Every finding on record at West Oaks Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinence. The facility failed to ensure Resident #1 did not have feces in her private area after she was provided incontinent care on 07/29/26 from 3:29 p.m. through 3:41 p.m. This failure could place residents at risk for pain, infection, injury, and hospitalization.Findings included: Record review of Resident #1's face sheet, dated 07/29/26, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypertension (when the blood pushing against the artery walls is constantly too high), hemiplegia (total or partial paralysis affecting only one side of the body), and cerebral infarction (breakdown of brain cells causing a serious decline in memory, thinking, and ability to do daily tasks). Record review of Resident #1's admission assessment MDS, dated [DATE], revealed a BIMS of 02 out of 15, which indicated severely impaired cognition. It also showed Resident #1 was dependent on staff with ADL care. Further review revealed the resident was incontinent of bowel and bladder. Record review of Resident #1s care plan, initiated 06/23/26, read the resident had incontinence related to self-care deficit. Intervention: check and change during rounds and as needed. During an interview on 07/29/2026 at 3:00 p.m., Resident #1 said she was provided incontinent care that day but could not remember when the care was provided. Resident #1 touched the front part of her incontinent brief and said she was itching there. During an interview on 07/29/2026 at 3:06 p.m., CNA A said she arrived to work around 2:03 p.m., and she was Resident #1's CNA. She said she had not checked on Resident #1 since she got to work. CNA A said aides made rounds every 2 hours to check residents for incontinent care. During an observation on 07/29/2026 between 3:29 p.m. and 3:41 p.m., CNA A provided incontinent care for Resident #1 and the Staffing Coordinator assisted with care. When CNA A opened Resident #1's incontinent brief it revealed the brief was clean and dry in the front. CNA A cleaned Resident #1's peri area(external region of the body located directly between the genitals and the anus), the wipe had a substantial amount of feces, from Resident #1's vagina area. She wiped the same area again, and the wipe still had feces, and she cleaned two more times and there was still substantial amounts of feces. When CNA A cleaned the fifth time there were faint feces on the wipe, and when she wiped the sixth time the wipe was clean. When she turned Resident #1 to her left side, it revealed the back of the incontinent brief with three faint streaks of feces and Resident #1 was not having a bowel movement at the time of the observation. CNA A cleaned Resident #1's rectum and there were no feces, she wiped both buttocks four times and there were faint feces on the wipe two times and on the third and fourth times the wipe was clean.During an interview on 07/29/26 at 3:49 p.m., the Staffing Coordinator said Resident #1 had a lot of bowel movement in her peri area and CNA A cleaned Resident #1's peri area about six times before the area was clean. Staffing Coordinator said the resident did not have an active bowel movement during this provided incontinent care. She said it could have happened earlier when Resident #1 was provided with incontinent care after she had a bowel movement. Staffing Coordinator said if Resident #1 was not cleaned properly the resident would have UTI (Urinary tract infection) or some kind of infection. During an interview on 07/29/26 at 4:01 p.m., CNA A said when she unfastened Resident #1's incontinent brief the front of the incontinent brief was clean and dry, and the back of the incontinent brief had light streaks of bowel movement. CNA A said she wiped Resident #1's peri area about 6 times before there was no bowel movement on the wipes. She said there was no bowel movement on Resident #1's rectum. She said she wiped Resident #1's buttocks six times and there was faint bowel movement and on the fifth and sixth times the wipes were clean. CNA A said Resident #1 was not wiped properly when she had a bowel movement before her shift. She said Resident #1's peri area could have itching, irritation, and infection if the bowel movement was not clean completely from the resident private area. During an interview on 07/29/26 at 5:12 p.m., ADON A said Resident #1 could have had an episode of bowel movement after the resident was provided incontinent care, and maybe she was not cleaned properly when she had a bowel movement. He said if Resident #1 had feces in her private area, it could lead to infection. When ADON A was asked if Resident #1 had a bowel movement after she was cleaned, why did she not have bowel movement on the incontinent brief and rectum and he did not respond. During an interview on 07/29/26 at 5:16 p.m., the DON said she expected the aides to follow the facility policy and protocol for incontinent care when any resident was provided care. She said if Resident #1 had feces in her private area it could lead to infection, and she could not say the staff did not clean the resident properly because she could not prove it. Record review of the facility policy titled, 2.7.3 Procedural Guideline #20 - Perineal Care/Incontinent Care Female revised 03/2024, read in part, . purpose.to clean the female perineum(between genitals and anus) without contaminating the urethral area(region surrounding the tiny opening where pee leaves the body with germs from the rectal area.emphasizing clean to dirty.

Based on observation, interview, and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible and receives adequate supervision to prevent accidents for 1 of 2 (Resident #24) residents reviewed for accident hazards.-The facility failed to ensure Resident #24 was transferred with a one-person assist when she was a two-person assist on 3/3/2026 and sustained an injury requiring stitches. This failure could place residents at risk of injury. Findings included:Record review of Resident #24's face sheet, dated 03/10/2026, revealed a [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Her medical diagnoses included end state renal disease (severe kidney disease), morbid obesity (excess weight defined by a body mass index of 40 or higher which can lead to increased risk of heart disease or death), type 2 diabetes mellitus (high blood sugar), heart failure, peripheral vascular disease (a condition characterized by narrowing of arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping) and anxiety disorder (disorder consisting of prolonged periods of worry and anxiousness).Record review of Resident #24's admission screening, dated 02/24/2026 and signed by ADON A, indicated she had a self-care deficit with the goal of maintaining or improving her ability to participate in her care with ADLs and an intervention of a 2-person assistance with transfer/toilet transfers. Record review of Resident #24's Comprehensive MDS, dated [DATE], indicated she scored a BIMS of 14, indicating high cognitive intactness related to memory and thinking. Further record review indicated Resident #24 required substantial to maximal assistance in bed mobility where the helper does more than half the effort like lifting or holding the trunk or limbs and provides more than half the effort for things such as chair or bed-to-chair transfer, sitting to lying, and lying and rolling left and right. Record review of Resident #24's progress notes for March 2026, indicated the following entries:-On 03/03/2026 at 2:43pm by a physician, she had bilateral heel ulcers. She had therapy precautions for falls/orthostatic (related to standing upright)/cardiac. High risk for falls if hypotension (low blood pressure) develops. Resident #24 was noted as having decline in performing ADLS and func (functional) mobility. -On 03/03/2026 at 2:57pm, she was seen for wound care that day.-On 3/3/2026 at 3:01pm Resident #24 was documented as having change in condition which was other change in condition. -On 3/3/2026 at 3:29 LVN A wrote that while being transferred to bed from her wheelchair with staff' assistance, the resident's right leg hit the grab handle of the bed causing a laceration to the right lower leg. Pressure was applied, actively bleeding. Area wrap with ace wrap.Intervention in placed resident is a two staff transfer. Area clean of any clutter. And maintain a safe transfer. Wound Care MD ordered Resident #24 to be transferred to the hospital. Record review of Resident #24's SBAR form dated 03/03/2026, she had a laceration to the right lower leg. Resident #24 had new pain rated at a level of 4 out of 10. Resident #24's primary care clinician was notified on 03/03/2026 at 2:30 p.m. and ordered the resident be sent to the ER. The summary of the event read in part, Resident was being transferred to her bed from wheelchair with staffs' assistance. Resident right leg hit the grab handle on the bed causing a laceration to right lower leg. Pressure apply actively bleeding. area wrap with ace wrap. Order by wound care MD to [NAME] resident to ER 911 called and Resident transfer to [hospital name] The document was signed by LVN A.Record review of Resident #24's hospital records, dated 3/4/2026 at 3:42 p.m., indicated Resident #24 told the MD that in the nursing while transferring from the wheelchair to the bed she accidentally had a leg injury resulting in the right leg laceration. Laceration was repaired and vital signs were stable. Resident #24 was admitted to the hospital due to hyperkalemia, with levels at 7.2, indicating high potassium levels. Resident #24 was alert and oriented x3.Record review of Resident #24's care plan, dated 03/09/2026, indicated she was care-planned for self-care deficit due to weakness with interventions including transfer/toilet transfers for 2-person assistance on 2/24/2026 and then 1-2-person assistance on 3/3/2026. Resident #24's care plan was revised on 03/12/2026 to reflect Resident #24 needed a 2-team member transfer/toilet transfer with a mechanical lift. Record review of Resident #24's therapy evaluation, dated 03/01/2026, indicated Resident #24 was referred for new onset of decrease in functional mobility, decrease in strength, decreased coordination, reduced dynamic balance and increased need for assistance from others. She required substantial or maximal assistance for chair or bed-to-chair transfer at baseline with the goal to improve ability to safely and efficiently transfer to and from a bed to a chair (or wheelchair) with setup or clean-up assistance with recognition of safety hazards. Record review indicated it was signed by PTA M on 3/3/2025 at 5:12 p.m Record review of Resident #24's therapy encounter notes, dated 3/3/2025, indicated she worked on strengthening and balance exercise while seated in her wheelchair. Resident #24 used assist bar in pulling up to sitting and bringing both legs off the bed and transferred from bed to wheelchair with minimum assist and verbal cues for sequencing and hand placement. Resident #24 did not transfer from wheelchair to bed during this encounter. Record review indicated it was signed by PTA G on 3/3/2026 at 1:50pm.Record review of Resident #24's wound care doctor's visit notes, dated 03/03/2026, indicated she had a diabetic wound on the left and right foot, both healing or maintaining healing. Record review of the wound nurse's notes, dated 03/13/2026, indicated she measured Resident #24's wound laceration which was 10.94 cm in length and 1.66 cm in width.During an interview on 3/10/2026 at 10:15 a.m., during initial rounds, Resident #24 said she just returned from the hospital. She said CNA B was trying to transfer her from the wheelchair to her bed. Resident #24 said she told CNA B that she needed another CNA to help, but CNA B said she could transfer her without anyone else and instructed the resident to hold onto the gelt belt, and while transferring her from the wheelchair to the bed, Resident #24's right leg got caught by an object in the bed and tore her leg. Resident #24 said she was sent to the hospital, where she received 18 stitches. Resident #24 said the facility was short of staff and sometimes it took 2 to 3 hours for staff to respond to her call light. In a later interview with Resident #24 on 3/12/2026 at 6:07 p.m., she said she told CNA B she wanted two people because she had always need two people assist transferring her, but CNA B said she was standing fine and that they both could do it without a second person. Resident #24 said she agreed to it, but she felt uncomfortable and she said she should not have agreed to having one person helping her. Resident #24 said she thought her leg hit the end of the assist bar. In an interview on 03/13/2026 at 9:33 a.m., Resident #24 said she was slipping off the bed and CNA B was assisting her to scoot closer to the center of the bed and when CNA B turned to help her get stable in bed that was when she lost balance and kicked out with her right leg. Resident #24 said she was not sitting stable at the time. She said there should have been two staff helping her back into bed. Resident #24 said due to her pressure ulcers on her foot she wanted to let it heal and she wanted to stay in bed for now and that she was told to stay in bed by hospital staff.During an observation and interview of Resident #24's wound on 03/10/2026 at 1:18 p.m., the WCN said Resident #24's injury ran down the center of her right leg. The WCN said last week someone was transferring Resident #24 from her wheelchair to her bed when she sustained the injury and was sent to the ER . Resident #24 returned 03/09/2026. The WCN got permission from Resident #24 to unwrap her bandage and began to unroll the outer wrap. Resident #24 had outer gauze around her right leg which the WCN unwrapped. The WCN then removed the tape covering the injury down her right leg, which revealed a line of stitches about 2 inches from the end of her knees to around 3-4 inches above her ankle. Resident #24's left and right shins were a dark red and covered most of the shins. The WCN said from what she remembered, she called the wound care doctor who was still in the building after she heard about the injury. The wound care doctor assessed Resident #24's injury and sent her to the ER around 4:00 p.m. the end of day (03/03/2026). During an interview on 03/10/2026 at 2:18 p.m., the Administrator and DON said they were aware of Resident #24's injury. The DON said that CNA B was transferring Resident #24 to bed and Resident #24 was holding the assist bar with her right hand. The DON said CNA B was holding Resident #24 with the gait belt and the left side to assist her back into bed when Resident #24 lifted her right leg up which kicked the assist bar and caused the laceration. The DON said the staff told her Resident #24 received 18 stitches. The DON said Resident #24 was a 1-to-2-person transfer. The DON said depending on the resident's needs, strength in the moment, if the resident requested two people that was her right to have two staff assist her and that her aide would need to ask another staff to come in the room to assist the resident. The DON said LVN A was the nurse who saw Resident #24 after the injury and who assessed her. The DON said she took off the bar that was attached to Resident #24's bed and replaced it. During an interview on 3/10/2026 at 2:40 p.m., CNA B said on the day of the incident, Resident #24 was in her wheelchair and she was trying to put Resident #24 back to bed. CNA B said she positioned Resident #24 toward the bed and Resident #24 was holding on the to the assist bar on the right side of the bed. She said Resident #24 was able to pivot on her own during that transfer. CNA B said she used her gait belt to lift Resident #24 back into bed and Resident #24 was sitting on the bed closer to the middle with her feet dangling off. Resident #24 said Resident #24 then raised her right leg in a swinging motion and hit the bar . CNA B said the bar was not sharp but Resident #24 had fragile skin. CNA B said that Resident #24 was a 1-to-2 person assist because she could assist with transfers. CNA B denied Resident #24 saying she wanted another staff to help with the transfer. CNA B did not remember Resident #24's injury but knew she was bleeding. CNA B said she called the WCN and wound care doctor to come to Resident #24's room and assist. CNA B said that if the resident wanted two staff to help her, she would have said so, but CNA B denied Resident #24 ever told her that Resident #24 wanted another aide to assist in the transfer from wheelchair to bed. CNA B said that when she asked LVN A how many people Resident #24 needed for transfers, LVN A told her that Resident #24 was a 1-person assist now. Interview with the wound care doctor on 3/10/2026 at 3:15 p.m., she said she was called to Resident #24's room and evaluated the injury. The wound care doctor told staff that Resident #24 had a laceration and needed to be sewn up at a hospital. Resident #24 was not bleeding out but there was a gash. During an interview on 3/10/2026 at 3:40 p.m., Resident #24's RP said that Resident #24 had to have 18 stitches. Resident #24's RP said Resident #24 told her there was something at the bottom of the bar which caused her to be injured. Resident #24's RP said Resident #24 told her there was a missing cap at the end of the bar at the time of the injury, but it was there when Resident #24 got back from the hospital on [DATE]. Resident #24's RP said she did not know if there were two people assisting Resident #24, but the resident told the RP there was one aide helping her back into bed. Resident #24's RP said Resident #24 was usually a one to one and a half person assist due to weakness, and that Resident #24 had her first therapy sessions that week and she might have been tired when she got back into bed.During an interview on 03/10/2026 at 4:00 p.m., the DoR said all admissions were assessed for function and the facility would get authorization to evaluate and treat like for Resident #24. The DoR said Resident #24 was evaluated on 03/01/2026 for chair to bed transfer at a maximum assist, and was also evaluated for bed mobility, transfers and walking. The DoR said Resident #24 was just starting therapy so she would have been at a maximum assist level, indicating a resident required 1 to 2 people to assist with a task. The DoR said Resident #24 was not able to easily move on her own. The DoR said the assessment was done by PTA M on 03/01/2026. The DoR said Resident #24 had therapy on 3/2/2026 and 3/3/2026 before being discharged to the hospital. During an interview on 03/12/2025 at 1:14 p.m., the DoR said another assessment was done for Resident #24 on 03/12/2026 and it was completed by PTA M. The DoR said Resident #24 required maximum encouragement during the evaluation. The DoR said Resident #24 completed a bed mobility assessment and refused standing and transfer assessments, saying that she feared her feet might bleed due to pressure ulcers she had upon admission. The DoR said the assessment indicated Resident #24 was modified independent which meant minimum help in bed for sitting to lying and lying to sitting. The DoR found that Resident #24 had no impairment with weight bearing with transfers, which meant she was able to stand on her own, so currently she did not have a medical limitation. The DoR said she found out about the incident on 3/4/2026 through a nurse's note in Resident #24's medical chart. The DoR said changing Resident #24's care plan to 1-2 person transfers on 03/03/2026 did not cause the DoR any concern, as Resident #24 was hospitalized for an unrelated issue at the time the care plan was updated. The DoR said if Resident #24 was sitting up in her chair after therapy, then she might have required more assistance getting back into bed and that therapy and nursing had different assessments they used to determine assistance and that nursing would make the final determination with the care plans The DoR said since Resident #24 did not want to get out of bed for therapy on 03/12/2026 because she wanted her heel ulcers to heal before she walks on them, so she recommended nursing staff use a mechanical lift so Resident #24 could feel less anxious if she did want to get out of bed.During an interview on 03/10/2026 at 4:04 p.m., the Maintenance Director said he was not at the facility the week of 03/03/2026 and he had made no adjustments on Resident #24's bed since she returned on 03/09/2026. The Maintenance Director said he did not receive any work orders in his log for Resident #24 and that he never made any repairs or changes to Resident #24's bed.During an interview on 03/10/2026 at 4:20 p.m., Resident #24 said the facility added a cap to the assist bar and that she felt safe now. Resident #24 said she was told to stay in bed to let her stitches heal by the hospital doctors.During an interview on 03/11/2026 at 8:05 a.m., the DON said the change to Resident #24's care plan from a two-person to a one-to-two-person assist was completed by her before the incident. The DON based it on therapy notes dated 03/03/2026, a session Resident #24 had completed that morning when she sustained the injury in the afternoon.During an interview on 3/11/2026 at 8:14 a.m., LVN A said she was working the week Resident #24 sustained the injury. She said CNA B was working with Resident #24 that day. She said CNA B told her Resident #24 was bleeding from the leg. LVN A said she entered Resident #24's room and saw the laceration to Resident #24's leg, got the wound cart, pressure wrapped the wound to stop the bleeding, and asked another nurse to call emergency services because the bleeding was significant. LVN A said once emergency services was called, she put pressure on the wound. LVN A said she called the wound care doctor, who was in the facility, to the room to assess the wound and the wound care doctor said it was deep and ordered the resident be sent out. LVN A said at the time, Resident #24 was sitting on the bed, there was blood on the floor. When LVN A asked CNA B what happened, CNA B reported she was transferring Resident #24 to the bed, when Resident #24 grabbed the assist bar and then kicked the bar with her right leg. She said CNA B also said Resident #24's leg was close to the assist bar before she kicked it. LVN A said Resident #24 reported pain in that area. LVN A said there was 1 person assisting Resident #24. Resident #24 was a 1-2 person assist but needed 2 people if she was unable to help with completing the transfer such as due to weakness, at which time the aide assisting her would get another staff to help with the transfer. LVN A did not know what Resident #24's strength really was because Resident #24 only got up twice for therapy while LVN A was her nurse. LVN A said she put a nurse's note in Resident #24's record that she was a two person assist due to the incident. LVN A said the second time she saw Resident #24 get up was on 3/3/2026. LVN A said the number of people required to assist her would be based on what therapy told nursing. LVN A said the cap underneath the assist bar handle was not covered. LVN A said she went to the DON after the incident and the DON came into the room and interviewed LVN A and CNA B. LVN A said there was usually a cover or cap under the bar but she was not sure if that was something that should be there. During an interview on 3/12/2026 at 9:33 a.m., LVN A said therapy told her they were able to get Resident #24 out of bed with one person and that Resident #24 was a one person transfer now. Later in the day on 03/03/2026, CNA B asked LVN A and that's what LVN A reported to CNA B. LVN A said she did not tell the DON about therapy making Resident #24 a 1-person transfer. LVN A said after the incident, the DON and Administrator came into the room to examine Resident #24's bed and said they put a cap on the grab bar.During an interview on 03/11/2026 at 8:40 a.m., MDS A said he got information about a resident's functional abilities through initial assessments upon admission, hospital discharge documentation, their previous nursing facility and family member interviews. MDS A said Resident #24 needed 1-2-person assistance for transfers. MDS A said he did not know if she could get up on her own. MDS A said Resident #24 had a laceration and did not know how she sustained the injury. MDS A said, according to Resident #24's most updated MDS, she required substantial to maximal assistance which translated to needing 1 to 2 people for transfers . MDS A said Resident #24 had generalized weakness and could not stand on her own so she was care-planned for two-person assist for her safety when he completed the baseline care plan on 02/24/2026. MDS A said he did not observe Resident #24's mobility assessments and that he interviewed her and could tell she had generalized weakness and would be unable to transfer safely on her own and would require maximal assistance of 1 to 2 persons. During an interview on 03/11/2026 at 10:17 a.m., the DON said substantial to maximal assistance would be 1-2-person assistance, depending on the resident's functional abilities that day. PTA G told LVN A that Resident #24 could be a one-person transfer and was a minimal assist. The DON said she updated the care plan the morning of 03/03/2026 based off of PTA G's notes. The DON said that the notes would be enough to change Resident #24's care plan and did not need to wait for the morning meeting or other consultation with the therapy department. The DON said that care plans could change based on assessments, talking to nursing and staff who would provide observations. During an interview on 03/11/2026 at 10:45 a.m., PTA G said she saw Resident #24 one time and assisted Resident #24 out of bed, where she took a few steps and was able to pivot to get into the wheelchair. PTA G said Resident #24 did not take any steps. PTA G said Resident #24 worked on exercises with PTA G, including reaching for items, and working on wheelchair mobility. PTA G said she assisted Resident #24 back to her room where Resident #24 stayed up in her wheelchair. PTA G said she took a table to her, gave her the call light, and told her to press it when she wanted to get back in bed. PTA G said she did not see her get into bed nor did she assist her with chair-to-bed transfer on 03/03/2026. PTA G said Resident #24 could not have gotten back into bed on her own. She said the level of assistance she needed depended on how long she was sitting up and on her energy level. She said Resident #24 required 1 to 2 people to get back into bed. PTA G said a nurse asked her after therapy was completed if Resident #24 was able to get up by herself and PTA G replied that PTA G got Resident #24 out of bed. PTA G said she never told LVN A that Resident #24 was a one-person assist going forward. PTA G said it was easier to get out of bed since at that time someone would be at a higher level and getting back into bed would be more difficult. During an interview on 03/11/2026 at 10:53 a.m., ADON C, said his responsibilities included re-checking admission orders and assessments. He said he did not remember which nurse admitted Resident #24. ADON C said he had Resident #24 as a two-person assist upon admission in her care plan because he assessed her on the first day and she did not get out of bed so they did not know how much help Resident #24 needed. He also said since Resident #24 was not the smallest person and arrived to the facility on a stretcher, he put her as a two-person assist. ADON C said care plans could change daily, but the plan remained at a two-person assist before therapy assessed her. ADON C said he expected that if the resident needed help, then he would make sure they were documented as a two-person assist before clearance from therapy. ADON C said that the facility received updates about residents from morning meetings and that any changes to the resident's MDS could update the Kardex which could be accessed by nurses and aides in providing resident care. During an interview on 03/11/2025 at 11:22 a.m., the Administrator said when a resident was admitted , the facility might have them as a two-person assist and when therapy assessed them, therapy could communicate with nursing and there would be a change in the care plan. The Administrator said management might talk about a resident's functional abilities after a treatment and then communicate further during morning meetings. She said therapy communicated with nursing that Resident #24 was a one-person assist. She said things could change throughout the day and any changes would not necessarily need to wait until the morning meeting.During an interview with the Administrator and DON on 03/12/2026 at 2:58 p.m., the DON said Resident #24 had her hand on the assist bar when she kicked up, and that Resident #24 shifted or leaned to the left to try to catch herself from falling over. The DON said Resident #24's care plan was updated to 1 to 2 people because therapy said so on 03/03/2026 . The DON said the therapist was able to transfer Resident #24 with one person, so the therapist told the nurse who told the aide. The DON said she made changes to the care plan based on therapy notes and changed Resident #24's assistance. The DON said Resident #24 only required one person, but she could have requested another person if she wanted and that was within her rights to do so. During an interview with PTA M on 03/12/2026 at 3:25 p.m. by telephone, he said he was a physical therapist and conducted resident evaluations, recertifications, and treatments. PTA M said he did an assessment for Resident #24 on the morning of 03/12/2026. PTA M said Resident #24 required moderate assistance with bed mobility and refused transfers so he could not conduct gait or wheelchair mobility assessments. PTA M said Resident #24 required a mechanical lift to get out of bed before she refused transfers. PTA M did not know how Resident #24 sustained her injury. PTA M said that transfers would mean going from one place to a different place, so going from wheelchair to the bed and vice versa. PTA M said that Resident #24 required maximum assistance during her first assessment on 03/01/2026, which still could mean needing one person to help her. PTA M said he could not speak on the care plan changes in assistance for transfers.During an interview with the DON and CNA B on 03/12/2025 at 3:54 p.m., the DON said she just talked to Resident #24 who said she was sitting in bed trying to readjust her pillows when she leaned back and injured herself. The DON said Resident #24 was already in bed when the injury happened. During an interview with the DON on 03/13/2026 at 9:12 a.m., she said she interviewed Resident #24 on 03/13/2026 and Resident #24 said she was holding on to the rail with her right hand and felt a sharp pain in her right leg. The DON said CNA B got Resident #24 in bed and went to get someone immediately. The DON said she thought the assist bar got caught on Resident #24's leg. The DON said when she went to inspect the bed, the bed was capped and she did not change anything with the bed. During an interview on 03/13/2026 at 9:49a.m., the wound care nurse said she waited for therapy to assess residents for transfer assistance and bed mobility. The wound care nurse said she would then be able to help residents with repositioning and sitting up in bed during wound care. She said she did not assist with transfers.Record review of the facility's policy titled Safe Resident Handling/Transfers last revised January 2023, it read in part, It is the policy of this community to ensure that patients/residents are handled and transferred safely to prevent or minimize risks for injury and promote a safe, secure and comfortable experience for the patient/resident while keeping the team members safe in accordance with current standards and guidelines. Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess individual mobility needs, considering other factors as well, such as weight and cognitive status. 2. The mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. 3. Mechanical lifting equipment or other approved transferring aids will be used based on individualized needs and per the care plan to prevent manual lifting except in medical or other emergencies.13. Lifting and transferring will be performed according to the individualized plan of care.Record review of the facility's policy titled, Statement of Resident Rights last revised January 2023, it read in part, Resident/Patient Rights include: 1. To all care necessary for them to have the highest possible level of health; 2. To safe, decent and clean conditions.10. To participate in developing a plan of care, to refuse treatment. The community will continue to care for the resident in a manner that allows the resident to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being to the extent possible given the refusal of recommended medical care and treatment. Treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms.Record review of the facility's policy on Care Plan Development, Review, and Update Policy dated February 2017, it read in part, The community develops a comprehensive care plan for each resident that includes measurable objectives designed to meet the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. The care plan should reflect the identified problem or risk, the measurable outcome objective, and the appropriate interventions based on the resident's abilities, needs, medical condition, and preventative measures. The care plan may also include the resident's expressed preferences. The care plan should be written in a manner that is understandable, and actionable for staff, ensuring that the interventions can be implemented as intended. The care plan should also allow for appropriate variability in care approaches when the resident's needs fluctuate, and within the scope of the resident's assessed needs and abilities. The care plan, in conjunction with the broader plan of care documented throughout the medical record, is developed to help the resident attain or maintain their highest practicable physical, mental, and psychosocial well being, in accordance with federal regulations and RAI guidance. 'Interdisciplinary' means that professional disciplines work together to provide the greatest benefit to the resident. The IDT should include within the care plan the right to refuse any recommended care, treatment or services identified but, that is not provided due to the resident exercising his or her right to refuse care, service, or treatment, as well as the resident's legal representative acting on behalf of the resident. The care plan should be prepared by an interdisciplinary team, including the attending physician, a registered nurse with responsibility for the resident, and other appropriate team members in disciplines as determined by the resident's needs.During an interview on 03/13/2026 at 5:45 p.m., the DON and VP of Operations said they did not have a policy on maintaining resident beds.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food to be used later with a temperature in the danger zone was discarded. 2. The facility failed to ensure leftover food past the due date was discarded.3. The facility failed to ensure that food past the use date was discarded. 4. The facility failed to ensure food was stored 6 inches off the floor.5. The facility failed to store in a separate container a scoop used for food bins in the kitchen storeroom.6. The facility failed to fix broken tiles in the kitchen These failures could place residents at risk of food borne illness and disease.During an observation of the facility kitchen on 03/10/26 at 8:00 a.m., it revealed the following: 1. Can opener blade with food debris.2. An open package of deli ham with no used by date in the fridge.3. A package of sliced swiss cheese not dated, no used by date in the fridge.4 A package of sliced cheddar cheese with no used by date in the fridge.5. A tray full of milk in glass was measured at 45 degrees Fahrenheit on the serving lunch table.6. A food rack where food is stored in the storeroom was 2 1/2 inches off the floor.7. Scoop dispenser left in flour bin. During an interview on 03/10/2026 at 8:00 a.m., the Dietary Food Service Manager stated that the following foods (deli ham, Swiss cheese, sliced cheddar cheese) stored in the refrigerator to be used for a later date should be discarded prior to the use by date. She stated the leftover food with danger food temperature 40 degrees Fahrenheit to 140 degrees Fahrenheit should have been discarded. She stated that she was responsible for meeting the requirements and she would in-service dietary staff on proper handling, storing, and dating leftover food for compliance.Record review of the facility's policies and procedures for Food Safety, not dated, read, .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded on the used by date unless otherwise indicated. For food storage keep off floor and food racks off the floor at least 6 inches off the floor.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 11 residents (Resident #8 and Resident #108) reviewed for infection control. 1.The facility failed to ensure CNA A used the required PPE (gown) for Resident #8, who was on enhanced barrier precautions while performing incontinent/indwelling foley catheter care on 3/10/26. 2. CNA A failed to perform hand hygiene with glove changes during perineal care on Resident #8 3, RN H poured iron supplement liquid into a medication cup and then poured it back into the original 6 fl oz bottle, which could cause contamination, on 3/10/26. These failures could place the residents at risk of cross-contamination and development of infection. Record review of Resident #108's face sheet, dated 3/10/26, revealed a [AGE] year-old male was admitted on [DATE] and re-admitted on [DATE]. Resident #108 had a diagnoses of gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), gastro-esophageal reflux( Gastric reflux) disease without esophagitis, aphasia (not able to talk) following unspecified cerebrovascular disease (stroke), functional quadriplegia (medical condition involving paralysis of all four limbs (both arms and both legs) and torso, unspecified severe protein-calorie malnutrition, tracheostomy status (surgically created hole in the front of the neck that leads directly into the windpipe, or trachea). Record review of Resident #108's admission MDS, dated [DATE], reflected the BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on staff for bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #108 was incontinent of bladder and bowel. Record review of Resident #108's care plan, dated 1/24/26, reflected Resident #108 had an ADL self-care performance deficit and the goal was the resident would improve current level of function. Record review of Resident #108's Physician's Orders, dated 2/17/26, reflected the following orders: Had NPO (nothing per oral/nothing by mouth) check gastric tube placement by auscultation ( using stethoscope to listen to bowel sound) prior to meds, formula, and H2O flushes every shift. Check for residual every shift if > 60ccs, stop feeding and notify MD every shift. Feeding of Nova source Renal @ 45 cc/hr via pump, Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift. During an observation of medication administration on 3/10/26 at 9:02 a.m., for Resident #108, RN H opened the medication cart, removed iron supplement liquid, poured 6cc in a medication cup from a 16 fl. oz. iron supplement liquid bottle. RN H said he needed to check Resident 108's blood pressure, then poured the 6 cc liquid iron back into the bottle. RN H was observed checking Resident #108's blood pressure (BP127/75, P81), RN H then went back to the medication cart, opened and poured out 5cc of iron supplement liquid in the medication cup During an interview via telephone on 3/12/26 at 4:43 p.m., RN H, said, regarding pouring Iron supplement back to bottle after pouring it in the medication cup, it was hygienic because the medication was clean. During an interview on 3/12/26 at 5:38 p.m., the DON when asked if iron supplement poured from the medication cup into bottle was hygienic, said, I am old school, I would have wasted the iron but I am not sure what the policy says, I have to look into it. Record review of Resident #8's face sheet, dated 3/10/2025, revealed an [AGE] year-old male admitted [DATE] and re-admitted [DATE]. His medical diagnoses included muscle wasting and atrophy ( loss of muscle tissue, causing muscles to become small, thinner and weaker) not elsewhere classified, unspecified shoulder, dysphagia ( difficulty swallowing), oropharyngeal phase(difficulty initiating a swallow or moving food from the esophagus), cognitive communication deficit, unsteadiness on feet, muscle weakness (generalized), obstructive and reflux uropathy,( blockage in the urinary tract that prevent urine from draining properly , causing backup and potential kidney damage) unspecified, nasal congestion, sepsis ( a life -threatening medical emergency that occurs when the body's immune system has an infection, causing it to damage its own tissue and organs) essential primary hypertension( high blood pressure ) and urinary tract infection. Record review of Resident #8's quarterly MDS assessment, dated 1/20/26, reflected a BIMS score of 13 out of 15, which indicated intact cognition. He required assistance from staff with ADL care. Record review of Resident #8 's care plan, dated 1/27/26, reflected, . The resident had an ADL self-care deficit .Interventions.Personal Hygiene and Toilet use- Resident is totally dependent . Resident #8 was also care-planned for a Foley catheter (a sterile tube that is inserted into your bladder to drain urine) and incontinent care, with interventions including following physician orders for catheter insertion, changes and maintenance. Review of Resident #8's Physician's orders, dated 1/25/2026 through 3/1/2026, reflected orders for the following: Foley Catheter cleansing and perineal hygiene daily and as needed if soiled, using a catheter securing device with a start date of 1/25/2026. During an observation on 3/12/26 at 5:20 p.m., during foley Catheter and incontinent care with Resident #8, revealed CNA A don (worn) PPE (gown), did not wash hands, wore a clean glove, picked up cleaned brief, wet wipes from Resident #8's dresser and placed it on the bed. CNA A then picked up the clean brief from the bed and placed it under Resident #8 without changing gloves. During an interview with CNA A on 3/12/26 at 5:41 p.m., she said she forgot to change gloves and wear PPE (gown) while performing incontinent care. She said she knew not wearing PPE could cause infection to her and the residents. During an interview on 3/12/26 at 4:35 p.m., the DON stated any resident who had a foley catheter was placed on Enhanced Barrier precautions (an infection control intervention designed to reduce the transmission of multidrug-resistant organisms and employs targeted gown and glove use during high-contact resident care activities for targeted residents) to help reduce the spread of MDRO's. She stated signage was posted outside to the door, which explained what PPE was to be worn and for what task. She stated any contact with a resident with a urinary catheter required the use of gown and gloves. She stated the staff had received training on the use of Enhanced Barrier Precautions and hand washing. Guidance/ProcedureEnhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; orWounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds: skin breaks/skin tears/or similar areas. Examples of chronic wounds: pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Examples of indwelling medical devices: central lines, urinary catheters, feeding tubes, and tracheostomies.When EBP are indicated, EBP should be employed for the following high-contact resident care activities: Dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, and wound care. In general, gowns and gloves would not be recommended when performing transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration.Therapy consideration: if close contact is required to perform therapy functions, gown and gloves are recommended.Residents are not restricted to their rooms or limited from participation in activities.The facility has discretion in how they choose to communicate these precautions to the staff.PPE for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.The facility has discretion in using EBP for residents who do not have wounds or indwelling medical devices and are infected or colonized with an MDRO that is not currently targeted by CDC. Review of the facility's policy titled, Subject: Incontinent Care- With or Without Catheter, not dated, indicated, POLICY: It is the policy of this center to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination.

Based on observation, interview, and record review, the facility failed to ensure residents with incontinent bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 18 resident (Resident #8) reviewed for incontinent care. The facility failed to ensure CNA A put on a gown and changed gloves and cleaned Resident #8's indwelling catheter and penis foreskin before putting on a clean brief during foley catheter and incontinent care on 3/12/26. This failure could place residents at risk for pain, infection, injury, and hospitalization. Record review of Resident #8's face sheet, dated 3/10/2025, revealed an [AGE] year-old male admitted [DATE] and re-admitted [DATE]. His medical diagnoses included muscle wasting and atrophy ( loss of muscle tissue, causing muscles to become small, thinner and weaker) not elsewhere classified, unspecified shoulder, dysphagia ( difficulty swallowing), oropharyngeal phase(difficulty initiating a swallow or moving food from the esophagus), cognitive communication deficit, unsteadiness on feet, muscle weakness (generalized), obstructive and reflux uropathy,( blockage in the urinary tract that prevent urine from draining properly , causing backup and potential kidney damage) unspecified, nasal congestion, sepsis ( a life -threatening medical emergency that occurs when the body's immune system has an infection, causing it to damage its own tissue and organs) essential primary hypertension( high blood pressure ) and urinary tract infection. Record review of Resident #8's quarterly MDS assessment, dated 1/20/26, reflected a BIMS score of 13 out of 15, which indicated intact cognition. He required assistance from staff with ADL care. Record review of Resident #8 's care plan, dated 1/27/26, reflected, . The resident had an ADL self-care deficit .Interventions.Personal Hygiene and Toilet use- Resident is totally dependent . Resident #8 was also care-planned for a Foley catheter (a sterile tube that is inserted into your bladder to drain urine) and incontinent care, with interventions including following physician orders for catheter insertion, changes and maintenance. Review of Resident #8's Physician's orders, dated 1/25/2026 through 3/1/2026, reflected orders for the following: Foley Catheter cleansing and perineal hygiene daily and as needed if soiled, using a catheter securing device with a start date of 1/25/2026. During an observation on 3/12/26 at 5:20 p.m., during Foley Catheter and incontinent care with Resident #8, revealed CNA A did not don (wear) PPE (gown), did not wash hands, wore clean gloves, picked up a cleaned brief, wet wipes from Resident #8's dresser and placed it on the bed. CNA A was observed using wet wipes and cleaned Resident #8's groin and the front part of the scrotum. Resident #8 was repositioned to his left, CNA A using the clean wet wipes cleaned in-between buttocks and around the buttocks. CNA A did not clean the back side of the scrotum, she then picked up the cleaned brief that was on the bed, placed it under Resident #8 without changing gloves. CNA A did not clean back part of the scrotum, penis fore skin, penis head and indwelling catheter before fastening the brief. During an interview with CNA A on 3/12/26 at 5:41 p.m., she said she did not clean the back part of the scrotum, penis fore skin, penis head and indwelling catheter because she forgot. She said she knew not cleaning the back part of the scrotum, penis fore skin, penis head and indwelling catheter could cause infection, skin break and odors. During an interview with CNA A on 3/12/26 at 5:41 p.m., she said she forgot to wear PPE while performing incontinent care, she knew not wearing PPE could cause infection to her and the residents.Review of the facility's policy titled Subject: Incontinent Care- With or Without Catheter, not dated, indicated: POLICYIt is the policy of this center to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination.MALE1. Follow steps below: . Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum. Using a new wipe with each stroke clean from the upper part of the leg to the hip. Repeat on the other side and then once from hip bone to hip bone Turn the resident over and repeat on the back side.2. Take off gloves, put them into the trash bag with the soiled brief and wipes.

Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 5 residents (Resident #108) reviewed for feeding tubes. The facility staff failed to check Resident #108's g-tube placement before administering medication on 3/10/26. This failure could place residents at risk for complications such as aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space), and/or hospitalization. Record review of Resident #108's face sheet, dated 3/10/26, revealed a [AGE] year-old male was admitted on [DATE] and re-admitted on [DATE]. Resident #108 had a diagnoses of gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), gastro-esophageal reflux( Gastric reflux) disease without esophagitis, aphasia (not enable to speak) following unspecified cerebrovascular disease (stroke), functional quadriplegia (medical condition involving paralysis of all four limbs (both arms and both legs) and torso, unspecified severe protein-calorie malnutrition, tracheostomy status (surgically created hole in the front of the neck that leads directly into the windpipe, or trachea). Record review of Resident #108's admission MDS, dated [DATE], reflected the BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on staff for bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #108 was incontinent of bladder and bowel. Record review of Resident #108's care plan, dated 1/24/26, reflected Resident #108 had an ADL self-care performance deficit and the goal was the resident would improve current level of function. Record review of Resident #108's Physician's Orders, dated 2/17/26, reflected the following orders: Had NPO (nothing per oral/nothing by mouth) check gastric tube placement by auscultation (using stethoscope to listen to bowel sound) prior to meds, formula, and H2O flushes every shift. Check for residual every shift if > 60ccs, stop feeding and notify MD every shift. Feeding of Nova source Renal @ 45 cc/hr via pump, Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift. During an observation of medication administration on 3/10/26 at 9:02 a.m., for Resident #108, RN H opened the medication cart, removed iron supplement liquid, poured 6cc in a medication cup from a 16 fl. oz. iron supplement liquid bottle. RN H said he needed to check Resident 108's blood pressure, then poured the 6 cc liquid iron back into the bottle. RN H was observed checking Resident #108's blood pressure (BP127/75, P81), RN H then went back to the medication cart, opened and poured out 5cc of iron supplement liquid in the medication cup and then punched three other medications, crushed it individually and then diluted with 20cc of water, then went back to the resident's room. RN H unplugged Resident #108's g-tube feeding of Nova source without checking for placement. During an interview with RN H on 3/10/26 at 9:25 a.m., regarding not checking for placement for Resident #108 before medications administration, RN H said he forgot and he knew not checking for placement could cause aspiration pneumonia, bloating, being too full and death. RN H said he had medication training upon hire by the DON. During an interview on 3/12/26 at 2:50 p.m.,, the DON said nurses should check the g-tube for proper placement by visual inspection and for aspirated stomach content prior to administering medication and water. The DON said not checking g-tube placement before administration of medication could result in infection, bloating, discomfort and death. Record review of the facility provided policy titled, Medication Administration Via Enteral Tube Care, dated 3/15/19, reflected the following . Policy Explanation and compliance Guidelines . To administer medications through a enteral tube in an accurate, safe, timely and sanitary manner. RESPONSIBLE DISCIPLINES Licensed Nurses EQUIPMENT: Prescribed medication Towel or incontinent pad 50 to 60 ml. Piston type catheter-tip syringe Stethoscope Cup for mixing medication and fluid 30-50 ml. of water Gloves GUIDELINES: 1. Verify correct medication to be administered. 2. Prepare medication 3. Verify resident identity & provide privacy 4. Explain procedure 5. Drape chest with towel or incontinent pad 6. Elevate head of bed to Fowler's position 7. Stop enteral pump, if applicable 8. Put on gloves 9. Auscultate for placement 10. Remove plug at the tip of the tube; check for residual; attach syringe to tip. 11. Instill 10-30 ml. of water into tube through syringe to check for patency. If water flows in easily, tube is patent. If it flows in slowly, raise funnel to increase pressure. If water does not flow properly, stop, notify physician, and follow orders.

Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 18 residents (Resident #89, Resident #310) who were observed for call light placement. The facility failed to ensure that call light were within reach for Resident #89 and Resident #310. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: 1. Record review of Resident #89's face sheet captured on 01/16/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE]. His medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right-sided weakness after a stroke), essential hypertension (high blood pressure), Schizophrenia (a serious mental health condition characterized by hallucinations, delusions and unorganized thinking), Bipolar Disorder(a serious mental health condition characterized by extreme mood swings ranging from depression to mania to hypermania), Anxiety Disorder (prolonged anxiousness and worry), acute kidney failure, Depression, and muscle wasting and atrophy (reduced muscle function). Record review of Resident #89's Quarterly MDS (a resident assessment tool) dated 11/20/2024 revealed a BIMS score of 4, indicating severe cognitive impairment in thinking and decision-making. Resident #89 required total assistance for activities of daily living such as toileting, showering or bathing, lower body dressing, and putting on and taking off footwear. Record review of Resident #89's care plan last completed 12/05/2024 revealed the following focus areas: -Self Care deficit related to Dementia, with interventions including one person assistance with bed mobility, dressing and grooming, and toileting and incontinent care. -Risk for falls secondary to deconditioning and gait/balance problems, with interventions including having the resident's call light within reach and encourage the resident to use it for assistance as needed The resident needs prompt response to all requests for assistance. Observation and interview with Resident #89 on 1/14/2025 at 10:11am, resident was lying in bed with his blanket covering from his legs to his upper torso and did not appear in distress. Resident #89 said that he did not like the temperature in the room and that he wanted the heat turned off but could not locate the call light. The call light wire was observed hanging off Resident #89's bed on his right side not within reach and the button was seen on the floor. Resident #89 said if he had the button, he would call for help. Observation and interview with LVN L on 1/14/2025 10:11am, after being informed about Resident #89's concerns regarding the temperature and call light, LVN L went into Resident #89's room and came out. She said she adjusted the temperature for him. After immediately re-entering Resident #89's room, the call light wire and button were observed in the same location. Interview with the DON on 1/14/2025 at 10:59am, she was informed of Resident #89's concerns regarding the call light and when she went into his room, she picked up the call light and reclipped it to his bed. The DON told Resident #89 to press the button, but he was unable to physically press down on it. The DON said she will switch Resident #89's call light from a button to a press pad so he could more easily press down on it to call for assistance. A later interview with the DON on 1/14/2025 at 1:03pm, she said that a press pad was installed in Resident #89's room and he was able to demonstrate using the press pad for her. Interview with LVN L on 1/14/2025 at 4:26pm, she said that call lights needed to be close to residents so they can call for help. If residents were unable to reach the call light, then they would not get the assistance they needed. Interview with the Administrator on 1/6/2024 at 3:02pm, she said that call lights were supposed to be answered in a timely manner and positioned within reach so residents could get things they need, and if not, they would be unable to get the help they require. 2. Record review of Resident #310's Face Sheet dated 01/14/2025 revealed, that Resident #310's was a [AGE] year-old female who admitted to the facility on [DATE]. Resident's diagnosis included nondisplaced subtrochanteric fracture of left femur (break in upper thigh bone), subsequent encounter for closed fracture with nonunion (not open to the outside, but failed to heel), idiopathic aseptic necrosis of left femur (blood flow to bone disrupted), anemia (low red blood), severe protein-calorie malnutrition (not enough protein for energy), hypertension (high blood pressure), fall, fracture of one rib, right side, subsequent encounter for fracture with routine healing, complete rotator cuff tear or rupture of right shoulder, specified as traumatic, bipolar disorder (shift in moods, energy, and activity level), alcohol abuse with unspecified alcohol-induced disorder, unsteadiness on feet, other lack of coordination, and muscle weakness. Record review of Resident #310's Care Plan undated revealed, that Resident #310 FOCUS: Resident at risk for falls and had an actual fall on 12/23/2024 attempting to self-transfer to wheelchair and slid to the floor 12/20/24. Resident had been noted sitting on floor beside her bed. Resident had an actual fall on 01/16/2025 while attempting to ambulate in response to a biological need. Date Initiated: 12/23/2024 Created on: 12/24/2024 Revision on: 01/16/2025. GOAL: Resident will have no significant injuries related to falls thru next review. Date Initiated: 12/23/2024 Created on: 12/24/2024 Revision on: 01/16/2025 Target Date: 03/17/2025. INTERVENTION: Access for hunger and provide nighttime snacks as desired. Date Initiated: 01/16/2025 Created on: 01/16/2025 Revision on: 01/16/2025. Anticipate resident needs. Date Initiated: 12/23/2024 Created on: 12/24/2024. CALL DONT FALL SIGN placed at bedside. Date Initiated: 12/24/2024 Created on: 12/24/2024 Revision on: 01/16/2025. Encourage resident to use call light for assistance. Date Initiated: 12/23/2024 Created on: 12/24/2024. Fall mat x1 placed at bedside. Date Initiated: 12/30/2024 Created on: 12/30/2024. Therapy to eval and treat as indicated. Date Initiated: 12/24/2024 Created on: 12/24/2024 Revision on: 01/16/2025. Record review of Resident #310's Admission Minimum Data Set (MDS) Assessment, dated 12/23/2024, reflected she had a Brief Interview for Mental Status (BIMS) score of 15 indicating her cognitive status was intact. In an observation/interview on 01/14/2025 at 10:37 a.m., Resident #310 was sitting in a wheelchair at bedside. Resident's call light cord underneath her wheelchair on the floor. Resident stated that she did not feel like she was in control of where she should and wanted to be. She stated that she was at the facility awaiting hip replacement surgery and rehabilitation. She stated that she was not aware of her call light being on the floor and stated she could not reach it. She stated that staff would not answer it anyway as they ignore her. In an observation on 01/14/2025 at 11:02 a.m., Licensed Vocational Nurse (LVN) A entered Resident #310's room and bent down to speak to resident at eye level. In an observation/interview on 01/14/2025 at 11:12 a.m., Resident #310 was observed sitting in her wheelchair bedside with call light cord still underneath the wheelchair on the floor. Resident stated that she asked LVN A for pain medication which she received as she had pain. Resident began crying and this surveyor waved down Certified Nursing Assistant (CNA) A to assist resident. In an observation/interview on 01/14/2025 at 11:16 a.m., CNA A stated that Resident #310 was residing on the hall she was assigned too, but had gone on vacation returning to find the resident had moved to another hall. CNA A asked resident what was wrong, resident told her that staff ignored her and would not answer her call bell. CNA A was informed that Resident #310's call light was on the floor. She stated that she was not working this hall, but that Resident #310 had been on the hall she worked prior to her going on vacation. CNA A immediately picked up the call bell and attached the cord to resident's wheelchair. CNA A stated that it was important for residents to have call bells in reach to ensure that they can call for help when they need assistance. She stated that she would come and check on the resident periodically during her shift. In an interview on 01/14/2025 at 11:41 a.m., LVN A stated when she entered Resident #310's room at 11:12 a.m. resident told her she was in pain and wanted to go smoke. She stated she passed the resident her narcotic medication for pain. She stated when she entered and exited the room, she believed that the resident's call light was attached to her bed. She stated she had not realized the location of the call light was on the floor and had she seen it, would put it within reach of resident and ensured it was in place. She stated that the importance of resident call bells being within reach was to ensure that residents were able to reach out for assistance in case they needed help. In an interview on 01/14/2025 at 11:46 a.m., the Administrator (ADMN) stated she was not aware that Resident #310's call light was not in reach. She stated that she would provide the latest in-services on call-lights. In an interview on 01/14/2025 at 02:47 p.m., the ADMN stated she received notice from LVN A that Resident #310's call light was on the floor. She stated that staff take in-services on an app and once complete, the ADMN would receive notice. She stated that LVN A would be completed an in-service on call lights and completed data would be provided. on your phone via an app. Once completed, a notification would be sent, and she would forward. In an interview on 01/15/2025 at 02:41 p.m., the Director of Nursing (DON) stated that she was not sure the status of Resident #310, but believed she was here to gain weight and increase her health condition for an anticipated hip replacement surgery. She stated that she was not aware that resident's call light was out of reach. She stated the importance for call lights to be in reach was to ensure resident were able to contact staff when they needed assistance. In an interview on 01/16/2025 at 02:57 p.m., the ADM stated that staff were responsible for answering call bells in timely manners, and that call bells were to be within reach of residents at all times so that they were able to call for assistance. She stated that if a resident could not call for assistance, they would not able to get the help they needed to meet needs. In an interview on 01/16/2025 at 03:06 p.m., the DON stated that resident's call bell should be in position of reach at all times. She stated if seen on the floor, the call bells were to be placed within reach and never left on the floor. Record review of In-Service dated 01/14/2025 revealed, LVN A had been in-serviced on call lights. Record review of policy undated and titled, Call Light Use and Patient Safety. Nursing home residents often require ongoing care to maintain their health. Throughout the day, they may need assistance from nursing staff to stand up, engage in daily activities, or handle medical emergencies. As such, each patient must have a call light system to notify nursing staff if they need help . Placement: Nurse call systems must be accessible within resident rooms. Generally, a call system is required beside the bed and in bathing or toilet facilities. Common areas should also allow access to nurse call systems. The purpose of a call light system is to enable residents to ask for assistance, so they must be placed in all locations where resident may be present. Accessibility: Call lights must also be accessible to all residents, including those with disabilities. If they are placed out of reach on a wall, some patients may be unable to call for help. For patients with limited mobility, a call system must be within reach of their bed and other locations. The nursing home is responsible for setting up each resident's call system to meet their needs . consequences of Call light Neglect: Neglecting call lights can have a devastating impact on a nursing home resident. Whether it means the resident has to wait a long time to be moved or a medical emergency escalates, it is crucial that a staff member can respond to the alert as soon as possible. Record review of policy dated February 2017 and revised date December 2023 titled Statement of Resident Rights revealed, Compliance Guidance: The community should educate, encourage, and honor the rights of those we serve . 1. To all care necessary for them to have the highest possible level of health. 2. To safe, decent, and clean conditions . 4. To be treated with courtesy, consideration, and respect.

Based on observation, interview, and record review, the facility failed to follow menus for pureed meals (lunch meal on 01/15/2025) reviewed for menus in that: The facility failed to follow the recipe for pureed diets meals prepared for the lunch meal on 01/15/2025. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings included: In an observation/interview on 01/15/2025 at 11:26 a.m., approximately 24-pieases of 4 ounce (oz) baked tilapia on a tray in the oven. [NAME] removed 7-pieces of tilapia from the tray and placed them into the mechanical blender along with 7 pieces of bread, and broth. The [NAME] stated that she was unsure exactly how many residents required pureed diets. She then asked the interim dietary manager (IDM) who had replied that there were 10-residents eating in the dining room and another 6-residents eating in their rooms. When asked how many pieces of fish the [NAME] had blended for those residents, she stated she added 15-pieces of fish to cover the 16-residents. She stated that 16-pieces of fish would also accommodate for any double portion or second portion requests. When the [NAME] had been informed that only 7-pieces of fish were observed being blended, the [NAME] disagreed stating she had placed 15 or 16-pieces of fish in the blender. In an interview on 01/15/2025 at 11:59 a.m., with the Dietitian and the IDM, the Dietitian stated that the Dietary Manager (DM) was off shift and that IDM was filling in until DM returned. IDM stated that there were 10-residents requiring puree meals and another 6residents requiring puree meals who ate in their rooms. She stated that with 16-residents needing puree meals the total number of fish that should have been prepared for puree should have been 16 plus an add additional 7 extra pieces given a total of 23-pieces of fish. She stated that the extra pieces of fish would compensate for double portions. She stated that that the number of portions of meat was always determined by the number of residents eating pureed and then they would refer to the Daily Spreadsheet which was the recipe the followed when preparing pureed meals. In an interview/observation on 01/15/2025 at 12:05 p.m., with the Dietitian and the IDM, the Dietitian was not aware of how many oz of fish each of the residents required for each meal. She stated that she observed roughly 24-pieces of fish on the oven pan cooking in the oven. She stated if [NAME] had removed 15-pieces of fish from the tray to cover the 16-residents, that the cooking tray would have been nearly empty. She stated when [NAME] removed the fish from the oven tray she had not placed a full or near full tray of fish into the blender. She stated once the [NAME] completed blending the fish more than half a tray of fish remained. IDM stated that based on the obserthey needed to make more fish to cover all residents receiving pureed fish with their meal. She was then observed going into the freezer bringing out box of frozen fish. She then pulled out the cooking instructions for pureed food and reviewed. In an interview on 01/15/2025 at 01:20 p.m., IMD stated that the puree fish tasted good, like flavored fish. She stated that she made another batch of fish and that was provided with the test tray. Stated that she tasted the first batch of pureed fish and it also tasted good. She stated that she could not have provided fish from the first mix of pureed fish because they had run out and had to make more pureed fish. She stated that they had enough fish to provide meals for all the residents and it was not required for more fish to have been cooked. She stated that the box of fish that was observed being taking from the freezer was placed back. In an interview on 01/15/2025 at 02:04 p.m., DM stated that she had been off shift due to illness and that the IDM had been filling her role while she was off. She stated that the facility had 16-residents that required puree diets. She stated that she placed the weekly orders for food for the facility. She stated that 1-box of tilapia contained 96-4-oz pieces of fish and more than enough to serve the present censes at the facility. She stated that pureed portions should be created to also accommodate double portions. She stated 16-pureed meals should have 16 to 24 pieces to allow for double portions. She stated [NAME] should have prepared the 96- pieces of fish, 72-pieces should have been plated leaving an overage of 24. She stated that IDM should not have opened and/or cooked any more fish, as 24-extra pieces should have covered all the residents. She stated that her staff were in-serviced as often as 1-time monthly on food preparation and following menus. She stated that importance of residents receiving that required portions was to ensure that the facility provided each resident with their required nutritional values. In an interview on 01/15/2025 at 3:51 p.m., IDM stated that it had been her understanding that [NAME] had not blended the correct amount of fish to compensate for the resident's requiring pureed meals. She stated according to the Daily Spreadsheet which was the corporate menu they followed for portion control it noted that if there were 16-residents to receive pureed fish, and the portions were per piece, each resident should have received at least 1-piece of fish. She stated that [NAME] should have pureed 16-pieces of fish. She stated that [NAME] knew to add 16-pieces, at the least and even make extra. She stated after [NAME] began plating the food, the [NAME] had to puree 10 more pieces of fish, because it had not been enough to plate all 16-residents. She stated the risk of not making enough pureed fish would that resident could lack nutritional value, and not be given what the other residents were given, and that would have been unfair. In an interview at 01/16/2025 at 10:30 a.m., [NAME] stated she had worked for the facility in the kitchen since April 2024. She stated that she had not counted the fish when she began the puree process. She stated that she believed it to have been 6 or 7-pieces of fish she placed in the blender with 6 or 7 pieces of bread and broth to feed the 10-residents eating in the dining room and the residents eating in their rooms. She stated that she should have blended 10-pieces of fish for the residents in the dining room and another 6 for the residents eating in their rooms. She stated that she had to puree another 14 or 15 pieces of fish after she was informed, she had not added enough fish to accommodate all pureed meals. She stated that the DM informed the kitchen staff daily how many pureed meals were needed, and it had also been posted on the wall. She stated she verified that the posting for 01/15/2025 read 16-pureed meals. She stated after a 01/16/2025 in-service given to her by the IDM she learned that each pureed resident needs at least 1-piece of fish each even if she adds thickener and/or bread. She stated it was importance for each resident to be feed the correct portion control and nutritional value. In an interview on 01/16/2025 at 02:57 p.m., the ADM stated that staff were required to follow food recipes for residents to get proper portions of food to receive their nutritional needs. She stated that the adverse effects would cause residents to lack of nutrition would be the adverse effect of resident not receive proper portions. She stated that the kitchen staff received in-services on the importance of portion control and following recipes. In an interview on 01/16/2025 at 03:06 p.m., the DON stated that kitchen staff were to follow recipes to ensure that residents received meals with nutritional values. She stated that failure could cause residents to lack adequate diet. Record review of policy dated June 24, 2024, 08:14:34 and titled Policy Daily Spreadsheet, Corporate Baked Fish 3-oz, 1. Prepare according to regular recipe 2. Prepare until slurry 3. Process until smooth using 1-oz slurry per portion . 1. Amount of Thickener required may vary relative to liquid content of cooked product. For best results. Alternative Thickener and processing, checking product consistency periodically. 2. Nutritional analysis based on using water in the slurry. If other liquid is used nutritional analysis will vary.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #6 and Resident #55) reviewed. -The facility failed to ensure that Resident #6's status of anticoagulants was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #6's status of oxygen was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure Resident #55's status of oxygen was a focus area in the resident's comprehensive care plan. These deficient practices could affect residents by contributing to inadequate care. The findings included: Record review of Resident #6's facility Admission Record dated 1/16/25 revealed that Resident #6 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #6's diagnoses included multiple sclerosis (MS is a chronic disease that damages the central nervous system. It is an autoimmune disease, meaning the immune system attacks healthy cells, including the protective sheath around nerve fibers) and acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen, resulting in low blood oxygen levels). Record review of Resident #6's Quarterly MDS dated [DATE] revealed Resident #6 had a BIM score of 2 out of 15 indicating severe impairment cognitively. Resident #6 was dependent with ADLs requiring substantial/maximum assistance. Record review of section N-Medications revealed Resident #6 received anticoagulants. Record review of Section O (special treatments, procedures, and programs), reflected the areas for oxygen therapy were blacked out. Record review or Resident #6's care plan printed date 1/15/25 revealed there were no care plans to address anticoagulants or oxygen. Record review of the care plan history report dated 1/15/25 for Resident #6 revealed the following: Description, Oxygen Therapy r/t my disease processes related to heart failure. Revision date 1/15/25 signed by the Regional RN. Record review of Resident #6's physician order summary report for January 2025 revealed a physician order for oxygen at 2-3 liters per nasal cannula (N/C) as needed for s/s of SOB/Comfort as needed for shortness of breath (SOB) with a start date of 9/20/24. Record review of Resident #6's physician order summary report for January 2025 revealed a physician order for Apixaban Oral Tablet 2.5 MG. Give 1 tablet by mouth two times a day for anticoagulants related to heart failure, unspecified with a start date of 8/26/24, hold date from 10/7/24 to 10/10/24. Record review of Resident #55's Admission Record dated 1/15/2025 revealed a [AGE] year-old female originally admitted on [DATE] with a re-admitted [DATE]. Her medical diagnoses included pneumonitis (inflammation of the lungs), sepsis (the immune system reacting to an infection which could lead to organ failure), hypothyroidism (low levels of the hormone thyroid which regulates the body's functions like the metabolism), Bipolar Disorder, Traumatic Brain Injury, Epilepsy (seizures), Type 2 Diabetes Mellitus, cognitive communication deficit, and vascular dementia (a type of dementia caused by brain damage from impaired blood flow). Record review of Resident #55's care plan last captured on 01/15/2025 at 9:40am revealed there was no focus area for oxygen. Resident #55 had a focus area of hypertension secondary to frontal lobectomy/craniotomy with an initiated date of 06/21/2019 and had interventions including notifying the MD as needed with any signs or symptoms of malignant hypertension including difficulty breathing. Record review of Resident #55's Physician Orders last captured 1/15/2025 at 9:38am revealed she was ordered and started on 01/02/2025 for Continuous Oxygen at 2-3 Liters per N/C every shift. Record review of Resident #55's January TAR revealed she had orders for Continuous Oxygen at 2-3 Liters per N/C every shift, with a start date of 1/2/2025 at 6:00pm and a discontinued date of 1/15/2025 at 12:06pm. Resident #55's oxygen saturation levels were within normal range. Record review of Resident #55's hospital records dated 12/26/2024 revealed she was admitted for Pneumonia and Acute hypoxic respiratory failure (lungs cannot release enough oxygen into the bloodstream and can cause shortness of breath and dizziness). Resident #55 was admitted to the hospital for respiratory distress on 12/22/2024. She was placed on oxygen and was weaned off to 2 L as of 12/26/2024. The records had special instructions for Resident #55 to have O2 NC on DC. Observations of Resident #55 on 1/14/2025 at unknown time revealed she was sleeping with oxygen. She did not appear to be in distress. Later observation on at 11:35am, revealed Resident #55 was sitting in the hallway near the entrance across from the nurse's station without an oxygen mask or tank. She appeared well-groomed, and was sitting up with no discomfort. Resident #55 did not respond to questions. During an interview on 1/15/25 at 8:59 AM, The care plans were given to the surveyor on 1/15/2025 to address Resident #6 for anticoagulants and oxygen. the DON confirmed that Resident # 6 was on anticoagulants and oxygen. she said she did not look at the date of the care plans, that she just printed the care plans. An interview on 1/15/25 at 3:16 PM with the MDS Coordinator/ RN and the DCR. The MDS Coordinator said they worked as a team to get care plans updated but for Resident #6, she did not do those changes regarding oxygen and anticoagulants. An interview with the DON on 1/15/25 at 11:35am, she said she will have to check if Resident #55 required oxygen and will provide an update. Another interview with the DON at 3:37 PM, she said they were already auditing Care plans yesterday and the day before yesterday (1/13/25 and 1/14/25). She said the care plans for anticoagulants and oxygen should have been there if there was an order. The DON said that the facility had 48-hours to update the plan. The DON also said Resident #55 had an order for oxygen and it should have been on the care-plan, but that she talked with the doctor and they put in a new order for oxygen as needed since her oxygen saturation levels have been stable. During an interview with the DON on 1/16/25 at 3:02 PM, she said that Care plans tell us what care to perform for residents. The regular care plan is done by the MDS nurses, and the acute care plan is done by residents' nurses for things like antibiotics. She said that Care plan updates are a team effort, in the mornings they talk about resident care, go over orders from the previous day either for acute or long-term care plans and meetings include the 2 ADONs, 2 MDS nurses and a nurse. During an interview on 1/16/25 at 3:02 PM with the Administrator, she said Care plans were used to match resident needs, they had care plan clinical meetings, they discuss expectations and update the care plans. Record review of the facility policy and procedure entitled Care Plans, dated revised January 2023 read in part . The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hrs., throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI manual. Additional updates to the care plan may be done as indicated.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #31) of 5 residents observed for medication administration. -The facility failed to administer Resident #31's medications Furosemide and Gabapentin at the scheduled time set by the NF, 8:00AM. This failure placed residents at risk of unwanted drug interactions and decrease in quality of life. Finding: Record review of Resident #31's face sheet dated 01/16/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident diagnoses included the following: heart disease, dementia (impairment of at least two brain functions that includes memory loss and judgement), peripheral artery disease (a condition in which narrow blood vessels reduce blood flow to the extremities), hypertension (elevated blood pressure), and chronic pain. Record review of Resident #31's quarterly MDS dated [DATE] revealed resident had a BIMS score of 10 indicating that resident cognition was moderately impaired. Record review of Resident #31's Care Plan dated 12/19/2024 revealed that resident was being care planned for diuretic (medication that increases urine production by the kidneys) r/t left leg edema (swelling). The intervention included to administer medication as ordered by physician, monitor for side effects and effectiveness Q shift. Record review of the NF Medication Administration times as follows: -BID (8:00AM and 8:00PM) -TID (8:00AM, 3:00PM, and 8:00PM) Record review of Resident #31's Physician Order Summary Report for the month of January 2025 included the following medications to be administered to resident: -Dated 03/31/22 Furosemide 20mg give 1 tablet by mouth two times a day for lower extremity swelling. -Dated 08/19/2024 Gabapentin capsule 300mg give 1 capsule by mouth three times a day for neuropathy (damaged nerves) related to peripheral artery disease. Record review of Resident #31's MAR for the month of January 2025 included the medications gabapentin and furosemide were scheduled to be administered to resident at 8:00AM. Observation of medication pass on 01/14/2025 at 10:00AM with Medication Aide E revealed she administered the medication gabapentin 300mg 1 capsule and furosemide 20mg 1 tablet by mouth to Resident #31. Interview on 01/15/25 at 3:57 PM with the DON said scheduled medications can be administered an hour before or an hour after its scheduled time. The DON said if this was not done, it was considered a medication error. The DON said the physician or NP should be notified to see if the physician needed to make any changes to the resident's medication. The DON said if the medication aide made an error, the medication aide needs to notify the nurse so that the nurse could call the physician. The DON said this was the NF protocol. The DON said the NF would also have to complete a medication error report. The DON said when a resident's medication is not given as scheduled it could cause the medication to not be as effective. The DON was asked for the NF policies on medication administration, the NF drug pass times regarding BID, TID, etc. Interview on 1/16/25 at 7:53AM with Medication Aide E said she was aware of the NF medication times and that she could administer the medication 1 hour early or 1 hour after the scheduled time. She said the reason she was late administering Resident #31's medications gabapentin and furosemide were due to her being on another hall and got behind. She said it was important to administer the medication at the appointed time to ensure that physician orders were being followed and the effectiveness of the medication. Medication Aide E said she did not notify the nurse of Resident #31's medication furosemide and gabapentin being administered late and the more she thought about it, she should have notified the nurse. Record review of a medication error form for Resident #31 dated 01/15/25 reflected that the NF had assessed resident with no adverse reactions identified and the NP was notified. Further review reflected that the NF had in-served Medication Aide E to inform the charge nurse when a resident's medication was administered late so that the physician could be contacted. Medication Aide E verbalizing understanding. Record review of the NF policy on Medication Administration revised January 2024 reflected in part: .Resident medications are administered in a accurate, safe, timely, and sanitary manner .

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Residents #8) reviewed for accidents. -The facility failed to ensure Resident #8 had two fall mats in his room according to his comprehensive care plan. -The facility failed to ensure Resident #8's Physician Orders for two fall mats with a start date of 1/10/2025 were added as interventions in his comprehensive care-plan. Record review of Resident #8's facility Admission record revealed that Resident #8 was an [AGE] year-old male admitted on [DATE]. Resident #8's diagnoses included: chronic heart failure, vascular dementia (a type of dementia caused by brain damage from impaired blood flow), chronic kidney disease, cardiomegaly (enlarged heart), hyperlipidemia (high fat content in the blood), hypothyroidism (low levels of the hormone thyroid which regulates the body's functions like the metabolism), Type 2 Diabetes Mellitus, malignant neoplasm of prostate (prostate cancer), nutritional deficiency, hypertension (high blood pressure), cognitive communication deficit, and Generalized Anxiety Disorder. Record review of Resident #8's Quarterly MDS dated [DATE] revealed he had a BIMS score of 9, indicating moderate cognitive impairment. Resident #8 was documented using a wheelchair. He required supervision for oral hygiene and upper body dressing and required moderate assistance with toileting, showering, lower body dressing, and personal hygiene. Resident #8 required moderate assistance with transfer in bed and from bed to wheelchair or the toilet. Record review of Resident #8's care plan last reviewed 11/19/2024 revealed he was at risk for falls due to Debility (loss of ability) and weakness, with interventions including anticipating and meeting his needs and keeping his call bell within reach as indicated, bed at appropriate height when unattended, and that he was non-compliant with fall intervention which placed him at high risk for falls and injury. Resident #8's care plan did not include interventions for fall mats. Record review of Resident #8's Physician Orders revealed he had an active order with a start date of 1/10/2025 for Fall mats x2 (two) at bedside for every shift. Record review of Resident #8's fall assessment on 1/5/2025, reflected he had an unwitnessed fall on 4:30pm. It was documented there was no evidence of possible head injury, and Resident #8 was alert, had no pain, had normal vitals and had no concern with his motor functions. The document revealed he had neuro-checks completed for 72 hours post-fall. Record review of Resident #8's nursing progress note dated 1/5/2025 at 5:11 am revealed he was noted lying on the floor at the right side of the bed during routine rounding. He was unable to verbalize how he got to the floor. Resident #8 was alert but not to the situation. Vital signs within normal range, and he was assisted back to bed with no discomfort noted. Observation of Resident #8 on 1/14/2025 at 9:39am, revealed he was resting in his bed at its lowest position, with a fall mat on the left side of his bed. Further observation of Resident #8 on 1/16/2024 at 11:35am, revealed he was sleeping in his room and had one fall mat on the left side of his bed. Resident #8 was sleeping during observations and was unable to be interviewed regarding fall mats. Interview with CNA G on 1/16/2025 at 11:34am, she stated that Resident #8 had only one fall mat that she was aware of. Interview with RN H on 1/16/2025 at 4:11pm, they said that Resident #8's mat had food spillage on it so the aide took the mat away to be cleaned and it was being air dried and not in his room. He said that the fall mat's purpose was to prevent significant injury and that RN H believed Resident #8's care plan needed to be updated since the fall mat was added when Resident #8 used to be mobile but since he was on Hospice he had a reduction in mobility and being more in bed meant he was not at risk of falls as much. During an interview with the DON on 1/16/25 at 3:02 PM, she said that Care plans tell us what care to perform for residents. The regular care plan is done by the MDS nurses, and the acute care plan is done by residents' nurses for things like antibiotics. She said that Care plan updates are a team effort, in the mornings they talk about resident care, go over orders from the previous day either for acute or long-term care plans and meetings include the 2 ADONs, 2 MDS nurses and a nurse. During an interview on 1/16/25 at 3:02 PM with the Administrator, she said Care plans were used to match resident needs, they had care plan clinical meetings, they discuss expectations and update the care plans. Record review of the facility policy and procedure entitled Care Plans, dated revised January 2023 read in part . The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hrs., throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI manual. Additional updates to the care plan may be done as indicated.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #38) of 8 residents reviewed for infection control. -The NF failed to change Resident #38's midline IV (a Thin flexible tube inserted into a vein in the upper arm) dressing weekly as ordered by the physician on 1/13/25. This failure placed residents at risk for infections and decrease in quality of life. Findings: Record review of Resident #38's face sheet dated 01/16/25 revealed a [AGE] year-old male admitted to the NF on 05/07/24. Resident diagnoses included the following: pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot) , hemiplegia (complete paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the of the body that can affect the arms, legs and facial muscles), Type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy), pneumonia (infection that inflames air sacs in one or both lungs which may be filled with fluid), and heart failure. Record review of Resident #38's quarterly MDS dated [DATE] revealed that resident had a BIMS score of 15 indicating that resident cognition was intact. Record review of Resident #38's Physician Orders for the month of January 2025 reflected the following order: -Dated 01/13/25 midline dressing change and cap change weekly using sterile technique per protocol one time a day every Monday. -Dated 01/13/25 Ceftriaxone 1 gm (antibiotic) intravenously one time a day for pneumonia for 7 days. Record review of Resident #38's MAR reflected that the NF was administering medication Ceftriaxone as ordered. Record review of Resident #38's care plan initiated 01/15/25 revealed that resident was being care planned for intravenous therapy r/t intravenous access device. The interventions included to change dressing to IV access device site as ordered. Observation on 01/14/25 on Hall 300 at 2:45PM of Resident #38 having a midline to his right upper arm. The date on the dressing was 01/6/25. Interview on 1/14/25 at 2:50PM with LVN G said the midline dressings were supposed to be changed every 24 hours to prevent infections. LVN G said she was Resident #38's nurse but could not say why Resident #38's midline dressing to his upper right arm had not been changed. Interview on 01/14/25 at 3:00PM with the Infection Control Nurse/ADON F said the midline dressings were supposed to be changed every week to prevent infections. Infection Control Nurse/ADON F said he was responsible for monitoring IV lines for 300 Hall. He said he must have forgotten to check Resident #38's midline dressing to ensure that it was being changed weekly. Interview on 01/14/25 at 3:04PM with the DON said the midline dressings were supposed to be changed every week to prevent an infection. The DON said it was the ADON that ensured the midline dressing was being changed every week. The DON said the ADON assigned to Hall 300 was the Infection Control Nurse. The DON said the NF did not have a policy on IV/midlines. Observation on 01/14/25 at 3:38PM revealed Resident #38's midline dressing to right upper arm being changed by LVN G. Resident's mid-line site was without redness, swelling, or drainage. On 01/16/2025 at 8:15AM the DON was asked for Resident #38's care plan. Record review of the nursing policy regarding Infection Control dated April 2024 reflected in part: .The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare associated infections, to guide appropriate interventions, and to prevent further infections .

Based on observations, interview and record review, the facility failed to ensure that residents needing respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centereed care plan for 1 of 2 residents (Resident #55) reviewed for oxygen therapy. --The facility failed to ensure Resident #55 had continuous oxygen according to Physician Orders when she was found without her oxygen cannula on 1/15/2025 at 11:35am. This deficient practice could affect residents getting medically required treatment and lead to a decline in health. Findings include: An interview with the DON on 1/15/25 at 11:35am, she said she will have to check if Resident #55 required oxygen and will provide an update. She said the care plans for oxygen should have been there if there was an order. The DON said that the facility had 48-hours to update the plan. The DON also said Resident #55 had an order for oxygen and it should have been on the care-plan, but that she talked with the doctor and they put in a new order for oxygen as needed instead of continuous oxygen since her oxygen saturation levels had been stable. The DON discontinued the order for Resident #55 for continuous oxygen on 2L/min after surveyor intervention. Record review of Resident #55's Admission Record dated 1/15/2025 revealed a [AGE] year-old female originally admitted on [DATE] with a re-admitted [DATE]. Her medical diagnoses included pneumonitis, sepsis , hypothyroidism (low levels of the hormone thyroid which regulates the body's functions like the metabolism), Bipolar Disorder, Traumatic Brain Injury, Epilepsy (seizures), Type 2 Diabetes Mellitus, cognitive communication deficit, and vascular dementia (a type of dementia caused by brain damage from impaired blood flow). Record review of Resident #55's care plan last captured on 01/15/2025 at 9:40am revealed there was no focus area for oxygen. Resident #55 had a focus area of hypertension secondary to frontal lobectomy/craniotomy with an initiated date of 06/21/2019 and had interventions including notifying the MD as needed with any signs or symptoms of malignant hypertension including difficulty breathing. Record review of Resident #55's Physician Orders last captured 1/15/2025 at 9:38am revealed she was ordered and started on 01/02/2025 for Continuous Oxygen at 2-3 Liters per N/C every shift. Record review of Resident #55's January TAR revealed she had orders for Continuous Oxygen at 2-3 Liters per N/C every shift, with a start date of 1/2/2025 at 6:00pm and a discontinued date of 1/15/2025 at 12:06pm. Resident #55's oxygen saturation levels were within normal range. Record review of Resident #55's hospital records dated 12/26/2024 revealed she was admitted for Pneumonia and Acute hypoxic respiratory failure (lungs cannot release enough oxygen into the bloodstream and can cause shortness of breath and dizziness). Resident #55 was admitted to the hospital for respiratory distress on 12/22/2024. She was placed on oxygen and was weaned off to 2 L as of 12/26/2024. The records had special instructions for Resident #55 to have O2 NC on DC . Observations of Resident #55 on 1/14/2025 at 9:39am revealed she was sleeping with oxygen. She did not appear to be in distress. Later observation on 1/15/2025 at 11:35am, revealed Resident #55 was sitting in the hallway near the entrance across from the nurse's station without an oxygen mask or tank . She appeared well-groomed and was sitting up with no discomfort. Resident #55 did not respond to questions. An interview with the DON on 1/15/25 at 11:35am, she said she will have to check if Resident #55 required oxygen and will provide an update. Another interview with the DON at 3:37 PM , she said they were already auditing Care plans yesterday and the day before yesterday (1/13/25 and 1/14/25). She said the care plans for anticoagulants and oxygen should have been there if there was an order. The DON said that the facility had 48-hours to update the plan. The DON also said Resident #55 had an order for oxygen and it should have been on the care-plan, but that she talked with the doctor and they put in a new order for oxygen as needed since her oxygen saturation levels have been stable. The DON discontinued the order after surveyor intervention. The DON said she heard the aide wheeled Resident #50 out of bed but did not place the oxygen on the resident and that she would investigate further. She also said the oxygen was on the resident's Kardex (a shortened version of a resident's care plan that aides can acccess on the electronic medical records) so the aide should have known Resident #50 needed oxygen. Later interview with the DON on 1/16/2025 at 4:11pm, she said that Resident #55's aide told the DON and she took Resident #55's oxygen off to get her changed to head outside her room and forgot to put it back on. The DON was requested to ask the aide to come into the room, the aide did not come in. Record review of the facility's Medication Administration policy implemented March 2019 read in part, Resident medications are administered in an accurate, safe, timely, and sanitary manner .Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The dish washing and sanitizing machine's water temperature and sanitizer levels were below the manufacturer's required minimum wash and rise temperatures and levels. These deficient practices could place residents who received meals from the main kitchen and place them at risk for food borne illness. Findings include: Interview and observations on 11/28/2023 at 7:37 AM with Dietary Manager The dishwasher displayed was a low temperature washer. The Dietary Manager agreed the water temperature was low. The water measured 110 degrees F and the sanitizer was measured three times and indicated the sanitizer levels were 25, 25, and 25 PPM . She said she typically worked 6:30 AM- 3:30 PM Monday through Friday. She said she had worked at the facility for 4 years and worked in food service since she was [AGE] years. She said the dishwasher used detergent and sanitizer to clean the dishes. She said the sanitizer was bleach and that was used to kill any viruses and germs on the dishes and silverware. She said her role at the facility was as the Dietary Manager. She said she routinely scheduled the kitchen staff, oversaw the cooks, dietary aide, daily job duties, ordered food and supplies, maintained the monthly budget, attended the Care Plan meetings, made sure the food was first in, first out, and any other any other duties assigned. She said the procedure for washing dishes was staff checked the dishwasher before each meal to ensure it was properly sanitizing. She said she was responsible for ensuring policy was followed regarding sanitizing and the temperature of the dishwasher. She said the risk to residents if the dishes and silverware were not properly cleaned there could be an outbreak among the residents. She said the worst thing that could happen to a resident if procedure was not followed was a resident could die. She said normally, the bleach PPM was over the acceptable amount. She said the dishwasher was last serviced was on 11/01/2023. She said the staff would hold off on washing the dishes until the service people came and looked at the dishwasher . Observation on 12/28/2023 at 09:05 AM of the dish machine revealed the wash temperature was 110 F and the rinse temperature was 110 F . Interview and observations on 11/28/2023 at 10:41 AM with Dietary Manager the dishes were piled up in the corner in the dish washing area and the Dietary Manager showed this surveyor the dishes had not been washed. The service person for the dishwasher was at the facility and adjusted the tubing for the sanitizer, and detergent. The Dietary Manager said the tubes leading to the dish washing and sanitizing machine were not in their proper containers. She said the detergent and the sanitizer tubes had been switched. She said the containers for the detergent, sanitizer, and Dry 3000 had color coded lids on them now to help identify which tube should go where. The dishwasher water and sanitizer were tested again, and the temperature measured 128 degrees F and the sanitizer/bleach read 50-100 PPM. Interview on 11/29/2023 at 2:05 PM with the Administrator. She said she had worked at the facility for 4 years and 4 months. She said her role at the facility was the as the Administrator- She said she oversaw the operations of the building, ensured policies and procedures were followed. She said she worked in the building 7 AM- 5 PM, Mon-Fri, but she was also on call 24 hours, 7 days a week. She said she routinely was here for the residents to oversee their care, listened to their concerns, and in general be there for them and facilitate their needs. She said the procedure for washing dishes was the dishwasher needed to run properly, have hot water and detergent and sanitizer. She said she did not know the specific minimum temperature and sanitizer levels for the dish and sanitizing machine. She said staff were required to take the temperature and record the temperature of the water. When asked when she was last in-serviced on procedure/policy for washing dishes, she said proper dishwashing was something the Dietary Manager did when doing rounds with the dietician. She said the Dietary Manager was responsible for ensuring staff followed protocol and she oversaw that the Dietary Manager followed protocol. She said the risk to the residents when procedure and protocol were not followed was residents could get sick if food was still on the plates and silverware. She said the worst thing to happen to a resident when procedure and protocol were not followed could be serious illness to the residents. She said the failure occurred because the dish machines could be mechanical and can fail. That was the reason the company was called out to service the dishwasher. Interview on 11/29/2023 at 2:18 PM the Dietary Manager said the maintenance company for the dishwasher was out [DATE]st, but staff had changed the sanitizer on 11/27/2023 and that was when the tubing had got switched around. Observation on 11/30/2023 at 08:37 AM of the dish washing and sanitizing machine indicated a manufacturer plate on machine displayed the minimum wash and rinse temperature was 120 F. Record review of the facility's Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment policy dated [DATE] read in part . 2. Make sure that the automatic detergent dispenser and/or liquid sanitizer injector is working properly. 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: The temperature of the wash water must be at least 120 degrees F . Record review of the facility Dish Machine Temperatures and Sanitizing Log dated [DATE] read in part . temperatures measured from 120- 130 degrees F, except on 11/29/2023 which measured 110 degrees F. The sanitizer Record review of the TFER dated [DATE], section S228.111(e)(1) read in part . a warewashing machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions .

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 3 errors out of 33 opportunities, which involved 2 of 8 residents (Resident #90 and Resident #99) reviewed for medication errors. MA A failed to give Resident #90 her Metoprolol (blood pressure medication) and Trazadone (antidepressant medication) as directed by pharmacy, which was with or immediately after meals. MA A failed to give Resident #99 his Fenofibrate (high cholesterol medication) as directed by pharmacy, which was with a meal. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings include: Resident #90 Record review of Resident #90's Face Sheet dated 11/29/2023 revealed, a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: senile degeneration of brain (severe dementia characterized by cell loss), seizures (uncontrolled electric activity in the brain caused abnormal muscle tone and movements), atrial fibrillation (irregular often rapid heart rate), osteomyelitis (inflammation of bone), hypertension (elevated blood pressure blood was pumping with more force than normal through the arteries) Dementia with mood disturbance ( Depression was the most common emotion and mood disorder) and bipolar (episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #90's quarterly MDS dated [DATE] revealed, Resident #90 usually made herself understood. Resident #90 usually had the ability to understand others. Resident #90's cognition was moderately impaired indicated by her BIMS score of 12 out of 15. Record review of Resident #90's care plan dated 11/15/2023 revealed: Focus: Resident #90 had activity intolerance related to hypertension; Goal: Resident #90 will not experience adverse effects or associated complications through next review date; Interventions: Monitor vital signs as indicted and report abnormal findings to physician. Record review of Resident #90's care plan dated 11/15/2023 revealed: Focus: Resident #90 required anti-depressant medication. Goal: Resident #90 would not have any complications related to anti-depressant medications through review date; Intervention: Educate on the potential side effects and risks associated with psychotropic medications (a psychoactive drug taken to affect the chemical makeup of the brain). Record review of Resident #90's Order Summary Report dated as of 11/29/2023 revealed Metoprolol Tartrate 25mg. Give by mouth one time a day for hypertension. Order dated 06/01/2023. Record review of Resident #90's Order Summary Report dated as of 11/29/2023 revealed Trazodone 50mg. Give 0.5 tablet two times a day for depression. Order dated 11/27/2023. An observation and interview on 11/29/2023 at 6:57 AM revealed MA A dispensed Metoprolol 25mg. The Metoprolol pharmacy container indicted Take immediately after a meal or with a meal. MA A dispensed Trazadone 50mg 0.5tablet. The Trazadone pharmacy container indicated take with food. Resident # 90 was awake and alert in bed. There was no food or snacks in Resident #90's room. MA A administered the medications to Resident #90. Interview with Resident #90 at this time she stated she had not eaten yet . Record review of Resident #90's MAR dated 11/01/2023-11/30/2023 revealed Metoprolol Tartrate 25mg daily was administered by MA A: November 7, 8, 9, 13, 14, 15, 16, 17, 20, 21, 22, 23, 24, 28 and 29, 2023 timed for administration qd morning Record review of Resident #90's MAR dated 11/01/2023-11/30/2023 revealed Trazadone 50mg 0.5 tablet=25mg two times a day was administered by MA A: November in the morning on 28 and 29, 2023 timed for administration qd morning In an observation and interview on 11/29/2023 at 10:24 AM MA observed Resident #90's Metoprolol and Trazadone pharmaceutical packet and stated this was the normal time she administered the medications to Resident #90. MA A stated she should not have administered the medications without food. MA A stated the pharmacy recommendations needed to be followed. MA A stated the risk to the resident the medication may not work correctly. MA A stated the person who administered the medication was responsible for doing it correctly. In an interview on 11/29/2023 at 10:45 AM Resident #90 stated she cannot remember every day when she got her medicine. Resident #99 Record review of Resident #99's Face Sheet dated 11/29/2023 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: hyperlipidemia ( high levels of fat particles in the blood), cerebral infarction due to occlusion (disrupted blood flow to the brain) acute embolism ( obstruction of an artery from a clot. Record review of Resident #99's Admission MDS dated [DATE] revealed , Resident #99 usually made himself understood. Resident #99 usually had the ability to understand others. Resident #99's cognition was moderately impaired indicated by his BIMS score of 08 out of 15. Record review of Resident #99's care plan dated 11/15/2023 revealed: Focus: Resident #99 was at risk of cardiac complications such as chest pain, shortness of breath fatigue dizziness related to hyperlipidemia; Goal: treatment regime to manage heart disease without any adverse effects Interventions: Monitor vital signs as indicted and report abnormal findings to physician. Record review of Resident #99's Order Summary Report dated 11/29/2023 revealed Fenofibrate 160mg one time a day. Order dated 09/11/2023. An observation and interview on 11/29/2023 at 7:00 AM revealed MA A dispensed Fenofibrate 160 mg. The Fenofibrate pharmacy container indicated take with meal. Resident # 99 was awake and alert in bed. There was no food or snacks in Resident #99's room. MA A administered the medciations to Resident #99. Interview with Resident #99 at this time he stated he had not eaten breakfast yet. In an observation and interview on 11/29/2023 at 10:24 AM MA observed Resident #99's Fenofibrate pharmaceutical packet and stated this was the normal time she administered the medication to Resident #99. MA A stated she should not have administered the medications without food. MA A stated the pharmacy recommendations needed to be followed. MA A stated the risk to the resident the medication may not work correctly. MA A stated the person who administered the medication was responsible for doing it correctly. In an interview on11/29/2023 at 10:39 AM Resident #99 stated this was the time he normally got his medication. Resident #99 stated he received his morning medications before breakfast. Resident #99 stated he had no problems with medications. Record review of Resident #99's MAR dated 11/01/2023-11/30/2023 revealed Fenofibrate 160mg one time daily was administered to Resident #99 by MA A: November: 7, 8,9, 13, 14, 15,16, 17, 20, 21, 22, 23, 24, 28, 29 2023 timed administration qd morning In an interview on 11/29/23 at 10:51 AM RN B stated she did staff training. RN B stated she would address the time on the MAR so the medications were not given before breakfast. RN B stated she would inservice the staff to review the pharmacy recommendations on the containers. RN B stated the medications needed to be given with food as indicted by the pharmacy. RN B stated the risk to the resident was stomach upset like nausea, vomiting and diarrhea. In an interview on 11/29/23 at 10:55 AM the DON stated she expected the staff to follow the pharmacy recommendations. The DON stated the risk to the resident was stomach upset. The DON stated they will Inservice the staff on following the pharmacy recommendations. In an interview on 11/29/2023 at 11:05 AM the Administrator stated she expected the pharmacy recommendations to be followed. The Administrator stated the pharmacy recommended the medications to be given with food this should have been followed. The Administrator stated she would expect the resident may experience side effects from getting the medication without food. The Administrator stated the staff was inserviced immediately. In an interview on 11/29/2023 at 1:00PM the facility pharmacist stated the reason the medications were to be given with food was to help decrease the side effects of the medications. The pharmacist stated the Fenofibrate was also to be given with food because it worked off the food for the best result. In an interview on 11/30/2023 at 9:31 AM MA A stated the initials documented on Resident # 90 and Resident #99's MARs were her initials that she administered the medications on the dates identified. In an interview on 11/30/2023 at 10:25 AM the DON stated the DON and RN B do random monitoring of medication administration. The DON stated the staff were observed randomly for medication administration accuracy. The DON stated the resident's MARs and physician's orders were reviewed for accurate administration as ordered. The DON stated the results of the monitoring was addressed in the daily manager meeting every morning. The DON stated the staff who administered the medications were responsible for accurate administration. Record review of the facility policy titled Medication Administration undated revealed Objective: Resident medications are administered in an accurate, safe timely and sanitary manner . Procedure: 2. Verify the medication label against the medication sheet for accuracy of drug, frequency, duration, strength and route. A. The nurse shall be responsible to read and follow precautionary or instructions on prescription labels .

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Residents #94) of three residents reviewed for feeding tubes. LVN C failed to set Resident #94's enteral feeding rate per the physician's order. LVN C failed to set Resident #94's enteral water flush per the physician's order. These failures could place residents at risk for fluid overload and inadequate nutrition which could lead to injury or harm. Findings included: Record review of Resident #94's face sheet revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #94's MDS dated [DATE] revealed she did not have a BIMS due to Resident #94 rarely/never being understood. Resident #94 received 51 percent or more of total calories through tube feeding. Resident #94 received 501 cc a day or more fluid through tube feeding. Record review of Resident #94's care plan dated 12/23/21 revealed Resident #94 was at risk for nutritional deficits and/or dehydration related to dependence on g-tube. Staff were to administer diet as ordered and administer flush as ordered. Record review of Resident #94's physician's orders dated September 2022 revealed Enteral Feed Order every shift Glucerna 1.5 cal at 65 ml/hour x 22 hours. Start date 09/13/22. Record review of Resident #94's physician's orders dated 09/2022 revealed Enteral Feed Order every shift H2O flush at 40 ml/hr x 22 hours. Start date 09/13/22. Observation on 09/22/22 at 9:54 AM revealed Resident #94 was lying in bed sleep. The feeding tube was infusing Glucerna 1.5 cal at 60ml/hr. There was 800 cc in the feeding bag. The bag was hung on 9/22/22 at 6:00 AM per the label. Resident #94's H2O flush was infusing at 50ml/hr flush. There was 800 cc in the water bag. The bag was hung on 9/22/22 at 5:00 AM per the label. In an interview on 09/22/22 at 10:04 AM LVN B stated Resident #94's feed should have been infusing at 65 ml/hr and her flush should be infusing at 40 ml/hr. LVN B said the night nurse, LVN C, hung the bag. She said she did rounds with LVN C, but things were crazy this morning because she got to work late around 6:35 AM. LVN B said she was supposed to start work at 6:00 AM. LVN B said she had not gotten the chance to check Resident #94's g-tube feeding. LVN B said it was important to give the resident the right feeding rate because they could become dehydrated. LVN B said the resident could also be malnourished from not getting the proper nutrients. In an interview on 09/22/22 at 11:13 AM LVN C stated she did not know what happened with Resident #94's feeding and the water flush. LVN C said she thought she set the pump right. LVN C said she made rounds with LVN B, after LVN B got to work late. LVN C said maybe someone could have turned the pump off during incontinent care, she was not sure. She said she did not want to make excuses. LVN C said if a resident got too much fluid, then the resident could get fluid overload. LVN C said a resident could lose weight from not getting the proper feed. In an interview on 09/22/22 at 10:22 AM the DON stated her expectations were for the nurses to follow the physician's orders when providing enteral feedings. The DON said the nurses were expected to check the feedings during rounds. The DON said increased fluids could cause fluid overload for the resident or inadequate nutrition from not getting enough feed. The DON said Resident #94 had several comorbidities and kidney issues which caused her to go in and out the hospital. Record review of the facility policy Enteral Feeding: Ready to Hang dated 05/16/2016 revealed Procedure: 1. Verify physician's order.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for 1 of 4 medication carts (100 Hall Nursing Cart) reviewed for pharmacy services. - The facility failed to ensure the 100 Hall Nursing Cart did not contain a discontinued, expired Insulin [MEDICATION(S)] pen. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: In an observation and interview on 09/21/22 at 09:12 AM, inventory of the 100 Hall Nursing Cart with LVN A revealed: - An open and in use Insulin [MEDICATION(S)] pen with an open date of 08/18/22. LVN A said nursing staff are expected to check their carts daily as used for expired or inappropriately labeled medications. She said once an insulin pen is opened/taken from the refrigerator an open date must be recorded on the pen in order to track the beyond use date. LVN A said the Insulin [MEDICATION(S)] pen expired 28 days (09/15/22) after opening so it was currently expired. She said when insulin expires it can lose potency, become cloudy or contaminated so the Insulin [MEDICATION(S)] pen could not be used. LVN A said she was new and didn't know the exact drug disposal process, but she would remove the pen from the cart and submitted it to the DON for destruction. She said the use of expired insulin could place residents at risk for uncontrolled blood sugar and possible infection. In an interview on 09/21/22 at 10:47 AM, the DON said nursing staff are expected to check their carts daily as used for expired medications. She said all insulin pens should be labeled with the date they are taken out of the fridge and/or used in order to track their expiration date and the binder on each nursing cart contained a list of the Insulin Beyond Use Dates that nursing staff could reference. She said after insulin expires it can lose its potency and use in residents would risk side effects or uncontrolled blood sugars. The DON said the resident's Insulin [MEDICATION(S)] order for the expired pen found in the cart was discontinued prior to the manufacturer assigned 28 day (09/15/22) expiration date so the medication had not been administered to the resident. She said once an order is discontinued, the nursing staff who received the order to discontinue is responsible for removing the medication from circulation, leaving it in a secure location until it is discarded. The DON said leaving expired or discontinued medications in the medication carts could place residents at risk for medication errors. Record review of the facility provided document titled Insulin Beyond Use Date revised on 12/01/22 revealed, Name of Insulin: [MEDICATION(S)] vials and Kwikpen ([MEDICATION(S)]), Beyond Use Date After Opening at room temp- 28 days. Record review of the facility policy titled Medication Management revised April 2011 revealed, Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws. Guidelines: 5- Medications discontinued shall be maintained in a secure area until returned to pharmacy or destroyed.

Based on interview and record review the facility failed to ensure the drug regimen of each resident was reviewed at least once monthly by a Licensed Pharmacist for facility wide drug regimen review. The facility had no documentation of a drug regimen review being conducted for each resident for the months of October 2020, February 2021, and May 2021. This failure affected all residents whose medications were not reviewed for irregularities placing them at increased risk of adverse drug consequences and decline in their physical and mental health status. Findings include: Resident #55 Record review of Resident #55's admission face sheet revealed an [AGE] year old male who was originally admitted to the facility on [DATE] with the following diagnoses of unspecified dementia without behavioral disturbance, dysphagia, prostate disorder, gastro-[CONDITION(S)] reflux disease, [CONDITION(S)], cerebral infarction, [CONDITION(S)], cognitive communication deficit, psychotic disorder with delusions, unspecified [CONDITION(S)], traumatic subdural hemorrhage with loss of consciousness, acute embolism and [CONDITION(S)], muscle wasting and atrophy, difficulty walking, abnormalities of gait and mobility, lack of coordination, and major depressive disorder. Record review of Resident #55's active orders dated 7/09/2021 revealed: [MEDICATION(S)] capsule - 4.5 mg, give 1 capsule by mouth one time a day for dementia. [MEDICATION(S)] solution 250 mg/5ml (Valproate Sodium) give 5ml by mouth two times a day for mood disorder. [MEDICATION(S)] Tab 5mg (Apixaban) give 1 tablet by mouth two times a day for [CONDITION(S)]. Monitor resident for anticoagulant side effects due to [MEDICATION(S)] intake: (0) for none, (1) bruising, (2) black tarry stools, (3) bleeding every shift for bleeding/bruising/tarry stool. Monitor resident for side effects of [MEDICATION(S)] such as (0)none, (1)stomach pain, (2) Nausea/Vomiting, (3) diarrhea, (4) swollen gums, (5)headache, (6) feeling tired or sleepy, (7) tremors, (8) weight gain, (9)thinning hair, (10)dry or sore mouth every shift for side effects. Monitor resident for bleeding, bruising, orange/red urine or dark tarry stools due to [MEDICATION(S)] every shift for [CONDITION(S)]. Record review of the facility's Pharmacy binder from 06/01/2020 to 06/11/2021 indicated no documentation of Medication Regimen Review were recorded for October 2020, February 2021, and May 2021. In an interview with the corporate nurse on 7/08/21 at 1:48 PM, she stated she started working at the facility in April 2021. Before her time, there was no pharmacy system established. She made an action plan to correct this deficiency and will share that document with the surveyors. Record review of the facility's Plan of Action dated 4/14/21 revealed, the facility listed concerns of Pharmacy system is not in compliance due to recommendations not being carried out in a timely manner, March follow up rate was 49 % expectation is 100%, Flagging for AP meds 8.3% state 2.2%, national 2.1%. There is no GDR list, or F/U on quarterly psych reviews noted, March pharmacy recommendations are not documented as followed through. In an interview with the DON on 7/08/2021 at 2:10 PM, she said the action plan was a result of a mock survey the facility conducted, and they are aware of the noncompliances, and she was hired to correct all these issues, since she started in June, she conducted GDR review, 8 residents have their medication reduced or discontinued. And she's still working on fixing all issues. Record review of facility Policy titled Policies and Procedures for LTC, (undated) under section 10.2 titled Medication Regime Reviews The consultant pharmacist will review each resident's medication regimen in accordance with the Pharmacy Services Agreement. The facility will provide adequate workspace and access to the resident's medical record. The facility should ensure that the physician/prescribers are provided with copies of the medication regimen review.

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to prevent, recognize, and control the onset and spread of infection to the extent possible, to include hand hygiene for 5 of 14 residents (#4, #43, #46, #73, #67) reviewed for infection control in that: - MA A did not sanitize the blood pressure cuff between residents #4, #46, #73, and #67 or follow infection control techniques to avoid the spread of infections. -LVN I failed to perform incontinent care prior to wound care for Resident #43. -LVN I failed to remove soiled gloves and perform hand hygiene prior to touching tube feeding pump for Resident #43 This failure placed residents at risk for cross-contamination and the spread of infection. Findings included: Resident #43 Record review of Resident #43's current admission record revealed an [AGE] year-old individual, admitted on [DATE] and initially admitted on [DATE]. Resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #43's quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had no spoken words, was usually understood and able to understand others. Brief Interview of Mental Status (BIMS) and staff assessment of mental status did not have results. Resident #43 was totally dependent on two-person assistance for bed mobility, transfers and toilet use. Resident required extensive assistance of one person for dressing and personal hygiene. Resident was always incontinent of bowel and had an indwelling urinary catheter. Record review of Resident #43's Order Summary Report (active orders as of 07/09/2021) included in part: cleanse sacrum wound with wound cleanser, pat dry, pack with Collagen and silver Alginate and cover with dry dressing every day. Order date 06/08/2021 Secure catheter with leg strap every shift, order date 07/06/2021. Record review of Resident #43's Care Plan dated 06/02/2021 included resident had a Pressure ulcer to sacrum, related to immobility, history of ulcer, Type 2 Diabetes Mellitus .Goal included in part: Pressure ulcer will show signs of healing and remain free from infection Interventions included in part: .administer treatments as ordered and observe for effectiveness .resident needed assistance to turn/reposition with rounds, more often as needed or requested; observe dressing while providing care to ensure it is intact and adhering. Report loose dressing to treatment nurse .Resident had activities of daily living (ADL)/Self Care deficit related to . incontinence of bowel .Goal included in part: . Resident will receive assist with activities of daily living (ADLs) and mobility daily from staff .Interventions included in part: .Brief Use: Resident used disposable briefs, provide care and change as indicated .Toileting tasks/foley catheter care/incontinent care x 2 person assistance . Observations on 07/08/2021 at 9:25 a.m., LVN I performed wound care for Resident #43 while CNA II assisted. Resident #43 was already laying on her right side with adult brief partially removed. The resident had a bowel movement and stool was on the buttocks, brief and linen. LVN I performed wound care to the stage 4 sacral pressure ulcer. LVN I removed soiled gloves, performed hand hygiene, donned clean gloves and performed incontinent care. LVN I touched the tube feeding pump with soiled gloves to silence the alarm. Observed liquid stool seeping into the loose edge of wound dressing. LVN I secured the clean adult brief, disposed the used supplies and gloves. LVN I restarted the tube feeding pump, washed hands and exited the room. In an interview on 07/08/2021 at 9:45 a.m., LVN I stated she thought the nurse aide had already done the incontinent care as Resident #43 always had bowel movements. She stated wound care should be done after incontinent care, so bowel movement does not get into wound. She said she usually does incontinent care herself before wound care if the aids are busy. When asked what she would have done differently in this situation: she stated she would redo the dressing. When asked what she should do if she touched the tube feeding pump with soiled gloves; she said she should sanitize for infection control. In an interview on 07/08/2021 at 12:10 p.m., ADON/Infection Preventionist stated that during wound care, incontinent care should be done first for infection control reasons. He did not say anything about LVN I touching the tube feeding pump. Record review of facility policy Skin: Clean Dressing Change, [NAME] Communities, updated 03/14/2019 revealed in part .Purpose: The licensed nurse or therapist applies dressings using clean technique to promote wound healing and prevent cross-contamination among and between residents and caregivers .Procedure: Follow standard precautions at all times . Record review of facility policy Infection Control, Standard Precautions, revised by [NAME]-Communities 2011, revealed in part .Policy Statement: Standard Precautions will be used in the care of all residents regardless of their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Policy Interpretation and Implementation .2. Gloves .d. Remove gloves after use, before touching non-contaminated items and environmental surfaces .6. Environmental Control: a. Environmental surfaces .bedside equipment and other frequently touched surfaces need to be appropriately cleaned . Resident# 4 Record review of Resident #4's face sheet revealed [AGE] year old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS dated [DATE] revealed he had a BIMS score of 12 indicating moderate impaired decision skills. Resident #46: Record review of Resident #46's face sheet revealed a [AGE] years old female with an admitted [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #46's quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 13 indicating no impaired cognition. Resident #73: Record review of Resident #73's face sheet revealed a [AGE] years old male with an admitted [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #73's admission MDS assessment dated [DATE] revealed he had a BIMS score of 15 indicating no impaired cognition. Resident #67: Record review of Resident #67's face sheet revealed a [AGE] years old female with an admitted [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #67's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 15 indicating no impaired cognition. Observation of MA A on 7/7/21 at 6:40 AM, she checked the resident's blood pressure revealed the following: Resident #4's lying in bed on 07/07/21 at 6:46 AM revealed, MA A entered the room and checked his blood pressure which read 149/91 and pulse 73. MA A did not sanitize the blood pressure cuff. MA A went to Resident #46's room at 6:55 AM, resident was lying in bed, MA A checked blood pressure, the reading was BP 132/55 and pulse 77. MA A did not sanitize the blood pressure cuff. MA A went to Resident #73's room at 6:58 AM, resident was lying in bed, MA A checked blood pressure, the reading was BP 167/86 and pulse 60. MA A did not sanitize the blood pressure cuff. MA A went to Resident #67's room at 7:00 AM, resident was lying in bed, MA A checked blood pressure, the reading was BP 138/79 and pulse 60. In an interview with MA A on 7/7/21 at 7:32 AM, regarding sanitizing the blood pressure cuff between residents, she said she forgot to sanitize after each resident. MA A said, I Am sorry. In an interview with the ADON on 7/8/21 at 5:00 PM, she said the MA's were all trained to sanitize blood pressure cuffs between residents. On 7/8/21 requested for policy non was provided before exit on handing blood pressure cuff between residents.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 30 opportunities which resulted in a 6 percent error rate involving 2 of 7 residents reviewed for medication pass. (Resident #4 and Resident #67) MA A did not administer- [MEDICATION(S)] as ordered by the physician for Resident #4. - MA A did not administer [MEDICATION(S)] ER (extended release) as ordered by the physician for Resident #67. These deficient practices affected residents and placed residents at risk for not receiving the intended therapeutic benefit of their medication. Findings include: Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS dated [DATE] revealed he had a BIMS score of 12 indicating moderate impaired decision making skills. Record review of Resident #4's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 30 minutes prior to meals. During observation on 7/07/21 at 6:50 AM, MA A administered [MEDICATION(S)] tablet 10 mg, 1 tablet (blister had Take 1 tablet by mouth after meals) and other medications by mouth with medpass (Vanilla supplement) Record review of Resident #4's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 30 minutes prior to meals. Medication schedule was 7:00 AM, 11:30 AM and 4:30 PM. Interview with MA A on 7/7/21at 6:50 AM, regarding not following [MEDICATION(S)] tablet 10mg pharmaceutical recommendation, ( blister had Take 1 tablet by mouth after meals) MA A said she gave Resident #4's medpass and the breakfast tray comes out at 8:30 AM. Resident #67: Record review of Resident #67's face sheet revealed a [AGE] years old female with an admitted [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #67's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 15 indicating no impaired cognition. Record review of Resident #67's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 2 tablets (20meq) to equal to 40 meq daily. Record review of Resident #67's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 2 tablets ( 20meq) to equal to 40 meq daily. During observation on 7/7/21 at 7:27 AM, MA A administered [MEDICATION(S)] ER 20 meq, 1 tablet and other medications by mouth with water. [MEDICATION(S)] ER 20 meq blister packet indicated to Take with Food. Interview with MA on 7/7/21 at 12:05 PM, regarding omission of [MEDICATION(S)] ER 20 meq not given earlier. MA A said she was going to give the medication and other medications by mouth with water. MA A said Resident #67 use to be on 20 meq of [MEDICATION(S)] ER, she did not realized it was changed. Interview with the facility ADON on 7/8/21 at 11:50 AM, revealed it was his expectation that the staff should ensure all medications were taken as prescribed in their entirety Interview with the DON on 7/8/21 at 4:05 PM, revealed she was not aware that Resident # 67 did not receive her entire dose of medication that morning. She said it was her expectation that the staff administer medications fully and follow the facility policy without exception. She said that in the event that a medication could not be administered for any reason, the staff should notify the resident's nurse, the physician, the family and the DON for follow-up. In an interview with the DON on 7/8/21 at 4:50 PM, regarding medications blister packet pharmaceutical recommendation on medications blister packet not being followed, she said the facility had problem with pharmaceutical company and they are planning to change it due to discrepancy. Review of meal times for hall tray for breakfast was 8:30 AM and breakfast tray was observed served at 8:30 AM on 7/8/21 and throughout the survey. Record review of the facility's policy entitled, Medication Administration dated 3/15/19 revealed the following: .2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route a. The nurse/medication aide shall be responsible to read and follow precautionary or instructions on prescription labels. b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved. .6. Medications must be administered in accordance with the orders, including any required time frame.

Based on observation , interview and record review, the facility failed to ensure that residents receive treatments and care in accordance with professional standards of practice, the comprehensive person- centered care plan that will meet each resident's physical, mental, and psychosocial needs for three of twenty residents (Resident #61, #1 and #20 ) reviewed for quality of care, in that; Resident #61 who had history of UTI and severe ventral erosion (split penis) did not have orders for his indwelling urinary catheter or catheter care/monitoring. Resident #61 repeatedly pleasured himself with catheter in place and split penis and did not have care plan for risks of infection associated with his self-pleasuring and penile condition (split penis). Resident #61 subsequently developed urinary tract infection [MEDICAL CONDITION]. Resident #1 was not provided dietician recommended or physician ordered [DEVICE] water flushes which resulted in an abnormal BUN. Resident #20 did not receive recommended mechanical soft diet. Resident #20 was provided a food tray without a physician order [REDACTED].>These failures affected three residents and placed them at increased risk of health decline and diminished quality of life. Findings include: Resident #61 Record review of Resident #61's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS of 8 indicating moderately impaired cognition. The MDS reflected resident had an indwelling urinary catheter. The MDS indicate the resident had [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] as active diagnoses. The MDS also indicated the resident had UTI in the last 30 days. Record review of Resident #61's care plan dated 1/17/19 revealed he had size 16F (French) catheter related to neuromuscular dysfunction of the bladder and was at risk for infections and discomfort. The interventions listed were for resident to have 16F Foley with balloon, catheter bag and tubing positioned below the level of the bladder and away from room entrance, check tubing for kinks each shift, Foley catheter care every shift and PRN, Foley: change catheter and drainage bag based on clinical indication such as infection, obstruction, or when the closed system is compromised, monitor and document intake and output as per facility policy, monitor/document for pain discomfort due to catheter, monitor/record/report to MD for signs/symptoms of UTI: pain burning blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and eating patterns. Further review of care plan revealed no mention of history of UTI's, severe ventral erosion, or repeated self-pleasuring in reference to his indwelling catheter and risks associated. Observation and interview on 5/30/19 at 1:00PM, Resident #61 was lying in bed, catheter not visible but resident said he keeps it in his pants with leg strap. Resident says he has trouble sometimes emptying it and said he does do it by himself but sometimes staff will help him clean up if it spills or if there's an issue. He said the bag gets full quickly and he had to try and keep up with emptying it. Resident grabbed the bag inside his pants and it moved around to hear how much urine was inside. Resident said it was full right now and when surveyor leaves out he was going to go empty it. Resident said he currently doesn't have any pain or concerns with his catheter. Resident was asked about previous issues with his catheter and he said, I had a few issues a while ago but I'm doing well now. Further observation revealed the resident had an old penis split. The split was from the tip of the penis and almost half way down it's base. The penis split was dry without any drainage noted. Record review of Resident #61's (MONTH) 2019 MAR's /TAR's and current physician's orders [REDACTED]. Record review of Resident #61's discontinued orders revealed on 4/8/19 the following orders were discontinued, and no new orders were started after: Foley: change catheter and drainage bag based on clinical indications such as infection, obstruction, or when the closed system is compromised one time a day every 4 weeks on Wednesday for [MEDICAL CONDITION]. Urinary catheter 16FR, 10CC. Diagnosis: [REDACTED]. Foley catheter care every shift and PRN for [MEDICAL CONDITION]. Interview on 5/30/19 at 1:25PM ADON - RN#2 was told about Resident #61 not having an order for [REDACTED].#2 was also asked for NP/Physician notes for Resident #61 and he said ADON #1 had them and he would let him know to bring them. Interview on 5/30/19 at 3:45PM, LVN #3 said she was told by ADON - RN#2 about Resident #61 not having order for catheter and said he was working on getting them. LVN #3 said even though Resident #61 did not have orders to monitor catheter she would observe it because he would be naked in his room a lot, self-pleasuring himself. She said she would assist the resident with his catheter if he asked or voiced he was having an issue with it. She said she would observe his catheter bag emptied during her shifts, so she knew someone was emptying it, she was not sure if it was him or the aide who emptied it. Interview on 5/30/19 at 3:56PM, ADON #1 and ADON #2 agreed there was not an order for [REDACTED].#2 said there was an order in admission note for the catheter, but it was not verified by the nurse which was why there was no order on the MAR/TAR for the catheter or catheter care. Record review of Resident #61's physicians orders dated 5/30/19 after surveyor's intervention revealed and order for Foley catheter care with perineal wipes and/or soap and water every shift and PRN - schedule and activated task on P[NAME] (Point of click -electronic medical record) . Record review of Resident #61's physician orders [REDACTED]. Interview on 5/31/19 at 10:00AM, ADON #2 said the last time Resident #61's catheter was changed in the hospital on [DATE] and previous to that it was last changed when he was in the hospital on [DATE]. He said given Resident #61's condition of his penis split almost halfway down, it was hard to change out his catheter and said it took him almost an hour sometimes to change it out. ADON #2 said he was the one who changed out Resident #61's catheter when it needed to be changed, not the floor nurses. He added the resident did self-pleasure himself several times throughout the day despite advisement not to because of his ventral erosion and catheter. The ADON said the behavior put him at risk for infection and complications with his catheter. ADON #2 said the nurses were making notation in the Resident #61's record about his catheter indicating they were monitoring it. ADON #2 said he changed the resident's Foley catheter himself because it took a long time to change the Foley. The ADON #2 provided copies of nurse's notes indicating his Foley catheter was intact with no issues. Record review of Resident #61's nurses notes provided by ADON #2 revealed his indwelling Foley catheter was intact with no issues on the following dates: 5/18/19, 5/15/19, 5/14/19, 5/13/19, 5/12/19 , 5/11/19, 5/9/19, 5/8/19, 5/7/19, 5/6/19, 5/5/19, 5/4/19, 5/2/19, and 5/1/19. Further review revealed no notes were found for 5/3/19, 5/16/19 and 5/17/19. Continued record review of Resident #61's nurse notes revealed: 4/30/19 - Resident returned to facility from hospital and was noted to have catheter in place. 4/26/19 - Resident went out to hospital, he was found with blood in Foley catheter bag, sheets, skin, and surrounding perineal area during rounds at 6:18PM. Resident was assessed and found to have pulled his Foley catheter out during self-pleasuring. Resident was noted shivering in pain. 4/19/19 - indwelling Foley catheter was intact with no issues. 4/18/19 - indwelling Foley catheter was intact with no issues. 4/15/19 - indwelling Foley catheter was intact with no issues. 4/12/19 - finished antibiotics [MEDICAL CONDITION]. 4/11/19 - indwelling Foley catheter was intact with no issues . 4/10/19 - indwelling Foley catheter was intact with no issues . 4/9/19 - indwelling Foley catheter was intact with no issues . 4/8/19 - Resident returned from hospital on antibiotic [MEDICAL CONDITION]. Resident was treated at hospital for UTI. Further review of Resident #61's nurse notes above indicated there were no documentations on the indwelling urinary catheter care and catheter monitoring for 26 days between 4/8/19 to 5/30/19. Record review on 5/31/19 at 2:00pm with ADON #1, Resident #61's progress notes from the physician and NP were requested throughout the survey and none were provided. ADON #1 provided a copy of fax cover sheet dated 5/30/19 requesting Resident #61's history , physical and progress notes between 12/28/18 - 5/30/19 the resident's physician office . Returned fax provided revealed only hospital records from stay on 4/26/19 - 4/30/19. Record review of Resident #61's hospital discharge records dated 4/30/19 revealed his [DIAGNOSES REDACTED]. [MEDICAL CONDITION] and [MEDICAL CONDITION] 3. UTI: due to Providencia Rettgeri (bacteria) . 4. History of [DIAGNOSES REDACTED]. 5. History of [MEDICAL CONDITION] incident. The Plan included: 1. Continue [MEDICATION NAME]. 2. Intravenous fluids 3. Continue current treatment. Further review of hospital records revealed the resident was diagnosed with [REDACTED]. Resident #1 Record review of Resident's #1's face sheet revealed a [AGE] year-old female with an admitted [DATE] and readmission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed on average she received 501 cc per day or more through tube feeding. MDS revealed no documentation for BIMS score and staff assessment of mental status was not completed. Resident #1 was dependent on staff for all ADLs. Record review of Resident #1's care plan with target date of 8/20/19 revealed she was at risk for dehydration or potential fluid volume deficit related to peg tube feeding. Her interventions included: monitor and document intake and output as per facility policy, monitor/document/report to MD PRN signs and symptoms of dehydration including dry mucous membranes, reduced urine output, skin turgor, and lethargy. The care plan also revealed Resident #1 required assisted nutrition/hydration and the interventions included: administer water flushes as ordered, IV fluid: [MEDICATION NAME] 1.5 cal, keep head of the bed elevated at least 30 degrees, Tube feeding formula: [MEDICATION NAME] 70cc/hr. Record review of Resident#1's readmission physician orders [REDACTED]. Record review of Resident #1's nurses notes dated 5/21/19 at 12:39AM revealed resident was readmitted to the facility with a peg tube and feeding running at 65ml/hour and water flush of 40ml every 4 hours. Resident had a double lumen PICC line noted to her right arm, the site was clean and intact. Resident had head of bed elevated at 45 degrees. Record review of Resident #1's nurses notes dated 5/23/19 at 6:20AM revealed resident was in bed resting well with her peg tube in place with iso-source 1.5 at 65/hours + water flush infusing well, resident was status [REDACTED]. Record review of Resident #1's nurses notes dated 5/23/19 at 4:49PM revealed resident had an abnormal lab; the MD was notified and gave no new orders. Record review of Resident #1's BMP lab results dated 5/23/19 revealed an abnormal BUN of 37 with normal ranges of 3-23mg/dL. Record review of Resident #1's nurses notes dated 5/28/19 at 4:36AM revealed her peg tube was intact with, continuous iso-source 1.5 at 65/hours, will continue to monitor. Observation on 5/28/19 at 11:01AM, Resident #1 was awake, she was unable to speak or communicate. She had a feeding tube attached to her that was attached to a feeding pump. Feeding/hydration pump was set at 65ml/hour and water flush set at 50ml every 4 hours. The head of her bed was elevated. Record review of Resident #1's physician's orders [REDACTED]. Further review of discontinued physician orders [REDACTED]. Interview and record review on 5/28/19 at 2:32PM, the Dietician reviewed Resident #1's record said he did not see a current water flush order for Resident #1. The Dietician said there should be an order for [REDACTED]. The Dietician said he puts his assessment in the system EMR (electronic medical record) and leaves a copy with the facility. He said usually the DON would consult with the physician about his recommendation. The Dietician said he considered the current setting of the resident's flushes (50ml/4 hours) to be low and said he would still recommend what he had in his assessment. Record review of Resident #1's nutrition assessment dated [DATE] revealed a summary and plan of care Resident currently does not have infusion rate or hydration flushes assigned to order. Based on estimated energy needs, I recommend providing current tube feeding prescription of Iso-source 1.5 at 60ml/hour x 22 hours; flush with 200ml fluid every 6 hours; new prescription provides 1980kcals, 89g protein, and 1026ml fluid/day. Flushes provide an additional 800ml fluid. New prescription meets 100% estimated energy and fluid needs and is appropriate for wound healing. Will continue to monitor. Observation on 05/28/19 at 3:00P revealed Resident #1's feeding pump was cut off, resident was sleeping. Observation and Interview on 5/28/19 at 4:02PM, LVN #14 was observed in Resident #1's room reattaching her feeding tube , she set the feeding pump at 65ml/hour and water flush at 50ml/4hrs. When asked how she knew what to set the flush on the feeding pump without a flush order , LVN #14 said she sent a text to the NP to get an order and once she responds, she would put it in as a new order and implement whatever setting NP orders. She said the resident's feeding had been off because it must be disconnected an hour before medication were given and an hour after so the resident doesn't get sick. Record review of Resident #1's nurses notes dated 5/28/19 at 4:27pm revealed BMP results were received with abnormal BUN - 48, the NP was notified and ordered to start 60ml [DEVICE] water flush every 4 hours and repeat BMP one week from today. Record review of Resident #1's BMP lab results dated and received 5/28/19 revealed an abnormal BUN level of 48 with reference range from 3-23mg/dl. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's nurses notes dated 5/29/19 at 3:32AM revealed in part, .peg tube intact with continuous iso-source 1.5 at 65/hours, AND WATER flush at 60ml per hours, will continue to monitor vital signs . Observation on 5/29/19 at 8:54am revealed Resident #1's feeding pump was not on, but hydration bag was hung and dated 5/29/19 and had water flush noted on bag for 60ml every 4 hours. Record review of Resident #1's nurses notes dated 5/29/19 at 3:28PM revealed a late entry note which indicated the NP was notified of dietary recommendation dated 5/21/19 for 200ml of water flush every 6 hours . Record review of Resident #1's physicians orders revealed order for 60ml flush every 4 hours was discontinued on 5/29/19 and new order to flush with 200ml every 6 hours was started on 5/29/19 at 4:00PM. Observation on 5/30/19 at 8:44am, Resident #1 was sleeping with tube feeding on and water flush was set at 60ml every 4 hours. Observation on 5/30/19 at 9:13AM, Resident #1's hydration bag had 820ml left in bag out of 1000ml. The water bag was dated 5/30/19 with no time written in and the pump was set to flush 60ml every 4 hours. Interview on 5/30/19 at 9:18AM, LVN #3 said about 30 minutes ago she went in to stop Resident #1's [DEVICE] and started it again to give her medication. LVN #3 said the night nurse hung the new bags of hydration and formula before she got to work. LVN #3 reviewed the EMR and confirmed there was a new order to flush [DEVICE] with 200ml every 6 hours. She said she did not know the order had changed, and said she was usually notified of an order change by the 24-hour report, nurses notes, or whoever changed the order would notify her. LVN #3 said she saw Resident #1 had an abnormal BUN and the NP ordered to have it redone on Monday. She saw the order changed to 60Ml every four hours but did not see the order for 200ml every 6 hours. Interview on 5/30/19 at 10:09AM, ADON #1 said he thought there was a flush order in the EMR for Resident #1 since she came back from the hospital on [DATE]. He said he would look in the discontinued records to see if there was a flush order between 5/20/19 and 5/28/19. Surveyor told ADON #1 Resident #1 did not receive the correct ordered amount of water flushes since new order on received on 5/29/19. The ADON then said LVN #3 should have known the order had changed from looking at the MAR. He said some nurses are proactive and will put changed orders in the 24-hour report or make note of it, but the nurse should see orders have changed from the MAR. Interview on 5/30/19 at 11:54AM, ADON #1 said he looked in the record and did not see an order for [REDACTED]. ADON #1 said he did not know where the flush for 50ml every 4 hours came from and said he would check Resident #1's admission record from hospital and see what the orders were. Record review of Resident #1's (MONTH) 2019 MAR indicated [REDACTED] 5/29/19 at 4:00PM by LVN #3 5/29/19 at 10:00PM by LVN #6 5/30/19 at 4:00AM by LVN #6 5/30/19 at 10:00AM by LVN #3 Observation on 5/31/19 at 9am revealed Resident #1 had feeding pump on and running . Her [DEVICE] water flush was set at 200ml every 6 hour as ordered. Interview on 6/14/19 at 3:40PM, ADON #1 said when a resident was sent out to the hospital their orders were discontinued after midnight. He said when the resident returns to the facility from the hospital, the nurse admitting the resident will put hospital discharge orders in for the resident's orders. Once the physician comes in to see the resident, they may give new orders or choose to change some orders from the hospital but until then, the hospital discharge orders were used for the resident care and treatment . He said the hospital may be more specific with their orders and the facility would just put in their equivalent. ADON #1 said the Dietician was new to the facility and their previous Dietician would communicate with them directly before leaving the facility if there were recommendations or changes that needed to be made . ADON #1 said their new Dietician was making recommendations and emailing them a copy and not verbalizing concerns to them or letting them know he made recommendations before leaving the facility. The ADON said since 5/31/19, they had spoken with the Dietician about speaking with them about recommendations because they may miss it from him just sending an email. ADON #1 said he wasn't sure if that was the case for Resident #1 [DEVICE] water flush order that was in the Dieticians recommendations . ADON #1 said ADON #2 would know why the recommendation wasn't seen or communicated to the Physician. The ADON #1 said they have a new practice for verifying resident orders upon readmission, he said the nurse should put hospital discharge orders in upon readmission and the ADON's would cross check the orders with the hospital discharge orders the following morning and go over them in the morning meeting. He said this was supposed to be the practice before but was not really being implemented. ADON #1 and ADON #2 were asked for rationale or hospital discharge orders for Resident #1's water flush settings which was not provided. Record review of medical test retrieved from United States National Library of Medicine in conjunction with Medline Plus on BUN (blood urea nitrogen https://medlineplus.gov/lab-tests/bun-blood-urea-nitrogen/) revealed normal BUN levels can vary, but generally a high level of blood urea nitrogen is a sign that your kidneys are not working correctly. Higher than normal BUN levels can also be caused by dehydration . Elevated blood urea nitrogen can also be due to dehydration, resulting from not drinking enough fluids or for other reasons . Resident #20 Record review of Resident #20's face sheet revealed a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #20's quarterly MDS dated [DATE] revealed a BIMS of 00 indicating the resident's cognition was severely impaired. The MDS revealed the resident received nutrition from a feeding tube. Record review of Resident #20's Care Plan with a target date of 6/25/19 revealed she had a feeding tube due to dysphagia and it put her at risk for nutritional problems. The resident also received 3 daily pleasure meals. Her interventions included to have pleasure feedings and tube feedings - please see MD orders., nurse to monitor for complication related to self-feeding. Resident #20's care plan for ADL's revealed she was able to feed herself but needed cueing and supervision. It was noted she also received bolus feedings. Further review of the care plan revealed she received nutritional status via peg tube and ate by mouth. The interventions included: on a mechanically altered diet - see current orders, monitor intake and record every meal, monitor/document/ report to MD PRN signs or symptoms of dysphagia, and report to nurse any difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, drooling, pocketing food in mouth, etc. Record review of Resident #20's physician's orders [REDACTED]. Review of Resident #20's discontinued orders revealed an order for [REDACTED]. Observation and interview on 05/28/19 at 9:14am , Resident #20 was observed crawling on the floor next to her bed, she did not respond when spoken to. She had a breakfast tray in her room with her name identified on it and a dinner tray on the night stand. The breakfast tray had oatmeal spilled all over it. The dinner tray had a meal ticket on the tray that was dated 5/27/19. The tray consisted of Frito pie (full Fritos with cheese on top) and a bowl of green beans. The Frito pie was not fully intact and had Fritos missing from the middle of the plate with the cheese smeared away from the middle of the plate as well. LVN #14 came into the room and said the resident crawling on the floor was a behavior of hers. She asked Resident #20 to get up from the floor and she slowly got up and got into her bed. LVN #14 removed the trays from the room and said the resident was on Bolus tube feeding so she did not know why they brought those trays into the room. Resident #20's bedside table drawer was open and revealed crackers, a piece of pound cake, and a half eaten double fudge cookie inside the drawer. Interview on 5/28/19 at 2:32 PM, the Dietician said Resident #20 had orders for Bolus feedings and he did not see a physician's orders [REDACTED]. He said in the tray card system Resident #20 was listed as a mechanical soft diet which was why she was still getting trays delivered to her. He said the Frito pie would not be considered mechanical soft. The Dietician said per his latest assessment the resident was supposed to be getting a mechanical soft consistency tray and said someone might have forgotten to put the order back in when she returned from the hospital. He said he would put a note in for the facility staff to clarify the consistency with the physician. Interview on 5/29/19 at 10:00AM, ADON #1 said Resident #20 was not NPO and she received a mechanical soft diet. He said he did not know why there was not an order and would contact the physician to clarify. Record review of Resident #20 physician's orders [REDACTED]. Interview and record review on 5/31/19 at 11:37 AM, the Dietary Manager stated Resident #20 had always had a mechanical soft diet and was not NPO. She said the resident liked to have a tray in front of her during meal times. The Dietary Manager said the tray cards were generated directly from the online orders, so she did not know how the resident was getting a tray with no orders in the online system. The Dietary Manager said per the spread sheet from the dietary company Frito pie was considered mechanical soft which was why the resident was provided Frito pie on 5/27/19 for dinner. The Dietary Manager provided the spread sheet for review and the area she pointed out to say Frito pie could be served, actually stated Fruit Pie. The Dietary Manager said she had mistaken the word Fruit for Frito, and she then discovered she was referring to the wrong meal day in the spread sheet. She turned to the correct day (5/27/19) and it revealed Frito pie was not to be served for mechanical altered diet and it stated residents should get casserole with ground meat and cheese with no Fritos in replacement of the Frito pie. Dietary Manager said the resident was not supposed to get the Frito Pie and she would look at the menus closer from now on. Interview on 5/31/19 at 2:55PM, the Director of Therapy said she was familiar with Resident #20. She said she was not currently on their services but had speech therapy back at the beginning of (YEAR). She said the resident was not NPO but was on a Mechanical soft diet related to swallowing issues and to her knowledge she had not had any changes to her diet orders. She said with her knowledge of the resident she would not recommend for her to eat Frito pie and that it could be a choking hazard. Interview on 6/14/19 at 3:47PM, the Corporate nurse said staff figured out what the issue was with missing orders, she said it was a training issue with the nurses not knowing how to put orders into the electronic record. She said some nurses were hitting the wrong button when putting in new orders and they thought they were finalizing the order when they hit the que button but it was not finalizing the order and caused the order to disappear. She said certain nurses that were found to be using the queue button were in-serviced and trained on how to properly put in orders. She said the facility was in the process of organizing a training for all the staff on using the electronic records. Record review of the facility's Quality of Care policy (February (YEAR)) revealed in part, quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on comprehensive assessment of a resident, the community will ensure residents received treatment and care in accordance with professional standard of practice, comprehensive person-centered care plans , and the resident choices including but not limited to the following ; Assisted nutrition and hydration. Based on resident's comprehensive assessment, the community will ensure that a resident: Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; Is offered sufficient fluid intake to maintain proper hydration and health . Record review of the facility's enteral Nutrition Checking Placement and Feeding policy (11/2018) revealed in part, .The nurse checks the orders for enteral feeding, enteral flush frequency orders for pre and post meds and free water orders for enteral . Record review of facility Therapeutic diets policy (February (YEAR)) revealed in part, .Resident receive and consume foods in the appropriate form and appropriate nutritive content as prescribed by a physician. Therapeutic diets are developed after the interdisciplinary team assessment in accordance with the resident treatment and plan of care . The purpose of therapeutic diet is to: provide food the resident is able to eat (e.g.' mechanically altered diet). A mechanically altered diet is one in which the texture is already. When the texture is modified the type of texture modification must be specific and be part of the physician's orders [REDACTED]. Record review of the facility Urinary tract infections policy (February (YEAR)) revealed in part, . The community's policy protocols include policies and procedures that monitor the risk, prevention, and detection of urinary tract infection . The community strives to keep resident and catheter clean of feces to minimize bacterial migration into the urethra and bladder. The Community takes measures to maintain free urine flow through any indwelling catheter . Record review of the facility's Indwelling Catheter policy (February (YEAR)) revealed in part, .For a resident who was admitted with an indwelling urinary catheter, the community will: define and implement pertinent interventions consistent with resident conditions, goals, and recognized standard of proactive to try to minimize complications from an indwelling urinary catheter and to remove it if clinically indicated; Monitor and evaluate residents response to interventions; Revise the approaches as appr (TRUNCATED)

Based on observation, interview, and record review, the facility to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for one of 20 residents (Resident #1) reviewed for nutritional status, in that; Resident #1 was not provided dietician recommended or physician ordered [DEVICE] water flushes which resulted in an abnormal BUN. This failure affected one resident and placed her at risk further dehydration and decline in overall health. Findings include: Resident #1 Record review of Resident's #1's face sheet revealed a [AGE] year-old female with an admitted [DATE] and readmission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed on average she received 501 cc per day or more through tube feeding. MDS revealed no documentation for BIMS score and staff assessment of mental status was not completed. Resident #1 was dependent on staff for all ADLs . Record review of Resident #1's care plan with target date of 8/20/19 revealed she was at risk for dehydration or potential fluid volume deficit related to peg tube feeding. Her interventions included: monitor and document intake and output as per facility policy, monitor/document/report to MD PRN signs and symptoms of dehydration including dry mucous membranes, reduced urine output, skin turgor, and lethargy. The care plan also revealed Resident #1 required assisted nutrition/hydration and the interventions included: administer water flushes as ordered, IV fluid: [MEDICATION NAME] 1.5 cal, keep head of the bed elevated at least 30 degrees, Tube feeding formula: [MEDICATION NAME] 70cc/hr. Record review of Resident #1's nurses notes dated 5/20/19 at 9:43PM revealed she was readmitted to the facility on this date. Record review of Resident#1's readmission physician orders [REDACTED]. Record review of Resident #1's nurses notes dated 5/21/19 at 12:39AM revealed resident was readmitted to the facility with a peg tube and feeding running at 65ml/hour and water flush of 40ml every 4 hours. Resident had a double lumen PICC line noted to her right arm, the site was clean and intact. Resident had head of bed elevated at 45 degrees. Record review of Resident #1's nurses notes dated 5/23/19 at 6:20AM revealed resident was in bed resting well with her peg tube in place with iso-source 1.5 at 65/hours + water flush infusing well, resident was status [REDACTED]. Record review of Resident #1's nurses notes dated 5/23/19 at 4:49PM revealed resident had an abnormal lab; the MD was notified and gave no new orders. Record review of Resident #1's BMP lab results dated 5/23/19 revealed an abnormal BUN of 37 with normal ranges of 3-23mg/dL. Record review of Resident #1's nurses notes dated 5/28/19 at 4:36AM revealed her peg tube was intact with, continuous iso-source 1.5 at 65/hours, will continue to monitor. Observation on 5/28/19 at 11:01AM, Resident #1 was awake, she was unable to speak or communicate. She had a feeding tube attached to her that was attached to a feeding pump. Feeding/hydration pump was set at 65ml/hour and water flush set at 50ml every 4 hours. The head of her bed was elevated. Record review of Resident #1's physician's orders [REDACTED]. Further review of discontinued physician orders [REDACTED]. Interview and record review on 5/28/19 at 2:32PM, the Dietician reviewed Resident#1's record said he did not see a current water flush order for Resident #1. The dietician said there should be an order water flush . He said he completed an assessment when the resident returned from the hospital on [DATE] and noticed there was no order for flushes . The Dietician said he gave a recommendation to set the flush at 200ml every 6 hours. The Dietician said he puts his assessment in the system EMR (electronic medical record) and leaves a copy with the facility. He said usually the DON would consult with the physician about his recommendation. The Dietician said he considered the current setting of the resident's flushes (50ml/4 hours) to be low and said he would still recommend what he had in his assessment. Record review of Resident #1's nutrition assessment dated [DATE] revealed a summary and plan of care Resident currently does not have infusion rate or hydration flushes assigned to order. Based on estimated energy needs, I recommend providing current tube feeding prescription of Iso-source 1.5 at 60ml/hour x 22 hours; flush with 200ml fluid every 6 hours; new prescription provides 1980lcals, 89g protein, and 1026ml fluid/day. Flushes provide an additional 800ml fluid. New prescription meets 100% estimated energy and fluid needs and is appropriate for wound healing. Will continue to monitor. Observation on 05/28/19 at 3:00PM, Resident #1's feeding pump was cut off, resident was sleeping. Observation and Interview on 5/28/19 at 4:02PM, LVN #14 was observed in Resident #1's room reattaching her feeding tube , she set the feeding pump at 65ml/hour and water flush at 50ml/4hrs. When asked how she knew what to set the flush on the feeding pump without a flush order , LVN #14 said she sent a text to the NP to get an order and once she responds, she would put it in as a new order and implement whatever setting NP orders. She said the resident's feeding had been off because it must be disconnected an hour before medication were given and an hour after so the resident doesn't get sick. Record review of Resident #1's nurses notes dated 5/28/19 at 4:27pm revealed BMP results were received with abnormal BUN - 48, the NP was notified and ordered to start 60ml [DEVICE] water flush every 4 hours and repeat BMP one week from today. Record review of Resident #1's BMP lab results dated 5/28/19 revealed an abnormal BUN level of 48 with reference range from 3-23mg/dl. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's nurses notes dated 5/29/19 at 3:32AM revealed in part, .peg tube intact with continuous iso-source 1.5 at 65/hours, AND WATER flush at 60ml per hours, will continue to monitor vital signs . Observation on 5/29/19 at 8:54am revealed Resident #1's feeding pump was not on, but hydration bag was hung and dated 5/29/19 and had water flush noted on bag for 60ml every 4 hours. Observation on 5/29/19 at 10:39AM, Resident #1 was sleeping with tube feeding on and water flush set to 60mL every 4 hours. Observation on 05/29/19 at 2:32PM, revealed Resident #1 was sleeping with tube feeding on and flush set to 60mL every 4 hours. Record review of Resident #1's nurses notes dated 5/29/19 at 3:28PM revealed a late entry note which indicated the NP was notified of dietary recommendation for 200ml of water flush every 6 hours . Record review of Resident #1's physicians orders revealed order for 60ml flush every 4 hours was discontinued on 5/29/19 and new order to flush with 200ml every 6 hours was started on 5/29/19 at 4:00PM. Observation on 5/29/19 at 3:42PM, Resident #1 was sleeping with tube feeding on and water flush was set at 60ml every 4 hours. Observation on 5/30/19 at 8:44am, Resident #1 was sleeping with tube feeding on and water flush was set at 60ml every 4 hours. Observation on 5/30/19 at 9:13AM, Resident #1's hydration bag had 820ml left in bag out of 1000ml. The water bag was dated 5/30/19 with no time written in and the pump was set to flush 60ml every 4 hours. Interview on 5/30/19 at 9:18AM, LVN #3 said about 30 minutes ago she went in to stop Resident #1's [DEVICE] and started it again to give her medication. LVN #3 said the night nurse hung the new bags of hydration and formula before she got to work. LVN #3 reviewed the EMR and confirmed there was a new order to flush [DEVICE] with 200ml every 6 hours. She said she did not know the order had changed, and said she was usually notified of an order change by the 24-hour report, nurses notes, or whoever changed the order would notify her. LVN #3 said she saw Resident #1 had an abnormal BUN and the NP ordered to have it redone on Monday. She saw the order changed to 60Ml every four hours but did not see the order for 200Ml every 6 hours. Interview on 5/30/19 at 10:09AM, ADON #1 said he thought there was a flush order in the EMR for Resident #1 since she came back from the hospital on [DATE]. He said he would look in the discontinued records to see if there was a flush order between 5/20/19 and 5/28/19. ADON #1 was told Resident #1 did not receive the correct ordered amount of water flushes since new order on received on 5/29/19. The ADON then said LVN #3 should have known the order had changed from looking at the MAR. He said some nurses are proactive and will put changed orders in the 24-hour report or make note of it, but the nurse should see orders have changed from the MAR. Interview on 5/30/19 at 11:54AM, ADON #1 said he looked in the record and did not see an order for [REDACTED]. ADON #1 said he did not know where the flush for 50ml every 4 hours came from and said he would check Resident #1's admission record from hospital and see what the orders were. Record review of Resident #1's (MONTH) 2019 MAR indicated [REDACTED] 5/29/19 at 4:00PM by LVN #3 5/29/19 at 10:00PM by LVN #6 5/30/19 at 4:00AM by LVN #6 5/30/19 at 10:00AM by LVN #3 Observation on 5/31/19 at 9am revealed Resident #1 had feeding pump on and running . Her [DEVICE] water flush was set at 200ml per hour as ordered. Interview on 6/14/19 at 3:40PM, ADON #1 said when a resident was sent out to the hospital their orders were discontinued after midnight. He said when the resident returns to the facility from the hospital, the nurse admitting the resident will put hospital discharge orders in for the resident's orders. Once the physician comes in to see the resident, they may give new orders or choose to change some orders from the hospital but until then, the hospital discharge orders were used for the resident care and treatment . He said the hospital may be more specific with their orders and the facility would just put in their equivalent. ADON #1 said the Dietician was new to the facility and their previous Dietician would communicate with them directly before leaving the facility if there were recommendations or changes that needed to be made . ADON #1 said their new Dietician was making recommendations and emailing them a copy and not verbalizing concerns to them or letting them know he made recommendations before leaving the facility. The ADON said since 5/31/19, they had spoken with the Dietician about speaking with them about recommendations because they may miss it from him just sending an email. ADON #1 said he wasn't sure if that was the case for Resident #1 [DEVICE] water flush order that was in the Dieticians recommendations . He said ADON #2 would know why the recommendation wasn't seen or communicated to the Physician. The ADON #1 said they have a new practice for verifying resident orders upon readmission, he said the nurse should put hospital discharge orders in upon readmission and the ADON's would cross check the orders with the hospital discharge orders the following morning and go over them in the morning meeting. He said this was supposed to be the practice before but was not really being implemented. ADON #1 and ADON #2 were asked for rationale or hospital discharge orders for Resident #1's water flush settings which was not provided. Record review of medical test retrieved from United States National Library of Medicine in conjunction with Medline Plus on BUN (blood urea nitrogen https://medlineplus.gov/lab-tests/bun-blood-urea-nitrogen/) revealed normal BUN levels can vary, but generally a high level of blood urea nitrogen is a sign that your kidneys are not working correctly. Higher than normal BUN levels can also be caused by dehydration . Elevated blood urea nitrogen can also be due to dehydration, resulting from not drinking enough fluids or for other reasons . Record review of the facility's Quality of Care policy (February (YEAR)) revealed in part, .Assisted nutrition and hydration. Based on resident's comprehensive assessment, the community will ensure that a resident: Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; Is offered sufficient fluid intake to maintain proper hydration and health . Record review of the facility's enteral Nutrition Checking Placement and Feeding policy (11/2018) revealed in part, .The nurse checks the orders for enteral feeding, enteral flush frequency orders for pre and post meds and free water orders for enterals .

Based on observation, interview and record review, the facility failed to ensure resident who entered the facility with an indwelling urinary catheter, received appropriate care and services to prevent urinary tract infections to the extent possible for one of 20 residents (Resident #61) reviewed for incontinence, in that; Resident #61 who had history of UTI's and severe ventral erosion (split penis) did not have orders for his indwelling urinary catheter or catheter care/monitoring. Resident #61 who was known to repeatedly pleasure himself with catheter in place and split penis did not have care plan for risks of infection associated with his self-pleasuring and penile condition (split penis). Resident #61 developed urinary tract infection. These failures affected one resident and placed him at risk for repeated urinary tract infections complications and decline in health. Findings include: Resident #61 Record review of Resident #61's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS of 8 indicating moderately impaired cognition. The MDS reflected resident had an indwelling urinary catheter. The MDS indicate the resident had [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] as active diagnoses. The MDS also indicated the resident had a UTI within the last 30 days. Record review of Resident #61's care plan dated 1/17/19 revealed he had size 16F (French) catheter related to neuromuscular dysfunction of the bladder and was at risk for infections and discomfort. The interventions listed were for resident to have 16F Foley with balloon, catheter bag and tubing positioned below the level of the bladder and away from room entrance, check tubing for kinks each shift, Foley catheter care every shift and PRN, Foley: change catheter and drainage bag based on clinical indication such as infection, obstruction, or when the closed system is compromised, monitor and document intake and output as per facility policy, monitor/document for pain discomfort due to catheter, monitor/record/report to MD for signs/symptoms of UTI: pain burning blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and eating patterns. Further review of care plan revealed no mention of history of UTI's, severe ventral erosion, or repeated self-pleasuring in reference to his indwelling catheter and risks associated. Observation and interview on 5/30/19 at 1:00PM, Resident #61 was lying in bed, catheter not visible but resident said he keeps it in his pants with leg strap. Resident says he has trouble sometimes emptying it and said he does do it by himself but sometimes staff will help him clean up if it spills or if there's an issue. He said the bag gets full quickly and he had to try and keep up with emptying it. Resident grabbed the bag inside his pants and it moved around to hear how much urine was inside. Resident said it was full right now and when surveyor leaves out he was going to go empty it. Resident said he currently doesn't have any pain or concerns with his catheter. Resident was asked about previous issues with his catheter and he said, I had a few issues a while ago but I'm doing well now. Further observation revealed the resident had an old penis split. The split was from the tip of the penis and almost half way down it's base. The penis split was dry without any drainage noted. Record review of Resident #61's (MONTH) 2019 MAR's /TAR's and current physician's orders [REDACTED]. Record review of Resident #61's discontinued orders revealed on 4/8/19 the following orders were discontinued, and no new orders were started after: Foley: change catheter and drainage bag based on clinical indications such as infection, obstruction, or when the closed system is compromised one time a day every 4 weeks on Wednesday for [MEDICAL CONDITION]. Urinary catheter 16FR, 10CC. Diagnosis: [REDACTED]. Foley catheter care every shift and PRN for [MEDICAL CONDITION]. Interview on 5/30/19 at 1:25PM ADON - RN#2 was told about Resident #61 not having an order for [REDACTED].#2 was also asked for NP/Physician notes for Resident #61 and he said ADON #1 had them and he would let him know to bring them. Interview on 5/30/19 at 3:45PM, LVN #3 said she was told by ADON - RN#2 about Resident #61 not having order for catheter and said he was working on getting them. LVN #3 said even though Resident #61 did not have orders to monitor catheter she would observe it because he would be naked in his room a lot, self-pleasuring himself. She said she would assist the resident with his catheter if he asked or voiced he was having an issue with it. She said she would observe his catheter bag emptied during her shifts, so she knew someone was emptying it, she was not sure if it was him or the aide who emptied it. Interview on 5/30/19 at 3:56PM, ADON #1 and ADON #2 agreed there was not an order for [REDACTED].#2 said there was an order in admission note for the catheter, but it was not verified by the nurse which was why there was no order on the MAR/TAR for the catheter or catheter care. Record review of Resident #61's physicians orders dated 5/30/19 after surveyor's intervention revealed and order for Foley catheter care with perineal wipes and/or soap and water every shift and PRN - schedule and activated task on P[NAME] (Point of click -electronic medical record) . Record review of Resident #61's physician orders [REDACTED]. Interview on 5/31/19 at 10:00AM, ADON #2 said the last time Resident #61's catheter was changed was in the hospital on [DATE] and previous to that it was last changed when he was in the hospital on [DATE]. He said given Resident #61's condition of his penis split almost halfway down, it was hard to change out his catheter and said it took him almost an hour sometimes to change it out. ADON #2 said he was the one who changed out Resident #61's catheter when it needed to be changed, not the floor nurses. He added the resident did self-pleasure himself several times throughout the day despite advisement not to because of his ventral erosion and catheter. The ADON said the behavior put him at risk for infection and complications with his catheter. ADON #2 said the nurses were making notation in the Resident #61's record about his catheter indicating they were monitoring it. ADON #2 said he changed the resident's Foley catheter himself because it took a long time to change the Foley. The ADON #2 provided copies of nurse's notes indicating his Foley catheter was intact with no issues. Record review of Resident #61's nurses notes provided by ADON #2 revealed his indwelling Foley catheter was intact with no issues on the following dates: 5/18/19, 5/15/19, 5/14/19, 5/13/19, 5/12/19 , 5/11/19, 5/9/19, 5/8/19, 5/7/19, 5/6/19, 5/5/19, 5/4/19, 5/2/19, and 5/1/19. Further review revealed no notes were found for 5/3/19, 5/16/19 and 5/17/19. Continued record review of Resident #61's nurse notes revealed: 4/30/19 - Resident returned to facility from hospital and was noted to have catheter in place. 4/26/19 - Resident went out to hospital, he was found with blood in Foley catheter bag, sheets, skin, and surrounding perineal area during rounds at 6:18PM. Resident was assessed and found to have pulled his Foley catheter out during self-pleasuring. Resident was noted shivering in pain. 4/19/19 - indwelling Foley catheter was intact with no issues. 4/18/19 - indwelling Foley catheter was intact with no issues. 4/15/19 - indwelling Foley catheter was intact with no issues. 4/12/19 - finished antibiotics [MEDICAL CONDITION]. 4/11/19 - indwelling Foley catheter was intact with no issues . 4/10/19 - indwelling Foley catheter was intact with no issues . 4/9/19 - indwelling Foley catheter was intact with no issues . 4/8/19 - Resident returned from hospital on antibiotic [MEDICAL CONDITION]. Resident was treated at hospital for UTI. Further review of Resident #61's nurse notes above indicated there were no documentations on the indwelling urinary catheter care and catheter monitoring for 26 days between 4/8/19 to 5/30/19. Record review on 5/31/19 at 2:00pm with ADON #1, Resident #61's progress notes from the physician and NP were requested throughout the survey and none were provided. ADON #1 provided a copy of fax cover sheet dated 5/30/19 requesting Resident #61's history and physical and progress notes between 12/28/18 - 5/30/19 from the resident's physician office. Returned fax provided revealed only hospital records from stay on 4/26/19 - 4/30/19. Record review of Resident #61's hospital discharge records dated 4/30/19 revealed his [DIAGNOSES REDACTED]. [MEDICAL CONDITION] and [MEDICAL CONDITION] 3. UTI: due to Providencia Rettgeri (bacteria) . 4. History of [DIAGNOSES REDACTED]. 5. History of [MEDICAL CONDITION] incident. The Plan included: 1. Continue [MEDICATION NAME]. 2. Intravenous fluids 3. Continue current treatment. Further review of hospital records revealed the resident was diagnosed with [REDACTED]. Record review of the facility Urinary tract infections policy (February (YEAR)) revealed in part, . The community's policy protocols include policies and procedures that monitor the risk, prevention, and detection of urinary tract infection . The community strives to keep resident and catheter clean of feces to minimize bacterial migration into the urethra and bladder. The Community takes measures to maintain free urine flow through any indwelling catheter . Record review of the facility's Indwelling Catheter policy (February (YEAR)) revealed in part, .For a resident who was admitted with an indwelling urinary catheter, the community will: define and implement pertinent interventions consistent with resident conditions, goals, and recognized standard of proactive to try to minimize complications from an indwelling urinary catheter and to remove it if clinically indicated; Monitor and evaluate residents response to interventions; Revise the approaches as appropriate . For a resident who has had a symptomatic urinary tract infection, the community will: Recognize and assess factors affecting the risk of symptomatic urinary tract infections and impaired urinary function; Define and implement to try to minimize the occurrence of symptomatic urinary tract infection and to address correctable underlying causes in accordance with resident's needs, goals, and recognized standards of practice .

Based on interview, and record review, the facility failed to immediately consult with the physician when the resident experienced a change in condition with need to alter treatment significantly for 1 of 9 residents ( Resident #3) reviewed for a change of condition, in that ; Resident #3's physician was not promptly consulted for abnormal doppler test result until 2 days later . Resident #3 was transferred to hospital where she required a surgical bypass to restore circulation to her left leg. These failures affected one resident who experienced delayed treatment and placed her placed her at risk of health decline and diminished quality of life. Findings include: Intake # 8 Resident #3 Record review of Resident # 3's face sheet revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the care plan for Resident #3 (Initiated: 11-22-17) read in part Problem: Resident #3 has [MEDICAL CONDITION]: Interventions: Monitor the extremities for s/sx of injury, infection, ulcers . Monitor/document for excessive [MEDICAL CONDITION] and encourage resident to elevate legs . Monitor/document/report to MD PRN any s/sx of complications of extremities . Monitor/document/report to MD PRN any s/sx of skin problems related to [MEDICAL CONDITION] . Record review of the admission MDS assessment dated [DATE] revealed Resident #3 was at risk for pressure ulcer development. Further record review revealed Resident #3 had 1 venous and arterial ulcer present. Record review of Resident #3's physician orders dated 3/21/19 revealed an order for [REDACTED]. Record review of Resident #3's nursing note dated 3/21/19 revealed .new order for venous doppler to left lower extremities . Resident noted with leg cold and darken in color, Resident family member is aware of test being given. Record review of Resident #3's arterial doppler diagnostic result dated 3/22/19 revealed no flow seen within distal femoral artery and posterior tibial arteries. Record review of physician orders dated 3/24/19 revealed an order to send Resident #3 to the hospital due to abnormal arterial doppler. Interview on 4/16/19 at 1:52 p.m., Resident #3's family member said Resident #3 almost lost her foot due to decreased circulation. He said the hospital completed a femoropopliteal bypass (surgical procedure used to treat femoral artery disease, by bypassing the blocked portion of main artery in the leg using a piece of another blood vessel) on the Resident's left leg to regain circulation on the lower extremity. Observation and interview with Resident #3 on 04/16/19 at 10:13 p.m., revealed she was in the restroom. She was alert and oriented, cleaning her dentures. Observation of LVN A complete wound care and weekly skin assessment for Resident #3 on 4/17/19 at 3:08 p.m. revealed no concerns. Old dressing applied to left inguinal area. The dressing had a date of 4/16/19. Stiches were observed in the inguinal area. The toes had gauze wrapped around them. No discoloration was noted. Interview with LVN A on 04/17/19 at 6:11 p.m., she said she spoke with the Nurse practitioner and received an order to complete an arterial doppler. At 6:27 p.m. she said she did not view doppler results. Interview with LVN B on 04/18/19 at 11:17 a.m., she said she works in the evening and she received in nursing report that Resident #3 was to be sent out. She said she was told the doppler study results and was supposed to send Resident #3 to the hospital. She said she was not sure what day the results were available but she sent Resident #3 out after she received the doppler study results. She said she was not sure what day but it could be Sunday when Resident #3 was sent to the hospital. Record review of Resident#3's nurses note written by LVN B dated 3/24/19 and created date: 3/25/19 read in part .sent out due to doppler results and blood flow . ambulance arrived at 10:35 p.m. Interview with ADON H on 4/18/19 at 11:39 a.m., he said he was not aware of doppler study results on 3/22/19. He said he did not review results. He said the nurse over the weekend reviewed the doppler results and informed the physician and family that Resident #3 would be transferred to the hospital. Interview with ADON L on 4/18/19 at 11:40 a.m., he said he did not see results from the arterial doppler test. He said LVN A reported the assessment finding the ADON H. He said the order was discussed in the morning clinical meeting. He said generally arterial doppler studies are available within 1-2 days. He said no nurse informed him of the doppler study results being available. Interview with RN D on 4/18/19 at 12:02 p.m., she said the arterial doppler results popped up in the computer on Sunday 3/24/19 at approximately 7:00 p.m. She said she gave report to LVN B to contact the NP. She said she instructed the night shift nurses to assists with the transfer. Interview with the DON on 4/18/19 at 12:16 p.m., she said the order for arterial doppler study popped up on Friday, 3/22/19. She said informed the unit manager to follow -up before the end of shift. She said nursing staff contacted her on Sunday 3/24/19 and informed her of the doppler results. Record Review of the facility policy, Medically Necessary laboratory services (February (YEAR)) , revealed in part: . the community provides or obtains radiology and other diagnostic services only when ordered by the attending physician and takes appropriate action .

Based on interview and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 9 residents (Resident # 3) reviewed for quality of care. Resident #3's abnormal doppler test result was not promptly communicated to the resident's physician. Resident #3 was transferred to hospital 2 days later and required a surgical bypass to restore circulation to her left leg. These failures affected one resident who experienced delayed treatment due to staff not promptly notifying residents' physician of result and placed her placed her at risk of health decline and diminished quality of life. Findings include: Intake # 8 Resident #3 Record review of Resident # 3's face sheet revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the care plan for Resident #3 (Initiated: 11-22-17) read in part Problem: Resident #3 has [MEDICAL CONDITION]: Interventions: Monitor the extremities for s/sx of injury, infection, ulcers . Monitor/document for excessive [MEDICAL CONDITION] and encourage resident to elevate legs . Monitor/document/report to MD PRN any s/sx of complications of extremities . Monitor/document/report to MD PRN any s/sx of skin problems related to [MEDICAL CONDITION] . Record review of the admission MDS assessment dated [DATE] revealed Resident #3 was at risk for pressure ulcer development. Further record review revealed Resident #3 had 1 venous and arterial ulcer present. Record review of Resident #3's physician orders dated 3/21/19 revealed an order for [REDACTED]. Record review of Resident #3's nursing note dated 3/21/19 revealed .new order for venous doppler to left lower extremities . Resident noted with leg cold and darken in color, Resident family member is aware of test being given. Record review of Resident #3's arterial doppler diagnostic result dated 3/22/19 revealed no flow seen within distal femoral artery and posterior tibial arteries. Record review of physician orders dated 3/24/19 revealed an order to send Resident #3 to the hospital due to abnormal arterial doppler. Interview on 4/16/19 at 1:52 p.m., Resident #3's family member said Resident #3 almost lost her foot due to decreased circulation. He said the hospital completed a femoropopliteal bypass (surgical procedure used to treat femoral artery disease, by bypassing the blocked portion of main artery in the leg using a piece of another blood vessel) on the Resident's left leg to regain circulation on the lower extremity. Observation and interview with Resident #3 on 04/16/19 at 10:13 p.m., revealed she was in the restroom. She was alert and oriented, cleaning her dentures. Observation of LVN A complete wound care and weekly skin assessment for Resident #3 on 4/17/19 at 3:08 p.m. revealed no concerns. Old dressing applied to left inguinal area. The dressing had a date of 4/16/19. Stiches were observed in the inguinal area. The toes had gauze wrapped around them. No discoloration was noted. Interview with LVN A on 04/17/19 at 6:11 p.m., she said she spoke with the Nurse practitioner and received an order to complete an arterial doppler. At 6:27 p.m. she said she did not view doppler results. Interview with LVN B on 04/18/19 at 11:17 a.m., she said she works in the evening and she received in nursing report that Resident #3 was to be sent out. She said she was told the doppler study results and was supposed to send Resident #3 to the hospital. She said she was not sure what day the results were available but she sent Resident #3 out after she received the doppler study results. She said she was not sure what day but it could be Sunday when Resident #3 was sent to the hospital. Record review of Resident#3's nurses note written by LVN B dated 3/24/19 and created date: 3/25/19 read in part .sent out due to doppler results and blood flow . ambulance arrived at 10:35 p.m. Interview with ADON H on 4/18/19 at 11:39 a.m., he said he was not aware of doppler study results on 3/22/19. He said he did not review results. He said the nurse over the weekend reviewed the doppler results and informed the physician and family that Resident #3 would be transferred to the hospital. Interview with ADON L on 4/18/19 at 11:40 a.m., he said he did not see results from the arterial doppler test. He said LVN A reported the assessment finding the ADON H. He said the order was discussed in the morning clinical meeting. He said generally arterial doppler studies are available within 1-2 days. He said no nurse informed him of the doppler study results being available. Interview with RN D on 4/18/19 at 12:02 p.m., she said the arterial doppler results popped up in the computer on Sunday 3/24/19 at approximately 7:00 p.m. She said she gave report to LVN B to contact the NP. She said she instructed the night shift nurses to assists with the transfer. Interview with the DON on 4/18/19 at 12:16 p.m., she said the order for arterial doppler study popped up on Friday, 3/22/19. She said informed the unit manager to follow -up before the end of shift. She said nursing staff contacted her on Sunday 3/24/19 and informed her of the doppler results. Record Review of the facility policy, Medically Necessary laboratory services (February (YEAR)) , revealed in part: . the community provides or obtains radiology and other diagnostic services only when ordered by the attending physician and takes appropriate action .

Based on interview and record review, the facility failed to develop and implement policies and procedures that prohibit mistreatment and neglect of residents for one of 12 residents (CR#1) reviewed for neglect. The facility failed to seek medical consultation for CR #1 who had a fall with a head injury when the resident's physician did not respond to the facility's calls. The facility failed to consult the physician for approximately 12 hours after CR #1 was assessed with [REDACTED]. The facility failed to continue to monitor, assess, and provide medical services to CR #1 after she was assessed as to having experienced a change in condition two days after a fall with a head injury. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern. This failure affected one resident who died in the facility and placed 16 other residents at risk for falls at risk of not receiving services necessary to ensure residents received the medical care from injuries which could lead to a decline in their health, untreated pain or death. Findings include: Incident intake # 4 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's MDS dated [DATE] revealed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Further review revealed CR #1 required extensive assistance for bed mobility, transfers, walking in room, walking in corridor, dressing, locomotion off unit, toilet use, personal hygiene and bathing. The resident required limited assistance for locomotion on unit, and eating. Further review of this MDS revealed the resident had a fall with injury that was not major. Record review of CR#1's incident report dated [DATE] at 1:28p.m., revealed resident was noted on the floor lying on her left side calling for help. Injuries noted were hematoma left forehead (brow area) and abrasion to left knee. The resident was alert. Further review of this incident report revealed the resident's physician was called and a message was left about the fall on [DATE] at 1:50p.m. Record review of CR #1's care plan, which was undated, revealed she had falls on [DATE], [DATE] and [DATE]. Further review revealed a goal which read My number of falls will be reduced through next review date. I have had an actual fall on [DATE]. Target date: [DATE]. Interventions included: Educate on use of call light and to wait for staff to come help. Be sure my call light is within reach and encourage me to use it. Follow facility fall protocol. Pt. evaluate and treat as ordered or PRN. After each fall episode evaluate current interventions and modify interventions based on IDT recommendations. Record review of CR#1's neurological evaluation flow sheet, revealed it was initiated on [DATE] at 1:28p.m. and stopped on [DATE] at 6a.m. Further review revealed the following pupil reaction documentation: [DATE] at 1:28p.m. - pupils were sluggish. [DATE] at 6:45p.m. - pupils were sluggish [DATE] at 7p.m. - pupils were sluggish [DATE] at 8p.m. - pupils were sluggish [DATE] at 8:30p.m. - pupils were sluggish [DATE] at 9p.m. - pupils were sluggish [DATE] at 10p.m.-pupils were sluggish [DATE] at 6a.m. - pupils were brisk [DATE] at 6p.m. - right pupil was brisk, notation for left pupil was illegible [DATE] at 6:00a.m. - pupils were sluggish. Record review of CR#1's progress notes dated [DATE] at 2:33p.m., revealed resident was noted lying on the floor by staff crying for help. A large raised area noted on forehead, scrape noted on left knee, no internal or external rotation on both upper and lower extremities. Vital laying down ,[DATE], pulse-103, R (respiration) 18, blood pressure sitting down ,[DATE], pulse 100, respiration 18 and temperature 98. Responsible party informed, physician's office called and message left re-fall, ice park to areas on forehead and neuro checks. Interview on [DATE] at 2:23p.m., LVN#1 stated when he was notified of CR #1's fall on [DATE], he went to the patient's room and took vitals, called the physician's office and told the office staff the reason for his call. LVN #1 said he called again 20 minutes later and was told by the office staff that the physician would call him back. LVN #1 reported he called the physician 3 times, called the resident's family and continued with neuro checks. LVN #1 stated the physician did not call back throughout his shift (6a.m.-6p.m.). He further said he notified the on-coming nurse to follow up with CR #1's physician. Interview on [DATE] at 1:20p.m., CNA #1 said she cared for CR #1 on the morning of [DATE]. She said CR #1 had a bruise to her forehead but was talking. She stated she cleaned CR #1 up and fed her in bed by the resident's choice. CNA #1 said the resident made no complaints to her, but was unable to go the bathroom like she would before the fall. She had incontinent brief on and had two brief changes during her shift, she did not notice any running nose, discharges and no pain was expressed or verbalized. CNA #1 said the resident previously would talk and say help me, help me and did not like to stay in bed, but preferred to be out of her room and sit by the nurse's station. Record review of CR#1's progress notes dated [DATE] at 5:11p.m., revealed resident in bed lying down, assisted patient with putting dentures in her mouth, resident is being monitored post fall, resident has bruising to left side of forehead, left per orbital and check area and less extensive bruising to right per orbital area, resident is alert to self and able to speak. Resident is now being fed by speech therapy. Record review of CR #1's progress notes dated [DATE] at 3:30a.m., revealed Resident in bed stable at the moment, no signs and symptoms of acute distress noted. Respiration even and unlabored, skin warm and dry to touch, resident status [REDACTED]. Vital signs were: blood pressure ,[DATE], R18, oxygen saturation 98%, active range of motion on upper and lower extremities. Safety measures in place and call light within reach and bed in lowest position, will continue with the care. Two attempts were made to interview the CNAs who cared for CR #1 on Sunday morning and Sunday afternoon without success. Phone calls were not returned. Record review of CR #1's progress notes dated [DATE] at 7:02p.m., revealed Patient was not responding and vital signs were BP,[DATE], Pulse -193, R-28, oxygen saturation was 75% room air. Called out MD immediately, the doctor said call the daughter, notified of patient status and what the doctor said, she requested call 911 immediately and let them wait for me, 911 was called, when they arrived there was no pulse, daughter came few minutes after as she said, at this hour they are here. Further review of progress report revealed: At 7:21p.m., ADON (#1) made aware of patient status, at 6:45p.m., resident was pronounced by 911 with family present and 9:35p.m., Resident was picked up by medical examiner via stretcher accompanied by two policemen, Resident's daughter and physician notified. Record review of a written statement by LVN #2 (CR#1's charge nurse on [DATE]) read in part .on [DATE], I reported to duty at 6a.m., during rounds I observed patient (CR#1) in bed with bruises on her face and eyes closed. I greeted her, she responded with help me, help me. Her right eye was running water, I went back to the night nurse to find out what happened to her face and her condition, the nurse told me that patient fell Friday [DATE] and hit her head, neuro check is in progress and she has been in bed since then. Vital signs were ,[DATE], pulse 120. Respiration 20, temperature 98.6, oxygen saturation was 95% at room air. I called the physician about 11a.m. concerning the patient eye and the bruises on her face, no call back. She was monitored throughout and was responding with help me, help me. At about 5:45p.m., during my last round, patient was not responding, I called for help and we checked vital signs, blood pressure was ,[DATE], pulse was 193, oxygen saturation was 75% at room air, notified the ADON (#1) who advised to call MD and family. Called out MD and updated him of patient status and the patient is DNR, MD ordered to call family member and ask what she wants, daughter asked to call 911 and sent patient to hospital but let the 911 staff wait I am on my way with my daughter, we are just 5 minutes away. In less than 5 minutes EMS were here and the daughter also came in, there was no pulse . Interview on [DATE] at 10:00a.m., the DON said she reviewed the 24 hour report for [DATE] looking for information indicating that staff were to follow up with notifying CR#1's physician of her fall with injury but there was none. The DON said she talked to the nurse who worked the evening shift (6p.m.-6a.m.) on [DATE] who said she was not told by the day shift nurse (LVN #1) to follow up or to call CR #1's physician. The DON agreed the resident's physician and the facility's medical director should have been promptly notified of both the fall and change in condition. The DON further said CR#1's physician said he was aware of the fall and did not think anything would have changed or been done differently. Interview on [DATE] at 2:44p.m., LVN #2 said when he made his rounds the morning of [DATE] around 6a.m. and noticed CR #1 was in bed sick with a bruise on her face. He asked the nurse what happened to CR #1 and was informed the resident fell on Friday ([DATE]). LVN #2 said the nurse told him CR #1 had not been doing well, had been in bed since the fall and Neuro checks were in progress. LVN #2 said this was all the report the outgoing night nurse gave him. LVN #2 reported he continued Neuro checks every hour, but CR #1 was not opening her eyes, so he called the physician around 11a.m. The physician did not respond and did not call back, so LVN #2 continued monitoring the resident every hour, talking to her, trying to get her to open her eyes and talk back to him. LVN #2 said about 5p.m., he noted the resident was not responding like before, so he reported it to the ADON #1 and was told to call the doctor. LVN #2 stated he called the doctor and the doctor told him to call the resident's daughter and ask what the family preferred since CR #1 was had a code status of DO NOT RESUSITATE (DNR). LVN #2 further said he called CR #1's daughter who asked him to call 911. He stated he called 911 and they arrived in about 5 minutes and found no pulse. LVN #2 said he had only one aide in the morning, so he could not use her to help him monitor the resident closely, since one aide had called in. LVN #2 said he checked the residents' vital signs twice in the morning and in the afternoon and they were all normal. He also said he expected the resident's physician was aware of the fall with head injuries and did not mention it when he called him on [DATE]. LVN #2 said after reflecting on the incident, he should have called the physician earlier when he noted the resident was not feeling well, but the nurse who worked the night before said that was how the resident had been throughout the night shift. LVN #2 said he would have continued to called the physician or report it to the ADON #1 earlier if he had known this was unusual for CR #1. LVN #2 said CR #1 was declared dead on arrival, EMS called police and medical examiner's office. Interview on [DATE] at 2:58p.m., LVN #2 when asked what CR#1 looked like during his last rounds stated CR#1 had an oxygen saturation of 75%, she was not breathing well-shallow breathing, pulse was 193 and very faint, color was normal and body was warm, no discharge was noted. Interview on [DATE] at 3:05p.m., ADON #1 said she was called by LVN #2 around after 6p.m. on [DATE]. She stated LVN #2 told her that CR #1 was unresponsive, had blood pressure and heart rate but no oxygen saturation was registering on pulse oximeter. She told LVN #2 to call the physician. ADON #1 said she called back about three minutes later and was told EMS was in the facility and the resident was dead. Interview on [DATE] at 3:20p.m., the Administrator reported she asked LVN #2 why CR#1's physician was not contacted earlier in his shift when he identified the change in her condition but he had no response. Interview on [DATE] at 1:38p.m., the Administrator, who was the abuse and neglect coordinator, said she believed the facility was in immediate jeopardy because of CR #1's death. She explained she reported the incident to the state agency. The Administrator said she was not notified of CR #1's fall with injury on Friday [DATE] until Sunday night ([DATE]), when CR #1 was found unresponsive and passed away the same day. The Administrator said she started investigating the incident and realized it should be reported. She expressed the safety of the residents was her priority. She stated CR #1 always wanted to be out of her room, and preferred to sit by the nurses' station but always yelled help me, help me. Interview on [DATE] at 1:5p.m., the DON said she believed the facility was in immediate jeopardy because LVN #2, who was CR #1's nurse on Sunday [DATE], failed to respond promptly to CR #1's clinical changes. The DON said when LVN #2 was asked why he did not promptly intervene; he had no response and just said he was monitoring her. The DON agreed nurses should work together and follow up from each other provided there was communication of what needed to be done for the residents. She said she expected staff to conduct proper assessment and intervene when needed. The DON said CR #1 always liked to sit by the nurses' station and always yelled help me, help me. She stated staff should have been alarmed when CR #1 stayed in bed all day Friday, Saturday and Sunday. Interview on [DATE] at 10:00a.m., the DON said she reviewed the 24 hour report for [DATE] looking for information indicating that staff were to follow up with notifying CR#1's physician of her fall with injury but there was none. The DON said she talked to the nurse who worked the evening shift (6p.m.-6a.m.) on [DATE] who said she was not told by the day shift nurse (LVN #1) to follow up or to call CR #1's physician. The DON agreed the resident's physician and the facility's medical director should have been promptly notified of both the fall and change in condition. The DON further said CR#1's physician said he was aware of the fall and did not think anything would have changed or been done differently considering CR #1's age and advance directives of DNR. The DON agreed LVN #2 should have called 911 when the resident was found unresponsive instead calling the ADON #1, then the physician, the resident's family and lastly 911. The DON agreed the ADON #1 contacted should have advised LVN #2 to call 911 immediately. The DON also said the night nurse reported CR #1 was stable all night ([DATE]) and showed no signs of a change in condition. Record review of facility's policy on abuse and neglect, which was not dated, read in part .what constitutes neglect - neglect is failure to provide goods or services including medical services that are necessary to provide physical or emotional harm, pain, or mental illness. The facility must determine if an injury, harm to or death of a resident was due to a facility's failure to provide services, treatment or care to a resident. Failure to provide good and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness . On [DATE] at 3:38p.m. an IJ was identified and the facility Administrator was notified. The IJ was removed on [DATE]. The facility submitted and implemented the following plan to remove the IJ on [DATE]. Plan to remove immediacy: I. The Administrator and Director of Nursing were notified on ,[DATE] at approximately 4:15p.m. of an Immediate Jeopardy for neglect related to failure to conduct proper assessment after a fall. The following steps are the facility's plan to remove the Immediate Jeopardy. a) On [DATE], Nurse Managers, Licensed Nurses, and the Director of Nursing immediately assessed current residents (99 residents) in the facility to ensure any changes in condition were identified, physician notification has occurred, interventions implemented, documentation in the medical record reflective of the residents status and the identified change in condition were care planned completed [DATE]. b.) On [DATE], Nurse Managers, Licensed Nurses, and the Director of nursing immediately assessed (99 residents) in the facility to reflect fall risk status of resident's current condition completed [DATE]. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Interdisciplinary Team to review and discuss the plan of action of properly assessing a resident after a fall with injury and the plan for physician notification if the primary physician does not return a call. The nursing staff will notify the primary physician and if a call is not returned within 30 minutes, the Medical Director is to be called; if Medical Director does not return the call within 15 minutes the resident is to be sent to ER. In the event that the injury requires immediate medical attention the resident will be transported to the emergency room . This is documented on Quality Assurance Performance Improvement Agenda form. Completed [DATE]. The Director of Nursing and Nurse Managers immediately began re-educating staff (RN/LVN/C.N.A./ MA) on the following: ([DATE]) On recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the resident condition some of the symptoms may include: Recognizing changes in mental status, functional status of a resident, respiratory, GI/abdomen, GU/urine. Head injury/Neuro checks- a neurological check form will be completed for any fall involving the head or any un-witnessed fall. If there are any changes in the neurological assessment: opening eyes and changes in pupil size or reaction, motor and verbal response changes from baseline to next assessment, or changes in the overall total Glasgow Score from previous perimeter the nurse will call the physician for further recommendations. Unresponsive Resident-if a resident is found unresponsive after assessment nurse is to call 911. Assessing the resident by completion of the Interact SBAR (Assessing the resident and documenting in the clinical records of the resident; for example, a significant change of condition is a decline or improvement of the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions and also impacts more than one area of the resident's health status requires interdisciplinary review and revision to the care plan and is ultimately based on the judgment of the clinical staff and guidelines of the resident assessment instrument)-documentation in the residents medical record (documenting residents condition, any changes, when a resident admits, or discharges from the facility) for example, the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status notification to the attending physicians/responsible party. The nursing staff will notify the primary physician and if a call is not returned within 30 minutes, the Medical Director is to be called; if Medical Director does not return the call within 15 minutes the resident is to be sent to ER. In the event that the injury requires immediate medical attention the resident will be transported to the emergency room . Care planning the change in condition (Care planning any change with a resident) Utilization of the Interact Stop and Watch tool -these items were in-serviced CNAs/MAs will immediately notify the charge nurse if any of the above occur. Fall education started on [DATE] by Director of Staff Development on 2- 10 shift that included License nurses re-educated to the policy and procedures of the 24 hour report. Utilization of the 24 hour report to report changes in condition. The following in-services started on [DATE] by the Director of Social Services on ,[DATE] shift. Abuse/neglect regarding assessing and documenting change in condition. Education started on [DATE] ,[DATE] shifts. Education will continue each shift until 100%of the Nursing Staff (RN/LVN/MA/CNA) is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Director of Staff development or designee will include in-services with the orientation process. No staff will be allowed to provide patient care until they have been trained. The DON, Nurse Managers/Designee will round daily starting [DATE] and will continue daily to ensure no changes in condition. To monitor the Director of Nursing/ designee clinical rounds to identify changes in condition. Review notifications of physician ' s clinical meeting. Review SBAR in clinical meetings. Review Incidents/Accidents in Clinical meeting. Weekend supervisor will conduct clinical meeting. The surveyor monitored the plan to remove the immediate jeopardy on [DATE] and [DATE] as follows: Monitoring began on [DATE]. LVNs and RNs were interviewed on two shifts on physician notification, and proper assessment following falls and changes in condition. Record review of the facility In-Services revealed: [DATE] - twelve staff members were trained on proper way of notifying/consulting the resident's physician, and facility's medical director and to call 911 if no response was received from the physicians; and staff were to notify the DON or designee of any identified changes in condition, falls with injury and the proper assessment, documentation and analysis of neurological assessment following falls with head injuries. 14 staff members were trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, and Recommendation) tool. [DATE] - more than 50% of the facility's nursing staff members were trained on parameters of when to notify facility administration on any changes in residents. Interview on [DATE] at 10:00 a.m., the DON stated she completed chart audits, evaluated all residents in the facility for changes in condition, falls with or without injuries and found that staff were implementing the appropriate and current plan. Record review of in-service, dated [DATE], the DON and ADONs trained all staff scheduled to work [DATE], [DATE], and [DATE]. Interviews with 6 MAs, and 5 CNAs on [DATE] between 4:25 p.m. and 5:15 p.m., revealed they received training on how to identify abuse and neglect, when to notify a charge nurse of anything usual noted about any patient, and if the nurses did not respond immediately to call the DON or the administrator. Record review of the in-service forms provided by the Administrator dated [DATE], [DATE] and [DATE] revealed on-going in-services concerning resident assessments, physicians' consultation, and post fall with head injury interventions. Interview on [DATE] at 9:30a.m., the Administrator stated she would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. She further reported she would continue to monitor the facility approved plan of removal to ensure the safety of the residents. She said she was monitoring and evaluating all fall incidents to ensure staff were implementing the plan. She also stated the facility's medical director had spoken with all other doctors to ensure they understood that he would be called for intervention should they not promptly respond to facility's calls. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 9:39a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following falls with injuries and following changes in condition. The Administrator reported 17 residents in the facility at high risk for falls.

Based on interview, and record review, the facility failed to promptly consult the physician when a change in condition occurred for one in 12 residents (CR#1) reviewed for physician consultation. CR#1 had a fall on [DATE] with head injury and the physician was not consulted promptly. CR#1 was assessed with [REDACTED].#1 died on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern. The facility was continuing to monitor to ensure physicians were consulted when residents were assessed with [REDACTED]. This failure affected one resident who died in the facility and placed 16 other residents at risk for falls at risk of not having the physician consulted, which could result in a decline in their medical condition, and psychosocial well-being. Findings include: Incident intake # 4 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's MDS dated [DATE] revealed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Further review revealed CR #1 required extensive assistance for bed mobility, transfers, walking in room, walking in corridor, dressing, locomotion off unit, toilet use, personal hygiene and bathing. The resident required limited assistance for locomotion on unit, and eating. Further review of this MDS revealed the resident had a fall with injury that was not major. Record review of CR#1's incident report dated [DATE] at 1:28p.m., revealed resident was noted on the floor lying on her left side calling for help. Injuries noted were hematoma left forehead (brow area) and abrasion to left knee. The resident was alert. Further review of this incident report revealed the resident's physician was called and a message was left about the fall on [DATE] at 1:50p.m. Record review of CR #1's care plan, which was undated, revealed she had falls on [DATE], [DATE], and [DATE]. Further review revealed a goal which read My number of falls will be reduced through next review date. I have had an actual fall on [DATE]. Target date: [DATE]. Interventions included: Educate on use of call light and to wait for staff to come help. Be sure my call light is within reach and encourage me to use it. Follow facility fall protocol. Pt. evaluate and treat as ordered or PRN. After each fall episode evaluate current interventions and modify interventions based on IDT recommendations. Record review of CR#1's neurological evaluation flow sheet, revealed it was initiated on [DATE] at 1:28p.m. and stopped on [DATE] at 6a.m. Further review revealed the following pupil reaction documentation: [DATE] at 1:28p.m. - pupils were sluggish. [DATE] at 6:45p.m. - pupils were sluggish [DATE] at 7p.m. - pupils were sluggish [DATE] at 8p.m. - pupils were sluggish [DATE] at 8:30p.m. - pupils were sluggish [DATE] at 9p.m. - pupils were sluggish [DATE] at 10p.m.-pupils were sluggish [DATE] at 6a.m. - pupils were brisk [DATE] at 6p.m. - right pupil was brisk, notation for left pupil was illegible [DATE] at 6:00a.m. - pupils were sluggish. Record review of CR#1's progress notes dated [DATE] at 2:33p.m., revealed resident was noted lying on the floor by staff crying for help. A large raised area noted on forehead, scrape noted on left knee, no internal or external rotation on both upper and lower extremities. Vital laying down ,[DATE], pulse-103, R (respiration) 18, blood pressure sitting down ,[DATE], pulse 100, respiration 18 and temperature 98. Responsible party informed, physician's office called and message left re-fall, ice park to areas on forehead and neuro checks. Interview on [DATE] at 2:23p.m., LVN#1 stated when he was notified of CR #1's fall on [DATE], he went to the patient's room and took vitals, called the physician's office and told the office staff the reason for his call. LVN #1 said he called again 20 minutes later and was told by the office staff that the physician would call him back. LVN #1 reported he called the physician 3 times, called the resident's family and continued with neuro checks. LVN #1 stated the physician did not call back throughout his shift (6a.m.-6p.m.). He further said he notified the on-coming nurse to follow up with CR #1's physician. Interview on [DATE] at 1:20p.m., CNA #1 said she cared for CR #1 on the morning of [DATE]. She said CR #1 had a bruise to her forehead but was talking. She stated she cleaned CR #1 up and fed her in bed by the resident's choice. CNA #1 said the resident made no complaints to her, but was unable to go the bathroom like she would before the fall. She had incontinent brief on and had two brief changes during her shift, she did not notice any running nose, discharges and no pain was expressed or verbalized. CNA #1 said the resident previously would talk and say help me, help me and did not like to stay in bed, but preferred to be out of her room and sit by the nurse's station. Record review of CR#1's progress notes dated [DATE] at 5:11p.m., revealed resident in bed lying down, assisted patient with putting dentures in her mouth, resident is being monitored post fall, resident has bruising to left side of forehead, left per orbital and check area and less extensive bruising to right per orbital area, resident is alert to self and able to speak. Resident is now being fed by speech therapy. Record review of CR #1's progress notes dated [DATE] at 3:30a.m., revealed Resident in bed stable at the moment, no signs and symptoms of acute distress noted. Respiration even and unlabored, skin warm and dry to touch, resident status [REDACTED]. Vital signs were: blood pressure ,[DATE], R18, oxygen saturation 98%, active range of motion on upper and lower extremities. Safety measures in place and call light within reach and bed in lowest position, will continue with the care. Two attempts were made to interview the CNAs who cared for CR #1 on Sunday morning and Sunday afternoon without success. Phone calls were not returned. Record review of CR #1's progress notes dated [DATE] at 7:02p.m., revealed Patient was not responding and vital signs were BP,[DATE], Pulse -193, R-28, oxygen saturation was 75% room air. Called out MD immediately, the doctor said call the daughter, notified of patient status and what the doctor said, she requested call 911 immediately and let them wait for me, 911 was called, when they arrived there was no pulse, daughter came few minutes after as she said, at this hour they are here. Further review of progress report revealed: At 7:21p.m., ADON (#1) made aware of patient status, at 6:45p.m., resident was pronounced by 911 with family present and 9:35p.m., Resident was picked up by medical examiner via stretcher accompanied by two policemen, Resident's daughter and physician notified. Record review of a written statement by LVN #2 (CR#1's charge nurse on [DATE]) read in part .on [DATE], I reported to duty at 6a.m., during rounds I observed patient (CR#1) in bed with bruises on her face and eyes closed. I greeted her, she responded with help me, help me. Her right eye was running water, I went back to the night nurse to find out what happened to her face and her condition, the nurse told me that patient fell Friday [DATE] and hit her head, neuro check is in progress and she has been in bed since then. Vital signs were ,[DATE], pulse 120. Respiration 20, temperature 98.6, oxygen saturation was 95% at room air. I called the physician about 11a.m. concerning the patient eye and the bruises on her face, no call back. She was monitored throughout and was responding with help me, help me. At about 5:45p.m., during my last round, patient was not responding, I called for help and we checked vital signs, blood pressure was ,[DATE], pulse was 193, oxygen saturation was 75% at room air, notified the ADON #1 who advised to call MD and family. Called out MD and updated him of patient status and the patient is DNR, MD ordered to call family member and ask what she wants, daughter asked to call 911 and sent patient to hospital but let the 911 staff wait I am on my way with my daughter, we are just 5 minutes away. In less than 5 minutes EMS were here and the daughter also came in, there was no pulse . Interview on [DATE] at 10:00a.m., the DON said she reviewed the 24 hour report for [DATE] looking for information indicating that staff were to follow up with notifying CR#1's physician of her fall with injury but there was none. The DON said she talked to the nurse who worked the evening shift (6p.m.-6a.m.) on [DATE] who said she was not told by the day shift nurse (LVN #1) to follow up or to call CR #1's physician. The DON agreed the resident's physician and the facility's medical director should have been promptly notified of both the fall and change in condition. The DON further said CR#1's physician said he was aware of the fall and did not think anything would have changed or been done differently. Interview on [DATE] at 2:44p.m., LVN #2 said when he made his rounds the morning of [DATE] around 6a.m. and noticed CR #1 was in bed sick with a bruise on her face. He asked the nurse what happened to CR #1 and was informed the resident fell on Friday ([DATE]). LVN #2 said the nurse told him CR #1 had not been doing well, had been in bed since the fall and Neuro checks were in progress. LVN #2 said this was all the report the outgoing night nurse gave him. LVN #2 reported he continued Neuro checks every hour, but CR #1 was not opening her eyes, so he called the physician around 11a.m. The physician did not respond and did not call back, so LVN #2 continued monitoring the resident every hour, talking to her, trying to get her to open her eyes and talk back to him. LVN #2 said about 5p.m., he noted the resident was not responding like before, so he reported it to the ADON #1 and was told to call the doctor. LVN #2 stated he called the doctor and the doctor told him to call the resident's daughter and ask what the family preferred since CR #1 was had a code status of DO NOT RESUSITATE (DNR). LVN #2 further said he called CR #1's daughter who asked him to call 911. He stated he called 911 and they arrived in about 5 minutes and found no pulse. LVN #2 said he had only one aide in the morning, so he could not use her to help him monitor the resident closely, since one aide had called in. LVN #2 said he checked the residents' vital signs twice in the morning and in the afternoon and they were all normal. He also said he expected the resident's physician was aware of the fall with head injuries and did not mention it when he called him on [DATE]. LVN #2 said after reflecting on the incident, he should have called the physician earlier when he noted the resident was not feeling well, but the nurse who worked the night before said that was how the resident had been throughout the night shift. LVN #2 said he would have continued to called the physician or report it to the ADON #1 earlier if he had known this was unusual for CR #1. LVN #2 said CR #1 was declared dead on arrival, EMS called police and medical examiner's office. Interview on [DATE] at 2:58p.m., LVN #2 when asked what CR#1 looked like during his last rounds stated CR#1 had an oxygen saturation of 75%, she was not breathing well-shallow breathing, pulse was 193 and very faint, color was normal and body was warm, no discharge was noted. Interview on [DATE] at 3:05p.m., ADON #1 said she was called by LVN #2 around after 6p.m. on [DATE]. She stated LVN #2 told her that CR #1 was unresponsive, had blood pressure and heart rate but no oxygen saturation was registering on pulse oximeter. She told LVN #2 to call the physician. ADON #1 said she called back about three minutes later and was told EMS was in the facility and the resident was dead. Interview on [DATE] at 3:20p.m., the Administrator reported she asked LVN #2 why CR#1's physician was not contacted earlier in his shift when he identified the change in her condition but he had no response. Record review of facility policy on resident rights which was not dated read in part .the facility will protect and protect the rights of each resident. The facility will immediately inform the resident and consult with the resident's physician, if appropriate when changes occur. If known, the facility shall also notify the resident's legal representative or an interested family member. Notification of changes shall include: An accident involving the resident which results in injury and has the potential for requiring physician intervention. A significant change in the resident's physical mental, or psychological status such as deterioration in health or psychosocial status in either life threatening conditions or clinical complications etc . On [DATE] at 3:38p.m., an IJ was identified and the facility Administrator was notified. The IJ was removed on [DATE]. The facility submitted and implemented the following plan to remove the IJ on [DATE]. Plan to remove immediacy: I. The Administrator and Director of Nursing were notified on [DATE] at approximately 4:15p.m. of an Immediate Jeopardy for neglect related to failure to conduct proper assessment after a fall. The following steps are the facility's plan to remove the Immediate Jeopardy. a) On [DATE], Nurse Managers, Licensed Nurses, and the Director of Nursing immediately assessed current residents (99 residents) in the facility to ensure any changes in condition were identified, physician notification has occurred, interventions implemented, documentation in the medical record reflective of the residents status and the identified change in condition were care planned completed [DATE]. b.) On [DATE], Nurse Managers, Licensed Nurses, and the Director of nursing immediately assessed (99 residents) in the facility to reflect fall risk status of resident's current condition completed [DATE]. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Interdisciplinary Team to review and discuss the plan of action of properly assessing a resident after a fall with injury and the plan for physician notification if the primary physician does not return a call. The nursing staff will notify the primary physician and if a call is not returned within 30 minutes, the Medical Director is to be called; if Medical Director does not return the call within 15 minutes the resident is to be sent to ER. In the event that the injury requires immediate medical attention the resident will be transported to the emergency room . This is documented on Quality Assurance Performance Improvement Agenda form. Completed [DATE]. The Director of Nursing and Nurse Managers immediately began re-educating staff (RN/LVN/C.N.A./ MA) on the following: ([DATE]) On recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the resident condition some of the symptoms may include: Recognizing changes in mental status, functional status of a resident, respiratory, GI/abdomen, GU/urine. Head injury/Neuro checks- a neurological check form will be completed for any fall involving the head or any un-witnessed fall. If there are any changes in the neurological assessment: opening eyes and changes in pupil size or reaction, motor and verbal response changes from baseline to next assessment, or changes in the overall total Glasgow Score from previous perimeter the nurse will call the physician for further recommendations. Unresponsive Resident-if a resident is found unresponsive after assessment nurse is to call 911. Assessing the resident by completion of the Interact SBAR (Assessing the resident and documenting in the clinical records of the resident; for example, a significant change of condition is a decline or improvement of the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions and also impacts more than one area of the resident's health status requires interdisciplinary review and revision to the care plan and is ultimately based on the judgment of the clinical staff and guidelines of the resident assessment instrument)-documentation in the residents medical record (documenting residents condition, any changes, when a resident admits, or discharges from the facility) for example, the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status notification to the attending physicians/responsible party. The nursing staff will notify the primary physician and if a call is not returned within 30 minutes, the Medical Director is to be called; if Medical Director does not return the call within 15 minutes the resident is to be sent to ER. In the event that the injury requires immediate medical attention the resident will be transported to the emergency room . Care planning the change in condition (Care planning any change with a resident) Utilization of the Interact Stop and Watch tool -these items were in-serviced CNAs/MAs will immediately notify the charge nurse if any of the above occur. Fall education started on [DATE] by Director of Staff Development on 2- 10 shift that included License nurses re-educated to the policy and procedures of the 24 hour report. Utilization of the 24 hour report to report changes in condition. The following in-services started on [DATE] by the Director of Social Services on ,[DATE] shift. Abuse/neglect regarding assessing and documenting change in condition. Education started on [DATE] ,[DATE] shifts. Education will continue each shift until 100%of the Nursing Staff (RN/LVN/MA/CNA) is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Director of Staff development or designee will include in-services with the orientation process. No staff will be allowed to provide patient care until they have been trained. The DON, Nurse Managers/Designee will round daily starting [DATE] and will continue daily to ensure no changes in condition. To monitor the Director of Nursing/ designee clinical rounds to identify changes in condition. Review notifications of physician's clinical meeting. Review SBAR in clinical meetings. Review Incidents/Accidents in Clinical meeting. Weekend supervisor will conduct clinical meeting. The surveyor monitored the plan to remove the immediate jeopardy on [DATE] and [DATE] as follows: Monitoring began on [DATE]. LVNs and RNs were interviewed on two shifts on physician notification, and proper assessment following falls and changes in condition. Record review of the facility In-Services revealed: [DATE] - twelve staff members were trained on proper way of notifying/consulting the resident's physician, and facility's medical director and to call 911 if no response was received from the physicians; and staff were to notify the DON or designee of any identified changes in condition, falls with injury and the proper assessment, documentation and analysis of neurological assessment following falls with head injuries. 14 staff members were trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, and Recommendation) tool. [DATE] - more than 50% of the facility's nursing staff members were trained on parameters of when to notify facility administration on any changes in residents. Interview on [DATE] at 10:00 a.m., the DON stated she completed chart audits, evaluated all residents in the facility for changes in condition, falls with or without injuries and found that staff were implementing the appropriate and current plan. Record review of in-service, dated [DATE], the DON and ADONs trained all staff scheduled to work [DATE], [DATE], and [DATE]. Interviews with 6 MAs, and 5 CNAs on [DATE] between 4:25 p.m. and 5:15 p.m., revealed they received training on how to identify abuse and neglect, when to notify a charge nurse of anything usual noted about any patient, and if the nurses did not respond immediately to call the DON or the administrator. Record review of the in-service forms provided by the Administrator dated [DATE], [DATE] and [DATE] revealed on-going in-services concerning resident assessments, physicians' consultation, and post fall with head injury interventions. Interview on [DATE] at 9:30a.m., the Administrator stated she would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. She further reported she would continue to monitor the facility approved plan of removal to ensure the safety of the residents. She said she was monitoring and evaluating all fall incidents to ensure staff were implementing the plan. She also stated the facility's medical director had spoken with all other doctors to ensure they understood that he would be called for intervention should they not promptly respond to facility's calls. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 9:39a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following falls with injuries and following changes in condition. The Administrator reported 17 residents in the facility at high risk for falls.

Based on interview and record review the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of 12 residents (CR #1) reviewed for quality of care. The facility failed to recognize CR #1's change in condition after she had a fall with a head injury and consult with the physician to obtain orders for prompt medical intervention or services. The facility failed to seek medical consultation and care for CR #1 who had a fall with a head injury and the resident's physician did not respond to the facility's calls. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and scope of pattern. This failure affected one resident who died in the facility following a significant change of condition and placed 16 other residents at risk for falls at risk of not receiving services necessary to ensure residents received medical care from injuries, which could lead to a decline in their health, untreated pain or death. Findings include: Incident intake # 4 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's MDS dated [DATE] revealed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Further review revealed CR #1 required extensive assistance for bed mobility, transfers, walking in room, walking in corridor, dressing, locomotion off unit, toilet use, personal hygiene and bathing. The resident required limited assistance for locomotion on unit, and eating. Further review of this MDS revealed the resident had a fall with injury that was not major. Record review of CR#1's incident report dated [DATE] at 1:28p.m., revealed resident was noted on the floor lying on her left side calling for help. Injuries noted were hematoma left forehead (brow area) and abrasion to left knee. The resident was alert. Further review of this incident report revealed the resident's physician was called and a message was left about the fall on [DATE] at 1:50p.m. Record review of CR #1's care plan, which was undated, revealed she had falls on [DATE], [DATE] and [DATE]. Further review revealed a goal which read My number of falls will be reduced through next review date. I have had an actual fall on [DATE]. Target date: [DATE]. Interventions included: Educate on use of call light and to wait for staff to come help. Be sure my call light is within reach and encourage me to use it. Follow facility fall protocol. Pt. evaluate and treat as ordered or PRN. After each fall episode evaluate current interventions and modify interventions based on IDT recommendations. Record review of CR#1's neurological evaluation flow sheet, revealed it was initiated on [DATE] at 1:28p.m. and stopped on [DATE] at 6a.m. Further review revealed the following pupil reaction documentation: [DATE] at 1:28p.m. - pupils were sluggish. [DATE] at 6:45p.m. - pupils were sluggish [DATE] at 7p.m. - pupils were sluggish [DATE] at 8p.m. - pupils were sluggish [DATE] at 8:30p.m. - pupils were sluggish [DATE] at 9p.m. - pupils were sluggish [DATE] at 10p.m.-pupils were sluggish [DATE] at 6a.m. - pupils were brisk [DATE] at 6p.m. - right pupil was brisk, notation for left pupil was illegible [DATE] at 6:00a.m. - pupils were sluggish. Record review of CR#1's progress notes dated [DATE] at 2:33p.m., revealed resident was noted lying on the floor by staff crying for help. A large raised area noted on forehead, scrape noted on left knee, no internal or external rotation on both upper and lower extremities. Vital laying down ,[DATE], pulse-103, R (respiration) 18, blood pressure sitting down ,[DATE], pulse 100, respiration 18 and temperature 98. Responsible party informed, physician's office called and message left re-fall, ice park to areas on forehead and neuro checks. Interview on [DATE] at 2:23p.m., LVN#1 stated when he was notified of CR #1's fall on [DATE], he went to the patient's room and took vitals, called the physician's office and told the office staff the reason for his call. LVN #1 said he called again 20 minutes later and was told by the office staff that the physician would call him back. LVN #1 reported he called the physician 3 times, called the resident's family and continued with neuro checks. LVN #1 stated the physician did not call back throughout his shift (6a.m.-6p.m.). He further said he notified the on-coming nurse to follow up with CR #1's physician. There was no other progress note documentation for [DATE]. Interview on [DATE] at 1:20p.m., CNA #1 said she cared for CR #1 on the morning of [DATE]. She said CR #1 had a bruise to her forehead but was talking. She stated she cleaned CR #1 up and fed her in bed by the resident's choice. CNA #1 said the resident made no complaints to her, but was unable to go the bathroom like she would before the fall. She had incontinent brief on and had two brief changes during her shift, she did not notice any running nose, discharges and no pain was expressed or verbalized. CNA #1 said the resident previously would talk and say help me, help me and did not like to stay in bed, but preferred to be out of her room and sit by the nurse's station. Record review of CR#1's progress notes dated [DATE] at 5:11p.m., revealed resident in bed lying down, assisted patient with putting dentures in her mouth, resident is being monitored post fall, resident has bruising to left side of forehead, left per orbital and check area and less extensive bruising to right per orbital area, resident is alert to self and able to speak. Resident is now being fed by speech therapy. There was no other progress note documentation for [DATE]. Record review of CR #1's progress notes dated [DATE] at 3:30a.m., revealed Resident in bed stable at the moment, no signs and symptoms of acute distress noted. Respiration even and unlabored, skin warm and dry to touch, resident status [REDACTED]. Vital signs were: blood pressure ,[DATE], R18, oxygen saturation 98%, active range of motion on upper and lower extremities. Safety measures in place and call light within reach and bed in lowest position, will continue with the care. Two attempts were made to interview the CNAs who cared for CR #1 on Sunday morning and Sunday afternoon without success. Phone calls were not returned. Record review of CR #1's progress notes dated [DATE] at 7:02p.m., revealed Patient was not responding and vital signs were BP,[DATE], Pulse -193, R-28, oxygen saturation was 75% room air. Called out MD immediately, the doctor said call the daughter, notified of patient status and what the doctor said, she requested call 911 immediately and let them wait for me, 911 was called, when they arrived there was no pulse, daughter came few minutes after as she said, at this hour they are here. Further review of progress report revealed: At 7:21p.m., ADON (#1) made aware of patient status, at 6:45p.m., resident was pronounced by 911 with family present and 9:35p.m., Resident was picked up by medical examiner via stretcher accompanied by two policemen, Resident's daughter and physician notified. Record review of a written statement by LVN #2 (CR#1's charge nurse on [DATE]) read in part .on [DATE], I reported to duty at 6a.m., during rounds I observed patient (CR#1) in bed with bruises on her face and eyes closed. I greeted her, she responded with help me, help me. Her right eye was running water, I went back to the night nurse to find out what happened to her face and her condition, the nurse told me that patient fell Friday [DATE] and hit her head, neuro check is in progress and she has been in bed since then. Vital signs were ,[DATE], pulse 120. Respiration 20, temperature 98.6, oxygen saturation was 95% at room air. I called the physician about 11a.m. concerning the patient eye and the bruises on her face, no call back. She was monitored throughout and was responding with help me, help me. At about 5:45p.m., during my last round, patient was not responding, I called for help and we checked vital signs, blood pressure was ,[DATE], pulse was 193, oxygen saturation was 75% at room air, notified the ADON (#1) who advised to call MD and family. Called out MD and updated him of patient status and the patient is DNR, MD ordered to call family member and ask what she wants, daughter asked to call 911 and sent patient to hospital but let the 911 staff wait I am on my way with my daughter, we are just 5 minutes away. In less than 5 minutes EMS were here and the daughter also came in, there was no pulse . Interview on [DATE] at 2:44p.m., LVN #2 said when he made his rounds the morning of [DATE] around 6a.m. and noticed CR #1 was in bed sick with a bruise on her face. He asked the nurse what happened to CR #1 and was informed the resident fell on Friday ([DATE]). LVN #2 said the nurse told him CR #1 had not been doing well, had been in bed since the fall and Neuro checks were in progress. LVN #2 said this was all the report the outgoing night nurse gave him. LVN #2 reported he continued Neuro checks every hour, but CR #1 was not opening her eyes, so he called the physician around 11a.m. The physician did not respond and did not call back, so LVN #2 continued monitoring the resident every hour, talking to her, trying to get her to open her eyes and talk back to him. LVN #2 said about 5p.m., he noted the resident was not responding like before, so he reported it to the ADON #1 and was told to call the doctor. LVN #2 stated he called the doctor and the doctor told him to call the resident's daughter and ask what the family preferred since CR #1 was had a code status of DO NOT RESUSITATE (DNR). LVN #2 further said he called CR #1's daughter who asked him to call 911. He stated he called 911 and they arrived in about 5 minutes and found no pulse. LVN #2 said he had only one aide in the morning, so he could not use her to help him monitor the resident closely, since one aide had called in. LVN #2 said he checked the residents' vital signs twice in the morning and in the afternoon and they were all normal. He also said he expected the resident's physician was aware of the fall with head injuries and did not mention it when he called him on [DATE]. LVN #2 said after reflecting on the incident, he should have called the physician earlier when he noted the resident was not feeling well, but the nurse who worked the night before said that was how the resident had been throughout the night shift. LVN #2 said he would have continued to call the physician or report it to the ADON #1 earlier if he had known this was unusual for CR #1. LVN #2 said CR #1 was declared dead on arrival, EMS called police and medical examiner's office. Interview on [DATE] at 2:58p.m., LVN #2 when asked what CR#1 looked like during his last rounds stated CR#1 had an oxygen saturation of 75%, she was not breathing well-shallow breathing, pulse was 193 and very faint, color was normal and body was warm, no discharge was noted. Interview on [DATE] at 3:05p.m., ADON #1 said she was called by LVN #2 around after 6p.m. on [DATE]. She stated LVN #2 told her that CR #1 was unresponsive, had blood pressure and heart rate but no oxygen saturation was registering on pulse oximeter. She told LVN #2 to call the physician. ADON #1 said she called back about three minutes later and was told EMS was in the facility and the resident was dead. Interview on [DATE] at 3:20p.m., the Administrator reported she asked LVN #2 why CR#1's physician was not contacted earlier in his shift when he identified the change in her condition but he had no response. Interview on [DATE] at 1:38p.m., the Administrator said she believed the facility was in immediate jeopardy because of CR #1's death. She explained she reported the incident to the state agency. The Administrator said she was not notified of CR #1's fall with injury on Friday [DATE] until Sunday night ([DATE]), when CR #1 was found unresponsive and passed away the same day. The Administrator said she started investigating the incident and realized it should be reported. She expressed the safety of the residents was her priority. She stated CR #1 always wanted to be out of her room, and preferred to sit by the nurses' station but always yelled help me, help me. Interview on [DATE] at 1:5p.m., the DON said she believed the facility was in immediate jeopardy because LVN #2, who was CR #1's nurse on Sunday [DATE], failed to respond promptly to CR #1's clinical changes. The DON said when LVN #2 was asked why he did not promptly intervene; he had no response and just said he was monitoring her. The DON agreed nurses should work together and follow up from each other provided there was communication of what needed to be done for the residents. She said she expected staff to conduct proper assessment and intervene when needed. The DON said CR #1 always liked to sit by the nurses' station and always yelled help me, help me. She stated staff should have been alarmed when CR #1 stayed in bed all day Friday, Saturday and Sunday. Interview on [DATE] at 10:00a.m., the DON said she reviewed the 24 hour report for [DATE] looking for information indicating that staff were to follow up with notifying CR#1's physician of her fall with injury but there was none. The DON said she talked to the nurse who worked the evening shift (6p.m.-6a.m.) on [DATE] who said she was not told by the day shift nurse (LVN #1) to follow up or to call CR #1's physician. The DON agreed the resident's physician and the facility's medical director should have been promptly notified of both the fall and change in condition. The DON further said CR#1's physician said he was aware of the fall and did not think anything would have changed or been done differently considering CR #1's age and advance directives of DNR. The DON agreed LVN #2 should have called 911 when the resident was found unresponsive instead calling the ADON #1, then the physician, the resident's family and lastly 911. The DON agreed the ADON #1 contacted should have advised LVN #2 to call 911 immediately. The DON also said the night nurse reported CR #1 was stable all night ([DATE]) and showed no signs of a change in condition. Record review of facility policy on resident rights which was not dated read in part .the facility will protect and protect the rights of each resident. The facility will immediately inform the resident and consult with the resident's physician, if appropriate when changes occur .Notification of changes shall include: An accident involving the resident which results in injury and has the potential for requiring physician intervention. A significant change in the resident's physical mental, or psychological status such as deterioration in health or psychosocial status in either life threatening conditions or clinical complications etc . On [DATE] at 3:38p.m., an IJ was identified and the facility Administrator was notified. The IJ was removed on [DATE]. The facility submitted and implemented the following plan to remove the IJ on [DATE]. Plan to remove immediacy: I. The Administrator and Director of Nursing were notified on [DATE] at approximately 4:15p.m. of an Immediate Jeopardy for neglect related to failure to conduct proper assessment after a fall. The following steps are the facility's plan to remove the Immediate Jeopardy. a) On [DATE], Nurse Managers, Licensed Nurses, and the Director of Nursing immediately assessed current residents (99 residents) in the facility to ensure any changes in condition were identified, physician notification has occurred, interventions implemented, documentation in the medical record reflective of the residents status and the identified change in condition were care planned completed [DATE]. b.) On [DATE], Nurse Managers, Licensed Nurses, and the Director of nursing immediately assessed (99 residents) in the facility to reflect fall risk status of resident's current condition completed [DATE]. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Interdisciplinary Team to review and discuss the plan of action of properly assessing a resident after a fall with injury and the plan for physician notification if the primary physician does not return a call. The nursing staff will notify the primary physician and if a call is not returned within 30 minutes, the Medical Director is to be called; if Medical Director does not return the call within 15 minutes the resident is to be sent to ER. In the event that the injury requires immediate medical attention the resident will be transported to the emergency room . This is documented on Quality Assurance Performance Improvement Agenda form. Completed [DATE]. The Director of Nursing and Nurse Managers immediately began re-educating staff (RN/LVN/C.N.A./ MA) on the following: ([DATE]) On recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the resident condition some of the symptoms may include: Recognizing changes in mental status, functional status of a resident, respiratory, GI/abdomen, GU/urine. Head injury/Neuro checks- a neurological check form will be completed for any fall involving the head or any un-witnessed fall. If there are any changes in the neurological assessment: opening eyes and changes in pupil size or reaction, motor and verbal response changes from baseline to next assessment, or changes in the overall total Glasgow Score from previous perimeter the nurse will call the physician for further recommendations. Unresponsive Resident-if a resident is found unresponsive after assessment nurse is to call 911. Assessing the resident by completion of the Interact SBAR (Assessing the resident and documenting in the clinical records of the resident; for example, a significant change of condition is a decline or improvement of the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions and also impacts more than one area of the resident's health status requires interdisciplinary review and revision to the care plan and is ultimately based on the judgment of the clinical staff and guidelines of the resident assessment instrument)-documentation in the residents medical record (documenting residents condition, any changes, when a resident admits, or discharges from the facility) for example, the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status notification to the attending physicians/responsible party. The nursing staff will notify the primary physician and if a call is not returned within 30 minutes, the Medical Director is to be called; if Medical Director does not return the call within 15 minutes the resident is to be sent to ER. In the event that the injury requires immediate medical attention the resident will be transported to the emergency room . Care planning the change in condition (Care planning any change with a resident) Utilization of the Interact Stop and Watch tool -these items were in-serviced CNAs/MAs will immediately notify the charge nurse if any of the above occur. Fall education started on [DATE] by Director of Staff Development on 2- 10 shift that included License nurses re-educated to the policy and procedures of the 24 hour report. Utilization of the 24 hour report to report changes in condition. The following in-services started on [DATE] by the Director of Social Services on ,[DATE] shift. Abuse/neglect regarding assessing and documenting change in condition. Education started on [DATE] ,[DATE] shifts. Education will continue each shift until 100%of the Nursing Staff (RN/LVN/MA/CNA) is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Director of Staff development or designee will include in-services with the orientation process. No staff will be allowed to provide patient care until they have been trained. The DON, Nurse Managers/Designee will round daily starting [DATE] and will continue daily to ensure no changes in condition. To monitor the Director of Nursing/ designee clinical rounds to identify changes in condition. Review notifications of physician ' s clinical meeting. Review SBAR in clinical meetings. Review Incidents/Accidents in Clinical meeting. Weekend supervisor will conduct clinical meeting. The surveyor monitored the plan to remove the immediate jeopardy on [DATE] and [DATE] as follows: Monitoring began on [DATE]. LVNs and RNs were interviewed on two shifts on physician notification, and proper assessment following falls and changes in condition. Record review of the facility In-Services revealed: [DATE] - twelve staff members were trained on proper way of notifying/consulting the resident's physician, and facility's medical director and to call 911 if no response was received from the physicians; and staff were to notify the DON or designee of any identified changes in condition, falls with injury and the proper assessment, documentation and analysis of neurological assessment following falls with head injuries. 14 staff members were trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, and Recommendation) tool. [DATE] - more than 50% of the facility's nursing staff members were trained on parameters of when to notify facility administration on any changes in residents. Interview on [DATE] at 10:00 a.m., the DON stated she completed chart audits, evaluated all residents in the facility for changes in condition, falls with or without injuries and found that staff were implementing the appropriate and current plan. Record review of in-service, dated [DATE], the DON and ADONs trained all staff scheduled to work [DATE], [DATE], and [DATE]. Interviews with 6 MAs, and 5 CNAs on [DATE] between 4:25 p.m. and 5:15 p.m., revealed they received training on how to identify abuse and neglect, when to notify a charge nurse of anything usual noted about any patient, and if the nurses did not respond immediately to call the DON or the administrator. Record review of the in-service forms provided by the Administrator dated [DATE], [DATE] and [DATE] revealed on-going in-services concerning resident assessments, physicians' consultation, and post fall with head injury interventions. Interview on [DATE] at 9:30a.m., the Administrator stated she would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. She further reported she would continue to monitor the facility approved plan of removal to ensure the safety of the residents. She said she was monitoring and evaluating all fall incidents to ensure staff were implementing the plan. She also stated the facility's medical director had spoken with all other doctors to ensure they understood that he would be called for intervention should they not promptly respond to facility's calls. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 9:39a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following falls with injuries and following changes in condition. The Administrator reported 17 residents in the facility at high risk for falls.

Based on record review, and interviews, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being of one of 12 residents (CR #1) reviewed for quality of care. The Administrator failed to oversee and assist with the implementation of effective policies and procedures on identifying a resident with a change in condition, promptly consulting with the physician and preventing neglect. The Administrator failed to supervise the DON on training and monitoring the nursing staff to assess, monitor, provide medical care to residents and promptly consult physicians concerning a change of condition in residents. The DON failed to ensure staff were trained to monitor, assess, provide care and consult physicians timely concerning resident who have falls with head injuries and/or changes in condition. The DON failed to ensure staff were trained to assess, and identify changes requiring the need of emergency medical services for prompt interventions. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and scope of pattern. This failure affected one resident who died in the facility following a significant change of condition and placed 16 other residents who were at risk for falls at risk of not being assessed, monitored, treated, and not having their physicians consulted for prompt interventions which could cause a delay in treatment, a decline in health, and death. Findings include: Incident intake # 4 Interview on [DATE] at 1:38p.m., the Administrator said she believed the facility was in immediate jeopardy because of CR #1's death. She explained she reported the incident to the state agency. The Administrator said she was not notified of CR #1's fall with injury on Friday [DATE] until Sunday night ([DATE]), when CR #1 was found unresponsive and passed away the same day. The Administrator said she started investigating the incident and realized it should be reported. She stated CR #1 always wanted to be out of her room, and preferred to sit by the nurses' station but always yelled help me, help me. She expressed the safety of the residents was her priority. The Administrator stated the nursing needs of the residents are typically addressed during daily clinical meetings when department heads who are assigned to particular residents see these needs while rounding and report them during the meetings. She further stated these needs are taken to the QA committee meetings and addressed. The Administrator stated she monitored the effectiveness of the DON through various ways including clinical meetings, monthly QA meetings, assessing the competency of the staff, and rounding. During this same interview the Administrator stated the company provided numerous resources for the Administrator and DON to utilize to assist in training and monitoring staff. She stated the company had a Medical Director, Corporate Nurses and other external resources. Interview on [DATE] at 1:55p.m., the DON said she believed the facility was in immediate jeopardy because LVN #2, who was CR #1's nurse on Sunday [DATE], failed to respond promptly to CR #1's clinical changes. The DON said when LVN #2 was asked why he did not promptly intervene; he had no response and just said he was monitoring her. The DON agreed nurses should work together and follow up from each other provided there was communication of what needed to be done for the residents. She said she expected staff to conduct proper assessment and intervene when needed. The DON said CR #1 always liked to sit by the nurses' station and always yelled help me, help me. She stated staff should have been alarmed when CR #1 stayed in bed all day Friday, Saturday and Sunday. The DON stated staff had been trained that when a fall occurred the resident should be assessed, the physician notified, family notified and his orders should be followed. She stated if a physician did not call back, staff were instructed to notify the DON. The DON stated she had numerous ways on ensuring the competency of her nursing staff which included inservices, skill check lists upon hire and yearly, education during clinical meetings, and talking to staff when things were not done correctly. The DON stated the facility offered numerous resources to assist in training and monitoring staff including a Medical Director, Nurse consultants, and Policies and Procedures. Interview on [DATE] at 10:00a.m., the DON said she reviewed the 24 hour report for [DATE] looking for information indicating that staff were to follow up with notifying CR#1's physician of her fall with injury but there was none. The DON said she talked to the nurse who worked the evening shift (6p.m.-6a.m.) on [DATE] who said she was not told by the day shift nurse (LVN #1) to follow up or to call CR #1's physician. The DON agreed the resident's physician and the facility's medical director should have been promptly notified of both the fall and change in condition. The DON further said CR#1's physician said he was aware of the fall and did not think anything would have changed or been done differently considering CR #1's age and advance directives of DNR. The DON agreed LVN #2 should have called 911 when the resident was found unresponsive instead calling the ADON #1, then the physician, the resident's family and lastly 911. The DON agreed the ADON #1 contacted should have advised LVN #2 to call 911 immediately. The DON also said the night nurse reported CR #1 was stable all night ([DATE]) and showed no signs of a change in condition. CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR#1's MDS dated [DATE] revealed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Further review revealed CR #1 required extensive assistance for bed mobility, transfers, walking in room, walking in corridor, dressing, locomotion off unit, toilet use, personal hygiene and bathing. The resident required limited assistance for locomotion on unit, and eating. Further review of this MDS revealed the resident had a fall with injury that was not major. Record review of CR#1's incident report dated [DATE] at 1:28p.m., revealed resident was noted on the floor lying on her left side calling for help. Injuries noted were hematoma left forehead (brow area) and abrasion to left knee. The resident was alert. Further review of this incident report revealed the resident's physician was called and a message was left about the fall on [DATE] at 1:50p.m. Record review of CR #1's care plan, which was undated, revealed she had falls on [DATE], [DATE] and [DATE]. Further review revealed a goal which read My number of falls will be reduced through next review date. I have had an actual fall on [DATE]. Target date: [DATE]. Interventions included: Educate on use of call light and to wait for staff to come help. Be sure my call light is within reach and encourage me to use it. Follow facility fall protocol. Pt. evaluate and treat as ordered or PRN. After each fall episode evaluate current interventions and modify interventions based on IDT recommendations. Record review of CR#1's neurological evaluation flow sheet, revealed it was initiated on [DATE] at 1:28p.m. and stopped on [DATE] at 6a.m. Further review revealed the following pupil reaction documentation: [DATE] at 1:28p.m. - pupils were sluggish. [DATE] at 6:45p.m. - pupils were sluggish [DATE] at 7p.m. - pupils were sluggish [DATE] at 8p.m. - pupils were sluggish [DATE] at 8:30p.m. - pupils were sluggish [DATE] at 9p.m. - pupils were sluggish [DATE] at 10p.m.-pupils were sluggish [DATE] at 6a.m. - pupils were brisk [DATE] at 6p.m. - right pupil was brisk, notation for left pupil was illegible [DATE] at 6:00a.m. - pupils were sluggish. Record review of CR#1's progress notes dated [DATE] at 2:33p.m., revealed resident was noted lying on the floor by staff crying for help. A large raised area noted on forehead, scrape noted on left knee, no internal or external rotation on both upper and lower extremities. Vital laying down ,[DATE], pulse-103, R (respiration) 18, blood pressure sitting down ,[DATE], pulse 100, respiration 18 and temperature 98. Responsible party informed, physician's office called and message left re-fall, ice park to areas on forehead and neuro checks. There was no other progress note documentation for [DATE]. Record review of CR#1's progress notes dated [DATE] at 5:11p.m., revealed resident in bed lying down, assisted patient with putting dentures in her mouth, resident is being monitored post fall, resident has bruising to left side of forehead, left per orbital and check area and less extensive bruising to right per orbital area, resident is alert to self and able to speak. Resident is now being fed by speech therapy. There was no other progress note documentation for [DATE]. Record review of CR #1's progress notes dated [DATE] at 3:30a.m., revealed Resident in bed stable at the moment, no signs and symptoms of acute distress noted. Respiration even and unlabored, skin warm and dry to touch, resident status [REDACTED]. Vital signs were: blood pressure ,[DATE], R18, oxygen saturation 98%, active range of motion on upper and lower extremities. Safety measures in place and call light within reach and bed in lowest position, will continue with the care. Record review of CR #1's progress notes dated [DATE] at 7:02p.m., revealed Patient was not responding and vital signs were BP,[DATE], Pulse -193, R-28, oxygen saturation was 75% room air. Called out MD immediately, the doctor said call the daughter, notified of patient status and what the doctor said, she requested call 911 immediately and let them wait for me, 911 was called, when they arrived there was no pulse, daughter came few minutes after as she said, at this hour they are here. Further review of progress report revealed: At 7:21p.m., ADON (#1) made aware of patient status, at 6:45p.m., resident was pronounced by 911 with family present and 9:35p.m., Resident was picked up by medical examiner via stretcher accompanied by two policemen, Resident's daughter and physician notified. Record review of a written statement by LVN #2 (CR#1's charge nurse on [DATE]) read in part .on [DATE], I reported to duty at 6a.m., during rounds I observed patient (CR#1) in bed with bruises on her face and eyes closed. I greeted her, she responded with help me, help me. Her right eye was running water, I went back to the night nurse to find out what happened to her face and her condition, the nurse told me that patient fell Friday [DATE] and hit her head, neuro check is in progress and she has been in bed since then. Vital signs were ,[DATE], pulse 120. Respiration 20, temperature 98.6, oxygen saturation was 95% at room air. I called the physician about 11a.m. concerning the patient eye and the bruises on her face, no call back. She was monitored throughout and was responding with help me, help me. At about 5:45p.m., during my last round, patient was not responding, I called for help and we checked vital signs, blood pressure was ,[DATE], pulse was 193, oxygen saturation was 75% at room air, notified the ADON (#1)who advised to call MD and family. Called out MD and updated him of patient status and the patient is DNR, MD ordered to call family member and ask what she wants, daughter asked to call 911 and sent patient to hospital but let the 911 staff wait I am on my way with my daughter, we are just 5 minutes away. In less than 5 minutes EMS were here and the daughter also came in, there was no pulse . Record review of facility's policy on abuse and neglect, which was not dated, read in part .what constitutes neglect - neglect is failure to provide goods or services including medical services that are necessary to provide physical or emotional harm, pain, or mental illness. The facility must determine if an injury, harm to or death of a resident was due to a facility's failure to provide services, treatment or care to a resident. Failure to provide good and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness . Record review of facility policy on resident rights which was not dated read in part .the facility will protect and protect the rights of each resident. The facility will immediately inform the resident and consult with the resident's physician, if appropriate when changes occur. If known, the facility shall also notify the resident's legal representative or an interested family member. Notification of changes shall include: An accident involving the resident which results in injury and has the potential for requiring physician intervention. A significant change in the resident's physical mental, or psychological status such as deterioration in health or psychosocial status in either life threatening conditions or clinical complications etc . Policies on quality of care and administration were requested from the Administrator but not provided prior to exit. Please refer to CMS form 2567 tags F157, 224, and 309 for additional interviews and information. On [DATE] at 3:38p.m., an IJ was identified and the facility Administrator was notified. The IJ was removed on [DATE]. The facility submitted and implemented the following plan to remove the IJ on [DATE]. Plan to remove immediacy: I. The Administrator and Director of Nursing were notified on [DATE] at approximately 4:15p.m. of an Immediate Jeopardy for neglect related to failure to conduct proper assessment after a fall. The following steps are the facility's plan to remove the Immediate Jeopardy. a) On [DATE], Nurse Managers, Licensed Nurses, and the Director of Nursing immediately assessed current residents (99 residents) in the facility to ensure any changes in condition were identified, physician notification has occurred, interventions implemented, documentation in the medical record reflective of the residents status and the identified change in condition were care planned completed [DATE]. b.) On [DATE], Nurse Managers, Licensed Nurses, and the Director of nursing immediately assessed (99 residents) in the facility to reflect fall risk status of resident's current condition completed [DATE]. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Interdisciplinary Team to review and discuss the plan of action of properly assessing a resident after a fall with injury and the plan for physician notification if the primary physician does not return a call. The nursing staff will notify the primary physician and if a call is not returned within 30 minutes, the Medical Director is to be called; if Medical Director does not return the call within 15 minutes the resident is to be sent to ER. In the event that the injury requires immediate medical attention the resident will be transported to the emergency room . This is documented on Quality Assurance Performance Improvement Agenda form. Completed [DATE]. The Director of Nursing and Nurse Managers immediately began re-educating staff (RN/LVN/C.N.A./MA) on the following: ([DATE]) On recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the resident condition some of the symptoms may include: Recognizing changes in mental status, functional status of a resident, respiratory, GI/abdomen, GU/urine. Head injury/Neuro checks- a neurological check form will be completed for any fall involving the head or any un-witnessed fall. If there are any changes in the neurological assessment: opening eyes and changes in pupil size or reaction, motor and verbal response changes from baseline to next assessment, or changes in the overall total Glasgow Score from previous perimeter the nurse will call the physician for further recommendations. Unresponsive Resident-if a resident is found unresponsive after assessment nurse is to call 911. Assessing the resident by completion of the Interact SBAR (Assessing the resident and documenting in the clinical records of the resident; for example, a significant change of condition is a decline or improvement of the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions and also impacts more than one area of the resident's health status requires interdisciplinary review and revision to the care plan and is ultimately based on the judgment of the clinical staff and guidelines of the resident assessment instrument)-documentation in the residents medical record (documenting residents condition, any changes, when a resident admits, or discharges from the facility) for example, the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status notification to the attending physicians/responsible party. The nursing staff will notify the primary physician and if a call is not returned within 30 minutes, the Medical Director is to be called; if Medical Director does not return the call within 15 minutes the resident is to be sent to ER. In the event that the injury requires immediate medical attention the resident will be transported to the emergency room . Care planning the change in condition (Care planning any change with a resident) Utilization of the Interact Stop and Watch tool -these items were in-serviced CNAs/MAs will immediately notify the charge nurse if any of the above occur. Fall education started on [DATE] by Director of Staff Development on 2 - 10 shift that included License nurses re-educated to the policy and procedures of the 24 hour report. Utilization of the 24 hour report to report changes in condition. The following in-services started on [DATE] by the Director of Social Services on ,[DATE] shift. Abuse/neglect regarding assessing and documenting change in condition. Education started on [DATE] ,[DATE] shifts. Education will continue each shift until 100%of the Nursing Staff (RN/LVN/MA/CNA) is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Director of Staff development or designee will include in-services with the orientation process. No staff will be allowed to provide patient care until they have been trained. The DON, Nurse Managers/Designee will round daily starting [DATE] and will continue daily to ensure no changes in condition. To monitor the Director of Nursing/ designee clinical rounds to identify changes in condition. Review notifications of physician ' s clinical meeting. Review SEAR in clinical meetings. Review Incidents/Accidents in Clinical meeting. Weekend supervisor will conduct clinical meeting. The surveyor monitored the plan to remove the immediate jeopardy on [DATE] and [DATE] as follows: Monitoring began on [DATE]. LVNs and RNs were interviewed on two shifts on physician notification, and proper assessment following falls and changes in condition. Record review of the facility In-Services revealed: [DATE] - twelve staff members were trained on proper way of notifying/consulting the resident's physician, and facility's medical director and to call 911 if no response was received from the physicians; and staff were to notify the DON or designee of any identified changes in condition, falls with injury and the proper assessment, documentation and analysis of neurological assessment following falls with head injuries. 14 staff members were trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, and Recommendation) tool. [DATE] - more than 50% of the facility's nursing staff members were trained on parameters of when to notify facility administration on any changes in residents. Interview on [DATE] at 10:00 a.m., the DON stated she completed chart audits, evaluated all residents in the facility for changes in condition, falls with or without injuries and found that staff were implementing the appropriate and current plan. Record review of in-service, dated [DATE], the DON and ADONs trained all staff scheduled to work [DATE], [DATE], and [DATE]. Interviews with 6 MAs, and 5 CNAs on [DATE] between 4:25 p.m. and 5:15 p.m., revealed they received training on how to identify abuse and neglect, when to notify a charge nurse of anything usual noted about any patient, and if the nurses did not respond immediately to call the DON or the administrator. Record review of the in-service forms provided by the Administrator dated [DATE], [DATE] and [DATE] revealed on-going in-services concerning resident assessments, physicians' consultation, and post fall with head injury interventions. Interview on [DATE] at 9:30a.m., the Administrator stated she would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. She further reported she would continue to monitor the facility approved plan of removal to ensure the safety of the residents. She said she was monitoring and evaluating all fall incidents to ensure staff were implementing the plan. She also stated the facility's medical director had contacted and communicated with all other doctors to ensure they understood that he would be called for intervention should they not promptly respond to facility's calls. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 9:39a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following falls with injuries and following changes in condition. The Administrator reported 17 residents in the facility at high risk for falls.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent the development of and promote the healing of pressure sores for three of six residents (Residents #3, #77 and #53 ) who were reviewed for pressure sore prevention. The facility failed to provide proper wound care to promote healing to a sacral pressure sore on Resident # 3 . The resident also developed five new sores to his left ear, bilateral medial knees, right upper back and right ischium in July 2015. The facility failed to provide proper position and preventive measures to prevent the decline in Resident #77's pressure sores. The resident was assessed with [REDACTED]. Two weeks later the pressure sores had declined to one stage IV, one stage III, two Stage II and one unstageable wound. One of the stage II sores being only one day in duration. The facility failed to provide care to prevent infection and the worsening of a pressure sore for Resident #53 . This failure affected three residents who had worsening of existing pressure sores and the development of new sores and placed four other residents with pressure sores at risk of worsening of the sores, decrease of new skin growth, infections and pain. Findings included: Resident # 3 Record review of Resident # 3 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had the following diagnoses; pressure ulcer stage IV, [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION], acute but ill-defined [MEDICAL CONDITION] disease, [MEDICAL CONDITION], gastrostomy, acute [MEDICAL CONDITIONS], diabetes mellitus, [MEDICAL CONDITION], hypopotassemia, Parkinson disease, pain, dementia, hypertension, urinary tract infection, and open wound. Continued review of the face sheet [DIAGNOSES REDACTED]. Record review of Resident #3 ' s MDS dated [DATE] revealed the resident ' s cognition skills for daily decision making was moderately impaired. The resident had bilateral upper and lower limitations in range of motion. Continued review revealed the resident was always incontinent of urine and stool. The MDS revealed the resident was totally dependent on two or more staff for bed mobility, transfers, toilet use and he was totally dependent on one staff for personal hygiene. The MDS revealed the resident was identified as not a risk for pressure ulcer development and did not have any pressure ulcers at the time of the assessment. Record review of the Wound Care Specialist Evaluation dated 5/15/15 revealed .Resident #3 was being followed for a sacrum wound stage IV of at least 224 days duration, etiology was pressure. Record review of Resident #3 ' s MDS dated [DATE] revealed the resident ' s cognition skills for daily decision making was severely impaired. The resident had bilateral upper and lower limitations in range of motion. Continued review revealed the resident had an indwelling catheter and was always incontinent of stool. The MDS revealed the resident was totally dependent on two or more staff for bed mobility, transfers, toilet use and he was totally dependent on one staff for personal hygiene. Continued review of the MDS revealed the resident was identified as a risk for pressure ulcer development and had three stage II, one stage IV which measured 5.0 cm x 6.0 cm x 2.0 cm and one unstageable pressure ulcer at the time of assessment. Record review of Resident #3's care plan originally dated 1/14/15 updated 5/27/2015 with a target date on the goal for 8/27/2015 revealed the resident had a low Braden scale , which meant he was a high risk for developing pressure sores. The resident was incontinent and had decreased mobility which put him at risk for pressure sores. The pressure sores identified on the care plan were: stage IV sacrum, escar tissue to left lateral heel, stage IIs to the right and left medial knee with the date initiated of 12/27/2015 for all the sores. The interventions were for staff to: turn and reposition, treatments as ordered, gastrostomy tube feeding and H2O flush as ordered. The goal was to decrease the size of the pressure ulcers. Record review of the facility laboratory results dated [DATE] revealed the following sacral wound culture results: Escherichia coli, Extended-Spectrum Beta-Lactamase (ESBL),Proteus mirabilis and [MEDICAL CONDITION] (MRSA). Observation on 7/13/15 at 8:51 A.M. during initial tour revealed Resident #3 in bed on on an air mattress positioned on his back with the head of his bed elevated. A tube feeding of [MEDICATION NAME] 1.5 was hanging at his bedside on a pump but turned off. The resident was nonverbal but his eyes were opened but did not track movement. Oxygen was being administered by [MEDICAL CONDITION] collar. Continued observation revealed his abdomen was round and distended. The resident did not have a pillow between his knees. Observation at this time revealed a sign on the wall at the top of the bed and next to the bed which revealed keep resident on side only. At this time the resident was repositioned to his left side by facility staff. The resident had been incontinent of a large diarrhea stool. The sacral wound dressing had dried stool on it and under it. The side of the dressing was loose and lifting off. Observations on the following dates and times revealed the resident was on his back with no pillow between his knees: 7/13/15 at 3:00 P.M. and 4:00 P.M. 7/14/15 at 7:43 A.M.,1:11 P.M., 2:50 P.M., 3:50 P.M., 6:45 P.M. and 7:40 P.M. 7/15/15 at 7:55 A.M. and 9:20 A.M. Observation on 7/15/15 at 9:20 A.M. during incontinent care revealed Resident #3 was turned on his right side. The resident had been incontinent of a large diarrhea stool. The large sacral wound dressing has hanging loosely and was not intact over the wound. CNA #31 cleaned the stool away from the anal area and buttocks into the wound. During the incontinent care observation CNA #16 and CNA #31 positioned Resident #3 on his back on the brief with a large amount of loose stool under the resident and no protective wound dressing. Both CNAs left the room to get the wound care nurse. Approximately 9:55 A.M. the CNAs returned to continue care. Further observation on 7/15/15 at 10:00 A.M. LVN# 7 cleaned the sacral wound with a gauze moistened with normal saline. The LVN cleaned inside the wound. He folded the same gauze and cleaned on the skin around the outside of the wound and went back across the wound using the same gauze. Continued observation on 7/15/15 at 10:00 A.M. revealed Resident #3 had an open pressure wound to his left ear which was bleeding on his linen. The resident had an open wound to his right ischium, his right upper back, inside his right knee and on the right side his left knee. Observation on 7/15/15 at 10:00 A.M. of Resident #3's sacral wound revealed it measured 7 cm x 6 cm x 2 cm with 2.5 cm undermining at 3 o ' clock. Right knee measured 2 cm x 5 cm x 1 cm with blistered areas on surface. Interview on 7/15/15 at 10:15 A.M. LVN #7 stated today was the first time he saw the wound on the right ischium right back. Record review of the facility weekly pressure ulcer progress report dated 7/15/15 revealed the sacrum wound measured 6.0 cm x 5.0 cm x 2.0 cm and was identified on 5/12/15. Record review of the facility weekly pressure ulcer progress report dated 7/15/15 revealed the left ear wound measured 0.5 cm x 0.3 cm x 0.1 cm and was identified on 7/3/15. Record review of the facility weekly pressure ulcer progress report dated 7/15/15 revealed the right medial knee wound measured 2.5 cm x 2.0 cm x 0.1 cm and was identified on 7/3/15. Record review of the facility weekly pressure ulcer progress report dated 7/15/15 revealed the left medial knee measured 3.0 cm x 2.0 cm x 0.1 cm and was identified on 7/9/15. Record review of the facility Non-Pressure skin condition record dated 7/15/15 revealed the right ischium wound measured 2.0 cm x 1.0 cm x 0.1 cm and was first observed on 7/15/15. Record review of the facility Non-Pressure skin condition record dated 7/15/15 revealed the right side of back wound measured 2.0 cm x 4.0 cm x 0.1 cm and was first observed on 7/15/15. Interview on 7/16/15 at 8:35 A.M. LVN #7 stated he had been doing wound care about five years. He stated he did not have formal training but he attended seminars and followed the wound care physician. He stated normally he would try not to cross contaminate the wound. He continued and stated pressure ulcer prevention was done by turning and repositioning. He stated residents were assessed by the Braden Scale. When someone had a stage III or bigger they would be provided an air mattress. He continued and stated the normal mattress were not pressure relieving mattresses. LVN#7 continued and stated he documented the ischium and back wound on the non-pressure record because they were not on pressure points and were from shearing or friction. Resident #77 Record review of the Admission Record, revealed Resident #77 was a [AGE] year old male admitted to the facility on [DATE]. Resident #77 was diagnosed with [REDACTED]. Record Review of Resident #77 ' s Care Plan created 11/5/14 revised to show a target dated of 10/11/2015 revealed I have a pressure ulcer to my medial right knee. Interventions included for staff to follow the facility policies/procedures for the prevention/treatment of [REDACTED]. Record review of the facility policy Pressure Ulcer Prevention/Treatmentdated 2001 and revised October 2010 revealed skin to skin contact needs to be avoided by placement of pillows, folded sheets or clothing.portect bony prominences as needed.use pillows or wedges to keep bony prominences such as knees or ankles from touching each other. Record Review of Resident #77 ' s MDS assessment dated [DATE] revealed Resident #77 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcer(s) at Stage 1 or higher, one Stage III and one deep tissue unstageable wound. Record Review of Resident #77 ' s Weekly Pressure Ulcer Progress Report completed by LVN # 7 revealed a right medial knee wound identified on 4/10/15. The resident's wound progress reports continued weekly ending on 6/5/15 with no mention of any progress of the wound healing. Record Review of Resident #77 ' s Non-Pressure Skin Condition Record completed by LVN #7 dated 5/30/15 revealed Ruptured blisters to medial right knee resolving. The preexisting wound remains open. Record review of Resident #77 ' s Physical Therapy (PT) Plan of Care dated 6/18/2015 revealed Skilled patient to address bilateral lower extremity contractures, positioning and bed mobility to prevent future contractures and decubitus ulcers. Without therapy patient at risk for more contractures and decubitus ulcers. Record review of Resident #77 ' s Treatment order dated 6/19/15 revealed Clean right medial knee wound with normal saline, pat dry apply calcium alginate, cover with dry dressing one time a day every Monday, Wednesday, Friday. Record review of Resident #77 ' s MDS assessment dated [DATE] revealed Resident #77 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcer(s) at Stage 1 or higher, three Stage 2 pressure ulcers, one pressure ulcer unstageable due to slough and/or eschar, and one deep tissue unstageable wound. Record Review of Resident #77 ' s Weekly Pressure Ulcer Progress Report completed by LVN # 7 revealed right medial knee DTI (deep tissue injury) wound identified on 7/3/15 and resolved on 7/9/15. Record Review of Resident #77 ' s Wound Care Specialist Evaluation dated 7/9/15, revealed 6 wounds. Specialist states Left Dorsalis Pedis unable to detect, right Dorsalis Pedis and Posterior Tibial unable to detect. Right medial knee wound Stage 4, duration is greater than 85 days. Right hip Stage 3 wound, duration greater than 20 days. Left heel Stage 2 wound, duration greater than 20 days. Right medial knee unstageable DTI (deep tissure injury) resolved on 7/9/15, duration greater than 7 days. Left lateral ankle unstageable due to necrosis, duration greater than 1 day, note: recurrence at previously healed site. Right distal hip Stage 2 wound, duration less than 1 day. Observation on 7/13/15 at 8:30 am revealed Resident #77 lying on an air mattress with eyes open, unable to communicate verbally, receiving nutrition via a feeding tube and pump. Resident #77 had contractures to the upper and lower extremities, wound dressings noted to right hip, right medial knee, left heel and right heel. Resident had improperly used positioning devices in bed. Pillows were in the bed but not positioned between knees and contracted areas to prevent pressure on identified wound and pressure areas. Interview on 7/13/15 at 8:30 am with RN #2 stated Resident #77 had only one sacral wound of unknown stage. Record review of Resident #77 ' s Treatment Orders dated 7/14/15 revealed Clean left heel wound with normal saline, pat dry apply calcium alginate, cover with dry dressing one time a day. Clean right hip wound with normal saline, pat dry apply calcium alginate, cover with dry dressing one time a day. Swab right lateral ankle DTI with skin prep LOTA (leave open to air) one time a day. Observation on 7/15/15 at 3:15 pm with LVN #7 present revealed Resident #77 had wound dressings to right lateral ankle, left medial heel, right medial knee, and right hip. Resident #77 had a large recently healed uncovered wound to the sacrum and multiple healed uncovered wounds to the lower extremities. When asked to remove Resident #77 ' s right medial knee wound dressing, LVN #7 stated These blisters are a mystery, they just pop up. Right medial knee wound had two separate open spots side by side, red flesh was exposed with surrounding larger brown skin. Resident #77 positioning devices (pillows) in the bed were not placed properly to relieve skin to skin contact. Resident # 53 Record review on 7/14/2015 at 10:00 AM of Resident #53 face sheet revealed a [AGE] year old male admitted to the facility on [DATE] with the following diagnosis; [MEDICAL CONDITION] & Recurrent [MEDICAL CONDITION], Autistic Disorder, Irritable Bowel Syndrome, and MI. Record review of Resident #53's care plan dated 3/23/2015 with a target date of 8/25/2015 revealed a stage IV pressure ulcer on the sacrum. Goal was to show signs of healing and remain free from infection. Interventions included: treatments as ordered, monitor for infections, turn and reposition, and notify nurse of any new areas of skin breakdown. Record review of Resident #53 Minimum Data Set (MDS) Admission assessment dated [DATE] revealed the Resident had (1) Stage III pressure ulcer, on admission. The pressure ulcer was documented as being 2 cm. (length) x 1.5 cm. (width) x 0.1 cm. (depth). Record review of Resident #53's care plan dated 4/22/2015 that was also marked resolved 6/03/2015 revealed the resident required transmission-based precautions and /or strict isolation [MEDICAL CONDITION] in the sacral wound. Interventions that were also marked resolved on 6/03/2015 revealed Monitor skin and sacral wound each shift. Monitor vital signs each shift. Administer medications and treatments as ordered. Report any change in the wound to the physician. Record review revealed for Resident #53 there were no other care plans to address the pressure ulcer dated after the resolved care plan dated 6/03/2015. Record review of Resident #53's Minimum Data Set (MDS) Quarterly review assessment dated [DATE] revealed the Resident Stage III pressure ulcer had progressed to a Stage IV pressure ulcer. The pressure ulcer was documented as being 1 cm. (length) x 1 cm. (width) x 0.5 cm. (depth) Observation on 7/14/2015 at 8:30 AM during observation of Resident #53 wound care revealed a sacral wound 1.0 cm round x 1.0 cm in depth. Interview on 7/16/2015 at 1:30 PM LVN#7 stated Resident #53 had been admitted to the facility with a Stage III pressure ulcer. He went on to state that the pressure ulcer had progressed to a Stage IV. Record review of the facility policy Pressure Ulcer Prevention/Treatment dated 2001 and revised October 2010 revealed .The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and prevention of additional pressure ulcers .The pressure ulcer treatment program should focus on the following strategies: assessing the resident and the pressure ulcer, managing the tissue loads, pressure ulcer care, managing bacterial colonization and infection . skin to skin contact needs to be avoided by placement of pillows, folded sheets or clothing.protect bony prominencesas needed.use pillows or wedges to keep bony prominences such as knees or ankles from touching each other. Facility CMS form 672 listed 7 residents had pressure ulcer. 6 residents were identified as having pressure ulcers on admission.

Based on observation, interview, and record review the facility failed to provide six of eight residents (Residents #3, #13, #77 #84 #97, and #78) reviewed for limited range of motion (ROM), appropriate treatment and services to prevent a decline in range of motion. The facility failed to provide Resident #3 repositioning and positioning devices to prevent worsening of his limitations and contractures to his left wrist, left elbow and bilateral foot drop. The facility failed to provide Resident #13 hand rolls/carrot to prevent worsening of his contractures to his left hand and upper extremity. The facility failed to provide Resident #77 positioning devices to prevent the development of contractures of the lower extremities. Resident 77 was assessed on 4/3/15 with no upper or lower extremities limitations. On 6/18/2015 she was assessed with [REDACTED]. The facility failed to provide Resident #84's positioning devices and hand rolls for her limitations and contractures to her right hand, her right leg and her left foot that had minimal flexion. The facility failed to identify and provide Resident #97 positioning devices for her contractures and dosiflexion (flexion of the feet upwards) condition. The facility failed to provide Resident #78 appropriate exercises and services to prevent the worsening of the dorsiflexion (flexion of the foot upwards) of the ankles. This deficient practice affected six residents who developed or had a worsening of contractures due to lack of identification or treatment and placed 39 residents with contractures at risk of developing new or worsening of their existing contractures. Findings include: Resident #3 Record review of Resident # 3 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had the following diagnoses; pressure ulcer stage IV, [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION], pneumonia organism unspecified, unspecified tear film insufficiency, acute but ill-defined [MEDICAL CONDITION] disease, [MEDICAL CONDITION], gastrostomy, acute [MEDICAL CONDITION], disturbance of salivary secretion, shortness of breath, [MEDICAL CONDITION], diabetes mellitus, nausea and vomiting, [MEDICAL CONDITIONS], hypopotassemia, chronic [MEDICAL CONDITIONS], Parkinson disease, pain, dementia, hypertension, [MEDICAL CONDITION] reflux, constipation, urinary tract infection, open wound, hypertrophy of prostate, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Record review of Resident #3 ' s MDS dated [DATE] revealed the resident ' s his cognition skills for daily decision making was moderately impaired. The resident had bilateral upper and lower limitations in range of motion. Continued review revealed the resident was always incontinent of urine and stool. The MDS revealed the resident was totally dependent on two or more staff for bed mobility, transfers, toilet use and he was totally dependent on one staff for personal hygiene. Record review of Resident #3 ' s MDS dated [DATE] revealed the resident ' s cognition skills for daily decision making was severely impaired. The resident had bilateral upper and lower limitations in range of motion. The MDS revealed the resident was totally dependent on two or more staff for bed mobility, transfers, toilet use and he was totally dependent on one staff for personal hygiene. Record review of Resident #3's care plan dated 7/2/13 with a target date for the goal being 8/27/2015 revealed the resident had an ADL deficit due to a [MEDICAL CONDITION]. One of the goals was listed for restorative to maintain or improve bilateral lower extremity and bed mobility. It also revealed the usage of handrolls. No interventions were listed on how goal was to be achieved. Record review of the form titled Nursing Rehab/Restorative Plan of Care for Resident #3 revealed it was undated. The Goals/ Objectives were : #1. To maintain bilateral upper extremity range of motion and # 2. to minimize risk of developing further joint contractures and potential for skin breakdown. The form did not have any documentation of dates, times and minutes spent. Observation on 7/13/15 at 8:51 A.M. during initial tour revealed Resident #3 in bed on his back with the head of his bed elevated. A tube feeding [MEDICATION NAME] 1.5 was hanging at his bedside on a pump but turned off. The resident was nonverbal but his eyes were opened but did not track movement. Oxygen was being administered by [MEDICAL CONDITION] collar. Continued observation revealed his abdomen was round and distended. The resident ' s left wrist and left elbow were contracted and resting on his chest. The resident had bilateral foot drop. No splints, rolls or supports were observed. Observations on the following dates and times revealed the resident was on his back with no splints, rolls or support to his left wrist, elbow and bilateral feet: 7/13/15 at 3:00 P.M. and 4:00 P.M. 7/14/15 at 7:43 A.M.,1:11 P.M., 2:50 P.M., 3:50 P.M., 6:45 P.M. and 7:40 P.M. 7/15/15 at 7:55 A.M. , 9:20 A.M. and 12:30 P.M. Observation and interview on 7/15/15 at 12:30 P.M. with the Therapy Director and LVN #18 revealed Resident #3 in bed on his back with the head of his bed elevated. The resident ' s left upper extremity was on his chest. The Therapy Director attempted to do range of motion to the resident's left elbow and left wrist. Interview at this time the Therapy Director stated he had limitations to his left upper extremities. Continued observation revealed bilateral foot drop. The Therapy Director attempted to do range of motion. Interview at this time she stated he had limitations to his ankles. She continued the interview and stated he did have contractures. Resident #13 Record review of Resident # 13 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had the following diagnoses; pneumonia, [MEDICAL CONDITION], lack of coordination, generalized muscle weakness, symbolic dysfunction, [MEDICAL CONDITION], abnormal involuntary movements, [MEDICAL CONDITION], acute kidney failure, [MEDICAL CONDITION], hypertrophy of prostate, dermatophytosis, allergy, [MEDICAL CONDITIONS], hypopotassemia, tear film insufficiency, hypertension, embolism and [MEDICAL CONDITION], constipation, memory loss, history of falls and aftercare for healing traumatic [MEDICAL CONDITION]. Record review of Resident #13 ' s MDS dated [DATE] revealed the resident ' s BIMS was 14 which indicated his cognition was intact. The resident had one side upper and lower limitations in range of motion. Continued review revealed the resident was frequently incontinent of urine and stool. Record review of Resident #13 ' s physician's order [REDACTED]. Observation on 7/13/15 at 9:55 A.M. revealed Resident #13 sitting in the chair at the bedside. He was alert and oriented. The resident had a contracted elbow and hand on the left side. His left hand was tightly closed without a carrot, roll or towel. Observation on 7/14/15 at 5:50 P.M. revealed Resident #13 in his motorized wheelchair in the hall. The resident ' s left side was contracted at his elbow and hand. There was no carrot, roll or splint on his elbow or hand. Observation and interview on 7/15/15 at approximately 12:40 P.M. revealed Resident #13 sitting in the chair in his room. He was alert and oriented and did not have any splint, roll or carrot for his left upper extremity contractures. Observation at this time the Therapy Director asked the resident to open his left elbow which he was able to partially open. She than asked the resident to open his left hand. The resident attempted to open his fist by using his right hand but only opened his index finger to the left hand. When he was not able to open his hand the Therapy Director attempted to open the fingers to his left hand. The resident grimaced and moaned. She attempted a second time and again he grimaced and moaned. LVN#18, who was present during the observation, said to stop. The Therapy Director stated the resident was having spasms. She stated she knew the resident could open his hand because she had seen it opened before. Interview on 7/15/15 at 2:00 P.M. Resident #13 stated it was very difficult for him to open his hand at all. He stated he never had anything like a carrot or towel in his hand. Resident #77 Record Review of the Admission Record, revealed Resident #77 was a [AGE] year old male admitted on [DATE]. Resident #77 was diagnosed with [REDACTED]. Record Review of Resident #77 ' s Care Plan dated 9/22/14 with a target date of 10/11/2015 revealed I have an ADL selfcare performance deficit related to generalized weakness. Focus goal includes Restorative: Patient will maintain or improve upper and lower extremity range of motion and grooming while out of bed sitting in gerichair; as tolerated. Care Plan does not have interventions in place to prevent new or worsening contractures. Record Review of Resident #77 ' s MDS assessment dated [DATE] revealed Resident #77 was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, hygiene, and bathing and had no impairment on either side of her upper or lower extremities. Record Review of Resident #77 ' s Occupational Therapy (OT) Plan of Care dated 6/18/2015 revealed Therapy necessary for sitting tolerance and postural alignment in gerichair for contracture management. Without therapy patient at risk for skin breakdown and further joint contracture. Limited active and passive range of motion in all upper extremity joints bilaterally, flexor contracture noted in both knees. Record Review of Resident #77 ' s Physical Therapy (PT) Plan of Care dated 6/18/2015 revealed Skilled patient to address bilateral lower extremity contractures, positioning and bed mobility to prevent future contractures and decubitus ulcers. Without therapy patient at risk for more contractures and decubitus ulcers. Record Review of Resident #77 ' s MDS assessment dated [DATE] revealed Resident #77 was totally dependent on staff for transfers, dressing, and eating and had impairment on both sides of his upper and lower extremities. Interview on 7/13/15 at 8:30 am with RN #2 revealed Resident #77 required total assistance with ADLs and had no contractures or splints. Observation on 7/13/15 at 8:31 am revealed Resident #77 lying on an air mattress with eyes open, unable to communicate verbally, receiving nutrition via a feeding tube and pump. Resident #77 had contractures to the upper and lower extremities, wound dressing on the right hip, right medial knee, left heel and right heel. Pillows were in the bed but not positioned between knees and contracted areas to prevent new and worsened contractures. Observation on 7/14/15 at 8:05 am revealed Resident #77 uncovered, lying in bed, legs were drawn up. There was a pillow between the two knees only with no positioning device to extend the legs. Interview on 7/14/15 at 8:07 am revealed RN #2 was unaware if Resident #77 ' s legs were contracted and stated I can try to stretch them out for you if you want me to. Interview on 7/15/15 at 1:25 pm with LVN #17 and PTA #1 revealed Resident #77 was on the therapy caseload. PTA #1 stated His right arm does not stretch out at the elbow joint. The pillows under his left calf and right shin and foot are for positioning, comfort, and to prevent his legs from flexing more. PTA #1 asked Resident #77 to demonstrate range of motion in both knees. The resident was unable to demonstrate movement of the legs. Resident #84 Record Review of the Admission Record, revealed Resident #84 was a [AGE] year old female admitted on [DATE] diagnosed with [REDACTED]. Record Review of Resident #84 ' s MDS assessment dated [DATE] revealed Resident #84 was totally dependent on staff for transfers, locomotion, dressing, eating, hygiene, and bathing and had impairment on both sides of her upper and lower extremities. Record Review of Resident #84 ' s Weekly Pressure Ulcer Progress Report completed by LVN #7 dated 4/9/15 revealed Right heel 5 x 2 unstageable purple wound caused by immobility. Record review of Resident #84 ' s MDS assessment dated [DATE] revealed Resident #84 was totally dependent on staff for transfers, locomotion, dressing, eating, toileting, hygiene, and bathing and had impairment on both sides of her upper and lower extremities. A request was made for Resident #84's care plan but none was provided for review . Record Review of Resident #84 ' s Physician ' s Telephone Order dated 7/11/2015 revealed Offload left heel on pillow, no heel protector. Record Review of Resident #84 ' s medical record revealed no physician's order [REDACTED]. Interview on 7/13/15 at 9:03 am with RN #2 revealed Resident #84 had resided in the facility for 2 years. The resident required total assistance with ADLs, and had no contractures or splints. Observation on 7/13/15 at 9:05 am revealed Resident #84 lying on a standard mattress with eyes open, unable to communicate verbally. The resident was receiving nutrition via a feeding tube and pump. Resident #84 had contractures to the upper and lower extremities and a wound dressing was noted to the resident ' s right heel. Resident #84 had improperly used positioning devices in the bed with her. Pillows were in the bed but not positioned between or behind knees and other contracted areas to prevent new or further decline of contractures. Resident #84 was wearing thick red non-skid socks on both feet with a heel protector on the left foot . Neither foot was offloaded. Resident #84 had a carrot in her left hand only. The resident ' s right hand appeared contracted without the use of a carrot, hand roll or splint. RN #2 attempted to demonstrate Resident #84 ' s right leg range of motion. The Resident grimaced when nurse attempted to stretch leg out and the demonstration was stopped. Observation on 7/14/15 at 7:05 am revealed Resident #84 lying in bed with heel protectors to both feet. There was no offloading to either foot. The resident ' s right leg remained folded at the knee and drawn upwards towards the body without any positioning pillows to prevent worsening of the contracture. Interview on 7/15/15 at 1:52 pm with LVN #17 and PTA #1 revealed Resident #84 was currently on a restorative nursing plan to include range of motion exercises to her bilateral upper extremities and right knee. She has carrots for both of her hands but the right one always ends up in the bed. PTA #1 asked Resident #84 to demonstrate range of motion in her left foot without any movement provided from the resident. PTA #1 stated Her left foot has very little flexion. It is almost frozen. A request was made for the restorative nursing care plan for Resident #84 but none was provided for review after three requests. Resident #97 Record Review of the Admission Record, revealed Resident #97 was a [AGE] year old female admitted on [DATE]. Resident #97 was diagnosed with [REDACTED]. Record Review of Resident #97 ' s Care Plan dated 12/11/2014 target date 10/15/2015 revealed I have limited physical mobility and contracture to right knee and right elbow. I have an ADL selfcare performance deficit, interventions include Nursing Rehab range of motion bilateral lower extremities up to 6-7 times a week as tolerated, up to 15 reps. Record Review of Resident #97 ' s MDS assessment dated [DATE] revealed Resident #97 was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, hygiene, and bathing and had no impairment on either side of her upper or lower extremities. Record Review of Resident #97 ' s Physical Therapy (PT) Progress and Discharge Summary dated 3/20/2015 revealed Patient has plateaued in her progress, unable to stand and complete transfers with total assistance from bed to wheelchair using lateral pivot transfers. Refer patient to Restorative Nursing for lower extremity range of motion exercises. Record Review of Resident #97 ' s Physical Therapy Plan of Care (Evaluation Only) dated 4/28/2015 revealed Skilled PT evaluation was completed however patient has no functional goals that she would like to work on. Without therapy patient will be placed on an RNA (restorative nurse aide) program. Patient does not have wounds or contractures at the time of evaluation. Record Review of Resident #97 ' s current Restorative Nursing Plan , not dated with a target date of 10/15/2015 revealed Range of motion bilateral lower extremities up to 6-7 times a week as tolerated, up to 15 reps. Bed mobility activities up to 6-7 times a week, patient will practice rolling left and right and patient will practice going from lying down to sitting and sitting up to lying down with Max assistance. Restorative Nursing Plan fails to address Resident #97 ' s right elbow contracture or dorsiflexion of the feet. Interview on 7/13/15 at 10:15 am with RN #2 revealed Resident #97 required total assistance with ADLs and had no contractures or splints. Observation on 7/13/15 at 10:15 am revealed Resident #97 lying in bed with eyes open, unable to communicate verbally, receiving nutrition via a feeding tube and pump. Resident #97 had contractures to the upper and lower extremities. No pillows or positioning devices were in the bed for upper or lower extremities to prevent new or further decline of contractures. Resident was not wearing any foot devices. Interview on 7/15/15 at 1:42 pm with LVN #17 and PTA #1 revealed Resident #97 is currently on a restorative nursing plan without the use of splints or hand rolls. LVN #17 stated She usually has pillows for positioning and comfort but I don ' t see them. PTA #1 asked Resident #97 to demonstrate range of motion in both feet, PTA #1 stated Her feet appear to be stuck in dorsiflexion. Interview on 7/16/15 at 11:35 am with RNA #3 revealed We used to transfer her to the chair for 2 hours but now we just sit her up for 10-15 minutes and do range of motion to her upper and lower extremities. She does not have any contractures and she has never had splints that I know of. Resident #78 Record Review of the Admission Record, revealed Resident #78 was a [AGE] year old female admitted on [DATE]. Resident #78 was diagnosed with [REDACTED]. Record Review of Resident #78 ' s MDS assessment dated [DATE] revealed Resident #78 was totally dependent on staff for bed mobility, transfers, locomotion, dressing, toileting, hygiene, and bathing and had no impairment on either side of her upper or lower extremities. Record Review of Resident #78 ' s Care Plan dated 12/12/14 revealed the resident had limited physical mobility and contracture to left arm related to [MEDICAL CONDITION]. There was no documentation concerning dorsiflexion of the resident's ankles. Further review revealed one of the interventions revealed Rehab nursing. Record Review of Resident #78 ' s current Restorative Nursing Plan 1/11/12 with a target date of 8/7/2015 revealed Nursing Rehab bilateral upper extremities range of motion up to 6-7 times a week as tolerated, up to 15 reps. Restorative Nursing Plan failed to address Resident #78 ' s dorsiflexion of the ankles. Record Review of Resident #78 ' s Physical Therapy (PT) Progress and Discharge Summary dated 7/6/2015 revealed Patient performed bilateral lower extremity active assistive range of motion and active range of motion as well as positioning, bed mobility, and transfers. The skilled training and education provided to the patient during therapy included positioning, bed mobility, contracture management which allowed transition of care from therapy to the RNA program. Patient with mild decrease gross motor control in left lower extremity, decreased range of motion in to dorsiflexion in bilateral ankles (dorsiflexion at -15 degrees bilaterally). Patient discharged from PT program to RNA program with RNA training. Interview on 7/13/15 at 8:35 am with RN #2 revealed Resident #78 required only limited assistance with ADLs and had no contractures or splints. Observation on 7/13/15 at 8:36 am revealed Resident #78 lying in bed with eyes open, able to verbally make needs known. Resident #78 had contractures to the upper and lower extremities. No pillows or positioning devices were in the bed for lower extremities to prevent further dorsiflexion of both ankles. Interview on 7/15/15 at 2:05 pm with LVN #17 and PTA #1 revealed Resident #78 was currently on a restorative nursing plan without the use of splints or hand rolls. PTA #1 stated She just came off of therapy and she was able to stand in therapy but would not be able to with her feet in this condition. We were working on her feet but they have gotten worse since I saw them last. She must not be doing her exercises. I am going to order her a pair of adjustable ankle splints to decrease the plantar flexion contractures. Frequent movement of the ankle joint up and down would result in not needing boots. PTA #1 asked Resident #78 to demonstrate range of motion in both feet with very limited success, PTA #1 stated Her feet are stuck in plantar dorsiflexion. Interview on 7/16/15 at 11:45 am with RNA #3 revealed We exercise her arms and try to sit her up but she often refuses. We bend her knees, exercise her ankles and toes. RNA #3 demonstrated the exercise to ankles and actually rolled ankle joint side to side, not up and down like PTA #1 had stated was needed. RNA #3 stated She does not have any contractures and she has never worn splints. Interview on 7/16/2015 at 5:00 P.M. the Administrator stated the facility did not have a policy on contracture management when one was requested. CMS 672 form revealed the facility had 45 residents with contractures.