complications. Intervention Give oxygen therapy as ordered by the physician. Record review of Resident #1's Physician Order Summary of all orders, dated 11/24/2023, reflected there was an order for oxygen administration O2 at 3 L/Min Continuous per nasal cannula. Observation for Resident #1 on 1/03/24 at 10:33am revealed the oxygen level on the oxygen concentration machine to be at 1.5L/MIN. Observation for Resident #1 on 1/03/24 at 11:41am revealed the oxygen level on the oxygen concentration machine to be at 1.5L/MIN. 2. Record review of Resident #2's electronic face sheet dated 1/03/2024 revealed he was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Pneumonia, Cirrhosis of Liver (Permanent Scarring of the Liver), Acute Pulmonary Edema (abnormal buildup of fluid in the lungs), Thrombocytopenia (low platelet count condition), Hypersplenism (enlarged spleen), Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in your body), Psoriasis (autoimmune skin condition), Type 2 Diabetes Mellitus without complications. Record review of Resident #2's comprehensive person-centered care plan, date 12/23/23 reflected Focus Resident #2 has Oxygen Therapy r/t acute respiratory failure, CHF, pneumonia. Intervention Oxygen setting: O2 at 2L via NC. Record review of Resident #2's Physician Order Summary of all orders, dated 12/27/2023, reflected there was an order for oxygen administration O2 at 2 L/Min via nasal cannula every shift related to Acute Respiratory Failure with Hypoxia. Observation for Resident #2 on 1/03/2024 at 1:36pm revealed the oxygen level on the oxygen concentration machine to be at 4L/MIN. 3. Record review of Resident #3's electronic face sheet dated1/3/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes air flow limitation), Acute and Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia (a condition where there's not enough oxygen or too much carbon dioxide in your body), Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (thickening or hardening of the arteries without chest pain), Chronic Kidney Disease, Stage 3 Unspecified, Unspecified Fracture of shaft of Humerus (break of the upper arm bone) Left Arm, Hypothyroidism(underactive thyroid gland), Primary Hypertension (high blood pressure), Record review of Resident #3's comprehensive MDS assessment, dated 1/03/24 a BIMS score of 13, indicating Resident #3 was cognitive intact. Record review of Resident #3's Physician Order Summary of all orders, dated 12/29/2023, reflected there was an order for oxygen administration O2 at 3 L/Min Continuous per nasal cannula every shift related to Chronic Obstructive Pulmonary Disease, Unspecified, Acute and Chronic Respiratory Failure, Unspecified whether Hypoxia or Hypercapnia Observation for Resident #3 on 1/03/2024 at 1:38am revealed the oxygen level on the oxygen concentration machine to be at 3.5 L/min. During an interview and observation on 1/03/2024 at 11:41am, LVN A, stated she is the nurse for Resident #1. She walked with the surveyor to the resident #1's room and verified the oxygen setting. LVN A stated the oxygen setting was below 2L/Min. LVN A then logged onto her computer, reviewed Resident #1's oxygen setting physician order and stated it has 3L/Min. She stated that Resident #1 at times removes his nasal cannula and his nebulizer mask. LVN A stated she checked the oxygen setting this morning at about 8am and it was at 3L/Min. She said resident has a nebulizer treatment scheduled at noon and would have checked the oxygen setting then. LVN A stated that these would be the only two times she would check until shift change, and the oncoming nurse would check it at 2pm. She stated the negative outcome to keeping Resident#1's oxygen setting at 1.5L/Min is that it would have drop Resident #1's oxygen saturation. Interviewed the ADON B on 1/3/24 at 11:54am, stated she does room rounds in the morning. The room rounds are in place to check settings on oxygen and feeding pumps. She stated each ADON has a set of rooms assigned. ADON B is assigned to the 200 hall and chooses one random room from another hall as well. She stated that the negative outcome to keeping the oxygen setting at 1.5L/Min in Residents #1 is that his oxygen saturation would drop. ADON B stated that the oxygen saturations are checked every shift. Interviewed the Admissions Coordinator C on 1/3/24 at 2:15pm, stated she does morning rounds every day. She stated she checked Resident #1's oxygen this morning around 7:05-7:10am and it was at 3L/Min. Admissions Coordinator C stated the nurses should be checking the oxygen settings every time they go into the resident's room. She stated that she checks the oxygen settings again in the afternoon before she leaves around 4-4:30pm. She stated that she has never noticed Resident# 1's oxygen being lower than 3L/Min. The nurse will notify her prior to going into the resident's rooms if the oxygen setting order has changed. She stated that she checks off on a piece of paper as she does her rounds. She does not document it anywhere in the resident's electronic chart that she has gone in each assigned room. She stated the negative outcome to keeping Residents #1's oxygen setting at 1.5L/Min is that Resident #1 would be low in oxygen. Interviewed the DON on 1/3/24 at 2:35pm, stated that in regards to who provides supervision is that if there is an issue that comes up, like a behavior issue, then the facility addressed it with care planning. He stated that anyone who is involved in residents care, will be informed at that time. He stated training provided for oxygen administration is done upon hire. The floor nurse does ongoing monitoring of the oxygen setting. The CNAs can help out too by notifying the nurse if the oxygen setting needs to be adjusted or whoever else is in the room and doing rounds. The DON stated that correct oxygen settings are communicated from staff to staff when report is given upon shift change. Interviewed the RN E Charge nurse on 1/3/24 at 4:20pm, stated she is the nurse for Resident #2, and Resident #3. She stated she checks their oxygen setting at the beginning of her shift. She works shift from 2pm-10pm. She stated she has not checked Resident #2, and Resident#3's oxygen setting today because she attended to an admission. The surveyor asked if that happens frequently, she stated no. She stated that if there are any changes in the oxygen setting that she gets the information from nurse giving her report upon shift change. She stated she could not think of a negative outcome if Resident #2 and Resident #3 would continue to stay at that high oxygen setting. Record review of the facility's policy subject titled, Oxygen, Use of, revised May 2021, revealed, It is the policy of this facility to promote resident safety in administering oxygen. Record review of the facility's policy subject titled, Physician Orders, reviewed, August 2022, revealed, It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order .

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 1 resident (Resident #4) of 5 residents reviewed for supervision and interventions, in that The facility failed to ensure Resident #4 received supervision and effective interventions to prevent Resident #4 from repeated falls with injuries. This failure could place residents at risk for accidents and injury. Findings included: Record review of the admission record for Resident #4 dated 01/04/24 reflected Resident #4 was readmitted to the facility on [DATE], was a [AGE] year-old male with diagnoses that included end stage renal disease (kidney failure), history of falling, diabetes (sustained high blood sugar levels), chronic kidney disease stage 5, cognitive communication deficit (trouble with cognitive process), glaucoma (eye disease) and unsteadiness on feet. Record review of Resident #4's physician orders dated as of 01/04/24 reflected Resident #4 had orders for hemodialysis three times a week, every Tuesday, Thursday, and Saturday, start date 11/28/23. Orders included to see optometrist of choice, start date, 08/12/23. Record review of Resident #4's quarterly MDS dated [DATE] reflected Resident #4 had moderate cognitive impairment, had impairment on both sides of upper (shoulder, elbow, wrist, hand, and lower (hip, knee, ankle, and foot) extremities. Resident #4 required substantial to maximal assistance transfer from chair/bed-to-chair and toilet transfer. MDS reflected Resident #4 had one fall with no injury since admission/entry or re-entry. Record review of the facility Incidents and Accidents logs revealed Resident #4 had nine falls after a fall on 08/07/23 where he sustained a fractured hip. Record review of Resident #4's care plans for each fall and reflected the following. 04/17/23:The resident was found sitting on floor mat leaning against the bed. Abrasion to right knee. Care plan was resolved and not included in the comprehensive care plan. 06/19/23: The resident was found on floor next to bed lying on his left side on floor mat. No injuries. Care plan was resolved and not included in the comprehensive care plan. 08/07/23: The resident heard yell out for help, noted laying on the floor supine, next to bed, complained of severe pain to left hip area as per CNA, had seen resident 5 minutes prior to laying in bed with the head of bed elevated, without any complaints or symptoms; as per resident states he sat at the edge of the bed, and dozed off, then fell on his left side from sitting position. Sustained abrasion to the left trochanter (hip). Transported to the hospital. Care plan resolved and not included in the comprehensive care plan. Head to toe assessment done, resident with swelling to left hip, asking to be sent to hospital. Room free of clutter, floor clean and dry wearing non-slip socks and was sent to the ER. Care plan with interventions was resolved and not included in the comprehensive care plan. 09/05/23: The resident found on the mat on the right side of the bed, leaning on his right side, holding onto the bed rail. No injuries observed. Care plan included interventions to consult with ophthalmology for cataract surgery, fall mat in place, bed at lowest position, call light, head to toe assessment and neuro checks started. 09/08/23: The resident was found sitting on floor at bed side with back against his low positioned bed. No injuries. Care plan included interventions for concave mattress for middle of the bed awareness, encourage use of non-slip socks in efforts to avoid sliding when sitting at the edge of the bed, fall mat at preferred bedside, instruct/teach resident to rise slowly from lying to sitting, bed at lowest position, call light within reach, education on call light use and safety, head to toe assessment and neuro checks started. 09/16/23: The resident slid from bed to floor and noted leaning against bed. No injuries. Care plans include interventions; call light education, head to toe assessment, encourage resident for self-positioning within bed, to promote comfort. 09/23/23: The resident slid from bed to floor mat. No injuries noted. Care plans included education on call light use, education on safety, head to toe assessment, therapy to be consulted and vital signs were assessed. 09/29/23: The resident found on floor-on-floor mat. No injuries noted. Care plans were resolved and not included in the comprehensive care plans. 10/02/23: the resident was found on floor mat at bedside. No injuries noted. Care plan interventions included complete head to toe assessment, bolsters in place while resident is in bed to serve as sensory for the edge of the bed due to resident legal blindness. 10/04/23:The resident found halfway off his bed; arms noted on the bed and his legs on the floor. No injuries noted. Care plan interventions included cueing signs as a reminder of man falling (sign in room)and obtaining possible injury., complete head to toe assessment. 10/08/23: The resident found on floor in mat in bedroom at bedside sitting position. No injuries noted. Care plan interventions included resident to be encouraged to stay up and out of bed throughout the day, complete head to toe assessment, activities that promote exercise and strength building where possible, bed at lowest position, check range of motion, therapy consult for strength and mobility. 12/06/23: The resident found kneeling on floor mat, stated he slid from bed to floor mat and kneeled to rest his head on the bed. No injuries noted. Care plan interventions included assessment for custom chair and orientation to room with therapy. Record review of nurse's notes dated 08/08/23 reflected staff received information the resident was admitted to the hospital with a fracture to left hip. Observation and interview on 01/03/24 at 10:26 am with Resident #4 revealed the resident was sitting up in bed, voicing he could not see very well, only the surveyor's glasses, but not her face. Resident #4 said he did not remember if he had any eye surgery or treatments for his diminished eyesight. Resident #4's bed was at lowest position and a floor mat on the right side of bed. The bed mattress was not a concave mattress and there were no bolsters on the bed. Resident #4 said he did not want to use his call light to ask for help because he did not need it. Resident #4 said he would just get out of bed and go where he wanted to go. Resident #4 said he didn't know why he was falling from his bed so often. Resident #4 said he did remember getting injured on his hip when he fell some time before. Interview on 01/03/24 at 2:56 pm with MDS Coordinator I revealed all resident's falls were care planned with new interventions. Interview on 01/03/24 at 1:45 pm with LVN F revealed Resident #4 had fallen many times due to his cognition, dementia and he would not use his call light to ask for help, even after he was reminded to use the call light before he attempted to get up from bed. Resident #4 did get eye surgery as part of the intervention developed for preventing falls. LVN F said he would refer to the care plan to get information on interventions developed to prevent falls. Interview on 01/03/24 at 2:06 pm with LVN J revealed Resident #4 had fallen many times from his bed and was found on floor. Resident #4 was short tempered and would not use his call light to ask for help. Resident #4 was receiving dialysis treatments three times a week and when he came back, he would be physically weak. LVN J said he would refer to the care plans for interventions on preventing falls. Interview on 01/04/24 at 9:37 am with the DON revealed Resident #4 had fallen several times and his care plan should be updated for interventions for each fall. Observation on 01/04/24 at 9:24 am revealed Resident #4 sitting up in bed on his left side. There was not a floor mat on the left side of bed, no concave mattress, and no bolsters on his bed. Resident #4 was not wearing a shirt. Interview on 01/04/24 at 10:09 am with CNA H revealed she began working in November of 2023. CNA H said she was not informed Resident #4 had several falls. CNA H said she would place his bed at the lowest position, floor mat on the right side, use non-slip socks, and his call light within his reach. CNA H said she had never seen Resident #4 with a concave mattress or bolsters on his bed. CNA H said Resident #4 was very verbal and would express his needs. CNA H said she had never educated Resident #4 to try not getting up from bed before asking for help or get up unassisted. Interview on 01/04/24 at 10:28 am with the Director of Rehabilitation revealed every time Resident #4 had a fall, the IDT would communicate with managers and implement the Fall Prevention Program. Interview on 01/04/24 at 10:32 am with PT G revealed Resident #4's falls were reviewed for developing interventions. Resident #4 had only fallen from his bed, and a custom chair was being considered to have the resident up during the day and be able to sleep at night. PT G said on 09/08/23 a concave mattress was implemented as an intervention so he could feel the boundary of the bed. On 10/02/23 bolsters in bed were used as an intervention for sensory boundary so he would be aware he was on the edge of the bed. On 01/04/24 at 11:18 am with CNA L revealed Resident #4 was always trying to get up from bed without asking for assistance. CNA L said Resident #4 did not have a concave mattress or bolsters on his bed. CNA L said she would place his bed at the lowest position, call light within reach and a floor mat on the right side of the bed, where he would normally get up from bed. Resident #4 would not use his call light to ask for help. Interview on 01/04/24 at 11:45 am with LVN F revealed he would refer to care plans to get information on focus areas of care and the interventions developed to prevent Resident #4 from falling. LVN F said he did communicate to his CNAs any information on the care plans such as falls so CNAs, and he could implement the interventions to prevent falls. Record review on 01/04/24 of the ophthalmologist statement reflected Resident #4 had received cataract surgery on 10/24/23. Interview on 01/05/24 at 9:30 am with the DON and MDS Coordinator K revealed several of Resident #4's care plans with interventions were indicated as resolved and taken out of the comprehensive care plans. Resolved care plans meant that the interventions for that fall were reviewed and if effective, were removed from the comprehensive care plans. The falls that were resolved were the falls on 04/17/23, 06/19/23, 06/19/23, 08/07/23 (when he sustained a fractured hip) and 09/29/23. The current comprehensive care plan included falls sustained on 09/09/23, 09/05/23, 09/08/23, 10/02/23, 10/04/23, 10/08/23 and 12/06/23. That care plan included interventions for each fall. The DON said Resident's falls had new interventions at each fall but had not prevented the resident from falling nine times after he fractured his hip on 08/07/23. Resident #4's last fall was on 12/06/23, less than a month before. Resident #4 had not sustained any injuries after 08/07/23. The DON said he did not know why the concave mattress and bolsters on Resident's bed were not implemented as the interventions were developed. The DON said care plans were the responsibility of the IDT. Every manager had their own areas that required updates, revisions on the resident's care plans including the interventions developed to prevent falls. The MDS coordinators were responsible to ensure a care plan was initiated and completed and all department heads were responsible to update and revise the care plans to prevent further falls. Resident #4 was care planned to be at risk for falls and no negative outcome could be foreseen if the care plan was developed to prevent falls. Record review of the facility policy titled Fall Management System dated January 2022 reflected It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessments and interventions to prevent falls and to minimize complications if a fall occurs. Review of the fall incident will include investigation to determine probable casual factors.

Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet the residents' psychosocial needs for one (Resident#10) of three residents reviewed for comprehensive person- centered care plan for recreational drug use. The facility did not care plan Resident #10's recreational drug use after paraphernalia was found in his room. This failure could affect residents and place them at risk of not receiving appropriate interventions. The findings were: Record review of Resident #10's electronic face sheet dated 1/5/24 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Disease of Spinal Cord, Muscle Weakness (Generalized), Depression, Muscle Wasting and Atrophy, Unspecified, Long Term (current) use of Antibiotics, Other Reduced Mobility. Record review of Resident #10's MDS dated [DATE] revealed resident had a BIM score of 15 indicating Resident #10's cognition was intact. Record review of the facility's Provider Investigation Report (PIR) dated 12/22/23 revealed the facility reported to HHSC an incident involving Resident #10 in which items resembling drug paraphernalia were found in his room. They were described as 2 glass pipes. Record review of Resident #10's care plan dated 12/15/23 revealed no documentation of Resident #10's recreational drug use. Further record review found no other care plan and no interventions documented after the discovery of the paraphernalia. In an interview on 01/03/24 at 11:00 am Resident #10 said that the drug paraphernalia found in his room was his. He said he brought it in with him from the hospital and forgot he had it. Resident #10 said he had used drugs before but he had not used any in the facility. In an interview on 01/04/24 at 5:54 pm the DON said that Resident #10's incident was not care planned because according to Resident #10 he was not using drugs and the labs drawn after drug paraphernalia was found did not show he had any drugs in his system . Interviews with staff found that they were not aware that Resident #10 was a drug user. In an interview on 01/05/24 at 10:15 am the Administrator said the incident was not care planned because labs were done on Resident #10 and were found to be normal. The Administrator also said that Resident #10 said he was not using drugs at the time. Record review of the facility's policy titled, Comprehensive Person-Centered Care Plan revised 1/2022 revealed, Policy It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on record review and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one Resident (R#7) of one resident reviewed for transfers. CNA D and CNA E did not provide R#7 with a safe transfer, resulting in R#7 sustaining tibial plateau (shinbone that involves the knee joint) and proximal fibular (bone of the lower leg) fractures. This failure could place residents who required assistance with transfers at risk for injuries. Findings included: Record review of R#7's face sheet revealed R#7 was admitted to the facility on [DATE] and discharged on [DATE]. R#7's [DIAGNOSES REDACTED]. Record review of R#7's nurse's notes, dated 02/28/20 at 10:35 p.m., revealed, Resident arrived via stretcher accompanied by x2 paramedics from hospital which was admitted for R leg [MEDICAL CONDITION] and hx of HTN, [MEDICAL CONDITION], MI, paralysis to BLE . Record review of R#7's Modification of Medicare 5 day MDS, dated [DATE], revealed R#7: -had difficulty hearing (minimal), -had clear speech, -was usually understood, -was usually able to make herself understood, -required extensive assistance from two staff for bed mobility, toilet use, and personal hygiene, and -required total assistance by two staff for bathing. Record review of R#7's care plan, date initiated and revised on 03/13/20, revealed: -(R#7) has ADL Self Care Performance Deficit r/t Limited Mobility - Paralysis BLE, Rt leg [MEDICAL CONDITION] -Goal: Will demonstrate the appropriate use of adaptive device(s) to increase ability in Bed mobility, transfers, eating, dressing toilet use, and personal hygiene, through the review date. -Interventions included: Transfer: requires extensive assistance with transfers X 1 staff participation. Record review of R#7's nurse's notes, dated 06/27/20 at 10:31 p.m., revealed: Staff was transferring resident to w/c and resident sat on edge of w/c then began to slide down onto the ground. Staff assisted with lowering resident onto floor and resident stated that her right leg got caught under w/c and that it twisted a bit Record review of R#7's hospital paperwork, dated 06/29/20 at 8:14 p.m., revealed: Right knee x-ray done in trauma bay positive for tibial plateau and proximal fibular fractures. Right tib/fib and ankle ordered due to increased pain and swelling on re-exam of the lower extremity . In a telephone interview, on 08/25/20 at 4:55 p.m., CNA E said R#7 was only able to bear weight on one leg, and was too heavy to be transferred without a mechanical lift. CNA E said R#7 should have only been transferred with a mechanical lift. In a telephone interview, on 08/26/20 at 1:59 p.m., CNA D said she and CNA E were transferring R#7 by grabbing R#1 underneath R#7's arm, one CNA on each side. CNA D said they were transferring R#7 from R#7's bed to a shower chair. CNA D said R#7 was not transferred correctly and R#7 ended up on the edge of the shower chair. CNA D said, she and CNA E let R#7 slide down to the floor. CNA D said R#7 got her right foot caught underneath the shower chair. CNA D said the nurse was called, and R#7 was transferred back to bed. CNA D said the shower chair was high and R#7 was not able to fully reach it. CNA D said R#7 was not able to stand by herself and was only able to bear weight on one foot. CNA D said she was trained how to transfer a resident, but grabbing a resident underneath the arms was not one of the ways. In a telephone interview on 08/26/20 at 2:24 p.m., the DON said CNA D said R#7 was transferred from bed to chair. R#7 was not transferred all the way back in the shower chair. The DON said staff were able to transfer a resident by grabbing the resident underneath the arms. The DON said staff were also able to use a gait belt, depending on the weight of the resident, or a towel underneath the resident, for the support. The DON said the team leader did a checklist upon hire and annually. The DON said R#7 was able to move her legs, but had not walked in a long time. The DON said the facility had no written policy on transfers. Record review of CNA Ds - Skills checklist-Transfer Techniques, dated 01/24/20, and CNA E - Skills checklist- Transfer Techniques, dated 06/28/20, revealed: I. Ask the person being tested to demonstrate how they would transfer a resident with a [MEDICAL CONDITION], a resident with a total hip prosthesis, and a resident with a [MEDICAL CONDITION] from the bed to the wheelchair; and from the wheelchair back to the bed 1. Identified the precautions, weight bearing status, involved side 2. Resident was told what was going to happen 3. Had resident lean forward and push down with hands on bed to stand up 4. Resident was instructed to pivot to wheelchair and all precautions (weight bearing, total hip, etc) were carried out 5. Resident was instructed to reach for wheelchair armrest prior to sitting down 6. Resident's rights, safety, and proper positioning were maintained throughout the transfer. Record review of Guidelines for Nursing Homes, at https://www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_guidelines.html, revised March 2009, revealed: -Figure 1. Transfer to and from: bed to chair, chair to toilet, chair to chair, or car to chair Stand and pivot technique using a gait/transfer belt (1 caregiver) .

Based on interview, and record review, the facility failed to implement written policies that prohibit neglect of residents, for one Resident (R#1) of 11 residents reviewed for neglect, in that: The facility did not obtain orders for insulin and blood sugar monitoring for 17 days after readmission for R#1, who had a [DIAGNOSES REDACTED].#1 went without receiving insulin or blood sugar monitoring for 49 shifts and was sent to the emergency room , where his blood sugar was measured to be 1503 mg/dl (normal range 70-110 mg/dl). R#1 was admitted to the hospital's Intensive Care Unit for treatment of [REDACTED]. R#1 was still in the hospital at the time of investigation. This failure could place all 25 diabetic residents at risk for deterioration in their health status, or death. This failure resulted in an Immediate Jeopardy (IJ) situation on 08/17/15. While the IJ was removed on 08/18/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope at pattern, due to staff needing more time to monitor the plan of removal for effectiveness. These findings included: The facility's policy on Abuse Prevention and Reporting, revised in May 2007, defined Neglect as, Action or inaction that avoids or prevents physical, mental harm, pain, demonstrates disregard or consequences that may constitute a clear and present danger. R#1's Face Sheet, printed 08/14/15, indicated R#1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]., and Hypertrophy of the Prostate. R#1's Minimum Data Set (MDS) assessment dated [DATE] indicated R#1: -had severe cognitive impairment, -required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene, and -had an active [DIAGNOSES REDACTED]. R#1's care plan, initiated on 04/24/14 indicated R#1 had a [DIAGNOSES REDACTED]. Interventions included: -to perform glucometer checks with [MEDICATION NAME] R per sliding scale per MD orders, and -to monitor for signs and symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis), [MEDICATION NAME] breath (smells fruity), stupor, and coma. R#1's Physician's Orders dated 06/01/15 indicated R#1 was to be administered injections of [MEDICATION NAME] R Solution 100 unit/ML (milliliters) insulin per sliding scale (insulin administration based on the results of a glucometer reading) subcutaneously, every six hours. R#1's June 2015 Medication Administration Record [REDACTED]. Start date was 04/21/14 and discontinue date was 07/22/15. The facility's Admit/Discharge form dated 08/14/15 indicated R#1 was sent to the hospital on [DATE]. Hospital Hematology (lab-work) Report for R#1 indicated blood work was collected on 07/24/15 at 5:30 p.m. R#1 had a glucose (blood sugar) level of 164 mg/dL (normal range 74-100 mg/dL.) The GFR (glomerular filtration rate- test used to tell how well kidneys are working) that was also done on 07/24/15 at 5:30 p.m. was 109.65. According to the hospital lab report the following were the Stages of [MEDICAL CONDITION]: - 1. Kidney damage and normal or elevated GFR >89 mL/min/1.73m - 2. Kidney damage and mildly low GFR 60-89 ml/min/1.73m - 3. Moderately low GFR 30-59 ml/min/1.73m - 4. Severely low GFR 15-29 ml/min/1.73m - 5. Kidney Failure <15 ml/min/1.73m R#1's Medication Administration Record [REDACTED]. R#1's hospital MAR indicated [REDACTED]. R#1's Medication Profile Record from the hospital, dated 07/25/15 did not include any orders for insulin administration or glucose monitoring. Patient Transfer Form from the hospital, dated 07/25/15, indicated R#1 had a [DIAGNOSES REDACTED]. R#1's Patient Transfer Form indicated, Continue with same orders. R#1's undated Admission Check Off List indicated to: -verify orders with MD (physician) and enter all orders in PCC with diagnosis, -if applicable, add batch orders for: Foley Catheter, Enteral Feedings, etc ., and -complete assessment to include: admission assessment comprehensive, bowel and bladder evaluation, Braden scale (to determine risk for development of pressure ulcers), Elopement/wandering evaluation, Fall risk evaluation, Nutrition/Hydration risk evaluation, Pain risk evaluation, AIMS, Psychoactive Medication Evaluation (if on [MEDICAL CONDITION] meds), and Restraint Enabling device/Safety Device Evaluation. R#1's Admission Check Off List was completed by Licensed Vocational Nurse (LVN) A. On R#1's Admission Assessment Comprehensive for admission, dated 07/25/15, Diabetes Mellitus was not listed as one of the [DIAGNOSES REDACTED]. Assessment was completed by LVN A. R#1's Physician's Orders, printed 08/14/15 indicated R#1 was admitted to the facility on [DATE]. Start dates on the orders were 07/25/15. R#1's Physician's Orders did not contain orders to check R#1's blood sugars at any time or to administer insulin at any time. On 08/17/15 at 12:52 p.m., LVN A said she had received R#1 upon readmission from the hospital on [DATE]. LVN A said when an admission was received at the facility the receiving nurse took a report from the hospital over the phone first. LVN A said that, upon the resident's arrival to the facility, the resident was assessed. Any documentation that arrived with the resident was reviewed over the telephone with the Physician. LVN A said the information packet that came with the resident from the hospital included a Patient Transfer Form , Physician's Orders, a Medication Profile Report and a Medication Administration Record, [REDACTED]. Surveyor, along with LVN A reviewed R#1's admission documents dated 07/25/15. LVN A said she had reviewed R#1's Patient Transfer Form, Medication Profile, and Medication Administration Record [REDACTED]. LVN A said she did not recall seeing the document. LVN A added that she only looked at R#1's Patient Transfer Form and Medication Profile. On 08/17/15 at 1:45 p.m., LVN A said that, when R#1 was readmitted to the facility on [DATE], she read R#1's admission [DIAGNOSES REDACTED]. Review of R#1's MAR for July 2015 revealed no documentation that R#1's blood sugar level was checked at any time. There was no documentation R#1 was administered insulin at any time. Review of R#1's MAR for August 2015 revealed no documentation that R#1's blood sugar level was checked at any time, from 08/01/15 to 08/10/15. There was no documentation R#1 was administered insulin from 08/01/15 to 08/10/15. Nursing Progress Notes dated 08/10/15 at 12:20 p.m. for R#1 documented, Family requested resident be sent out to Hospital ER (emergency room ). Called (hospital) ER and gave report. Recent Labs and x-ray included in packet. Nursing Progress Notes dated 08/10/15 at 12:29 p.m. for R#1 documented R#1's Primary Physician was called and notified that, as per family request, R#1 was being sent out to the ER. No blood sugar check was noted in R#1's Nurses Note. Discharge Summary for R#1, effective date of 08/10/15, completed by LVN A, indicated R#1 had a temperature of 98.9, pulse of 84 (regular), respirations of 28, and oxygen at 92% while R#1 was receiving oxygen via nasal cannula. The Progress note section of the Discharge Summary indicated R#1 was using abdominal muscles to assist in breathing and his respirations were at 28 with oxygen at 92%. No blood sugar check was noted on R#1's Discharge Summary. Transfer/Discharge Report dated 08/11/15 for R#1 indicated that R#1 arrived at the facility on 07/25/15 and was transferred out of the facility on 08/10/15. The report indicated that the chief complaint (reason for transfer) for R#1's transfer to the hospital emergency room was: decline in condition, fever, abnormal breathing, and pneumonia. The Transfer/Discharge Report indicated R#1 had a [DIAGNOSES REDACTED].#1's status as a Diabetic in the chief complaint. R#1's hospital ER admission data listed admission date of [DATE]. Reason for visit was listed as Hyperosmolar Monketotic State (life threatening derangement of metabolism in individuals with Diabetes) Severe [MEDICAL CONDITION] (severely elevated blood sugar). Under comments, additional [DIAGNOSES REDACTED]. R#1's hospital Patient Record documented R#1 had a glucose reading of 1503 mg/dl on 08/10/15 at 2:07 p.m. Additional lab findings indicated the eGFR was at 26mL/min. (severely low GFR). According to the hospital lab the following were the Stages of [MEDICAL CONDITION]: - 4. Severely low GFR 15-29 ml/min/1.73m Hospital Progress Note for R#1, dated 08/10/15, indicated R#1 was admitted to the Intensive Care Unit and that he was unresponsive. The Progress Note listed [DIAGNOSES REDACTED]. The Progress Note indicated R#1's condition was serious and prognosis was serious. On 08/14/15 at 3:25 p.m., LVN E said she never checked R#1's blood sugar during his stay from 07/25/15 to 08/10/15. LVN E said she did not have any order to check R#1's blood sugar and she was just following the Physician's orders. LVN E said that, if she would have checked R#1's blood sugar without orders, it would have been an assault. On 08/14/15 at 3:35 p.m., LVN N said, If we have a diabetic resident, we must obtain orders for insulin or medications that address the resident's diabetes. LVN N said orders must also be obtained for blood sugar checks for diabetic residents. LVN N said, As a nurse, when you come in and start your shift it is your responsibility to review your resident's information, including their [DIAGNOSES REDACTED]. On 08/17/15 at 1:25 p.m., the Director of Nurses (DON) said that, upon readmission, R#1 would have been admitted with complete orders. The DON said orders were received as part of a packet that came with the resident from the referring entity. The DON said the admitting nurse received the orders, then input them into the system. A copy was then made and put in the resident's chart so the original could go to medical records. The DON said the admitting nurse should review the whole packet in order to verify the orders with the Physician. Surveyor asked if the admission process was done by more than one person. The DON said the admission process was completed by the same person unless there was a change of shift. The DON said that, in R#1's case, LVN A handled the full admission. On 08/17/15 at 3:49 p.m. the DON said the facility conducted an IDT (interdisciplinary team) meeting when a resident was admitted or readmitted to the facility. The DON said, We don't get too detailed, we look at the resident's orders and, if there is any treatment that they may need or medication, we try to make sure they get it. Surveyor asked the DON if the IDT would have identified the [DIAGNOSES REDACTED].#1's hospital Medication Administration Record. The DON replied, We don't get that detailed. On 08/17/15 at 4:30 p.m., surveyor interviewed Physician C. Physician C said he had been working as the on-call Physician for R#1's Primary Physician on 07/25/15. When asked what kind of care he would expect a facility to provide for a diabetic resident, Physician C replied, They would need to provide scheduled glucose monitoring, scheduled medications for glucose control, and PRN (as needed) medications for breakthrough [DIAGNOSES REDACTED] or [MEDICAL CONDITION] episodes. Physician C said he could not recall exactly what was discussed when the facility contacted him about R#1's readmission to the facility on [DATE]. Physician C said what probably happened was that a nurse called him and read out about 20 orders for a resident that he was not completely familiar with. Physician C said it was possible that the [DIAGNOSES REDACTED]. Physician C said, If you as a nurse call a doctor and he gives an order that does not make any sense, omits something, or is a total contradiction of what the patient needs, it is up to the nurse to clarify the order with the physician. Physician C went on to say that, This is a system of checks and balances, if the order did not make sense and the doctor still insisted upon it, at that point the nurse should notify administration. Once administration is involved they can speak with the doctor or the facility's Medical Director would speak with the doctor and attempt to gain clarification for the order. We have this system to ensure patient safety. It is also the nurse's job to advocate for the patient and ensure that needs of patient are being met. On 08/17/15 at 5:05 p.m., the facility's Administrator was informed an IJ situation was identified due to the above failures. On 08/17/15 at 5:05 p.m., following declaration of Immediate Jeopardy, the Director of Nurses said nursing staff were assessing for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] in residents who were diabetic. The facility's Plan of Removal was submitted by the Administrator and accepted on 08/17/15 at 7:45 p.m. Review of the facility's immediate jeopardy plan of removal dated 08/17/15 revealed: -All new and readmitted resident's orders and admitting information will be reviewed by the Charge Nurse utilizing an Admission Check List to verify orders and [DIAGNOSES REDACTED]. -The Charge Nurse will notify the PCP (primary care physician) and review the admission orders [REDACTED] -The ADON (Assistant Director of Nurses) or Unit Nurse Manager will review the admission and or re-admission orders [REDACTED]. 08/17/15 -The IDT (interdisciplinary team) will review all new and readmitted residents at the morning mtg.(meeting) to verify the check list has been completed by the Charge Nurse and signed by the ADON or unit manager at the time of the admission. 08/18/15. -The DNS (Director of Nurse Service) or designee will educate currently employed licensed staff and Nurse Manager, as well as any new licensed staff hired by the Facility, on the above admission and re-admission procedures. The ED (executive director) will make this education a part of the Facility orientaion and make it a mandatory topic of training for all newly hired licensed staff. The facility's new Resident Admission Checklist (undated) included: -principal diagnosis, -co-morbid conditions, -adverse events during treatment at transferring facility, -vital signs, -lab results, -current medications, -antibiotics, -feeding tube formula, fluid restrictions, insulin type, last blood sugar result, glucometer checks . On 08/18/15 at 10:25 a.m., surveyor observed LVN A receive report for a new admission (R#4) via telephone. LVN A filled out the facility's new Resident Admission Checklist, revised on 08/17/15. LVN A repeated the [DIAGNOSES REDACTED]. On 08/18/15 at 11:25 a.m., surveyor observed LVN A receive R#4 from transport staff, assist with R#4's transfer to bed from stretcher and get R#4 set up in bed and comfortable. LVN A had R#4's Resident Admission Checklist with her while getting R#4 set up and was going down the form to ensure that she followed each order listed. LVN A told surveyor that she and the other facility nurses would be using the form on admissions from now on. LVN A then left R#4's room to go to the nurses station and contact R#4's Physician. LVN A reviewed R#4's Resident Admission Checklist and went through each of R#4's [DIAGNOSES REDACTED]. LVN A then transcribed R#4's orders and began to input the information for R#4 in the system. On 08/18/15 at 2:15 p.m., Medical Records Staff D said it was the facility's policy/practice that all [DIAGNOSES REDACTED]. Medical Records Staff D said the nurses were the ones who discontinued medications and diagnoses. Medical Records Staff D said this happened when a resident went to the hospital and was readmitted . Medical Records Staff D said that when a resident came back to the facility, the admitting nurse did a new admission packet. All of the resident's old orders and [DIAGNOSES REDACTED]. Medical Records Staff D said that even the items that they tried to delete or which were mistakes were still present, these items just had a line through them. On 08/18/15 at 10:45 a.m., LVN M, when asked about symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION], listed the following: -[DIAGNOSES REDACTED]: diaphoretic, cold, lethargic, complaints of blurred vision, and anger. (If you feel tired or dizzy, or have a headache or mood swings, your blood sugar may be low. According to the American Diabetes Association (ADA), low blood sugar ([DIAGNOSES REDACTED]) is when your blood sugar falls below 70 mg/dL.) -[MEDICAL CONDITION]: lethargic, and, they seem out of it. (With high blood sugar, you may feel: Very thirsty or hungry, like you need to pass urine more than usual, like your mouth and skin are dry, like your vision is blurry, and sleepy). The Administrator was informed the IJ was lifted on 08/18/15 at 11:55 a.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope at pattern. On 08/18/15 at 12:10 p.m., LVN E said signs and symptoms of [DIAGNOSES REDACTED] were sweating, confusion, and dizziness. LVN E said signs and symptoms of [MEDICAL CONDITION] were basically the same, lethargic or if there was a change in condition or confusion. On 08/18/15 at 12:20 p.m., the DON said signs and symptoms of [DIAGNOSES REDACTED] were diaphoretic, lethargic or any change in condition. Signs and symptoms of [MEDICAL CONDITION] would be lethargic, change in condition, or non-responsive. The facility's [DIAGNOSES REDACTED].

Based on interview, and record review, the facility failed to implement policies that prohibit neglect of residents, for one Resident (R#1) of 11 residents reviewed for neglect, in that: The facility did not obtain orders for insulin and blood sugar monitoring for 17 days after readmission for R#1, who had a [DIAGNOSES REDACTED].#1 went without receiving insulin or blood sugar monitoring for 49 shifts and was sent to the emergency room , where his blood sugar was measured to be 1503 mg/dl (normal range 70-110 mg/dl). R#1 was admitted to the hospital's Intensive Care Unit for treatment of [REDACTED]. R#1 was still in the hospital at the time of investigation. This failure could place all 25 diabetic residents at risk for deterioration in their health status, or death. This failure resulted in an Immediate Jeopardy (IJ) situation on 08/17/15. While the IJ was removed on 08/18/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope at pattern, due to staff needing more time to monitor the plan of removal for effectiveness. These findings included: R#1's Face Sheet, printed 08/14/15, indicated R#1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]., and Hypertrophy of the Prostate. R#1's Minimum Data Set (MDS) assessment dated [DATE] indicated R#1: -had severe cognitive impairment, -required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene, and -had an active [DIAGNOSES REDACTED]. R#1's care plan, initiated on 04/24/14 indicated R#1 had a [DIAGNOSES REDACTED]. Interventions included: -to perform glucometer checks with [MEDICATION NAME] R per sliding scale per MD orders, and -to monitor for signs and symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis), [MEDICATION NAME] breath (smells fruity), stupor, and coma. R#1's Physician's Orders dated 06/01/15 indicated R#1 was to be administered injections of [MEDICATION NAME] R Solution 100 unit/ML (milliliters) insulin per sliding scale (insulin administration based on the results of a glucometer reading) subcutaneously, every six hours. R#1's June 2015 Medication Administration Record [REDACTED]. Start date was 04/21/14 and discontinue date was 07/22/15. The facility's Admit/Discharge form dated 08/14/15 indicated R#1 was sent to the hospital on [DATE]. Hospital Hematology (lab-work) Report for R#1 indicated blood work was collected on 07/24/15 at 5:30 p.m. R#1 had a glucose (blood sugar) level of 164 mg/dL (normal range 74-100 mg/dL.) The GFR (glomerular filtration rate- test used to tell how well kidneys are working) that was also done on 07/24/15 at 5:30 p.m. was 109.65. According to the hospital lab report the following were the Stages of [MEDICAL CONDITION]: - 1. Kidney damage and normal or elevated GFR >89 mL/min/1.73m - 2. Kidney damage and mildly low GFR 60-89 ml/min/1.73m - 3. Moderately low GFR 30-59 ml/min/1.73m - 4. Severely low GFR 15-29 ml/min/1.73m - 5. Kidney Failure <15 ml/min/1.73m R#1's Medication Administration Record [REDACTED]. R#1's hospital MAR indicated [REDACTED]. R#1's Medication Profile Record from the hospital, dated 07/25/15 did not include any orders for insulin administration or glucose monitoring. Patient Transfer Form from the hospital, dated 07/25/15, indicated R#1 had a [DIAGNOSES REDACTED]. R#1's Patient Transfer Form indicated, Continue with same orders. R#1's undated Admission Check Off List indicated to: -verify orders with MD (physician) and enter all orders in PCC with diagnosis, -if applicable, add batch orders for: Foley Catheter, Enteral Feedings, etc ., and -complete assessment to include: admission assessment comprehensive, bowel and bladder evaluation, Braden scale (to determine risk for development of pressure ulcers), Elopement/wandering evaluation, Fall risk evaluation, Nutrition/Hydration risk evaluation, Pain risk evaluation, AIMS, Psychoactive Medication Evaluation (if on [MEDICAL CONDITION] meds), and Restraint Enabling device/Safety Device Evaluation. R#1's Admission Check Off List was completed by Licensed Vocational Nurse (LVN) A. On R#1's Admission Assessment Comprehensive for admission, dated 07/25/15, Diabetes Mellitus was not listed as one of the [DIAGNOSES REDACTED]. Assessment was completed by LVN A. R#1's Physician's Orders, printed 08/14/15 indicated R#1 was admitted to the facility on [DATE]. Start dates on the orders were 07/25/15. R#1's Physician's Orders did not contain orders to check R#1's blood sugars at any time or to administer insulin at any time. On 08/17/15 at 12:52 p.m., LVN A said she had received R#1 upon readmission from the hospital on [DATE]. LVN A said when an admission was received at the facility the receiving nurse took a report from the hospital over the phone first. LVN A said that, upon the resident's arrival to the facility, the resident was assessed. Any documentation that arrived with the resident was reviewed over the telephone with the Physician. LVN A said the information packet that came with the resident from the hospital included a Patient Transfer Form , Physician's Orders, a Medication Profile Report and a Medication Administration Record, [REDACTED]. Surveyor, along with LVN A reviewed R#1's admission documents dated 07/25/15. LVN A said she had reviewed R#1's Patient Transfer Form, Medication Profile, and Medication Administration Record [REDACTED]. LVN A said she did not recall seeing the document. LVN A added that she only looked at R#1's Patient Transfer Form and Medication Profile. On 08/17/15 at 1:45 p.m., LVN A said that, when R#1 was readmitted to the facility on [DATE], she read R#1's admission [DIAGNOSES REDACTED]. Review of R#1's MAR for July 2015 revealed no documentation that R#1's blood sugar level was checked at any time. There was no documentation R#1 was administered insulin at any time. Review of R#1's MAR for August 2015 revealed no documentation that R#1's blood sugar level was checked at any time, from 08/01/15 to 08/10/15. There was no documentation R#1 was administered insulin from 08/01/15 to 08/10/15. Nursing Progress Notes dated 08/10/15 at 12:20 p.m. for R#1 documented, Family requested resident be sent out to Hospital ER (emergency room ). Called (hospital) ER and gave report. Recent Labs and x-ray included in packet. Nursing Progress Notes dated 08/10/15 at 12:29 p.m. for R#1 documented R#1's Primary Physician was called and notified that, as per family request, R#1 was being sent out to the ER. No blood sugar check was noted in R#1's Nurses Note. Discharge Summary for R#1, effective date of 08/10/15, completed by LVN A, indicated R#1 had a temperature of 98.9, pulse of 84 (regular), respirations of 28, and oxygen at 92% while R#1 was receiving oxygen via nasal cannula. The Progress note section of the Discharge Summary indicated R#1 was using abdominal muscles to assist in breathing and his respirations were at 28 with oxygen at 92%. No blood sugar check was noted on R#1's Discharge Summary. Transfer/Discharge Report dated 08/11/15 for R#1 indicated that R#1 arrived at the facility on 07/25/15 and was transferred out of the facility on 08/10/15. The report indicated that the chief complaint (reason for transfer) for R#1's transfer to the hospital emergency room was: decline in condition, fever, abnormal breathing, and pneumonia. The Transfer/Discharge Report indicated R#1 had a [DIAGNOSES REDACTED].#1's status as a Diabetic in the chief complaint. R#1's hospital ER admission data listed admission date of [DATE]. Reason for visit was listed as Hyperosmolar Monketotic State (life threatening derangement of metabolism in individuals with Diabetes) Severe [MEDICAL CONDITION] (severely elevated blood sugar). Under comments, additional [DIAGNOSES REDACTED]. R#1's hospital Patient Record documented R#1 had a glucose (blood sugar) reading of 1503 mg/dl on 08/10/15 at 2:07 p.m. Additional lab findings indicated the eGFR was at 26mL/min. (severely low GFR). According to the hospital lab the following were the Stages of [MEDICAL CONDITION]: - 4. Severely low GFR 15-29 ml/min/1.73m Hospital Progress Note for R#1, dated 08/10/15, indicated R#1 was admitted to the Intensive Care Unit and that he was unresponsive. The Progress Note listed [DIAGNOSES REDACTED]. The Progress Note indicated R#1's condition was serious and prognosis was serious. On 08/14/15 at 3:25 p.m., LVN E said she never checked R#1's blood sugar during his stay from 07/25/15 to 08/10/15. LVN E said she did not have any order to check R#1's blood sugar and she was just following the Physician's orders. LVN E said that, if she would have checked R#1's blood sugar without orders, it would have been an assault. On 08/14/15 at 3:35 p.m., LVN N said, If we have a diabetic resident, we must obtain orders for insulin or medications that address the resident's diabetes. LVN N said orders must also be obtained for blood sugar checks for diabetic residents. LVN N said, As a nurse, when you come in and start your shift it is your responsibility to review your resident's information, including their [DIAGNOSES REDACTED]. On 08/17/15 at 1:25 p.m., the Director of Nurses (DON) said that, upon readmission, R#1 would have been admitted with complete orders. The DON said orders were received as part of a packet that came with the resident from the referring entity. The DON said the admitting nurse received the orders, then input them into the system. A copy was then made and put in the resident's chart so the original could go to medical records. The DON said the admitting nurse should review the whole packet in order to verify the orders with the Physician. Surveyor asked if the admission process was done by more than one person. The DON said the admission process was completed by the same person unless there was a change of shift. The DON said that, in R#1's case, LVN A handled the full admission. On 08/17/15 at 3:49 p.m. the DON said the facility conducted an IDT (interdisciplinary team) meeting when a resident was admitted or readmitted to the facility. The DON said, We don't get too detailed, we look at the resident's orders and, if there is any treatment that they may need or medication, we try to make sure they get it. Surveyor asked the DON if the IDT would have identified the [DIAGNOSES REDACTED].#1's hospital Medication Administration Record. The DON replied, We don't get that detailed. On 08/17/15 at 4:30 p.m., surveyor interviewed Physician C. Physician C said he had been working as the on-call Physician for R#1's Primary Physician on 07/25/15. When asked what kind of care he would expect a facility to provide for a diabetic resident, Physician C replied, They would need to provide scheduled glucose monitoring, scheduled medications for glucose control, and PRN (as needed) medications for breakthrough [DIAGNOSES REDACTED] or [MEDICAL CONDITION] episodes. Physician C said he could not recall exactly what was discussed when the facility contacted him about R#1's readmission to the facility on [DATE]. Physician C said what probably happened was that a nurse called him and read out about 20 orders for a resident that he was not completely familiar with. Physician C said it was possible that the [DIAGNOSES REDACTED]. Physician C said, If you as a nurse call a doctor and he gives an order that does not make any sense, omits something, or is a total contradiction of what the patient needs, it is up to the nurse to clarify the order with the physician. Physician C went on to say that, This is a system of checks and balances, if the order did not make sense and the doctor still insisted upon it, at that point the nurse should notify administration. Once administration is involved they can speak with the doctor or the facility's Medical Director would speak with the doctor and attempt to gain clarification for the order. We have this system to ensure patient safety. It is also the nurse's job to advocate for the patient and ensure that needs of patient are being met. The facility's policy on Abuse Prevention and Reporting, revised in May 2007, defined Neglect as, Action or inaction that avoids or prevents physical, mental harm, pain, demonstrates disregard or consequences that may constitute a clear and present danger. On 08/17/15 at 5:05 p.m., the facility's Administrator was informed an IJ situation was identified due to the above failures. On 08/17/15 at 5:05 p.m., following declaration of Immediate Jeopardy, the Director of Nurses said nursing staff were assessing for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] in residents who were diabetic. The facility's Plan of Removal was submitted by the Administrator and accepted on 08/17/15 at 7:45 p.m. Review of the facility's immediate jeopardy plan of removal dated 08/17/15 revealed: -All new and readmitted resident's orders and admitting information will be reviewed by the Charge Nurse utilizing an Admission Check List to verify orders and [DIAGNOSES REDACTED]. -The Charge Nurse will notify the PCP (primary care physician) and review the admission orders [REDACTED] -The ADON (Assistant Director of Nurses) or Unit Nurse Manager will review the admission and or re-admission orders [REDACTED]. 08/17/15 -The IDT (interdisciplinary team) will review all new and readmitted residents at the morning mtg.(meeting) to verify the check list has been completed by the Charge Nurse and signed by the ADON or unit manager at the time of the admission. 08/18/15. -The DNS (Director of Nurse Service) or designee will educate currently employed licensed staff and Nurse Manager, as well as any new licensed staff hired by the Facility, on the above admission and re-admission procedures. The ED (executive director) will make this education a part of the Facility orientaion and make it a mandatory topic of training for all newly hired licensed staff. The facility's new Resident Admission Checklist (undated) included: -principal diagnosis, -co-morbid conditions, -adverse events during treatment at transferring facility, -vital signs, -lab results, -current medications, -antibiotics, -feeding tube formula, fluid restrictions, insulin type, last blood sugar result, glucometer checks . On 08/18/15 at 10:25 a.m., surveyor observed LVN A receive report for a new admission (R#4) via telephone. LVN A filled out the facility's new Resident Admission Checklist, revised on 08/17/15. LVN A repeated the [DIAGNOSES REDACTED]. On 08/18/15 at 11:25 a.m., surveyor observed LVN A receive R#4 from transport staff, assist with R#4's transfer to bed from stretcher and get R#4 set up in bed and comfortable. LVN A had R#4's Resident Admission Checklist with her while getting R#4 set up and was going down the form to ensure that she followed each order listed. LVN A told surveyor that she and the other facility nurses would be using the form on admissions from now on. LVN A then left R#4's room to go to the nurses station and contact R#4's Physician. LVN A reviewed R#4's Resident Admission Checklist and went through each of R#4's [DIAGNOSES REDACTED]. LVN A then transcribed R#4's orders and began to input the information for R#4 in the system. On 08/18/15 at 2:15 p.m., Medical Records Staff D said it was the facility's policy/practice that all [DIAGNOSES REDACTED]. Medical Records Staff D said the nurses were the ones who discontinued medications and diagnoses. Medical Records Staff D said this happened when a resident went to the hospital and was readmitted . Medical Records Staff D said that when a resident came back to the facility, the admitting nurse did a new admission packet. All of the resident's old orders and [DIAGNOSES REDACTED]. Medical Records Staff D said that even the items that they tried to delete or which were mistakes were still present, these items just had a line through them. On 08/18/15 at 10:45 a.m., LVN M, when asked about symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION], listed the following: -[DIAGNOSES REDACTED]: diaphoretic, cold, lethargic, complaints of blurred vision, and anger. (If you feel tired or dizzy, or have a headache or mood swings, your blood sugar may be low. According to the American Diabetes Association (ADA), low blood sugar ([DIAGNOSES REDACTED]) is when your blood sugar falls below 70 mg/dL.) -[MEDICAL CONDITION]: lethargic, and, they seem out of it. (With high blood sugar, you may feel: Very thirsty or hungry, like you need to pass urine more than usual, like your mouth and skin are dry, like your vision is blurry, and sleepy). The Administrator was informed the IJ was lifted on 08/18/15 at 11:55 a.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope at pattern. On 08/18/15 at 12:10 p.m., LVN E said signs and symptoms of [DIAGNOSES REDACTED] were sweating, confusion, and dizziness. LVN E said signs and symptoms of [MEDICAL CONDITION] were basically the same, lethargic or if there was a change in condition or confusion. On 08/18/15 at 12:20 p.m., the DON said signs and symptoms of [DIAGNOSES REDACTED] were diaphoretic, lethargic or any change in condition. Signs and symptoms of [MEDICAL CONDITION] would be lethargic, change in condition, or non-responsive. The facility's [DIAGNOSES REDACTED].

Based on interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for one Resident (R#1) of 11 residents reviewed for quality of care, in that: The facility did not obtain orders for insulin and blood sugar monitoring for 17 days after readmission for R#1, who had a [DIAGNOSES REDACTED].#1 went without receiving insulin or blood sugar monitoring for 49 shifts and was sent to the emergency room , where his blood sugar was measured to be 1503 mg/dl (normal range 70-110 mg/dl). R#1 was admitted to the hospital's Intensive Care Unit for treatment of [REDACTED]. R#1 was still in the hospital at the time of investigation. This failure could place all 25 diabetic residents at risk for deterioration in their health status, or death. This failure resulted in an Immediate Jeopardy (IJ) situation on 08/17/15. While the IJ was removed on 08/18/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope at pattern, due to staff needing more time to monitor the plan of removal for effectiveness. These findings included: R#1's Face Sheet, printed 08/14/15, indicated R#1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]., and Hypertrophy of the Prostate. R#1's Minimum Data Set (MDS) assessment dated [DATE] indicated R#1: -had severe cognitive impairment, -required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene, and -had an active [DIAGNOSES REDACTED]. R#1's care plan, initiated on 04/24/14 indicated R#1 had a [DIAGNOSES REDACTED]. Interventions included: -to perform glucometer checks with [MEDICATION NAME] R per sliding scale per MD orders, and -to monitor for signs and symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis), [MEDICATION NAME] breath (smells fruity), stupor, and coma. R#1's Physician's Orders dated 06/01/15 indicated R#1 was to be administered injections of [MEDICATION NAME] R Solution 100 unit/ML (milliliters) insulin per sliding scale (insulin administration based on the results of a glucometer reading) subcutaneously, every six hours. R#1's June 2015 Medication Administration Record [REDACTED]. Start date was 04/21/14 and discontinue date was 07/22/15. The facility's Admit/Discharge form dated 08/14/15 indicated R#1 was sent to the hospital on [DATE]. Hospital Hematology (lab-work) Report for R#1 indicated blood work was collected on 07/24/15 at 5:30 p.m. R#1 had a glucose (blood sugar) level of 164 mg/dL (normal range 74-100 mg/dL.) The GFR (glomerular filtration rate- test used to tell how well kidneys are working) that was also done on 07/24/15 at 5:30 p.m. was 109.65. According to the hospital lab report the following were the Stages of [MEDICAL CONDITION]: - 1. Kidney damage and normal or elevated GFR >89 mL/min/1.73m - 2. Kidney damage and mildly low GFR 60-89 ml/min/1.73m - 3. Moderately low GFR 30-59 ml/min/1.73m - 4. Severely low GFR 15-29 ml/min/1.73m - 5. Kidney Failure <15 ml/min/1.73m R#1's Medication Administration Record [REDACTED]. R#1's hospital MAR indicated [REDACTED]. R#1's Medication Profile Record from the hospital, dated 07/25/15 did not include any orders for insulin administration or glucose monitoring. Patient Transfer Form from the hospital, dated 07/25/15, indicated R#1 had a [DIAGNOSES REDACTED]. R#1's Patient Transfer Form indicated, Continue with same orders. R#1's undated Admission Check Off List indicated to: -verify orders with MD (physician) and enter all orders in PCC with diagnosis, -if applicable, add batch orders for: Foley Catheter, Enteral Feedings, etc ., and -complete assessment to include: admission assessment comprehensive, bowel and bladder evaluation, Braden scale (to determine risk for development of pressure ulcers), Elopement/wandering evaluation, Fall risk evaluation, Nutrition/Hydration risk evaluation, Pain risk evaluation, AIMS, Psychoactive Medication Evaluation (if on [MEDICAL CONDITION] meds), and Restraint Enabling device/Safety Device Evaluation. R#1's Admission Check Off List was completed by Licensed Vocational Nurse (LVN) A. On R#1's Admission Assessment Comprehensive for admission, dated 07/25/15, Diabetes Mellitus was not listed as one of the [DIAGNOSES REDACTED]. Assessment was completed by LVN A. R#1's Physician's Orders, printed 08/14/15 indicated R#1 was admitted to the facility on [DATE]. Start dates on the orders were 07/25/15. R#1's Physician's Orders did not contain orders to check R#1's blood sugars at any time or to administer insulin at any time. On 08/17/15 at 12:52 p.m., LVN A said she had received R#1 upon readmission from the hospital on [DATE]. LVN A said when an admission was received at the facility the receiving nurse took a report from the hospital over the phone first. LVN A said that, upon the resident's arrival to the facility, the resident was assessed. Any documentation that arrived with the resident was reviewed over the telephone with the Physician. LVN A said the information packet that came with the resident from the hospital included a Patient Transfer Form , Physician's Orders, a Medication Profile Report and a Medication Administration Record, [REDACTED]. Surveyor, along with LVN A reviewed R#1's admission documents dated 07/25/15. LVN A said she had reviewed R#1's Patient Transfer Form, Medication Profile, and Medication Administration Record [REDACTED]. LVN A said she did not recall seeing the document. LVN A added that she only looked at R#1's Patient Transfer Form and Medication Profile. On 08/17/15 at 1:45 p.m., LVN A said that, when R#1 was readmitted to the facility on [DATE], she read R#1's admission [DIAGNOSES REDACTED]. Review of R#1's MAR for July 2015 revealed no documentation that R#1's blood sugar level was checked at any time. There was no documentation R#1 was administered insulin at any time. Review of R#1's MAR for August 2015 revealed no documentation that R#1's blood sugar level was checked at any time, from 08/01/15 to 08/10/15. There was no documentation R#1 was administered insulin from 08/01/15 to 08/10/15. Nursing Progress Notes dated 08/10/15 at 12:20 p.m. for R#1 documented, Family requested resident be sent out to Hospital ER (emergency room ). Called (hospital) ER and gave report. Recent Labs and x-ray included in packet. Nursing Progress Notes dated 08/10/15 at 12:29 p.m. for R#1 documented R#1's Primary Physician was called and notified that, as per family request, R#1 was being sent out to the ER. No blood sugar check was noted in R#1's Nurses Note. Discharge Summary for R#1, effective date of 08/10/15, completed by LVN A, indicated R#1 had a temperature of 98.9, pulse of 84 (regular), respirations of 28, and oxygen at 92% while R#1 was receiving oxygen via nasal cannula. The Progress note section of the Discharge Summary indicated R#1 was using abdominal muscles to assist in breathing and his respirations were at 28 with oxygen at 92%. No blood sugar check was noted on R#1's Discharge Summary. Transfer/Discharge Report dated 08/11/15 for R#1 indicated that R#1 arrived at the facility on 07/25/15 and was transferred out of the facility on 08/10/15. The report indicated that the chief complaint (reason for transfer) for R#1's transfer to the hospital emergency room was: decline in condition, fever, abnormal breathing, and pneumonia. The Transfer/Discharge Report indicated R#1 had a [DIAGNOSES REDACTED].#1's status as a Diabetic in the chief complaint. R#1's hospital ER admission data listed admission date of [DATE]. Reason for visit was listed as Hyperosmolar Monketotic State (life threatening derangement of metabolism in individuals with Diabetes) Severe [MEDICAL CONDITION] (severely elevated blood sugar). Under comments, additional [DIAGNOSES REDACTED]. R#1's hospital Patient Record documented R#1 had a glucose reading of 1503 mg/dl on 08/10/15 at 2:07 p.m. Additional lab findings indicated the eGFR was at 26mL/min. (severely low GFR). According to the hospital lab the following were the Stages of [MEDICAL CONDITION]: - 4. Severely low GFR 15-29 ml/min/1.73m Hospital Progress Note for R#1, dated 08/10/15, indicated R#1 was admitted to the Intensive Care Unit and that he was unresponsive. The Progress Note listed [DIAGNOSES REDACTED]. The Progress Note indicated R#1's condition was serious and prognosis was serious. On 08/14/15 at 3:25 p.m., LVN E said she never checked R#1's blood sugar during his stay from 07/25/15 to 08/10/15. LVN E said she did not have any order to check R#1's blood sugar and she was just following the Physician's orders. LVN E said that, if she would have checked R#1's blood sugar without orders, it would have been an assault. On 08/14/15 at 3:35 p.m., LVN N said, If we have a diabetic resident, we must obtain orders for insulin or medications that address the resident's diabetes. LVN N said orders must also be obtained for blood sugar checks for diabetic residents. LVN N said, As a nurse, when you come in and start your shift it is your responsibility to review your resident's information, including their [DIAGNOSES REDACTED]. On 08/17/15 at 1:25 p.m., the Director of Nurses (DON) said that, upon readmission, R#1 would have been admitted with complete orders. The DON said orders were received as part of a packet that came with the resident from the referring entity. The DON said the admitting nurse received the orders, then input them into the system. A copy was then made and put in the resident's chart so the original could go to medical records. The DON said the admitting nurse should review the whole packet in order to verify the orders with the Physician. Surveyor asked if the admission process was done by more than one person. The DON said the admission process was completed by the same person unless there was a change of shift. The DON said that, in R#1's case, LVN A handled the full admission. On 08/17/15 at 3:49 p.m. the DON said the facility conducted an IDT (interdisciplinary team) meeting when a resident was admitted or readmitted to the facility. The DON said, We don't get too detailed, we look at the resident's orders and, if there is any treatment that they may need or medication, we try to make sure they get it. Surveyor asked the DON if the IDT would have identified the [DIAGNOSES REDACTED].#1's hospital Medication Administration Record. The DON replied, We don't get that detailed. On 08/17/15 at 4:30 p.m., surveyor interviewed Physician C. Physician C said he had been working as the on-call Physician for R#1's Primary Physician on 07/25/15. When asked what kind of care he would expect a facility to provide for a diabetic resident, Physician C replied, They would need to provide scheduled glucose monitoring, scheduled medications for glucose control, and PRN (as needed) medications for breakthrough [DIAGNOSES REDACTED] or [MEDICAL CONDITION] episodes. Physician C said he could not recall exactly what was discussed when the facility contacted him about R#1's readmission to the facility on [DATE]. Physician C said what probably happened was that a nurse called him and read out about 20 orders for a resident that he was not completely familiar with. Physician C said it was possible that the [DIAGNOSES REDACTED]. Physician C said, If you as a nurse call a doctor and he gives an order that does not make any sense, omits something, or is a total contradiction of what the patient needs, it is up to the nurse to clarify the order with the physician. Physician C went on to say that, This is a system of checks and balances, if the order did not make sense and the doctor still insisted upon it, at that point the nurse should notify administration. Once administration is involved they can speak with the doctor or the facility's Medical Director would speak with the doctor and attempt to gain clarification for the order. We have this system to ensure patient safety. It is also the nurse's job to advocate for the patient and ensure that needs of patient are being met. On 08/17/15 at 5:05 p.m., the facility's Administrator was informed an IJ situation was identified due to the above failures. On 08/17/15 at 5:05 p.m., following declaration of Immediate Jeopardy, the Director of Nurses said nursing staff were assessing for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] in residents who were diabetic. The facility's Plan of Removal was submitted by the Administrator and accepted on 08/17/15 at 7:45 p.m. Review of the facility's immediate jeopardy plan of removal dated 08/17/15 revealed: -All new and readmitted resident's orders and admitting information will be reviewed by the Charge Nurse utilizing an Admission Check List to verify orders and [DIAGNOSES REDACTED]. -The Charge Nurse will notify the PCP (primary care physician) and review the admission orders [REDACTED] -The ADON (Assistant Director of Nurses) or Unit Nurse Manager will review the admission and or re-admission orders [REDACTED]. 08/17/15 -The IDT (interdisciplinary team) will review all new and readmitted residents at the morning mtg.(meeting) to verify the check list has been completed by the Charge Nurse and signed by the ADON or unit manager at the time of the admission. 08/18/15. -The DNS (Director of Nurse Service) or designee will educate currently employed licensed staff and Nurse Manager, as well as any new licensed staff hired by the Facility, on the above admission and re-admission procedures. The ED (executive director) will make this education a part of the Facility orientaion and make it a mandatory topic of training for all newly hired licensed staff. The facility's new Resident Admission Checklist (undated) included: -principal diagnosis, -co-morbid conditions, -adverse events during treatment at transferring facility, -vital signs, -lab results, -current medications, -antibiotics, -feeding tube formula, fluid restrictions, insulin type, last blood sugar result, glucometer checks . On 08/18/15 at 10:25 a.m., surveyor observed LVN A receive report for a new admission (R#4) via telephone. LVN A filled out the facility's new Resident Admission Checklist, revised on 08/17/15. LVN A repeated the [DIAGNOSES REDACTED]. On 08/18/15 at 11:25 a.m., surveyor observed LVN A receive R#4 from transport staff, assist with R#4's transfer to bed from stretcher and get R#4 set up in bed and comfortable. LVN A had R#4's Resident Admission Checklist with her while getting R#4 set up and was going down the form to ensure that she followed each order listed. LVN A told surveyor that she and the other facility nurses would be using the form on admissions from now on. LVN A then left R#4's room to go to the nurses station and contact R#4's Physician. LVN A reviewed R#4's Resident Admission Checklist and went through each of R#4's [DIAGNOSES REDACTED]. LVN A then transcribed R#4's orders and began to input the information for R#4 in the system. On 08/18/15 at 2:15 p.m., Medical Records Staff D said it was the facility's policy/practice that all [DIAGNOSES REDACTED]. Medical Records Staff D said the nurses were the ones who discontinued medications and diagnoses. Medical Records Staff D said this happened when a resident went to the hospital and was readmitted . Medical Records Staff D said that when a resident came back to the facility, the admitting nurse did a new admission packet. All of the resident's old orders and [DIAGNOSES REDACTED]. Medical Records Staff D said that even the items that they tried to delete or which were mistakes were still present, these items just had a line through them. On 08/18/15 at 10:45 a.m., LVN M, when asked about symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION], listed the following: -[DIAGNOSES REDACTED]: diaphoretic, cold, lethargic, complaints of blurred vision, and anger. (If you feel tired or dizzy, or have a headache or mood swings, your blood sugar may be low. According to the American Diabetes Association (ADA), low blood sugar ([DIAGNOSES REDACTED]) is when your blood sugar falls below 70 mg/dL.) -[MEDICAL CONDITION]: lethargic, and, they seem out of it. (With high blood sugar, you may feel: Very thirsty or hungry, like you need to pass urine more than usual, like your mouth and skin are dry, like your vision is blurry, and sleepy). The Administrator was informed the IJ was lifted on 08/18/15 at 11:55 a.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope at pattern. On 08/18/15 at 12:10 p.m., LVN E said signs and symptoms of [DIAGNOSES REDACTED] were sweating, confusion, and dizziness. LVN E said signs and symptoms of [MEDICAL CONDITION] were basically the same, lethargic or if there was a change in condition or confusion. On 08/18/15 at 12:20 p.m., the DON said signs and symptoms of [DIAGNOSES REDACTED] were diaphoretic, lethargic or any change in condition. Signs and symptoms of [MEDICAL CONDITION] would be lethargic, change in condition, or non-responsive. The facility's [DIAGNOSES REDACTED].

Based on interview, and record review, the facility failed to ensure nursing staff provided services that met professional standards of quality, for one Resident (R#1) of 11 residents reviewed in that: The facility did not obtain orders for insulin and blood sugar monitoring for 17 days after readmission for R#1, who had a [DIAGNOSES REDACTED].#1 went without receiving insulin or blood sugar monitoring for 49 shifts and was sent to the emergency room , where his blood sugar was measured to be 1503 mg/dl (normal range 70-110 mg/dl). R#1 was admitted to the hospital's Intensive Care Unit for treatment of [REDACTED]. R#1 was still in the hospital at the time of investigation. This failure resulted in an Immediate Jeopardy (IJ) situation on 08/17/15. While the IJ was removed on 08/18/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope at pattern, due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place all 25 diabetic residents at risk for deterioration in their health status, or death. The findings were: According to Texas Board of Nursing 15.27, The Licensed Vocational Nurse Standards of Practice-Essential Skills Used in Nursing Process Clinical Reasoning indicated, The Clinical reasoning is another integral component in the nursing process. LVNs must use clinical reasoning and established evidence-based policies, procedures or guidelines as the basis for decision making in nursing practice. LVNs are accountable and responsible for the quality of nursing care provided and must exercise prudent nursing judgment to ensure the standards of nursing practice are met at all times. Texas Board of Nursing, published February 2015 indicated: § 217.12. Unprofessional Conduct. The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (1) Unsafe Practice - actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered or advanced practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11; (B) Carelessly or repeatedly failing to conform to generally accepted nursing standards in applicable practice settings; (C) Improper management of client records; . (2) Failure of a chief administrative nurse to follow appropriate and recognized standards and guidelines in providing oversight of the nursing organization and nursing services for which the nurse is administratively responsible . (4) Careless or repetitive conduct that may endanger a client's life, health, or safety. Actual injury to a client need not be established. R#1's Face Sheet, printed 08/14/15, indicated R#1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]., and Hypertrophy of the Prostate. R#1's Minimum Data Set (MDS) assessment dated [DATE] indicated R#1: -had severe cognitive impairment, -required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene, and -had an active [DIAGNOSES REDACTED]. R#1's care plan, initiated on 04/24/14 indicated R#1 had a [DIAGNOSES REDACTED]. Interventions included: -to perform glucometer checks with [MEDICATION NAME] R per sliding scale per MD orders, and -to monitor for signs and symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis), [MEDICATION NAME] breath (smells fruity), stupor, and coma. R#1's Physician's Orders dated 06/01/15 indicated R#1 was to be administered injections of [MEDICATION NAME] R Solution 100 unit/ML (milliliters) insulin per sliding scale (insulin administration based on the results of a glucometer reading) subcutaneously, every six hours. R#1's June 2015 Medication Administration Record [REDACTED]. Start date was 04/21/14 and discontinue date was 07/22/15. The facility's Admit/Discharge form dated 08/14/15 indicated R#1 was sent to the hospital on [DATE]. Hospital Hematology (lab-work) Report for R#1 indicated blood work was collected on 07/24/15 at 5:30 p.m. R#1 had a glucose (blood sugar) level of 164 mg/dL (normal range 74-100 mg/dL.) The GFR (glomerular filtration rate- test used to tell how well kidneys are working) that was also done on 07/24/15 at 5:30 p.m. was 109.65. According to the hospital lab report the following were the Stages of [MEDICAL CONDITION]: - 1. Kidney damage and normal or elevated GFR >89 mL/min/1.73m - 2. Kidney damage and mildly low GFR 60-89 ml/min/1.73m - 3. Moderately low GFR 30-59 ml/min/1.73m - 4. Severely low GFR 15-29 ml/min/1.73m - 5. Kidney Failure <15 ml/min/1.73m R#1's Medication Administration Record [REDACTED]. R#1's hospital MAR indicated [REDACTED]. R#1's Medication Profile Record from the hospital, dated 07/25/15 did not include any orders for insulin administration or glucose monitoring. Patient Transfer Form from the hospital, dated 07/25/15, indicated R#1 had a [DIAGNOSES REDACTED]. R#1's Patient Transfer Form indicated, Continue with same orders. R#1's undated Admission Check Off List indicated to: -verify orders with MD (physician) and enter all orders in PCC with diagnosis, -if applicable, add batch orders for: Foley Catheter, Enteral Feedings, etc ., and -complete assessment to include: admission assessment comprehensive, bowel and bladder evaluation, Braden scale (to determine risk for development of pressure ulcers), Elopement/wandering evaluation, Fall risk evaluation, Nutrition/Hydration risk evaluation, Pain risk evaluation, AIMS, Psychoactive Medication Evaluation (if on [MEDICAL CONDITION] meds), and Restraint Enabling device/Safety Device Evaluation. R#1's Admission Check Off List was completed by Licensed Vocational Nurse (LVN) A. On R#1's Admission Assessment Comprehensive for admission, dated 07/25/15, Diabetes Mellitus was not listed as one of the [DIAGNOSES REDACTED]. Assessment was completed by LVN A. R#1's Physician's Orders, printed 08/14/15 indicated R#1 was admitted to the facility on [DATE]. Start dates on the orders were 07/25/15. R#1's Physician's Orders did not contain orders to check R#1's blood sugars at any time or to administer insulin at any time. On 08/17/15 at 12:52 p.m., LVN A said she had received R#1 upon readmission from the hospital on [DATE]. LVN A said when an admission was received at the facility the receiving nurse took a report from the hospital over the phone first. LVN A said that, upon the resident's arrival to the facility, the resident was assessed. Any documentation that arrived with the resident was reviewed over the telephone with the Physician. LVN A said the information packet that came with the resident from the hospital included a Patient Transfer Form , Physician's Orders, a Medication Profile Report and a Medication Administration Record, [REDACTED]. Surveyor, along with LVN A reviewed R#1's admission documents dated 07/25/15. LVN A said she had reviewed R#1's Patient Transfer Form, Medication Profile, and Medication Administration Record [REDACTED]. LVN A said she did not recall seeing the document. LVN A added that she only looked at R#1's Patient Transfer Form and Medication Profile. On 08/17/15 at 1:45 p.m., LVN A said that, when R#1 was readmitted to the facility on [DATE], she read R#1's admission [DIAGNOSES REDACTED]. Review of R#1's MAR for July 2015 revealed no documentation that R#1's blood sugar level was checked at any time. There was no documentation R#1 was administered insulin at any time. Review of R#1's MAR for August 2015 revealed no documentation that R#1's blood sugar level was checked at any time, from 08/01/15 to 08/10/15. There was no documentation R#1 was administered insulin from 08/01/15 to 08/10/15. Nursing Progress Notes dated 08/10/15 at 12:20 p.m. for R#1 documented, Family requested resident be sent out to Hospital ER (emergency room ). Called (hospital) ER and gave report. Recent Labs and x-ray included in packet. Nursing Progress Notes dated 08/10/15 at 12:29 p.m. for R#1 documented R#1's Primary Physician was called and notified that, as per family request, R#1 was being sent out to the ER. No blood sugar check was noted in R#1's Nurses Note. Discharge Summary for R#1, effective date of 08/10/15, completed by LVN A, indicated R#1 had a temperature of 98.9, pulse of 84 (regular), respirations of 28, and oxygen at 92% while R#1 was receiving oxygen via nasal cannula. The Progress note section of the Discharge Summary indicated R#1 was using abdominal muscles to assist in breathing and his respirations were at 28 with oxygen at 92%. No blood sugar check was noted on R#1's Discharge Summary. Transfer/Discharge Report dated 08/11/15 for R#1 indicated that R#1 arrived at the facility on 07/25/15 and was transferred out of the facility on 08/10/15. The report indicated that the chief complaint (reason for transfer) for R#1's transfer to the hospital emergency room was: decline in condition, fever, abnormal breathing, and pneumonia. The Transfer/Discharge Report indicated R#1 had a [DIAGNOSES REDACTED].#1's status as a Diabetic in the chief complaint. R#1's hospital ER admission data listed admission date of [DATE]. Reason for visit was listed as Hyperosmolar Monketotic State (life threatening derangement of metabolism in individuals with Diabetes) Severe [MEDICAL CONDITION] (severely elevated blood sugar). Under comments, additional [DIAGNOSES REDACTED]. R#1's hospital Patient Record documented R#1 had a glucose reading of 1503 mg/dl on 08/10/15 at 2:07 p.m. Additional lab findings indicated the eGFR was at 26mL/min. (severely low GFR). According to the hospital lab the following were the Stages of [MEDICAL CONDITION]: - 4. Severely low GFR 15-29 ml/min/1.73m Hospital Progress Note for R#1, dated 08/10/15, indicated R#1 was admitted to the Intensive Care Unit and that he was unresponsive. The Progress Note listed [DIAGNOSES REDACTED]. The Progress Note indicated R#1's condition was serious and prognosis was serious. On 08/14/15 at 3:25 p.m., LVN E said she never checked R#1's blood sugar during his stay from 07/25/15 to 08/10/15. LVN E said she did not have any order to check R#1's blood sugar and she was just following the Physician's orders. LVN E said that, if she would have checked R#1's blood sugar without orders, it would have been an assault. On 08/14/15 at 3:35 p.m., LVN N said, If we have a diabetic resident, we must obtain orders for insulin or medications that address the resident's diabetes. LVN N said orders must also be obtained for blood sugar checks for diabetic residents. LVN N said, As a nurse, when you come in and start your shift it is your responsibility to review your resident's information, including their [DIAGNOSES REDACTED]. On 08/17/15 at 1:25 p.m., the Director of Nurses (DON) said that, upon readmission, R#1 would have been admitted with complete orders. The DON said orders were received as part of a packet that came with the resident from the referring entity. The DON said the admitting nurse received the orders, then input them into the system. A copy was then made and put in the resident's chart so the original could go to medical records. The DON said the admitting nurse should review the whole packet in order to verify the orders with the Physician. Surveyor asked if the admission process was done by more than one person. The DON said the admission process was completed by the same person unless there was a change of shift. The DON said that, in R#1's case, LVN A handled the full admission. On 08/17/15 at 3:49 p.m. the DON said the facility conducted an IDT (interdisciplinary team) meeting when a resident was admitted or readmitted to the facility. The DON said, We don't get too detailed, we look at the resident's orders and, if there is any treatment that they may need or medication, we try to make sure they get it. Surveyor asked the DON if the IDT would have identified the [DIAGNOSES REDACTED].#1's hospital Medication Administration Record. The DON replied, We don't get that detailed. On 08/17/15 at 4:30 p.m., surveyor interviewed Physician C. Physician C said he had been working as the on-call Physician for R#1's Primary Physician on 07/25/15. When asked what kind of care he would expect a facility to provide for a diabetic resident, Physician C replied, They would need to provide scheduled glucose monitoring, scheduled medications for glucose control, and PRN (as needed) medications for breakthrough [DIAGNOSES REDACTED] or [MEDICAL CONDITION] episodes. Physician C said he could not recall exactly what was discussed when the facility contacted him about R#1's readmission to the facility on [DATE]. Physician C said what probably happened was that a nurse called him and read out about 20 orders for a resident that he was not completely familiar with. Physician C said it was possible that the [DIAGNOSES REDACTED]. Physician C said, If you as a nurse call a doctor and he gives an order that does not make any sense, omits something, or is a total contradiction of what the patient needs, it is up to the nurse to clarify the order with the physician. Physician C went on to say that, This is a system of checks and balances, if the order did not make sense and the doctor still insisted upon it, at that point the nurse should notify administration. Once administration is involved they can speak with the doctor or the facility's Medical Director would speak with the doctor and attempt to gain clarification for the order. We have this system to ensure patient safety. It is also the nurse's job to advocate for the patient and ensure that needs of patient are being met. On 08/17/15 at 5:05 p.m., the facility's Administrator was informed an IJ situation was identified due to the above failures. On 08/17/15 at 5:05 p.m., following declaration of Immediate Jeopardy, the Director of Nurses said nursing staff were assessing for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] in residents who were diabetic. The facility's Plan of Removal was submitted by the Administrator and accepted on 08/17/15 at 7:45 p.m. Review of the facility's immediate jeopardy plan of removal dated 08/17/15 revealed: -All new and readmitted resident's orders and admitting information will be reviewed by the Charge Nurse utilizing an Admission Check List to verify orders and [DIAGNOSES REDACTED]. -The Charge Nurse will notify the PCP (primary care physician) and review the admission orders [REDACTED] -The ADON (Assistant Director of Nurses) or Unit Nurse Manager will review the admission and or re-admission orders [REDACTED]. 08/17/15 -The IDT (interdisciplinary team) will review all new and readmitted residents at the morning mtg.(meeting) to verify the check list has been completed by the Charge Nurse and signed by the ADON or unit manager at the time of the admission. 08/18/15. The facility's new Resident Admission Checklist (undated) included: -principal diagnosis, -co-morbid conditions, -adverse events during treatment at transferring facility, -vital signs, -lab results, -current medications, -antibiotics, -feeding tube formula, fluid restrictions, insulin type, last blood sugar result, glucometer checks . On 08/18/15 at 10:25 a.m., surveyor observed LVN A receive report for a new admission (R#4) via telephone. LVN A filled out the facility's new Resident Admission Checklist, revised on 08/17/15. LVN A repeated the [DIAGNOSES REDACTED]. On 08/18/15 at 11:25 a.m., surveyor observed LVN A receive R#4 from transport staff, assist with R#4's transfer to bed from stretcher and get R#4 set up in bed and comfortable. LVN A had R#4's Resident Admission Checklist with her while getting R#4 set up and was going down the form to ensure that she followed each order listed. LVN A told surveyor that she and the other facility nurses would be using the form on admissions from now on. LVN A then left R#4's room to go to the nurses station and contact R#4's Physician. LVN A reviewed R#4's Resident Admission Checklist and went through each of R#4's [DIAGNOSES REDACTED]. LVN A then transcribed R#4's orders and began to input the information for R#4 in the system. On 08/18/15 at 2:15 p.m., Medical Records Staff D said it was the facility's policy/practice that all [DIAGNOSES REDACTED]. Medical Records Staff D said the nurses were the ones who discontinued medications and diagnoses. Medical Records Staff D said this happened when a resident went to the hospital and was readmitted . Medical Records Staff D said that when a resident came back to the facility, the admitting nurse did a new admission packet. All of the resident's old orders and [DIAGNOSES REDACTED]. Medical Records Staff D said that even the items that they tried to delete or which were mistakes were still present, these items just had a line through them. On 08/18/15 at 10:45 a.m., LVN M, when asked about symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION], listed the following: -[DIAGNOSES REDACTED]: diaphoretic, cold, lethargic, complaints of blurred vision, and anger. (If you feel tired or dizzy, or have a headache or mood swings, your blood sugar may be low. According to the American Diabetes Association (ADA), low blood sugar ([DIAGNOSES REDACTED]) is when your blood sugar falls below 70 mg/dL.) -[MEDICAL CONDITION]: lethargic, and, they seem out of it. (With high blood sugar, you may feel: Very thirsty or hungry, like you need to pass urine more than usual, like your mouth and skin are dry, like your vision is blurry, and sleepy). The Administrator was informed the IJ was lifted on 08/18/15 at 11:55 a.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope at pattern. On 08/18/15 at 12:10 p.m., LVN E said signs and symptoms of [DIAGNOSES REDACTED] were sweating, confusion, and dizziness. LVN E said signs and symptoms of [MEDICAL CONDITION] were basically the same, lethargic or if there was a change in condition or confusion. On 08/18/15 at 12:20 p.m., the DON said signs and symptoms of [DIAGNOSES REDACTED] were diaphoretic, lethargic or any change in condition. Signs and symptoms of [MEDICAL CONDITION] would be lethargic, change in condition, or non-responsive. The facility's [DIAGNOSES REDACTED].

Based on observation, record review, and interview, the facility failed to ensure services were provided according to the Physician's Plan of Care (physician's orders [REDACTED].#12, R#7, R#20) of 20 residents reviewed for plans of care, in that: 1) R#12 had a pressure ulcer to the sacrum. physician's orders [REDACTED]. Nursing staff failed to provide wound care treatments as ordered. 2) R#7 had a pressure ulcer to the left hip. physician's orders [REDACTED]. R#7's written care plans called for R#7 to use an air mattress. R#7's bed was not equipped with an air mattress. These failures could place all 14 residents with pressure ulcers at risk for decreased healing or development of new pressure ulcers. 3) R#20 had a physician's orders [REDACTED]. Staff did not mix R#20's liquid protein supplement with water as ordered by the Physician. This failure could place all 21 residents receiving liquid protein supplements at risk for adverse effects. The findings were: 1) Facesheet documented R#12 was an [AGE] year-old female and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Patient Transfer Form documented R#12 was admitted to the facility from the hospital on [DATE] with a Stage 2 pressure ulcer (Partial thickness skin loss presenting as a shallow open ulcer with red-pink wound bed without slough/dead tissue. May also present as an intact or open/ruptured blister) to the coccyx. R#12's Order Summary Report dated 10/01/14 indicated to, "Cleanse right buttock Stage II ulcer with wound cleanser and 4X4 gauze, pat dry with 4X4 gauze, apply [MEDICATION NAME] oint. (ointment)... BID (twice daily) and PRN (as needed)..." Admission Minimum Data Set (MDS) assessment dated [DATE] documented R#12: -had severely impaired cognition (never/rarely made decisions), -was rarely/never able to understand others or make herself understood, -was totally dependent on two or more staff for bed mobility, -required extensive assistance from one staff for transfers, locomotion, dressing, eating, and personal hygiene, -had an indwelling urinary catheter (tube inserted into the bladder to drain urine), -was always incontinent of bowel, -had range of motion impairment to upper and lower extremities on both sides, -had a feeding tube (gastrostomy tube), and, -had one Stage 2 pressure ulcer at admission. R#12's Care Plan, initiated on 10/08/14, documented R#12 had a Stage 2 Pressure Ulcer to the sacrum. Per skin assessment, 10/18/14, wounds to sacrum fused with wounds to bilateral buttocks, now only one Stage 2 Pressure Ulcer to Sacrum. The Goal was for R#12's pressure ulcer to show signs of healing and remain free from infection. Interventions included: -"Administer treatments as ordered and monitor for effectiveness." -"Assess/record/monitor wound healing. Measure length, width and depth where possible." -"Assess and document status of wound perimeter, wound bed and healing progress." -"Report improvements and decline to MD." R#12's Order Summary Report dated 10/20/14 indicated to, "Cleanse wound to sacrum with wound cleanser, pat dry using gauze, apply [MEDICATION NAME] gel (antimicrobial wound gel) using cotton tip applicator, and cover with absorbent non-adherent pad b.i.d. (two times a day) for wound care." On 11/04/14 at 10:05 a.m., Registered Nurse (RN) "D" said R#12 had a Stage 2 pressure ulcer to the sacrum. RN "D" said R#12's wound care was to be done as follows: -Cleanse with wound cleanser, -pat dry with 4x4's, -apply [MEDICATION NAME] gel with q-tip applicator, and, -cover with non-adhering absorbent pad. RN "D" said R#12's wound care was ordered to be done twice a day and as needed due to soiling. On 11/04/14 at 10:05 a.m., surveyor observed RN "D" provide wound care to the pressure ulcer to R#12's sacrum. R#12 was resting on her right side, with eyes open. Team Leader "G" assisted Registered Nurse (RN) "D" with elevating R#12's left hip, allowing access to the wound area. RN "D" removed the adult brief from R#12's left hip, exposing the wound dressing in place. Surveyor observed a date of 11/02 written on the dressing. RN "D" confirmed that the date on the dressing (11/02) was indicative of the last time wound care was done and the dressing was changed. RN "D" proceeded with R#12's ordered wound care and obtained a measurement of 8.0 cm x 7.0 cm x 0.8 cm. RN "D" said the pressure ulcer was being measured as one pressure ulcer since two areas had merged. RN "D" assessed the pressure ulcer as a Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone tendon or muscle is not exposed. Slough or dead tissue, may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) due to visible slough to the center of the wound bed. Surveyor observed non-blanchable reddened areas of skin to bilateral intergluteal cleft, reddened areas connected at the superior end of intergluteal cleft with Stage 3 sacral pressure ulcer. Stage 3 pressure ulcer with visible slough noted to center of wound bed. Surveyor also noted a blanchable reddened area above the pressure ulcer measuring, as confirmed by RN "D", approximately 4.5 cm. On 11/04/14 at 10:45 a.m., RN "D" provided surveyor with R#12's November 2014 Treatment Administration Record (TAR). TAR revealed the physician's orders [REDACTED]." The TAR documented wound care was administered to R#12 on: -11/01/14 at 8:00 a.m. and 4:00 p.m., -11/02/14 at 4:00 p.m., and, -11/03/14 at 4:00 p.m. There were no treatments documented as done at 8:00 a.m. on 11/02/14 or 11/03/14. On 11/04/14 at 11:02 a.m., surveyor asked the Director of Nurses (DON) about the 11/02 date on R#12's dressing and the missing documentation on R#12's Treatment Administration Record. The DON had no response. On 11/04/14 at 1:15 p.m., the DON informed surveyor that he had contacted Licensesd Vocational Nurse (LVN) "F", the nurse who documented the pressure ulcer treatment administered to R#12 on 11/03/14 at 4:00 p.m. The DON stated LVN "F" admitted no wound care was provided as documented on 11/03/14 at 4:00 p.m. The DON provided surveyor with a new TAR printout that documented that the 8:00 a.m. wound care was done on 11/02/14 by RN "D." On 11/04/14 at 2:45 p.m., RN "D" said he was scheduled to do a wound care treatment for [REDACTED]. RN "D" said, "I was just real caught up." Surveyor asked RN "D" if he had provided wound care for R#12 on the morning of 11/02/14. RN "D" said he did not work on 11/02/14. On 11/04/14 at 3:00 p.m., Assistant Director of Nurses (ADON) "I" said that either RN "C" or LVN "E" provided the 8:00 a.m. wound care treatment for [REDACTED]. On 11/04/14 at 3:05 p.m., LVN "E" said she was not scheduled to work on 11/02/14, but was called in to help out and arrived around 11:00 a.m. LVN "E" said she did not remember doing R#12's wound care on 11/02/14. On 11/04/14 at 3:10 p.m., RN "C" said she did not do R#12's wound care on 11/02/14. On 11/04/14 at 4:00 p.m., LVN "E" said she now remembered she did do the wound care for R#12 on 11/02/14. LVN "E" said she had R#12 confused with another resident. LVN "E" had no explanation for RN "D's" initials being on R#12's TAR for the 11/02/14, 8:00 a.m. wound treatment. The facility's Policy/Procedure-Nursing Clinical, Revised: 05/2007, Subject: Stage II, Stage III, and Stage IV revealed the Goal of Treatment: Prevent further deterioration. The facility's procedure did not address adherence to physician's orders [REDACTED]. 2) Admission Record dated 09/04/14 revealed R#7 was an [AGE] year-old female with an admission date of [DATE]. November 2014 Order Summary Report for R#7 documented [DIAGNOSES REDACTED]. Slough or eschar may be present. Often includes undermining and tunneling) to Left Hip, Personal History of Fall, Dysphagia, Cachexia (wasting syndrome), Senile Dementia, Hypertension, [MEDICAL CONDITION], Chronic Ischemic [MEDICAL CONDITIONS] Reflux, and Anxiety State. R#7's LN-Admission Assessment Comprehensive dated 10/25/14 documented R#12 had one Stage 4 pressure ulcer to the left hip, which measured 5.0 cm by 6.0 cm, with a depth of 0.8 cm. Admission MDS assessment dated [DATE] indicated R#7: -was at risk for developing pressure ulcers, and, -had one Stage 4 pressure ulcer which was present upon admission/entry or reentry, measuring 5.0 cm by 6.0 cm, with a depth of 0.8 cm. Care Plan dated 03/14/14 indicated R#7 had a Stage 4 pressure ulcer to the left hip. Interventions included, "uses air mattress, ensure it is connected and working properly." Computerized Phone order dated 03/14/14 indicated R#7, "may have alternating air mattress to help promote wound healing and prevent further skin breakdown." Incident Report dated 03/29/14 indicated R#7 was found on the floor near her bed. No injuries were noted. The Incident Report documented there was an air mattress on R#7's bed. All four bed siderails were up but, "reached below the level of the bed in up position." The Incident Report indicated R#7 tended to be restless when in bed. R#7's Physician was notified. Incident Report section on, "Immediate Action Taken" indicated R#7's air mattress was changed to a regular mattress for R#7's safety. The Incident Report indicated R#7's Physician returned the facility's call and gave no new orders. Quarterly MDS assessment dated [DATE] indicated R#7: -had memory problems, -had moderately impaired cognition (decisions poor, cues/supervision required), -required extensive assistance from two or more staff for bed mobility, transfers, locomotion on unit, locomotion off unit, dressing, eating, and personal hygiene, -required total assistance from staff for toilet use, -had no impairment of the upper or lower extremities, -had falls since admission/entry or reentry, -had two or more falls with no injury, -was at risk for developing pressure ulcers, and, -had one Stage 4 pressure ulcer which was present upon admission/entry or reentry, measuring 2.5 cm by 4.8 cm, with a depth of 0.2 cm. Wound Care Specialist Evaluation dated 10/10/14 indicated R#7 had a Stage 4 pressure ulcer to the left hip for at least 136 days, measuring 4 cm by 1.5 cm, with a depth of 0.3 cm. The Wound Care Specialist Evaluation indicated the pressure ulcer was improved as evidenced by decreased surface area. R#7's Wound Care Specialist Evaluation dated 10/31/14 indicated R#7 had a Stage 4 pressure ulcer to the left hip measuring 4 cm by 1.5 cm, with a depth of 0.3 cm. On 11/03/14 at 11:14 a.m., during initial tour, LVN/MDS Coordinator "A" said R#7 had a Stage 4 pressure ulcer to the sacral area. LVN/MDS Coordinator said R#7's bed had a gel mattress, not an air mattress. On 11/04/14 at 11:06 a.m., surveyor observed no air mattress on R#7's bed. On 11/04/14 at 12:48 p.m., RN "C" said R#7 had a Stage IV pressure ulcer to the left hip. RN "C" said R#7 had a urinary catheter to assist in healing the wound and was turned/repositioned every two hours. RN "C" said R#7 initially had an air mattress; however the air mattress was discontinued because R#7 was attempting to get out of bed. RN "C" said R#7's air mattress was ordered on [DATE] and there were no orders to discontinue the air mattress. RN "C" said R#7 had to have an air mattress because there was a physician's orders [REDACTED]. On 11/04/14 at 1:05 p.m., Assistant Director of Nurses (ADON) "D" said initially R#7's air mattress was ordered and being used, however, the facility stopped using the air mattress because R#7 had falls. ADON "D" said R#7 now had a pressure-reducing mattress. There was no documentation in R#7's physician's orders [REDACTED].#7's air mattress was discontinued by R#7's Physician. On 11/04/14 at 2:51 p.m., ADON "D" said an alternating air mattress off-loads the patient; it will not stay firm or stuck in one position, and was to assist with healing of pressure ulcers. On 11/04/14 at 2:58 p.m., the DON said an alternating air mattress shifted the air mattress in different directions to relieve pressure. On 11/05/14 at 8:17 a.m., surveyor observed no air mattress on R#7's bed. On 11/05/14 at 8:53 a.m., the DON said R#7 had a fall. R#7's Physician was contacted and said to remove the air mattress due to R#7 having falls. The DON said R#7's air mattress was removed and a pressure reduction mattress was placed. The DON said, "may use" on the order meant there was the option to use it or not use it. On 11/05/14 at 9:56 a.m., LVN "B" said R#7 fell from the air mattress in March 2014. LVN "B" said she contacted R#7's Physician to notify him about the fall and, "it was okay changing the air mattress." LVN "B" said she did not recall any further information because the incident happened so long ago. On 11/05/14 at 12:30 p.m. and 2:22 p.m., surveyor interviewed R#7's Physician via telephone. R#7's Physician said he was not aware an air mattress was not being used for R#7. R#7's Physician said he did not recall anyone from the facility contacting him or notifying him about the air mattress not being used. R#7's Physician said R#7 needed the air mattress. The facility's physician's orders [REDACTED]. "1. physician's orders [REDACTED]." The facility's Policy/Procedure-Nursing Clinical, Subject: Air Fluidized Therapy Mattress, dated 05/2007 revealed: "It is the policy of this facility to utilize air fluidized therapy under the direction of a physician's orders [REDACTED]." "Resident may or may not have air mattress unless specified as needed by physician orders. A "may use" can be obtained to have if needed by resident or responsible party." The facility's Policy/Procedure-Nursing Clinical, dated 05/2007, Subject: Preventative Protocol Measures for Residents at High Risk, under " Pressure Relief" revealed: "2. Consider a pressure-reducing device (i.e., pressure reducing mattress, air mattress, gel mattress, alternating air mattress) to address underlying cause." 3) Admission Record dated 11/04/14 documented R#20 was a [AGE] year-old male with an admission date of [DATE]. November 2014 Physician order [REDACTED]. Significant Change MDS dated [DATE] indicated R#20: -had a BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact), -was able to understand others and make himself understood, -had no memory problems, and, -had no behavior problems. physician's orders [REDACTED].#20 was to receive a sugar-free liquid protein supplement, "...give 45 ml (milliliters) mixed with 75 mL of H2O (water) b.i.d." On 11/04/14 at 8:10 a.m., during medication pass, surveyor observed Medication Aide (MA) "H" administer 45 mL of liquid protein supplement by mouth to R#20. The liquid protein supplement was not diluted with water. On 11/05/14 at 9:00 a.m., MA "H" said she did not dilute the liquid protein for R#20 because R#20 did not like it diluted. MA "H" said she had not contacted R#20's Physician to obtain an order to change the administration of the liquid protein supplement. On 11/05/14 at 1:45 p.m., R#20 said he did not know the liquid protein supplement was supposed to be diluted in water. R#20 said it would be much better if it were diluted with water because it would make it much easier to drink because it was thick and had an "awful" taste. R#20 said staff had never offered to dilute his liquid protein with water. During the pre-exit conference conducted on 11/05/14 at 4:30 p.m., the facility was given an opportunity to provide additional information regarding following care plans, including Physicians' plans of care. The facility provided no additional information. On 11/05/14, the facility provided an undated list of 14 residents with air mattresses. R#7's name was not on the list. The facility's Resident Census and Conditions of Residents form indicated 14 residents had pressure ulcers. On 11/05/14 the facility provided a list of 21 residents who received liquid protein supplements, including R#20.

Based on observation, interview, and record review, the facility failed to ensure two Residents (R#12 and R#7) of five residents reviewed for pressure ulcers, received necessary treatment and services to promote healing of pressure ulcers and prevent new ulcers from developing. 1) The facility failed to provide wound care as ordered to R#12's Stage 2 pressure ulcer. There was a decline from a Stage 2 to a Stage 3 pressure ulcer. 2) R#7 had a pressure ulcer to the left hip. physician's orders [REDACTED]. R#7's written care plans called for R#7 to use an air mattress. R#7's bed was not equipped with an air mattress. This failure could place all 14 residents with pressure ulcers at risk for developing new pressure ulcers and decline in existing pressure ulcers. The findings included: 1) Facesheet documented R#12 was an [AGE] year-old female and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Patient Transfer Form documented R#12 was admitted to the facility from the hospital on [DATE] with a Stage 2 pressure ulcer (Partial thickness skin loss presenting as a shallow open ulcer with red-pink wound bed without slough/dead tissue. May also present as an intact or open/ruptured blister) to the coccyx. LN-Skin Assessment/Evaluation dated 09/30/14 documented R#12 had two Stage 2 ulcers. The ulcer to R#12's right buttock measured 1.1 cm (centimeter) by 0.1 cm, with 0 depth. The ulcer to R#12's coccyx measured 1.0 cm x 0.9 cm, with 0 depth. Additional comments were, "Wounds are in close proximity to each other. Wounds are serosanguineous (clear, pinkish, watery drainage), scant, pink in color and edges are well defined." R#12's Order Summary Report dated 10/01/14 indicated to, "Cleanse right buttock Stage II ulcer with wound cleanser and 4X4 gauze, pat dry with 4X4 gauze, apply [MEDICATION NAME] oint. (ointment)... BID (twice daily) and PRN (as needed)..." Admission Minimum Data Set (MDS) assessment dated [DATE] documented R#12: -had severely impaired cognition (never/rarely made decisions), -was rarely/never able to understand others or make herself understood, -was totally dependent on two or more staff for bed mobility, -required extensive assistance from one staff for transfers, locomotion, dressing, eating, and personal hygiene, -had an indwelling urinary catheter (tube inserted into the bladder to drain urine), -was always incontinent of bowel, -had range of motion impairment to upper and lower extremities on both sides, -had a feeding tube (gastrostomy tube), and, -had one Stage 2 pressure ulcer at admission. LN-Skin Assessment/Evaluation dated 10/11/14 documented R#12 had two Stage 2 pressure ulcers to the sacrum, measuring 4.5 cm by 3.7 cm, with 0 depth, and 1.5 cm by 0.5 cm, with 0 depth. Additional Comments were, "Continues with wound care twice a day and as needed. Treatment tolerated well." LN-Skin Assessment/Evaluation dated 10/18/14 documented R#12 had one Stage 2 pressure ulcer to the sacrum, measuring 4.0 cm by 7.0 cm, with 0.1 cm depth. Description: Wounds to sacrum fused with wounds to bilateral buttocks. Measurements 4 cm by 7 cm by 0.1 cm. Upon assessment wound base is pink, scant serosanguineous drainage, no foul smell, no redness around wound. R#12's Care Plan, initiated on 10/08/14, documented R#12 had a Stage 2 Pressure Ulcer (Partial thickness skin loss involving epidermis, or both) to the sacrum. Per skin assessment, 10/18/14, wounds to sacrum fused with wounds to bilateral buttocks, now only one Stage 2 Pressure Ulcer to Sacrum. The Goal was for R#12's pressure ulcer to show signs of healing and remain free from infection. Interventions included: -"Administer treatments as ordered and monitor for effectiveness." -"Assess/record/monitor wound healing. Measure length, width and depth where possible." -"Assess and document status of wound perimeter, wound bed and healing progress." -"Report improvements and decline to MD." R#12's Order Summary Report dated 10/20/14 indicated to, "Cleanse wound to sacrum with wound cleanser, pat dry using gauze, apply [MEDICATION NAME] gel (antimicrobial wound gel) using cotton tip applicator, and cover with absorbent non-adherent pad bid (two times a day) for wound care." R#12's LN-Skin Assessment/Evaluation dated 10/25/14 documented R#12 had one Stage 2 pressure ulcer measuring 3.2 cm by 4.0 cm by 0.1 cm with small serosanguineous drainage noted, wound bed pink. R#12's LN-Skin Assessment/Evaluation dated 11/02/14 documented one Stage 2 pressure ulcer measuring 3.2 cm by 4.0 cm by 0.1 cm with small serosanguineous drainage noted, wound bed pink. On 11/04/14 at 10:05 a.m., Registered Nurse (RN) "D" said R#12 had a Stage 2 pressure ulcer to the sacrum. RN "D" said R#12's wound care was to be done as follows: -Cleanse with wound cleanser, -pat dry with 4x4's, -apply [MEDICATION NAME] gel with q-tip applicator, and, -cover with non-adhering absorbent pad. RN "D" said R#12's wound care was ordered to be done twice a day and as needed due to soiling. On 11/04/14 at 10:05 a.m., surveyor observed RN "D" provide wound care to the pressure ulcer to R#12's sacrum. R#12 was resting on her right side, with eyes open. Team Leader "G" assisted RN "D" with elevating R#12's left hip, allowing access to the wound area. RN "D" removed the adult brief from R#12's left hip, exposing the wound dressing in place. Surveyor observed a date of 11/02 written on the dressing. RN "D" confirmed that the date on the dressing (11/02) was indicative of the last time wound care was done and the dressing was changed. RN "D" proceeded with R#12's ordered wound care and obtained a measurement of 8.0 cm x 7.0 cm x 0.8 cm. RN "D" said the pressure ulcer was being measured as one pressure ulcer since two areas had merged. RN "D" assessed the pressure ulcer as a Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) due to visible slough to the center of the wound bed. Surveyor observed non-blanchable reddened areas of skin to bilateral intergluteal cleft, reddened areas connected at the superior end of intergluteal cleft with Stage 3 sacral pressure ulcer. Stage 3 pressure ulcer with visible slough noted to center of wound bed. Surveyor also noted a blanchable reddened area above the pressure ulcer measuring, as confirmed by RN "D", approximately 4.5 cm. On 11/04/14 at 10:45 a.m., RN "D" provided surveyor with R#12's November 2014 Treatment Administration Record (TAR). TAR revealed the physician's orders [REDACTED]." The TAR documented wound care was administered to R#12 on: -11/01/14 at 8:00 a.m. and 4:00 p.m., -11/02/14 at 4:00 p.m., and, -11/03/14 at 4:00 p.m. There were no treatments documented as done at 8:00 a.m. on 11/02/14 or 11/03/14. On 11/04/14 at 11:02 a.m., surveyor asked the Director of Nurses (DON) about the 11/02 date on R#12's dressing and the missing documentation on R#12's Treatment Administration Record. The DON had no response. On 11/04/14 at 1:15 p.m., the DON informed surveyor that he had contacted LVN "F", the nurse who documented the pressure ulcer treatment administered to R#12 on 11/03/14 at 4:00 p.m. The DON stated LVN "F" admitted no wound care was provided as documented on 11/03/14 at 4:00 p.m. The DON provided surveyor with a new TAR printout that documented that the 8:00 a.m. wound care was done on 11/02/14 by RN "D." On 11/04/14 at 2:45 p.m., RN "D" said that he was scheduled to do a wound care treatment for [REDACTED]. RN "D" said, "I was just real caught up." Surveyor asked RN "D" if he had provided wound care for R#12 on the morning of 11/02/14. RN "D" said he did not work on 11/02/14. On 11/04/14 at 3:00 p.m., Assistant Director of Nurses (ADON) "I" said that either RN "C" or LVN "E" provided the 8:00 a.m. wound care treatment for [REDACTED]. On 11/04/14 at 3:05 p.m., LVN "E" said she was not scheduled to work on 11/02/14, but was called in to help out and arrived around 11:00 a.m. LVN "E" said she did not remember doing R#12's wound care on 11/02/14. On 11/04/14 at 3:10 p.m., RN "C" said she did not do R#12's wound care on 11/02/14. On 11/04/14 at 4:00 p.m., LVN "E" said she now remembered she did do the wound care for R#12 on 11/02/14. LVN "E" said she had R#12 confused with another resident. LVN "E" had no explanation for RN"D's" initials being on R#12's TAR for the 11/02/14, 8:00 a.m. wound treatment. The facility's Policy/Procedure-Nursing Clinical, dated Revised:05/2007, Subject: Stage II, Stage III, and Stage IV revealed the Goal of Treatment: Prevent further deterioriation. The facility's procedure did not address adherence to physician's orders [REDACTED]. 2) Admission Record dated 09/04/14 revealed R#7 was an [AGE] year-old female with an admission date of [DATE]. November 2014 Order Summary Report for R#7 documented [DIAGNOSES REDACTED]. R#7's LN-Admission Assessment Comprehensive dated 10/25/14 documented R#12 had one Stage 4 pressure ulcer (Stage 4 - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) to the left hip, which measured 5.0 cm by 6.0 cm, with a depth of 0.8 cm. Admission MDS assessment dated [DATE] indicated R#7: -was at risk for developing pressure ulcers, and, -had one Stage 4 pressure ulcer which was present upon admission/entry or reentry, measuring 5.0 cm by 6.0 cm, with a depth of 0.8 cm. Care Plan dated 03/14/14 indicated R#7 had a Stage 4 pressure ulcer to the left hip. Interventions included, "uses air mattress, ensure it is connected and working properly." Computerized Phone order dated 03/14/14 indicated R#7, "may have alternating air mattress to help promote wound healing and prevent further skin breakdown." Incident Report dated 03/29/14 indicated R#7 was found on the floor near her bed. No injuries were noted. The Incident Report documented there was an air mattress on R#7's bed. All four bed siderails were up but, "reached below the level of the bed in up position." The Incident Report indicated R#7 tended to be restless when in bed. R#7's Physician was notified. Incident Report section on, "Immediate Action Taken" indicated R#7's air mattress was changed to a regular mattress for R#7's safety. The Incident Report indicated R#7's Physician returned the facility's call and gave no new orders. Quarterly MDS assessment dated [DATE] indicated R#7: -had memory problems, -had moderately impaired cognition (decisions poor, cues/supervision required), -required extensive assistance from two or more staff for bed mobility, transfers, locomotion on unit, locomotion off unit, dressing, eating, and personal hygiene, -required total assistance from staff for toilet use, -had no impairment of the upper or lower extremities, -had falls since admission/entry or reentry, -had two or more falls with no injury, -was at risk for developing pressure ulcers, and, -had one Stage 4 pressure ulcer which was present upon admission/entry or reentry, measuring 2.5 cm by 4.8 cm, with a depth of 0.2 cm. Wound Care Specialist Evaluation dated 10/10/14 indicated R#7 had a Stage 4 pressure ulcer to the left hip of at least 136 days of duration, measuring 4 cm by 1.5 cm, with a depth of 0.3 cm. The Wound Care Specialist Evaluation indicated the pressure ulcer was improved as evidenced by decreased surface area. Wound Care Specialist Evaluation dated 10/31/14 indicated R#7 had a Stage 4 pressure ulcer to the left hip measuring 4 cm by 1.5 cm, with a depth of 0.3 cm. On 11/03/14 at 11:14 a.m., during initial tour, LVN/MDS Coordinator "A" said R#7 had a Stage 4 pressure ulcer to the sacral area. LVN/MDS Coordinator said R#7's bed had a gel mattress, not an air mattress. On 11/04/14 at 11:06 a.m., surveyor observed no air mattress on R#7's bed. On 11/04/14 at 12:48 p.m., RN "C" said R#7 had a Stage IV pressure ulcer to the left hip. RN "C" said R#7 had a urinary catheter to assist in healing the wound and was turned/repositioned every two hours. RN "C" said R#7 initially had an air mattress; however the air mattress was discontinued because R#7 was attempting to get out of bed. RN "C" said R#7's air mattress was ordered on [DATE] and there were no orders to discontinue the air mattress. RN "C" said R#7 had to have an air mattress because there was a physician's orders [REDACTED]. On 11/04/14 at 1:05 p.m., Assistant Director of Nurses (ADON) "D" said initially R#7's air mattress was ordered and being used, however, the facility stopped using the air mattress because R#7 had falls. ADON "D" said R#7 now had a pressure-reducing mattress. There was no documentation in R#7's physician's orders [REDACTED].#7's air mattress was discontinued by R#7's Physician. On 11/04/14 at 2:51 p.m., ADON "D" said an alternating air mattress off-loads the patient; it will not stay firm or stuck in one position, and was to assist with healing of pressure ulcers. On 11/04/14 at 2:58 p.m., the DON said an alternating air mattress shifted the air mattress in different directions to relieve pressure. On 11/05/14 at 8:17 a.m., surveyor observed no air mattress on R#7's bed. On 11/05/14 at 8:53 a.m., the DON said R#7 had a fall. R#7's Physician was contacted and said to remove the air mattress due to R#7 having falls. The DON said R#7's air mattress was removed and a pressure reduction mattress was placed. The DON said, "may use" on the order meant there was the option to use it or not use it. On 11/05/14 at 9:56 a.m., LVN "B" said R#7 fell from the air mattress in March 2014. LVN "B" said she contacted R#7's Physician to notify him about the fall and, "it was okay changing the air mattress." LVN "B" said she did not recall any further information because the incident happened so long ago. On 11/05/14 at 12:30 p.m. and 2:22 p.m., surveyor interviewed R#7's Physician via telephone. R#7's Physician said he was not aware an air mattress was not being used for R#7. R#7's Physician said he did not recall anyone from the facility contacting him or notifying him about the air mattress not being used. R#7's Physician said R#7 needed the air mattress. The facility's physician's orders [REDACTED]. "1. physician's orders [REDACTED]." The facility's Policy/Procedure-Nursing Clinical, Subject: Air Fluidized Therapy Mattress, dated 05/2007 revealed: "It is the policy of this facility to utilize air fluidized therapy under the direction of a physician's orders [REDACTED]." "Resident may or may not have air mattress unless specified as needed by physician orders. A "may use" can be obtained to have if needed by resident or responsible party." The facility's Policy/Procedure-Nursing Clinical, dated 05/2007, Subject: Preventative Protocol Measures for Residents at High Risk, under "Pressure Relief" revealed: "2. Consider a pressure-reducing device (i.e., pressure reducing mattress, air mattress, gel mattress, alternating air mattress) to address underlying cause." During the pre-exit conference conducted on 11/05/14 at 4:30 p.m., the facility was given an opportunity to provide additional information regarding provision of treatment and services to promote healing of pressure ulcers. The facility provided no additional information. The facility's Resident Census and Conditions of Residents form indicated 14 residents had pressure ulcers. On 11/05/14, the facility provided an undated list of 14 residents with air mattresses. R#7's name was not on the list.