Every finding on record at West Janisch Health Care Center

Based on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for 1 of 5 Halls (400 Hall) 22 of 22 residents (CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) reviewed for neglect.- On [DATE] the facility failed to timely extinguish the fire when CR #44 was engulfed in flames and failed to assess and render aid to CR #44 after the fire was extinguished. The resident expired in the facility immediately after the fire.- The facility failed to take action for over 6 months when it knew after activation of the fire system, control access doors locked and prevented staff from entering to provide services to residents in the 400 Hall without the use of a code. During a fire on [DATE], while CR #44 was engulfed in flames, staff could not access the 400 Hall to provide aide to CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61 and Resident #66 for 3 minutes when the doors closed and locked with only CNA F on the hall.- The facility failed to ensure staff knew the unlocking mechanisms for controlled access doors in the facility that could prevent them from providing services to residents during emergency circumstances like fires. An Immediate Jeopardy was identified on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 05:00 PM. While the immediacy was removed on [DATE], at 04:54 PM, the facility remained out of compliance at a severity level of no actual harm, with a potential for more than minimal harm that was not an immediate jeopardy, and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of potential smoke inhalation, fire-related burns, debilitating injuries and death. Findings included Observation of the facility time stamped security footage of the front hall dated [DATE] revealed, at 01:16 AM staff at the nursing station looked around with the doors open to the 400 Hall. At 01:17 AM staff in a blue top and black pants (CNA D) walked into the 400 Hall and shortly after 2 staff one in all black (CNA P) and one in blue walked toward the 400 Hall when CNA D runs out from the 400 Hall and to the nursing station. The staff in blue moved out of frame towards the 500/600 Hall, while CNA P walked into the 400 Hall and CNA D entered the med room located behind the nursing station, grabbed the fire extinguisher and walked into the 400 Hall. The staff in blue and 1 other staff walk into the 400 Hall behind her with the staff in blue holding the door. At 01:18 AM staff in a pink jacket (LVN I) comes out of the 400 Hall and walked in a fast pace out of frame towards the [DATE] Hall and the staff in the blue is seen at the front door looking into the 400 Hall with her hands over her mouth as a resident (Resident #4) walked out pushing her wheelchair. As Resident #4 came out of the 400 Hall the door is seen to hit her and the staff in blue held the door open and then entered the 400 hall. CNA D runs out of the 400 Hall followed by 1 other staff and was seen on the phone as the other staff moved out of frame by the 500/600 Hall. At this time Resident 4 was alone, standing while holding her wheelchair immediately in front of the 400 Hall, when CNA P walked out followed by the staff in blue. CNA P walked back into the 400 Hall and out again and the doors to the 400 Hall slowly closed behind her at 01:18:52 AM. At 01:19 AM, the staff realized the door was closed, banged on the door and attempted were seen entering a code at a keypad. At this time, LVN I entered codes at the door to the 400 Hall with 2 other staff, CNA D was on the phone at the nursing station with the staff in blue, and CNA P runs out the door with another staff. Resident #4 sat in her wheelchair in the front hall and received no assessments or evaluation as staff moved in and out of frame. At 1:21 AM an unknown resident (unknown resident #1) in a wheelchair moved toward the door of the 400 Hall, appeared to enter a code on the keypad and the door opened at 01:21: 53 AM (3 minutes after closing and 5 minutes after staff were alerted of the fire) and CNA P ran to the 400 Hall doors, held it open and smoke is seen coming out at the top the door. At 01:22:09 a resident (unknown resident #2) walked out the door, CNA P, CNA D and another staff enter into the 400 Hall as the staff in blue attempted to push the 2nd door in the double door to the 400 Hall. The door did not open and Resident #4 and unknown resident #1 who opened the door are wheeled out of frame toward the 500/600 Hall. At 01:23 AM CNA D is seen wheeling an unknown resident out the front door while unknown resident #2 is seen walking around the hall as smoke is seen coming out of the 400 Hall. CNA D, CNA P, the staff in blue, LVN I and other staff wheeled other residents out the front door until 01:26 AM when fully geared fire men arrived and entered the 400 Hall. At 01:28 AM the firefighters exit the 400 Hall and return into the hall and at 01:29 AM the EMTs arrive and enter into the 400 Hall. More firefighters arrived, moved in and out of the unit, at 1:33 AM (6 minutes after the fire was identified) an EMT walked out of the 400 Hall, while a fire fighter pushed against the 2nd door to the double doored 400 Hall that remained locked in place during this incident. Fire men turned sideways as they carried their equipment and walked through the single door open in the double doors to the 400 Hall and on and off attempted to open the locked door. Record review of the Fired Department NFIRS-1 Basic report dated [DATE] revealed, the fire department arrived to the facility on [DATE] at 01:33 PM (a 7 minute discrepancies from the facility's timestamped video) for a building fire.- Actions taken: evacuate area and ventilate.- Casualties: 1 civilian and no injuries- Hazardous Materials Release: None- Property Use: Nursing HomeRemarks: Dispatched to a nursing home on fire. [fire department staff] were the first to arrive on scene of a 1-story pitched roofbuilding with nothing showing from the exterior. residents were being evacuated by building personnel. [fire department staff]assumed [facility] road command. [fire department staff] was ordered to investigate and reports a haze inside the building. [fire department staff] arrived and was ordered to assist with evacuation & prepare for horizontal ventilation. [fire department staff] reports a [location of fire] was found and the fire is out. [fire department staff] arrived and were ordered to assist with evacuationand ventilation. [fire department staff] were disregarded. arson was requested. [fire department staff] arrived and was assigned toevacuation group. [fire department staff] reports 11 residents were protected in place, haze is clearing out, and the room the 10-50 is in has been secured. the incident was tapped out holding [fire department staff] , [fire department staff] , [fire department staff] , & [fire department staff] . building personnel report the fire alarm was triggered and went to the wing to find the source of the alarm. CNA D was the 1st to find the source and used a fire extinguisher. the [location of fire] was in a 2-person room. the 2nd resident wasevacuated by building personnel. the small fire looks to have started on the bed near the victims head. There was no extension beyond the items on the bed. building personnel report the deceased is a smoker, but no one witnessed how the fire started. no signs of medical oxygen use in the room. a pump can was used to apply a small amount of water on a small book that was next to the deceased . [police department] units arrive .- Ignition: 21-Bedroom - < 5 persons- Area of Fire Origin: Undetermined- Heat Source: Undetermined- Item First Ignited: Undetermined- Cause of Ignition: Cause Under Investigation- Factors Contributing to Ignition: Undetermined- Human Factors Contributing to Ignition: Asleep- Mobile Property Involved: None- Fire Spread: Confined to Object of Origin- Presence of Detectors: Present- Detector Type: Smoke- Detector Operation: Operated- Detector Effectiveness: Alerted Occupants, Occupants Responded- Presence of Automatic Extinguishing System: Present- Operation of Automatic Extinguishing System: Fire Too Small To Activate- [fire department staff]: arrived and was assigned evacuation group. Some patients were evacuated from building and 11 were sheltered in place. [fire department staff]- observed that the deceased pt appeared to not have any oxygen because of the absence of o2 bottle or o2 bib on the wall. notified command and secured the room.- [fire department staff]: arrived on location and was ordered by fire department staff]to investigate. upon entry we found the fire alarm system to be active and there was smoke in the lobby area. nursing home staff were evacuating residents. We made our way to the fire room and found one deceased victim in the first bed. i appears the fire started in the bed she occupied. fire department staff]notified command and we then assisted fire department staff] and fire department staff]with ventilating that wing of thenursing home. we also checked on the other occupants on that hallway. due to smoke conditions the rest of the hallway was sheltered in place. CR #44 Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The residents advanced directive was Full Code and she expired in the facility on [DATE] at 01:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left sided weaknessCare Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 ft 8 inches, and 274 lbs. Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Record review of CR #44's Discharge MDS dated [DATE] revealed, discharged Status- deceased . Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Clinical Assessments revealed, the last clinical assessment documented was on [DATE]. Record review of CR #44's Progress Notes revealed,- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the Hoyer Lift. Resident tolerated well.- [DATE] 01:54 AM signed by the DON, After speaking with the charge nurse and CNA, I called the RP's daughter to inform her that her mother was involved in a fire incident and that she was being treated for possible burns. Explained that the ambulance was working on [CR #44] at this time, and they would probably take her to the [Hospital]. The RP said she was not in town and that she would call her brother to see if he was closer than she was. RP said she would leave where she is and head to [Hospital] to check on her mother.- [DATE] 08:03 AM signed by LVN I, At approximately 01:00 AM the writer was on hall 600 to check on the other resident in my care. On my way back to 400, as I was walking down the hall I observed residents in bed sleeping including room [ROOM NUMBER]. As the writer was at the back of the hall 400, approximately 10 minutes later the writer heard alarm sound with flashing lights. I heard a CNA calling me and telling me the fire was in room [ROOM NUMBER]. As the writer was going to room [ROOM NUMBER], the CNA who was in front of me, grabbed the extinguisher and entered the room before I got there. When I entered the room I said to the CNA to call 911, then I assisted the CNA to evacuate the room-mate while the other 2 CNA's was trying to put the fire out. Once the roommate was safely evacuated, I immediately went to render aide to [CR #44]. As I was getting ready to assess the resident 911 was already here and in the room. The EMT's asked where the other resident was, and I told them she was outside. EMT's were providing medical care to [CR #44] and I left the room to go be with the residents that were outside. I then notified the DON once the residents were evacuated off of the hall and accounted for.- [DATE] 10:21 AM signed by MA C, resident expired. In an interview on [DATE] at 01:27 PM, CNA M said CR #44 did not exhibit any behaviors such as hoarding or hiding items, she was a smoker but she was complaint with the facility smoking policy. CNA M said there were no issues with CR #44 smoking. In an interview on [DATE] at 01:28 PM, LVN C said CR #44 was bed/wheelchair bound, required total assistance with all ADLs, had left side paralysis but could eat with setup/assistance. She said while the resident was grumpy, sarcastic and refused care there were no issues hoarding or hiding times. CR #44 was compliant with the facility smoking policy and would only smoke in the designated area. An observation on [DATE] at 09:58 AM revealed, CR #44's room floor covered by white powder and the room had been cleared of contents. There were gloves and packs of Personal Cleaning Wipes on the floor and on the bed. An off-white metal bed lie closest to the entrance, with no mattress and visible black fire damage. The center of the headboard was warped and melted with black burn marks, black ash/soot was observed on the base of the headboard, bed frame, and on the floor. There was limited evidence of smoke damage on the walls and ceiling with wipe marks on the ceiling directly above CR #44's bed and an imprint caused by smoke on the wall were a something was hung that was now removed. An observation and interview on [DATE] at 01:35 PM revealed, a box containing resident cigarettes and lighters locked in the med room. A box of cigarettes bearing CR #44's initials contained 7 cigarettes. The [NAME] said CR #44 had no behaviors of hoarding or hiding of items like cigarettes. She said her only behavior was to make complaints about staff, and that behavior was in her care plan. The DON said CR #44 diligently followed facility smoking policy and she would wait for staff to take her out to smoke. In an interview on [DATE] at 03:31 PM, the Medical Director said she had been Medical Director in the facility for the last 1 1/2 to 2 years. She said if a resident had extensive burns, the facility would not initially treat the burns while in an emergency situation but would cover the resident with clean, dry sheets; monitor breathing and keep the resident warm after the fire was extinguished. She said a resident with severe burns would need specialized treatment that could only the hospital could provide but she would expect nursing facility staff to assess the residents signs, mainly the breathing. The Medical Director said to maintain a resident's life prior to arrival of EMS, staff must monitor vital signs and monitor alertness. Once the resident was moved away from the fire source, staff should make sure airway was clear, resident was breathing, provide oxygen if necessary, monitor the residents pulse and blood pressure until EMS arrive. The Medical Director said if assessments and aide was not rendered to a resident with severe burns the resident could go into shock and a lot of things could happen. She said a resident with severe burns to the upper chest with shallow breathing should not be left unattended and someone should be with a resident if they have severe burns. The Medical Director said nursing home staff can provide services to help sustain life until EMS arrives and the resident should be continuously monitored. In an interview on [DATE] at 04:15 PM, the DON said when an individual experienced extensive burns they must be immediately assessed. Bleeding should be stopped, the airway must be assessed for lung sounds, and vitals assessed. She said nursing staff must stay with the resident until help arrived, and part of the competency of a nurse is training on how to react in an emergency situation. The DON said prior to the fire on [DATE] staff were not trained on what do to if a resident had a severe burn, but they know what to do now. She said to her knowledge nursing staff did not assess CR #44 after the fire was extinguished. The DON said no one assessed CR #44 after the fire but they should have as it was a professional standard. When asked about the risk to residents if staff failed to assess them following extensive burns, the DON said based on her investigation, she thought CR #44 was expired when she was found on fire and no one told her the resident was moving and groaning at the time of the fire. She said, only god has the power over life and death, and if a resident expired it was in God's Hands. When pressed the [NAME] said treatment rendered to a resident with extensive burns was based on what the assessments yields, but staff should make sure the resident was breathing. In an interview on [DATE] at 03:25 PM, the ME said CR #44's cause of death was still pending but the resident suffered from 2nd (burn that damages the top layer of skin and part of the 2nd layer) and 3rd (burn that destroys the first three layers of skin and the fatty tissue) degree burns on her head, upper torso and extremities. She had significant charring (severe burn that has destroyed all layers of skin and may extend into underlying tissue caused by prolonged exposure to extreme heat that appears black or ash-gray) especially to the left side of her body not the right. There was soot deposition in her airway/bronchi, which indicated she was breathing while on fire. 26% of CR #44's body surface was burned. Resident #2 Record review of Resident #2's Face Sheet dated [DATE], revealed a 93- year- old female who admitted to the facility on 03/13/ 20 with diagnosis which included: Type 2 diabetes, COPD, dementia, epilepsy, and irregular heartbeat. Record review of Resident #2's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 0 out of 15. The resident had lower extremity functional limitations in range of motion used automobile chair and required maximum assistance for most ADL's. For mobility, the resident was either dependent or required maximum assistance. The resident was fully dependent on staff to propel in a motorized wheelchair for 50 to 150 feet. Record review of Resident #2's undated Care Plan revealed, Focus- Requires a wander guard bracelet and is at risk for injury from wandering in an unsafe environment; Interventions: Monitor resident in facility and document attempts to elope out of facility. Focus: ADL self-care performance deficit r/t impaired cognition, poor safety awareness. Ambulates without use of an assistive device. She will at times hold onto the rails in hallway. Resident may require increased assistance with transfers depending on level of surface she is transferring from. Interventions: requires assistance of one staff to turn and reposition in bed at regular intervals. Record review of Resident #2's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- Resident #2 requires assistance of 1 staff to turn and reposition in bed at regular intervals and as necessary; requires assistance with lying to sitting at times. Transfer- requires assistance of one staff for supervision to move between surfaces as tolerated. Resident # 2 May require assistance with sit to stand if sitting for prolonged period of time or level of surface. Resident #3 Record review of Resident #3's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, paralysis following a stroke, dementia, anxiety disorder, and bed confinement status. Record review of Resident #3's Quarterly MDS dated 9/11 25 revealed, severely impaired cognition skills for daily decision making and impairments in functional limitations in range of motion for both sides of her upper and lower extremity. Record review of Resident #3's undated Care Plan revealed, Focus-Resident received oxygen as needed. The shortness of breath. Interventions: Monitor for signs and symptoms of respiratory distress- SOB, dyspnea, low O2, cyanosis, diaphoresis, changes in behavior. Record review of Resident #3's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- total dependence on staff for repositioning and turning in bed. Lying to Sitting on side of bed: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Roll Left and Right: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to lying: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to stand: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Toilet transfer: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transfer: total dependence on staff for transfer. An observation on [DATE] at 10:19 AM revealed, Resident #3 lying in bed with eyes closed, well-dressed well-groomed in no immediate distress. Resident #4 Record Review of Resident #4's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, generalized anxiety disorder, unspecified dementia with other behavioral disturbances, adjustment disorder, major depressive disorder, Constipation, bradycardia, and repeated false. Record review of Resident #4's BIMS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 10.Record review of Resident #4's undated Care Plan revealed, Focus- impaired cognitive function/dementia or impaired thoughtProcesses; Interventions: needs supervision/assistance with all decision making. Focus: impaired visual function r/t Glaucoma; Interventions: during activities provide the resident with items that have larger print and bigger pictures to promote participation. Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs; Interventions: partial/moderate assistance with upper and lower body dressing. Transfer- Supervision by 1 staff to move between surfaces, as necessary. Bed Mobility- Supervision by 1 staff to move between surfaces, as necessary.An observation and interview on [DATE] at 02:41 PM revealed, Resident #4 was well groomed, well dressed in no immediate distress in a wheelchair. The resident was not interviewable, she was confused and repeated that she did not want to spend a night. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis), type 2 diabetes, difficulty swallowing, dementia, and anorexia. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The use of a manual wheelchair, total dependence on most ADL's, and total dependence for most functional abilities. Record review of Resident #6's undated Care Plan revealed, Focus: Impaired visual function; Interventions: notify where you are placing their items. Be consistent and cater to the resident's preference of item placement. Focus: ADL self-care performance deficit, requires staff assist with ADL cares, refused to get out of bed daily; Interventions: Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Record review of Resident #6's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Am observation on [DATE] at 10:20 AM revealed, Resident #6 well dressed, well-groomed lying in bed awake. The resident responded to the surveyor with head nods and indicated she needed help. Resident #11 Record review of Resident #11's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia, bipolar disorder, diabetes and hypertension. Record review of Resident #11's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, one sided upper extremity and 2 sided lower extremity functional limitations in range of motion. Use of a wheelchair, total dependence with most ADLs and all functional abilities, total dependence for use of a manual scooter. Record review of Resident #11's undated Care Plan revealed, ADL self-care performance deficit and requires maximum assistance with ADLs r/t activity intolerance, Alzheimer's, impaired balance and limited M=mobility Record review of Resident #11's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- lying to sitting on side of the bed- dependent helper does all the effort; roll left and right- substantial/maximal assistance helper does more than half of the effort. Sit to stand- dependent helper does all the effort. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more was required for the resident to complete the activity. Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Parkinsonism. epilepsy, hypertension, difficulty breathing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, short term and long term memory OK. And independent cognitive skills for daily decision making The use of a wheelchair, no upper or lower extremity functional limitations in range of motion, substantial or maximum assistance to total dependence for all ADL's and substantial maximum assistance to total dependence on staff for mobility. Record review of Resident #18's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Parkinson's Disease. Interventions: chair/bed-to-chair transfer: Resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Lying to sitting on side of bed: resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Roll left and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces Resident #25 Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure. Depression, dependence on dialysis, and dementia. The resident discharged to the hospital on [DATE]. Record review of Resident #25's Discharge MDS dated [DATE] revealed, Modified independence. Cognitive skills for daily decision making and set up or clean up assistance with most ADL's. As well as partial to moderate assistance with most functional abilities. Record review of Resident #25's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues,setup, and/or assistance with ADLs r/t dx dementia, anxiety, depression; Interventions- Chair/bed-to-chair transfer: resident's usual independent - resident completes the activity with no assistance from a helper. Lying to sitting on side of bed- resident's usual independent - resident completes the activity with no assistance from a helper. Roll left and right- resident's usual independent - resident completes the activity with no assistance from a helper. Sit to lying- resident's usual independent - resident completes the activity with no assistance from a helper. Sit to

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 13 of 22 residents (CR #44, Resident #2 Resident #3, Resident #6, Resident #11, Resident #18, Resident #20, Resident #36, Resident #43, Resident #48, Resident #54, Resident #58, and Resident #60) and 1 of 4 Halls (400 Hall) reviewed for quality of care.- Facility staff failed to immediately put out CR #44 when she was engulfed in flames with a fire extinguisher, a non-fire retardant blanket was used that worsened the fire. After the fire was extinguished staff failed to assess and render aide to CR #44. The resident expired in the facility immediately after the fire.- Facility failed to follow the facility fire safety plan when evacuating residents from the 400 hall by leaving Resident #2 Resident #3, Resident #6, Resident #11, Resident #18, Resident #20, Resident #36, Resident #43, Resident #48, Resident #54, Resident #58, and Resident #60 in their rooms during a fire on [DATE] which resulted in prolonged exposure to smoke. An Immediate Jeopardy was identified on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 11:20 AM. While the IJ was removed on [DATE], at 04:54 PM, the facility remained out of compliance at a severity level of no actual harm, with a potential for more than minimal harm that was not an immediate jeopardy, and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving care and services needed to meet their needs Findings included Observation of the facility time stamped security footage of the front hall dated [DATE] revealed, at 01:16 AM staff at the nursing station looked around with the doors open to the 400 Hall. At 01:17 AM staff in a blue top and black pants (CNA D) walked into the 400 Hall and shortly after 2 staff one in all black (CNA P) and one in blue walked toward the 400 Hall when CNA D runs out from the 400 Hall and to the nursing station. The staff in blue moved out of frame towards the 500/600 Hall, while CNA P walked into the 400 Hall and CNA D entered the med room located behind the nursing station, grabbed the fire extinguisher and walked into the 400 Hall. The staff in blue and 1 other staff walk into the 400 Hall behind her with the staff in blue holding the door. At 01:18 AM staff in a pink jacket (LVN I) came out of the 400 Hall and walked in a fast pace out of frame towards the [DATE] Hall and the staff in the blue was seen at the front door looking into the 400 Hall with her hands over her mouth as a resident (Resident #4) walked out pushing her wheelchair. As Resident #4 came out of the 400 Hall the door is seen to hit her and the staff in blue held the door open and then entered the 400 hall. CNA D runs out of the 400 Hall followed by 1 other staff and was seen on the phone as the other staff moved out of frame by the 500/600 Hall. At this time Resident 4 was alone, standing while holding her wheelchair immediately in front of the 400 Hall, when CNA P walked out followed by the staff in blue. CNA P walked back into the 400 Hall and out again and the doors to the 400 Hall slowly closed behind her at 01:18:52 AM. At 01:19 AM, the staff realized the door was closed, banged on the door and were observed pressing a keypad. At this time, LVN I entered codes at the door to the 400 Hall with 2 other staff, CNA D was on the phone at the nursing station with the staff in blue, and CNA P ran out the door with another staff. Resident #4 sat in her wheelchair in the front hall and received no assessments or evaluation as staff moved in and out of frame. At 1:21 AM an unknown resident (unknown resident #1) in a wheelchair moved toward the door of the 400 Hall, appeared to enter a code on the keypad and the door opened at 01:21: 53 AM (3 minutes after closing and 5 minutes after staff were alerted of the fire) and CNA P ran to the 400 Hall doors, held it open and smoke was seen coming out at the top the door. At 01:22:09 a resident (unknown resident #2) walked out the door, CNA P, CNA D and another staff enter into the 400 Hall as the staff in blue attempted to push the 2nd door in the double door to the 400 Hall. The door did not open and Resident #4 and unknown resident #1 who opened the door are wheeled out of frame toward the 500/600 Hall. At 01:23 AM CNA D was seen wheeling an unknown resident out the front door while unknown resident #2 is seen walking around the hall as smoke was seen coming out of the 400 Hall. CNA D, CNA P, the staff in blue, LVN I and other staff wheeled other residents out the front door until 01:26 AM when fully geared fire men arrived and entered the 400 Hall. At 01:28 AM the firefighters exit the 400 Hall and return into the hall and at 01:29 AM the EMTs arrive and enter into the 400 Hall. More firefighters arrived, moved in and out of the unit, at 1:33 AM (6 minutes after the fire was identified) an EMT walked out of the 400 Hall, while a fire fighter pushed against the 2nd door to the double doored 400 Hall that remained locked in place during this incident. Fire men turned sideways as they carried their equipment and walked through the single door open in the double doors to the 400 Hall and on and off attempted to open the locked door. Record review of the Fire Department NFIRS-1 Basic report dated [DATE] revealed, the fire department arrived to the facility on [DATE] at 01:33 PM (a 7 minute discrepancies from the facility's timestamped video) for a building fire.- Actions taken: evacuate area and ventilate.- Casualties: 1 civilian and no injuries- Hazardous Materials Release: None- Property Use: Nursing HomeRemarks: Dispatched to a nursing home on fire. [fire department staff] were the first to arrive on scene of a 1-story pitched roof building with nothing showing from the exterior. residents were being evacuated by building personnel. [fire department staff] assumed [facility] road command. [fire department staff] was ordered to investigate and reports a haze inside the building. [fire department staff] arrived and was ordered to assist with evacuation & prepare for horizontal ventilation. [fire department staff] reports a [location of fire] was found and the fire is out. [fire department staff] arrived and were ordered to assist with evacuation and ventilation. [fire department staff] were disregarded. arson was requested. [fire department staff] arrived and was assigned to evacuation group. [fire department staff] reports 11 residents were protected in place, haze is clearing out, and the room the 10- 50 is in has been secured. the incident was tapped out holding [fire department staff] , [fire department staff] , [fire department staff] , & [fire department staff] . building personnel report the fire alarm was triggered and went to the wing to find the source of the alarm. CNA D was the 1st to find the source and used a fire extinguisher. the [location of fire] was in a 2-person room. the 2nd resident was evacuated by building personnel. the small fire looks to have started on the bed near the victims head. There was no extension beyond the items on the bed. building personnel report the deceased is a smoker, but no one witnessed how the fire started. no signs of medical oxygen use in the room. a pump can was used to apply a small amount of water on a small book that was next to the deceased . [police department] units arrive .- Ignition: 21-Bedroom - < 5 persons- Area of Fire Origin: Undetermined- Heat Source: Undetermined- Item First Ignited: Undetermined- Cause of Ignition: Cause Under Investigation- Factors Contributing to Ignition: Undetermined- Human Factors Contributing to Ignition: Asleep- Mobile Property Involved: None- Fire Spread: Confined to Object of Origin- Presence of Detectors: Present- Detector Type: Smoke- Detector Operation: Operated- Detector Effectiveness: Alerted Occupants, Occupants Responded- Presence of Automatic Extinguishing System: Present- Operation of Automatic Extinguishing System: Fire Too Small To Activate- [fire department staff]: arrived and was assigned evacuation group. Some patients were evacuated from building and 11 were sheltered in place. [fire department staff]- observed that the deceased pt appeared to not have any oxygen because of the absence of o2 bottle or o2 bib on the wall. notified command and secured the room.- [fire department staff]: arrived on location and was ordered by [fire department staff] to investigate. upon entry we found the fire alarm system to be active and there was smoke in the lobby area. nursing home staff were evacuating residents. We made our way to the fire room and found one deceased victim in the first bed. i appears the fire started in the bed she occupied. fire department staff] notified command and we then assisted fire department staff] and fire department staff]with ventilating that wing of thenursing home. we also checked on the other occupants on that hallway. due to smoke conditions the rest of the hallway was sheltered in place. CR #44 Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The resident expired in the facility on [DATE] at 01:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left sided weaknessCare Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 ft 8 inches, and 274 lbs. Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Record review of CR #44's Discharge MDS dated [DATE] revealed, discharged Status- deceased . Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Clinical Assessments revealed, the last clinical assessment documented was on [DATE]. No clinical assessments were completed after the fire. Record review of CR #44's Progress Notes revealed,- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the mechanical lift. Resident tolerated well.- [DATE] 01:54 AM signed by the DON, After speaking with the charge nurse and CNA, I called the RP's family member to inform her that CR #44 was involved in a fire incident and that she was being treated for possible burns. Explained that the ambulance was working on her at this time, and they would probably take her to the [Hospital]. The RP said she was not in town and that she would call her to see if he was closer than she was. RP said she would leave where she was and head to [Hospital] to check on CR #44.- [DATE] 08:03 AM signed by LVN I, At approximately 01:00 AM the writer was on hall 600 to check on the other resident in my care. On my way back to 400, as I was walking down the hall I observed residents in bed sleeping including room [ROOM NUMBER]. As the writer was at the back of the hall 400, approximately 10 minutes later the writer heard alarm sound with flashing lights. I heard a CNA calling me and telling me the fire was in room [ROOM NUMBER]. As the writer was going to room [ROOM NUMBER], the CNA who was in front of me, grabbed the extinguisher and entered the room before I got there. When I entered the room I said to the CNA to call 911, then I assisted the CNA to evacuate the room-mate while the other 2 CNA's was trying to put the fire out. Once the roommate was safely evacuated, I immediately went to render aide to [CR #44]. As I was getting ready to assess the resident 911 was already here and in the room. The EMT's asked where the other resident was, and I told them she was outside. EMT's were providing medical care to [CR #44] and I left the room to go be with the residents that were outside. I then notified the DON once the residents were evacuated off of the hall and accounted for.- [DATE] 10:21 AM signed by MA C, resident expired. An observation on [DATE] at 09:58 AM revealed, CR #44's room floor covered by white powder and the room had been cleared of contents. There were gloves and packs of Personal Cleaning Wipes on the floor and on the bed. An off-white metal bed lie closest to the entrance, with no mattress and visible black fire damage. The center of the headboard was warped and melted with black burn marks, black ash/soot was observed on the base of the headboard, bed frame, and on the floor. There was limited evidence of smoke damage on the walls and ceiling with wipe marks on the ceiling directly above CR #44's bed and an imprint caused by smoke on the wall where something was hung that was now removed. In an interview on [DATE] at 03:31 PM, the Medical Director said she had been Medical Director in the facility for the last 1 1/2 to 2 years. She said if a resident had extensive burns, the facility would not initially treat the burns while in an emergency situation but would cover the resident with clean, dry sheets; monitor breathing and keep the resident warm after the fire was extinguished. She said a resident with severe burns would need specialized treatment that only the hospital could provide but she would expect nursing facility staff to assess the residents signs, mainly the breathing. The Medical Director said to maintain a residents life prior to arrival of EMS, staff must monitor vital signs and monitor alertness. Once the resident was moved away from the fire source, staff should make sure the airway is clear, resident is breathing, provide oxygen if necessary, monitor the residents pulse and blood pressure until EMS arrive. The Medical Director said if assessments and aid is not rendered and the resident had severe burn the resident could go into shock and a lot of things could happen. She said a resident with severe burns to the upper chest with shallow breathing should not be left unattended and someone should be with a resident if they have severe burns. The Medical Director said nursing home staff can provide services to help sustain life until EMS arrives and the resident should be continuously monitored. In an interview on [DATE] at 04:15 PM, the DON said when an individual experienced extensive burns they must be immediately assessed. Bleeding should be stopped, the airway must be assessed for lung sounds, and vitals assessed. She said nursing staff must stay with the resident until help arrived, and part of the competency of a nurse is training on how to react in an emergency situation. The DON said prior to the fire on [DATE] staff were not trained on what do to if a resident had a severe burn, but they know what to do now. She said to her knowledge nursing staff did not assess CR #44 after the fire was extinguished. The DON said no one assessed CR #44 after the fire but they should have as it was a professional standard. When asked about the risk to residents if staff failed to assess them following extensive burns., The DON said based on her investigation, she thought CR #44 was expired when she was found on fire and no one told her the resident was moving and groaning at the time of the fire. She said, only god has the power over life and death, and if a resident expired it was in God's Hands. When pressed the DON said treatment rendered to a resident with extensive burns was based on what the assessments yields, but staff should make sure the resident was breathing. In an interview on [DATE] at 03:25 PM, the ME said CR #44's cause of death was still pending but the resident suffered from 2nd (burn that damages the top layer of skin and part of the 2nd layer) and 3rd (burn that destroys the first three layers of skin and the fatty tissue) degree burns on her head, upper torso and extremities. She had significant charring (severe burn that has destroyed all layers of skin and ,ay extend into underlying tissue caused by prolonged exposure to extreme heat that appears black or ash-gray) especially to the left side of her body not the right. There was soot deposition in her airway/bronchi, which indicated she was breathing while on fire. 26% of CR #44's body surface was burned. Resident #2 Record review of Resident #2's Face Sheet dated [DATE], revealed a 93- year- old female who admitted to the facility on [DATE] with diagnosis which included: Type 2 diabetes, COPD, dementia, epilepsy (brain disorder with recurrent, unprovoked seizures), and Irregular heartbeat. Record review of Resident #2's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 0 out of 15. The resident had lower extremity functional limitations in range of motion used automobile chair and required maximum assistance for most ADL's. For mobility, the resident was either dependent or required maximum assistance. The resident was fully dependent on staff to propel in a motorized wheelchair for 50 to 150 feet. Record review of Resident #2's undated Care Plan revealed, Focus- Requires a wander guard bracelet and is at risk for injury fromwandering in an unsafe environment; Interventions: Monitor resident in facility and document attempts to elope out of facility. Focus: ADL self-care performance deficit r/t impaired cognition, poor safety awareness. Ambulates without use of an assistive device. She will at times hold onto the rails in hallway. Resident may require increased assistance with transfers depending on level of surface she is transferring from. Interventions: requires assistance of one staff to turn and reposition in bed at regular intervals. Record review of Resident #2's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- Resident #2 requires assistance of 1 staff to turn and reposition in bed at regular intervals and as necessary; requires assistance with lying to sitting at times. Transfer- requires assistance of one staff for supervision to move between surfaces as tolerated. Resident # 2 May require assistance with sit to stand if sitting for prolonged period of time or level of surface. Resident #3 Record review of Resident #3's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, paralysis following a stroke, dementia, anxiety disorder, and bed confinement status. Record review of Resident #3's Quarterly MDS dated 9/11 25 revealed, severely impaired cognition skills for daily decision making and impairments in functional limitations in range of motion for both sides of her upper and lower extremity. Record review of Resident #3's undated Care Plan revealed, Focus-Resident received oxygen as needed. The shortness of breath. Interventions: Monitor for signs and symptoms of respiratory distress- SOB, dyspnea (difficulty or labored breathing), low O2, cyanosis (bluish discoloration of skin indicating poor blood oxygen and circulation), diaphoresis (sweating), changes in behavior. Record review of Resident #3's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- total dependence on staff for repositioning and turning in bed. Lying to Sitting on side of bed: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Roll Left and Right: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to lying: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to stand: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Toilet transfer: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transfer: total dependence on staff for transfer. An observation on [DATE] at 10:19 AM revealed, Resident #3 lying in bed with eyes closed, well-dressed well-groomed in no immediate distress. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis), type 2 diabetes, difficulty swallowing, dementia, and anorexia. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The use of a manual wheelchair, total dependence on most ADL's, and total dependence for most functional abilities. Record review of Resident #6's undated Care Plan revealed, Focus: Impaired visual function; Interventions: notify where you are placing their items. Be consistent and cater to the resident's preference of item placement. Focus: ADL self-care performance deficit, requires staff assist with ADL cares, refused to get out of bed daily; Interventions: Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of lift Record review of Resident #6's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of lift An observation on [DATE] at 10:20 AM revealed, Resident #6 well dressed, well-groomed lying in bed awake. The resident responded to the surveyor with head nods and indicated she needed help. Resident #11 Record review of Resident #11's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia, bipolar disorder, diabetes and hypertension. Record review of Resident #11's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, one sided upper extremity and 2-sided lower extremity functional limitations in range of motion. Use of a wheelchair, total dependence with most ADLs and all functional abilities, total dependence for use of a manual scooter. Record review of Resident #11's undated Care Plan revealed, ADL self-care performance deficit and requires maximum assistance with ADLs r/t activity intolerance, Alzheimer's, impaired balance and limited mobility Record review of Resident #11's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- lying to sitting on side of the bed- dependent helper does all the effort; roll left and right- substantial/maximal assistance helper does more than half of the effort. Sit to stand- dependent helper does all the effort. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Parkinsonism, epilepsy, hypertension, difficulty breathing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, Short term and long term memory OK. And independent cognitive skills for daily decision making. The use of a wheelchair, no upper or lower extremity functional limitations in range of motion, substantial or maximum assistance to total dependence for all ADL's and substantial maximum assistance to total dependence on staff for mobility. Record review of Resident #18's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues,setup, and/or assistance with ADLs r/t Parkinson's Disease. Interventions: chair/bed-to-chair transfer: Resident's usual performance isdependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Lying to sitting on side of bed: resident's usual performance ispartial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Roll left and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces. Resident #36 Record review of Resident #36's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: dementia, generalized weakness, obesity, hip implant and altered mental status. The Resident's Code Status was do not resuscitate. Record review of Resident #36's Significant Change MDS dated [DATE], short-term and long-term memory problems, severely impaired cognitive skills for daily decision making, no upper and lower extremity functional limitations in range of motion, use of a wheelchair, and substantial/maximum assist with most self-care and all mobility. Resident #43 Record review of Resident #43's Face Sheet dated [DATE] revealed, a 72- year- old female who admitted to the facility on [DATE] with diagnosis which included COPD, bipolar disorder, and depression. Record review of Resident #43's Quarterly MDS dated [DATE] revealed, short and long term memory OK, moderately impaired cognitive skills for daily decision making, no behaviors, use of wheelchair with no upper or lower extremity functional limitations and range of motion and total dependence for self-care and mobility. Record review of Resident #43's undated Care Plan revealed, Focus: ADL self-care performance deficit r/t chronic pain,bipolar disorder and anxiety, has a specialized w/c; Intervention: bed mobility- total assist of one staff to turn and reposition in bed at regular intervals and as necessary. Transfer: totally dependent on 2 staff for transferring with a mechanical lift. Focus: Mobility and/or Assistive Device(s) Utilized by Resident: manual wheelchair. Resident #48 Record review of Resident #48's Face Sheet dated [DATE] revealed, a Three- year- old female who admitted to the facility with diagnosis, which included difficulty swallowing, memory deficit, major depressive disorder, generalized anxiety disorder, hypertension, left dominant side hemiplegia and hemiparesis following a stroke, Record review of Resident #48's Quarterly MDS dated [DATE] revealed, Severely impaired cognition as indicated by a BIMS score of 0 out of 10, upper and lower extremity functional limitations in range of motion on one side, total dependence for self-care and substantial to maximum assistance for most mobility. Total dependence for mobility with manual wheelchair for 50- 150 feet. Record review of Resident #48's undated Care Plan revealed, Focus: a self-care performance deficit r/t requires extensiveto total assistance r/t dementia, late effects of CVA, aphasia, bedbound, incontinence; Interventions: locomotion: utilizes a wheelchair when for proper positioning r/t impaired sitting balance and poor trunk control. Extensive assistance by one-two staff to turn and reposition in bed and wheelchair. Lift and extensive assistance by two staff to transfer at all time. Resident #54 Record review of Resident #54's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Quadriplegia (paralysis that affects all limbs), anxiety disorder, weakness, and difficulty swallowing. The residents advanced directive was full code. Record review of Resident #54's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, use of a wheelchair, upper and lower body, total dependence for all self-care, mobility, and quadriplegia. Record review of Resident #54's undated Care Plan revealed, focus: full code; interventions: appropriate care within guidelines of advanced directives; should [resident #54] be found with no pulse, respirations, or blood pressure, start CPR & call 9-1-1 immediately. Focus: ADL self-care performance deficit and requires cues setup, and/or assistance with ADLs r/t quadriplegia; interventions: usual performance is dependent - helper does all of the effort. [resident #54] does none of the effort to complete the activity or the assistance of 2 or more is required for [resident #54] to complete the activity. lying to sitting on side of bed: [resident #54]'s usual performance is dependent - helper does all of the effort. [resident #54] does none of the effort to complete the activity or the assistance of 2 or more is required for

Based on observation, interview, and record review the facility failed to administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #24) residents reviewed for parenteral fluids. - The facility failed to follow physician orders for Resident #24 to receive an oncologist evaluation for the removal of her implanted central venous access (port) for 58 days after the order was given on 07/23/25. On 09/19/25 the facility scheduled Resident #24 for evaluation by her oncologist on 10/07/25. This failure could place residents at risk of unwanted infections, hospitalization and further decrease in quality of life. Findings include: Resident #24 Record review of Resident #24's Face Sheet dated 10/02/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: left sided paralysis after a stroke, insomnia (difficulty sleeping), depression, anxiety, stomach bleed, repeated falls and lung cancer. An implanted port was not documented in her diagnosis. Record review of Resident #24's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, upper and lower body functional limitations in range of motion, maximal assistance with most ADLs and maximum assistance with the use of a manual wheelchair. Active Diagnoses of: Cancer, hypertension, high cholesterol, one sided paralysis, anxiety and depression. Record review of Resident #24's undated Care Plan revealed, Focus: potential for skin tear of the r/t limited mobility. Focus: The resident is on pain medication therapy -ACETAMENIPHEN-CODEINE, LIDOCAINE; Interventions: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness. Focus: chronic pain on lidocaine,acetaminophen codeine; Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Focus: enhanced barrier precautions r/t indwelling medical device; Interventions: ENHANCED BARRIER PRECAUTIONS is necessary during high-contact care: Dressing; Bathing; Transferring; Providing hygiene; Changing linens, Changing briefs or assisting with toileting; Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes; Wound care: any skin opening requiring a dressing. Her care plan did not specify the indwelling medical device was a port. Record review of Resident #24's Order Summary Report revealed,- 07/18/25 Enhanced Barrier Precautions ( infection control interventions designed to reduced the spread of MDRO) due to indwelling medical device to right upper chest dated 07/18/25.- 07/18/25 Central line dressing change-Catheter to the Right Upper Chest - Change sterile transparent dressing (or sterile gauze)to insertion site Q Weekly and PRN if wet, soiled, or not intact. as needed Change transparent dressing PRN when wet.- 07/21/25 Central line dressing change-Catheter to the Right Upper Chest - Change sterile transparent dressing (or sterile gauze) to insertion site Q Weekly and PRN if wet, soiled, or not intact. every day shift every Mon. Discontinued 09/10/25- 07/23/25 needs oncology follow up related to port removal to right chest.Record review of Resident #24's Progress Notes from 05/20/25 to 09/19/25- there was no documentation of communication to Resident #24's RP from admission to 09/17/25 in regards to the implanted port, its use, maintenance, adverse reactions or removal.- 09/19/2025 12:40 PM signed by the DON, While auditing the chart noticed an order from 7/23/25 from MD A requesting for the resident to follow up with Oncology for port removal. After speaking with the nurse, it was told that the family did not want the port removed. Spoke with NP A to discuss the order and if she still wanted to follow up. NP A said yes, because every time she speaks to [Resident #24] she complains of pain to the port site. Called the RP and educated him on the port and what the NP said about his [Resident #24] experiencing pain related to the port. The RP said if Resident #24 wants the port out, then we need to take it out. Educated Resident #24 on what the said. The RP was not able to give me information about who the Oncologist was. Called the caregiver who was able to give the writer the information. The caregiver said, they did not want the port removed because they thought Resident #24 was still going to get cancer treatments. Explained to the caregiver what the said and the caregiver was in agreement. The caregiver gave the writer for the follow-up appointment. Writer was able to obtain an appointment for October 7, 2025. Record review of Resident #24's Physician Order dated 09/19/25 revealed, follow up with oncologist for port removal. An observation and interview on 09/29/25 at 11:07 AM revealed, Resident #24 lying in bed in no immediate distress. She said she was all right but her chest was bothering her. She said it hurt to turn her arm because the tube in her (implanted port) caused her discomfort and she wanted it removed. Resident #24 said she wanted a walker because her implanted port hurt when she used a wheelchair. An observation and interview on 10/02/25 at 12:40 PM revealed, Resident #24 was well-dressed, well-groomed in no immediate distress sitting in a wheelchair in her room. Resident #24 said her port was giving her hell, and it hurt whenever she wheeled herself in her wheelchair and the port goes up and down. She didn't say her port hurt when she was not using her wheelchair, but it let her know it is there. Resident #24 said Acetaminophen controlled her pain and the facility was working with the doctor to get her port taken out. Her implanted port was observed as circular raised area on her right chest, with loss of pigment. Her skin was intact with no redness, [NAME] or drainage observed. In an interview on 10/06/25 at 10:10 AM, the DON said she did not know what happened between the order received in July but in September when she found the missed order she took immediate action and got her an appointment for October. She said she didn't see any action/notifications following the physicians orders and failure to follow physician order to assess a port with no care could place residents at risk of infection. In an interview on 10/06/25 at 10:29 AM, RP #1 said prior to September the facility had not notified him of the discomfort Resident #24 experienced due to her port. He said he had no issues with the port being removed and it was up to him and he provided the facility the information of her oncologist. In an interview on 10/06/25 at 10:39 AM, Resident #24's family member said September 2025 was the first time the facility notified any of the residents family that her physician recommended removal of her port and that it caused her discomfort. In an interview on 10/06/25 at 11:09 AM, NP A said the facility scheduled an appointment in September with Resident #24's Oncologist to evaluate removal of the resident's implanted port since she was no longer using it for chemotherapy. NP A said prior to September Resident #24 had an infection on her foot so she could not undergo surgery to remove the port, but she did not have any concerns for the port because it was an implanted devices, and the facility was not accessing it. NP A said evaluation of Resident #24's port site and labs indicated no signs and symptoms of infection. She said the facility did not have the ability to remove the port and required an Oncologist to evaluate. In an interview on 10/06/25 at 11:27 AM, the ADON said if a resident arrived to the facility nursing staff must investigate if the port should be removed or will continue to be used. She said a port must be maintained with flushes to make sure they continue to work and the presence of a port could place residents at risk of infection and if they become colonized they make an infection harder to fight and could result in sepsis. The ADON said nursing staff are expected to follow up on the need of any kind of port. She said she was not responsible for infection control when the resident arrived at the facility and the DON was responsible to ensure the port was assessed by the oncologist but she took maternity leave. The ADON said to her knowledge nothing had been done about the physicians order to remove Resident #24's port, and there was no reason she had not had her evaluation by an oncologist. In an interview on 10/06/25 at 11:47 PM, LVN E said she sometimes worked with Resident #24. She said the resident had not complained about pain or discomfort due to the port. In an interview on 10/06/25 at 12:52 PM, RN B said Resident #24 had not reported any pain or discomfort associated with the port In an interview on 10/07/25 at 10:12 AM, the ADON said she started her position as the Infection Preventionist at the end of August of 2025. She said it was her responsibility to monitor all venous access devices. Since a port is indwelling it should be monitored to check for apparent signs of trauma. The ADON said a resident that admits with an implanted port should have orders in place when they arrive. She said she monitored residents with lines/ports upon admission or once treatment is initiated in the facility for their use and when the antibiotic is finished or the port is no longer in use she initiates orders with their provider to remove the device. The ADON said prior to September she was unaware Resident #24 had a port so she was not following her and could not initiate orders to remove her port. In an interview of 10/06/25 at 02:47 PM, the DON said the failure to remove Resident #24 port could place resident at risk for infection. Record review of the facility policy titled Infection Preventionist with no revision date revealed, Policy: The facility will employ one or more qualified infection prevention and control program. There was no information addressing implantable device monitoring.

Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 6 of 6 meals reviewed for food and nutrition services.The facility failed to ensure the menu was followed for the lunch and dinner meals on 10/02/25, 10/03/25, and 10/04/25. This failure placed the residents at risk of not receiving meals that are adequate to meet their nutritional needs and a decline in nutritional health status.The findings included:Review of the facility's weekly menu, entitled Senior Living S/S Southern 2024, Week 2, revealed the following menu plan:10/02/25 Lunch: Breaded catfish, potato wedges, creamy cole slaw, wheat bread, and [NAME] hash pie10/02/25 Dinner: Roasted red pepper soup, saltines, French dip sandwich, cottage cheese, and mixed melon salad.10/03/25 Lunch: Fried Chicken, okra, cornbread, brownie mousse bar.10/03/25 Dinner: Cheese Quesadilla, seasoned black beans, southwest slaw, apple slices.10/04/25 Lunch: Baked glazed ham, au gratin potatoes, Key [NAME] vegetable blend, wheat bread, banana cupcake10/04/25 Dinner: Unstuffed peppers, roll, orange wedges.Review of the Menu board posted outside of the dining room on 10/02/25 at 11:28 AM revealed the following:lunch menu for the day: bacon maple fish, potato wedges, coleslaw, pudding.dinner menu: homemade soup, cottage cheese, melon salad, corn bread. Everyday Menu listed Grill Cheese comes with soup and side salad, Hamburgers Basket comes with fries or chips, Sandwich of the day comes with fries, chips, or soup. There was no weekly menu posted. In an observation and interview on 10/02/2025 at 12:40 PM, Resident #53 received a hamburger from the Everyday Menu as requested but no side came with the hamburger. Resident #53 did not know why she did not receive a side with her hamburger. The posted Everyday Menu has comes with fries or chips for the Hamburger Basket, which Resident #53 had ordered.In an interview on 10/03/25 at 9:30 AM Resident #53 reported she was offered broccoli cheese soup and cornbread for dinner the previous evening, 10/02/25. She declined the soup and ate cornbread with milk. She ate in her room and did not see what other residents were offered.In an interview on 10/03/2025 at 10:36 AM with the Dietary Director, she reported they served a vegetable soup with hamburger meat, cornbread, a sandwich, and the cottage cheese and melons for dinner on 10/02/25. She reported that the residents do not like roasted red pepper soup, so it was substituted for a soup with hamburger meat with vegetables because the meat makes it a more substantial meal with the protein. She reported all the changes were approved by the dietitian. They just had a quarterly meeting to review the menus with the dietitian. The menu in her office had red pen marks noting changes for each meal in the month. She said there would be a new menu coming with the changes. When asked for records of dietitian approval for menu changes, she was not able to produce any paperwork or documentation. The Dietary Director reported that the residents do not like the fancy food on the menu such as quesadillas and chicken parmesan. The residents prefer the southern cooking that reminds them of home. She also reported that she was unable to order the desserts listed on the menu due to the cost of the ingredients. The Brownie Mousse Bar was substituted for cake because they could not purchase ingredients like chocolate or purchase pre-prepared deserts like lemon cookies or tiramisu cake and stay within the budget. They make the deserts from scratch to save money. The menus are prepared by a new service provider to this facility. The menus were previously done by another company, but that contract was cancelled recently. They order food from the new vendor as well as getting the menus quarterly. She orders food by determining needs from her changed menu.In an interview on 10/03/25 at 12:22 PM the [NAME] who prepared the dinner on 10/02/25 reported there was not a sandwich served with the soup. The soup was broccoli cheddar. Grilled cheese sandwich was served as alternate meal. There was not a side served with the soup other than cottage cheese with fruit syrup on it. No fruit was served. The [NAME] reported that she cooks whatever the Dietary Director tells her is the meal. The menu is not posted in the kitchen.Review of the Menu board posted outside of the dining room on 10/03/25 at 10:06 AM revealed the following:lunch menu for the day: oven fried chicken, okra/tomato, rice, cornbread, cake with whipped topping.dinner menu: Enchiladas, southwest salad, black beans, apple slices.Review of the Menu board posted outside of the dining room on 10/04/25 at 11:26 AM revealed the following:lunch menu for the day: pork loin, au gratin potatoes, Malibu vegetable blend, rolls, chocolate chip cookies. dinner menu: Unstuffed peppers, green beans, bread, apple slices. In an interview on 10/06/25 at 12:08 PM with the Registered Dietitian for the facility, she revealed the approvals for changes of the weekly menu were made by the Regional Registered Dietitian and she had not approved any menu changes made by the Dietary Director.In an interview on 10/07/25 at 10:16 AM with the Regional Registered Dietitian, she reported the menu process is that the vendor sends out Spring and Summer menus. The facility started using them for menus in February of this year. She reported that they try to focus on residents' choices. They have a food committee of residents that meet and the upcoming menu is reviewed. The resident council can submit feedback on the meals as well. Their feedback is used in decision making to change menu items but they stay within the same nutritional value. The protein will stay the same and swap a vegetable for a vegetable. They have a substitution log that should be completed and signed off by the Registered Dietitian. She was not aware if there was a specific food committee at the facility. She reported they always have an alternate menu available. Residents should be offered what is on the printed menu or a substitute of equal nutritional value.In an interview on 10/07/25 at 12:26 PM with the Administrator, she reported she was not aware that the Dietary Director was not following the weekly printed menu and substitutions were being made without appropriate approval. She reported she will ensure the menus and meal preparations are carried out following the policies going forward.Record review of the facility policy, Menus and Adequate Nutrition, 2025 revision, revealed: Policy section titled Policy Explanation and Compliance Guidelines: 3. Menus shall be prepared at least two weeks in advance for timely approval and ordering of food. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance. 4. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods with comparable nutritive value.8. The facility's dietitian or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #41) of 7 resident reviewed for infection control. The facility failed to ensure LVN C wore a gown while performing wound care for Resident #41. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases. The findings included:Record review of Resident #41's face sheet dated 10/1/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (high blood sugar) with Foot Ulcer and Other Acute Osteomyelitis (the bone infection) of the Right Tibia and Fibula (bones of the lower leg). Record review of Resident #41's quarterly MDS dated [DATE] revealed a BIMS score of 8 that indicated moderate cognitive impairment.Record review of Resident #41's Order Summary Report dated 10/1/25 revealed Enhanced Barrier Precautions due to wound with order date of 6/19/2025.Record review of Resident #41's Care Plan Report printed 10/1/25 revealed Resident #41 was on enhanced barrier precautions consisting of gown and gloves and was necessary during high-contact care including wound care.Observation on 10/1/25 at 10:15 a.m. revealed LVN C did not wear a gown while providing wound care to Resident #41 who was on enhanced barrier precautions. Observation also revealed Enhanced Barrier Precautions sign was at door of Resident #41's room. During interview on 10/1/25 at 10:42 a.m., Resident #41 said the staff usually wore a yellow gown when they performed wound care. During interview on 10/1/25 at 10:43 a.m., LVN C said she forgot to wear the yellow gown. LVN C said she normally wore a gown when providing wound care. When LVN C was asked why she forgot to wear a gown during wound care she replied everything that went on today as it had been reported that LVN C had a wreck on her way into the facility that morning. During interview on 10/2/25 at 2:14 p.m. with the ADON said Enhanced Barrier Precautions was used for a resident when they have any hole that was artificial like an open wound that required a dressing. The ADON said staff needed to wear a gown and gloves if they were providing hands on care. The ADON said if a staff member provided wound care to a resident on Enhanced Barrier Precautions and did not wear a gown that it could possibly open a portal to infection and a wound was a possibility of introducing bacteria, so it was a way for the resident to get an infection. The ADON was also the Infection Preventionist. Record review of facility's policy Enhanced Barrier Precautions dated 2025 revealed PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and high contact resident care activities included wound care.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured and locked in accordance with currently accepted professional principles during medication administration of 1 of 2 staff (LVN G).The facility failed to ensure that LVN G did not throw Resident #1's crushed Metoprolol in the trashcan in the resident's room.This failure could place residents at risk of obtaining medications that were not ordered for them and potential adverse reactions or side effects. Findings included:Record review of Resident #1's face sheet dated 10/3/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction (disorder when blood flow to a part of the brain is blocked leaking to lack of oxygen and nutrients) and Gastrostomy Status (surgical opening in the abdominal wall). Record review of Resident #1's quarterly MDS dated [DATE] revealed BIMS could not be conducted. Record review of Resident #1's Order Summary Report dated 10/3/25 revealed Metoprolol Tartrate Oral Tablet 25 mg with instructions to give 1 tablet via G-tube one time a day with order and start date of 8/19/25. Observation on 10/3/25 at 9:32 a.m. revealed LVN G crushed Resident #1's Metoprolol Tartrate Oral Tablet 25 mg and placed in an individual cup.Observation on 10/3/25 at 10:01 a.m. revealed LVN G attempted to check Resident #1's blood pressure but was unable as the blood pressure cuff had low battery. LVN G said she would give Resident #1's Metoprolol later after administering the rest of Resident #1's medications she had ready when she was able to obtain a working blood pressure cuff. Observation on 10/3/25 at 10:15 a.m. revealed LVN G threw the medication cup with the crushed Metoprolol in the trashcan in the resident's room. During interview on 10/3/25 at 10:16 a.m., LVN G said medications were supposed to be disposed of in the sharp's container which was located on the medication cart. LVN G said she was unsure if she could take the medication out of the room since the resident was on precautions. LVN G said an effect of disposing medications in the trash can in the resident's room could have on residents was someone could pick it up or notice it. During interview on 10/3/25 at 3:31 p.m., the Consultant Pharmacist said if a medication was opened but not given, she recommended the medication to be placed in the sharps container so potentially no one could reach in and take it out. The Consultant Pharmacist said the effect it could have on a resident if a medication was thrown away into a resident's trash can was there was a concern that someone could take it out of the trash can. Record review of facility's policy Destruction of Unused Drugs dated 2023 revealed drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in condition in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 2 of 8 residents (Resident #1 and Resident #24) reviewed for notification of changes. - The facility failed to notify Resident #1's RP of physician orders on 10/01/25 for a chest x-ray due to a newly identified cough. The RP was notified on 10/06/25. - The facility failed to notify Resident #24's RP of physician order dated 07/23/2025 for an oncologist (doctor that specializes in cancer) evaluation for the removal of her implanted central venous catheter (a port device under the skin that allows long term IV access for administration of medications, chemotherapy) that was causing the resident discomfort. RN B failed to document the order and follow up with the x-ray when RP #1 notified the facility of needed appointment then the facility scheduled the appointment for 10/7/2025. This failure could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering. Findings included:Resident #1 Record review of Resident #1's Face Sheet dated 10/02/25 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: left side paralysis, aphasia (inability to speak) after a stroke (interruption of blood flow to the brain that causes tissue damage), difficulty swallowing, anxiety disorder, gastrostomy ( a tube passed through the abdomen into the stomach used for food or medication administration), and pneumonia (infection of the lungs). Record review of Resident #1's Quarterly MDS dated [DATE] revealed severely impaired cognitive skills for daily decision making, upper and lower extremity functional limitations in range of motion, total dependence for most ADLs and use of a feeding tube. Record review of Resident #1's undated Care Plan revealed, Focus: responsible party requests full code status; Goal- resident's wishes will be honored on an ongoing basis; Interventions: Monitor for decline in change of condition-report to MD and responsible party. Record review of Resident #1's Physician Progress Note dated 10/01/25 at 8:00 AM signed by MD A revealed, Chief Complaint: Cough with congestion; Audible cough with congestion noted with diminished breath sounds on exam. Resident #1 remains on room air without signs of respiratory distress. Chest V-ray ordered continues on tube feeds. Diagnostics Tests- chest X-ray ordered, Record review of Resident #1's Order Entry dated 10/01/25 revealed, Description: CXR to evaluate cough. The order was entered by MDA on 10/01/25 at 3:03 PM and confirmed by RN B on 10/01/25 at 4:32 PM. Record review of Resident #1's Progress Notes dated 10/01/25 to 10/07/25 revealed the following; - No evidence of follow up or X-ray completion from 10/01/25 to 10/05/25.- On 10/06/25 at 2:43 PM, CXR order from 10/1/2025 re-entered MD A called to notify. Radiology Company was notified and CXR has been completed.- On 10/06/25 at 3:49 PM, Respiratory assessment completed. Pulse Ox 97% on room air no cough noted at this time. Resp effort and rate WNL. Relaxed and regular. Rhythm regular 18 resp per min lung sounds clear throughout. Resident sitting in bed with HOB 45 degrees. No distress noted.- On 10/06/25 at 11:45 PM, Chest X-Ray 2 views results: No evidence of acute cardiopulmonary disease. Stable when compared to prior exam. Result send to NP for review. No new orders. Responsible party at bedside and was notified. Record review of Resident #1's Radiology Results Report dated 10/06/25 at 6:20 PM revealed, PROCEDURE: Chest Xray; INDICATION: Pneumonia; IMPRESSION: No evidence of acute cardiopulmonary (relating to the heart and the lungs) disease. An observation on 09/29/25 at 11:34 AM revealed Resident #1 lying in bed receiving formula via G-tube. The resident was non-responsive to this surveyor but appeared to be in no immediate distress. His breathing appeared unlabored, and he did not have a cough. An observation on 10/06/25 at 1:13 PM revealed Resident #1 lying in bed receiving formula via G-tube. The resident was non-responsive to the surveyor but appeared to be in no immediate distress. His breathing appeared unlabored, and he did not have a cough. In an interview on 10/06/25 at 1:18 PM, RN B said when a physician gave an order for an x-ray it must be documented in the 24- hour report. RN B said she was Resident #1's nurse, she had not observed him with a cough, she did not know there was a pending X-ray, she didn't know any orders were entered for Resident #1's CXR (chest x-ray). RN B said there has been no communication to her, nursing, or the RP about the pending CXR. In an interview of 10/06/25 at 1:20 PM, the DON said when radiology orders were entered by a provider, nursing staff must then confirm the order. She said she didn't know why Resident #1's X-ray had not been taken yet, Resident #1's cough that required a CXR for further evaluation was considered a change in condition so all the notifications that should be sent out. The DON said RN B confirmed the order for Resident #1's CXR in the EMR system. In an interview on 10/06/25 at 3:42 PM, MD A said when she assessed Resident #1 on 10/01/25 he was observed to have diminished lung sounds and a cough. The resident had been in and out of the hospital with pneumonia and received enteral feeds via a G-tube which put him at risk for aspiration pneumonia (pneumonia as a result of inhaling vomit) so she was concerned about the cough. She said older individuals like Resident #1 present differently from young, healthy people because their weak immune system can result in normal WBC (elevation indicative of infection), no fever, and since they can't mount the same immune response, they end up with Walking Pneumonia. MD A said in individuals like Resident #1 she would order an X-ray to rule out pneumonia. She said normally when she entered CXR orders, it took the radiology company a day perform the imaging, and the facility would then call her to notify her of the results. MD A said she was not aware the facility had not completed the CXR order she entered on 10/01/25, a 5-day delay was not acceptable and the facility shouldn't drop the ball on things like this. She would not identify any risks associated with failure to implement radiology orders timely but said it would delay identification of an issue or fail to rule out a suspected concern. In an interview on 10/06/25 at 6:04 PM, RP #2 said he did not receive notification from the facility regarding Resident #1's change of condition (cough), or the ordered CXR, and he last saw Resident #1 on 10/02/25. RP #2 said Resident #1 and was fully disabled and paralyzed on one side, and sometimes he received notifications from the facility regarding Resident #1 but this time he had not received notification of the cough or ordered CXR. Record review of Resident #24's Face Sheet dated 10/02/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: left sided paralysis after a stroke, insomnia (difficulty sleeping), depression, anxiety, stomach bleed, repeated falls and lung cancer. An implanted port was not documented in her diagnosis. Record review of Resident #24's Quarterly MDS dated [DATE] revealed severely impaired cognition as indicated by a BIMS score of 3 out of 15, upper and lower body functional limitations in range of motion, maximal assistance with most ADLs and maximum assistance with the use of a manual wheelchair. Active Diagnoses of: Cancer, hypertension, high cholesterol, one sided paralysis, anxiety and depression. Record review of Resident #24's undated Care Plan revealed, Focus: potential for skin tears of the r/t limited mobility. Focus: The resident is on pain medication therapy -ACETAMENIPHEN-CODEINE, LIDOCAINE; Interventions: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness. Focus: chronic pain on lidocaine,acetaminophen codeine; Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Focus: enhanced barrier precautions r/t indwelling medical device; Interventions: ENHANCED BARRIER PRECAUTIONS is necessary during high-contact care: Dressing; Bathing; Transferring; Providing hygiene; Changing linens, changing briefs or assisting with toileting; Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes; Wound care: any skin opening requiring a dressing. Resident #24's care plan did not specify if the indwelling medical device was a port. Record review of Resident #24's Physician Order dated 07/23/25 revealed needs oncology follow up related to port removal to right chest. Record review of Resident #24's Physician Order dated 09/19/25 revealed a follow up with oncologist for port removal. Record review of Resident #24's Progress Notes from 05/20/25 to 10/07/25 reflected the following;- there was no documentation of communication to Resident #24's RP from admission to 09/17/25 in regard to the implanted port, its use, maintenance, adverse reactions or removal.- On 09/19/2025 12:40 PM signed by the DON, While auditing the chart noticed and order from 7/23/25 from MD A requesting for the resident, to follow up with Oncology for port removal. After speaking with the nurse, it was told that the family did not want the port removed. Spoke with NP A to discuss the order and if she still wanted to follow up. NP A said yes, because every time she speaks to [Resident #24]she complains of pain to the port site. Called the RP and educated him on the port and what the NP said about his mother experiencing pain related to the port. The RP son said if Resident #24 wants the port out, then we need to take it out. Educated Resident #24 on what the son said. The RP was not able to give me information about who the Oncologist was. Called the caregiver who was able to give the writer the information. The caregiver said, they did not want the port removed because they thought Resident #24 was still going to get cancer treatments. Explained to the caregiver what the [RP #2] said and the caregiver was in agreement. The caregiver gave the writer for the follow-up appointment. Writer was able to obtain an appointment for October 7, 2025. An observation and interview on 09/29/25 at 11:07 AM revealed Resident #24 lying in bed in no immediate distress. She said she was all right, but her chest was bothering her. She said it hurt to turn her arm because the tube in her (implanted port) caused her discomfort and she wanted it removed. Resident #24 said she wanted a walker because her implanted port hurt when she used a wheelchair. An observation and interview on 10/02/25 at 12:40 PM revealed Resident #24 appeared well dressed, well-groomed and in no immediate distress sitting in a wheelchair in her room. Resident #24 said her port was giving her hell, and it hurt whenever she wheeled herself in her wheelchair and the port goes (moves) up and down. She didn't say her port hurt when she was not using her wheelchair, but it let her know it is there. Resident #24 said Acetaminophen controlled her pain and the facility was working with the doctor to get her port taken out. Her implanted port was observed as circular raised area on her right chest, with loss of pigment. Her skin was intact with no redness, swelling or drainage observed. In an interview on 10/06/25 at 10:10 AM, the DON said she did not know what happened between the order received in July and September when she found the missed order. She said she didn't see any action/notifications following the physician's orders and failure to follow physician orders to assess a port with no care, could place residents at risk of infection. In an interview on 10/06/25 at 10:29 AM, RP #1 said prior to September 2025 the facility had not notified him of the discomfort Resident #24 experienced due to her port. He said he had no issues with the port being removed and it was up to [Resident #24] and he provided the facility the information of her oncologist. In an interview on 10/06/25 at 10:39 AM, Resident #24's family member said September 2025 was the first time the facility notified any of the resident's family that her physician recommended removal of her port and that it caused her discomfort. In an interview on 10/06/25 at 11:09 AM NP A said the facility scheduled an appointment in September with Resident #24's Oncologist to evaluate removal of the resident's implanted port since she was no longer using it for chemotherapy. NP A said prior to September Resident #24 had an infection on her foot so she could not undergo surgery to remove the port, but she did not have any concerns for the port because it was an implanted device and the facility was not accessing it. NP A said evaluation of Resident #24's port site and labs indicated no signs and symptoms of infection. She said the facility did not have the ability to remove the port and required an Oncologist to evaluate. In an interview of 10/06/25 at 2:47 PM, the DON said when staff received a physician's order for radiology, they must enter it into the EMR which was integrated with the laboratory and then document it in the progress note and in-house 24-hour report log. She said RN B failed to document the order and follow up with the x-ray and that was why they were missed. The DON said there was no evidence of family notification of Resident #1's cough or the order for a CXR. The DON said failure to timely complete radiology orders could place residents at risk for worsening of condition and delay in care. She said Resident #1's cough and subsequent order for CXR was a change of condition and all changes of condition required notification of the doctor, notification of the family and the nursing staff to follow up on all orders and changes. The DON said failure to notify a resident's RP of changes could leave the family unaware of a resident's change of condition. Record review of the facility policy titled Notification of Changes with no date revealed, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 22 of 22 (CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) reviewed for neglect. - The Administrator failed to report to the State Survey Agency a fire in the 400 Hall, in which 22 residents (Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) were exposed to smoke and CR #44 expired, to the State Survey Agency within 2 hours. This failure could result in the state agency receiving late notification of alleged incidents of fire, resident injuries and resident deaths. Findings included: Record review of the HHSC TULIP (system to which providers report accidents and incidents) on [DATE] revealed, the facility reported a fire with a fatality on [DATE] at 05:15 AM via through an email. Reporter's Name and Title: [Administrator]; Date/Time the administrator first learned of the incident on [DATE] at 01:31 AM; Date/Time the incident occurred: [DATE], approximately 01:20 AM. This administrator was informed by the Director of Nursing that there was a fire in the facility. It was reported that a CNA saw smoke and identified a resident on fire. The fire was extinguished. The staff immediately contacted 911 and notified the DON and this Administrator. The resident's roommate was removed from the room and surrounding residents were relocated to other rooms in the facility. Upon arrival to the facility, this administrator was informed by a first response officer that the affected resident was pronounced deceased . Assessment Details: The date and time of the assessment: The resident expired Record review of the Intake Investigation Worksheet dated [DATE] revealed, the reporter states that the upper part of the resident was engulfed in flames, along with the upper left part of their bed. the fire was contained and was isolated to the resident (upper half/above the waist) and the bed. additional reporters stated that they spoke with arson investigators and ruled out the usage of cigarettes, smoking, electrical, cellphone, or parts from a lighter as the cause of the fire, at this time it is still unknown how the fire started. Observation of the facility time stamped security footage of the front hall dated [DATE] revealed, at 01:16 AM staff at the nursing station looked around with the doors open to the 400 Hall. At 01:17 AM staff in a blue top and black pants (CNA D) walked into the 400 Hall and shortly after 2 staff one in all black (CNA P) and one in blue walked toward the 400 Hall when CNA D runs out from the 400 Hall and to the nursing station. The staff in blue moved out of frame towards the 500/600 Hall, while CNA P walked into the 400 Hall and CNA D entered the med room located behind the nursing station, grabbed the fire extinguisher and walked into the 400 Hall. The staff in blue and 1 other staff walk into the 400 Hall behind her with the staff in blue holding the door. At 01:18 AM staff in a pink jacket (LVN I) comes out of the 400 Hall and walked in a fast pace out of frame towards the [DATE] Hall and the staff in the blue is seen at the front door looking into the 400 Hall with her hands over her mouth as a resident (Resident #4) walked out pushing her wheelchair. As Resident #4 came out of the 400 Hall the door is seen to hit her and the staff in blue held the door open and then entered the 400 hall. CNA D runs out of the 400 Hall followed by 1 other staff and was seen on the phone as the other staff moved out of frame by the 500/600 Hall. At this time Resident 4 was alone, standing while holding her wheelchair immediately in front of the 400 Hall, when CNA P walked out followed by the staff in blue. CNA P walked back into the 400 Hall and out again and the doors to the 400 Hall slowly closed behind her at 01:18:52 AM. At 01:19 AM, the staff realized the door was closed, banged on the door and attempted were seen entering a code at a keypad. At this time, LVN I entered codes at the door to the 400 Hall with 2 other staff, CNA D was on the phone at the nursing station with the staff in blue, and CNA P runs out the door with another staff. Resident #4 sat in her wheelchair in the front hall and received no assessments or evaluation as staff moved in and out of frame. At 1:21 AM an unknown resident (unknown resident #1) in a wheelchair moved toward the door of the 400 Hall, appeared to enter a code on the keypad and the door opened at 01:21: 53 AM (3 minutes after closing and 5 minutes after staff were alerted of the fire) and CNA P ran to the 400 Hall doors, held it open and smoke is seen coming out at the top the door. At 01:22:09 a resident (unknown resident #2) walked out the door, CNA P, CNA D and another staff enter into the 400 Hall as the staff in blue attempted to push the 2nd door in the double door to the 400 Hall. The door did not open and Resident #4 and unknown resident #1 who opened the door are wheeled out of frame toward the 500/600 Hall. At 01:23 AM CNA D is seen wheeling an unknown resident out the front door while unknown resident #2 is seen walking around the hall as smoke is seen coming out of the 400 Hall. CNA D, CNA P, the staff in blue, LVN I and other staff wheeled other residents out the front door until 01:26 AM when fully geared fire men arrived and entered the 400 Hall. At 01:28 AM the firefighters exit the 400 Hall and return into the hall and at 01:29 AM the EMTs arrive and enter into the 400 Hall. More firefighters arrived, moved in and out of the unit, at 1:33 AM (6 minutes after the fire was identified) an EMT walked out of the 400 Hall, while a fire fighter pushed against the 2nd door to the double doored 400 Hall that remained locked in place during this incident. Fire men turned sideways as they carried their equipment and walked through the single door open in the double doors to the 400 Hall and on and off attempted to open the locked door. Record review of the Fired Department NFIRS-1 Basic report dated [DATE] revealed, the fire department arrived to the facility on [DATE] at 01:33 PM (a 7 minute discrepancies from the facility's timestamped video) for a building fire. - Actions taken: evacuate area and ventilate.- Casualties: 1 civilian and no injuries- Hazardous Materials Release: None- Property Use: Nursing HomeRemarks: Dispatched to a nursing home on fire. [fire department staff] were the first to arrive on scene of a 1-story pitched roofbuilding with nothing showing from the exterior. residents were being evacuated by building personnel. [fire department staff]assumed [facility] road command. [fire department staff] was ordered to investigate and reports a haze inside the building. [fire department staff] arrived and was ordered to assist with evacuation & prepare for horizontal ventilation. [fire department staff] reports a [location of fire] was found and the fire is out. [fire department staff] arrived and were ordered to assist with evacuationand ventilation. [fire department staff] were disregarded. arson was requested. [fire department staff] arrived and was assigned toevacuation group. [fire department staff] reports 11 residents were protected in place, haze is clearing out, and the room the 10-50 is in has been secured. the incident was tapped out holding [fire department staff] , [fire department staff] , [fire department staff] , & [fire department staff] . building personnel report the fire alarm was triggered and went to the wing to find the source of the alarm. CNA D was the 1st to find the source and used a fire extinguisher. the [location of fire] was in a 2-person room. the 2nd resident wasevacuated by building personnel. the small fire looks to have started on the bed near the victims head. There was no extension beyond the items on the bed. building personnel report the deceased is a smoker, but no one witnessed how the fire started. no signs of medical oxygen use in the room. a pump can was used to apply a small amount of water on a small book that was next to the deceased . [police department] units arrive .- Ignition: 21-Bedroom - < 5 persons- Area of Fire Origin: Undetermined- Heat Source: Undetermined- Item First Ignited: Undetermined- Cause of Ignition: Cause Under Investigation- Factors Contributing to Ignition: Undetermined- Human Factors Contributing to Ignition: Asleep- Mobile Property Involved: None- Fire Spread: Confined to Object of Origin- Presence of Detectors: Present- Detector Type: Smoke- Detector Operation: Operated- Detector Effectiveness: Alerted Occupants, Occupants Responded- Presence of Automatic Extinguishing System: Present- Operation of Automatic Extinguishing System: Fire Too Small To Activate- [fire department staff]: arrived and was assigned evacuation group. Some patients were evacuated from building and 11 were sheltered in place. [fire department staff]- observed that the deceased pt appeared to not have any oxygen because of the absence of o2 bottle or o2 bib on the wall. notified command and secured the room.- [fire department staff]: arrived on location and was ordered by fire department staff]to investigate. upon entry we found the fire alarm system to be active and there was smoke in the lobby area. nursing home staff were evacuating residents. We made our way to the fire room and found one deceased victim in the first bed. i appears the fire started in the bed she occupied. fire department staff]notified command and we then assisted fire department staff] and fire department staff]with ventilating that wing of thenursing home. we also checked on the other occupants on that hallway. due to smoke conditions the rest of the hallway was sheltered in place. CR #44 Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The residents advanced directive was Full Code and she expired in the facility on [DATE] at 01:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left sided weakness Care Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 ft 8 inches, and 274 lbs. Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Record review of CR #44's Discharge MDS dated [DATE] revealed, discharged Status- deceased . Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Clinical Assessments revealed, the last clinical assessment documented was on [DATE]. Record review of CR #44's Progress Notes revealed,- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the Hoyer Lift. Resident tolerated well.- [DATE] 01:54 AM signed by the DON, After speaking with the charge nurse and CNA, I called the RP's daughter to inform her that her mother was involved in a fire incident and that she was being treated for possible burns. Explained that the ambulance was working on [CR #44] at this time, and they would probably take her to the [Hospital]. The RP said she was not in town and that she would call her brother to see if he was closer than she was. RP said she would leave where she is and head to [Hospital] to check on her mother.- [DATE] 08:03 AM signed by LVN I, At approximately 01:00 AM the writer was on hall 600 to check on the other resident in my care. On my way back to 400, as I was walking down the hall I observed residents in bed sleeping including room [ROOM NUMBER]. As the writer was at the back of the hall 400, approximately 10 minutes later the writer heard alarm sound with flashing lights. I heard a CNA calling me and telling me the fire was in room [ROOM NUMBER]. As the writer was going to room [ROOM NUMBER], the CNA who was in front of me, grabbed the extinguisher and entered the room before I got there. When I entered the room I said to the CNA to call 911, then I assisted the CNA to evacuate the room-mate while the other 2 CNA's was trying to put the fire out. Once the roommate was safely evacuated, I immediately went to render aide to [Resident #24]. As I was getting ready to assess the resident 911 was already here and in the room. The EMT's asked where the other resident was, and I told them she was outside. EMT's were providing medical care to [Resident #24] and I left the room to go be with the residents that were outside. I then notified the DON once the residents were evacuated off of the hall and accounted for.- [DATE] 10:21 AM signed by MA C, resident expired. In an interview on [DATE] at 01:27 PM, CNA M said CR #44 did not exhibit any behaviors such as hoarding or hiding items, she was a smoker but she was complaint with the facility smoking policy. CNA M said there were no issues with CR #44 smoking. In an interview on [DATE] at 01:28 PM, LVN C said CR #44 was bed/wheelchair bound, required total assistance with all ADLs, had left side paralysis but could eat with setup/assistance. She said while the resident was grumpy, sarcastic and refused care there were no issues hoarding or hiding times. CR #44 was compliant with the facility smoking policy and would only smoke in the designated area. An observation on [DATE] at 09:58 AM revealed, CR #44's room floor covered by white powder and the room had been cleared of contents. There were gloves and packs of Personal Cleaning Wipes on the floor and on the bed. An off-white metal bed lie closest to the entrance, with no mattress and visible black fire damage. The center of the headboard was warped and melted with black burn marks, black ash/soot was observed on the base of the headboard, bed frame, and on the floor. There was limited evidence of smoke damage on the walls and ceiling with wipe marks on the ceiling directly above CR #44's bed and an imprint caused by smoke on the wall were a something was hung that was now removed. An observation and interview on [DATE] at 01:35 PM revealed, a box containing resident cigarettes and lighters locked in the med room. A box of cigarettes bearing CR #44's initials contained 7 cigarettes. The [NAME] said CR #44 had no behaviors of hoarding or hiding of items like cigarettes. She said her only behavior was to make complaints about staff, and that behavior was in her care plan. The DON said CR #44 diligently followed facility smoking policy and she would wait for staff to take her out to smoke. In an interview on [DATE] at 03:31 PM, the Medical Director said she had been Medical Director in the facility for the last 1 1/2 to 2 years. She said if a resident had extensive burns, the facility would not initially treat the burns while in an emergency situation but would cover the resident with clean, dry sheets; monitor breathing and keep the resident warm after the fire was extinguished. She said a resident with severe burns would need specialized treatment that could only the hospital could provide but she would expect nursing facility staff to assess the residents signs, mainly the breathing. The Medical Director said to maintain a resident's life prior to arrival of EMS, staff must monitor vital signs and monitor alertness. Once the resident was moved away from the fire source, staff should make sure airway was clear, resident was breathing, provide oxygen if necessary, monitor the residents pulse and blood pressure until EMS arrive. The Medical Director said if assessments and aide was not rendered to a resident with severe burns the resident could go into shock and a lot of things could happen. She said a resident with severe burns to the upper chest with shallow breathing should not be left unattended and someone should be with a resident if they have severe burns. The Medical Director said nursing home staff can provide services to help sustain life until EMS arrives and the resident should be continuously monitored. In an interview on [DATE] at 04:15 PM, the DON said when an individual experienced extensive burns they must be immediately assessed. Bleeding should be stopped, the airway must be assessed for lung sounds, and vitals assessed. She said nursing staff must stay with the resident until help arrived, and part of the competency of a nurse is training on how to react in an emergency situation. The DON said prior to the fire on [DATE] staff were not trained on what do to if a resident had a severe burn, but they know what to do now. She said to her knowledge nursing staff did not assess CR #44 after the fire was extinguished. The DON said no one assessed CR #44 after the fire but they should have as it was a professional standard. When asked about the risk to residents if staff failed to assess them following extensive burns, the DON said based on her investigation, she thought CR #44 was expired when she was found on fire and no one told her the resident was moving and groaning at the time of the fire. She said, only god has the power over life and death, and if a resident expired it was in God's Hands. When pressed the [NAME] said treatment rendered to a resident with extensive burns was based on what the assessments yields, but staff should make sure the resident was breathing. In an interview on [DATE] at 03:25 PM, the ME said CR #44's cause of death was still pending but the resident suffered from 2nd (burn that damages the top layer of skin and part of the 2nd layer) and 3rd (burn that destroys the first three layers of skin and the fatty tissue) degree burns on her head, upper torso and extremities. She had significant charring (severe burn that has destroyed all layers of skin and may extend into underlying tissue caused by prolonged exposure to extreme heat that appears black or ash-gray) especially to the left side of her body not the right. There was soot deposition in her airway/bronchi, which indicated she was breathing while on fire. 26% of CR #44's body surface was burned. Resident #2 Record review of Resident #2's Face Sheet dated [DATE], revealed a 93- year- old female who admitted to the facility on 03/13/ 20 with diagnosis which included: Type 2 diabetes, COPD, dementia, epilepsy, and irregular heartbeat. Record review of Resident #2's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 0 out of 15. The resident had lower extremity functional limitations in range of motion used automobile chair and required maximum assistance for most ADL's. For mobility, the resident was either dependent or required maximum assistance. The resident was fully dependent on staff to propel in a motorized wheelchair for 50 to 150 feet. Record review of Resident #2's undated Care Plan revealed, Focus- Requires a wander guard bracelet and is at risk for injury from wandering in an unsafe environment; Interventions: Monitor resident in facility and document attempts to elope out of facility. Focus: ADL self-care performance deficit r/t impaired cognition, poor safety awareness. Ambulates without use of an assistive device. She will at times hold onto the rails in hallway. Resident may require increased assistance with transfers depending on level of surface she is transferring from. Interventions: requires assistance of one staff to turn and reposition in bed at regular intervals. Record review of Resident #2's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- Resident #2 requires assistance of 1 staff to turn and reposition in bed at regular intervals and as necessary; requires assistance with lying to sitting at times. Transfer- requires assistance of one staff for supervision to move between surfaces as tolerated. Resident # 2 May require assistance with sit to stand if sitting for prolonged period of time or level of surface. Resident #3 Record review of Resident #3's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, paralysis following a stroke, dementia, anxiety disorder, and bed confinement status. Record review of Resident #3's Quarterly MDS dated 9/11 25 revealed, severely impaired cognition skills for daily decision making and impairments in functional limitations in range of motion for both sides of her upper and lower extremity. Record review of Resident #3's undated Care Plan revealed, Focus-Resident received oxygen as needed. The shortness of breath. Interventions: Monitor for signs and symptoms of respiratory distress- SOB, dyspnea, low O2, cyanosis, diaphoresis, changes in behavior. Record review of Resident #3's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- total dependence on staff for repositioning and turning in bed. Lying to Sitting on side of bed: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Roll Left and Right: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to lying: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to stand: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Toilet transfer: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transfer: total dependence on staff for transfer. An observation on [DATE] at 10:19 AM revealed, Resident #3 lying in bed with eyes closed, well-dressed well-groomed in no immediate distress. Resident #4 Record Review of Resident #4's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, generalized anxiety disorder, unspecified dementia with other behavioral disturbances, adjustment disorder, major depressive disorder, Constipation, bradycardia, and repeated false. Record review of Resident #4's BIMS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 10.Record review of Resident #4's undated Care Plan revealed, Focus- impaired cognitive function/dementia or impaired thoughtProcesses; Interventions: needs supervision/assistance with all decision making. Focus: impaired visual function r/t Glaucoma; Interventions: during activities provide the resident with items that have larger print and bigger pictures to promote participation. Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs; Interventions: partial/moderate assistance with upper and lower body dressing. Transfer- Supervision by 1 staff to move between surfaces, as necessary. Bed Mobility- Supervision by 1 staff to move between surfaces, as necessary.An observation and interview on [DATE] at 02:41 PM revealed, Resident #4 was well groomed, well dressed in no immediate distress in a wheelchair. The resident was not interviewable, she was confused and repeated that she did not want to spend a night. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis), type 2 diabetes, difficulty swallowing, dementia, and anorexia. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The use of a manual wheelchair, total dependence on most ADL's, and total dependence for most functional abilities. Record review of Resident #6's undated Care Plan revealed, Focus: Impaired visual function; Interventions: notify where you are placing their items. Be consistent and cater to the resident's preference of item placement. Focus: ADL self-care performance deficit, requires staff assist with ADL cares, refused to get out of bed daily; Interventions: Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Record review of Resident #6's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Am observation on [DATE] at 10:20 AM revealed, Resident #6 well dressed, well-groomed lying in bed awake. The resident responded to the surveyor with head nods and indicated she needed help. Resident #11 Record review of Resident #11's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia, bipolar disorder, diabetes and hypertension. Record review of Resident #11's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, one sided upper extremity and 2 sided lower extremity functional limitations in range of motion. Use of a wheelchair, total dependence with most ADLs and all functional abilities, total dependence for use of a manual scooter. Record review of Resident #11's undated Care Plan revealed, ADL self-care performance deficit and requires maximum assistance with ADLs r/t activity intolerance, Alzheimer's, impaired balance and limited M=mobility Record review of Resident #11's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- lying to sitting on side of the bed- dependent helper does all the effort; roll left and right- substantial/maximal assistance helper does more than half of the effort. Sit to stand- dependent helper does all the effort. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more was required for the resident to complete the activity. Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Parkinsonism. epilepsy, hypertension, difficulty breathing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, short term and long term memory OK. And independent cognitive skills for daily decision making The use of a wheelchair, no upper or lower extremity functional limitations in range of motion, substantial or maximum assistance to total dependence for all ADL's and substantial maximum assistance to total dependence on staff for mobility. Record review of Resident #18's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Parkinson's Disease. Interventions: chair/bed-to-chair transfer: Resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Lying to sitting on side of bed: resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Roll left and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces Resident #25 Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure. Depression, dependence on dialysis, and dementia. The resident

Based on interview, observation and record review, the facility failed to ensure that assessments accurately reflected residents' status for 2 (CR #44 and Resident #28) of 6 residents reviewed for accuracy of assessments. The failed to ensure CR #44's left sided hemiplegia and hemiparesis (paralysis and weakness was documented accurately in her Quarterly MDS dated [DATE] as a functional limitation in range of motion and diagnosis.The facility failed to ensure that Resident #28's behavior of wandering was documented on their quarterly MDS assessment dated [DATE].Findings included:Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The resident expired in the facility on [DATE] at 1:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left side weakness Care Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 feet 8 inches, and 274 lbs.Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers.Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Progress Notes revealed the following;- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the mechanical Lift. Resident CR#44 tolerated well.In an interview on [DATE] at 01:28 PM, LVN C said CR #44 was bed/wheelchair bound, required total assistance with all ADLs, had left sided paralysis but could eat with setup/assistance. She said while the resident was grumpy, sarcastic and refused care there were no issues hoarding or hiding times. CR #44 was compliant with the facility smoking policy and would only smoke in the designated area.During interview on [DATE] at 12:39 PM, CNA L said she usually worked on the #400 hallway which was where CR #44 had resided. CR #44's left arm and leg were paralyzed, she could move her right side perfectly fine but not her left side . CNA L said CR #44 transferred out of bed to a wheelchair by using a Hoyer lift and two-person assistance. In an interview on [DATE] at 12:42 PM., LVN E said CR #44 suffered from paralysis from a previous CNA and had left sided weakness with no movement on her left side. LVN E said CR #44 was a two person assist and was transferred using a Hoyer lift. In an interview on [DATE] at 08:24 PM, the MDS Nurse said she was responsible for completing all facility MDSs. She said the MDA represents the resident's status and is usually a 7 day look back period. She said a resident's functional limitation in range of motion documents how a resident performs their day to day activities. She said failure to have the correct diagnosis or an incorrect MDS placed residents at risk for missed services and an inaccurate plan of care. The MDS said CR #44 had paralysis on one side of her body. After she reviewed the MDS, she said CR #44's MDS was coded incorrectly because it did not document her paralysis as a functional limitation of range of motion. She said she was responsible for completing CR #44's diagnosis, MDS and care plan and the errors were an oversight.Record review of Resident #28's face sheet dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities).Record review of Resident #28's quarterly MDS dated [DATE] revealed a BIMS score of 0 that indicated severe cognitive impairment. Record review of Resident #28's unmodified quarterly MDS dated [DATE] revealed wandering behavior was not exhibited in Section E. Record review of Resident #28's modified quarterly MDS dated [DATE] of Section E revealed wandering behavior occurred 1 to 3 days. Section P revealed daily use of wander/elopement alarm.Record review of Resident #28's Order Summary Report as of [DATE] revealed WANDER DEVICE: Wander device alarm applied with order date of [DATE]. Record review of Resident #28's care plan with revision date of [DATE] and target date of [DATE] revealed Resident #28 was care planned with a focus of requiring a wander guard bracelet and was at risk for injury from wandering. Record review of Resident #28's Elopement Risk Screener dated [DATE] revealed Resident #28 had a wandering history but had never eloped. Record review of Resident #28's [DATE] TAR revealed task from 9/1-[DATE] to visually check placement of Wandering Alert Device every shift from 9/1-[DATE].Observation on [DATE] at 12:24 p.m. revealed Resident #28 walking up and down the #400 hallwayDuring interview on [DATE] at 2:15 p.m., CNA M said Resident #28 walked a lot and would walk back and forth in every hallway. Observation on [DATE] at 2:19 p.m. revealed Resident #28 walking down the #100 hallway when her room was on the #400 hallway. During interview on [DATE] at 2:33 p.m., MDS RN said the Social Services Director completed Section E of the MDS and showed the surveyor Section P where use of wander/elopement alarm was captured. During interview on [DATE] at 2:41 p.m., the DON said she was familiar with Resident #28, and she walks all day. The DON said the MDS RN was responsible for completing the MDS. The DON said if the MDS was not accurate it was not a direct accurate reflection of who the resident was. During interview on [DATE] at 2:47 p.m., the MDS RN said she was going to modify Resident #28's MDS. During interview on [DATE] at 4:07 p.m., the Social Services Director answered yes when asked if Resident #28 wandered. The Social Services Director said she completed sections B, C, D, E and Q of the MDS. The Social Services Director said she documented that wandering behavior was not exhibited as Resident #28 walks the hallways but did not wander outside. The Social Services Director said Resident #28 had a wanderguard and she was not sure what happened prior for Resident #28 to get the wanderguard. The Social Services Director said something must have happened for the resident to be at risk for the wanderguard. The Social Services Director said if the MDS did not reflect the resident accurately then that was false information because you would not be looking for those behaviors. Record review of the facility's policy MDS 3.0 Completion dated 2023 revealed According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity.

Based on observations, interviews, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1(Resident #11) of 6 residents reviewed for care plan.Resident #11's care plan printed 9/30/25 was not revised to reflect removal of a urinary catheter with an order to remove the foley catheter on 8/13/24 and when a pressure ulcer wound resolved with a discontinued order dated 9/1/25. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included:Record review of Resident #11's face sheet dated 10/1/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Other Schizophrenia (disorder characterized by hallucinations, delusions, disorganized thinking and difficulty distinguishing reality from imagination).Record review of Resident #11's quarterly MDS dated [DATE] revealed a BIMS score of 9 that indicated moderate cognitive impairment. Section H revealed Resident #11 did not have an indwelling catheter. Section M revealed 1 number of Stage 3 pressure ulcers. Record review of Resident #11's discontinued orders revealed wound care to left lower extremity with end date on 9/1/25 and order to remove Foley catheter on 8/13/24.Record review of Resident #11's August 2025 MAR revealed Remove Foley catheter with documentation on 8/13/25.Record review of Resident #11's Progress Note dated 8/13/25 at 11:37 p.m. revealed Resident #11's Foley catheter was removed at 9:45 p.m. Record review of Resident #11's Weekly Wound Observation dated 8/28/25 revealed Stage 3 pressure ulcer to left distal posterior lower leg that was closed, and wound progress was resolved. Record review of Resident #11's care plan printed 9/30/25 revealed a focus of an indwelling suprapubic catheter and actual impairment to skin integrity from a left lower leg pressure ulcer. Record review of Resident #11's order Summary Report as of 10/1/25 did not reveal any orders regarding a catheter or wound care for left lower leg pressure ulcer.Record review of Resident #11's Skin Observation dated 10/1/25 revealed no documentation regarding pressure ulcers with only documentation regarding rashes. Record review of Resident #11's care plan printed 10/3/25 no longer had a focus if an indwelling suprapubic catheter or actual impairment to skin integrity from a left lower leg pressure ulcer. This care plan was revised after surveyor intervention. Observation on 9/29/25 at 10:21 a.m. of Resident #11 revealed no visible catheter. During an interview on 9/29/25 at 11:59 a.m., LVN C said she had been the wound care nurse for the last two weeks and would be the wound care nurse for the next two weeks and then there would be someone coming to be the wound care nurse. During an interview on 9/29/25 at 12:27 p.m., LVN E said Resident #11 did not have a suprapubic catheter. During an interview on 9/29/25 at 12:39 p.m., CNA L said Resident #11 did not have a catheter. During an interview on 10/3/25 at 2:22 p.m., LVN F said if a catheter was removed or it a wound resolved then she would relay the message to the wound care nurse or ADON and they would update the care plan. During an interview on 10/3/25 at 2:33 p.m., MDS RN said the DON and ADON was who made changes to the care plan like if a resident's catheter was removed. During an interview on 10/3/25 at 2:41 p.m., DON said the nurse on the unit, herself or the ADON, was responsible for updating care plans like when a Foley catheter was removed. The DON said the wound care nurse, ADON or herself would be responsible for updating the care plan when a wound was resolved. The DON said if the care plan was not revised that it did not directly reflect the care that they were providing to Resident #11. At 3:03 p.m., the DON went to check Resident #11 as the DON said she was still learning the residents and confirmed that Resident #11 did not have a catheter. At 3:05 p.m., the DON said she removed the catheter from Resident #11's care plan. The DON said a wound should come off the resident's care plan when the wound was resolved. During an interview on 10/3/25 at 3:10 p.m., ADON said she completed the baseline care plans for new admissions. ADON said the previous DON preferred to update the care plans and attended the care plan meetings. ADON said the MDS RN was responsible for completing the MDS. During an interview on 10/3/25 at 5:23 p.m., LVN C, who was the current wound care nurse, said she was only responsible for wound care and not updating the resident's care plans. LVN C said probably DON or ADON was responsible for updating the residents' care plans regarding wound care. Record review of facility's policy Comprehensive Care Plans dated 2025 revealed The comprehensive care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, interview and record review the facility failed to ensure nurses were able to demonstrate competency in skills to provide nursing and related services for 1 of 1 resident (Resident #1) by 1 of 2 nurses (LVN G) reviewed for competent staff, in that: The facility failed to ensure LVN G was competent to administer medications and knowledgeable regarding Enhanced Barrier Precautions. This failure could place residents at complications from g-tube medication administration or possible infection risk. Findings included:Record review of Resident #1's face sheet dated 10/3/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction (disorder when blood flow to a part of the brain is blocked leaking to lack of oxygen and nutrients) and Gastrostomy Status (surgical opening in the abdominal wall). Record review of Resident #1's quarterly MDS dated [DATE] revealed BIMS could not be conducted. Section K revealed Resident #1 had a feeding tube while a resident. Record review of Resident #1's Order Summary Report dated 10/3/25 revealed GT: Enhanced Barrier Precautions (the targeted use of gowns and gloves during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms) due to the presence of G-Tube with order date of 8/19/25.Record review of Resident #1's Care Plan printed 10/3/25 revealed Resident #1 was on enhanced barrier precautions related to indwelling medical device of PEG tube. Care Plan also revealed a focus that Resident #1 will receive all nutrition and hydration via feeding tube with intervention to administer medications as ordered. During observation on 10/3/25 at 10:08 a.m., LVN G administered medications to Resident #1 individually through his g-tube. LVN G poured water in the medication cups just prior to administering each medication and slightly agitated the cup to mix by picking the medication up and moving it in a circular motion for a few seconds. Significant residue was observed in the medication cups that was used for Sennoside, Vitamin C, Thiamine and One Daily Multivitamin after administration to Resident #1. Metoprolol was crushed and was at bedside but was not administered as LVN G was unable to check Resident #1's blood pressure as the blood pressure cuff had low battery.Observation on 10/3/25 at 10:15 a.m. revealed LVN G threw the medication cup with the crushed Metoprolol that was not administered in the trashcan in the resident's room. During interview and observation on 10/3/25 at 10:16 a.m., LVN G said medications were supposed to be disposed of in the sharp's container which was located on the medication cart. LVN G said she was unsure if she could take the medication out of the room since the resident was on precautions. LVN G said she was unsure if she could take the Metoprolol out of the room since the resident was on precautions. LVN G said Resident #1 was on standard precautions and then said she was not sure what precautions Resident #1 was on. Enhanced Barrier Precautions sign on the doorway near the residents' name was visible during the interview. When LVN G was asked what Enhanced Barrier Precautions was, she said I don't know. When LVN G was asked how she normally kept the medications from having residue in the medication cups, LVN G said she crushed all the medications and put them in a large cup and mixed with water so there was normally no residue left. LVN G said normally she would put all the medications in one cup but wanted to do the right thing. During interview on 10/3/25 at 11:32 a.m., LVN G said she had worked at the facility for about a month. LVN G said she had no training regarding g-tube administration in orientation at the facility. LVN G said she shadowed a nurse and then the nurse shadowed her once she was on the floor. LVN G said she was observed giving g-tube medications during the shadowing time. LVN G said the nurse she shadowed administered all the g-tube mediations together. LVN G did not know the last name of the nurse who shadowed her but gave the first name as the same as the first name of RN B. During interview on 10/3/25 at 11:39 a.m., the Regional Nurse Consultant said he offered the facility proficiency checks and would be observing LVN G performing g-tube administration. During interview on 10/3/25 at 2:41 p.m., the DON said the nurses get a competency check off for g-tube administration. The DON said the Consultant Pharmacist and the Regional Nurse Consultant walked with a nurse until they were proficient. The DON said the Regional Nurse found two or three people to observe for medication administration which could include g-tube administration and was at the facility weekly. The DON said the Consultant Pharmacist came to the facility monthly and went with the nurses, which could include g-tube administration. The DON said it was her goal to do more of a finalized training since she had only been at the facility for six weeks. During interview on 10/3/25 at 3:31 p.m., the Consultant Pharmacist said if there were nurses in need of any type of observation the facility could ask her to watch the nurse or medication aide for medication pass and denied any issues with observation of g-tube medication administration in the past. The Consultant Pharmacist said medications should be given individually when given through a g-tube. The Consultant Pharmacist said you want to make sure the medications were well dissolved, and the cup was rinsed as the resident might not get the entire dose if there was residual left in the medication cup when administering medications. During interview on 10/3/25 at 3:42 p.m., RN B said they administered medications separately though a g-tube after being mixed with 10-15 cc of water and said she had not precepted anyone since she had been at the facility . During interview on 10/4/25 at 12:26 p.m., the DON said she was unable to find training records for LVN G. The DON said she did not know how records were kept prior to her arrival, which was six weeks ago but she had put a binder together once she arrived. The DON said the records have been stored in the DON's office and she had been gathering the training documents. The DON said nurses new to the facility train with another nurse for three days . The DON said LVN G had trained with a nurse who was no longer at the facility and gave a different first name from RN B who still worked at the facility. The DON said if a nurse needed more time, then we always give it and work with them. The DON said she would provide the training records for LVN G if she found them. The DON said the effect it could have on the residents if there were no training records for staff was the nurse should be proficient and competent as they have been licensed by the board. During interview on 10/4/25 at 1:27 p.m., the Corporate Director of Compliance said there was not a policy regarding nurse competency when a policy regarding nurse competency or training was requested. In an interview on 10/06/25 at 01:40 PM, the DON said the facility never assessed LVN G's competency for administration of medication via G-tube. She said the consultant pharmacist was supposed to assess her prior to the medication error on 10/03/25 but it didn't happen because LVN G said she would only perform oral medication administration. Record review of LVN G's employee records revealed, she was a PRN staff and her date of hire was 09/02/25.Record review of facility's policy Enhanced Barrier Precautions dated 2025 revealed all staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. Record review of facility's policy Medication Administration via Enteral Tube dated 2023 revealed Each medication will be administered separately, not combined or added to an enteral feeding formula.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 9% based on 4 errors out of 43 opportunities, which involved 1 of 1 resident (Resident #1) and 1 of 2 staff (LVN G) observed during medication administration reviewed for medication error.The facility failed to ensure Resident #1 received the complete doses of:1. Multivitamin Oral Tablet2. Sennosides-Docusate Sodium Oral Tablet 8.6-50 mg3. Vitamin C 500 mg4. Thiamine HCL Oral Tablet 100 mgThe failure could place residents at risk of not receiving therapeutic dosages and/or effects of medications. Findings included:Record review of Resident #1's face sheet dated 10/3/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction (disorder when blood flow to a part of the brain is blocked leaking to lack of oxygen and nutrients) and Gastrostomy Status (surgical opening in the abdominal wall). Record review of Resident #1's quarterly MDS dated [DATE] revealed BIMS could not be conducted. Section K revealed Resident #1 had a feeding tube while a resident. Record review of Resident #1's Order Summary Report with active orders as of 10/3/25 revealed physicians orders for Multivitamin Oral Tablet with instructions to give 1 tablet via G-Tube one time a day for wound healing, Sennosides-Docusate Sodium Oral Tablet 8.6-50 mg with instructions to give 1 tablet via G-Tube one time a day for constipation, Thiamine HCL Oral Tablet 100 mg with instructions to give 1 tablet via G-Tube one time a day for dietary supplement and Vitamin C 500 mg with instructions to give 1 tablet via G-Tube two times a day for wound healing. Record review of Resident #1's Care Plan printed 10/3/25 revealed Resident #1 was on enhanced barrier precautions (the targeted use of gowns and gloves during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms) related to indwelling medical device of PEG tube. Care Plan also revealed a focus that Resident #1 will receive all nutrition and hydration via feeding tube with intervention to administer medications as ordered. During observation on 10/3/25 at 10:08 a.m., LVN G administered medications to Resident #1 individually through his g-tube. LVN G poured water in the medication cups just prior to administering each medication and slightly agitated the cup to mix by picking the medication up and moving it in a circular motion for a few seconds. Significant residue was observed in the medication cups after administration to Resident #1 that was used for Sennoside, Vitamin C, Thiamine and One Daily Multivitamin. During interview on 10/3/25 at 10:22 a.m., the DON said LVN G was new to the facility. The DON said the Consultant Pharmacist was in the building this morning and she had asked the Consultant Pharmacist to work with LVN G. During interview on 10/3/25 at 11:32 a.m., LVN G said the effect it could have on the resident if there was residual left in the medication cup after administering medication would be the resident would not be getting all the medication they needed. LVN G said she had worked at the facility for about a month. LVN G said she had no training regarding g-tube administration in orientation at the facility. LVN G said she shadowed a nurse and then the nurse shadowed her once she was on the floor. LVN G said she was observed giving g-tube medications during the shadowing time. LVN G said the nurse she shadowed administered all the g-tube mediations together. LVN G did not know the last name of the nurse who shadowed her but gave the first name as the same as the first name of RN B. During interview on 10/3/25 at 11:39 a.m., the Regional Nurse Consultant said he offered the facility proficiency checks and would be observing LVN G performing g-tube administration. During interview on 10/3/25 at 2:41 p.m., the DON said the effect on a resident if residual was left in the medication cup when administering medication was that the resident was not getting all of the medication, so the medication was not effective. During interview on 10/3/25 at 3:31 p.m., the Consultant Pharmacist said if there were nurses in need of any type of observation the facility could ask her to watch the nurse or medication aide for medication pass and denied any issues with observation of g-tube medication administration in the past. The Consultant Pharmacist said medications should be given individually when given through a g-tube. The Consultant Pharmacist said you want to make sure the medications were well dissolved, and the cup was rinsed as the resident might not get the entire dose if there was residual left in the medication cup when administering medications. Record review of the facility's policy Medication Administration dated 2024 revealed the six rights of medication administration are followed which includes the right dosage and crushed medications are not to be combined and given all at once, if via feeding tube.

Based on observation, interview and record review, the facility failed to provide diagnostic services to meet the needs of its residents in a timely manner for 1 of 1 (Resident #1) residents review for radiology services. - The facility failed to ensure a chest x-ray was performed timely for Resident #1 following his physicians order given to rule out pneumonia on 10/01/25. The chest x-ray was performed on 10/06/25. This failure could place residents at risk of delayed diagnosis and medical treatment to prevent complications and injuries. Findings Included: Resident #1 Record review of Resident #1's Face Sheet dated 10/02/25 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: left side paralysis, aphasia (inability to speak) after a stroke (interruption of blood flow to the brain that causes tissue damage), difficulty swallowing, anxiety disorder, gastrostomy ( a tube passed through the abdomen into the stomach used for food or medication administration), and pneumonia (infection of the lungs). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, upper and lower extremity functional limitations in range of motion, total dependence for most ADLs and use of a feeding tube. Record review of Resident #1's undated Care Plan revealed, Focus: responsible party requests full code status; Goal- resident's wishes will be honored on an ongoing basis; Interventions: Monitor for decline in change of condition-report to M.D. and responsible party. Record review of Resident #1's Physician Progress Note dated 10/01/25 at 08:00 AM signed by MD A revealed, Chief Complaint: Cough with congestion; Audible cough with congestion noted with diminished breath sounds on exam. Resident #1 remains on room air without signs of respiratory distress. Chest V-ray ordered continues on tube feeds. Diagnostics Tests- chest X-ray ordered, Record review of Resident #1's Order Entry dated 10/01/25 revealed, Description: CXR to evaluate cough. The order was entered by MD A on 10/01/25 at 03:03 PM and confirmed by RN B on 10/01/25 at 4:32 PM. Record review of Resident #1's Progress Notes dated 10/01/25 to 10/07/25 revealed:- No evidence of follow up or X-ray completion from 10/01/25 to 10/05/25.- 10/06/25 at 02:43 PM, CXR order from 10/1 re-entered MD A called to notify. Radiology Company was notified and CXR has been completed.- 10/06/25 at 03:49 PM, Respiratory assessment completed. Pulse Ox 97% (the measure of oxygen carried in the blood) on room air no cough noted at this time. Resp effort and rate WNL. Relaxed and regular. Rhythm regular 18 resp per min lung sounds clear throughout. Resident sitting in bed with HOB 45 degrees. No distress noted.- 10/06/25 at 11:45 PM, Chest X-Ray 2 views results: No evidence of acute cardiopulmonary disease. Stable when compared to prior exam. Result send to NP for review. No new orders. Responsible party at bedside and was notified. Record review of Resident #1's Radiology Results Report dated 10/06/25 at 06:20 PM revealed, PROCEDURE: Chest Xray; INDICATION: Pneumonia; IMPRESSION: No evidence of acute cardiopulmonary (relating to the heart and the lungs) disease. An observation on 09/29/25 at 11:34 AM revealed, Resident #1 lying in bed receiving formula via his G-tube. The resident was nonresponsive to the surveyor but appeared to be in no immediate distress. His breathing appeared unlabored and he did not have a cough. An observation on 10/06/25 at 01:13 PM revealed, Resident #1 lying in bed receiving formula via his G-tube. The resident was non-responsive to the surveyor but appeared to be in no immediate distress. His breathing appeared unlabored, and he did not have a cough. In an interview on 10/06/25 at 01:18 PM, RN B said when a physician gave an order for an x-ray it must be documented in the 24 hour report. She said she was Resident #1's nurse, she had not observed him with a cough, she did not know there was a pending X-ray, she didn't know any orders were entered for Resident #1's CXR. RN B said there has been no communication to her, nursing, or the RP about the pending CXR. In an interview of 10/06/25 at 01:20 PM, the DON said when radiology orders were entered by a provider, nursing staff must then confirm the order. She said she didn't know why Resident #1's X-ray had not been taken yet, Resident #1's cough that required a CXR for further evaluation was considered a change in condition so all the notifications that should be sent out. The DON said RN B confirmed the order for Resident #1's CXR in the EMR system. In an interview of 10/06/25 at 02:47 PM, the DON said when staff received a physician order for radiology they must enter it into the EMR which is integrated with the laboratory and then document it in the progress note and in-house 24 hour report log. She said RN B failed to document the order and follow up with the x-ray and that is why it was missed. The DON said failure to timely complete radiology orders could place residents at risk for worsening of condition and delay in care. In an interview on 10/06/25 at 03:42 PM, MD A said when she assessed Resident #1 on 10/01/25 he was observed to have diminished lung sounds and a cough. The resident had been in and out of the hospital with pneumonia and received enteral feeds via a G-tube which put him at risk for aspiration pneumonia (pneumonia as a result of inhaling vomit) so she was concerned about the cough. She said older individuals like Resident #1 present differently from young, healthy people because their weak immune system can result in normal WBC (elevation indicative of infection), no fever, and since they can't mount the same immune response they end up with Walking Pneumonia. MD A said in individuals like Resident #1 she would order an X-ray to rule out pneumonia. She said normally when she entered CXR orders, it took radiology company a day perform the imaging and the facility would then call her to notify her of the results. MD A said she was not aware the facility had not completed the CXR order she entered on 10/01/25, a 5 day delay was not acceptable and the facility shouldn't drop the ball on things like this. She would not identify any risks associated with failure to implement radiology orders timely but said it would delay identification of an issue or fail to rule out a suspected concern. Record review of the facility policy titled Radiology and other Diagnostic Services and Reporting with no revision date revealed, Policy: The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant; nurse practitioner or clinical nurse specialist in accordance with state law. Policy Explanation and Compliance Guidelines: 1. The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. 3. All radiology and other diagnostic services will only be ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law, including scope of practice laws.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update the facility nursing postings on 09/29/25, 10/03/25 and 10/04/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 09/29/25 at 10:16 AM revealed, the facility Daily Staffing Report posting located on the top of the counter at the central nursing station that read 09/24/25. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM). The posting indicated the facility census, staff types (RN, Wound Care, LVN/LPN, CNA, Shower tech, CMA and RN Admin) and hours worked for both shifts. An observation on 10/03/25 at 02:54 PM revealed, the facility Daily Staffing Report posting located on the top of the counter at the central nursing station that read 10/03/25. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM). The posting indicated the facility census, staff types (RN, Wound Care, LVN/LPN, CNA, Shower tech, CMA and RN Admin) and hours worked for both shifts. An observation on 10/04/25 at 08:22 AM revealed, the facility Daily Staffing Report posting located on the top of the counter at the central nursing station that read 10/03/25. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM). The posting indicated the facility census, staff types (RN, Wound Care, LVN/LPN, CNA, Shower tech, CMA and RN Admin) and hours worked for both shifts. In an interview on 10/06/25 at 02:47 PM, the DON said she was responsible for the facility nurse staffing posting. She said the posting had to include the date, census, facility staffing and the quantity of each staff type and its purpose was to let everyone know the staffing for that day. The DON said she updated the posting Monday- Friday and prepared Saturday and Sundays for the weekend supervisor to uncover on each day. She said the posting is normally updated when she comes in at 9 AM, and failure to update the posting will leave people unaware of how much staff they have in the building. The DON denied failing to update the posting. Record review of the facility policy titled Nurse Staffing Posting Information revised 03/2025 revealed, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift.

Based on observations, interviews and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of two medication carts reviewed for medication storage. The facility failed to keep resident medications in their original containers/packaging located in the medication cart assigned to LVN M. There were 18 loose pills at the bottom of one of the drawers belonging to unknown residents. These failures could affect residents receiving medications placing them at risk of receiving the wrong medication and adverse side effects. Findings included: During observation and interview on [DATE] at 2:45PM, the medication aide cart for the skilled unit which was assigned to LVN M had 18 loose pills of various shapes, sizes, and colors at the bottom of the second drawer from the left of the cart. The loose pills were underneath the medication blister cards that were tightly packed together. LVN M stated her role for the day was to administer medications that were usually assigned to a medication aide. LVN M stated she was responsible to keep the medication cart clean and ensure there were no expired meds and no loose pills. LVN M stated the potential issues were allergic reaction to a resident if loose pills fall out onto the floor and a resident takes it. LVN M stated she did not know but would check with DON on how to dispose of the loose pills. During an interview on [DATE] at 3:15PM the DON who stated the charge nurses, DON and ADON were responsible to check med carts. The DON stated the risks to having loose pills would be not knowing exactly what the pills were for and if a resident were to get a hold of loose pills it could cause side effects, it could cause harm, vital signs could drop, and heart rate could increase. The DON stated the medication supply could run out for that resident and a refill order would have to be placed. The Regional Nurse Consultant stated there would be no extra cost to the resident when reordered. The Regional Nurse Consultant stated that at times pills tend to fall out of blister cards d/t pharmacy packaging when cards are removed or replaced back into the cart. During an interview on [DATE] at 8:30AM, the DON who stated that LVN M did come to her after the loose pills were found and she instructed LVN M to crush the pills then put them into the sharps container. The DON stated, during audits, she ensured carts are checked, that over-the-counter medications were dated, insulins were dated accordingly, blister cards were not ripped, foil intact and made sure liquid medications were not leaking. She stated the DON would do audits weekly and the pharmacist checked carts monthly. The DON stated moving forward, she will check carts more often, conduct in-services for the nurses and medication aides, lift everything out cart and check bottom of drawers for loose pills. Record review of the undated facility policy and procedures for Medication Storage read in part: .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medications rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation .and security All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .

Based on observation interview and record review, the facility failed to ensure comprehensive care plans with the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being were developed for 2 of 3 residents (Resident #34 and #28) reviewed for care plans, in that: Resident #34 and #28, who were both identified as high risk for falls and in need of fall mats, did not have the intervention of fall mat included in their care plans. This failure places residents at for not receiving adequate care. Findings included: Resident #34 Record review of Resident #34's face sheet reflected a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of the facility incident log reported, dated 03/10/2024 - 09/10/2024 revealed the Resident #34 had three falls in the past six months, on dates 07/14/2024, 08/03/2024 and 08/07/2024. Record review of Resident #34's care plan reflected the resident was care planned for falls and documented to have an actual fall that occurred on 08/07/2024 but did not include the intervention of a fall mat. Record review of Resident #34's quarterly MDS, dated [DATE], reflected the resident did not have any falls since their prior assessment upon admission. Observations on 09/12/24 at 11:54AM, revealed Resident #34 lying in bed with a fall mat to the side of her bed. Record review of Resident #28's face sheet reflected a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia and metabolic encephalopathy. Record review of the facility incident reported, dated 03/10/2024 - 09/10/2024 reflected the Resident #28 had on fall that occurred on 07/28/2024. Record review of Resident #28's nurses notes reflected the resident on 09/06/2024, that the resident slid off her bed and fell on to the fall mat. Record review of Resident #28's care plan, not dated, reflected the resident was care planned for falls and documented to have an actual fall that occurred on 07/28/202, but did not include the intervention of a fall mat. Record review of Resident #28's admission MDS, dated [DATE], reflected the resident did not have any falls since their admission. In an interview with CNA T on 09/12/24 at 12:00PM, who stated he usually worked often with Residents #34 and #28. He stated he referenced a chart or kiosk to know who needs a fall mat. He stated Resident #34 tended to swing herself to the right while sleeping causing her to slide off the bed and Resident #28 would sometimes throw herself off the bed. If the fall mat was not placed for both of the residents, they could possibly be injured in a fall. In an interview with LVN E on 09/12/24 at 12:08PM, who stated she worked frequently with Resident #34 who rolled out of her bed. She said they keep a wedge to prevent her from rolling off the bed, kept fall mats in place and the bed low. She stated Resident #34 did fall on the end of her shift once. She also said Resident #28 had a history of being confused and rolling herself out of the bed. The fall mat was there when she fell , and she did not have any major injury as a result. She stated the interventions should be listed on the care plan, and because she was new, she would not have known if the fall mat if she did not already see it placed on the floor when she came in. She stated nurses were to at least verbally report needs of patients to the nursing team and bring up pertinent information such as interventions at the morning meetings for the MDS or another staff to note and update the care plan. She said without fall mats residents can experience an increased risk of injury of the head. In an interview with the DON on 09/12/24 12:41PM, who stated that her and the Administrator were responsible for updating the care plans to add new information and resolved interventions that are no longer applicable. Residents can change, they need to keep the care plan interventions updated and they can also attach the task attached to the kardex (desktop file system) for the CNAs to reference it as well. Fall mats should have been on the care plan. She stated Resident #34 and #28 both need fall mats, or else they would injure themself in fall. Record review of the facility's policy on Care Plan Revisions Upon Status Change, not dated, reflected, . The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . The care plan will be updated with the new or modified interventions .

Based on observation, record review, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 4 (Residents #1, #2, #3, and #4) of 6 residents reviewed for wound care. -The facility failed to provide wound care services for Resident #1 as ordered for 08/18/23 to 08/19/23, 09/02/23, 09/07/23, 09/10/23, 09/16/23, 09/17/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23, 10/01/23, and 10/14/23. -The facility failed to provide wound care services for Resident #2 as ordered on 10/01/23. -The facility failed to provide wound care services for Resident #3 as ordered for 08/01/23, 8/11/23, 08/24/23, 08/26/23 to 08/27/23, 09/02/23, 09/10/23, 09/16/23, 09/17/23, 09/24/23, 09/26/23, 09/27/23, 09/28/23, 10/01/23, 10/02/2023, and 10/14/23. -The facility failed to provide wound care services for Resident #4 as ordered for 10/01/23 and 10/15/23. This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life. The findings included: Resident #1 Record review of Resident #1's Admission Record, dated 10/17/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included acute hematogenous osteomyelitis (an acute infection in the bone or bone marrow caused by bacteria or fungi) to left ankle and foot, speech and language deficits following cerebral infarction (stroke), slurred speech, hemiplegia, and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side, pressure ulcer of left ankle, unstageable, and pressure ulcer of unspecified site, stage 4. Record review of Resident #1's care plan, undated, revealed the following: - had arterial wound to (L) ankle and foot >potential for wound healing delay r/t claudication of chronic occlusion of LLE arteries >PAD >osteomyelitis. Interventions included treatment as per order and monitor for s/sx of infection. - had a pressure area to location: Sacrum Stage III. Interventions included perform treatment per order. -had Left Inner Ankle Wound x 2 (vascular) and open area to sacrum. Interventions included to provide treatment per physician order. - had Wound to Left Lateral Leg (vascular). Interventions included follow facility protocols for treatment of injury. - had potential for impairment to skin integrity r/t decreased mobility. Interventions included observe and identify any new affected skin area, intervene with treatment as necessary and notify MD. - had an arterial ulcer of the left outer foot. Interventions included monitor/document wound, monitor/document/report PRN any s/sx of infection, and weekly treatment documentation. - had an arterial/ischemic ulcer of the left outer ankle. Interventions included monitor/document wound, monitor/document/report PRN any s/sx of infection, and weekly treatment documentation. Record review of Resident #1's annual MDS assessment, dated 08/08/23, revealed Section C, Cognitive Patterns, C0100, BIMS was unable to be conducted as resident was rarely/never understood. Further review revealed she required one-person physical assist with bed mobility and toileting, and two-person physical assist with transferring. Section M, Skin Conditions, M0150. Risk of Pressure Ulcers/Injuries revealed she was at risk of developing pressure ulcers/injuries. Record review of Resident #1's treatment orders, dated August 2023, included: -Left ankle (inner area) wound, clean with NS, pat dry, apply Santyl and Bactroban cover with dry dressing QD. every day shift for wound care, start date 08/08/23 and discontinued date 08/23/23. -Left foot (inner area) wound, clean with NS, pat dry, apply Santyl and Bactroban and cover with dry dressing QD. every day shift for wound care, start date 08/08/23 and discontinued date 08/23/23. Record Review of Resident #1's TAR dated for August of 2023, revealed wound care treatment on 08/18/23 and 08/19/23 was blank. Record review of Resident #1's treatment orders, dated September 2023, included: - Left ankle (inner area) Arterial wound, clean with NS, pat dry, apply Alginate cover with dry dressing QD. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date of 08/24/23. -Left foot (inner area) Arterial wound, clean with NS, pat dry, apply Alginate and cover with dry dressing QD. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 08/24/23 to 09/13/23. -Left foot (inner area) Arterial wound, clean with NS, pat dry, apply Skin Prep and LOTA. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 09/14/23. -Stage 2 Coccyx: cleanse with wound cleanser pat dry, apply ca alginate, cover with dry dressing once a shift and PRN. Report any changes to Wound Dr and TX Nurse. every day shift for wound care, start date of 09/05/23 to 09/07/23. - Stage 3 Sacrum: cleanse with wound cleanser pat dry, apply ca alginate and Santyl, cover with dry dressing once a shift and PRN Report any changes to Wound Dr. and TX Nurse. every day shift for wound care, start date 09/14/23. -Stage 3 Sacrum: cleanse with wound cleanser pat dry, apply ca alginate, cover with dry dressing once a shift and PRN. Report any changes to Wound Dr. and TX Nurse. every day shift for wound care, start date 09/08/23 to 09/13/23. -Stage 2 Sacrum: Cleanse with NS, pat dry, apply zinc and LOTA every shift and PRN. Report any changes to Wound Dr and TX Nurse. every shift for Wound Treatment, start date of 08/23/23 to 09/05/23. Record Review of Resident #1's TAR dated for September of 2023, revealed wound care treatment on 09/02/23, 09/07/23, 09/10/23, 09/16/23, 09/17/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23 was blank. Record review of Resident #1's treatment orders, dated October 2023, included: -Left ankle (inner area) Arterial wound, clean with NS, pat dry, apply Alginate cover with dry dressing QD. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 08/24/23. -Left foot (inner area) Arterial wound, clean with NS, pat dry, apply Skin Prep and LOTA. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 09/14/23. -Stage 3 Sacrum: cleanse with wound cleanser pat dry, apply ca alginate and Santyl, cover with dry dressing once a shift and PRN. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 09/14/23. - Wound Treatment to Left ankle (outer area) Arterial wound Remove old dressing, cleanse with wound cleanser, apply skin prep and LOTA. every day shift for Wound Care, start date 10/12/23. - Wound Treatment to left big toe: cleanse with wound cleanser, apply CA, Honey, and LOTA every day shift for Wound Care, start date 10/12/23. -Wound Treatment to left medial toe. Cleanse with wound cleanser, apply skin prep and LOTA every day shift for Wound Care, start date 10/12/23. Record Review of Resident #1's TAR dated for October of 2023, revealed wound care treatment on 10/01/23 and 10/14/23 was blank. Record review of Resident #1's wound care assessments completed by the Wound Care Physician, dated 08/07/2023 and 10/18/23, revealed the following: -Left, medial malleolus wound improved from 2.7x2.5x0.5 to 0.9x1.4x0.1 -Left, medial midfoot wound improved from 1.3x1.2x0.2 to 0.9x0.9 -Sacrum wound improved from 6.5x3.9x0.1 to 3.9x2.9x0.1 -Left, medial forefoot improved 1.6x1.4 to 1.5x1.2x1 -Left, medial first toe improved 1.6x1.4 to 0.5x0.7 Resident #2 Record review of Resident #2's Admission Record, dated 10/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnoses included sepsis (infection of the blood stream), type 2 diabetes (high blood sugar) without complications, and pressure ulcer of sacral (below lumbar spine and above tailbone) region, stage 4. Record review of Resident #2's care plan, undated, revealed the following: - at risk for impairment to skin integrity r/t hx of pressure ulcers. Interventions included observe and identify any new affected skin area, intervene with treatment as necessary and notify MD. - pressure ulcer(s) stage 4 to sacrum. Interventions included administer treatments as ordered and monitor for effectiveness. Record review of Resident #2's admission MDS assessment, dated 10/06/23, revealed a BIMS score of 9, indicating moderately impaired cognitive skills. Further review revealed resident required 2-person assistance with toileting, bathing, and dressing. Section M, Skin Conditions, M0150. Risk of Pressure Ulcers/Injuries revealed he was at risk of developing pressure ulcers/injuries. Record review of Resident #2's treatment orders, dated October 2023, included the following: -Stage 4 pressure wound (Sacrum): Cleanse with ns/wc, pat dry, apply Calcium Alginate and cover with dry dressing daily and PRN soiled every day shift for pressure wound, start date 10/01/23 and discontinued date 10/11/23. Record Review of Resident #2's TAR, dated for October of 2023, revealed Resident #2's wound care treatment on 10/01/23 was left blank. Record review of Resident #2's wound care assessments completed by the Wound Care Physician, dated 10/04/23 and 10/18/23, revealed sacrum wound had improved from 10.9x14.6x3.9 to 9.9x13x3.3. Resident # 3 Record review of Resident #3's Admission Record, dated 10/17/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease with late onset, hypertensive heart disease (high blood pressure) with heart failure, pressure ulcer of sacral (below lumbar spine and above tailbone) region, unstageable, and cellulitis (bacterial infection of the skin) of left lower limb. Record review of Resident #3's care plan, undated, revealed the following: - had a pressure area to location: Sacral, 7/29/2023-Unstageable wound to Sacrum. Interventions included perform treatment per order. - had an arterial ulcer of the 4th toe left foot. Interventions included monitor/document wound, monitor/document/report PRN any s/sx of infection, and weekly treatment documentation. Record review of Resident #3's quarterly MDS assessment, dated 09/29/23, revealed the BIMS was unable to be conducted due to resident rarely/never being understood. Further review revealed resident required two-person physical assist with mobility, transferring, and toileting. Section M, Skin Conditions, M0150. Risk of Pressure Ulcers/Injuries revealed she was at risk of developing pressure ulcers/injuries. Record review of Resident #3's treatment orders, dated August 2023, included: - Left 2nd Toe (Trauma wound): Cleanse with normal saline/wound cleanser, pat dry, apply Bactroban and LOTA every day shift, start date 08/09/23 to 08/23/23. - Sacrum (Stage 3): Cleanse with normal saline/wound cleanser, pat dry, apply CA-Alginate and cover with dry absorptive dressing daily. Report any changes to Wound Dr. and TX Nurse every day shift for Wound Treatment, start date 08/25/23 to 08/29/23. - Sacrum (Unstageable pressure injury): Cleanse with normal saline/wound cleanser, pat dry, apply Santyl, apply Alginate and cover with dry absorptive dressing daily every day shift for pressure wound, start date 08/09/23 to 08/24/23. - Wound Treatment- (Arterial) 4th toe on right foot: cleanse with NS or Wound Cleanser, pat dry, apply Alginate to area, and cover with dry dressing. Report any changes to Wound Dr and TX Nurse every day shift for Wound Treatment, start date 08/25/23 to 10/02/23. -Wound Treatment to coccyx area: remove old dressing, cleanse with Vashe, pat dry, apply collagen Santyl & Ca Alginate to wound bed, and cover with bordered gauze dressing every 24 hours for wound, start date 08/01/23 to 08/09/23. -Wound Treatment to left second toe: clean with betadine. Leave open to air. Monitor swelling. every 24 hours, start date 08/01/23 to 08/09/23. Record Review of Resident #3's TAR dated for August of 2023, revealed Resident #3's wound care treatment on 08/01/23, 08/11/23, 08/24/23, 08/26/23, and 08/27/23 was blank. Record review of Resident #3's treatment orders, dated September 2023, included: -Sacrum (Stage 3): Cleanse with normal saline/wound cleanser, pat dry, apply CA-Alginate and cover with absorptive dressing foam daily. Report any changes to Wound Dr. and TX Nurse every day shift for Wound Treatment, start date 08/30/23. -Wound Treatment- (Arterial) 4th toe on right foot: cleanse with NS or Wound Cleanser, pat dry, apply Alginate to area, and cover with dry dressing. Report any changes to Wound Dr and TX Nurse every day shift for Wound Treatment, start date 08/25/23 to 10/02/23. Record Review of Resident #3's TAR dated for September of 2023, revealed wound care treatment on 9/2/23, 9/10/23, 9/16/23, 9/17/23, 9/24/23, 9/26/23, 9/27/23, 9/28/23 was blank. Record review of Resident #3's treatment orders, dated October 2023, included: -Sacrum (Stage 3): Cleanse with normal saline/wound cleanser, pat dry, apply CA-Alginate and cover with absorptive dressing foam daily. Report any changes to Wound Dr. and TX Nurse every day shift for Wound Treatment, start date 08/30/23. -Wound Treatment- (Arterial) 4th toe on right foot: cleanse with NS or Wound Cleanser, pat dry, apply Alginate to area, and cover with dry dressing. Report any changes to Wound Dr and TX Nurse every day shift for Wound Treatment, start date 08/25/23 to 10/02/23. Record Review of Resident #3's TAR dated for October of 2023, revealed wound care treatment on 10/01/23, 10/02/23, and 10/14/23 was blank. Record review of Resident #3's wound care assessments completed by the Wound Care Physician, dated 10/18/23 and 08/07/23, revealed sacrum wound improved from 3.0x1x0.5 to 2.2x0.7x0.2. Resident #4 Record review of Resident #4's Admission Record, dated 10/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included sepsis (infection of the blood stream), type 2 diabetes mellitus (high blood sugar) without complications, unspecified open wound of penis, and pressure ulcer of unspecified site, unspecified stage. Record review of Resident #4's care plan, undated, revealed the following: - had potential for actual impairment to skin integrity r/t decreased mobility. Interventions included observe and identify any new affected skin area, intervene with treatment as necessary and notify MD. Record review of Resident #4's admission MDS assessment, dated 09/25/23, revealed a BIMS score of 14, indicating intact cognitive skills. Further review revealed resident was a two-person assist with mobility, transferring, and toileting. Section M, Skin Conditions, M0150. Risk of Pressure Ulcers/Injuries revealed he was at risk of developing pressure ulcers/injuries. Record review of Resident #4's treatment orders, dated October 2023, included the following: -Cleanse sacral ulcer with normal saline, pat dry, cover with protective dressing every day shift for sacral ulcer, start date 09/21/23. -Cleanse tip of penis with normal saline, pat dry, apply xeroform, cover with abd pad for gangrene every day shift for gangrene, start date 09/21/23. Record Review of Resident #4's TAR, dated for October of 2023, revealed wound care treatment on 10/01/23 and 10/15/23 was blank. Record review of Resident #4's wound care assessments completed by the Wound Care Physician, dated 10/04/23 and 11/01/23, revealed coccyx wound improved from 4.0x2.9x1.2 to 3.2x1.6x1.0 and his penis wound remained the same at 12.6x7.9x0.2. In an interview on 10/18/23 at 11:51 a.m., Nurse B said she had been working at the facility for 3 1/2 months. She said she worked on Station 1 which covered halls 100, 200, and 300. She said she only did wound care once since she started working at the facility. She said she did the wound care for her residents on her hall because they just got a new wound care nurse who was in training. She said she did not know the exact time, but it was within the past three weeks that the wound care nurse started working at the facility. She said it was prior to the new wound care nurse being employed. She said she heard the new DON was the wound care nurse then and had just been promoted to DON. She said the weekend supervisor (she was not sure of the name of the supervisor) also did wound care on weekends. She said if the wound care nurse was not in the building, she did not know who was responsible for doing wound care and said no one ever told her who would be responsible if the wound care nurse not there. She said, they always have wound care nurse. She said she never encountered a situation when the wound care nurse was not at the facility. She said she got three days of training on general stuff - on the care to be provided to residents but did not have any competency checks - like when she did wound care, and someone watched her. She said she was a new graduate nurse, and she still remembered all her stuff and she would watch videos. She said staff were a great support - her fell ow workers and the DON. She said she never heard any complaints from the residents about their wounds. She said she never saw any outdated wound dressings. In an interview on 10/18/2023 at 12:10 p.m., Agency Nurse A said she worked the day shift on 09/10/23. She said she did wound care for a couple of the residents but did not quite remember. She said she did not remember documenting them. She said she did not really remember everything from that day. She said she knew that it was her and a nurse on the other side and a nurse in the locked unit. She said she did not think there was a wound care nurse at that time. She said she did not remember having a conversation with anyone about who would be responsible to do wound care if the wound care nurse was not in the building. She said that day was like the first time I ever been to that place and no resident complained to her about their wound. Observation on 10/18/2023 at 1:55 p.m., wound care with the DON for Resident #3- revealed sacrum wound stage 2 had a dressing dated 10/17/23. Surveyor observed for technique and infection control during the wound care and there were no concerns at the time of the observation. In an interview on 10/18/2023 at 3:44 p.m., the Wound Care Nurse said she was hired on 10/10/23 and started working on the floor on 10/12/23. She said she was still in training. She said today was the first day she completed rounds with the wound care doctor who came to the facility every Wednesday. In an interview on 10/19/2023 at 9:10 a.m., Nurse A said she had been working at the facility since June 2023. She said she completed wound care on various days but most of the time during the week and not as much during the weekends. She said wound care was always completed during the first shift, 6:00 a.m. to 6:00 p.m. She said the last time she performed wound care was last Saturday, 10/14/23, for halls 500 and 600. She said there was not a wound care nurse working that day. She said approximately 3 weeks ago, 09/27/23, she was the designated wound care nurse for the entire building, and said she was able to complete wound care on all the residents. She said she also probably performed her own wound care for her assigned residents on 09/02, 09/16, and 09/17. She said on October 15th they had a wound care nurse. She said every time she completed wound care, she went into the computer system and documented it was completed on the TAR. She said she would not document completion of treatment anywhere else unless there was something unusual i.e., change in the wound, in which case she would write a progress note. She said she was bad at remembering to chart the completion of wound care treatments on the TAR. She said the purpose of the TAR was to chart treatments and the instructions for the wound treatment orders. She said if the treatment was not charted then it was not done. She said the potential effect on residents if their wound care was not completed was wound deterioration. In a telephone interview on 10/19/23 at 12:22 p.m. Agency Nurse B said she had been picking up shifts at the facility for over a year and did not do wound care as a floor nurse but said she did do wound care on 10/10/23 when she was working as the treatment nurse. She said she documented all of her treatments on 10/10/23. She said she last worked at the facility on 10/10/23 and worked the 9:00 a.m. to 5:00 p.m. shift. She said she also worked on 09/28/23. She said she worked halls 500 and 600 on 09/28/23 and on 10/10/23. She said on 09/28/23 she did not have to complete wound care because there was a wound care nurse, but she did not remember their name. She said they would specify on the agency app, or the agency would tell them if they needed to perform wound care on the shift they picked up. She said she did not follow-up with the residents to see if they received their wound care treatments on 09/28/23 because she was certain the wound care nurse was there. In an interview on 10/19/23 at 1:31 p.m., the DON said she had been the facility's DON since 10/02/23. She said prior to the new hire of the wound care nurse, she was the treatment nurse from 08/01/23 to 10/01/23. She said the purpose of the TAR was to follow the treatment that was on there and to sign off on it once it had been completed. She said she worked 6:00 a.m. to 6:00 p.m., Mondays-Thursdays, and on Fridays she would only do wounds and would then go home. She said if she was out of the building the nurses on the floor were responsible for providing wound care to their assigned residents. She said on the weekends they used to have a weekend supervisor. She said as soon as the weekend supervisor quit, she made a sign that said nurses were to do their wounds on the weekends they worked. She said the nurses were told verbally, and a sign was posted at the nurse's station. She said agency staff were notified via the same method and that they were responsible for doing their own wound care. She said agency staff were already supposed to be trained on performing wounds and should be advanced in that they go from facility to facility conducting wound care. She said the only documentation they do was on the TAR. She said the TAR was the documentation that showed wound care was completed. In a follow-up interview on 10/19/23 at 2:04 p.m., the DON said she was not scheduled to work on 08/11/23. She said she was out with COVID-19 from 09/24/2023 to 10/01/2023. She stated sometimes when she got pulled from the treatment or if any nurse called out sick, she would work the floor and every nurse would be responsible to do their own wound care for the residents on the floor. In a follow-up interview on 11/01/23 at 12:30 p.m., the DON said the wound care doctor came to the facility every Wednesday. She said there was one day in September, when he texted her on 09/27/2023 at 7:17 a.m., and said he would not be going to the facility because he had a procedure. She said she completed wound care reports every time he saw a resident, he left the reports with the facility, and asked them if they had any questions. She said he would let them know if there were any changes to a resident's orders or if they were staying the same. She said every time he was at the facility, a nurse rounded with him, he would let the nurse know if the wound had gotten better or worse, if the resident needed an air mattress, if they need a vascular order, or anything he thought was needed based on his observation. She said the wound care nurse was no longer working at the facility. She said the last day she worked was on October 24, 23. She said she currently did the Wound Care rounds with the wound care doctor on Wednesdays, and after he was done, she would update the wound care report and orders on that same day. She said during the week, the nurses were doing their own wound care treatments for their assigned halls. She said the facility had a Weekend Supervisor who did wound care treatments for all the residents on the weekends. In a telephone interview on 11/01/23 at 2:16 p.m., Agency Nurse C said she was not sure when she last worked at the facility but believed it was 2 to 3 weeks ago. She said she was not 100% sure but believed she performed a few wound care treatments on 10/01/23. She said she did not follow-up with anyone that day to see if the residents got their wound care treatments. She said the facility did not tell her who was responsible for doing wound care if the wound care nurse was not in the building. She said she honestly did not remember and was not asked anything by facility staff. She said she also worked on 10/07/23 and helped the wound care nurse complete wound care treatments but did not remember the nurse's name. She said if a resident had an order for wound care, she followed the order, and would check it off on the order after it was completed. She said there was not a sign posted at the nurse's station that said if there was not a wound care nurse in the building, the nurses were responsible for doing their own wound care. In an interview on 11/01/2023 at 2:52 p.m., Agency Nurse D said there was only one day, and he was not too sure what day, but believed it was 10/01/2023, that he was initially listed on the schedule to be the wound care nurse. He said he was reassigned that day to be a floor nurse because one of the nurses did not show up. He said as far as he could recall, he never performed wound care for the facility but was not too positive. He said he did not know who was assigned to do wound care on 10/01/23. He said he did not recollect the facility ever telling him that he had to do wound care for his assigned residents if there was not a wound care nurse on shift. He said he did not check with the residents to see if wound care was completed because sometimes, they were not able to verbalize. He said he was not sure if the facility had a wound care nurse on 10/01/23. He said he did not recall ever seeing a posted sign at the nurses' station stating if there was not a wound care nurse, the floor nurse was responsible for doing their own wound care. He said he did not know if there was a weekend supervisor at the facility on 10/01/23. He said if he had to do wound care, he wound go into the computer system, would look at the orders, and would document on the TAR that it was completed. In a follow-up interview on 11/02/2023, Nurse A said she always worked the day shift, 6:00 a.m. to 6:00 p.m. She said sometimes her duties included wound care. She said the DON would let them know when they had to do wound care which happened once in a while. She said the blanks on the TAR did not necessarily mean wound care was not done. She said it could have been done or somebody did it and did not chart. She said in nursing, if it was not charted, it was not done. She said charting was on a different screen, so if you did not go to that screen, it would not get charted. She said it used to happen often, but not anymore. She said it really did not happen often that it was not done or not charted. She said on 10/30/23 she came to work late and worked half a day. She said when she came in on the 30th, no one told her to do wound care. She said she was probably supposed to do wound care that day but did not. She said she did not know she was supposed to do it that day. She said the night shift nurse or day shift could do it. She said sometimes wound care was done on the night shift. She said they communicated during clinical hand off, that wounds did not get done. She said on 10/30/23 she did not tell the night shift that wounds did not get done. She said possibly the DON or ADON may have known about Resident #1 missing treatment that day. She said she had a few in-services on wound care in the last 4 months. She said if wound care was not done, skin breakdown or infection could happen. An attempted telephone interview on 11/02/2023 at 12:28 p.m., with the Wound Care Doctor was made. A voicemail was left requesting a return call. In an interview on 11/02/23 at 1:15 p.m., the Weekend Supervisor said she started working at the facility on 10/15/23. She said she worked weekends from 7:00 a.m. to 7:00 p.m. She said some of her job responsibilities included completing wound care. She said she believed they had a treatment nurse during the weekdays. She said once she completed wound care, she would document it on the TAR. She said if she was not able to work her shift, she would notify the DON. She said she trained with the DON on 10/15/23 and the following weekend with Nurse C. She said if the completion of wound care was not documented on the TAR, it meant it was not done. She said she would have to check her records to see if she did wound care on 10/15/23. She said in order to answer what could happen it a resident did not to get their wound care treatment she would also have to check her records. In a telephone interview on 11/02/23 at 1:48 p.m., Nurse C said she had been working for the facility since May 2021 and worked during the week and weekends. She said she worked 6:00 p.m. to 6:00 a.m. on Thursday, 10/26/23. She said she did not remember if she had to do wound care that day. She said if a resident's dressing came off, she would redo the wound care. She said she remembered having to do a redressing for Resident #2 on 10/26/23. She said she did not have to do wound care because the facility had a wound care nurse. She said she had not seen any outdated dressings as far as she could remember. She said on Thursday, 10/26/23, she completed wound care for resident in room [ROOM NUMBER]. She said she did not remember who was responsible for wound care on 10/26/23. She said she thought the nurse did wound care for Resident #4 that day. She said the DON told her that if the wound care nurse was not in the building, the nurses were responsible for completing their wound care. She said once wound care was completed, it was checked off on the TAR. She said if it was not checked off on the TAR, it meant it was not done. She said if wound care treatment was not completed, sepsis and/or an infection could set in. In an interview on 11/02/23 at 2:08 p.m., Agency Nurse E said there was never a wound care nurse when she worked. She said she worked on the weekends and usually worked the day shift from 6:00 a.m. to 6:00 p.m. She said the last time she worked was in September 2023. She said she received a notification from the agency that she did not complete all of the residents' wound care treatments. She said she did not know there was a different screen that she had to go into to see who needed wound care treatments. She said she had no idea about the treatment tab in their computer system. She said throughout providing care for the residents, she noticed residents that had wounds and questioned the nurse. She said the nurse showed her where to look in the computer system. She said she never noticed any outdated dressings. She said when she logged on for her shift it would tell her if she had residents that had wounds. She said she never received training from the facility on their computer system. She said she completed whatever she could see in the system. She said if there was not a wound care nurse in the building, she was never told who was responsible for completing wound care. She said once wound care was completed, she would check it off on the TAR. She said it was very possible she missed doing wound care treatments in August 2023. She said if wound care was not checked off on the TAR, it ultimately meant it was not done and/or someone forgot to check it off. In a follow-up interview on 11/02/23 at 2:49 p.m., the DON said there had been no negative outcomes with Residents #3 and #4. She said Resident #4's sacrum wound was improving, and his penis wound was not going to improve because those wounds just did not normally heal as told by the wound care doctor. She said this was discussed with Resident #4. She said Resident #

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10.26 % based on 4 errors out of 39 opportunities, which involved 2 of 6 residents (Resident #167, Resident #26) reviewed for medication errors. 1. The facility failed to ensure Medication Aide A administered medications as ordered to Resident #167 by administering Ferrous Sulfate 325 mg instead of the ordered Ferrous Fumarate 325 mg (medication for low red blood cells). 2. Medication Aide A failed to administer medications as ordered to Resident #26 by omitting the ordered Potassium Chloride ER 8 mEq (medication for build-up of fluid in the body's tissue). 3. Medication Aide A failed to administer medications as ordered by Resident #26 by omitting the ordered Vitamin B Complex (medication for Vitamin deficiency). 4. Medication Aide A administered Vitamin D 25 mcg to Resident #26 without a physician order. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and side effects of medications that were not intended for the residents to receive. Resident #167 Record review of Resident #167's Face Sheet dated 08/09/2023 revealed, a [AGE] year-old male, that admitted to the facility on [DATE] with diagnoses which included fracture to the left hip, multiple fractures of the ribs, and pain. Record review of Resident #167's Admission MDS assessment with the ARD (assessment reference date) date of 08/10/2023, revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #167's Baseline Care Plan dated 08/05/2023 revealed, he was receiving antibiotic therapy and did not self-administer medications. He required one person assistance with personal hygiene, toilet use, dressing and bathing. He required two-person physical assistance with bed mobility. Record review of Resident #167's order sheet signed by the resident's Physician on 08/08/2023 at 9:44AM, revealed a telephone order dated 08/05/2023 at 2:19AM for Ferretts Oral Tablet (Ferrous Fumarate) give 325 mg by mouth two times a day for anemia with breakfast and dinner. The order was confirmed by RN B. An observation on 08/09/2023 at 8:50AM revealed, Med Aide A preparing for administration of medications to Resident #167. Med Aide A retrieved one tablet of Ferrous Sulfate 325 mg and placed into one medication cup along with four other medications. Med Aide A prepared the Miralax 17 gm powder and mixed it with 8 oz of water into a cup and entered Resident #167's room. Med Aide A administered all six medications to Resident #167. Resident #26 Record review of Resident #26's Face Sheet dated 08/09/2023 revealed, a [AGE] year-old male, that admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included metabolic encephalopathy (a brain dysfunction), chronic deep vein blood clots to the lower extremity, diabetes, enlarged prostate, urinary tract infection, muscle wasting and cognitive communication deficit. Record review of Resident #26's Admission MDS dated [DATE] revealed, a BIMS score of 12 out of 15 indicating he had moderate cognitive impairment. He required extensive assistance with 2 persons for bed mobility, dressing, toilet use and personal hygiene. He required total assist with 2 persons for transfers. Record review of Resident #26's Order Summary Report of active orders dated 08/09/2023 at 11:31AM revealed Potassium Chloride ER oral capsule 8 mEq, give one capsule by mouth one time a day for edema, order date 08/08/2023, Vitamin B complex oral tablet order date 07/16/2023, give one tablet by mouth in the morning for Vitamin Deficiency and Vitamin B12 oral tablet (Cyanocobalamin) give 2 tablets by mouth in the morning every Monday, Wednesday, and Friday for Vitamin Deficiency order date 07/16/2023. Further review revealed there was no order for Vitamin D 25 mcg tablets. An observation on 08/09/2023 at 9:00AM revealed Med Aide A preparing for administration of medications to Resident #26. Med Aide A retrieved one tablet of Vitamin D 25 mcg and placed into one medication cup along with Omeprazole 20 mg capsule, Allopurinol 100 mg 2 tablets, Carvedilol 25 mg tablet, Colestipol 1 gm tablet, Aspirin 81 mg tablet, Ferrous Sulfate 325 mg tablet, Furosemide 20 mg tablet, Gabapentin 300 mg two capsules, Losartan Potassium 25 mg tablet, Vitamin B-12 two tablets. Med Aide A entered Resident #26's room and administered the medications that were in the medication cup. In an interview on 08/09/2023 at 2:13PM, Medication Aide A was asked about the medications given to Resident #167 and Resident #26. Medication Aide A stated she was unable to get into the computer to view past medications administered. Medication Aide A stated, Resident #167's had a bottle of Ferrous Fumarate tablets at one time, and it was completed. Medication Aide A stated that Ferrous Sulfate 325 mg was in stock and can be given in replacement of Ferrous Fumarate. When ask who gave the instructions to give Ferrous Sulfate 325 mg, she did not reply with an answer. Medication Aide A stated she recalled giving the Potassium Chloride to Resident #26 and that she took the blister pack away before the surveyor could look at it. She stated that there was a Potassium Chloride tablet taken from the blister pack and that was the one she administered in the morning. In an interview on 08/09/2023 at 2:14PM, Medication Aide A removed the bottles of Aspirin 81 mg, Ferrous Sulfate 325 mg, vitamin D 25 mcg and Vitamin B-12 500 mcg from the top drawer of the medication cart and stated those were the floor stock medications she gave to Resident #26. When asked about why she did not administer Vitamin B Complex. Medication Aide A stated she was unable to go back into the computer to find past orders administered. When asked about why she gave Vitamin D 25 mcg to Resident #26 without an order, Medication Aide A stated she was unable to go back into the computer to find past orders administered. In an interview on 08/09/2023 at 2:15PM, LVN K stated the Iron supplement given to Resident #167 should match up with the physician order for Ferrous Fumarate 325 mg. LVN K stated, We can always call the physician to change the order to what we have in stock. LVN K stated she was not here and that it was the admitting nurse's responsibility to put orders in correctly. In an interview on 08/10/2023 at 7:50AM, the DON was asked who was authorized to make changes to the Ferrous Fumarate 325mg to Ferrous Sulfate 325mg for Resident #167, she stated the order needed to be fixed and did not know who didn't catch the issue. She stated that Ferrous Fumarate was interchangeable with Ferrous Sulfate, and this was what the pharmacy wrote on the sheet. She stated the assumption was that the medication aides knew these two drugs were interchangeable. When asked exactly how much Ferrous Sulfate was equivalent to Ferrous Fumarate 325mg, she stated it was written on the list from the pharmacy that they were interchangeable. When asked what she expected the Medication Aide to do prior to administering the iron supplement, she stated that the order would be corrected because the two iron supplements were interchangeable. The DON stated prior to administering any medication, she expected the Medication Aide to verify the medication, verify the order and pass medications using aseptic technique. The DON stated she spoke with Medication Aide A who told her that she did not give Vitamin D to Resident #26 and pulled out the bottle of Vit B Complex when she realized she retrieved the wrong bottle. The DON stated Medication Aide A told her that she did give Resident #26 Potassium Chloride on 08/09/2023 at 9:00AM. The DON stated she had only been at the facility for 2 weeks and was still getting to know the residents. She stated she would have to follow up with the physician about the reason Resident #26 was ordered Potassium Chloride ER 8 mEq. She stated generally, the potential risk to a resident if they did not receive Potassium Chloride was cardiac issues. She stated all members of Nursing Administration would oversee to ensure the Medication Aides were following the policy for Medication Administration. Record review of the Iron Preparation list from the Pharmacy, revised on 06/2012 revealed one tablet of Ferrous Fumarate 200mg was interchangeable with 1 tablet of Ferrous Sulfate 325mg. The equivalent iron preparation for Ferrous Fumarate 325mg was 3 tablets of Ferrous Gluconate 325mg. Further review revealed there was no equivalent Ferrous Sulfate dose for Ferrous Fumarate 325mg. In an interview on 08/10/2023 at 8:00AM, the Administrator stated medication administration was not her area of expertise, but she would expect the Medication Aide would first verify the medication order to make sure it was the right medication, right route, right dose and to follow facility policy and procedures. The Administrator stated it was ultimately the facility's responsibility to clarify the physician order for the iron supplement for Resident #167. She stated she would expect the nurse to contact the physician and it would be the physician's decision whether to substitute a medication or not. She stated she would expect if the Medication Aide found a discrepancy, to stop and get clarification by notifying the charge nurse and DON who would then contact the physician. The Administrator stated the Ferrous Fumarate 325mg was not interchangeable with Ferrous Sulfate 325mg, on the list of iron supplements from the pharmacy and that we made the mistake. The Administrator stated she did not like that the Medication Aide lied about administering Vitamin D and not administering Vitamin B Complex, that there would be nothing wrong with just being honest. In a telephone interview on 08/10/2023 at 9:19AM, the Physician C stated she was not right in front of her computer but typically Ferrous Sulfate was ordered and the iron supplement for Resident #167 was not written correctly. Physician C stated the order had been corrected. Physician C stated Resident #26 was put on Lasix. She stated residents tended to lose some potassium, and that was why she added low dose Potassium Chloride. Physician C stated she was keeping an eye on his kidney function as well. Physician C stated there was no risk if Resident #26 missed a dose of Potassium d/t he was getting potassium in the foods he was eating. Physician C stated she had ordered labs for Resident #26 next week as a follow up. Physician C stated there was no risk to Resident #26 if he missed receiving Vitamin B complex d/t he was also receiving Vit B-12. Physician C stated she would have to look at Resident #26's records as she was not in front of her computer to see what the risks would be for receiving Vitamin D if he did not need it. She stated if Vitamin D was given without an order, she would expect the facility to follow facility policy and procedures. She stated she expected the Medication Aides/Nurses who pass medications to check the resident's medication list to ensure they were giving the correct medication. Record review of the facility policy and procedure for Administrating Medications, revised on April 2019 read in part: Medications are administered in a safe and timely manner and as prescribed .2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions .4. Medications are administered in accordance with prescriber orders .6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Record review of the facility In-Service Training Report dated 07/18/2023, conducted by the ADON for Medication Aides on the topic of Medication Administration/Availability, revealed the summary of training session: Med Aides please make sure you are notifying your charge nurse for any medications that is not available. Ensure you are notifying and asking questions about any medications you are not sure about to reduce errors/omissions. Further review revealed Medication Aide A signed the training. Record review of the Med-Pass Observation Checklist for Medication Aide A, dated on 06/072023 and observed by LVN T, revealed the technique #6. Correct medication verified by visual check of medication, label and MAR was checked as met.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate care to maintain highest practical physical and psychosocial well-being for 1 of 15 residents (Resident #27) reviewed for ADL care, in that: - The facility failed to ensure Resident #27 did not have long fingernails with black grime packed underneath the nails. This failure placed residents at risk of experiencing a decreased quality of life and an increase risk of infection. Findings included: Record review of Resident #27's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, glaucoma, and hemiplegia and hemiparesis. Record review of Resident #27's comprehensive MDS assessment, dated 07/16/2023, revealed the resident had a BIMS score of 99, indicating the resident's cognition was not intact or the resident was rarely or never understood during the BIMS assessment. It also revealed the resident was dependent on staff for personal hygiene. Observation and interview with Resident #27 on 08/08/2023 at 9:52AM revealed Resident #27 lying in a geri chair. The resident stated they had been cutting her nails and shaving her but was found to have long fingernails, approximately a quarter-inch past the nail bed with black grime packed in three of her of nails on the right hand and under all of her nails on the left hand. When the surveyor pointed out the condition of the resident's nails, Resident #27 agreed and said her nails needed to be cut. In an interview with CNA J on 08/08/2023 at 9:59AM, she acknowledged the Resident #27's nails were very dirty and would not like it if her nails were to look similarly to hers. She said the residents' showers days were usually on Tuesday, Thursday and Saturday but they could clean the resident as needed. In a phone interview with CNA W on 08/10/2023 at 9:06AM, she stated she worked with Resident #27 on the 2-10 PM shift on 08/07/2023 and it was not Resident #27's bath day on Monday. She said she usually never cut residents' nails, including Resident #27's nails. She stated she only wiped resident hands down with a cloth to clean them. She stated she didn't notice the condition of Resident #27 nails and could not recall whether they were dirty or not. She stated she had never been instructed to cut any resident's nails before but believed that it was the job of a specialist to do to avoid injury. In an interview with RN A on 08/10/2023 at 9:44AM, she stated CNAs, nurses, and the wound treatment nurse all took part in nail care. She stated she worked on Tuesday, 08/08/2023, with Resident #27 and generally looked at all her residents' nails once a day. She stated grooming and nail care usually occured on their shower days. She stated she did not notice Resident #27's nails while working on Tuesday. She stated nails were to be clean for infection control purposes, especially if the resident was touching their mouth and face. She said black grime under the nails are to be cleaned and CNAs are usually the first to notice them and clean them. In an interview with the DON on 08/10/2023 at 2:05PM, she stated shower days were Tuesdays, Wednesdays and Thursdays for Resident #27 and nurses, CNAs, and treatment nurses were responsible for monitoring residents' hygiene. She stated it was up to mainly the nurses and CNAs to check if the residents need nail care on at least the shower days. She said nail care was important for infection prevention, good hygiene and to prevent the residents from scratching themselves. Record review of the facility's policy on ADL, dated March 2018, revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview, and record review, the facility failed to ensure the MDS assessment was accurately completed for 1 of 15 residents (Resident #50) reviewed for MDS assessments, in that: - The facility failed to ensure Resident #50 was accurately assessed to not need translation services although she could only communicate in the Russian language. This failure placed residents at risk of not receiving adequate services and/or care. Findings included: Record review of Resident #50's face sheet revealed an [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia and stage 1 pressure ulcer of sacral region. Record review of Resident #50's comprehensive MDS assessment, dated 06/26/2023, revealed the resident was noted to be rarely/never understood, therefore had no BIMS score. The resident was also assessed to not need or want an interpreter to communicate with a doctor or health care staff and preferred language was not identified. In an interview with Resident #50 on 08/08/2023 at 9:45AM, the resident did not respond to surveyor's questions when asked in English. In an interview with Resident #43 on 08/08/2023 at 9:45AM, the resident stated Resident #50 had been her roommate for a while, and Resident #50 was able to communicate but was only able understand and speak in her native language. She stated the staff usually had to call her family member or use a translation app to communicate with her. In an interview with Resident #50 on 08/08/2023 at 11:45AM, with a use of a translator over the phone, the resident was able to respond stating that she was doing well and had no complaints. In an interview with RN A on 08/10/2023 at 9:44AM, she stated to communicate with Resident #50, she had called Resident #50's family member to encourage her to eat. She stated the resident would often respond by shaking her head yes or no but required translation for almost every interaction except basic yes or no questions, like offering food or medicine. The resident only speaks back in Russian. RN A stated they had not run into a situation where Resident #50's family member had not been reached over the phone to translate. In a phone interview with the Corporate MDS Nurse on 08/10/2023 at 11:34AM, she stated if a resident did not speak English, she would expect to see the answer, Yes to the MDS question regarding the resident's need for translation services to communicate with health care staff. She stated the resident's specific language should have also be identified on the MDS. She stated the risk of not accurately assessing communication barriers was an impact on care, especially for residents who are more dependent on the staff for providing direct care. The corporate MDS Nurse stated the facility used the RAI manual for guidance on MDS assessments. In an interview with the Administrator on 08/10/2023 at 2:34PM, she stated Resident #50 was able to respond to her when miming. She stated the resident was very observant and quiet, and she had a family member who would help translate for her, and when he was not available, another family member or friend was available to help them with translation. She said the resident did need translation services for effective communication, especially when encouraging her to eat. She stated they have not been in been a situation before in which either of these family members were unavailable to translate for them over the phone and she has not thought as far as how they would communicate with her if none of them were available in the time of an emergency. Record review of the RAI Manual, dated October 2019, revealed, . Language barriers can interfere with accurate assessment . When a resident needs or wants an interpreter, the nursing home should ensure that an interpreter is available An alternate method of communication also should be made available to help to ensure that basic needs can be expressed at all times, such as a communication board with pictures on it for the resident to point to (if able) . 1. Ask the resident if he or she needs or wants an interpreter to communicate with a doctor or health care staff. 2. If the resident is unable to respond, a family member or significant other should be asked .

Based on observation, record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 3 residents (CR#1) reviewed for wound care. -The facility failed to establish wound care services for CR#1 as ordered from 07/24/2023-07/25/2023. This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life. Findings included: Record review of Resident CR#1's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE], readmitted on 08/06/2022, with a principal diagnosis of cerebral infarction, also known as a stroke, and secondary diagnosis of diabetes mellitus. CR#1 was discharged on [DATE]. Record review of CR#1's MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating residents' cognition was severely impaired in Section C. Section I revealed CR#1 was triggered for Diabetes Mellitus. Section I revealed that CR#1 was triggered for risk of developing pressure ulcers, with no current venous or arterial ulcers, and treatments in place for a pressure reduction device for the bed. Record review of weekly skin observation completed by LVN E dated 07/19/2023, revealed no new wounds to be identified. Record review of progress note completed by LVN A dated 07/24/2023 stated, Wound DR notified of PT wounds. Record review of wound care assessment completed by the Wound Care Physician dated 07/24/2023 revealed the following for CR#1: Acute Left Medial Ankle Arterial Ulcer that measured at 3cm in length and 2.5cm in width with no onset date provided. Acute Left, Medial Foot(proximal) Arterial Ulcer that measured at 1.5cm in length and 1.5cm in width with no onset date provided. Orders: Wound Dressing paint with betadine and leave open to air daily. Plan of Care discussed with facility staff. Follow up next week. Record Review of Resident CR#1's MAR dated for July of 2023, revealed that CR#1 did not receive wound care treatment on 07/24/2023 or 07/25/2023. Record review of Resident CR#1's physician order summary, dated 08/02/2023, revealed the resident had orders to: -Cleanse Wound #1 (left inner ankle) and Wound#2 (left Lateral Leg) with normal saline, pat dry, apply betadine and have open to air daily every day shift for unstageable wound with a start date of 07/26/2023. -Portable 2 view x-ray of left lower extremity involving left inner ankle to rule out osteomyelitis(infection) with a start date of 07/26/2023. -Left Lower Extremity duplex scan with start date of 07/27/23. -Left Lower Extremity duplex scan with start date of 07/28/23. Record review radiology exam results dated 07/27/2023 of the left tibia and fibula with no evidence of infection. Record review radiology exam results dated 07/27/2023 of the doppler performed on left lower extremity with no abnormalities found. Record review radiology exam results dated 07/28/2023 of the doppler performed on left lower extremity with abnormalities found. Record review of SBAR completed by LVN A dated 07/29/2023, revealed abnormal arterial study confirmed, physician notified with recommendation to transfer to ER, and family notified. Record review of Resident #CR#1's undated care plan, revealed: Focus: [CR #1] has left inner ankle wound x2. Goal: [CR#1] will maintain or develop clean and intact skin by the review date. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Provide treatment per physician order. Specialty mattress to bed. Pressure reduction mattress. Turn and reposition per facility protocol and PRN. Use a draw sheet or lifting device to move resident. Record review of CR#'1 medical records from a local hospital dated 07/29/2023 that indicated that resident presented with a nonhealing wound to the left medial ankle with no palpable pulses on the dorasalis pedis on left foot. MRI indicated, non pressure wound of left ankle, osteomyelitis, and peripheral artery disease. In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said that she observed the wound on 07/29/2023 while visiting, and CR#1 was sent to the hospital the same day because of the wound. In a phone interview with LVN E on 08/01/2023 at 11:12am, she said that she started at the facility on 02/08/2023 as the wound care nurse. She said that she works Monday -Friday from 8:30am-5pm. She said that she completes all weekly skin assessments and wound care for the residents. She said that the floor nurses complete wound care when she is not in the building, and her last day at work was 07/19/2023. She said that she completed a weekly head to toe skin assessment of CR#1 on 07/19/2023, with no new wounds identified. In a phone interview with Physician C on 08/01/2023 at 4:07pm, he said that he is the wound care doctor for the facility. He said that he was notified by nursing staff on 07/24/2023 while rounding that CR#1 had a new wound identified to the left ankle. He said that he assessed the wound to be arterial with Eschar, that was warm to touch, with pulse present. He said that he gave orders to treat the wound with betadine. He said that he ordered x-ray and doppler, to confirm if there was infection or blood flow issues to leg, but the results showed no sign. He said that there was a delay in treatment as he gave verbal orders to the nurse assigned to CR#1, verbal orders for treatment. He said that it could take 1-2 weeks for the wound to progress, but could progress faster due to issues with blood flow. He said that he was notified CR#1 was sent out to the hospital after abnormal doppler results were received by primary doctor. In a phone interview with Physician B on 08/01/2023 at 12:48pm, he said that he is the primary doctor for CR#1, he said that he was not made aware that CR#1 had new wounds identified until 07/26/2023. He said that the Wound Care doctor was following CR#1 for the wound, and order x-ray and doppler on the lower extremities. He said that he was contacted with results of x-ray that had no signs of infection. He said that he was contacted on 07/29/2023 with abnormal results from the doppler. He said that gave order to send CR#1 to hospital due to concerns of Peripheral Vascular Disease. He said if he were contacted when wound was first identified he would have told staff to consult wound care doctor. In a telephone interview with Physician D on 08/02/2023 at 11:49pm, she said that she is the Medical Director for the facility. She said that she was contacted to assessed CR#1 as a part of QAPI on 07/28/2023 to address wound care. She said that there was a concern that CR#1's wound was not identified timely and reported to wound care doctor. She said that she assessed CR#1 with no concerns for infection but she had concerns with poor circulation. She said that CR#1 had x-ray and doppler that revealed no concern for infection or blood flow. She said that when she assessed CR#1 she saw some discoloration, she gave order to repeat doppler, and the results were abnormal. She said that CR#1 was sent out to the hospital on 07/29/2023 after results were confirmed. She said that she estimated the wound to be 1 week old, and the wound could have progress faster due to circulation issues. She said that if staff identified the wound on 07/24/2023, and resident did not receive treatment until 07/26/2023 that is a concern as treatment was delayed. She said that staff should have notified the family, primary physician, and wound care doctor once the wound was identified. In an interview with LVN A on 08/02/2023 at 12:39pm, she said she has worked at the facility for 3 months. She said that she first saw that CR#1 had two wounds to her left ankle on 07/24/2023. She said that she noticed the wound while assisting the CNA F with transfer of resident for bed bath. She said that the CNA F said that the wound was not present when she gave the previous bed bath. She said that the wounds were circular, dark in color, and she held her hand up to show the size that was a little larger than a quarter. She said that she did not see any discoloration of the foot, the foot was warm to touch, and pulse present. She said that the facility has a treatment nurse that completes wound care on all residents. She said that when the treatment nurse is out, the floor nurses must complete wound care. She said that the treatment nurse was not in the building on 07/24/2023. She said that she notified Physician C while he was in the building rounding, and he said that he would assess the resident. She said that when a new wound is identified the appearance should be documented. She said that the primary doctor, wound care doctor, and family should be notified. She said that the Treatment Nurse, ADON, and DON are to be notified. She said that Physician C assessed CR#1 on 07/24/2023 , but she did not remember if he provided orders. She said that she should have followed up with Physician C before he left the building or contacted him by phone to confirm treatment orders for CR#1. She said that she did not notify the family or primary doctor after the wound was identified. She said that she did not notify the ADON or DON when the wound was identified. She said that she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR. She said that she should have completed the tasks, she got busy, and she did not follow up or complete tasks. She said that because she did not complete the tasks CR#1's treatment was delayed. In an interview with DON on 08/02/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that the facility has a treatment nurse that completes wound care and weekly skin assessments on all residents Monday-Friday. She said that the Weekend supervisor completes wound care on Saturday-Sunday. She said that if the treatment nurse is out during the week the floor nurses were responsible for completing wound care and skin assessments. She said that the Treatment Nurse has been out since 07/19/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress note completed by LVN A, but resident did not have treatment orders in place, skin assessment, or SBAR. She said that LVN A did notify Physician C, but she did not follow up to confirm orders for CR#1 that caused delay in treatment. She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wound. She said that CR#1 was sent out to the hospital on 07/29/2023 after testing confirmed there was no blood circulation to the left leg. She said that each resident was assessed for new skin issues that may not have been identified. She said that she initiated an in-services, notified the medical director, held a QAPI, and PIP was put in place to address wound care. She said that LVN A will receive disciplinary action. In an interview with CNA F on 08/02/2023 at 4:15pm, she said that she started at the facility in 2018. She is assigned the hall where CR#1 was housed while admitted to the facility. She said that she first saw resident to have wound on 07/24/2023 when LVN A was helping her with transfer of CR#1. She said that CR#1 had wound to her ankle, but she could not remember if was located on the right or left. She said that the wound was dark in color close to the skin color of CR#1. She said that she would report a new wound to the floor nurse or wound care nurse depending on who was in the building. She said that she did not have to report the wound because the floor nurse was present, and the wound care nurse has not been at work for a few weeks. She said that the wound care doctor was in the building the same day, and the floor nurse said that she was going to have the wound care doctor look at the wound. She said that when she gave CR#1 a bed bath on 07/21/2023 she did not see the wound. Record review of facility policy, Medication and Treatment Orders dated July 2016 read in part, 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescribers last name, credentials, the date and the time of the order. Record review of facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol dated July 2016 read in part, 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width and depth .d. current treatments .e. All active diagnoses Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR communication Form

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and that each resident received assistive devices to prevent accidents for 1 of 7 residents (CR #1) reviewed for accident hazards. -The facility failed to prevent CR #1 from falling out of her wheelchair when left alone sitting in her room. These failures affected one former resident and had the potential to place the remaining 11 residents residing in the facility with contractures, at risk of falls or an injury of unknown source. Finding Include: Intake # 6, # 0, # 2, # 5, # 6, # 6 CR #1 Record review of Resident CR's admission face sheet revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was [AGE] years old. CR #1's admission [DIAGNOSES REDACTED]. Record review of CR #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed: - The resident sometimes understands others and sometimes makes self-understood, she had unclear speech; - Her Brief Interview for Mental Status (BIMS) was 99 out of a possible 15 which indicated she was unable to complete the interview. The resident's cognitive skills for daily decision making was assessed as severely impaired; - The resident required extensive assistance of two person for bed mobility, extensive assistance of one staff for dressing and personal hygiene, she was totally dependent on two staff for transfers; -The resident had impairment in her functional limitation in range of motion to upper and lower left side. -The resident was always incontinent of bowel and bladder. Record review of the facility incident and accident report for CR #1 dated 03/22/18 read in part: -The top of the form read as Un-witnessed; -Incident description: Nursing description: Therapy got resident up on wheelchair, resident, attempted to walk, fell out of wheelchair, on the floor on her left side, left knee slightly bend on the left side. -Immediate Action Taken: . Hematoma 4x3 noted to left upper eye brow . -Witness information: No witness found Record review of CR #1's care plans dated 03/16/2018 read in part: Focus: CR #1 has altered thought process related to -short and long term memory impairment, impaired decision making and [MEDICAL CONDITION]. Record review of CR #1's care plans date initiated 03/16/2018 and last updated on 03/22/18 read in part: Focus: CR #1 was a high risk for falls related to trying to get out of bed without assistance, keeps putting legs out of bed, and trying to get out of bed and chair. Intervention: keep call light in reach and answer in a timely manner. Record review of Skull X-Ray dated 03/22/18 read in part Results: .Mild soft tissue swelling of the frontal scalp is seen. No evidence of fracture is noted. No osseous abnormalities are seen. The orbital rims are within normal limits . Record review of the facility Fall Risk Screener dated 04/13/18 revealed high risk, assessment revealed the resident was disoriented and had decreased muscular coordination. In a phone interview on 4/17/18 at 11:25am with a family member he stated CR #1 was contracted and unable to move. He did not understand how she could fall. When he asked the facility, they could not explain it and he was told no one saw her fall or knew how it happened In an interview on 04/19/18 at 8:20 am RN K stated CR #1 had contractures to upper and lower extremities. She stated she believed the contractures were worse on the left than the right side. RN K stated the resident could slightly shift the position of her buttocks and chest. In an interview on 04/19/18 at 12:15 pm Corporate RN stated the incident involving CR #1 on 03/22/18 was not reported she was not sure why because it was usually the administrator who called it in. She stated she was not aware of the details that occurred because she just started as the interim DON and was walking down the hall when she was asked to assist getting the resident off the floor and back to bed. In an interview on 04/19/18 at 12:21 pm RN N stated physical therapy got CR #1 up in the wheelchair. There was no one in the room at the time. It was unwitnessed. I happened quickly and he was put back into bed. The resident had a hematoma. The corporate RN was notified at the time. In an interview on 04/19/18 at 12:28 pm DOR stated she helped get CR #1 up in a reclining wheelchair. She said she gave the resident the call bell, positioned her and made sure she was comfortable. No one was in the room at the time was told she was found on the floor in front of the wheelchair. In an interview on 04/19/18 at 12:40 pm, PT stated he saw the resident on the floor after her fall. He stated he was told she was found on the floor. He did not assist to get her up because a nurse was needed to assess the resident first. He stated he did not see the way she was lying but she was on the floor across the front of the wheelchair. In an interview on 04/19/18 at 1:33 pm the administrator stated she did not have a report or investigation regarding CR #1's 03/22/18 incident. The administrator stated maybe Corporate RN had one. In an interview on 04/19/18 at 1:48 pm the Corporate RN stated maybe the former ADON had an investigation or report because he left a lot behind when he left. She stated she would look and provide it if she found it. No investigation or report was provided prior to exit. Record review of the facility's policy titled, Nursing Services Policy and Procedure Manual for Long-Term Care @2001 MED-PASS, Inc, Revised (MONTH) 2007, page 5, Falls and Fall Risk, Managing, read in part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . 1. The staff, with the attending Physician, will identify appropriate interventions to reduce the risk of falls .6. Staff will identify and implement relevant interventions, to try to minimize serious consequences of falling. 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling The CMS 672 form indicated 12 residents with contractures.

Based on observation, interview and record review the facility failed to provide the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 of 15 (Resident #14) residents reviewed for wound care /treatments in that: - Resident #14 acquired two new pressure sores while in the facility and failed to reposition the resident every 2 hours. These failures affected 1 resident and placed an additional 4 residents with Pressure Ulcers at risk of developing pressure ulcer, wound infection, delayed healing, and worsening pressure ulcer. Findings Included: Record review of Resident #14's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #14's Significant change in status MDS assessment dated [DATE] revealed he had severe cognitive impairment with a BIMS score of 5 out of a total possible of 15, indicating severe cognitive impairment. He required extensive assistance of two persons physical assist for bed mobility and toilet use and extensive assistance of one person physical assist for transfer, locomotion on unit, dressing, eating and personal hygiene. He was always incontinent of bladder and bowel. Further record review revealed that he was at risk of developing a pressure ulcer and had a 2 stage pressure ulcer and one stage 3 pressure ulcer that he acquired while at the facility. The stage 3 pressure ulcer measured 2.0x1.5x0.3c.m. (LWD). Continued record review revealed that he was not on a turning/repositioning program. Resident #14 did not have pain at time of assessment. Record review of Resident #14's Braden Scale for Predicting Pressure Sore Risk dated 11/4/2016 revealed he was at risk with a score of 16.0. Record review of Resident #14's care plan initiated on 01/02/15 revealed in part: -Focus: Resident #14 had ADL self-care performance related to disease process and tremor both hands. Care plan initiated 1/15/2016: Is at risk for alteration in skin integrity related to incontinent of bowel and bladder and decreased mobility. Stage 3 on left buttocks and shearing to sacrum and right buttocks. -Interventions: Bed mobility: Resident #14 requires extensive assistance of 1-2 staff to turn and reposition in bed. Turn and reposition with staff assistance as needed, treatment as per order. Continued record review of the care plan revealed no information that Resident #14 would refuse to be turn or reposition while in bed or that Resident #14 would turn on his back when he was assisted to his side. Record review of Resident #14's MD order revealed in part; -10/27/2016 - Apply [MEDICATION NAME] cream to right buttocks one time a day for shear wound stage 2. Cleanse area with normal saline, pat dry and apply barrier cream every day. Further record review revealed that order was discontinued on 1/11/2017 at 8:23 a.m. -10/27/2016 - Apply [MEDICATION NAME] cream to sacral area one time a day for shear wound stage 2. Cleanse area with normal saline, pat dry and apply barrier cream every day. -01/11/2017 at 8:23 a.m.- Cleanse bilateral buttocks with normal saline or wound cleanser, pat dry, apply hydrogel and collagen powder, cover with dressing one time a day for 14 days. Record review of Resident #14's MAR for January 2017 revealed orders for [MEDICATION NAME] tablet 500 mg. Give one tablet by mouth three times a day for pain. Further record review revealed that Resident #14 had [MEDICATION NAME] 500 mg tablet at 8:00 a.m. Continued record review revealed that [MEDICATION NAME] tablet 500 mg. Give one tablet by mouth every 4 hours as needed for pain had not been administered at all in January 2017. Record review of Resident #14's progress/nurses notes dated 12/22/2016 at 12:02 p.m. revealed in part; Resident #14's sacral wound stage 2 and right buttocks stage 2 resolved . Record review of Resident #14's Weekly Skin Observation tool revealed in part: -12/23/2016: Notes: Resident #14 had left buttocks stage 3 pressure area resolved, apply [MEDICATION NAME] to right and left buttocks every shift every day. Further record review revealed no open areas identified on assessment. -12/30/2016: Notes: Resident #14 has redness around inner bilateral buttocks, skin intact. Cleanse with normal saline, apply barrier cream to right and left buttocks every shift. Further record review revealed no open areas identified on assessment. -1/6/2017: Notes: Resident #14 has redness around inner bilateral buttocks, skin intact. Cleanse with normal saline, apply barrier cream to right and left buttocks every shift. Further record review revealed no open areas identified on assessment. Record review of the facility's pressure/wound injury weekly report dated 1/4/2017 revealed that Resident #14 was not on the list. Further record review of the facility's pressure/wound injury weekly report dated 1/11/2017 revealed in part: -Resident #14. Location of wound: Right and left buttocks. Stage: 3. Wound description: redness with slough. Pressure. Position devices: no information written. Onset: 1/11/2017. During observation on initial tour on 01/10/2017 at 8:49 a.m. revealed that Resident #14 was lying on his back in the bed with the head of the bed elevated at 45 degrees. Further observation and interview, LVN D stated that she believed that Resident #14 had a stage 2 pressure sore to his buttocks but was not sure about Resident #14's current skin condition. Observation on 01/10/2017 at 1:05 p.m. revealed Resident #14 was still lying on his back in bed with the head of the bed elevated at 45 degrees. Observation on 01/11/2017 at 7:55 a.m. revealed Resident #14 was still lying on his back in bed with the head of the bed elevated at 45 degrees. During observation and interview on 01/11/2017 at 8:45 a.m. Resident #14 was in bed on his back with the head of the bed elevated at about 45 degrees. Further observation and interview at that time, CNA C stated that he had already provided incontinent care to Resident #14. At that time, Resident #14 gave permission to do skin observations. Observation at this time revealed that Resident #14 had an open area to his right buttocks approx 2.0 x 1.0 c.m. wound base red and to his left buttocks approx 2.0x1.0 c.m. wound base red. Open areas were not protected with a dressing and there was stool around the open areas. CNA C then closed Resident #14's brief and assisted him to his back and covered him with a blanket and left the room at that moment after the wound care nurse arrived. During observation on 01/11/2017 at 8:55 a.m. during wound care and incontinent care to Resident #14, the wound care nurse washed her hands and donned gloves. The wound care nurse then went out of the room with her gloves on and said I will get a trash bag. The wound care nurse then entered room and attempted to turn Resident #14 to his side and then she said let me go out and get some help to turn him. Further observation revealed that wound care nurse went out of the room with her gloves on. Continued observation revealed that the wound care nurse entered the room again and attempted to turn Resident #14 again with same gloves. Wound care nurse then opened Resident #14's brief while Resident #14 was on his back. Further observation on 01/11/2017 at 9:12 a.m. CNA C entered room and donned gloves without washing his hands. Wound care nurse then removed her gloves and washed her hands and donned gloves at this time. CNA C then turned Resident #14 to his side and grabbed a wet towel and started wiping the rectal area and buttocks area and said to Resident #14 let me get the poop off. Continued observation at this time revealed that Resident #14 had an open area to his right buttocks approx 2.0 x 1.0 c.m. wound base red and to his left buttocks approx 2.0x1.0 c.m. wound base red. Open areas were not protected with a dressing and there was stool around the open areas. CNA C then held Resident #14 to his side by touching his right hip without changing gloves or washing his hands after he provided incontinent care to Resident #14. Wound care nurse then said at that time I think Resident #14 was very soiled. Continued observation and interview on 01/11/2017 at 9:16 a.m. the wound care nurse said Resident #14 orders were for skin barrier only without any dressings, yesterday his skin was intact, it wasn't this way. Due to the deterioration of his wounds, I just got a new treatment order earlier today, at around 8:30 a.m. Yesterday, his skin was only irritated but when I saw him earlier today, he had open areas already. At that time, CNA C replied did it get like this over night?, the wound care nurse said well, yes. Continued observation and interview on 01/11/2017 at 9:16 a.m., the wound care nurse said Resident #14 orders were for skin barrier only without any dressings, yesterday his skin was intact, it wasn't this way. Due to the deterioration of his wounds, I just got a new treatment order earlier today, at around 8:30 a.m. Yesterday, his skin was only irritated but when I saw him earlier today, he had open areas already. At that time, CNA C replied did it get like this over night?, the wound care nurse said well, yes. Further observation at that time, the wound care nurse removed her gloves and donned new gloves without washing her hands. Resident #14's right leg noted shaking while he softly moaned. The wound care nurse then placed the hydrogel and collagen powder with her gloved hand to the right and left buttocks wounds while Resident #14 flinched his buttocks and moaned in pain. Wound care nurse kept saying I am sorry, so sorry, don't move. Resident #14's right leg continued shaking while he softly moaned during procedure. Wound care nurse then placed a dry dressing and covered both wounds to Resident #14's buttocks. Resident #14's grimaced his face after wound care procedure. In a second interview with the wound care nurse on 1/11/2017 at 10:00 a.m. surveyor informed the wound care nurse that Resident #14 was still with pain. Further interview at that time, the wound care nurse stated his buttocks were not like that yesterday. Buttocks had redness but skin was intact. I have not measure the wounds yet. I saw the wounds this morning and went and got orders. I was going to put the dressing after getting orders . Observation on 1/11/2017 at 2:10 p.m. revealed Resident #14 was lying on his back in bed with the head of the bed elevated at 45 degrees. Observation on 1/12/2017 at 8:15 a.m. revealed Resident #14 was lying on his back in bed with the head of the bed elevated at 45 degrees. Observation on 1/12/2017 at 9:27 a.m. revealed Resident #14 was still lying on his back in bed with the head of the bed elevated at 45 degrees. Observation on 1/12/2017 at 10:10 a.m. revealed Resident #14 was still lying on his back in bed with the head of the bed elevated at 45 degrees. Observation and interview on 1/12/2017 at 11:55 a.m. revealed Resident #14 was still on the same position, lying on his back in bed with the head of the bed elevated at 45 degrees. CNA C who was inside of Resident #14's room, when asked how often Resident #14 was turn and reposition, CNA C stated I am supposed to turned Resident #14 and reposition him every 2 hours. I just turned him at around 9:00 a.m. or 9:30 a.m., but I usually turn residents twice per shift. When told that Resident #14 had been on the same position since 8:15 a.m. on his back, CNA C stated Oh, OK. In an interview on 1/12/2016 at 12:00 p.m. with the wound care nurse, she stated that she was not responsible for monitoring that residents get turned and repositioned every 2 hours and that the charge nurse was responsible for monitoring. Observation and interview on 1/12/2016 at 12:05 p.m. revealed that Resident #14's open areas to right and left buttocks were not protected with a dressing. Resident #14's brief was soiled with bowel movement. CNA C stated at that time there were no dressings when I did incontinent care earlier today. When asked if he had notified to anyone that Resident #14's wounds had no dressings, CNA C stated No, I did not notify anyone because I had been waiting for the wound care nurse. Interview at that time with the wound care nurse, she stated Nobody reported to me that Resident #14's pressure sores did not have dressings. Protocol is to notify the charge nurse. Continued observation and interview at that time revealed that Resident #14's right buttocks had a circular reddened area next to the open pressure sore. The wound care nurse touched the reddened area and stated its a non-blanchable reddened area, its about 1.5 c.m. in diameter. We need to clean the stool to his buttocks areas. In an interview on 01/12/2017 at 12:11 p.m. with LVN D, she stated that she was the charge nurse for Resident #14 and further said Resident #14 needs to be turn every 2 hours and I also noticed that he had been on his back all day. He was in his back every-time I saw him today since breakfast, I will make sure he gets repositioned. Charge nurses and C.N.A's are responsible to monitor that residents get repositioned every 2 hours. In an interview on 1/12/2016 at 1:00 p.m. with the Administrator and the DON, the DON stated we ask patients prior to wound care procedure for pain . The Administrator then said We go by facial grimacing if they can not tell us. If the patient is in pain during the wound care procedure, you have to stop. Further interview at that time the DON said You need to re-assess for pain , the Administrator then stated you need to ask patient, are you OK. Continued interview on 01/12/2017 at 1:09 p.m., the DON stated that the facility prevented pressure sores on residents by turning and repositioning. He further said that if the C.N.A. discovered a wound or saw a wound that was not protected with a dressing, the C.N.A. was responsible of calling the charge nurse. Further interview at that time, the Administrator stated that the charge nurses were responsible of monitoring that residents get turned and repositioned while in bed and further said Resident #14 is able to turn and reposition himself by holding the half rail. He turns on his back when you turn him on his side. In an interview on 01/12/2017 at 2:25 p.m. with LVN D and CNA B, both said that Resident #14 was not able to turn and reposition by himself and both said Resident #14 can try to help but he needs extensive assistance to turn and reposition while in bed. In an interview on 01/12/2017 with the DON, he stated that he was not able to find the policy and procedure for turning and repositioning of residents in prevention of pressure sores. Record review of www.webmd.com/ ./four-stages-of-pressure-sores Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it. At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister <http://www.webmd.com/skin-problems-and-treatments/guide/understanding-blisters-basics>, or a shallow crater in the skin. Sometimes this stage looks like a blister <http://www.webmd.com/skin-problems-and-treatments/ss/slideshow-blisters> filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die. During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone. At stage 4, the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur. Relieving and spreading out pressure is the most important part of both preventing and treating pressure sores <http://www.webmd.com/hw-popup/pressure-sores>. Putting pressure on one spot for long periods of time decreases blood <http://www.webmd.com/heart/anatomy-picture-of-blood> flow to that area. This damages or kills the cells and creates a sore. Pressure can be relieved and spread in several ways. Often a combination of these is best. To relieve and spread pressure: 1.- Change positions at least every 2 hours if you are confined to a bed. Change as often as every 15 minutes if you are in a wheelchair. 2.- Avoid sliding, slipping, or slumping, or being in positions that put pressure directly on an existing pressure sore. Try to keep the head of a bed, a recliner chair, or a reclining wheelchair raised no more than 30 degrees. Record review of the facility Policy and Procedure titled Pressure Ulcers/Skin Breakdown - Clinical Protocol revised March 2014 revealed in part: The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility and history of pressure ulcer (s) Treatment/Management: 1.- The physician will authorize pertinent orders related to wound treatments .2.- The physician will help identify medical interventions related to wound management Further record review revealed no information on how the facility would prevent pressure sores. Record review of the facility Policy and Procedure revised June 2013 titled Pain - Clinical Protocol revealed in part: .3.- The staff will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. A.- Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. B.- The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while having a wound dressing changed. Treatment/Management:4.- Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning. Monitoring: 1.- The staff will reassess the individual's pain and related consequences at regular intervals . Record review of the facility's Pressure/Wound injury weekly report dated 1/4/2017 there were 4 residents who received wound care at the facility not including Resident #14.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of fifteen residents (Resident #14) reviewed for pain management. -The facility failed to ensure the wound care nurse assessed for pain prior to, during or after the wound dressing change to Resident #14 who moaned and verbalized pain during wound care. This failure affected one resident and could place the other four residents receiving wound care at risk for experiencing pain unnecessarily. Findings include: Record review of Resident #14's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #14's Significant change in status MDS assessment dated [DATE] revealed he had severe cognitive impairment with a BIMS score of 5 out of a total possible of 15, indicating severe cognitive impairment. He required extensive assistance of two persons physical assist for bed mobility and toilet use and extensive assistance of one person physical assist for transfer, locomotion on unit, dressing, eating and personal hygiene. He was always incontinent of bladder and bowel. Further record review revealed that he was at risk of developing a pressure ulcer and had a 2 stage pressure ulcer and one stage 3 pressure ulcer that he acquired while at the facility. The stage 3 pressure ulcer measured 2.0x1.5x0.3c.m. (LWD). Continued record review revealed that he was not on a turning/repositioning program. Resident #14 did not have pain at time of assessment. Record review of Resident #14's MD order revealed in part; -6/19/2016 - [MEDICATION NAME] tablet 500 mg. Give one tablet by mouth every 4 hours as needed for pain. -6/19/2016 - [MEDICATION NAME] tablet 500 mg. Give one tablet by mouth three times a day for pain. -10/27/2016 - Apply [MEDICATION NAME] cream to right buttocks one time a day for shear wound stage 2. Cleanse area with normal saline, pat dry and apply barrier cream every day. Further record review revealed that order was discontinued on 1/11/2017 at 8:23 a.m. -10/27/2016 - Apply [MEDICATION NAME] cream to sacral area one time a day for shear wound stage 2. Cleanse area with normal saline, pat dry and apply barrier cream every day. -01/11/2017 at 8:23 a.m.- Cleanse bilateral buttocks with normal saline or wound cleanser, pat dry, apply hydrogel and collagen powder, cover with dressing one time a day for 14 days. Record review of Resident #14's MAR for January 2017 revealed orders for [MEDICATION NAME] tablet 500 mg. Give one tablet by mouth three times a day for pain. Further record review revealed that Resident #14 had [MEDICATION NAME] 500 mg tablet at 8:00 a.m. Continued record review revealed that [MEDICATION NAME] tablet 500 mg. Give one tablet by mouth every 4 hours as needed for pain had not been administered at all in January 2017. During observation on 01/11/2017 at 8:55 a.m. during wound care and incontinent care to Resident #14, the wound care nurse washed her hands and donned gloves. The wound care nurse then went out of the room with her gloves on and said I will get a trash bag. The wound care nurse then entered room and attempted to turn Resident #14 to his side and then she said let me go out and get some help to turn him. Further observation revealed that wound care nurse went out of the room with her gloves on. Continued observation revealed that the wound care nurse entered the room again and attempted to turn Resident #14 again with same gloves. Wound care nurse then opened Resident #14's brief while Resident #14 was on his back. Further observation on 01/11/2017 at 9:12 a.m. CNA C entered room and donned gloves without washing his hands. Wound care nurse then removed her gloves and washed her hands and donned gloves at this time. CNA C then turned Resident #14 to his side and grabbed a wet towel and started wiping the rectal area and buttocks area and said to Resident #14 let me get the poop off. Continued observation at this time revealed that Resident #14 had an open area to his right buttocks approx 2.0 x 1.0 c.m. wound base red and to his left buttocks approx 2.0x1.0 c.m. wound base red. Open areas were not protected with a dressing and there was stool around the open areas. CNA C then held Resident #14 to his side by touching his right hip without changing gloves or washing his hands after he provided incontinent care to Resident #14. Wound care nurse then said at that time I think Resident #14 was very soiled. Continued observation and interview on 01/11/2017 at 9:16 a.m., the wound care nurse said Resident #14 orders were for skin barrier only without any dressings, yesterday his skin was intact, it wasn't this way. Due to the deterioration of his wounds, I just got a new treatment order earlier today, at around 8:30 a.m. Yesterday, his skin was only irritated but when I saw him earlier today, he had open areas already. At that time, CNA C replied did it get like this over night?, the wound care nurse said well, yes. Further observation on 1/11/2017 at 9:19 a.m. while the wound care nurse cleaned Resident #14's open areas to his buttocks, Resident #14 moaned auuuuuu , wound care nurse replied I am sorry, I need to clean them as much as I can. The wound care nurse continued cleaning the open wounds to Resident #14's buttocks while Resident #14 kept flinching his buttocks and moaned again aaaaa. Further observation at that time, the wound care nurse removed her gloves and donned new gloves without washing her hands. Resident #14's right leg noted shaking while he softly moaned. The wound care nurse then placed the hydrogel and collagen powder with her gloved hand to the right and left buttocks wounds while Resident #14 flinched his buttocks and moaned in pain. Wound care nurse kept saying I am sorry, so sorry, don't move. Resident #14's right leg continued shaking while he softly moaned during procedure. Wound care nurse then placed a dry dressing and covered both wounds to Resident #14's buttocks. Resident #14's grimaced his face after wound care procedure. In an interview on 1/11/2017 at 9:40 a.m. with the wound care nurse, she stated that she did notice that Resident #14 was in pain but that she did not have access to his pain medications record and then said I did notice that he was in pain. I don't know anything about his pain medications. The charge nurse is the only one that knows about the residents' pain medications. When asked if she would assess for pain prior to wound care, the wound care nurse responded I did not ask Resident #14 if he was in pain. I assumed he was OK. Probably he was in pain because the area had been irritated during incontinent care. When asked what happens when residents complain of pain during the wound care procedure, the wound care nurse responded If the patient is really, really in pain, you could stop and can either come back later, but that is kind of impossible, or just have to continue, most residents would just let you continue. When asked if she believed Resident #14 was really, really in pain, the wound care nurse said I just thought I was escalating the pain, we kind of caused more irritation. Further interview on 1/11/2017 at 9:50 a.m., the wound care nurse said as she opened her computer let me see on my computer if Resident #14 had any pain medications. Further observation and interview at that time while the wound care looked at the computer she stated Resident #14 had Tylenol 500mg at 8:23 a.m. He is not due until 12:00 p.m. again. In an interview on 1/11/2017 at 9:55 a.m. with Resident #14, when asked if he had pain during wound care, Resident #14 stated Yeah, when asked how much pain?, Resident #14 responded bad . When asked how was the pain from 1 to 10, Resident #14 responded 10. When asked if he still had pain, Resident #14 stated yes When asked how was the pain from 1 to 10, Resident #14 responded 3 but was unable to describe where the pain was. In a second interview with the wound care nurse on 1/11/2017 at 10:00 a.m. surveyor informed the wound care nurse that Resident #14 was still with pain. Further interview at that time, the wound care nurse stated his buttocks were not like that yesterday. Buttocks had redness but skin was intact. I have not measure the wounds yet. I saw the wounds this morning and went and got orders. I was going to put the dressing after getting orders . In an interview on 1/12/2016 at 1:00 p.m. with the Administrator and the DON, the DON stated we ask patients prior to wound care procedure for pain. The Administrator then said We go by facial grimacing if they can not tell us. If the patient is in pain during the wound care procedure, you have to stop. Further interview at that time the DON said You need to re-assess for pain, the Administrator then stated you need to ask the patient, are you OK. Record review of the facility Policy and Procedure revised June 2013 with title Pain - Clinical Protocol revealed in part: .3.- The staff will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. A.- Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. B.- The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while having a wound dressing changed. Treatment/Management:4.- Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning. Monitoring: 1.- The staff will reassess the individual ' s pain and related consequences at regular intervals . Record review of the facility's Pressure/Wound injury weekly report dated 1/4/2017 there were 4 residents who received wound care at the facility not including Resident #14.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property for 1 of 12 residents (Resident #1) reviewed for abuse and neglect. -Resident #1 expressed pain in her leg following a transfer from her bed to the shower chair at 9:30 AM. CNA's A and B failed to notify the nurse of the resident's pain until 1:00 PM. -Two CNA's (CNA A and CNA B) continued to transfer the resident for a shower and had the resident stand and bear weight before nursing staff was notified. -Resident #1 did not receive appropriate pain assessments or pain intervention after the nursing staff was notified. -The nurse on the 2:00 PM - 10:00 PM shift failed to notify the direct care staff on that shift of Resident #1's condition, which resulted in CNA C and another staff member transferring Resident #1 from her wheelchair to her bed. Following this transfer Resident #1 began to cry due to the pain. -The resident was transferred to the hospital at 11:30 pm following an x-ray which identified the source of pain as a displaced spiral femur fracture. -Following the report of an injury of an unknown source, the Administrator failed to conduct a thorough investigation of the injury and implemented no corrective actions. An Immediate Jeopardy was identified on 7/3/2014 at 12:54PM. While the IJ was removed on 7/7/2014, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed the remaining 88 residents currently residing in the facility at risk by failing to comply with state laws and failing to protect residents from potential abuse, neglect and/or mistreatment. Findings include: Incident # 6 Record review of Resident #1's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. This resident was [AGE] years of age. Record review of the facility's "Provider Investigation Report" revealed the incident occurred on 6/16/2014 at 9:30 AM and read in part; "...Description of injury: Unknown fx to left fibula. ...Investigation Summary: On 6/16/2014 (Resident #1) was being provided care by two certified nursing aides when she began complaining of pain to her left leg. The certified nursing aides notified the charge nurse (LVN B). (LVN B) did an assessment and notified the attending physician of her condition. The attending physician gave an order to have her left leg x-rayed to rule out fracture. The results were that (Resident #1) had an acute displaced spiral oblique francture (sic) of the dismal (sic) femoral shaft. (Resident #1) was transferred to the hospital. The Charge Nurse who indicated that she was not award (sic) of any incident involving (Resident #1), only that she assessed and made required notifications and transferred. The two certified nursing assistants, (CNA A) and (CNA B) wasn't aware (sic) of any situation involving the incident, only that they notified the Charge Nurse of her complaint. The internal investigation was performed with no definite indication as to what had occurred. There were no witnesses to the fracture therefore I was unable to determine the orgin (sic) of the fracture. ...Provider Action Taken Post-Investigation: Inservice staff on closely monitoring (Resident #1) going forward and continue to make notification if a resident complains." This document was signed by The ADM and dated 6/20/2014. Record review of the facility's "Incident Report" dated 6/17/2014 revealed Resident #1 was transported to the hospital at 11:30 PM on 6/16/2014. This document was signed by LVN B. Record review of Resident #1's "Nurses Notes" read in part; "6/16/2014 at 2:30 PM - Around 1:00 PM this day staff reported to this nsg (sic) that resident complained of pain to L knee when transferring her. ...(Physician) was called a n/o was given for x-ray to L knee, RP was called, no answer, a message was left on her voice machine. ...6/16/2014 at 10:20 PM - Resident given Tylenol 325mg tabs two by mouth for pain." Record review of Resident #1's June 2014 MAR indicated [REDACTED]. [MEDICATION NAME], 50 mg, one-half tablet (25mg) by mouth three times daily. This document also revealed on 6/16/2014, Resident #1 was documented as having received only one dose of [MEDICATION NAME]. Record review of Resident #1's "Pain Assessment" revealed she was experiencing a pain level of 9 on a scale of 0-10. This document was written by LVN B, had no time and was not dated. Record review of Resident #1's clinical record revealed no documentation of additional pain assessments related to the incident on 6/16/2014. Record review Resident #1's hospital records read in part; "Clinical Report - ...History of Present Illness: Chief Complaint (left femur injury). The injury occurred yesterday. Occurred at a nursing home. Pt had images performed which confirmed left distal femoral fracture. Staff unsure how this happened. Daughter is very upset by not knowing what happened to cause fracture. ...The patient complains of moderate pain. No neck pain or loss of consciousness. (Transport unit says leg had deformity and decreased pulses so pulled straight and put in hare traction splint)." This document was dated 6/17/2014. Record review of the written statement from CNA A read; " On June 16, 2014, at 9:30 AM, I (CNA A) and (CNA B) transferred (Resident #1) from her bed to the shower chair to give her a shower, she complained about leg pain so I reported her pain to the charge nurse (LVN A). This document was signed by CNA A and dated 6/16/2014. Record review of the written statement from CNA B read; "June 16, 2014 at 9:30 AM, I (CNA B) assisted (CNA A) in transferring (Resident #1) from her bed to the shower chair for her shower. (Resident #1) complain (sic) of pain so we reported her pain to the charge nurse (LVN A)." This document was signed by CNA B and dated 6/16/2014. In an interview with CNA A on 7/2/2014 at 1:18 PM when asked about the incident with Resident #1, she said she went to Resident #1's room around 9:30 AM, to take her to the shower. She said she and CNA B transferred Resident #1 from her bed to the shower chair. She said following the transfer Resident #1 complained of leg pain. She then said she proceeded to take the resident to the shower room and had intended to report the resident's pain to nurse but there was no nurse at the nurse's station so she continued to the shower room. She said following the shower, she took Resident #1 back to her room, then she and CNA B transferred her from the shower chair to her wheelchair. She then said she and CNA B stood the resident up to pull up her brief and pants and then sat her back down in the wheelchair to finish getting the resident dressed. She also said the resident again complained of pain after the CNA's stood the resident up to dress her. She then said she took Resident #1 to the dining room for lunch. She then said following lunch she saw Resident #1 sitting in her wheelchair in the dining room and realized she had not reported the resident's pain to the nurse yet. She said she then reported Resident #1's pain to LVN A at around 12:30 PM. When asked why she did not notify the nurse prior to giving the resident a shower, she said there was no nurse at the nurse ' s station. When asked why she did not send another CNA to find a nurse, she did not have an answer. In an interview with CNA B on 7/3/2014 at 12:40 PM when asked about the incident with Resident #1, she said CNA A has asked her to assist with the transfer of Resident #1 from her bed to the shower chair. When asked if the resident at any point during the transfer had supported her own weight, she said yes. She then said, following the transfer the resident made an "ugh" sound and made a "pain face". She then said that CNA A told her that she would notify the nurse on the way to the shower. She then said she went back to her own duties. She said CNA A called her again after the Resident ' s shower to assist with a transfer and dressing of the resident. She said they dried the resident off and stood the resident up to put on her brief and pull up her pants. She then said the resident complained of pain. When asked what should be done if a resident makes a complaint of pain, she said report to the nurse immediately. In an interview with CNA C on 7/3/2014 at 4:35 PM, she said at about 7:00 PM on 6/16/2014 she and another CNA transferred Resident #1 to her bed from her wheelchair. She said during the transfer the resident said "Ah!" and she asked Resident #1 what was wrong and she began to cry. She said she reported this to the LVN B and was told about the resident's previous reports of pain. When asked if she was told by LVN B at the start of her shift at 2:00 PM about Resident #1's pain, she said no. In an interview with LVN A on 7/2/2014 at 1:36 PM when asked about the incident with Resident #1, she said she first became aware of Resident #1's pain at 1:00 PM from CNA A. She said CNA A told her she had forgotten to report the resident's pain earlier. She then said she immediately went to assess Resident #1 and the resident pointed to her knee when asked about her pain. She said "I touched her knee and she confirmed the pain". She also said about two minutes later she asked the resident again about her pain and she said the resident denied pain at that time. She said she then called the physician and received an order for [REDACTED]. When asked if she administered any pain medications to Resident #1 to relieve her pain, she said no, because Resident #1 reported no pain the second time she asked her. When asked if she assessed Resident #1's entire leg for pain, she said no, she only assessed the resident's knee. In an interview with LVN B on 7/3/2014 at 4:50 PM, when asked about the incident with Resident #1, she said she did conduct the pain assessment on Resident #1 when she reported a pain level of 9 on a scale of 0-10. She said she conducted the pain assessment on 6/16/2014 at about 9:00 PM after CNA C reported to her that Resident #1 reported pain during her transfer from her wheelchair to the bed. She said she also administered two 325mg Tylenol following the assessment. She said Resident #1 never complained of pain to her prior to that during her shift. She said she did periodically check on the resident during the shift but did not document it. She said she was told during shift change by LVN A that Resident #1 was experiencing pain and that the MD was notified and an x-ray had been ordered. When asked if she had told CNA C about Resident #1's reported pain and that an x-ray had been ordered, she said no. In an interview with the DON on 7/3/2014 at 2:30 PM, when asked what could happen if after a resident complained of pain, they were transferred again and made to bear weight, she said "could be a fracture". When asked if after Resident #1 reported pain to the CNA's, should the resident had been given a shower and transferred again? She said she could not answer that question. In an interview with Resident #1's daughter on 7/2/2014 at 2:38 PM when asked about Resident #1's course of treatment following her transfer to the hospital, she said her mother had surgery on 6/18/2014 to repair the fracture. She had a rod and screws placed in her leg to repair the fracture. In an interview with the DON on 7/7/2014 at 5:45 PM, when asked if from the time Resident #1's pain had been reported to LVN A had any pain monitoring been conducted, she said other than the one pain assessment when Resident #1 reported a pain level of 9, she did not find any pain monitoring. She also said other than the Tylenol at 10:20 PM and her scheduled 25 mg [MEDICATION NAME], she did not find any documentation that any pain intervention was conducted. When asked if she was aware of any deformity in Resident #1's leg, she said no. When asked if LVN B should have made Resident #1's direct care staff aware of her pain, she said, normally she would tell her CNA's don ' t touch or move the resident because they were waiting on an x-ray. When asked how she thought this incident came about, she said "You're asking me to speculate. I only have their word, I wasn't there. When they got her up to shower, something happened to her body." In an interview with the ADM on 7/2/2014 at 4:32 PM, when asked who conducted the investigation related to the incident with Resident #1, he said "I did". When asked if he interviewed the CNA's involved in the incident, he said the DON interviewed the CNA's. When asked, during his investigation, if he found any problems related to the timeline on the day of the incident, he said the nurse said she called the doctor at 2:00 PM and the incident occurred at 9:30 AM. He said the nurse was notified around 1:30 PM. When asked if that seemed significant to him, he said yes. When asked if he looked further into the time discrepancy during his investigation, he said no. When asked when a report of pain should be reported, he said staff should report immediately. When asked if any in-services were conducted with the CNA ' s following the incident, he said he was not sure. When asked if during his investigation, he found that pain monitoring and pain intervention for Resident #1 was not done, he said no. In an interview with the ADM on 7/7/2014 at 6:20 PM, when asked why he thought this immediate jeopardy came about, he said they didn't match the actual timeframe to what actually happened and did not get it written down in a significant amount of time. He also said, she had surgery so significant harm occurred. He said he was told about the incident on 6/17/2014. He said he called the DON and got her to give him all the documentation and he talked to the nurse to find out basically what occurred. When asked if he felt the incident was thoroughly investigated, he said "not as much as I'd like." When asked if he felt the nursing staff appropriately monitored and assessed Resident #1's pain appropriately, he said "no, I don't think it was." When asked, other than Resident #1's scheduled pain medication of 25 mg [MEDICATION NAME], three times daily and two 325mg Tylenol at 10:20 PM, did the staff provide any intervention for Resident #1's pain, he said no. When asked if he was aware of any deformity in Resident #1's leg prior to her being transferred to the hospital, he said no. When asked, from the time Resident #1 first complained of pain to the time she was transferred to the hospital at 11:30 PM, was that an appropriate timeframe, he said no. When asked if the charge nurse should notify the direct care staff if a resident had complained of pain and there was an MD order for an x-ray, he said yes. Record review of the facility's "Abuse and Neglect Policy" read in part; "Policy: Abuse, as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardians, friends or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Definitions: Neglect - The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the resident. ...Investigative Issues: Policy - Any employee having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately. Procedure - Any and all staff observing or hearing about such events must report the event immediately to the Abuse Prevention Coordinator or Administrator. The event should also be reported immediately to the employee's supervisor. ...Policy - All events reported as possible abuse will be investigated to determine whether abuse did nor (sic) did not take place. Procedure - The Abuse/Neglect Prevention Coordinator will initiate investigative action immediately. The Administrator of the center, the Director of Nurses and/or the Social Worker (Abuse Prevention Coordinator) will be notified of the complaint immediately and action being taken immediately or within 24 hours of reporting to DADS consumer rights division." This document was not dated. Record review of the facility's "Pain Evaluation" policy and procedure read in part; "Documentation - The person performing this evaluation should record the following information in the resident's medical record. The date and time the evaluation was performed. The name and title of the individual(s) who performed the procedure. Document assessment of pain when prn pain medication is required. All assessment data obtained during the procedure including location of pain, description of site if indicated, level of pain using the appropriate pain scale, and type of pain relief used. Reassessment of pain and the resident's response to the pain relief used." This document was dated 5/22/2013. An Immediate Jeopardy was identified on 7/3/2014 at 12:54 PM and the ADM was notified at that time. A plan of removal was submitted and after some revisions was accepted on 7/7/2014 at 6:40 PM. Summary of the Plan of Action to Remove Immediate Jeopardy: Facility will in-service staff on Abuse, Neglect and Exploitation with emphasis on providing necessary, timely communication to the supervisor or the Abuse Coordinator. In addition the following areas were covered including: Abuse, Neglect, Exploitation, verbal abuse, sexual abuse, mental abuse, involuntary seclusion and Misappropriation of Residents property. a. Certified Nursing Aides were in serviced on change of condition including recognizing nonverbal pain and how to respond to non-verbal and verbal pain in a timely manner to preclude further injury to resident. b. All investigations will be conducted by the Administrator or Abuse Coordinator according to DADS Provider letter 06-43 and the facility Abuse and Neglect Policy and Procedure. c. The two (2) staff that were involved with the incident occurring on 6/16/2014 were terminated for failure to notify charge nurse of incident in a timely manner. d. In-services were completed on 7/3/2014 with 73% of participant educated. All staff that was not educated on this date will be required to complete education and sign for completion prior to returning to work. This would include all staff on vacation, workman comp, sick leave and those unable to be contacted. e. Additional in-service was completed on properly completing Internal Investigation and Resident Investigation Forms by licensed staff. Properly Techniques to include: Transferring the resident from bed to chair, utilizing lifting machine, Active transferring, independent, standing pivot transfer (assisted) and dependent transfer. f. All incident reports 30 days or less will be reviewed for completion and appropriate interventions. Completed on 7/5/2014 g. The Administrator was educated on Abuse, Neglect and exploitation which included the effective process of evaluating a complaint, effective gathering of information, assessing information, interviewing identified residents and staff, protection of residents and the timely procedure to ensure DADS is notified. This training was provided by the CRN. Completion date: 7/4/2014. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Record Reviews as follows: -In-service Training records for abuse/neglect, pain management and transfers for all nursing staff, to include nurse managers, CNA's and medicaiton aides. Training was provided by the CRN. 90 staff signed in for abuse/neglect in-services, 21 staff signed in for pain management in-services, 58 staff signed in for transfers in-services. - In-service for abuse and neglect to include conducting a thorough investigation was conducted with the ADM. This training was provided by the CRN. -Intervention audits of residents with pain. Interviews as follows: - Six nursing staff to include LVN nursing managers and CNA's to determine if they were familiar with abuse/neglect and pain assessment/treatment policies and pain reporting procedures, as well as what to do in the event a similar incident to the IJ occurred. - Resident interviews to determine if they had any issues related to pain. Observations as follows: - Six random observations with CNA's of resident transfers. The Administrator was informed on 7/7/2014 at 6:50 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. According to the facility's CMS Form 672, the census was 88.

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 psychological well-being, in accordance with the comprehensive assessment and plan of care for 1 of 12 residents (Resident #1) reviewed for quality of care. Resident #1 expressed pain in her leg following a transfer from her bed to the shower chair at 9:30 AM. Resident #1 also expressed pain following her shower when CNA's A and B transferred her from the shower chair to her wheelchair and had the resident stand up to be dressed. CNA's A and B failed to notify the nurse of the resident's pain until 1:00 PM. After the nurse was notified, Resident #1 did not receive appropriate pain assessments or pain intervention. The nurse on the 2:00 PM - 10:00 PM shift failed to notify the direct care staff of the resident's complaints of pain. At 7:00 PM, CNA C and another staff member transferred Resident #1 from her wheelchair to her bed. Following this transfer Resident #1 began to cry due to the pain. The resident was transferred to the hospital following an x-ray which revealed a fractured femur at approximately 11:30 PM. An Immediate Jeopardy was identified on 7/3/2014 at 12:54PM and the administrator was notified at that time. While the IJ was removed on 7/7/2014, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed the remaining 88 residents currently residing in the facility at risk of not receiving adequate pain intervention, ADL care and/or decline in health status. Findings include: Incident # 6 Record review of Resident #1's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. This resident was [AGE] years of age. Record review of the facility's "Provider Investigation Report" revealed the incident occurred on 6/16/2014 at 9:30 AM and read in part; "...Description of injury: Unknown fx to left fibula. ...Investigation Summary: On 6/16/2014 (Resident #1) was being provided care by two certified nursing aides when she began complaining of pain to her left leg. The certified nursing aides notified the charge nurse (LVN B). (LVN B) did an assessment and notified the attending physician of her condition. The attending physician gave and order to have her left leg x-rayed to rule out fracture. The results were that (Resident #1) had an acute displaced spiral oblique francture (sic) of the dismal (sic) femoral shaft. (Resident #1) was transferred to the hospital. The Charge Nurse who indicated that she was not award (sic) of any incident involving (Resident #1), only that she assessed and make required notifications and transferred. The two certified nursing assistants, (CNA A) and (CNA B) wasn't aware (sic) of any situation involving the incident, only that they notified the Charge Nurse of her complaint. The internal investigation was performed with no definite indication as to what had occurred. There were no witnesses to the fracture therefore I was unable to determine the orgin (sic) of the fracture. ...Provider Action Taken Post-Investigation: Inservice staff on closely monitoring (Resident #1) going forward and continue to make notification if a resident complains." This document was signed by The ADM and dated 6/20/2014. Record review of the facility's "Incident Report" dated 6/17/2014 revealed Resident #1 was transported to the hospital at 11:30 PM on 6/16/2014. This document was signed by LVN B. Record review of Resident #1's "Nurses Notes" read in part; "6/16/2014 at 2:30 PM - Around 1:00 PM this day staff reported to this nsg (sic) that resident complained of pain to L knee when transferring her. ...(Physician) was called a n/o was given for x-ray to L knee, RP was called, no answer, a message was left on her voice machine. ...6/16/2014 at 10:20 PM - Resident given Tylenol 325mg tabs two by mouth for pain." Record review of Resident #1's June 2014 MAR indicated [REDACTED]. [MEDICATION NAME], 50 mg, one-half tablet (25mg) by mouth three times daily. This document also revealed on 6/16/2014, Resident #1 was documented as having received only one dose of [MEDICATION NAME]. Record review of Resident #1's "Pain Assessment" revealed she was experiencing a pain level of 9 on a scale of 0-10. This document was completed by LVN B, had no time and was not dated. Record review of Resident #1's clinical record revealed no documentation of additional pain assessments related to the incident on 6/16/2014. In an interview with LVN B on 7/3/2014 at 4:50 PM, when asked about the incident with Resident #1, she said she did conduct the pain assessment on Resident #1 when she reported a pain level of 9 on a scale of 0-10. She said she conducted the pain assessment on 6/16/2014 at about 9:00 PM after CNA C reported to her that Resident #1 reported pain during her transfer from her wheelchair to the bed. She said she also administered two 325mg Tylenol following the assessment. She said Resident #1 never complained of pain to her prior to that during her shift. She said she did periodically check on the resident during the shift but did not document it. Record review Resident #1's hospital records read in part; "Clinical Report - ...History of Present Illness: Chief Complaint (left femur injury). The injury occurred yesterday. Occurred at a nursing home. Pt had images performed which confirmed left distal femoral fracture. Staff unsure how this happened. Daughter is very upset by not knowing what happened to cause fracture. ...The patient complains of moderate pain. No neck pain or loss of consciousness. (Transport unit says leg had deformity and decreased pulses so pulled straight and put in hare traction splint)." This document was dated 6/17/2014. Record review of the written statement from CNA A read; " On June 16, 2014, at 9:30 AM, I (CNA A) and (CNA B) transferred (Resident #1) from her bed to the shower chair to give her a shower, she complained about leg pain so I reported her pain to the charge nurse (LVN A). This document was signed by CNA A and dated 6/16/2014. Record review of the written statement from CNA B read; "June 16, 2014 at 9:30 AM, I (CNA B) assisted (CNA A) in transferring (Resident #1) from her bed to the shower chair for her shower. (Resident #1) complain (sic) of pain so we reported her pain to the charge nurse (LVN A)." This document was signed by CNA B and dated 6/16/2014. In an interview with CNA A on 7/2/2014 at 1:18 PM when asked about the incident with Resident #1, she said she went to Resident #1's room around 9:30 AM, to take her to the shower. She said she and CNA B transferred Resident #1 from her bed to the shower chair. She said following the transfer Resident #1 complained of leg pain. She then said she proceeded to take the resident to the shower room and had intended to report the resident's pain to nurse but there was no nurse at the nurse's station so she continued to the shower room. She said following the shower, she took Resident #1 back to her room, then she and CNA B transferred her from the shower chair to her wheelchair. She then said she and CNA B stood the resident up to pull up her brief and pants and then sat her back down in the wheelchair to finish getting the resident dressed. She also said the resident again complained of pain after the CNA's stood the resident up to dress her. She then said she took Resident #1 to the dining room for lunch. She then said following lunch she saw Resident #1 sitting in her wheelchair in the dining room and realized she had not reported the resident's pain to the nurse yet. She said she then reported Resident #1's pain to LVN A at around 12:30 PM. When asked why she did not notify the nurse prior to giving the resident a shower, she said there was no nurse at the nurse ' s station. When asked why she did not send another CNA to find a nurse, she did not have an answer. In an interview with CNA B on 7/3/2014 at 12:40 PM when asked about the incident with Resident #1, she said CNA A has asked her to assist with the transfer of Resident #1 from her bed to the shower chair. When asked if the resident at any point during the transfer had supported her own weight, she said yes. She then said, following the transfer the resident made an "ugh" sound and made a "pain face". She then said that CNA A told her that she would notify the nurse on the way to the shower. She then said she went back to her own duties. She said CNA A called her again after the Resident ' s shower to assist with a transfer and dressing of the resident. She said they dried the resident off and stood the resident up to put on her brief and pull up her pants. She then said the resident complained of pain. When asked what should be done if a resident makes a complaint of pain, she said report to the nurse immediately. In an interview with CNA C on 7/3/2014 at 4:35 PM, she said at about 7:00 PM on 6/16/2014 she transferred Resident #1 to her bed from her wheelchair. She said during the transfer the resident said "Ah!" and she asked Resident #1 what was wrong and she began to cry. She said she reported this to the LVN B and was told about the resident's previous reports of pain. When asked if she was told by LVN B at the start of her shift at 2:00 PM about Resident #1's pain, she said no. In an interview with LVN A on 7/2/2014 at 1:36 PM when asked about the incident with Resident #1, she said she first became aware of Resident #1's pain at 1:00 PM from CNA A. She said CNA A told her she had forgotten to report the resident's pain earlier. She then said she immediately went to assess Resident #1 and the resident pointed to her knee when asked about her pain. She said "I touched her knee and she confirmed the pain". She also said about two minutes later she asked the resident again about her pain and she said the resident denied pain at that time. She said she then called the physician and received an order for [REDACTED]. When asked if she administered any pain medications to Resident #1 to relieve her pain, she said no, because Resident #1 reported no pain the second time she asked her. When asked if she assessed Resident #1's entire leg for pain, she said no, she only assessed the resident's knee. Record review of Resident #1's "Nurse's Notes" dated 6/16/2014 at 2:30 PM read in part; "Around 1:00 PM this day staff reported to this nsg (sic) that res c/o of pain to L knee when transferring her, when this nsg eval the knee 0 swellen (sic) was noted. Knee was not warm to touch." This nurse's note was signed by LVN A. In an interview with LVN B on 7/3/2014 at 4:50 PM, she said she was told during shift change by LVN A that Resident #1 was experiencing pain and that the MD was notified and an x-ray had been ordered. When asked if she had told CNA C about Resident #1's reported pain and that an x-ray had been ordered, she said no. In an interview with the DON on 7/3/2014 at 2:30 PM, when asked what could happen if after a resident complained of pain, they were transferred again and made to bear weight, she said "could be a fracture". When asked if after Resident #1 reported pain to the CNA's, should the resident had been given a shower and transferred again? She said she could not answer that question. In an interview with Resident #1's family member on 7/2/2014 at 2:38 PM when asked about Resident #1's course of treatment following her transfer to the hospital, she said her mother had surgery on 6/18/2014 to repair the fracture. She had a rod and screws placed in her leg to repair the fracture. In an interview with the DON on 7/7/2014 at 5:45 PM, when asked if from the time Resident #1's pain had been reported to LVN A had any pain monitoring been conducted, she said other than the one pain assessment when Resident #1 reported a pain level of 9, she did not find any pain monitoring. She also said other than the Tylenol at 10:20 PM and her scheduled 25 mg [MEDICATION NAME], she did not find any documentation that any pain intervention was conducted. When asked if she was aware of any deformity in Resident #1's leg, she said no. When asked if LVN B should have made Resident #1's direct care staff aware of her pain, she said, normally she would tell her CNA's don ' t touch or move the resident because they were waiting on an x-ray. When asked how she thought this incident came about, she said "You're asking me to speculate. I only have their word, I wasn't there. When they got her up to shower, something happened to her body." In an interview with the ADM on 7/2/2014 at 4:32 PM, when asked who conducted the investigation related to the incident with Resident #1, he said "I did". When asked if he interviewed the CNA's involved in the incident, he said the DON interviewed the CNA's. When asked, during his investigation, if he found any problems related to the timeline on the day of the incident, he said the nurse said she called the doctor at 2:00 PM and the incident occurred at 9:30 AM. He said the nurse was notified around 1:30 PM. When asked if that seemed significant to him, he said yes. When asked if he looked further into the time discrepancy during his investigation, he said no. When asked when a report of pain should be reported, he said staff should report immediately. When asked if any in-services were conducted with the CNA's following the incident, he said he was not sure. When asked if during his investigation, he found that pain monitoring and pain intervention for Resident #1 was not done, he said no. In an interview with the ADM on 7/7/2014 at 6:20 PM, when asked why he thought this immediate jeopardy came about, he said they didn't match the actual timeframe to what actually happened and did not get it written down in a significant amount of time. He also said, she had surgery so significant harm occurred. He said he was made aware of the incident on 6/17/2014. He said he called the DON and got her to give him all the documentation and he talked to the nurse to find out basically what occurred. When asked if he felt the incident was thoroughly investigated, he said "not as much as I'd like." When asked if he felt the nursing staff appropriately monitored and assessed Resident #1's pain appropriately, he said "no, I don't think it was." When asked, other than Resident #1's scheduled pain medication of 25 mg [MEDICATION NAME], three times daily and two 325mg Tylenol at 10:20 PM, did the staff provide any intervention for Resident #1's pain, he said no. When asked if he was aware of any deformity in Resident #1's leg prior to her being transferred to the hospital, he said no. When asked, from the time Resident #1 first complained of pain to the time she was transferred to the hospital at 11:30 PM, was that an appropriate timeframe, he said no. When asked if the charge nurse should notify the direct care staff if a resident had complained of pain and there was an MD order for an x-ray, he said yes. Record review of the facility's "Pain Evaluation" policy and procedure read in part; "Documentation - The person performing this evaluation should record the following information in the resident's medical record. The date and time the evaluation was performed. The name and title of the individual(s) who performed the procedure. Document assessment of pain when prn pain medication is required. All assessment data obtained during the procedure including location of pain, description of site if indicated, level of pain using the appropriate pain scale, and type of pain relief used. Reassessment of pain and the resident's response to the pain relief used." This document was dated 5/22/2013. An Immediate Jeopardy was identified on 7/3/2014 at 12:54 PM and the ADM was notified at that time. A plan of removal was submitted and after some revisions was accepted on 7/7/2014 at 6:40 PM. Summary of the Plan of Action to Remove Immediate Jeopardy: Licensed staff was educated on performing Pain Assessment to include treatment, pain management, proper documentation and monitoring. Licensed staff evaluated all resident to ascertain if pain exist and will treat appropriately. a. Based on the resident pain evaluation there were no residents that exhibited or needed treatment for [REDACTED]. b. West Janisch nursing administration IDT evaluated each resident on 7/3/2014 for pain by utilizing verbal, non-verbal cue to determine if pain existed. d. Inservices were completed on 7/3/2014 with 73% of participant educated. All staff that was not educated on this date will be required to complete education and sign for completion prior to returning to work. This would include all staff on vacation, workman comp, sick leave and those unable to be contacted. Completion date: 7/4/2014. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Record Reviews as follows: -In-service Training records for abuse/neglect, pain management and transfers for all nursing staff, to include nurse managers, CNA's and medicaiton aides. Training was provided by the CRN. 90 staff signed in for abuse/neglect in-services, 21 staff signed in for pain management in-services, 58 staff signed in for transfers in-services. - In-service for abuse and neglect to include conducting a thorough investigation was conducted with the ADM. This training was provided by the CRN. -Intervention audits of residents with pain. Interviews as follows: - Six nursing staff to include LVN nursing managers and CNA's to determine if they were familiar with abuse/neglect and pain assessment/treatment policies and pain reporting procedures, as well as what to do in the event a similar incident to the IJ occurred. - Resident interviews to determine if they had any issues related to pain. Observations as follows: - Six random observations with CNA's of resident transfers. The Administrator was informed on 7/7/2014 at 6:50 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. According to the facility's CMS Form 672, the census was 88.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property for 1 of 12 residents (Resident #1) reviewed for abuse and neglect. -Resident #1 expressed pain in her leg following a transfer from her bed to the shower chair at 9:30 AM. CNA's A and B failed to notify the nurse of the resident's pain until 1:00 PM. -Two CNA's (CNA A and CNA B) continued to transfer the resident for a shower and had the resident stand and bear weight before nursing staff was notified. -Resident #1 did not receive appropriate pain assessments or pain intervention after the nursing staff was notified. -The nurse on the 2:00 PM - 10:00 PM shift failed to notify the direct care staff on that shift of Resident #1's condition, which resulted in CNA C and another staff member transferring Resident #1 from her wheelchair to her bed. Following this transfer Resident #1 began to cry due to the pain. -The resident was transferred to the hospital at 11:30 pm following an x-ray which identified the source of pain as a displaced spiral femur fracture. -Following the report of an injury of an unknown source, the Administrator failed to conduct a thorough investigation of the injury and implemented no corrective actions. An Immediate Jeopardy was identified on 7/3/2014 at 12:54PM. While the IJ was removed on 7/7/2014, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed the remaining 88 residents currently residing in the facility at risk by failing to comply with state laws and failing to protect residents from potential abuse, neglect and/or mistreatment. Findings include: Incident # 6 Record review of the facility's "Abuse and Neglect Policy" read in part; "Policy: Abuse, as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardians, friends or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. Definitions: Neglect - The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the resident. ...Investigative Issues: Policy - Any employee having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately. Procedure - Any and all staff observing or hearing about such events must report the event immediately to the Abuse Prevention Coordinator or Administrator. The event should also be reported immediately to the employee's supervisor. ...Policy - All events reported as possible abuse will be investigated to determine whether abuse did nor (sic) did not take place. Procedure - The Abuse/Neglect Prevention Coordinator will initiate investigative action immediately. The Administrator of the center, the Director of Nurses and/or the Social Worker (Abuse Prevention Coordinator) will be notified of the complaint immediately and action being taken immediately or within 24 hours of reporting to DADS consumer rights division." This document was not dated. Record review of Resident #1's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. This resident was [AGE] years of age. Record review of the facility's "Provider Investigation Report" revealed the incident occurred on 6/16/2014 at 9:30 AM and read in part; "...Description of injury: Unknown fx to left fibula. ...Investigation Summary: On 6/16/2014 (Resident #1) was being provided care by two certified nursing aides when she began complaining of pain to her left leg. The certified nursing aides notified the charge nurse (LVN B). (LVN B) did an assessment and notified the attending physician of her condition. The attending physician gave an order to have her left leg x-rayed to rule out fracture. The results were that (Resident #1) had an acute displaced spiral oblique francture (sic) of the dismal (sic) femoral shaft. (Resident #1) was transferred to the hospital. The Charge Nurse who indicated that she was not award (sic) of any incident involving (Resident #1), only that she assessed and made required notifications and transferred. The two certified nursing assistants, (CNA A) and (CNA B) wasn't aware (sic) of any situation involving the incident, only that they notified the Charge Nurse of her complaint. The internal investigation was performed with no definite indication as to what had occurred. There were no witnesses to the fracture therefore I was unable to determine the orgin (sic) of the fracture. ...Provider Action Taken Post-Investigation: Inservice staff on closely monitoring (Resident #1) going forward and continue to make notification if a resident complains." This document was signed by The ADM and dated 6/20/2014. Record review of the facility's "Incident Report" dated 6/17/2014 revealed Resident #1 was transported to the hospital at 11:30 PM on 6/16/2014. This document was signed by LVN B. Record review of Resident #1's "Nurses Notes" read in part; "6/16/2014 at 2:30 PM - Around 1:00 PM this day staff reported to this nsg (sic) that resident complained of pain to L knee when transferring her. ...(Physician) was called a n/o was given for x-ray to L knee, RP was called, no answer, a message was left on her voice machine. ...6/16/2014 at 10:20 PM - Resident given Tylenol 325mg tabs two by mouth for pain." Record review of Resident #1's June 2014 MAR indicated [REDACTED]. [MEDICATION NAME], 50 mg, one-half tablet (25mg) by mouth three times daily. This document also revealed on 6/16/2014, Resident #1 was documented as having received only one dose of [MEDICATION NAME]. Record review of Resident #1's "Pain Assessment" revealed she was experiencing a pain level of 9 on a scale of 0-10. This document was written by LVN B, had no time and was not dated. Record review of Resident #1's clinical record revealed no documentation of additional pain assessments related to the incident on 6/16/2014. Record review Resident #1's hospital records read in part; "Clinical Report - ...History of Present Illness: Chief Complaint (left femur injury). The injury occurred yesterday. Occurred at a nursing home. Pt had images performed which confirmed left distal femoral fracture. Staff unsure how this happened. Daughter is very upset by not knowing what happened to cause fracture. ...The patient complains of moderate pain. No neck pain or loss of consciousness. (Transport unit says leg had deformity and decreased pulses so pulled straight and put in hare traction splint)." This document was dated 6/17/2014. Record review of the written statement from CNA A read; " On June 16, 2014, at 9:30 AM, I (CNA A) and (CNA B) transferred (Resident #1) from her bed to the shower chair to give her a shower, she complained about leg pain so I reported her pain to the charge nurse (LVN A). This document was signed by CNA A and dated 6/16/2014. Record review of the written statement from CNA B read; "June 16, 2014 at 9:30 AM, I (CNA B) assisted (CNA A) in transferring (Resident #1) from her bed to the shower chair for her shower. (Resident #1) complain (sic) of pain so we reported her pain to the charge nurse (LVN A)." This document was signed by CNA B and dated 6/16/2014. In an interview with CNA A on 7/2/2014 at 1:18 PM when asked about the incident with Resident #1, she said she went to Resident #1's room around 9:30 AM, to take her to the shower. She said she and CNA B transferred Resident #1 from her bed to the shower chair. She said following the transfer Resident #1 complained of leg pain. She then said she proceeded to take the resident to the shower room and had intended to report the resident's pain to nurse but there was no nurse at the nurse's station so she continued to the shower room. She said following the shower, she took Resident #1 back to her room, then she and CNA B transferred her from the shower chair to her wheelchair. She then said she and CNA B stood the resident up to pull up her brief and pants and then sat her back down in the wheelchair to finish getting the resident dressed. She also said the resident again complained of pain after the CNA's stood the resident up to dress her. She then said she took Resident #1 to the dining room for lunch. She then said following lunch she saw Resident #1 sitting in her wheelchair in the dining room and realized she had not reported the resident's pain to the nurse yet. She said she then reported Resident #1's pain to LVN A at around 12:30 PM. When asked why she did not notify the nurse prior to giving the resident a shower, she said there was no nurse at the nurse ' s station. When asked why she did not send another CNA to find a nurse, she did not have an answer. In an interview with CNA B on 7/3/2014 at 12:40 PM when asked about the incident with Resident #1, she said CNA A has asked her to assist with the transfer of Resident #1 from her bed to the shower chair. When asked if the resident at any point during the transfer had supported her own weight, she said yes. She then said, following the transfer the resident made an "ugh" sound and made a "pain face". She then said that CNA A told her that she would notify the nurse on the way to the shower. She then said she went back to her own duties. She said CNA A called her again after the Resident ' s shower to assist with a transfer and dressing of the resident. She said they dried the resident off and stood the resident up to put on her brief and pull up her pants. She then said the resident complained of pain. When asked what should be done if a resident makes a complaint of pain, she said report to the nurse immediately. In an interview with CNA C on 7/3/2014 at 4:35 PM, she said at about 7:00 PM on 6/16/2014 she and another CNA transferred Resident #1 to her bed from her wheelchair. She said during the transfer the resident said "Ah!" and she asked Resident #1 what was wrong and she began to cry. She said she reported this to the LVN B and was told about the resident's previous reports of pain. When asked if she was told by LVN B at the start of her shift at 2:00 PM about Resident #1's pain, she said no. In an interview with LVN A on 7/2/2014 at 1:36 PM when asked about the incident with Resident #1, she said she first became aware of Resident #1's pain at 1:00 PM from CNA A. She said CNA A told her she had forgotten to report the resident's pain earlier. She then said she immediately went to assess Resident #1 and the resident pointed to her knee when asked about her pain. She said "I touched her knee and she confirmed the pain". She also said about two minutes later she asked the resident again about her pain and she said the resident denied pain at that time. She said she then called the physician and received an order for [REDACTED]. When asked if she administered any pain medications to Resident #1 to relieve her pain, she said no, because Resident #1 reported no pain the second time she asked her. When asked if she assessed Resident #1's entire leg for pain, she said no, she only assessed the resident's knee. In an interview with LVN B on 7/3/2014 at 4:50 PM, when asked about the incident with Resident #1, she said she did conduct the pain assessment on Resident #1 when she reported a pain level of 9 on a scale of 0-10. She said she conducted the pain assessment on 6/16/2014 at about 9:00 PM after CNA C reported to her that Resident #1 reported pain during her transfer from her wheelchair to the bed. She said she also administered two 325mg Tylenol following the assessment. She said Resident #1 never complained of pain to her prior to that during her shift. She said she did periodically check on the resident during the shift but did not document it. She said she was told during shift change by LVN A that Resident #1 was experiencing pain and that the MD was notified and an x-ray had been ordered. When asked if she had told CNA C about Resident #1's reported pain and that an x-ray had been ordered, she said no. In an interview with the DON on 7/3/2014 at 2:30 PM, when asked what could happen if after a resident complained of pain, they were transferred again and made to bear weight, she said "could be a fracture". When asked if after Resident #1 reported pain to the CNA's, should the resident had been given a shower and transferred again? She said she could not answer that question. In an interview with Resident #1's daughter on 7/2/2014 at 2:38 PM when asked about Resident #1's course of treatment following her transfer to the hospital, she said her mother had surgery on 6/18/2014 to repair the fracture. She had a rod and screws placed in her leg to repair the fracture. In an interview with the DON on 7/7/2014 at 5:45 PM, when asked if from the time Resident #1's pain had been reported to LVN A had any pain monitoring been conducted, she said other than the one pain assessment when Resident #1 reported a pain level of 9, she did not find any pain monitoring. She also said other than the Tylenol at 10:20 PM and her scheduled 25 mg [MEDICATION NAME], she did not find any documentation that any pain intervention was conducted. When asked if she was aware of any deformity in Resident #1's leg, she said no. When asked if LVN B should have made Resident #1's direct care staff aware of her pain, she said, normally she would tell her CNA's don ' t touch or move the resident because they were waiting on an x-ray. When asked how she thought this incident came about, she said "You're asking me to speculate. I only have their word, I wasn't there. When they got her up to shower, something happened to her body." In an interview with the ADM on 7/2/2014 at 4:32 PM, when asked who conducted the investigation related to the incident with Resident #1, he said "I did". When asked if he interviewed the CNA's involved in the incident, he said the DON interviewed the CNA's. When asked, during his investigation, if he found any problems related to the timeline on the day of the incident, he said the nurse said she called the doctor at 2:00 PM and the incident occurred at 9:30 AM. He said the nurse was notified around 1:30 PM. When asked if that seemed significant to him, he said yes. When asked if he looked further into the time discrepancy during his investigation, he said no. When asked when a report of pain should be reported, he said staff should report immediately. When asked if any in-services were conducted with the CNA ' s following the incident, he said he was not sure. When asked if during his investigation, he found that pain monitoring and pain intervention for Resident #1 was not done, he said no. In an interview with the ADM on 7/7/2014 at 6:20 PM, when asked why he thought this immediate jeopardy came about, he said they didn't match the actual timeframe to what actually happened and did not get it written down in a significant amount of time. He also said, she had surgery so significant harm occurred. He said he was told about the incident on 6/17/2014. He said he called the DON and got her to give him all the documentation and he talked to the nurse to find out basically what occurred. When asked if he felt the incident was thoroughly investigated, he said "not as much as I'd like." When asked if he felt the nursing staff appropriately monitored and assessed Resident #1's pain appropriately, he said "no, I don't think it was." When asked, other than Resident #1's scheduled pain medication of 25 mg [MEDICATION NAME], three times daily and two 325mg Tylenol at 10:20 PM, did the staff provide any intervention for Resident #1's pain, he said no. When asked if he was aware of any deformity in Resident #1's leg prior to her being transferred to the hospital, he said no. When asked, from the time Resident #1 first complained of pain to the time she was transferred to the hospital at 11:30 PM, was that an appropriate timeframe, he said no. When asked if the charge nurse should notify the direct care staff if a resident had complained of pain and there was an MD order for an x-ray, he said yes. Record review of the facility's "Pain Evaluation" policy and procedure read in part; "Documentation - The person performing this evaluation should record the following information in the resident's medical record. The date and time the evaluation was performed. The name and title of the individual(s) who performed the procedure. Document assessment of pain when prn pain medication is required. All assessment data obtained during the procedure including location of pain, description of site if indicated, level of pain using the appropriate pain scale, and type of pain relief used. Reassessment of pain and the resident's response to the pain relief used." This document was dated 5/22/2013. An Immediate Jeopardy was identified on 7/3/2014 at 12:54 PM and the ADM was notified at that time. A plan of removal was submitted and after some revisions was accepted on 7/7/2014 at 6:40 PM. Summary of the Plan of Action to Remove Immediate Jeopardy: Facility will in-service staff on Abuse, Neglect and Exploitation with emphasis on providing necessary, timely communication to the supervisor or the Abuse Coordinator. In addition the following areas were covered including: Abuse, Neglect, Exploitation, verbal abuse, sexual abuse, mental abuse, involuntary seclusion and Misappropriation of Residents property. a. Certified Nursing Aides were in serviced on change of condition including recognizing nonverbal pain and how to respond to non-verbal and verbal pain in a timely manner to preclude further injury to resident. b. All investigations will be conducted by the Administrator or Abuse Coordinator according to DADS Provider letter 06-43 and the facility Abuse and Neglect Policy and Procedure. c. The two (2) staff that were involved with the incident occurring on 6/16/2014 were terminated for failure to notify charge nurse of incident in a timely manner. d. In-services were completed on 7/3/2014 with 73% of participant educated. All staff that was not educated on this date will be required to complete education and sign for completion prior to returning to work. This would include all staff on vacation, workman comp, sick leave and those unable to be contacted. e. Additional in-service was completed on properly completing Internal Investigation and Resident Investigation Forms by licensed staff. Properly Techniques to include: Transferring the resident from bed to chair, utilizing lifting machine, Active transferring, independent, standing pivot transfer (assisted) and dependent transfer. f. All incident reports 30 days or less will be reviewed for completion and appropriate interventions. Completed on 7/5/2014 g. The Administrator was educated on Abuse, Neglect and exploitation which included the effective process of evaluating a complaint, effective gathering of information, assessing information, interviewing identified residents and staff, protection of residents and the timely procedure to ensure DADS is notified. This training was provided by the CRN. Completion date: 7/4/2014. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Record Reviews as follows: -In-service Training records for abuse/neglect, pain management and transfers for all nursing staff, to include nurse managers, CNA's and medicaiton aides. Training was provided by the CRN. 90 staff signed in for abuse/neglect in-services, 21 staff signed in for pain management in-services, 58 staff signed in for transfers in-services. - In-service for abuse and neglect to include conducting a thorough investigation was conducted with the ADM. This training was provided by the CRN. -Intervention audits of residents with pain. Interviews as follows: - Six nursing staff to include LVN nursing managers and CNA's to determine if they were familiar with abuse/neglect and pain assessment/treatment policies and pain reporting procedures, as well as what to do in the event a similar incident to the IJ occurred. - Resident interviews to determine if they had any issues related to pain. Observations as follows: - Six random observations with CNA's of resident transfers. The Administrator was informed on 7/7/2014 at 6:50 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. According to the facility's CMS Form 672, the census was 88.

Based on interview and record review, the facility failed to ensure services provided or arranged by the facility met professional standards of quality for 1 of 9 residents (Resident #1) reviewed for pain. Resident #1 expressed pain in her leg following a transfer from her bed to the shower chair at 9:30 AM. CNA's A and B failed to notify the nurse of the resident's pain until 1:00 PM. After the nurse was notified, Resident #1 did not receive appropriate pain assessments or pain intervention. The nurse on the 2:00 PM - 10:00 PM shift failed to notify the direct care staff on that shift and at 7:00 PM, CNA C and another staff member transferred Resident #1 from her wheelchair to her bed. Following this transfer Resident #1 began to cry due to the pain. The resident was transferred to the hospital following an x-ray at approximately 11:30 PM. An Immediate Jeopardy was identified on 7/3/2014 at 12:54PM. While the IJ was removed on 7/7/2014, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. This failure affected one resident and placed the remaining 44 residents in the facility at risk of not receiving adequate pain assessments, pain intervention, and/or decline in health status. Findings include: Incident # 6 According to http://www.bon.state.tx.us/olv/ The Texas Board of Nursing Rule 217.11 Standards of Nursing Practice read in part: " . . . The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization . . . (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ... (B) Implement measures to promote a safe environment for clients and others; ... (M)Institute appropriate nursing interventions that might be required to stabilize a client ' s condition and/or prevent complications; ... (2) Standards Specific to Vocational Nurses. ... (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by:... (i) collecting data and performing focused nursing assessments;... (iv) implementing appropriate aspects of care within the LVN ' s scope of practice; and ... (v) assisting in the evaluation of the client ' s responses to nursing interventions and the identification of client needs; ... (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client; (ii) making nursing [DIAGNOSES REDACTED]. (iii) developing a plan of care based on the assessment and nursing diagnosis; (iv) implementing nursing care; and (v) evaluating the client ' s responses to nursing interventions; ..." Record review of the facility's "Pain Evaluation" policy and procedure read in part; "Documentation - The person performing this evaluation should record the following information in the resident's medical record. The date and time the evaluation was performed. The name and title of the individual(s) who performed the procedure. Document assessment of pain when prn pain medication is required. All assessment data obtained during the procedure including location of pain, description of site if indicated, level of pain using the appropriate pain scale, and type of pain relief used. Reassessment of pain and the resident's response to the pain relief used." This document was dated 5/22/2013. Record review of Resident #1's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. This resident was [AGE] years of age. Record review of the facility's "Provider Investigation Report" revealed the incident occurred on 6/16/2014 at 9:30 AM and read in part; "...Description of injury: Unknown fx to left fibula. ...Investigation Summary: On 6/16/2014 (Resident #1) was being provided care by two certified nursing aides when she began complaining of pain to her left leg. The certified nursing aides notified the charge nurse (LVN A). (LVN A) did an assessment and notified the attending physician of her condition. The attending physician gave and order to have her left leg x-rayed to rule out fracture. The results were that (Resident #1) had an acute displaced spiral oblique francture (sic) of the dismal (sic) femoral shaft. (Resident #1) was transferred to the hospital. The Charge Nurse who indicated that she was not award (sic) of any incident involving (Resident #1), only that she assessed and make required notifications and transferred. The two certified nursing assistants, (CNA A) and (CNA B) wasn't aware (sic) of any situation involving the incident, only that they notified the Charge Nurse of her complaint. The internal investigation was performed with no definite indication as to what had occurred. There were no witnesses to the fracture therefore I was unable to determine the orgin (sic) of the fracture. ...Provider Action Taken Post-Investigation: Inservice staff on closely monitoring (Resident #1) going forward and continue to make notification if a resident complains." This document was signed by The ADM and dated 6/20/2014. Record review of the facility's "Incident Report" dated 6/17/2014 revealed Resident #1 was transported to the hospital at 11:30 PM on 6/16/2014. This document was signed by LVN B. Record review of Resident #1's "Nurses Notes" read in part; "6/16/2014 at 2:30 PM - Around 1:00 PM this day staff reported to this nsg (sic) that resident complained of pain to L knee when transferring her. ...(Physician) was called a n/o was given for x-ray to L knee, RP was called, no answer, a message was left on her voice machine. ...6/16/2014 at 10:20 PM - Resident given Tylenol 325mg tabs two by mouth for pain." Record review of Resident #1's June 2014 MAR indicated [REDACTED]. [MEDICATION NAME], 50 mg, one-half tablet (25mg) by mouth three times daily. This document also revealed on 6/16/2014, Resident #1 was documented as having received only one dose of [MEDICATION NAME]. Record review of Resident #1's "Pain Assessment" revealed she was experiencing a pain level of 9 on a scale of 0-10. This document was written by LVN B, had no time and was not dated. Record review of Resident #1's clinical record revealed no documentation of additional pain assessments related to the incident on 6/16/2014. Record review Resident #1's hospital records read in part; "Clinical Report - ...History of Present Illness: Chief Complaint (left femur injury). The injury occurred yesterday. Occurred at a nursing home. Pt had images performed which confirmed left distal femoral fracture. Staff unsure how this happened. Daughter is very upset by not knowing what happened to cause fracture. ...The patient complains of moderate pain. No neck pain or loss of consciousness. (Transport unit says leg had deformity and decreased pulses so pulled straight and put in hare traction splint)." This document was dated 6/17/2014. Record review of the written statement from CNA A read; " On June 16, 2014, at 9:30 AM, I (CNA A) and (CNA B) transferred (Resident #1) from her bed to the shower chair to give her a shower, she complained about leg pain so I reported her pain to the charge nurse (LVN A). This document was signed by CNA A and dated 6/16/2014. In an interview with CNA A on 7/2/2014 at 1:18 PM when asked about the incident with Resident #1, she said she went to Resident #1's room around 9:30 AM, to take her to the shower. She said she and CNA B transferred Resident #1 from her bed to the shower chair. She said following the transfer Resident #1 complained of leg pain. She then said she proceeded to take the resident to the shower room and had intended to report the resident's pain to nurse but there was no nurse at the nurse's station so she continued to the shower room. She said following the shower, she took Resident #1 back to her room, then she and CNA B transferred her from the shower chair to her wheelchair. She then said she and CNA B stood the resident up to pull up her brief and pants and then sat her back down in the wheelchair to finish getting the resident dressed. She also said the resident again complained of pain after the CNA's stood the resident up to dress her. She then said she took Resident #1 to the dining room for lunch. She then said following lunch she saw Resident #1 sitting in her wheelchair in the dining room and realized she had not reported the resident's pain to the nurse yet. She said she then reported Resident #1's pain to LVN A at around 12:30 PM. When asked why she did not notify the nurse prior to giving the resident a shower, she said there was no nurse at the nurse's station. When asked why she did not send another CNA to find a nurse, she did not have an answer. In an interview with CNA C on 7/3/2014 at 4:35 PM, she said at about 7:00 PM on 6/16/2014 she and another CNA transferred Resident #1 to her bed from her wheelchair. She said during the transfer the resident said "Ah!" and she asked Resident #1 what was wrong and she began to cry. She said she reported this to the LVN B and was told about the resident's previous reports of pain. When asked if she was told by LVN B at the start of her shift at 2:00 PM about Resident #1's pain, she said no. In an interview with LVN A on 7/2/2014 at 1:36 PM when asked about the incident with Resident #1, she said she first became aware of Resident #1's pain at 1:00 PM from CNA A. She said CNA A told her she had forgotten to report the resident's pain earlier. She then said she immediately went to assess Resident #1 and the resident pointed to her knee when asked about her pain. She said "I touched her knee and she confirmed the pain". She also said about two minutes later she asked the resident again about her pain and she said the resident denied pain at that time. She said she then called the physician and received an order for [REDACTED]. When asked if she administered any pain medications to Resident #1 to relieve her pain, she said no, because Resident #1 reported no pain the second time she asked her. When asked if she assessed Resident #1's entire leg for pain, she said no, she only assessed the resident's knee. In an interview with LVN B on 7/3/2014 at 4:50 PM, when asked about the incident with Resident #1, she said she did conduct the pain assessment on Resident #1 when she reported a pain level of 9 on a scale of 0-10. She said she conducted the pain assessment on 6/16/2014 at about 9:00 after CNA C reported to her that Resident #1 reported pain during her transfer from her wheelchair to the bed. She said she also administered two 325mg Tylenol following the assessment. She said Resident #1 never complained of pain to her prior to that during her shift. She said she did periodically check on the resident during the shift but did not document it. She said she was told during shift change by LVN A that Resident #1 was experiencing pain and that the MD was notified and an x-ray had been ordered. When asked if she had told CNA C about Resident #1's reported pain and that an x-ray had been ordered, she said no. In an interview with the DON on 7/3/2014 at 2:30 PM, when asked what could happen if after a resident complained of pain, they were transferred again and made to bear weight, she said "could be a fracture". When asked if after Resident #1 reported pain to the CNA's, should the resident had been given a shower and transferred again? She said she could not answer that question. In an interview with Resident #1's daughter on 7/2/2014 at 2:38 PM when asked about Resident #1's course of treatment following her transfer to the hospital, she said her mother had surgery on 6/18/2014 to repair the fracture. She had a rod and screws placed in her leg to repair the fracture. In an interview with the DON on 7/7/2014 at 5:45 PM, when asked if from the time Resident #1's pain had been reported to LVN A had any pain monitoring been conducted, she said other than the one pain assessment when Resident #1 reported a pain level of 9, she did not find any pain monitoring. She also said other than the Tylenol at 10:20 PM and her scheduled 25 mg [MEDICATION NAME], she did not find any documentation that any pain intervention was conducted. When asked if she was aware of any deformity in Resident #1's leg, she said no. When asked if LVN B should have made Resident #1's direct care staff aware of her pain, she said, normally she would tell her CNA's don't touch or move the resident because they were waiting on an x-ray. When asked how she thought this incident came about, she said "You're asking me to speculate. I only have their word, I wasn't there. When they got her up to shower, something happened to her body." In an interview with the ADM on 7/2/2014 at 4:32 PM, when asked who conducted the investigation related to the incident with Resident #1, he said "I did". When asked if he interviewed the CNA's involved in the incident, he said the DON interviewed the CNA's. When asked, during his investigation, if he found any problems related to the timeline on the day of the incident, he said the nurse said she called the doctor at 2:00 PM and the incident occurred at 9:30 AM. He said the nurse was notified around 1:30 PM. When asked if that seemed significant to him, he said yes. When asked if he looked further into the time discrepancy during his investigation, he said no. When asked when a report of pain should be reported, he said staff should report immediately. When asked if any in-services were conducted with the CNA's following the incident, he said he was not sure. When asked if during his investigation, he found that pain monitoring and pain intervention for Resident #1 was not done, he said no. In an interview with the ADM on 7/7/2014 at 6:20 PM, when asked if he felt the nursing staff appropriately monitored and assessed Resident #1's pain appropriately, he said "no, I don't think it was." When asked, other than Resident #1's scheduled pain medication of 25 mg [MEDICATION NAME], three times daily and two 325mg Tylenol at 10:20 PM, did the staff provide any intervention for Resident #1's pain, he said no. When asked if he was aware of any deformity in Resident #1's leg prior to her being transferred to the hospital, he said no. When asked, from the time Resident #1 first complained of pain to the time she was transferred to the hospital at 11:30 PM, was that an appropriate timeframe, he said no. When asked if the charge nurse should notify the direct care staff if a resident had complained of pain and there was an MD order for an x-ray, he said yes. An Immediate Jeopardy was identified on 7/3/2014 at 12:54 PM and the ADM was notified at that time. A plan of removal was submitted and after some revisions was accepted on 7/7/2014 at 6:40 PM. Summary of the Plan of Action to Remove Immediate Jeopardy: Licensed staff was educated on performing Pain Assessment to include treatment, pain management, proper documentation and monitoring. Licensed staff evaluated all resident to ascertain if pain exist and will treat appropriately. a. Based on the resident pain evaluation there were no residents that exhibited or needed treatment for [REDACTED]. b. West Janisch nursing administration IDT evaluated each resident on 7/3/2014 for pain by utilizing verbal, non-verbal cue to determine if pain existed. d. Inservices were completed on 7/3/2014 with 73% of participant educated. All staff that was not educated on this date will be required to complete education and sign for completion prior to returning to work. This would include all staff on vacation, workman comp, sick leave and those unable to be contacted. This training was provided by the CRN. Completion date: 7/4/2014. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Record Reviews as follows: -In-service Training records for abuse/neglect, pain management and transfers for all nursing staff, to include nurse managers, CNA's and medicaiton aides. Training was provided by the CRN. 90 staff signed in for abuse/neglect in-services, 21 staff signed in for pain management in-services, 58 staff signed in for transfers in-services. -Intervention audits of residents with pain. Interviews as follows: - Six nursing staff to include LVN nursing managers and CNA's to determine if they were familiar with abuse/neglect and pain assessment/treatment policies and pain reporting procedures, as well as what to do in the event a similar incident to the IJ occurred. - Resident interviews to determine if they had any issues related to pain. The Administrator was informed on 7/7/2014 at 6:50 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. Refer to F309 for additional evidence. According to the facility's CMS Form 802, there were 44 residents identified as having moderate/severe pain.

Based on interview and record review, the Administrator and Director of Nurses failed to effectively and efficiently manage facility resources resulting in system failures which resulted in immediate jeopardies in the areas of Quality of Care and Resident Behaviors and Facility Practice. The Administrator failed to: Related to Immediate Jeopardy/SQC: Supervise and monitor the DON to ensure she carried out her responsibilities in the areas of assessments and monitoring of medical conditions. Carry out his responsibilities as abuse prevention coordinator by not thoroughly investigating an incident involving an injury of an unknown source. Failed to implement the facility's policy and procedure to prohibit neglect. The DON failed to: Related to Immediate Jeopardy/SQC: Ensure that staff were adequately monitoring residents for pain and potential injuries of unknown origin. Ensure that staff were providing interventions to treat pain and actual or potential injuries of unknown origin. Ensure the staff were appropriately treating resident conditions and providing adequate ADL care. Charge Nurse, LVN B failed to: Related to Immediate Jeopardy/SQC: Communicate information related to Resident #1's pain to the direct care staff responsible for the care of the Resident. As a direct result, CNA C transferred Resident #1 from her wheelchair to her bed causing pain to the Resident. An Immediate Jeopardy was identified on 7/3/2014 at 12:54PM. While the IJ was removed on 7/7/2014, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. These failures of the Administrator and the DON affected one resident and placed all 88 residents at risk for not receiving the necessary care and services to maintain the highest practicable well-being. Findings include: Incident # 6 Record review of Resident #1's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the facility's "Provider Investigation Report" revealed the incident occurred on 6/16/2014 at 9:30 AM and read in part; "...Description of injury: Unknown fx to left fibula. ...Investigation Summary: On 6/16/2014 (Resident #1) was being provided care by two certified nursing aides when she began complaining of pain to her left leg. The certified nursing aides notified the charge nurse (LVN B). (LVN B) did an assessment and notified the attending physician of her condition. The attending physician gave and order to have her left leg x-rayed to rule out fracture. The results were that (Resident #1) had an acute displaced spiral oblique francture (sic) of the dismal (sic) femoral shaft. (Resident #1) was transferred to the hospital. The Charge Nurse who indicated that she was not award (sic) of any incident involving (Resident #1), only that she assessed and make required notifications and transferred. The two certified nursing assistants, (CNA A) and (CNA B) wasn't aware (sic) of any situation involving the incident, only that they notified the Charge Nurse of her complaint. The internal investigation was performed with no definite indication as to what had occurred. There were no witnesses to the fracture therefore I was unable to determine the orgin (sic) of the fracture. ...Provider Action Taken Post-Investigation: Inservice staff on closely monitoring (Resident #1) going forward and continue to make notification if a resident complains." This document was signed by The ADM and dated 6/20/2014. Record review of the facility's "Incident Report" dated 6/17/2014 revealed Resident #1 was transported to the hospital at 11:30 PM on 6/16/2014. This document was signed by LVN B. Record review of Resident #1's "Nurses Notes" read in part; "6/16/2014 at 2:30 PM - Around 1:00 PM this day staff reported to this nsg (sic) that resident complained of pain to L knee when transferring her. ...(Physician) was called a n/o was given for x-ray to L knee, RP was called, no answer, a message was left on her voice machine. ...6/16/2014 at 10:20 PM - Resident given Tylenol 325mg tabs two by mouth for pain." Record review of Resident #1's June 2014 MAR indicated [REDACTED]. [MEDICATION NAME], 50 mg, one-half tablet (25mg) by mouth three times daily. This document also revealed on 6/16/2014, Resident #1 was documented as having received only one dose of [MEDICATION NAME]. Record review of Resident #1's "Pain Assessment" revealed she was experiencing a pain level of 9 on a scale of 0-10. This document had no time and was not dated. Record review of Resident #1's clinical record revealed no documentation of additional pain assessments related to the incident on 6/16/2014. Record review Resident #1's hospital records read in part; "Clinical Report - ...History of Present Illness: Chief Complaint (left femur injury). The injury occurred yesterday. Occurred at a nursing home. Pt had images performed which confirmed left distal femoral fracture. Staff unsure how this happened. Daughter is very upset by not knowing what happened to cause fracture. ...The patient complains of moderate pain. No neck pain or loss of consciousness. (Transport unit says leg had deformity and decreased pulses so pulled straight and put in hare traction splint)." This document was dated 6/17/2014. Record review of the written statement from CNA A read; " On June 16, 2014, at 9:30 AM, I (CNA A) and (CNA B) transferred (Resident #1) from her bed to the shower chair to give her a shower, she complained about leg pain so I reported her pain to the charge nurse (LVN A). This document was signed by CNA A and dated 6/16/2014. Record review of the written statement from CNA B read; "June 16, 2014 at 9:30 AM, I (CNA B) assisted (CNA A) in transferring (Resident #1) from her bed to the shower chair for her shower. (Resident #1) complain (sic) of pain so we reported her pain to the charge nurse (LVN A)." This document was signed by CNA B and dated 6/16/2014. In an interview with CNA A on 7/2/2014 at 1:18 PM when asked about the incident with Resident #1, she said she went to Resident #1's room around 9:30 AM, to take her to the shower. She said she and CNA B transferred Resident #1 from her bed to the shower chair. She said following the transfer Resident #1 complained of leg pain. She then said she proceeded to take the resident to the shower room and had intended to report the resident's pain to nurse but there was no nurse at the nurse's station so she continued to the shower room. She said following the shower, she took Resident #1 back to her room, then she and CNA B transferred her from the shower chair to her wheelchair. She then said she and CNA B stood the resident up to pull up her brief and pants and then sat her back down in the wheelchair to finish getting the resident dressed. She also said the resident again complained of pain after the CNA's stood the resident up to dress her. She then said she took Resident #1 to the dining room for lunch. She then said following lunch she saw Resident #1 sitting in her wheelchair in the dining room and realized she had not reported the resident's pain to the nurse yet. She said she then reported Resident #1's pain to LVN A at around 12:30 PM. When asked why she did not notify the nurse prior to giving the resident a shower, she said there was no nurse at the nurse's station. When asked why she did not send another CNA to find a nurse, she did not have an answer. In an interview with CNA B on 7/3/2014 at 12:40 PM when asked about the incident with Resident #1, she said CNA A has asked her to assist with the transfer of Resident #1 from her bed to the shower chair. When asked if the resident at any point during the transfer had supported her own weight, she said yes. She then said, following the transfer the resident made an "ugh" sound and made a "pain face". She then said that CNA A told her that she would notify the nurse on the way to the shower. She then said she went back to her own duties. She said CNA A called her again after the Resident ' s shower to assist with a transfer and dressing of the resident. She said they dried the resident off and stood the resident up to put on her brief and pull up her pants. She then said the resident complained of pain. When asked what should be done if a resident makes a complaint of pain, she said report to the nurse immediately. In an interview with CNA C on 7/3/2014 at 4:35 PM, she said at about 7:00 PM on 6/16/2014 she transferred Resident #1 to her bed from her wheelchair. She said during the transfer the resident said "Ah!" and she asked Resident #1 what was wrong and she began to cry. She said she reported this to the LVN B and was told about the resident's previous reports of pain. When asked if she was told by LVN B at the start of her shift at 2:00 PM about Resident #1's pain, she said no. In an interview with LVN A on 7/2/2014 at 1:36 PM when asked about the incident with Resident #1, she said she first became aware of Resident #1's pain at 1:00 PM from CNA A. She said CNA A told her she had forgotten to report the resident's pain earlier. She then said she immediately went to assess Resident #1 and the resident pointed to her knee when asked about her pain. She said "I touched her knee and she confirmed the pain". She also said about two minutes later she asked the resident again about her pain and she said the resident denied pain at that time. She said she then called the physician and received an order for [REDACTED]. When asked if she administered any pain medications to Resident #1 to relieve her pain, she said no, because Resident #1 reported no pain the second time she asked her. When asked if she assessed Resident #1's entire leg for pain, she said no, she only assessed the resident's knee. In an interview with LVN B on 7/3/2014 at 4:50 PM, when asked about the incident with Resident #1, she said she did conduct the pain assessment on Resident #1 when she reported a pain level of 9 on a scale of 0-10. She said she conducted the pain assessment on 6/16/2014 at about 9:00 after CNA C reported to her that Resident #1 reported pain during her transfer from her wheelchair to the bed. She said she also administered two 325mg Tylenol following the assessment. She said Resident #1 never complained of pain to her prior to that during her shift. She said she did periodically check on the resident during the shift but did not document it. She said she was told during shift change by LVN A that Resident #1 was experiencing pain and that the MD was notified and an x-ray had been ordered. When asked if she had told CNA C about Resident #1's reported pain and that an x-ray had been ordered, she said no. In an interview with the DON on 7/3/2014 at 2:30 PM, when asked what could happen if after a resident complained of pain, they were transferred again and made to bear weight, she said "could be a fracture". When asked if after Resident #1 reported pain to the CNA's, should the resident had been given a shower and transferred again? She said she could not answer that question. In an interview with Resident #1's family member on 7/2/2014 at 2:38 PM when asked about Resident #1's course of treatment following her transfer to the hospital, she said her mother had surgery on 6/18/2014 to repair the fracture. She had a rod and screws placed in her leg to repair the fracture. In an interview with the DON on 7/7/2014 at 5:45 PM, when asked if from the time Resident #1's pain had been reported to LVN A had any pain monitoring been conducted, she said other than the one pain assessment when Resident #1 reported a pain level of 9, she did not find any pain monitoring. She also said other than the Tylenol at 10:20 PM and her scheduled 25 mg [MEDICATION NAME], she did not find any documentation that any pain intervention was conducted. When asked if she was aware of any deformity in Resident #1's leg, she said no. When asked if LVN B should have made Resident #1's direct care staff aware of her pain, she said, normally she would tell her CNA's don ' t touch or move the resident because they were waiting on an x-ray. When asked how she thought this incident came about, she said "You're asking me to speculate. I only have their word, I wasn't there. When they got her up to shower, something happened to her body." In an interview with the ADM on 7/2/2014 at 4:32 PM, when asked who conducted the investigation related to the incident with Resident #1, he said "I did". When asked if he interviewed the CNA's involved in the incident, he said the DON interviewed the CNA's. When asked, during his investigation, if he found any problems related to the timeline on the day of the incident, he said the nurse said she called the doctor at 2:00 PM and the incident occurred at 9:30 AM. He said the nurse was notified around 1:30 PM. When asked if that seemed significant to him, he said yes. When asked if he looked further into the time discrepancy during his investigation, he said no. When asked when a report of pain should be reported, he said staff should report immediately. When asked if any in-services were conducted with the CNA's following the incident, he said he was not sure. When asked if during his investigation, he found that pain monitoring and pain intervention for Resident #1 was not done, he said no. In an interview with the ADM on 7/7/2014 at 6:20 PM, when asked why he thought this immediate jeopardy came about, he said they didn't match the actual timeframe to what actually happened and did not get it written down in a significant amount of time. He also said, she had surgery so significant harm occurred. He said he was made aware of the incident on 6/17/2014. He said he called the DON and got her to give him all the documentation and he talked to the nurse to find out basically what occurred. When asked if he felt the incident was thoroughly investigated, he said "not as much as I'd like." When asked if he felt the nursing staff appropriately monitored and assessed Resident #1's pain appropriately, he said "no, I don't think it was." When asked, other than Resident #1's scheduled pain medication of 25 mg [MEDICATION NAME], three times daily and two 325mg Tylenol at 10:20 PM, did the staff provide any intervention for Resident #1's pain, he said no. When asked if he was aware of any deformity in Resident #1's leg prior to her being transferred to the hospital, he said no. When asked, from the time Resident #1 first complained of pain to the time she was transferred to the hospital at 11:30 PM, was that an appropriate timeframe, he said no. When asked if the charge nurse should notify the direct care staff if a resident had complained of pain and there was an MD order for an x-ray, he said yes. Record review of the facility's "Abuse and Neglect Policy" read in part; "Policy: Abuse, as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardians, friends or any other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. ...Investigative Issues: Policy - Any employee having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately. Procedure - Any and all staff observing or hearing about such events must report the event immediately to the Abuse Prevention Coordinator or Administrator. The event should also be reported immediately to the employee's supervisor. ...Policy - All events reported as possible abuse will be investigated to determine whether abuse did nor (sic) did not take place. Procedure - The Abuse/Neglect Prevention Coordinator will initiate investigative action immediately. The Administrator of the center, the Director of Nurses and/or the Social Worker (Abuse Prevention Coordinator) sill be notified of the complaint immediately and action being taken immediately or within 24 hours of reporting to DADS consumer rights division." This document was not dated. Record review of the facility's "Pain Evaluation" policy and procedure read in part; "Documentation - The person performing this evaluation should record the following information in the resident's medical record. The date and time the evaluation was performed. The name and title of the individual(s) who performed the procedure. Document assessment of pain when prn pain medication is required. All assessment data obtained during the procedure including location of pain, description of site if indicated, level of pain using the appropriate pain scale, and type of pain relief used. Reassessment of pain and the resident's response to the pain relief used." This document was dated 5/22/2013. An Immediate Jeopardy was identified for on 7/3/2014 at 12:54 PM and the ADM was notified at that time. A plan of removal for was submitted and after some revisions was accepted on 7/7/2014 at 6:40 PM. Summary of the Plans of Action to Remove Immediate Jeopardy: Facility will in-service staff on Abuse, Neglect and Exploitation with emphasis on providing necessary, timely communication to the supervisor or the Abuse Coordinator. In addition the following areas were covered including: Abuse, Neglect, Exploitation, verbal abuse, sexual abuse, mental abuse, involuntary seclusion and Misappropriation of Residents property. a. Certified Nursing Aides were in serviced on change of condition including recognizing nonverbal pain and how to respond to non-verbal and verbal pain in a timely manner to preclude further injury to resident. b. All investigations will be conducted by the Administrator or Abuse Coordinator according to DADS Provider letter 06-43 and the facility Abuse and Neglect Policy and Procedure. c. The two (2) staff that was involved with the incident occurring on 6/16/2014 was terminated for failure to notify charge nurse of incident in a timely manner. d. In-service were completed on 7/3/2014 with 73% of participant educated. All staff that was not educated on this date will be required to complete education and sign for completion prior to returning to work. This would include all staff on vacation, workman comp, sick leave and those unable to be contacted. e. Additional in-service was completed on properly completing Internal Investigation and Resident Investigation Forms by licensed staff. Properly Techniques to include: Transferring the resident from bed to chair, utilizing lifting machine, Active transferring, independent, standing pivot transfer (assisted) and dependent transfer. f. All incident reports 30 days or less will be reviewed for completion and appropriate interventions. Completed on 7/5/2014 g. The Administrator was educated on Abuse, Neglect and exploitation which included the effective process of evaluating a complaint, effective gathering of information, assessing information, interviewing identified residents and staff, protection of residents and the timely procedure to ensure DADS is notified. Completion date: 7/4/2014. Outcome: To ensure all residents are identified for risk of falls by evidence of having falls in last 30 days and have appropriate plan of care related to falls. g. The Facility Administrator was educated on Abuse, Neglect and Exploitation which included Abuse, Neglect and Exploitation, protection of residents, assessing documentation, interviewing residents, staff and any outside individual, investigation procedures and effective time lines. Licensed staff was educated on performing Pain Assessment to include treatment, pain management, proper documentation and monitoring. Licensed staff evaluated all resident to ascertain if pain exist and will treat appropriately. a. Based on the resident pain evaluation there were no residents that exhibited or needed treatment for [REDACTED]. b. West Janisch nursing administration IDT evaluated each resident on 7/3/2014 for pain by utilizing verbal, non-verbal cue to determine if pain existed. d. Inservice were completed on 7/3/2014 with 73% of participant educated. All staff that was not educated on this date will be required to complete education and sign for completion prior to returning to work. This would include all staff on vacation, workman comp, sick leave and those unable to be contacted. In an interview with the DON on 7/7/2014 at 5:45 PM, when asked what training the nurses had in order to care for residents with pain and residents requiring 2 person transfer, she said they watch film on transfer techniques in orientation. She said they have education on the computer, in-services on transfers and documentation. She said she walks through the building and they also use audit tools. When asked how did she identify if the nurses were competent in their skills in caring for residents with pain and residents requiring 2 person transfer, she said from now on, she would be auditing resident charts and in-services for training. When asked what type of plan was in place for residents with pain and residents requiring 2 person transfer, she said the facility had no specific policy related to residents with pain who need to be transferred. When asked how did she think this immediate jeopardy came about, she said "You're asking me to speculate. I only have their word, I wasn't there." When they got her up to shower, something happened to her body. When asked what resources were available to the facility, she said she had "medsurg" (medical/surgical) book, policies and procedures, corporate nurses, information from hospitals, therapy department and medical director. In an interview with the ADM on 7/7/2014 at 6:20 PM, when asked what type of procedures were in place to ensure the nursing needs of residents were being met, he said he and the DON made rounds in the morning and they monitored the quality assurance committee and monitored nursing 24 hour reports. He said they also made sure the "Redilearning" system was put in place. He also said he had an open door policy and had concern forms and in-services. When asked how he monitored staff (DON) to ensure the systems they monitor were being done sufficiently, he said they talk about everything on a daily basis. He said they monitor staff by observing them with residents, such as when they go in rooms and how long they stay in the rooms. He said they do rounds daily and any issues are brought to the staff. He also said if there was any condition, CNA's would be made aware by the charge nurse. When asked how he monitored the competency of staff, he said through in-services, he said he would also walk and make rounds with the DON and the unit managers monitor staff as well. He also said staff are trained via the "Redilearning" classes. When asked how he evaluates the policy and procedure, he said they address issues as they occur and have the ability to make changes to the facility's policy and procedure as needed. When asked how he thought the incident/immediate jeopardy came about, he said they didn't match the actual timeframe to what actually happened and did not get it written down in a significant amount of time. He also said, she had surgery so significant harm occurred. He said he was made aware of the incident on 6/17/2014. He said he called the DON and got her to give him all the documentation and he talked to the nurse to find out basically what occurred. When asked if he felt the incident was thoroughly investigated, he said "not as much as I'd like." When asked what resources were available to him and his staff, he said they have monthly quality assurance committee meetings, policies, physicians and corporate nurses. Refer to: F-225, F-281, F-309. According to the facility's CMS Form 672, the census was 88.

Based on observation, interview and record review, the facility failed to provide the necessary supervision and interventions to prevent accidents for 3 residents (Residents # 2, 22, and 23), provide a environment free hazards for 1 resident (Resident # 35) for 4 of 29 residents reviewed for accidents and hazards. -Resident # 2 was independent to minimal assistance with her ADL care and mobility. She resided on the secured unit, requiring supervision with risk of history of falls. She sustained a fall on 11/15/12 which resulted in a fracture of her left hip, shoulder, nasal bone and a hematoma with laceration to the left eye area. Less than 6 months later Resident # 2 requires max/total care with ADLs and mobility, has a tube feeding for 100 % of her nutrition, suffered a significant weight loss and is bedridden. -Resident # 23 admitted on [DATE] and was ambulatory, continent and required limited assistance with ADLs. She resided on the secured unit, requiring supervision with a risk of falls. On 9/12/12 she sustained a fall with no injures in the hallway. On 11/14/12 she had an altercation with another resident and sustained scratches on her neck and chest. On 12/26/12 she sustained an unwitnessed injury to her right thumb. On 2/7/13 she sustained a fall which resulted in a fractured left hip and fractured left wrist. Currently Resident # 23 is incontinent, non-ambulatory and requires 1 person assist with her ADLs. - Resident # 22 resided on the secured unit, and had cigarette burn holes in her clothing and had a history of [REDACTED]. She had a history of [REDACTED]. She required supervision due to recent falls and [DIAGNOSES REDACTED]. - Resident #35 was admitted on [DATE] for therapy due to a right knee replacement. She was being pushed in a wheelchair by the PT when her foot was caught in a hole in the floor between the facility's breezeway and Station 2. Her leg was pulled under the wheelchair which severely bent her right knee under the wheelchair resulting in severe pain. An Immediate Jeopardy was identified on 5/17/13 at 2:57 PM and the administrator and the DON were notified at that time. While the IJ was removed on 5/22/13, the facility remained out of compliance at a scope of pattern and a severity of no actual harm that is not immediate jeopardy because all staff had not been trained and the facility was continuing to monitor the effectiveness of the plan. Non Immediate Jeopardy -A used syringe with a needle was observed on Resident # 52's over the bed table. This deficient practice affected 4 residents and placed the additional 94 residents at risk for accidents which could result in a decline in health status, quality of life and the need for additional treatment. Findings Include: Resident # 2 Record review of Resident # 2's face sheet revealed she admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed her BIMS score was 3 (severely cognitive impairment), she was independent with bed mobility, transfer, walking, locomotion and eating, required minimal assistance with dressing and total care with toileting. She had no ROM issues. She was always incontinent of bowel and bladder. She triggered for being at risk for falls and due to taking psychotropic medications and would be care planned. She resided on the secured unit. Record review of Resident #2's plan of care dated 2/8/12 revealed the following: -a care plan for falls - at risk for falls r/t medication on antipsychotic and antidepressant medication. The goal was resident will be safe in their own environment and free from injury over next 90 days. Interventions were: assist with transfers as needed, refer to PT/OT when appropriate, Encourage resident to ask for assistance. -a care plan for wander - at risk for injury r/t wandering /restlessness. Goal was resident will remain safe in environment over next 90 days. Interventions were: encourage activity/exercise within limits of individual ' s ability, quiet environment and secure unit placement. The care plan was reviewed 2/14/12, 5/10/12. 8/2/12, 10/18/12, 12/12/12 and 3/25/12. Record review of Resident #2's September MAR revealed she was on an anticonvulsant medication (Keppra 1500 mg side effects listed on the MAR included weakness, drowsiness and fatigue) twice daily, enalapril 20 mg (a blood pressure medication side effects listed on the MAR include hypotension) daily, escitalopram 10 mg (an antidepressant- side effects listed on the MAR include drowsiness) daily, and quetiapine (Seroquel an antipsychotic - side effects listed on the MAR included dizziness, weakness and drowsiness) 25 mg every AM and 50 mg every PM. In addition, she was also taking Namenda and Aricept (anti-dementia agents) which listed dizziness as side effects on the MAR. Record review of Resident #2's nurses notes dated 9/14/12 at 8:25 PM read, in part, "After supper today in dining room Resident was getting up to go to her Hall 400 and suddenly slumped down. On checking vital signs it was noted her B/P was low. She probably had a dizzy spell and fell ... Resident placed in bed and BP monitored. Last check BP increased. Record review of the Incident Report for Resident # 2 dated 9/14/12 revealed her blood pressure was 90/58. It further stated "After resident completed supper she got up to go to the 400 hall and suddenly slumped to the floor ..." Under additional comments and/or steps taken to prevent recurrence there was nothing documented. Record review of the Resident # 2's electronic and written nurses notes revealed no notes for 9/15/12 and 9/16/12. Record review of Resident #2's physician progress notes [REDACTED]. Record review of Resident # 2's nurses notes dated 10/2/12 at 10:00 AM read in part, "Called to lock (sic) unit by staff. Resident "had seizure". Writer observed resident lethargic..MD notified and stated to continue to watch ..." Record review of Resident # 2's nurses notes dated 10/3/12 at 7:00 AM read "awake-alert and up in chair in no apparent distress. No episode from 10/2 apparent this AM. Vital signs stable ... answering questions yes/no but remains with confusion." Record review of Resident # 2's care plan dated 10/3/12 revealed the following: Resident has a history of seizures and is at risk for injury. The goal was will be free of seizure activity over next 90 days. Approaches were: Monitor for warning signs - prior to seizures. Give meds per order, monitor labs - report abnormal to MD. Ensure direct care staff are aware of residents history. If a seizure occurs, protect from injury- do not restrain, turn to side, loosen tight clothing, ect. Take vital signs inform MD and responsible party. The care plan was updated on 10/18/12, 12/12/12, 2/14/13 and 4/25/13. Record review of Resident # 2's clinical record revealed there were no additional nurses notes (electronic or written) from 10/4/12-10/10/13. Record review of Resident #2 nurses notes revealed she went to see a neurologist on 10/11/12 who ordered her Keppra at 750 mg twice a day. Record review of Resident # 2's Fall Risk assessment dated [DATE] was coded as a "6" (a score of 10 or above represent high risk for falls). In section B, History of Falls in past 3 months, 0 was coded instead of a 2 (1-2 falls in past 3 months). In section C Ambulation/elimination status was coded 0 (ambulatory and continent) instead of 4 (ambulatory/incontinent). In section G Medications was coded 2 (takes 1-2 medications), but should have been coded 4 (3-4 of the medication type listed - antiseizure, antihypertensive, psychotropic (antipsychotic and antidepressant). The adjusted score would have been a 14, or high risk for falls. Continued review of Resident #2's Fall Risk Assessment's dated 4/5/11, 10/1/11, 1/19/12, 2/8/12, 5/10/12, 8/2/12, 10/18/12, 12/12/12, 2/14/13 and 4/25/13 revealed all these assessments were coded the same way, totaling 6 on the score. There was no variation on all 10 of the assessments. Record review of Resident # 2's quarterly MDS assessment dated [DATE] revealed she was independent with transfers, walking, locomotion and eating, required limited assistance with bed mobility and dressing, total dependence with toileting and supervision with personal hygiene. There were no ROM issues with her lower extremities. She was always incontinent of bowel and bladder. Her weight was 150 pounds. She was coded as wandering daily. Her BIMS score was a 3 (severely cognitive deficit). She was coded as having no history of falls. She resided on the secured unit. Record review of Resident # 2's nurses note dated 11/15/12 at 1:15 PM read, in part, "CNA call nurse to room states resident fell and is lying on the left side noted blood on floor has a small 1.0 laceration left eye ... small hematoma to check area. Complained left shoulder area hurting and hip ... Resident was put in wheelchair and CNA ' s will monitor ... 1:30 PM ...order for facial x-ray, left shoulder and left hip ...3:40 PM Resident left facility for ...hospital via ambulance ..." Record review of Resident #2's Incident Report dated 11/15/132 at 1:15 PM read " CNA found resident lying on left side of the floor. Noted small laceration to left outer eye brow has small hematoma to left side of upper cheek. Resident complaints of left shoulder and left hip hurting " . Under additional comments and/or steps taken to prevent recurrence it was left blank. Continued review of the incident report revealed a handwritten note by CNA J which read, in part, " on 11/15/12 in the middle of the day about 1:15 PM, I ... was feeding resident and (CNA D) was in dining room. I heard family member yell for help ... I came out the room and asked what was wrong. She stated that (Resident #2) had falling (sic). I went to get charge nurse (LVN D) she came down and assess resident, then me and (LVN D) and (a MA) picker her up and put her in bed". Record review of Resident # 2's x-ray report dated 11/15/12 revealed the following: facial bones - no definite acute fracture is visualize, correlate with CT for greater detail, left shoulder - mildly displaced fracture of the humeral neck, left hip - mildly displace fracture of the femoral neck. Record review of Resident # 2's physician order [REDACTED]. Record review of Resident # 2's hospital admission noted dated 11/15/12 read, in part, "...(Resident # 2) ...history of seizures and dementia, who was admitted ... due to blunt head injury after accidental fall ..." Record review of Resident # 2's hospital consult noted dated 11/16/12 read, in part, " ...She has a past medical history of [REDACTED]. Record review of Resident # 2's hospital CT scan of the facial area dated 11/16/12 revealed a nasal bone fracture. Record review of Resident # 2's physician order [REDACTED]. Record review of Resident # 2's clinical record revealed she went to the hospital for left hip surgery on 12/5/12 and returned back the facility on 12/11/12. Record review of Resident # 2's Fall Risk assessment dated [DATE] was coded as a " 6 " (a score of 10 or above represent high risk for falls). In section B, History of Falls in past 3 months, 0 was coded instead of a 2 (1-2 falls in past 3 months). In section C Ambulation/elimination status was coded 0 (ambulatory and continent) instead of 4. In section G Medications was coded 2 (takes 1-2 medications), but should have been coded 4 (3-4 of the medication type listed - antiseizure, antihypertensive, psychotropic (antipsychotic and antidepressant)). The adjusted score would have been a 14, or high risk for falls. Record review of Resident # 2's annual MDS assessment dated [DATE] revealed she no longer walked, required minimal assistance with eating, extensive assistance with bed mobility, transfers, dressing and personal hygiene, and was totally dependent for locomotion and bathing. She had limited ROM impairment to one side of her lower extremities. Her weight was 140 pounds, and was coded as having weight loss of 5% or more in the last month or loss of 10% or more in 6 months and not on a physician prescribed weight loss regimen. She no longer wandered. Record review of Resident # 2's clinical record revealed she transferred to the hospital on [DATE]-3/14/13 due to seizure activity Record review of Resident #2's clinical record revealed she transferred to the hospital on [DATE]-4/10/13 due to respiratory distress. She had a feeding tube placed during this hospital stay. Record review of Resident # 2 Significant change MDS assessment dated [DATE] her weight was 127 pounds, she was not on a physician prescribed weight loss plan, and had lost 5% or more in the last month or 10% in the last 6 months. She was coded as having a feeding tube and receiving 51% or more of her total calories from the feeding tube. She required total care with bed mobility, transfers, locomotion, eating, toileting and bathing. She was non ambulatory. Observations of Resident # 2 were conducted as follows: -on 5/14/13 at 11:58 AM revealed she was in bed with her eyes closed with a feeding tube. -on 5/15/13 at 7:45 AM revealed she was in bed with her eyes closed with a feeding tube. -on 5/16/17 at 8:00 AM revealed she was asleep in bed with a feeding tube. -on 5/16/2013 at 8:35 AM during incontinent care revealed she required 2 persons assistance with care. -on 5/18/13 at 11:45 AM revealed she required total assistance to roll over in bed. In an interview on 5/18/13 at 8:40 AM, LVN G was asked what interventions were put in place after Resident #2 fell on [DATE] and 10/2/12. LVN G stated the family and MD were called, her BP was monitored and she was put back into bed. She stated she went to a doctor a month later. When asked if there was a care plan in place to monitor for seizures, LVN G stated no she did not see one before 10/3/2012. In a confidential interview on 5/18/13 at 9:05 AM, she/he stated she/he was working the secured unit on 11/15/12 when Resident # 2 fell . She/he stated during the meals, 1 of the 2 aides assigned to the unit goes to the dining room off the unit. She/he stated there were about 22 residents on the unit, and some would go to the dining room for meals off the unit. She/he stated she was the aide on the unit, and was in another resident's room feeding the resident. She/he stated she/he thought she/he was the only staff member on the secured unit at that time. She/he stated she saw Resident # 2 walk by the room she/he was in, and soon after a family member came to tell her/him a resident had fallen. She/he stated she left the room she/he was in and walked down the hall and found Resident # 2 in the doorway of her room. She/he stated she/he went to get the nurse through the secured door. She/he stated Resident # 2 was laying on her side. She/he stated the nurse looked at the resident, and then the resident was lifted and put to bed. She/he stated Resident # 2 was bleeding from her head. She/he stated the nurse called the paramedics. She/he stated Resident # 2 could walk and could do a lot of her ADLs before she fell , but that after she fell and came back, she had a broken hip and arm and it took 2 people to care for her. When asked how the residents that remained on the unit were being supervised during meals when she/he was feeding a resident in their room and the other aide and nurse were not on the unit, she/he stated she/he kept the door open and listened for noise and residents arguing and would go out and look if she/he heard something. When asked if she/he felt the residents were being adequately supervised during these times, she/he stated no because she/he was feeding someone in their room. She/he stated if there was another aide they could be assisting other residents on the unit. In a confidential interview on 5/18/13 at 9:23 AM with a different staff member, she/he stated she/he was working on the secured unit the day Resident # 2 fell . She/he stated she/he was working off the unit in the dining room and did not know what happened to Resident # 2. She/he stated at about 11:50 AM she would go to the dining room and would not return until the last person was finished eating their meal, anywhere from 45 minutes to an hour. She/he stated the number of residents from the secured unit that went to the dining room off the unit varied day by day, some meals it was 5, 10 or 12 residents, depending on their mood. She/he stated she usually was the aide to stay on the unit for breakfast, and for lunch she/he went to the dining room. She/he stated during the meals, there was only 1 staff person on the secured unit, but sometimes someone would come in to pass meds, but mostly it was just 1 CNA. When asked how she/he would know if something was happening on the unit if she/he were in a resident room and was the only staff person on the unit, she/he stated she would leave the door cracked open and try to listen. She/he stated the day Resident # 2 fell , by the time she/he arrived to help the nurse was already there. When asked how the resident seemed, she/he stated about the same but maybe her arm was sore and she was bleeding from her head. She/he stated they were trying to change the residents shirt and she made a grimacing face. In an interview with the DON on 5/19/2013 at 10:25 AM she was asked if she had any additional incident reports for May 2013. She said she would have to check. None was provided for Resident # 2. In an interview on 5/20/13 at 4:05 PM, LVN D stated she was the charge nurse for Hall 400 (secured hall) and 500 odd side, and was the nurse on 11/15/12 when Resident # 2 fell . She stated there were 2 aides assigned to the 400 hall, and that 1 aide was assisting residents in the dining off the unit, while the other aide was on the secured unit. She stated when an aide is on break or assisting in the dining room, only one staff person is on the secured unit. She stated she was in the dining room during lunch on 11/15/12 when Resident # 2 fell on the secured unit. LVN D stated she was called to the secured unit by a CNA who told her Resident # 2 had fallen. She stated Resident # 2 had a hematoma to her left eye and there was blood on the floor in her room and she was laying on her left side. She stated she did not know how Resident # 2 fell , but that she walked. She stated she cleaned her up, started to do her paperwork at the desk (off the secured unit) and call the doctor. She stated before the resident went to the hospital she was told the resident had a seizure, but it was after her shift had ended. In an interview on 5/22/13 at 10:20 AM the DON stated the facility was not monitoring for seizure activity for residents who had seizures, including Resident #2. She stated Resident #2 should have had a plan of care that addressed seizure and had follow-up charting done. Resident # 22 Record review of Resident # 22's Face Sheet revealed she had been admitted to the facility on [DATE] and had a recent re-admission date of [DATE]. Her [DIAGNOSES REDACTED]. The re-admission on 3/01/2013 revealed a fractured right great toe. Observation of Resident # 22 on 5/14/2013 at 8:05 AM revealed she was up ambulating in the hall with several holes in her pink robe that appeared to be cigarette burns. Observation of Resident # 22 on 5/17/2013 at 3:48 PM revealed she was ambulating down the hall with CNA I. She had a burn hole in her shirt at her waist level that that was larger than a nickel but smaller than a quarter in size. CNA I told CNA K that she was taking the resident off the unit to the machine (vending). Resident # 22 returned to the unit with CNA I at 3:52 PM. Observation of Resident # 22 on 5/17/2013 at 4:50 PM lying on her bed in her room. The bed was a low bed and she had a fall mat beside the bed. Resident # 22 was observed to have both feet elevated on pillows. She was dressed in day clothing and was well groomed. No burn holes were observed on her clothing at this time. During an interview on 5/17/2013 at 4:50 PM with Resident # 22 she stated that she smoked, but did not wear any protective device to prevent being burned. She denied being burned by cigarettes and denied having burned any clothes. In an interview with CNA L on 5/19/2013 at 3:10 PM she said worked on the secured unit. She said Resident # 22 goes out to smoke usually at 6:00 PM and 8:00 PM. She stated the resident mostly stayed in bed all day and ate in her robe. When asked about her pink robe she said burn holes in it and she did not know when they occurred because she did not take the resident out to some. Interview with Resident # 22 on 5/20/2013 at 9:11 AM she said she was getting ready to go to the doctor regarding her blood sugar. When she was asked what happened to her robe she said it was burnt smoking. When she was asked where that had happened she said at the facility more than once. When Resident # 22 was asked if someone from the facility was with her when she smoked outside at the facility she said yes, someone was with her. She said she had never burned anything else. In an interview with the DON on 5/20/2013 at 9:47 AM she said Resident # 22's robe had the holes when she came to the facility. Observation on 5/21/2013 at 2:50 PM of the closet for Resident # 22 revealed no clothing with burn holes. Resident gave permission for surveyor to look in her chest of drawers. The resident continued to deny she had burns from cigarettes on any of her clothes. However, a balled up green sweater was located that had a large burn hole in it that had been placed at the back of the top drawer. Resident # 22 stated she had put it in there and was not going to wear it anymore. Record review of Resident # 22's facility medical record revealed no documentation of having seizure activity. It did reflect that Resident had critical drops in blood sugars. Record review of Resident # 22's glucometer readings from March 2013 revealed that on at least four different occasions (2/22/13, 2/27/13, 3/20/13 and 4/25/13) her blood sugars were critically low. Record review of Resident # 22 incident reports revealed the following: -on 1/13/13 a fall out of bed. Intervention on the report was the bed to lowest possible position -on 2/2/13 a fall in her room. Intervention on the report was that the resident was instructed to call for assistance when ambulating to the restroom and encouraged to wear shoes with heel in. -on 2/17/13 a fall in her room. Interventions on the report were none (line was blank). -on 2/25/13 falls in her room (times 2). Interventions on the report were none (line was blank). -on 5/21/13 a fall in the hallway. Intervention on the report was " resident encouraged to ask for assist before ambulating " . Record review of Resident # 22's Care Plan dated 10/10/2012 read in part "Fall/Safety Risk/Elopement: Resident will remain free of injuries and falls: Interventions: Keep call light within reach; Orthostatic hypotension precautions; frequent visual checks by CNA; Bed/chair alarm if applicable; and complete fall risk assessment. Under the heading "ADLS functional" the Care Plan dated 10/10/2012 read in part that for transfers Resident # 22 needed supervision. Record review of Resident # 22's Care Plan dated 1/13/2013 revealed under heading: Actual Fall/Recent Fall the goal was "Resident will be assessed to prevent further falls and maintain safety over the next 90 days" and "Resident will be free of injury from fall during next 90 days." Record review of Resident # 22's Care Plan for falls dated 2/02/2013 revealed she had falls on 2/02/2013, 2/17/2013 and 2/27/2013 with one of the interventions being that she would wear non-slip shoes. Record review of Resident # 22's facility medical record revealed a hand written nurse note dated 2/27/13 which read in part " Resident had yet another episode of [DIAGNOSES REDACTED] at 2:00 AM, BS 22 mg/dl. Glucagen given as ordered and was effective. This is episode #4 in less than 3 days..." Continued nurse notes read on 2/27/13 at 5:30 AM "NP aware of situation". Further review of the nurse notes for 2/27/13 revealed that on 2/27/2013 at 7:25 AM " Resident found unresponsive, sweating, BS 27. Gave OJ with sugar, called UM in building and RN called NP. Received orders to transfer to hospital 911." "Resident was transferred in stable condition " dated 2/27/2013 at 08:10 AM. Continued review of Resident # 22's facility computer nurse notes dated 3/05/2013 read in part "Recent hospitalization r/t [DIAGNOSES REDACTED] and being found unresponsive." Record review of Resident # 22's Fall Risk assessment dated [DATE] coded her risk for falls as 7 (not high risk), despite her frequent falls resulting in a fractured great toe (2/27/13) and recent hospitalization due to [DIAGNOSES REDACTED], and a fall on 5/21/2013 resulting in a fractured left ankle. Her adjusted score from 3/21/13 would have been an 11 (she was not coded for 3 or more falls and her predisposing diseases of fractures and seizures), which would have made her at high risk for falls. Record review of Resident # 22's quarterly MDS dated [DATE] revealed the Falls with injury was checked. Record review of Resident # 22's lab results revealed critical low glucose level of 21 on 4/25/2013 at 10:46 AM (normal glucose level is 70-110). Record review of Resident # 22's May 2013 MAR revealed she was currently taking Dilantin and Depakote for an admission [DIAGNOSES REDACTED]. During an interview on 5/17/2013 at 3:00 PM with the DON, when asked about the reason for Resident # 22's last hospital visit she stated that it was due to a fall because of seizure. Observation on 5/18/2013 at 09:15 AM revealed Resident # 22 was ambulating toward the secure unit with other residents from a smoke break. She was observed to walk slowly and independently. However, she was wearing mule (open backed) type slippers which were loose fitting, and she had a shuffling gait. Observation on 5/21/2013 at 2:45 PM of Resident # 22 lying on her bed with both feet elevated on pillows. Denied any problems. Permission was given by Resident for surveyor to check skin for evidence of possible cigarette burns. No evidence of burn on her skin was found. During an interview on 5/21/2013 at 12:30 PM with the RN Pharmacy Consultant, when asked why Resident # 22 was taking the medications Depakote and Dilantin, she stated she had not found [DIAGNOSES REDACTED]. During an interview on 5/21/2013 at 3:30 PM with LVN D she stated that Resident # 22 was being sent to the hospital ER due to a fall at 05:30 AM "today." She stated that Resident had a swollen left ankle and did not complain to anyone about pain until "9:00 AM. Two of the CNAs called me in to look at her foot. I called the NP and got a stat order for an X-ray. We got the results at 12:40 PM today and it was showing an oblique fracture of the distal fibula with tissue swelling." When asked about Resident # 22's blood glucose levels that morning, LVN D stated that she checked them at " 7:30 to 8:00 AM and it was 392 and I gave her 5 units sliding scale. Then I re-checked it at 9:30 AM and it was 176. She said she was hungry so I gave her skim milk and 10 vanilla wafers. Later I checked her blood sugar at 11:30 AM and it was 131." Resident # 23 Review of Resident #23's face sheet in the current medical record revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the "Incident Report" dated 9/21/12 involving Resident #23 read in part "Time of Incident - 2 PM. Exact Location of Incident - Hallway. Exactly What Happened - Staff saw Resident fall in hallway - slipped - Lost balance. Hit left hip to floor. Did not hit head. Floor dry and no debris". In the section titled "Final Comments and/or Steps Taken to Prevent Recurrence" read in part "anticipate (sic) needs - assist resident more frequently, 1 - 2 hours checks". Review of the "Incident Report" dated 11/14/12 involving Resident #23 read in part "Time of Incident - 7 PM. Exact Location of Incident - Hallway. Exactly What Happened - After resident completed visit with son she proceed to exchange good feeling with any person in the immediate surrounding. Resident #14 was jealous of this display and precede to grab and yelled at resident. Scratch marks to neck and chest noted". In the section titled "Final Comments and/or Steps Taken to Prevent Recurrence" read "One CNA monitoring long hall in 400". Review of the "Incident Report" dated 12/26/12 involving Resident #23 read in part "Time of Incident - 3 PM. Exact Location of Incident - N/A. Exactly What Happened - Resident noted with redness at base of right thumb. On applying pressure resident complains of pain. Origin of condition unknown" The section titled "Final comments and/or Steps Taken to Prevent Recurrence" was left blank. Review of the "Incident Report" dated 2/7/13 involving Resident #23 read in part "Time of Incident - 7 PM. Exact Location of Incident - Hallway. Exactly What Happened - Noticed resident on the floor yelling out. Resident stated that she fell noticed abnormalities to L arm and L hip". In the section titled "Final Comments and/or Steps Taken to Prevent Recurrence" read "Stabilized patient prepared for EMR pickup gave PRN pain meds". Review of the nurses notes written by LVN N, dated 2/7/13 at 7:15 PM read "At or about around 7:00 PM on 2/7/13 after a late dinner, the door to the locked unit was open so that both nurses can help 400 hall while the CNA's picked up meal trays from the patients rooms. While sitting at the nurses station, noticed yelling down 400 hall and noticed patient on the floor. Patient stated that as she was walking she lost her balance and fell to the floor. Both nurses stabilized patient and prepared for transport". Review of the "Admission Nursing Assessment" revealed Resident #23 was readmitted to the facility on dated 3/7/13 at 3 PM. Review of the "Skin Condition" section under "Comments" read "left thigh surgical open incision, left wrist .. with cast and sling". In an interview with LVN N on 5/21/13 at 3:55 PM he said during meal times on the secure unit, normally one CNA is in the main dining room and the other is assisting the remaining residents in the secure unit. He said that's what the assignment is during the meal times. He said the LVN working that night (2/7/13) was an agency nurse. He was assigned to the other unit but decided to assist her because the agency nurse was not familiar with the residents. When asked if he felt one CNA on the unit could monitor the residents, he said "I was under the impression that it was enough. However I felt is wasn't, that's why I left the door open, because that one aide was busy with residents in their rooms and resident were walking around. I normally have the door open because I felt more comfortable with another set of eyes on the residents wandering in the hallway". Review of Resident #23's "Fall Risk Assessment" stated a score of 10 or greater is considered at high risk for potential falls, revealed on 8/28/12 and 12/29/12 she scored a 12. On 2/7/13 and 3/7/13 she scored a 16. Review of Resident #23's "Late Loss ADL Flow Sheet" for February 2013 1 to 6 revealed she was independent for bed mobility and transfers. She required setup help for meals and limited assistance by 1 person for toilet use. Review of the May 2013 1 to 15 sheets revealed she required 1 person limited assistance with bed mobility and eating. She required extensive assistance with 1 person assist with transfers and is total dependence with 1 person assist for toilet use. Resident #35 Record review of Resident #35's face sheet revealed she was admit

Based on record review and interview the facility failed to ensure 9 of 29 residents (Residents # 2, # 22, # 73, # 26, # 39, # 85, # 95, # 38, and # 44) received adequate monitoring for potential and adverse reactions for individuals on [MEDICAL CONDITION], blood pressure and blood sugar, and had adequate indications for use of the medications for residents reviewed for unnecessary medications: -Resident # 2 was on [MEDICAL CONDITION] medication without adequate monitoring of the medications. Resident # 2 suffered a fall with fractures in [DATE]. She had [MEDICAL CONDITION] activity resulting in hospitalization with a low [MEDICATION NAME] level in March 2013. She has suffered significant weight loss and had a feeding tube placed in March 2013. Her feeding tube was not held as per manufacturer recommendations for [MEDICAL CONDITION] medication and when her blood pressure was low, the medication was held without parameters. - Resident # 22 was on two anticonvulsant medications without adequate indications for it's use. She had a [DIAGNOSES REDACTED]. Her blood sugars were not being monitored. -Resident # 73 was receiving [MEDICATION NAME] and did not have a related care plan. His level was not in range. He was also on [MEDICATION NAME] 10 mg (antihypertensive) and [MEDICATION NAME] 20 mg (antihypertensive) there were no parameters on the blood pressure. The [MEDICATION NAME] was without adequate indications for use. His blood pressure was not taken daily. He had Zolpeidem 10 mg ordered without adequate indications for use. -Resident # 26 was receiving [MEDICATION NAME] without adequate indications for use. He was receiving [MEDICATION NAME] and his blood pressure was not monitored daily as ordered. -Resident # 39 was receiving [MEDICATION NAME] without adequate indications for use and there was no related care plan. -Resident # 85 was receiving [MEDICATION NAME] and there was no care plan. Her [MEDICATION NAME] level was not in range. -Resident # 95 was to have his blood sugar tested twice a day on Mondays and Thursdays. It was only scheduled to be tested on ce a day on those days. It was only tested twice a day on one day. An Immediate Jeopardy was identified on 5/19/13 at 4:07 PM and RN A, DON and ADM were notified at this time. While the IJ was removed on 5/22/13, the facility remained out of compliance at a scope of pattern and a severity of no actual harm that is not immediate jeopardy because the facility was continuing to monitor the plan and in-servicing staff. Non Immediate Jeopardy -Resident # 38 had an order 4/25/13 for [MEDICATION NAME] for two weeks and received it for 26 days. -Resident # 44 was receiving [MEDICATION NAME] without adequate indications for use. These failures affected 9 residents and resulted in the decline of 2 resident (Resident # 2 and # 23) and placed 89 additional residents at risk of decline in their function and health status due to not having their conditions promptly assessed, monitored and treated. Findings include: Resident # 2 Record review of Resident # 2's face sheet revealed she admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Record review of Resident #2's September MAR indicated [REDACTED]. In addition, she was also taking [MEDICATION NAME] and [MEDICATION NAME] (anti-dementia agents) which listed dizziness as side effects on the MAR. Record review of Resident #2's nurses notes dated 9/14/12 at 8:25 PM read, in part, " After supper today in dining room Resident was getting up to go to her Hall 400 and suddenly slumped down. On checking vital signs it was noted her B/P was low. She probably had a dizzy spell and fell ... Resident placed in bed and BP monitored. Last check BP increased. Record review of the Incident Report for Resident # 2 dated 9/14/12 revealed her blood pressure was 90/58. It further stated " After resident completed supper she got up to go to the 400 hall and suddenly slumped to the floor ... " Under additional comments and/or steps taken to prevent recurrence there was nothing documented. Record review of the Resident # 2's electronic and written nurses notes revealed no notes for 9/15/12 and 9/16/12. Record review of Resident #2's physician progress notes [REDACTED]. Record review of Resident # 2's nurses notes dated 10/2/12 at 10:00 AM read in part, " Called to lock unit by staff. Resident " had [MEDICAL CONDITION] " . Writer observed resident lethargic..MD notified and stated to continue to watch ... " Record review of Resident # 2's nurses notes dated 10/3/12 at 7:00 AM read " awake-alert and up in chair in no apparent distress. No episode from 10/2 apparent this AM. Vital signs stable ... answering questions yes/no but remains with confusion. " Record review of Resident # 2's care plan dated 10/3/12 revealed the following: Resident has a history of [MEDICAL CONDITION] and is at risk for injury. The goal was will be free of [MEDICAL CONDITION] activity over next 90 days. Approaches were: Monitor for warning signs - prior to [MEDICAL CONDITION]. Give meds per order, monitor labs - report abnormal to MD. Ensure direct care staff are aware of residents history. If a [MEDICAL CONDITION] occurs, protect from injury- do not restrain, turn to side, loosen tight clothing, ect. Take vital signs inform MD and responsible party. The care plan was updated on 10/18/12, 12/12/12, 2/14/13 and 4/25/13. Record review of Resident # 2's clinical record revealed there were no additional nurses notes (electronic or written) from 10/4/12-10/10/12. Record review of Resident #2's physician order [REDACTED]. Continued review of the orders dated 10/11/12 revealed to discontinue [MEDICATION NAME] 500 mg twice a day and start [MEDICATION NAME] 750 mg twice a day. Record review of Resident #2's nurses notes revealed she went to see a neurologist on 10/11/12 who ordered her [MEDICATION NAME] at 750 mg twice a day. Record review of Resident # 2's nurses note dated 11/15/12 at 1:15 PM read, in part, " CNA call nurse to room states resident fell and is lying on the left side noted blood on floor has a small 1.0 laceration left eye ... small hematoma to check area. Complained left shoulder area hurting and hip ... Resident was put in wheelchair and CNA ' s will monitor ... 1:30 PM ...order for facial x-ray, left shoulder and left hip ...3:40 PM Resident left facility for ...hospital via ambulance ... " Record review of Resident # 2's x-ray report dated 11/15/12 revealed the following: facial bones - no definite acute fracture is visualize, correlate with CT for greater detail, left shoulder - mildly displaced [MEDICAL CONDITION] neck, left hip - mildly displace [MEDICAL CONDITION] neck. Record review of Resident # 2's physician order [REDACTED]. Record review of Resident # 2's hospital admission noted dated 11/15/12 read, in part, " ...(Resident # 2) ...history of [MEDICAL CONDITION] and dementia, who was admitted ... due to [MEDICATION NAME] head injury after accidental fall ... " Record review of Resident # 2's hospital consult noted dated 11/16/12 read, in part, " ...She has a past medical history of [REDACTED]. Record review of Resident # 2's hospital CT scan of the facial area dated 11/16/12 revealed a nasal bone fracture. Record review of Resident # 2's physician order [REDACTED]. Record review of Resident # 2's clinical record revealed she went to the hospital for left hip surgery on 12/5/12 and returned on 12/11/12. Record review of Resident #2's nurses notes dated 12/31/12 read as followed: -9:30 AM -staff was call to therapy department resident was having a grand mal [MEDICAL CONDITION] last up to 3 minutes emesis moderate amount of digested food. [MEDICAL CONDITION] lasted 3 minutes Vital signs 125- 18- 90/60, blood sugar 135 skin color pale. -9:35 AM - Resident alert and oriented to name only. Stable. Notified doctor of patient having [MEDICAL CONDITION] 3 minutes. Doctor gave order to give [MEDICATION NAME] 300 mg now and increase [MEDICATION NAME] 1000 mg twice daily ... Record review of Resident #2's physician order [REDACTED]. Record review of Resident # 2's electronic nurses note were as follows: 12/31/12 at 5:00 PM read, in part, " Called placed to Dr ... concerning possible aspiration for episode of [MEDICAL CONDITION] today. Lungs were clear ... " 1/1/13 at 10:00 AM read in part, " ...resident lying supine no [MEDICAL CONDITION] activity noted will cont to monitor ... " 1/1/13 at 11:18 PM read in part, " ...CXR results called in to MD who ordered Z-Pack (a antibiotic) ... Also order for [MEDICATION NAME] given as well as [MEDICATION NAME] and [MEDICATION NAME] blood levels on 1/15/13 ... " 1/2/13 at 1:14 PM read in part, " ... No [MEDICAL CONDITION] activity this 8 hours. Resident alert cont to monitor ... " There were no other entries in Resident #2's clinical record regarding monitoring for [MEDICAL CONDITION] activity until 3/7/13. Record review of Resident # 2's physician order [REDACTED]. Record review of Resident # 2's [MEDICATION NAME] lab level drawn on 1/15/13 revealed it was low at <2.5 (reference range was 10-20). Record review of Resident # 2's physician order [REDACTED]. Record review of Resident #2's clinical record revealed there were no labs for [MEDICATION NAME] level done the rest of January, February and March 2013 at the facility. Record review of Resident #2's March Behavior/Intervention Monthly Flow Record revealed behavior monitoring including monitoring for potential side effects of her antidepressant and antipsychotic was not completed on parts or all of the shifts on the following days: 3/1-3/9 and 3/14-3/17. There was no monitoring for potential side effects of the [MEDICAL CONDITION] medications. Record review of Resident # 2's nurses note dated 3/7/13 read, in part, " 10:10 AM CNA calls me to resident room - [MEDICAL CONDITION] in progress last about 2 minutes. Vitas signs 97.2, 80, 18 136/88. Skin warm and dry. No acute respiratory distress. 10:15 AM Call placed to doctor ... 10:30 AM doctor ... calls back ... new order ... [MEDICATION NAME] 200 mg extra and [MEDICATION NAME] 1000 mg (10 ml) then increase [MEDICATION NAME] to 1500 mg (15 ml) twice a day and [MEDICATION NAME] and [MEDICATION NAME] levels in AM... " Record review of Resident # 2's physician order [REDACTED]. Record review of Resident #2's March 2013 MAR indicated [REDACTED]. There was another 1500 mg written which also was crossed through, and 10 ml was hand written next to it. Review of www.drugs.com <http://www.drugs.com> levetiraceta ([MEDICATION NAME]) solution comes in 100 mg per 1 ml. Record review of Resident # 2's labs revealed no labs for [MEDICATION NAME] or [MEDICATION NAME] were drawn on 3/8/13. Record review of Resident # 2's nurses note dated 3/8/13 at 7:00 AM read, in part, " ... no acute distress will monitor for [MEDICAL CONDITION]. " At 2:00 PM it read " no [MEDICAL CONDITION] this 8 hours " Record review of Resident # 2's nurses note revealed the next note was written on 3/9/13 at 9:50 AM which read, in part, " Resident observed in her room after eating breakfast to be unresponsive to verbal stimulation while slumped over in her chair. Resident appeared to have urinated on herself and mucous hanging from her nose. Once layed (sic) down for evaluation resident responded to sternal rubs and became responsive ... Doctor ... gave order to send to ... hospital ... " Record review of Resident # 2's physician order [REDACTED]. Record review of Resident #2's hospital records from admission date of [DATE] revealed the following: -Admission note dated 3/9/13 which read, in part, " ... transferred from nursing home due to [MEDICAL CONDITION] activity. Patient has history of [MEDICAL CONDITION] disorder and she is under treatment ... " -Consult note dated 3/10/13 which read, in part, " ...we are asked to assess her pursuant to a breakthrough [MEDICAL CONDITION], which occurred apparently at the nursing home. The patient apparently has a longstanding history of [MEDICAL CONDITION] and has been maintained on a combination of [MEDICATION NAME] ... and [MEDICATION NAME] ... Unfortunately, her level were subtherapeutic at 5.1 and medication adjustments have been required during this admission ... " Record review of Resident # 2's physician order [REDACTED]. Record review of Resident #2's nurses notes from 3/14/13 through 3/18/13 revealed the following: -3/15/13 no [MEDICAL CONDITION] activity noted at 3:00 AM and 7:00 AM and will continue to monitor for active [MEDICAL CONDITION]. -3/16/13 No nurse notes -3/17/13 resident had temperature of 100 which was relieved with medication. She had slight congestion with and oxygen saturation of 93%. New orders for nebulizer, antibiotic and urinalysis order. -3/18/13 at 5 AM resident had labored breathing, oxygen saturation of 87% and pulse of 132. Notified MD and order to send to hospital 911. Record review of Resident # 2's physician order [REDACTED]. She had a feeding tube placed during this hospital stay. Record review of Resident # 2's physician order [REDACTED]. It further revealed she now had a feeding tube placed and it was ok to administer all medications per the feeding tube. Continued review of her readmission orders [REDACTED]. Record review of Resident #2's clinical record revealed there were no behavior monitoring including monitoring for potential side effects of her antidepressant and antipsychotic medication from 4/10-4/30/2013. There was no monitoring for [MEDICAL CONDITION] activity or for potential side effects of the [MEDICAL CONDITION] medication. Record review of Resident #2's clinical record revealed there were no labs for [MEDICATION NAME] level done for April 2013. LVN A was observed administering medications to Resident # 2 on 5/15/2013 at 8:10 AM. When she prepared the [MEDICATION NAME] 125 mg/5 ml she did not shake the medication before she poured it into the medication cup. LVN A said the [MEDICATION NAME] ordered amount was 8 ml. She poured some into the medication cup and then poured some back into the medication bottle. LVN A said 1.5 and 7.5 equals 8. She then put the contents of the syringe in the medication cup. When she finished there was between 9 and 10 ml of [MEDICATION NAME] in the medication cup. At 8:42 AM she took the resident ' s blood pressure with a wrist cuff by holding the residents left arm down on the bed. The blood pressure was 91/63. She removed the [MEDICATION NAME] 20 mg 2 tablets from the medication cup and said she was going to hold it due to the blood pressure. The tube feeding was off when entered the room. LVN A then turned on the tube feeding pump at 75 cc/hr. Record review of Resident # 2's May 2013 Physician order [REDACTED]. -[MEDICATION NAME] Suspension 125/5 ml, give 8 ml (200 mg) per [DEVICE] every 12 hours. -[MEDICATION NAME] 20 mg, one tablet per [DEVICE] once daily. There were no adequate indications for use and no parameters when to hold the medication. Record review of Resident # 2's 5/15/2013 May 2013 MAR indicated [REDACTED] -[MEDICATION NAME] Suspension 125/5 ml, give 8 ml (200 mg) per [DEVICE] every 12 hours. -[MEDICATION NAME] 20 mg, one tablet per [DEVICE] once daily. There were no adequate indications for use and no parameters when to hold the medication. The blood pressure recorded for 5/15/2013 was 85/54. The medication was not circled to indicate it had been held and there was no documentation on the MAR. -[MEDICATION NAME] 1.2 75 ml off 20 hours, off at 12 midnight. 6 AM on. Record review of the nurse's notes and the electronic notes from 5/15-5/16/13 revealed there was not documentation the physician was called regarding the blood pressure and the [MEDICATION NAME] being held. Record review of Resident # 2's lab dated 5/17/13 revealed her [MEDICATION NAME] level was low at 7.4 (reference range of 10-20). Record review of Resident # 2's clinical record from September 2012 through the end of the survey revealed there were no letters to the physician with any pharmacy recommendations. In an interview with LVN A she said she wanted to check Resident # 2's blood pressure with a manual blood pressure cuff but she had to get it from the other station. She said she had been the unit manager since November. In an interview with LVN A, Unit Manager for Station I on 5/16/2013 at 1:35 PM she said When she was asked about any precaution with the [MEDICATION NAME] she said you were supposed to shake it before pouring into the cup. LVN A further stated she had shaken the [MEDICATION NAME] bottle before she poured it. Regarding starting the tube feeding after administering [MEDICATION NAME] she said some facility's have a policy to hold the tube feeding one hour before administering [MEDICATION NAME] and one hour after administering the [MEDICATION NAME]. When she was asked the reason it was held she said the tube feeding affected the effects of the medication. LVN A was asked if holding the [MEDICATION NAME] was a facility policy or a standard of practice she said she always used to hold it. When she was asked about the 7.5 cc plus 1.5 cc in the syringe she said she did not give the correct dose. LVN A said she did not follow doctor ' s orders and it was a medication error. According to Drugs.com: [MEDICATION NAME] ([MEDICATION NAME]) is an anti-epileptic drug, also called an anticonvulsant. It works by slowing down impulses in the brain that cause [MEDICAL CONDITION] . . . [MEDICATION NAME] is used to control [MEDICAL CONDITION] . . . Take [MEDICATION NAME] exactly as prescribed by your doctor. Do not take in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label . . . Shake the [MEDICATION NAME] oral suspension (liquid) well just before you measure a dose. Measure the liquid with a special dose-measuring spoon or medicine cup . . . According to Nursing 2013 Handbook ebook: [MEDICATION NAME] . . . . Drug-food. Enteral tube feeding: May interfere with absorption of oral drug. Stop enteral feedings for 2 hours before and 2 hours after drug use . . . [MEDICATION NAME] . . . Antihypertensive . . . Indication and Dosages Hyperextension . . . Adjunct treatment . . . for heart failure . . . " An interview was conducted with the DON, the ADON and Station I Unit Manager LVN A on 5/19/2013 at 8:10 AM with RN A in the room. When the DON was asked about the [MEDICATION NAME] level for Resident # 2 she said the [MEDICATION NAME] level was done. She said the [MEDICATION NAME] levels were checked per doctor ' s orders. She stated Resident # 2's [MEDICATION NAME] level was less than it should be and the doctor should have been notified to follow up on what he wanted to do. Resident # 22 Record review of Resident # 22's Face Sheet revealed she had been admitted to the facility on [DATE] and had a recent re-admission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 22's May 2013 MAR indicated [REDACTED]. BID. Continued record review of Resident # 22's facility medical record revealed there was no documentation in her chart indicating she had any [MEDICAL CONDITION] activity. She did not have any Care Plan documenting [MEDICAL CONDITION] activity monitoring or the use of anticonvulsant medications. During an interview on 5/16/2013 at 3:00 PM with the DON when asked about Resident # 22's, she said that Resident # 22 was "being monitored" for [MEDICAL CONDITION] activity. Record review of Resident # 22's 2/26/13 HGBA1C (a blood test to measure the average blood sugar over 2 to 3 months) was 9.9 high (reference range was 4.5-5.7). Record review of Resident # 22's April 2013 MAR indicated [REDACTED]. Record review of Resident # 22's May 2013 MAR indicated [REDACTED]. Record review of Resident # 22's facility medical record revealed a hand written nurse note dated 2/27/13 which read in part " Resident had yet another episode of [DIAGNOSES REDACTED] at 2:00 AM, BS 22 mg/dl. [MEDICATION NAME] given as ordered and was effective. This is episode # 4 in less than 3 days..." Continued nurse notes read on 2/27/13 at 5:30 AM "NP aware of situation". Further review of the nurse notes for 2/27/13 revealed that on 2/27/2013 at 7:25 AM " Resident found unresponsive, sweating, BS 27. Gave OJ with sugar, called UM in building and RN called NP. Received orders to transfer to hospital 911." "Resident was transferred in stable condition " dated 2/27/2013 at 08:10 AM. Continued review of Resident # 22's facility computer nurse notes dated 3/05/2013 read in part "Recent hospitalization r/t [DIAGNOSES REDACTED] and being found unresponsive." Record review of Resident # 22's lab results revealed critical low glucose level of 21 on 4/25/2013 at 10:46 AM (normal glucose level is 70-110). Interview with Resident # 22 on 5/20/2013 at 9:11 AM she said she was getting ready to go to the doctor regarding her blood sugar. Record review of Resident # 22's facility medical record revealed no documentation of having [MEDICAL CONDITION] activity. It did reflect that Resident had critical drops in blood sugars. Record review of Resident # 22's glucometer readings from March 2013 revealed that on at least four different occasions (2/22/13, 2/27/13, 3/20/13 and 4/25/13) her blood sugars were critically low. During an interview on 5/21/2013 at 11:10 AM with the RN Pharmacy Consultant she stated she had looked through Resident # 22's chart and did not find any [MEDICAL CONDITION] activity documented. During an interview on 5/21/2013 at 3:30 PM with LVN D she stated that Resident # 22 was being sent to the hospital ER due to a fall at 05:30 AM "today." She stated that Resident had a swollen left ankle and did not complain to anyone about pain until "9:00 AM. Two of the CNAs called me in to look at her foot. I called the NP and got a stat order for an X-ray. We got the results at 12:40 PM today and it was showing an oblique [MEDICAL CONDITION] fibula with tissue swelling." When asked about Resident # 22's blood glucose levels that morning, LVN D stated that she checked them at " 7:30 to 8:00 AM and it was 392 and I gave her 5 units sliding scale. Then I re-checked it at 9:30 AM and it was 176. She said she was hungry so I gave her skim milk and 10 vanilla wafers. Later I checked her blood sugar at 11:30 AM and it was 131." Resident #73 Record review of Resident # 73's face sheet revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 73's April 2013 and May 2013 physician orders [REDACTED]. -[MEDICATION NAME] 10 mg, one tablet by mouth daily for [DIAGNOSES REDACTED]. -[MEDICATION NAME] 20 mg, one tablet by mouth daily with no adequate indications for use or parameters. -[MEDICATION NAME] EX 100 mg, three capsules (300 mg) by mouth at bedtime. -Zolpeidem 10 mg, one tablet at bedtime. There were no adequate indications for use. Record review of Resident # 73's April 2013 MAR indicated [REDACTED] -[MEDICATION NAME] 10 mg, one tablet by mouth daily for [DIAGNOSES REDACTED]. On 7 days no blood pressures were recorded: 4/5/2013 - 4/6/2013, 4/12/2013, 4/17/2013 - 4/19/2013, and 4/24/2013. -[MEDICATION NAME] 20 mg, one tablet by mouth daily with no adequate indications for use or parameters. -[MEDICATION NAME] EX 100 mg, three capsules (300 mg) by mouth at bedtime. Record review of Resident # 73's May 2013 MAR indicated [REDACTED] -[MEDICATION NAME] 10 mg, one tablet by mouth daily for [DIAGNOSES REDACTED]. On 2 days no blood pressures were recorded: 5/12/2013 and 5/15/2013. -[MEDICATION NAME] 20 mg, one tablet by mouth daily with no adequate indications for use or parameters. -[MEDICATION NAME] EX 100 mg, three capsules (300 mg) by mouth at bedtime. There were no initials in the signature space on 5/10/2013 to indicate that it had been administered. It was the only medication that was not signed as administered on that day. -Blood Sugar checks twice daily. There was no blood sugar recorded on 5/14/2013 for 6:30 AM. Record review of the consultant Pharmacy drug regimen review revealed that the pharmacist had signed every month from 6/2012 through 5/12/2013. Most of the months have the date of the review and the pharmacist signature. Only on the following days there were there written comments beside the Pharmacist ' s signature: - 7/25/2012 written by the signature was Dil ([MEDICATION NAME]) 4/12. -10/31/2013 written by the signature was Dil 10/12 WNL. -5/15/2013 Dil 4/13. Record review of Resident # 73's medical record revealed no documentation monitoring for [MEDICAL CONDITION]. In an interview with the DON and the ADON on 5/17/2013 at 10:25 AM they were asked who was responsible for making sure the labs were done and the results called to the physician called with the results. They said the nurses on the floor were responsible. When they were asked who was responsible for making sure the nurses on the floor were doing as they were supposed to the DON said the unit manager and the ADON and herself. They said there should be documentation that was done. When the DON asked about Resident # 73's [MEDICATION NAME]/[MEDICATION NAME] level the DON said it was not within range. She further stated it had trended down. An interview was conducted with the DON, the ADON and Station I Unit Manager LVN A on 5/19/2013 at 8:10 AM with RN A in the room. The ADON and the DON said Resident # 73 had not had any [MEDICAL CONDITION] in the facility. When they were asked the reason for the medication the DON said she would have to look at the chart. When they were asked if it was a necessary medication the DON said she did not know. Record review of Resident # 73's 5/21/2013 updated care plan revealed the following care plans: -There was no care plan related to [MEDICAL CONDITION] prior to 5/21/2013 or any care plan related to hypertension. Record review of Resident # 73's 5/19/2013 physician telephone order revealed the following order [MEDICATION NAME] level every month. Record review of Resident # 73's 5/21/2013 [MEDICATION NAME] level lab revealed the result was less than 2.5 with a reference range of 10- 20. Written on the lab slip was the following 5/21/2013 4:50 PM 1. 200 mg every am times 5 days. 2. 300 mg at bedtime times 5 days. 3. Repeat [MEDICATION NAME] level on Friday (5/24/2013_ and call results to Dr. Do not fax (this was underlined twice). Resident # 26 Record review of Resident # 26's face sheet revealed he was admitted to the facility 7/5/2011 with the following Diagnoses: [REDACTED]. Record review of Resident # 26's May 2013 physician orders [REDACTED]. -[MEDICATION NAME] 250 mg ER (For [MEDICATION NAME] ER), one tablet by mouth at bedtime (Give with [MEDICATION NAME] 500 mg for total dose of 750 mg at bedtime). There were no adequate indications for use. -[MEDICATION NAME] 500 mg ER (For [MEDICATION NAME] ER), one tablet by mouth at bedtime (Give with [MEDICATION NAME] 250 mg for total dose of 750 mg at bedtime). There were no adequate indications for use. -Blood pressure every morning. -[MEDICATION NAME] 5 mg one tablet every day, hold for SBP less than 110. This medication was started on 4/25/2013. -[MEDICATION NAME] acid level every 3 months. -[MEDICATION NAME] 50 mg, ? tablet (25 mg) by mouth at bedtime as needed for [MEDICAL CONDITION]. Record review of Resident # 26's April 2013 MAR indicated [REDACTED] -[MEDICATION NAME] 250 mg ER (For [MEDICATION NAME] ER), one tablet by mouth at bedtime (Give with [MEDICATION NAME] 500 mg for total dose of 750 mg at bedtime). There were no adequate indications for use. -[MEDICATION NAME] 500 mg ER (For [MEDICATION NAME] ER), one tablet by mouth at bedtime (Give with [MEDICATION NAME] 250 mg for total dose of 750 mg at bedtime). There were noadequate indications for use. -[MEDICATION NAME] 10 mg, one tablet by mouth once daily. There were no parameters for this medication. -Blood pressure every morning. The blood pressure was not documented as having been completed on 4/11/2013, 4/12/2013, 4/17/2013 through 4/19/2013, 4/23/2013 through 4/24/2013, 4/28/2013, and 4/30/2013. -[MEDICATION NAME] 5 mg one tablet every day, hold for SBP less than 110. This medication was started on 4/25/2013 and there was no blood pressure recorded on 4/30/2013. Record review of Resident # 26's April 2013 Behavior/Intervention Monthly Flow Record revealed for the [MEDICATION NAME] the behavior was elopement attempts. The [MEDICATION NAME] the behavior was antidepressant. There were no behaviors documented for the entire month. Record review of Resident # 26's 4/12/2013 Behavior Medicine Evaluation and Management tool read in part: ". . . this is an urgent consult. Staff asked to see this patient urgently for change in behavior. They have noticed that the patient is pulling all his clothes out of the closet and throwing them on the floor. This is a repetitive behavior. The patient has been very difficulty (sic) redirect. There is no associated distress. There are no other behavioral problems. Staff has not seen any increase in anxiety, depression, or [MEDICAL CONDITION] . . . This is dementia related behavior. It is to be noted that I had recently decreased his [MEDICATION NAME] for GDR. At this time the patient behavior is not a danger to self and others and he is not in distress. Therefore, we will not increase medications, but if needed increase [MEDICATION NAME] in future. . ." Record review of Resident # 26's 4/25/2013 Behavior Medicine Evaluation and Management tool read in part: " . . . Staff reported that patient stays confused, but they have not seen any significant behavioral problems especially pulling clothes from his closet. The patient remains redirectable (sic). On examination, the patient is calm. His only request is to be able to go home. Record review of Resident # 26's May 2013 MAR indicated [REDACTED] -[MEDICATION NAME] 250 mg ER (For [MEDICATION NAME] ER), one tablet by mouth at bedtime (Give with [MEDICATION NAME] 500 mg for total dose of 750 mg at bedtime). There were no adequate indications for use. -[MEDICATION NAME] 500 mg ER (For [MEDICATION NAME] ER), one tablet by mouth at bedtime (Give with [MEDICATION NAME] 250 mg for total dose of 750 mg at bedtime). There were no adequate indications for use. -Blood pressure every morning. The blood pressure was not documented as having been completed on 5/5/2013 and 5/6/2013. -[MEDICATION NAME] 5 mg one tablet every day, hold for SBP less than 110. This medication was started on 4/25/2013 and there was no

Based on observation, interview and record review, the Administrator and Director of Nurses failed to effectively and efficiently manage facility resources resulting in multiple system failures which resulted in two immediate jeopardies, both in the area of Quality of Care, and four substandard quality of care in the areas of Quality of Care and Resident Behavior and Facility Practices. The Administrator failed to: Related to Immediate Jeopardy/SQC: -Provide the necessary staff to prevent accidents. - Carry out his responsibilities as abuse prevention coordinator by not investigating and reporting allegations, and not providing training to his staff as to whom, what, and when to report. -Have policies and procedures related to lab procedures and on following physician's order [REDACTED]. -Supervise and monitor the DON to ensure she carried out her responsibilities in the areas of assessments, staff training, medication administration, monitoring of medical conditions and side effects of medications. The DON failed to: Related to Immediate Jeopardy/SQC: -Train, monitor, and supervise staff to ensure that residents were being supervised, ensure nursing staff were trained and knowledgeable on how to complete assessments correctly, and ensure that interventions were being put into place to prevent actual or potential harm from falls. -Ensure that the staff were adequately monitoring residents for potential and adverse reactions for individuals on [MEDICAL CONDITION], blood pressure, and blood sugar medications. -Ensure the staff were assessing, monitoring and treating resident conditions. -Monitor staff to ensure that dietary recommendations and physicians orders were followed. These failures of the Administrator and the DON affected all 98 residents and placed them at risk for not receiving the necessary care and services to maintain the highest practicable well-being. Findings: As a result of lack of supervision, Resident # 2, 22, and 23 sustained falls with injuries; and Resident # 35 caught her leg in a hole in the floor while being transported in a wheelchair causing her pain. Record review of Resident # 2's face sheet revealed she admitted to the facility on [DATE]. The following diagnoses were listed; Dementia, delusional, wandering, falls, right [MEDICAL CONDITION], arthoplasty, agitation and aggression. Record review of Resident # 2's records revealed she had two unwitnessed falls on 9/14/12 and 10/2/12 prior to seeing the neurologist. Record review of Resident #2's nurses notes revealed she went to see a neurologist on 10/11/12 who ordered her [MEDICATION NAME] at 750 mg twice a day. Record review of Resident # 2's Fall Risk assessment dated [DATE] was coded as a "6" (a score of 10 or above represent high risk for falls). In section B, History of Falls in past 3 months, 0 was coded instead of a 2 (1-2 falls in past 3 months). In section C Ambulation/elimination status was coded 0 (ambulatory and continent) instead of 4 (ambulatory/incontinent). In section G Medications was coded 2 (takes 1-2 medications), but should have been coded 4 (3-4 of the medication type listed - [MEDICAL CONDITION], antihypertensive, [MEDICAL CONDITION] (antipsychotic and antidepressant). The adjusted score would have been a 14, or high risk for falls. In an interview on 5/18/13 at 8:40 AM, LVN G was asked what interventions were put in place after Resident #2 fell on [DATE] and 10/2/12. LVN G stated the family and MD were called, her BP was monitored and she was put back into bed. She stated she went to a doctor a month later. When asked if there was a care plan in place to monitor for [MEDICAL CONDITION], LVN G stated no she did not see one before 10/3/2012. In an interview on 5/20/13 at 4:05 PM, LVN D stated she was the charge nurse for Hall 400 (secured hall) and 500 odd side, and was the nurse on 11/15/12 when Resident # 2 fell . She stated there were 2 aides assigned to the 400 hall, and that 1 aide was assisting residents in the dining room off the unit, while the other aide was on the secured unit. She stated when an aide was on break or assisting in the dining room, only one staff person was on the secured unit. She stated she was in the dining room during lunch on 11/15/12 when Resident # 2 fell on the secured unit. LVN D stated she was called to the secured unit by a CNA who told her Resident # 2 had fallen. She stated Resident # 2 had a hematoma to her left eye and there was blood on the floor in her room and she was lying on her left side. In an interview on 5/22/13 at 10:20 AM the DON stated the facility was not monitoring for [MEDICAL CONDITION] activity for residents who had [MEDICAL CONDITION], including Resident #2. She stated Resident #2 should have had a plan of care that addressed [MEDICAL CONDITION] and had follow-up charting done. Review of Resident #23's face sheet in the current medical record revealed she was admitted to the facility on [DATE]. Her diagnoses include dementia, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] and depression. Review of Resident #23's "Fall Risk Assessment" stated a score of 10 or greater was considered at high risk for potential falls, revealed on 8/28/12 and 12/29/12 she scored a 12. On 2/7/13 and 3/7/13 she scored a 16. Review of the "Incident Report" dated 2/7/13 involving Resident #23 read in part "Time of Incident - 7 PM. Exact Location of Incident - Hallway. Exactly What Happened - Noticed resident on the floor yelling out. Resident stated that she fell noticed abnormalities to L arm and L hip". In the section titled "Final Comments and/or Steps Taken to Prevent Recurrence" read "Stabilized patient prepared for EMR pickup gave PRN pain meds". Review of the nurses notes written by LVN N, dated 2/7/13 at 7:15 PM read "At or about around 7:00 PM on 2/7/13 after a late dinner, the door to the locked unit was open so that both nurses can help 400 hall while the CNA's picked up meal trays from the patients rooms. While sitting at the nurses station, noticed yelling down 400 hall and noticed patient on the floor. Patient stated that as she was walking she lost her balance and fell to the floor. Both nurses stabilized patient and prepared for transport". Record review of Resident # 22's Face Sheet revealed she had been admitted to the facility on [DATE] and had a recent re-admission date of [DATE]. Her diagnoses included: diabetes, [MEDICAL CONDITION] disease, stroke, hypertension, convulsions, and [MEDICAL CONDITION]. The re-admission on 3/01/2013 revealed a fractured right great toe. Record review of Resident # 22's facility medical record revealed no documentation of [MEDICAL CONDITION]. It did reflect that Resident had critical drops in blood sugars. Record review of Resident # 22's glucometer readings from March 2013 revealed that on at least four different occasions (2/22/13, 2/27/13, 3/20/13 and 4/25/13) her blood sugars were critically low ranges. During an interview on 5/21/2013 at 3:30 PM with LVN D she stated that Resident # 22 was being sent to the hospital ER due to a fall at 05:30 AM "today." She stated that Resident had a swollen left ankle and did not complain to anyone about pain until "9:00 AM. Two of the CNAs called me in to look at her foot. I called the NP and got a stat order for an X-ray. We got the results at 12:40 PM today and it was showing an oblique [MEDICAL CONDITION] fibula with tissue swelling." When asked about Resident # 22's blood glucose levels that morning, LVN D stated that she checked them at "7:30 to 8:00 AM and it was 392 and I gave her 5 units sliding scale. Then I re-checked it at 9:30 AM and it was 176. She said she was hungry so I gave her skim milk and 10 vanilla wafers. Later I checked her blood sugar at 11:30 AM and it was 131." In an interview with the DON and the Administrator on 5/17/2013 at 2:57 PM the DON said the staffing for the secured unit was 2 CNAs. The Administrator said at the time there is just one CNA on the secured unit when one of the CNAs was in the dining room. When he was asked about the door to the secured unit being propped open he said it was not the facility practice, they did not prop the door open. An interview was conducted with the DON on 5/23/13 at 4:10 PM. When asked about how she monitored falls for trends, she stated the facility had morning meetings and information was gathered, and falls gone over. She stated therapy was in the meeting and they help address residents who are at high risk.When asked how the facility staffed the units, she stated it was by the resident acuity and how many residents on the unit. Record review of Resident #35's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the "Incident Report" dated 5/13/2013 involving Resident #35 read in part; "Time of incident - 3:30 PM. Exact location of incident - hallway between breezeway and front lobby. Exactly what happened - Patient just finished gait training from therapy room to main door of building. Patient was sitted (sic) on w/c pushed by physical therapist to go back to gym. Patient ' s right leg was suddenly caught when passing a bump on hallway (between breezeway and wood tile on front lobby) which created too much bending on right knee. Patient was put back to bed, PT placed ice on right knee, advised patient not to move extremity. " Record review of the written statement from the PT regarding the incident with Resident #35 read; " This is regarding an incident with (Resident #35) was under physical therapy. After gait training from therapy to the main entrance of the building, patient was asked to sit on w/c to go back to the gym. Patient ' s w/c was pushed by Physical Therapist. Patient ' s right foot suddenly was caught on the uneven surface of the floor (from wood tile to breezeway) that created to much flexion of right knee. Patient was in excruciating pain after incident. Physical Therapist discontinued therapy and placed patient in bed. Placed (unknown word) and advised patient not to move extremity. Advised patient that if pain increased, notify the facility staff. " This document was not dated. Observation of the threshold between the breezeway and Station 2 on 5/15/2013 at 3:06 PM revealed a hole in the linoleum floor on the breezeway side of the threshold. The hole was observed to be 6 inches in length, 1 inch in width, and .5 inch deep. In an interview with the Maintenance Director on 5/18/2013 at 2:54 PM when shown the hole in the floor between the breezeway and Station 2 he was asked if anyone had asked him to repair the floor, he said no. When asked if he was aware of the incident involving Resident #35 on 5/13/2013, he said no. In an interview with the ADM on 5/23/2013 at 3:34 PM, he said that the facility had no policies and procedures for environmental hazards and physical environment. Resident # 2, 22, 39, 73, 85, and 95 were receiving medications without adequate indications for use or monitoring of the medications and side effects. Resident # 2 was on [MEDICAL CONDITION] medication without adequate monitoring of the medications. Resident # 2 suffered a fall with fractures in [DATE]. She had [MEDICAL CONDITION] activity resulting in hospitalization with a low [MEDICATION NAME] level in March 2013. Resident # 22 was on two anticonvulsant medications without clinical indications for it's use. She had a diagnoses of convulsions, but did not have a care plan for convulsions or the use of anticonvulsant Medication. Her blood sugars were not being monitored. Resident # 39 was receiving [MEDICATION NAME], an anticonvulsant, with no clinical indication for use and there was no related care plan. Resident # 73 was receiving [MEDICATION NAME] used for [MEDICAL CONDITION] and did not have a related care plan. His [MEDICATION NAME] level was not in range to prevent [MEDICAL CONDITION]. He was also on [MEDICATION NAME] 10 mg (antihypertensive) and [MEDICATION NAME] 20 mg (antihypertensive) there were no parameters on the blood pressure. The [MEDICATION NAME] had no indications for use. His blood pressure was not taken daily. He had Zolpeidem 10 mg ordered with no indications for use. Resident # 85 was receiving [MEDICATION NAME] and there was no care plan. Her [MEDICATION NAME] level was not in range to prevent [MEDICAL CONDITION]. Resident # 95 was to have his blood sugar tested twice a day on Mondays and Thursdays. It was only scheduled to be tested on ce a day on those days. It was only tested twice a day on one day. An interview was conducted with the DON, the ADON and Station I Unit Manager LVN A on 5/19/2013 at 8:10 AM with RN A in the room. The ADON and the DON said Resident # 73 had not had any [MEDICAL CONDITION] in the facility. When they were asked the reason for the medication the DON said she would have to look at the chart. When they were asked if it was a necessary medication the DON said she did not know. Record review of Resident # 2 ' s physician order [REDACTED]. It further revealed she now had a feeding tube placed and it was ok to administer all medications per the feeding tube. Continued review of her readmission orders [REDACTED]. Resident # 2 was on two different [MEDICAL CONDITION] medications. Record review of Resident #2 ' s clinical record revealed there were no behavior monitoring including monitoring for potential side effects of her antidepressant and antipsychotic medication from 4/10-4/30/2013. There was no monitoring for [MEDICAL CONDITION] activity or for potential side effects of the [MEDICAL CONDITION] medication. Record review of Resident #2 ' s clinical record revealed there were no labs for [MEDICATION NAME] level done for April 2013. An interview was conducted with the DON, the ADON and Station I Unit Manager LVN A on 5/19/2013 at 8:10 AM with RN A in the room. When they were asked who was responsible for checking to make sure the nurses called labs and documented that the labs were done when ordered, the DON said she was and she, the ADON, and unit manager checked orders in the morning and made sure labs were done and the results were received and noted that day. The ADON said they pulled orders to go over in the morning meeting. When they were asked about the process for labs they said lab results were faxed to the facility and the nurse was responsible for pulling of the fax and reading them off to the physician. When that was complete they were put in the chart under the lab section with the nurse ' s signature and date. They further stated when the labs were faxed to a physician they would initial the fax and fax it back. When they were asked about psychoactive medications they said consent would need to be obtained from the responsible party and the nurse was responsible for obtaining. When they were asked about monitoring they said depending on the labs and documenting on the behavior sheet any side effect. The DON said medications were not to be administered outside of parameters and they were to be given in the room. When the DON was asked about the [MEDICATION NAME] level for Resident # 2 she said the [MEDICATION NAME] level was done. She said the [MEDICATION NAME] levels were checked per doctor ' s orders. She stated Resident # 2 ' s [MEDICATION NAME] level was less than it should be and the doctor should have been notified. In an interview the ADON on 5/19/2013 at 2:35 PM she said if a nurse reported a [MEDICAL CONDITION] it would be documented in the nursing notes. She said there was no other documentation for [MEDICAL CONDITION]. She said pain would be documented in the nursing notes and the effectiveness on the back of the MAR indicated [REDACTED]. The ADON said when a resident admitted to the facility on a psychoactive medication she said they usually asked for a physician referral to psychiatric services to see if the medication can be reduced or discontinued. She further stated a few of the physicians regulate their own psychoactive medications. She said that nursing monitors the behavior sheet and if there are no behaviors for a long time they ask the physician if want to keep the resident on the medications. She stated if a resident had not used a medication 30 to 40 days they see if it can be discontinued. The ADON said the most common side effects would be listed on the behavior sheet. She stated the consultant pharmacist was in the facility two days per month to look at the resident ' s medications. She further stated he would give nursing recommendation verbally or on a list. The ADON said the list was not kept it was addressed and then destroyed. She said the list might have something to do with labs or drug reduction. When she had any documentation of the process she said the pharmacist gave the list to the DON who would give to the nurses on the floor to address. She further stated once it was addressed it was given back to the DON. She was asked if anyone looked to see if they recommendations had been carried out and she said the time frame for the recommendations to be addressed was 24 hours. The ADON was asked if letters to the physician were done by the pharmacist she said not all the time, not every visit. The facility was asked for a policy on following physician's orders [REDACTED]. At 4:15 PM the ADON stated the facility did not have a policy regarding following physician's orders [REDACTED]. The medication error rate was 25% with 11 errors in 44 opportunities involving 5 staff when combined administered medications to 6 of 6 Halls and 6 Residents (Resident # 2, # 10, # 66, # 78, # 80, and # 95) reviewed for medication pass (LVN A, LVN B, MA A, MA B, and LVN C). In an interview with the DON and the ADON on 5/17/2013 at 10:25 AM they were asked what should be on a physician order [REDACTED]. When asked if these things were not present what the staff was supposed to do the ADON said they would have to call the doctor/nurse practitioner to obtain. When they were asked about a low blood pressure they said the staff would need to call the doctor so they could be advised what needed to be done. When they were asked what was the process for administering medications through a [DEVICE] they said the staff needed to check the order. They said each medication was placed in an individual cup. When they were asked what could happen if the medication were crushed together they said there was a possibility of reaction, missing with something else could change the property. They were asked if they had watched [DEVICE] medication administration. The DON said she had watched and was asked to provide documentation of this. No documentation was provided by the time if exit. Resident # 2 had a 12% weight loss over 6 months (weight 130) on May 17, 2013. An interview was conducted with the DON, the ADON and Station I Unit Manager LVNA on 5/19/2013 at 8:10 AM with RN A in the room. When they were asked about the process for dietary recommendations they said the dietician gave the recommendations on a piece of paper with the recommendations. A copy was given to the nurses and they were to notify the doctor of the recommendations. They further stated that if the physician agrees an order was written. When asked about Resident # 2's dietary recommendation from 12/14/12, she stated "we missed the recommendations". She stated the recommendations should be carried out within 72 hours. Resident # 4 was assessed in the admission assessment on 6/22/2012 as having tooth/mouth pain with a pain level of 9, on a scale of 1-10. The facility failed to assess pain and implement interventions for 12 months, resulting in severe and ongoing pain. The resident was not seen by a dentist until 5/9/2013. When seen by the dentist, it was determined she needed to have 6 teeth extracted. The lowest pain level the resident experiences is 5 out of 10. On 5/14/2013 she complained her pain was a 10 at 8:00 AM. In an interview with the DON on 5/18/2013 at 11:32 AM when asked how the facility evaluated Resident #4's pain she said staff ask the resident to evaluate her pain on a pain scale of 1-10. She said after the medication had been administered, staff go back and reevaluate the resident's pain again using the pain scale. She then said staff must document this on the pain management flow sheet. When asked how long Resident # 4 has had pain, she said quite a while. When asked why Resident # 4 had not seen the dentist until 5/9/2013, she said she did not know. When asked how often the dentist came to the facility, she said she was not quite sure. When asked why Resident # 4's pain had not been properly monitored, she said she would have to find out. Resident # 2 sustained a dislocated jaw and was sent to theER on [DATE]. The facility did not report or investigate the injury of unknown origin. Resident # 1, 44, and 67 reported allegations of abuse. The allegations were not reported to the State or investigated thoroughly. In an interview with the ADM and DON on 5/19/13 at 10:17 AM they indicated they were unaware that Resident # 2 had an injury of unknown origin and had not reported it to DADS. At the time of exit from the facility it had not been reported. In an interview with the DON on 5/18/13 at 11:33 AM The DON stated when a resident makes an allegation of abuse by staff the ADM does the investigation since he is the abuse coordinator. She stated they remove the staff from the resident and assign them to another hall. In an interview with the ADM on 5/18/2013 at 11:32 when asked if a resident made an allegation of abuse and/or neglect, would he report that allegation to DADS, he said only after he investigated an allegation of abuse/neglect and he determined the abuse/neglect occurred, he would then call the incident in to DADS. An Immediate Jeopardy was identified for F323 on 5/17/13 at 2:57 PM and the ADM and the DON were notified at that time. A plan of removal for F323 was accepted on 5/19/13 at 3:30 PM. A second Immediate Jeopardy was identified for F329 on 5/19/13 at 4:07 PM and RN A, DON and ADM were notified at this time. A plan to remove the IJ was accepted on 5/21/13 at 4:38 PM. Summary of the Plans of Action to Remove Immediate Jeopardy: Memory care unit will have an additional 7.5 staffing hours added to allow for more supervision of residents. During mealtime when it is necessary to supervise residents movement to and from dining room from the MCU; doors will never be propped open but controlled opening and closing to allow residents safe transfer with additional oversight provided by designated staff. Additionally, the unit will never have less than two supervising staff members to ensure resident safety from hazards. Facility Administration will be reviewing all incidents and investigations daily. The interdisciplinary team will develop interventions to reduce and/or eliminate hazards, risk, and injuries related to identified potential future occurrences. The risk management/safety committee will meet weekly to review all documented injuries, accidents, or hazards to ensure ongoing compliance of documented plan, safety and supervision of residents. If any additional approaches are identified the interventions will be reviewed and changes implemented as necessary to ensure residents do not have negative outcomes. Nursing has generated a look back for three (3) months to identify all residents that have had falls. All identified residents will have their Fall Risk Assessment updated. All residents receiving anticonvulsive class medication will be reviewed for appropriate diagnosis, routine lab orders if indicated, and that physicians were notified of current lab values. All residents receiving anti-hypertensive medications will be reviewed to ensure parameters are ordered where indicated and that no medications are held without physician orders. Facility will review all accucheck orders to ensure appropriate monitoring of resident blood sugars. All parameters will be reviewed to ensure they are appropriately followed and communicated to MD when indicated. All sliding scale orders will be reviewed to ensure scheduled times are reflected on MARs accurately. All licensed and unlicensed nursing staff will receive training in the following areas specific to the issues identified in the IJ ' s and SQC: -taking manual blood pressures and blood pressure appropriately via wrist cuff to ensure accuracy of readings; -following parameters to hold anti-hypertensive meds and obtaining orders prior to holding anti-hypertensive meds without parameters and communicating with physician; -safe and appropriate administration of dilatin to ensure accurate and therapeutic dosing; obtaining, monitoring, and communicating therapeutic lab levels for anticonvulsant medications when ordered to ensure accurate, safe and therapeutic levels are maintained and unnecessary meds are avoided; -education on obtaining [DIAGNOSES REDACTED]. -blood sugar monitoring, calibrating glucometers, and following parameters when ordered to monitor hypoglycemic and hyperglycemic instances; -all certified nursing aides will be in-serviced on How to Identify Residents Who are at Risk of Falls, completing witness statements, the proper use of the Care Plan Cardex, following documented interventions as identified in plan of care, and documentation of daily interventions to identify residents who are at risk; -Care Plan/MDS Assessors will be in-serviced by the Regional Nurse on Proper Procedure to Develop and update care plans that reflect all risks associated with all identified residents; -all licensed staff will be in-serviced and trained on the Proper Procedure to Perform a Fall Risk Assessment, Completing Incident/Accident Investigations, completing witness statements, Implementing and updating care plan cardex, and 72 hours acute charting by the Regional Nurse for Health Services Management or designee. Both of the IJ's were lifted on 5/22/13 at 5:45 PM. While the IJ's were removed on 5/22/13, the facility remained out of compliance at a scope of pattern and a severity of no actual harm that is not immediate jeopardy because the facility was continuing to monitor the plans and in-service staff. An interview on 5/23/13 at 4:25 PM, the DON was conducted. When asked about how did she ensure staff were trained to take care of residents with fall risks, [MEDICAL CONDITION] and medication administration, she stated there was a rotation list and calendar for training. She stated vendors such as hospice, pharmacy, wound care and doctors would come in to give training. When asked how she ensured staff was competent in their skill for in caring for residents, she stated she would ask questions, get feed back, use questionnaires, demonstration such as what if this happened what would you do. When asked what type of plan was in place for falls, labs and medications she stated chart checks were done a couple a day by the unit managers and a lab audit was done about a month ago. She stated the goal for falls is for no more falls and to monitor and look closely. With unnecessary medications she said if a resident is on medication and the goal is to have a lower blood sugar, they would go to the MD. She stated they did go through the charts and audit. When asked if in-services had been done she stated the following: falls and fall prevention and unnecessary medications. She stated, "We do talk to the nurse and tell them if they see something to call the MD to see if it can be changed". She stated for [MEDICAL CONDITION] medications besides monitoring for labs, the facility should be monitoring and care planning for interventions. When asked about how she thought the IJ came about, she stated she was not really sure. She stated the facility was monitoring labs more closely attempting to monitor weights, diet, pain, abuse/neglect, fall/accidents and medications and make a difference with care for residents. When asked what resources were available to her she stated all are available to help her. She stated there were people who came and did audits. When asked what type of training she had when she started as DON, she stated corporate helped her, had in-services, meetings, and there was someone at the facility to help her. In an interview with the ADM on 5/23/13 at 4:17 PM when asked how he thought the immediate jeopardy came about he stated "I think there was some misunderstanding about what was going on over there (in the secured unit)" . He stated they don't prop the door to the secured unit open. He stated the door being propped open was an "isolated incident" . The Administrator stated he thought they could've had better staffing on the secured unit. He stated originally they had a nurse back there, but when they had budget cuts, they had to take the nurse out. He stated the [MEDICAL CONDITION] medications can cause more falls, but he did not think falls were at the level of an immediate jeopardy. When the Administrator was asked about what happened with the unnecessary medications, he stated, "It's hard to say. I thought everything was being done". He stated as far as the medication pass was concerned, no one had ever complained that there was any problem with medications "except Resident # 1 and she's a nurse". He stated no one else, other residents or the physicians, the pharmacy consultant etc. had ever had any complaints about medications. He stated he's "not a nurse" so it was hard for him to say about medications administered with no diagnoses for them. When the Administrator was asked about how he monitored the DON, he stated they meet every morning and go over everything that has occurred in the last 24 hours. He stated they look at everything with the Medical Director. He stated he makes a lot of observations walking through the building every day and keeps a checklist of things that have to be done. When asked how they evaluate the competency of staff, he stated that they had competency tests they did at one time, but he was not sure they were still doing them. The Administrator stated they do discuss medication pass and they do med pass and it had been good. He stated the highest error rate they had ever had was 5%. The Administrator stated their Policies are written by the Regional Corporate office and the Regional Nurse goes through them and makes any changes that are needed. When the Administrator was asked how they ensure the effectiveness of systems, he responded "Through the QA process " . The Administrator stated the Regional Nurse comes and checks the carts and does training. He stated that he assumed that the Regional Nurse looks at falls, accidents, etc. Refer to F-225, F-226, F-309, F-323, F-325, F-329, F-332. According to the facility's CMS Form 672 the census was 98.

Based on observation, interview, and record review, the facility failed to provide 1 of 29 residents (Resident # 2) reviewed for nutrition and necessary care and services to prevent unplanned weight loss when she was identified with a nutritional problem. -Resident # 2 had dietary recommendation for a nutritional supplement and a fortified food plan on 12/14/12 for a 5.53% weight loss over 1 month (weight 140 lbs). The facility did not implement the dietary recommendations until 2/21/13; 69 days later (weight 132 lbs). Resident # 2 had a feeding tube placed in March 2013, and the facility was not administering formula at the recommended and ordered time frame for 17 days. Resident # 2 had a 12% weight loss over 6 months (weight 130) on May 17, 2013. This failure affected 1 Resident and placed 6 other residents with at risk of inadequate nutrition and unplanned weight loss by not following dietician recommendations and physician orders. Finding include: Resident # 2 Record review of Resident # 2's face sheet revealed she admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Record review of Resident # 2's quarterly MDS assessment dated [DATE] revealed her weight was 150 pounds. Record review of Resident # 2's Nutritional Services Progress note dated 12/14/12, read in part, "Resident readmitted to facility at this current weight of 140 pounds. Resident with 5.53% weight change over 1 month ...Registered dietician recommends Prostat (a dietary supplement) 30 ml twice daily for 30 days and add fortified food plan (an extra 500 calories) with meals ... goal to maintain current weight...". Record review of Resident # 2's weight from the weekly weight flow sheet revealed on 12/18/12 she weighed 142 pounds. Record review of Resident # 2's weight from the weekly weight flow sheet revealed on 1/4/13 she weighed 139.8 pounds. Record review of Resident #2's Nutritional Services Progress Note dated 1/14/13 read, in part, " Resident with continued weight loss trend. Current weight 139 pounds ...no oral supplements notes ... registered dietician recommends to add Prostat 30 ml twice daily for 30 days with fortified food plan at meals. Goal is to maintain current weight ... " Record review of Resident # 2's annual MDS assessment dated [DATE] revealed her weight was 140 pounds, and was coded as having weight loss of 5% or more in the last month or loss of 10% or more in 6 months and not on a physician prescribed weight loss regimen. Record review of Resident # 2's care plan revealed under diet- altered nutrition, an update on 2/8/13 which read significant weight loss in 30 days 5.44% - 7.6 pounds and 3 months 10.92% - 16.2 pounds. Under interventions was listed monitor intake and output, provide nutritional diet as ordered, weigh patient as ordered and 2/21/13 (nutritional supplement) as ordered. Record review of Resident # 2's Nutritional Services Progress Note dated 2/18/13 read in part, "Resident with weight loss trend current weight 132 pounds, weight change 5.94% 1 month and 10.92%. Noted resident with decrease in diet to pureed on 2/7/13 ... no oral supplements and no appetite stimulants. Registered dietician recommends to add fortified food plan ...". Record review of Resident # 2's weight from the weekly weight flow sheet revealed on 2/22/13 she weighed 132 pounds. Record review of Resident # 2's physician orders revealed on 2/21/13 an order for [REDACTED]. An interview was conducted with the DON, the ADON and Station I Unit Manager LVN A on 5/19/2013 at 8:10 AM with RN A in the room. When they were asked about the process for dietary recommendations they said the dietician gave the recommendations on a piece of paper with the recommendations. A copy was given to the nurses and they were to notify the doctor of the recommendations. They further stated that if the physician agrees an order was written. If the physician did not agree the family was notified and if the family wanted the recommendation the facility would let the physician know the family wanted the recommendation implemented and that would be documented it in the medical record. When they were asked about the weekly weights the DON said she kept a copy of the weekly weights and they should be documented in the record. When asked about Resident # 2's dietary recommendation from 12/14/12, she stated "we missed the recommendations". She stated the recommendations should be carried out within 72 hours. Record review of Resident # 2's physician orders revealed she went the hospital on [DATE] and returned on 4/10/13. During this hospital stay she had feeding tube placed for a failed swallowing evaluation. Record review of Resident # 2 Significant change MDS assessment dated [DATE] her weight was 127 pounds, she was not a physician prescribed weight loss plan, and had lost 5% or more in the last month or 10% in the last 6 months. She was coded as having a feeding tube and receiving 51% or more of her total calories from the feeding tube. Record review of Resident # 2's care plan revealed under diet- altered nutrition, an update on 4/17/13 which read tube feeding [MEDICATION NAME] 1.2 as ordered. Hospital in March 2013 left at 134.5 pounds, re-admit 126.6 pounds on 4/10/13. Significant weight loss in 1 month 5.87% - 7.9 pounds, 3 months 9.44 % - 13.2 pounds, 6 months 15.32% - 22.9 pounds. Under interventions was listed: provide nutritional diet as ordered. Record review of Resident # 2's physician order dated 4/24/12 revealed an order to increase the resident ' s formula to 23 hours a day at 70 cc per hour. Review of her April 2013 MAR indicated [REDACTED]. Record review of Resident # 2 physician order dated 4/26/13 revealed an order to increase the formula to 75 cc per hour for 20 hours. Review of her April 2013 MAR indicated [REDACTED]. Record review of Resident # 2's May 2013 MAR indicated [REDACTED]. There was a handwritten entry which read "[MEDICATION NAME] 1.2 75 ml for 20 hours Off at midnight, 6 AM on" and was signed off from 5/1/13 through 5/17/13 as being given (17 days). Observation on 5/15/13 at 7:45 AM was conducted of Resident # 2. She was receiving her tube feeding at 75 cc per hour. The 1500 cc bag of formula was dated that it was hung on 5/14/13 at 10:00 PM. Observation at 8:10 AM was conducted of Resident # 2. Her tube feeding had a little less than the 1500 cc. In an interview with LVN A on 5/15/13 at 8:10 AM, she stated the formula is ordered to be off from 12:00 AM to 6:00 AM. She stated the formula was probably started at 6:00 AM. When asked how much formula should have been left in the bottle, she stated 1200 cc. Observation on 5/16/13 at 8:00 AM was conducted of Resident # 2. She was receiving her tube feeding at 75 cc per hour. The bag was hung on 5/15/13 at 10:30 PM with 1000 ml. There was 850 ml left in the bag. In an interview with LVN A on 5/17/13 at 7:45 AM, she was asked to clarify Resident # 2's order for her formula. She stated 75 cc for 20 hours would be the most recent order, but it did not match what was on the MAR. When asked if holding the formula for 6 hours would be correct and if the resident was getting the ordered formula, she stated she would have to clarify with the doctor. Record review of Resident # 2's Enteral Assessment Form dated 5/17/13 revealed the formula order was [MEDICATION NAME] 1.2 at 75 cc for 20 hours, weight was 130 pounds (12 % loss over 6 months). Record review of Resident #2's nurses notes from 12/14/12 through 2/20/13 revealed no nurses note that stated the MD did not agree to dietary recommendations. The ADON was asked for a policy on following physician orders on 5/21/13 at 3:06 PM. At 4:15 PM she stated the facility did not have a policy on following physician orders. An interview was conducted with the DON on 5/23/13 at 4:10 PM. She stated she could not recall seeing any dietary recommendations for Resident #2. Record review of the facility's 8/14/2008 [MEDICAL CONDITION] Tube Feeding policy and procedure read in part: "Purpose: To provide nourishment to the resident who is unable to obtain nourishment orally. [MEDICAL CONDITION] Tube Feeding via Pump: Verify that there is a physician's order for this procedure..." According to the CMS 672 there were 7 residents with unplanned significant weight loss.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care for 4 of 29 residents (Resident #4, # 23, # 49, and # 73) reviewed for quality of care. - Resident #4 was assessed in the admission assessment on 6/22/2012 as having tooth/mouth pain with a pain level of 9, on a scale of 1-10. The facility failed to assess pain and implement interventions for 12 months, resulting in severe and ongoing pain. The resident was not seen by a dentist until 5/9/2013. When seen by the dentist, it was determined she needed to have 6 teeth extracted. The lowest pain level the resident experiences is 5 out of 10. On 5/14/2013 she complained her pain was a 10 at 8:00 AM. - Resident #23 on 5/16/2013, she displayed excruciating pain which she described as low left abdomen pain radiating over her left hip area. When asked what level of pain her pain was, Resident # 23 was unable to verbalize a number, but grimaced and cried out. She verbalized that it was "very bad". She did not have the ordered pain patch on at that time. - Resident # 49 sustained a fall with a fractured wrist on 5/2/2013. On 5/18/2013 at 1:30 PM she had a very tight ace wrap bandage on her left arm from the wrist past the elbow and her hand and fingers were very swollen on . She was crying and very distressed. - Resident # 73 was not receiving the necessary care and services to promote wound healing. The was a stage III and had recent infection. The treatment he was receiving differed from the wound care physician notes. He did not have an order for [REDACTED]. wound care on his May 2013 physician orders. Calcium Alginate was being used in the wound care without an order. This failure affected 4 residents and had the potential to affect 94 remaining residents and puts them at risk of not receiving adequate pain or wound care intervention and/or decline in health status. Findings include: Resident #4 Record review of Resident #4's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. In an interview with Resident #4 on 5/14/2013 at 8:00 AM when asked about her pain, she said "It hurts bad, it's a 10". She said she was having pain on the left side of her face mainly in her teeth and she also had some neck pain as well. An observation on 5/14/2013 at 8:08 AM of Resident #4 ' s room revealed a bottle of "oral pain relief" in her top nightstand drawer. Resident #4 said she used it for her tooth pain. In an interview with LVN A on 5/14/2013 at 4:20 PM when asked about Resident #4's tooth pain, she said the resident began to complain of the tooth pain about a month ago. She also said that she thought the dentist saw her recently. When asked who was responsible for setting up dental appointments, she said the LBSW was responsible for making dental appointments for the residents. When asked how Resident #4's pain had been recently , she said every time she asked the resident yesterday, her pain was at a 10 on a 1-10 scale. In an interview with Resident #4 on 5/14/2013 at 4:58 PM when asked about her pain level, she said her pain was at "8". In an interview with LVN N on 5/16/2013 at 8:40 AM when asked about how often the dentist comes to the facility, and he said the dentist came monthly. When asked what "approaches" were care planned for Resident #4's pain, he said he did not see any "approaches" for pain on her care plan. In an interview with Resident #4 on 5/16/2013 at 9:00 AM when asked about her pain level, she said her pain was at "8". When asked what the lowest level her pain was ever at, and she said a "5". She then said, " I want them to pull my teeth " . In an interview with the social worker on 5/16/2013 at 10:10 AM when asked about Resident #4 seeing the dentist, she said Resident #4 was evaluated by the dentist on 5/9/2013 but the dentist did not leave any documentation. She then said she called the dentist office today to see if they could schedule an appointment for Resident #4 to get her teeth extracted. She then said the resident has an appointment with the dentist on 5/20/2013 at 11:00 AM. When asked who was responsible for setting up dental appointments, she said "I'm here 2 days a week. If a concern is identified, staff will tell me and I will schedule an appointment and set-up transportation." When asked if 5/9/2013 was the first time Resident #4 had seen a dentist, she said yes. She said the dentist usually came monthly and that most dentists in private practice would not take older residents with Medicaid because they don't know if they will get paid. In an interview with MR on 5/16/2013 at 10:20 AM she said that she had looked through all of Resident #4's thinned medical records and said she could not find any documentation for any other dental visits for Resident #4 prior to 5/9/2013. In an interview with Resident #4 on 5/16/2013 at 12:30 PM she was observed finishing her meal. She had a regular diet. When asked if she had any trouble with eating due to her pain, she said she had trouble chewing meat. She said the meat would get stuck in her teeth. She also said that she had trouble speaking due to the pain in her teeth. She also said that cold foods hurt her teeth. She was eating ice cream and said it did not hurt her teeth because it did not touch her teeth. During the interview the resident was observed to have problems with her speech. In an interview with Resident #4 on 5/16/2013 at 1:46 PM Resident said that her teeth hurt every day, "I hurt so bad". When asked how the pain had affected her daily life, she said that she was "ashamed to talk". When asked what her pain level was at, she said at an "8". In an interview with Resident #4's family member on 5/16/2013 at 2:18 PM when asked about his mother's pain, he said she has waited 8 months to see a dentist. He said the social worker is only here Monday and Thursday until 3:00 PM. He then said that she had been complaining about the dentist for the longest time. He then said the facility apologized about Resident #4 not seeing the dentist. He said he spoke with the DON last week about his mom not having seen the dentist. When asked what the facility said to him when he would complain about his mother's pain, he said the facility staff told him they thought she would just want more medicine. He also said he had never spoken with the DON prior to last week, in the past he would just talk with nurses on the floor. He said when he asked the DON why it took so long for them to get a dental appointment for his mother, she said she did not know why it took so long. When asked if he had ever been invited to a care plan meeting, he said no. when asked if he was his mother's responsible party, he said yes. He also said that LVN A told him that the reason the doctor did not want to change her pain medication was because he thought she would be medication seeking. In an interview with MD A on 5/17/2013 at 11:08 AM when asked about Resident #4's pain, he said she had bad teeth. He then said he did not want to change her pain medication because she usually had little to no pain before or after she received her medication. He then said he did not think she was "in that much pain all the time" and that she was asking for pain medications just to get pain medications. When asked why Resident #4 had not seen a dentist until 5/9/2013, he said he did not know. In an interview with the DON on 5/18/2013 at 11:32 AM when asked how the facility evaluated Resident #4's pain she said staff ask the resident to evaluate her pain on a pain scale of 1-10. She said after the medication had been administered, staff go back and reevaluate the resident's pain again using the pain scale. She then said staff must document this on the pain management flow sheet. When asked how long Resident #4 has had pain, she said quite a while. When asked why Resident #4 had not seen the dentist until 5/9/2013, she said she did not know. When asked how often the dentist came to the facility, she said she was not quite sure. When asked why Resident #4's pain had not been properly monitored, she said she would have to find out. When asked who Resident #4's responsible party was, and she said her son. She said she spoken to him 2 weeks ago when the dentist was going to visit Resident #4 on 5/9/2013. She then said she had never spoken with him prior to that. When asked why Resident #4's son was not invited to care plan meetings, she said she would have to talk to the MDS office. When asked if a dental consult should have been made for Resident #4 shortly after her admission, she said yes. Observation of Resident # 4 on 5/18/2013 at 12:20 PM revealed she had three teeth on the top of her mouth, one on the right side of the mouth and two on the left side. The teeth were broken with missing portions of silver filling. There was brown decay noted at the gum line. There were two teeth on the bottom left side of the mouth with brown decay at the bottom of the tooth at the gum line. When asked which teeth caused her pain the resident pointed to above five teeth. In an interview with the ADM on 5/18/2013 at 12:42 PM when asked about Resident #4's pain, he said he was not aware of her pain prior to her getting seen by the dentist. When asked why Resident #4 had not seen a dentist until 5/9/2013, he said he did not know. Record review of Resident #4's Admission MDS dated [DATE] revealed the following: Section J: Pain Assessment Interview. Pain Presence - Ask resident: "Have you had pain or hurting at any time in the last 5 days?" Coded 1 (Yes). Pain Frequency - Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?" Coded 1 (Almost constantly). Pain Effect on Function - Ask resident : "Over the past 5 days, has pain made it hard for you to sleep at night? " Coded 1 (Yes). Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?" Coded 1 (Yes). Pain Intensity - Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." Coded 9. Record review of Resident #4's Quarterly MDS dated [DATE] revealed the following: Section J: Pain Assessment Interview. Pain Presence - Ask resident: "Have you had pain or hurting at any time in the last 5 days?" Coded 1 (Yes). Pain Frequency - Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days? " Coded 2 (Frequently). Pain Effect on Function - Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?" Coded 1 (Yes). Pain Intensity - Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." Coded 6. Record review of Resident #4's Annual MDS dated [DATE] revealed the following: Section J: Pain Assessment Interview. Pain Presence - Ask resident: "Have you had pain or hurting at any time in the last 5 days?" Coded 1 (Yes). Pain Frequency - Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?" Coded 2 (Frequently). Pain Effect on Function - Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?" Coded 1 (Yes). Pain Intensity - Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." Coded 3. Record review of correspondence from a dental provider to the facility dated 5/16/2013, read in part; " (Resident #4) was evaluated by (dentist) on 5/9/13. It is recommended that she have 6 extractions and an upper denture and a lower partial made." Record review of Resident #4's "Pain Assessment" dated 5/25/12 read in part; " Reason for Assessment - Admission. ...Frequency of pain - Frequent. ...Intensity: (Patient rates the pain on 0-10 scale) At this time - 10. ...Comments: Patient indicates that pain frequently felt in oral cavity and related to her teeth." Record review of Resident #4's "Pain Management Flowsheet" dated 6/23/2012 - 6/28/2012 revealed Resident # 's pain level was as follows: -6/23/12 - pain rating of 9, 6/13/12 - pain rating of 10, -6/14/12 - pain rating of 8, 6/15/12 - pain of 8, -6/15/12 - pain of 10, 6/19/12 - pain of 10, -6/20/12 - pain of 10, 6/20/12 - pain of 10, -6/25/12 - pain of 10, 6/26/12 - pain of 10, - 6/27/12 - pain of 10, 6/27/12 - pain of 10, -6/28/12 - pain of 10 and 6/28/12 - pain of 10. Record review of Resident #4's clinical record revealed following the 6/2012 pain management flowsheet, there were no other pain management flowsheets found in her clinical record until 4/25/2013. Record review of Resident #4's "Pain Management Flowsheet" dated 4/25/2013 - 5/10/2013 revealed Resident #4 ' s pain level was as follows: 4/25/13 - pain of 10, 4/26/13 - pain of 10, 4/27/13 - pain of 10, 5/1/13 - pain of 10, 5/1/13 - pain of 10, 5/2/13 - pain of 10, 5/2/13 - pain of 10, 5/3/13 - pain of 10, 5/3/13 - pain of 10, 5/4/13 - pain of 10, 5/4/13 - pain of 10, 5/7/13 - pain of 10, 5/8/13 - pain of 10, 5/9/13 - pain of 10, 5/9/13 - pain of 10, 5/10/13 - pain of 10. The column "Pain After Intervention" was left blank on all dates. Record review of Resident #4's "Comprehensive Plan of Care" read in part; "6/10/12 - Problem/Need: resident has dental concerns and is at risk for increased pain and infections. Goal: Will consume adequate nutrition and hydration, pain will be relived within hour of intervention and no s/s of infection will occur over next 90 days. Approach: ...3. Monitor for pain, excessive bleeding, etc. report to MD. ...5. Provide dental care as needed." Record review of Resident #4's "Nurses Notes" dated 5/15/2013 read in part; " 6:55 PM - Doctor (MD A) called to notify him about present complaints of resident pain sensation of 10/10 at the level of 1-10. As per (MD A) 'She is getting the highest pain medication she can get now with [MEDICATION NAME]/apap tab 10-325 mg, 1 tab PO Q4 hours. No change given, nothing can be done as per (MD A) because she has been complaining of tooth pain for years.' No change given. Will continue to monitor." Record review of Resident #4's referral for psychiatric services with an outside provider dated 5/16/2013 read in part; Referring MD: Referred by: (LVN N). Primary reason(s) for referral: Patient continues to ask frequently for pain medication. Establishing other techniques (denies) patient is irritable. ...Pain management (e.g., patient is prescribed pain medications; need clinician to assess if patient can work from a non-pharmacological perspective using established pain management techniques like guided imagery and relaxation skills)." Resident # 23 Review of Resident #23's face sheet in the current medical record revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #23's "Pain Assessment" dated revealed on 2/07/2013 after her fall she scored a 10 (worst pain imaginable). Review of the 5/07/2013 pain assessment revealed she scored a 0 on the pain assessment (no pain). No other assessments were given by the end of the survey. Review of the physicians orders dated 4/2/13 read "clarification order [MEDICATION NAME] 5% (Lidicaine) apply patch to lift hip peri-incisional area once daily up to 12 hours. On at 8 AM off at 8 PM. Tramodol 50 mg 1 tablet by mouth TID for left hip pain". Record review of the May 2013 MAR for Resident # 23 revealed she was to have a Lidicaine 5% patch placed over her left hip at 8:00 AM and removed at 8:00 PM. The MAR indicated [REDACTED]. Observation on 5/16/2013 at 9:45 AM of incontinent care for Resident # 23 by CNA C and CNA D revealed no evidence of any pain patches on her body during incontinent care. Upon movement, Resident # 23 was observed to display excruciating pain which she described as low left abdomen pain radiating over her left hip area. She also expressed fear of falling from the bed while having incontinent care provided. Even though Resident 23 was in a great deal of pain, CNA C and CNA D proceeded with the incontinent care. CNA D stated they would " tell the nurse she needed pain medication. Observation on 5/16/2013 at 11:30 AM of Resident # 23 in her bed, smiling. When asked if she was in pain, she stated she was feeling less pain. She stated she did not remember getting any medication. Observation and interview on 5/16/2013 at 12:45 PM with Resident # 23 revealed she was smiling. When asked about her pain level, Resident # 23 stated the pain patch had been put on and " That helped a lot. " Observation of Resident # 23's left hip area revealed the Lidicaine patch in place. During an interview on 5/16/2013 at 11:35 AM with LVN D when asked who would have been responsible for placement of the Lidicaine pain patch on Resident # 23, she stated the medication aide would be responsible. When asked if she had given any pain medication to Resident # 23, she stated she had not. When asked what hall she was the charge nurse for, LVN D stated she had the secure unit where Resident # 23 resided and the back of Hall 500. She stated she only went to the secure unit occasionally during her shift. She stated there were two CNAs on the secured unit except at meal times, when one CNA would go to the dining room for about one hour. During an interview on 5/16/2013 at 12:40 PM with the DON, she was shown Resident # 23's MAR indicated [REDACTED]. She stated the initials were MA C. During an interview on 5/16/2013 at 12:55 PM with MA C when asked if she had put the Lidicaine patch on Resident # 23 that morning, she stated she had. When asked when she put it on, MA C said "about 9:15." Resident # 49 Record review of Resident # 49's Face Sheet revealed she had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 49's hand written nurse notes for 5/02/2013 at 5:58 PM read in part "Resident was found on floor at 4:25 PM. Assessment indicated no acute injury, RP and PCP notified." Record review of Resident # 49's Pain assessment dated [DATE] reflected her pain as the highest being a 6 out of 10 (10 = worst pain imaginable) and the least pain as 0 (0 = no pain). Under the section titled "Effects of Pain" : the following areas were checked as problem areas due to pain: sleep disturbance, mood/behavior, and physical activity change. Record review from 5/8/2013 through 5/18/2013 revealed that her arm, hand and fingers were swollen and she was pulling at the dressing. The resident was agitated and had complaints of pain. An observation on 5/18/2013 at 1:30 PM of Resident # 49 sitting in her wheelchair at the nurses station revealed she was crying and was very distressed. She was observed to have a very tight ace wrap bandage on her left arm from the wrist past the elbow. There was evidence of [MEDICAL CONDITION] below and above the ace bandage. Her fingers were very swollen. Her arm was not elevated. She was crying out that she was in pain. She was observed to be attempting to remove ace wrap. She was observed to be hitting out at staff at this time. Observation on 5/19/2013 at 08:30 AM of Resident # 49 in her wheelchair at the nurse's station. She was asleep in her wheelchair. Her left hand was wrapped tightly in an ace wrap. Above and below the ace wrap the resident's hand and arm was very swollen. An interview on 5/21/2013 at 2:00 PM with LVN D revealed that Resident # 49 had been sent to a hospital on [DATE] due to her fractured left wrist and her behaviors. Record review of Resident # 49's hand written nurse notes for 5/03/2013 at 3:44 PM read in part "Resident asked what happened to arm. She stated "I was in the bathroom drinking coffee and it dropped. I stood up to get it and slipped." Continued hand written nurse notes for this date at 3:50 PM reflected that X-ray results were called to physician with orders to send to specialist to be seen "today or Monday". Continued review of hand written nurse notes for 5/03/2013 at 4:00 PM reflected that the specialist was contacted and nursing was told to "splint Resident's arm and he will see on Monday." Record review of Resident # 49's hand written nurse notes dated 5/18/2013 at 1;20 PM read in part "Phoned Dr... request for pain med for break through pain..received orders for Tylenol 500 mg. one or two every 4-6 hours PRN pain." Continued record review of the nurse notes dated 5/18/2013 revealed that at 1:25 PM Resident denied any pain after receiving 2 Tylenol 500 mg. At 4:00 PM Resident received [MEDICATION NAME] 10/325 mg. At 6:48 PM the notes reflected that Resident # 49 was in additional and acute pain and the MD was notified and gave orders to X-ray left hand and wrist. Continued review of the nurses notes dated 5/18/2013 at 8:20 PM that Resident refused to allow X-ray and became increasingly agitated and hitting at staff. According to the continuing nurse notes, Resident # 49 was given IM [MEDICATION NAME] at 9:00 PM for increasing agitation and then calmed down and slept. According to the nurse notes dated 5/19/2013 at 7:45 PM she was sent to a behavioral hospital per physician orders. Record review of Resident # 49's left wrist X-ray results dated 5/19/2013 revealed there was a "recent non displaced wrist fracture ....involving distal ulna". No other X-results were located on resident's facility medical record. Record review of Resident # 49's Fall Risk assessment dated [DATE] coded her as "20" which indicated a high risk for falls and history of having 2 or more falls in the past 3 months. Record review of an incident report related to the fall for Resident # 49 on 5/02/2013 read in part that she was found by therapy staff that happened to be walking past her room and noticed her on the floor in a sitting position. According to a hand written description of the incident by COTA A, Resident # 49 was found on the floor and reported by her room-mate to her at the nurse's station. According to the report by the COTA A, Resident # 49 was found by the bathroom door, on her left side with her left elbow and left hand on the floor. Resident # 73 Record review of Resident # 73's face sheet revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Observation on 5/15/13 at 9:30 AM, LVN M was observed providing wound care to Resident # 73 ' s left heel. After washing his hands, LVN M removed the resident ' s bootie, and there was a wrapped dressing around the resident ' s ankle/foot area which had brown drainage saturated through the dressing. LVN M then started to proceed with the wound care, wiping the wound downwards motion and back and forth. He opened the foam dressing with calcium alginate and collagen before securing with a wrap dressing. LVN M stated to Resident #73 that the bootie he was wearing needed to be laundered since the dressing had saturated through the dressing. Observation on 5/15/13 at 10:30 AM revealed Resident # 73 had no bootie on his foot. Record review of Resident # 73's admission assessment dated [DATE] revealed the following under the skin assessment: left foot healed dry skin to heel. Record review of Resident # 73's 6/25/2012 skin assessment: "(Right) BKA (with) healed incision scar. (Left) foot toes amputation healed incision scar (with) healed scab at bottom of heel. Skin very dry. (No) skin breakdown. Skin intact". Record review of Resident # 73's 6/25/2011 physician orders [REDACTED]. -Wound care to evaluate and treat left foot. Record review of the 7/22/2011 skin assessment revealed that left heel was written in the comments. Record review of Resident # 73's Head to Toe Skin Condition Record revealed that on 7/27/2012 Resident # 73 had a stage III ulcer to the left heel with moderate drainage and odor that measured 8.9 cm by 6.7 cm by .02 cm. Record review of Resident # 73's 2/6/2013 physician telephone order revealed the following order: Wound culture and sensitivity of left heel ulcer on Friday 2/8/2013. Record review of Resident # 73's 2/7/2013 electronic nursing notes revealed that the wound care physician had ordered a wound culture and sensitivity via swab technique. It further revealed it would be performed on the next dressing change on Friday. It further revealed that there were no changes to wound treatment orders. The wound care was [MEDICATION NAME] ointment followed by collagen and foam dressing every Monday, Wednesday, Friday, Sunday and PRN. Record review of Resident # 73's 2/11/2013 lab result revealed that the test was rejected due to the specimen being too old, greater than 48 hours and the not being labeled with a date of birth on the swab. It read "Please recollect". Record review of Resident # 73's medical record revealed no lab results or documentation that the specimen had been recollected. Record review of Resident # 73's 2/14/2013 electronic nursing notes revealed that wound had some sort of infection and it had been cultured and the results were pending at that time. It further revealed the culture results would be reviewed and reported to the attending physician or wound care physician as soon as available. Record review of Resident # 73's 2/22/2013 physician telephone order revealed the following order: Discontinue collagen to left heel ulcer. Apply Santyl [MEDICATION NAME] and calcium alginate daily to left heel. Record review of Resident # 73's 3/1/2013 physician telephone order revealed the following order: wound culture and sensitivity of left heel ulcer next Monday. (3/4/2013) Record review of Resident # 73's 3/1/2013 Wound Progress/Procedure Note, Physician revealed that the left heel ulcer was currently being treated with Santyl, [MEDICATION NAME] and calcium alginate. It further revealed that the wound had increased in size. It also revealed that wound culture was to be obtained because the previous sample was not collected by the lab. It revealed that plan of care was discussed with the facility staff. Record review of Resident # 73's 3/1/2013 electronic nursing notes revealed that the current orders were Santyl and [MEDICATION NAME] ointment topically to wound bed daily with dressing changes. It further revealed that wound care physician had ordered another wound culture and sensitivity. Record review of Resident # 73's March 2013 Treatment Record revealed the following: -Clean wound to left heel with wound cleanser, pat dry, apply Santyl, Mupirocin and apply calcium alginate, wrap with rolled gauze and secure with tape once daily. This was completed from 3/1/2013 through 3/15/2013. Written next to the order after 3/15/2013 was discontinue, order change. -Cleanse ulcer left heel with wound cleanser, pat dry apply callasorb collagen to wound bed (in combination with [MEDICATION NAME]), change every Monday Wednesday Friday Sunday and PRN. There were initials to indicate this had been completed on 3/17/2013 only. Next to the date written in was changed. -Cleanse ulcer on left heel with wound cleanser and apply [MEDICATION NAME] gel to wound bed daily, cover with dry gauze dressing. There were initials to indicate that the dressing was done from 3/20/2013 through 3/28/2013. Written next to the order after 3/28/2013 was discontinue, order change. -Cleanse ulcer to left heel with wound cleanser, pat dry, apply [MEDICATION NAME] and collagen to wound bed Monday Wednesday Friday and PRN. There were initials to indicate that this had been done from 3/29/2013 through 3/31/2013. Record review of Resident # 73's 3/8/2013 Wound Progress/Procedure Note revealed that the left heel ulcer was currently being treated with Santyl, [MEDICATION NAME] and calcium alginate. It further revealed the ulcer had increased size from the previous exam. It also revealed if it were to remain clean for next exam would change to collagen. It revealed the physician was waiting for sensitivities form wound culture. It revealed that plan of care was discussed with the facility staff. Record review of Resident # 73's 3/10/2013 Aerobic Culture lab result revealed that it was obtained on 3/5/2013. It had faxed 3/10/2013 written on the lab slip. The results were as follows: Prelim 2 left heel: -Isolate: 3 + Providencia stuartii isolated. -Isolate: 3 + Morganella morgaii isolated. -Isolate: 3 + [MEDICAL CONDITION] Resistant Staphylococcus aureas (MRSA) isolated. The date of these results was 3/8/2013. It revealed that the culture was in progress and incubation was required. Final left heel -Isolate: 3 + Providencia stuartii isolated. -Isolate: 3 + Morganella morgaii isolated. -Isolate: 3 + [MEDICAL CONDITION] Resistant Staphylococcus aureas (MRSA) isolated. -Isolate: 3 + Pseudomonias serginosa isolated. Record review of Resident # 73's 3/11/2013 electronic nursing notes revealed that the current treatment was [MEDICATION NAME] and that the wound had clinical signs of infection with an increased drainage and a malodorous scent. Record review of Resident # 73's 3/12/2013 physician telephone order revealed the following order: Keflex 500 mg one by mouth twice daily for 14 days for infected ulcer left heel. Record review of Resident # 73's 3/15/2013 Wound Progress/Procedure Note revealed that the left heel ulcer was currently being treated with Santyl, [MEDICATION NAME] and calcium alginate. It further revealed the ulcer had increased size from the previous exam. The plan revealed that the Santyl and alginate were going to being discontinued and resume [MEDICATION NAME] and collagen changing every Monday Wednesday Friday and PRN secondary to soiling. It further revealed that the wound culture and sensitivity had been reviewed and the antibiotic was changed. It revealed that plan of care was discussed with the facility staff. Record review of Resident # 73's 3/15/2013 physician telephone order revealed the following order: -Discontinue Santyl and calcium alginate to left heel ulcer. Apply [MEDICATION NAME] and collagen to left heel ulcer changing Monday Wednesday Friday and PRN secondary to soiling. -Discontinue Keflex -[MEDICATION NAME] 1 g IM daily times 7 days re left heel wound infection. Record review of Resident # 73's 3/18/2013 physician telephone order revealed the following order: -Discontinue Mupirocin ointment to left heel ulcer. -Begin [MEDICATION NAME] topical ointment, apply to left heel ulcer daily with dressing change. Record review of Resident # 73's 3/19/2013 electronic nursing notes revealed that the resident had recent changes in treatment including combating the infection. It further revealed the current treatment was [MEDICATION NAME] and collagen to the wound bed every Monday, Wednesday, Friday and PRN. Record review of Resident # 73's 3/21/2013 electronic nursing notes revealed that the wound had been displaying clinical signs of infection with malodorous scent and discolored tissue to wound bed. Record review of Resident # 73's 3/24/2013 Wound Progress/Procedure Note revealed that the left heel ulcer treatment was changed to [MEDICATION NAME] on 3/18/2013 due to insurance not covering [MEDICATION NAME], It further revealed the ulcer had decreased in size. It also revealed that the plan was to add a collagen to the wound changing Monday Wednesday Friday and PRN secondary to soiling. . It revealed that plan of care was discussed with the facility staff. Record review of Resident # 73's physician telephone orders revealed the following orders: -3/29/2013 Discontinue [MEDICATION NAME] 1 %. -Discontinue Mupirocin 2 % to left heel. - Discontinue Mupirocin 2 %on Monday, Wednesday, Friday. There was no time on this orders Record review of Resident # 73's 3/29/2013 physician telephone order revealed the following order: Apply [MEDICATION NAME] ointment and collagen to left heel ulcer changing Monday Wednesday Friday and PRN secondary to soiling. This order did not have a time and it was b