Every finding on record at Wharton Nursing and Rehabilitation Center

Based on interviews, and record review, the facility failed to ensure dialysis residents received services consistent with standards of practice, comprehensive person-centered care plan, and the residents' goals and preferences for 1 out of 5 residents (Resident # 2) reviewed for quality of care. The facility failed to document Resident # 2 dialysis communication sheets of snack or food prior to dialysis treatment, list specific chair time of treatment and record all vitals once Resident #2 returned from treatment.The facility failed to document the monitoring of Resident # 2's daily nutrition intake for all meals, refusal of meals, as well as any meal substitutions or offers.This failure could place dialysis residents at risk of not receiving adequate care and services, lethargy, weakness, and dialysis residents with diabetes at risk for low blood sugar and or hypoglycemia resulting in decreased quality of life. Findings include: Resident # 2 Record review of Resident # 2;s admission record revealed a [AGE] year-old male with current admission date of 3/16/2026 and original admission date of 3/19/2024. Diagnoses were End-Stage Renal Disease (Stage 5 chronic kidney disease, occurs when the kidneys lose 85% to 90% of their function), Dependence on Renal Dialysis (is a life-sustaining treatment for end-stage renal disease (ESRD) when kidneys lose 85-90% of their function), Moderate Protein-Calorie Malnutrition (a condition where inadequate intake of food-specifically macronutrients like protein and calories-leads to physical decline), Type 2 Diabetes Mellitus with Hyperglycemia (occurring when the body cannot effectively use insulin (insulin resistance) or produce enough of it). Record review of Resident #2's Quarterly MDS dated [DATE] had a BIMS score of 9 indicating resident was able to communicate needs and recall information and treatments included Dialysis. Record review of Resident # 2's Care Plan last reviewed on 4/9/2026 indicated Resident # 2 required dialysis related to CKD- chronic kidney disease (general term for gradual, long-term kidney damage). Intervention included encourage dialysis treatment Monday, Wednesday, Friday, monitor vital signs every shift. Further review indicated a focus for Resident # 2 of unplanned/unexpected weight loss and is at risk for malnutrition. Staff interventions included alert dietician, give supplements as ordered, monitor and record food intake at each meal. Record review of Order Summary Report active order as of 5/28/2026 indicated Resident # 2 was to receive dietary supplement of Nepro (a specialized, calorically dense nutrition shake) three times a day for weight loss, decreased appetite order date 5/14/2026. Further review indicated a Renal - Liberalized diet order for high protein snack between meals order date 11/26/2025. Record review of Resident # 2 Dialysis Communication Forms dated 5/11/2026, 5/13/2026, 5/18/2026, 5/20/2026, 5/22/2026, 5/25/2026 indicated resident was sent to dialysis treatment from facility without a snack or food. Further review dated 5/11/2026, 5/13/2026, 5/18/2026, 5/20/2026,5/22/2026 did not indicate day and/or chair time for treatment or completion of assessment and observation post-dialysis on 5/20/2026 and 5/25/2026. Record review of Resident #2 Progress Notes from (4/27/2026 to 5/28/2026) dated 5/11/2026 and 5/12/2026 did not indicate Resident#2 was sent to dialysis with high calorie snack or received a meal prior to dialysis with medication due to missed scheduled time at the facility. * Further review of Progress note dated 5/15/2026 read in part Resident # 2 experienced a hypoglycemic episode (occurs when blood sugar drops below 70 mg/dL. Mild symptoms include shakiness, sweating, and confusion) due to refusal of meal tray after receiving scheduled insulin dosage. Progress note dated 5/15/2026 indicated Resident # 2 did not eat snack at 10:30am or lunch tray and meal replacement shake was given after hypoglycemic episode occurred. * Further review of Resident # 2 progress notes dated 5/11/2026, 5/13/2026, 5/18/2026, 5/20/2026,5/22/2026 did not indicate food intake recorded daily for each meal nor any refusals or substitutions. Interview on 5/28/2026 at 1:23pm with DON did not provide facility policy and procedures that included a policies for resident care, process or procedures regarding outside services for dialysis treatment. DON stated the facility does not have such policies. Record review of Dialysis Compliant Agreement contact indicated the facility retains primary responsibility for the development and implementation of the residents plan of care. The facility and provider will coordinate and develop plan of care that includes day, date and times of dialysis treatment, transportation, information transmitted to provider by facility, information transmitted to the facility by provider, and dialysis access orders. Contract also indicated facility must educate its staff's ability to perform interventions, if necessary, of monitoring nutritional needs. In an interview on 5/26/2026 at 2:18 p.m., Resident # 2 said he does not like the food the facility provides and will have family bring him food. He said the staff do not offer another meal or snack if he does not like the food. Resident # 2 said he does not get a meal or snack prior to dialysis treatment and will eat something when he returns. In an interview on 5/26/2026 at 2:18 p.m., Family Member said Resident # 2 often did not eat the facility meals and they will need to bring food for Resident # 2 to eat. FM * said when Resident #2 missed meals they were not notified by the facility so someone could bring something else for Resident # 2 to eat. FM* said there was concern about him eating every day and if the facility knows when he has missed meals. In an interview on 5/27/2026 at 10:28 a.m., Resident # 2 said he has refused meals due to meals being cold and staff not doing anything about that. He said he will eat personal snacks due to cold food and not being offered anything else or warming his food. In an interview on 5/27/2026 at 2:21 p.m., CNA A said she reviewed residents care plans on the computer and will ask the nurse about any resident care needs or changes. She said she was informed by transportation that Resident #2's dialysis schedule was changed from 5 am to later in the afternoon today. She said meals are provided depending on the time Resident # 2 goes to dialysis. CNA A said he got a shake in the morning as a meal replacement but did not believe he received any snacks or food prior to dialysis treatments. She said Resident # 2 will usually get a meal when he returns from dialysis. CNA A said dialysis residents need to eat prior to dialysis since the treatment takes a lot out of them and they are weak or tired. In an interview on 5/28/2026 at 12:18 p.m., the Dietitian said residents are to be offered another meal equal in nutrition or given a med pass/ shake. The Dietitian said residents on dialysis need to be sure they are receiving enough protein and should leave with a snack on the way to dialysis by nursing staff or dietary. She said the risk of not getting enough nutrition needed for their daily intake for dialysis residents are often tired and lethargic after treatment. She said his intake was usually 50% - 100% of meals according to nursing notes (progress note), although Resident # 2 reported to her that his meal intake varies due to refusal or wanting something else. The Dietitian said on 5/15/2026 there was a nursing note (progress note) of Resident # 2 refusal of meal and a change in condition. She said she was usually at the facility 3x monthly and would follow up with the residents after any concerns. The Dietitian did not have a recent documented note or recollection of Resident # 2's nutrition or meal refusals or lack of substitutions. Attempted interview on 5/28/2026 at 1:36 pm and 1:41 pm with Dialysis Treatment Center. Surveyor left call back information on voicemail. Interview on 5/28/2026 at 1:23 p.m., the ADON said she reviews resident care plans and assessments. The ADON said interventions in care plans indicate why and what was needed, the goals, follow up and what will be achieved by using these interventions. The ADON said the dialysis communication form was how the facility and provider communicate about the residents interventions to and from the facility and what day and time that resident has treatment. She said if Resident # 2 had not been eating prior to dialysis there would be a potential risk due to Resident # 2 being diabetic and potential for hypoglycemia. ADON said Resident # 2 should get a sack type lunch prior to leaving the facility for dialysis treatment. She said her expectation was that Resident # 2 would be given his meal later in the day or an alternative if he refused a meal. ADON said the facility was to call the resident's families when residents refused meals and see about an alternative. The ADON said the dialysis communication form was to be completed correctly to reflect the state of the resident prior to leaving the facility. The ADON said if the section for snacks/ food was blank on the dialysis communication form she would believe it was not given to the resident. The ADON said care plans would not include timeframes for non-pharmaceutical interventions like rehab or meals and that would be on the residents MAR. In an interview on 5/28/2026 at 2:58pm with DON said the facility had dialysis contracts but not a policy for dialysis care due to the facility not providing the treatment. She said the expectations for her staff were to ensure dialysis residents were dressed appropriately, complete dialysis communication sheet, and receive breakfast or lunch. DON said Resident # 2 had no issues with getting meals and was not aware of any missed meals or issues from missed meals. DON said the dialysis communicate sheet was used to inform the center if the resident received any medications, food, or had a change in condition. She said dialysis forms are never blank and always are completed with vitals and any updates from dialysis. DON said meals would be documented as given or not given not by amount in the ADL online system the CNAs use. DON said Resident # 2 would be given a shake prior to dialysis as an alternative to a snack or a meal for his morning chair time morning. DON said Resident # 2 dialysis chair time was not indicated in the care plan due times would change although Resident # 2 had the same chair time for majority of the time he received treatment. She said if there was a change in chair time it would come from transportation and they would call the facility.

Based on observation, interviews, and record review, the facility failed to ensure a resident with limited range in motion receives the treatment and services to increase range of motion, a person-centered care plan including specific interventions, equipment, frequency, duration and measurable objectives addressing hand contracture for 1 out of 5 residents (Resident # 4) reviewed for quality of care.The facility failed to ensure Resident #4's hand roll/ splint/ foam tubing was scheduled, used and monitored for left hand contracture and prevention of palm injury. The facility also failed to ensure Resident # 4 person-centered care plan addressed specific interventions with the use of equipment to address left hand contracture.This failure could place residents at risk diminished skin integrity, decreased range in motion resulting in a decreased quality of life.Findings include: Resident # 4 Record review of Resident # 4's admission record revealed an [AGE] year-old male with original admission date of 11/25/2020 and current admission date of 4/9/2025. Diagnoses were Stiffness of unspecified joint, Muscle Wasting and Atrophy, Upper Arm (wasting or loss of muscle mass in the biceps, triceps, or shoulders), Unsteadiness on Feet, Cognitive Communication Deficit (an impaired ability to speak, listen, read, write, or socialize effectively), Unspecified intellectual disabilities, and Poly Osteoarthritis (a condition where osteoarthritis affects five or more joints simultaneously) Record review of Resident # 4 Care Plan dated 5/15/2026 indicated:*Resident # 4 had skin integrity problem abrasion to left palm. Interventions indicated CNA to monitor skin daily and report to nurse, clean and dry hand before applying splint, keep nails cut and trimmed with date to be initiated 4/17/2026.*Resident # 4 risk for pain related to arthritis, left hand contracture with interventions of administer medication as ordered, anticipate needs, identify and record, monitor and document cause for pain, notify if interventions are unsuccessful, encourage different pain relieving methods like positioning, relation therapy, bathing, hot/cold application last revised on 12/16/2020.* Resident # 4 risk for physical mobility related to weakness, left hand contracted with interventions of abductor wedge, halo bars and padded, foam roll to left hand revised on 4/20/2026, monitor and report signs of contracture forming or worsening, thrombus formation, skin break down, last revised on 8/16/2021. Record review of Resident # 4's Order summary active orders as of 5/28/2026 did not indicate orthotic device or equipment of foam roller or abduction wedge for mobility intervention. Summary indicated abrasion to left palm - cleanse, pat dry with gauze, apply skin prep, and leave open to air as needed and every shift. Further review of Resident # 4 task list did not indicate frequency of foam roller use or splint. Record review of Resident # 4's Occupational Therapy Progress Report dated 4/13/2026 - 5/4/2026 indicated Resident # 4 received treatments of therapeutic exercises, group therapeutic procedures, orthotics/prosthetics with a frequency of 8 times a week for 3 weeks daily for 15 mins. The report also indicated a short-term goal that stated Resident # 4 would wear orthotic foam tubing in left palm for up to 2 hours and a long-term goal of up to 8 hours with minimal redness, swelling, discomfort or pain. Further review indicated reason for OT referral was due to evaluation and treatment for contracture management. History and complexities revealed Resident # 4 had digit contracture with wound in left palm from nail digging. Resident # 4 had a decrease in both hand and wrist range of motion. Resident # 4 recommendations for splint/ orthotics due to left hand contracture indicated Resident # 4 was to start with foam tubing and increase tubing size and eventually a orthotic carrot. OT Progress Report indicated Resident # 4 would benefit from plan of care in order to promote contracture management, positioning, and maintenance of prior level of functioning in any ADL's specified within a reasonable time frame and without risk to injury and skin integrity. Record review of Resident # 4's OT Progress report dated 4/27/2026 indicated the facility did not have a restorative program and the facility nursing staff would continue promoting participation in ADL task such as contracture management as Resident # 4 would be discharged from OT services as of 4/27/2026. Record review of Resident # 4 Occupational Therapy Progress Report dated 5/19/2026 - 6/17/2026 indicated Resident # 4 short term goal would wear ortho foam tube on left hand progressing to a hand roll due to 3rd, 4th, and 5th digit (finger) contracture for up to 2 hours and a long term goal for up to 6 hours with minimum signs of redness, swelling, discomfort or pain. Resident # 4 goals were to decrease risk of contracture and maintain contracture management. OT Progress report indicated splint/ orthotic recommendations was a carrot orthotic (a specialized, cone-shaped hand splint designed to manage severe hand contractures. By gently separating the fingers and keeping the palm open, it reduces muscle spasticity, relieves pressure, prevents nail puncture injuries, and improves hand hygiene and). Further review of Change of Condition Communication Form for Resident #4 dated 5/22/2026 read in part Patient has moisture maceration wound on palm surface due to finger digging into skin. an abrasion to left plan. cleansed, patted dry with gauze, applied skin prep and left open to air.Observation on 5/26/2026 at 3:44 pm, Resident # 4 was in wheelchair, left hand was contracted without a device in place. Observation on 5/27/2026 At 10:36 a.m., Resident # 4's left hand contracture was without hand splint or roller. In an interview on 5/27/2026 at 4:56 p.m., with Family Member said when she had spoken to rehab they would either tell her he refused therapy or he did not have therapy that week. Family Member said she was unaware when he had therapy or what was being done because she had not received any calls from the facility. She said the facility only called her to update Medicaid or Medicare paperwork but did not inform her of the therapy treatments Resident # 4 was receiving to help with his mobility. Family Member said she had not seen him with any hand devices when she visits and today did not see one on Resident # 4's left hand. She said she brought a hand type glove for his left hand because his hand would not open and his nails were digging into his skin. Family Member said she has spoken to the facility about concerns and said they are to call her about care plan meetings but says she never got the call. In an interview on 5/28/20226 at 9:37 a.m., the Rehab Director said most of the residents needing skilled come in with orders and will screen for speech and complete the eval within the first 3 days, said residents are screened for therapy need either PT, OT or speech within first 7 days. She said Resident # 4 was on PASRR services since 2021 and it is 5x a week 30 min session and is certification 6 months at a time, said it is habilitative PASRR PT to maintain range of motion of knees, and wheelchair mobility and bed mobility, said last year he received a new wheelchair. Said for PASRR OT is a level of maintaining, said he had a new contractor in hand and was first seen 5/4/2026 and was denied PASSRR and had to reapply through Medicare, said 5/19/2026 re eval for OT, said he should be screened 3 - 4 months. Rehab Director said the resident had has a soft foam tubing on the left hand for 7 hours between 9am - 3 pm. She said the purpose of the foam roller was to stop the nails from going into the skin and prevent further contraction and w/c mobility and avoid skin breakdown. She said if a resident refused therapy they will go back to try again or move it to another day to make it up and would note it in the therapy notes. In an interview on 5/28/2026 at 2:58 pm with DON said she was unaware of any concerns with Resident # 4 receiving rehab services or refusal of the services. She said Resident # 4 used a hand roller however it would not be listed in the care plan the length of time to use and not use the hand roller. DON said care plan listed as tolerated for the use of hand roller and PT consult as appropriate interventions included in Resident # 4 care plan regarding his left-hand contraction In an interview on 5/28/2026 at 1:23 pm with ADON said resident specific interventions state what the intervention is related to and why it is needed. She said it would also include goals and follow up. ADON said therapy (Rehab) did devices for hand rollers/splint and CNAs are sent to therapy for in-services on how to use the device. ADON said if there was an order for the hand roller or splint the nurse would ensure the device was used correctly. ADON said Resident # 4 had a different hand device like a hand sleeve, but it caused skin integrity issues. ADON said care plans should have time frames of when the assistive device was needed and recommendations from Rehab included in the care plan Record review of facility policy Specialized Rehabilitative Services dated 7/1/2023 read in part the services will be provided and coordinated by qualified personnel Record review of facility policy Activities of Daily Living dated 5/26/2023 read in part A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and person and oral hygiene

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for tracheostomy care. 1. The facility failed to ensure staff caring for Resident #1 were aware of the location of emergency equipment or how to use it in case of accidental extubation of his tracheostomy (a medical emergency where the tracheostomy tube is inadvertently removed. A tracheostomy is a surgically created opening in the neck leading into the trachea to assist with breathing, often using a tube to maintain the airway). 2. The facility failed to ensure Resident #1 had a same-size tracheostomy at the bedside in case of accidental extubation on 1/12/26. 3. The facility failed to ensure staff caring for Resident #1 were aware of tracheostomy sizes and the size Resident #1 required based on his physician's order. An Immediate Jeopardy (IJ) situation was identified on 2/5/26. While the IJ was removed on 2/6/26, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of corrective systems. These failures could place resident at risk of respiratory distress which could lead to low oxygen levels, airway loss, cognitive and emotional damage, organ failure or death. Findings include:Record review of Resident #1's admission Record revealed he was admitted to the facility on [DATE]. Resident #1 had diagnoses which included epileptic seizure (a transient, involuntary alteration in behavior, sensation, or consciousness caused by abnormal, excessive electrical activity in the brain, typically lasting one to two minutes), shortness of breath, other specified respiratory disorders and tracheostomy. He was [AGE] years old.Record review of Resident #1's care plan, dated 4/12/2023 and revised on 1/18/2024, revealed he had a tracheostomy related to injury to his larynx (the hollow muscular organ forming an air passage to the lungs and holding the vocal cords) and was at risk of alterations in respiratory status. Intervention included, Change disposable trach (Shiley #6) inner cannula secure with trach tie every shift for trach care. Tube Out Procedures: Keep extra trach tube and obturator (a guide tool inserted into the outer cannula to facilitate safe insertion of a tracheostomy tube into the airway) at bedside. If tube is coughed out, and tube cannot be reinserted, monitor/document for signs of respiratory distress.obtain medical help Immediately.Record review of Resident #1's quarterly MDS assessment, dated 11/26/25, revealed he had a BIMS of 4, which indicated he had severe cognitive impairment. He was dependent on others for personal and oral hygiene. The assessment indicated he had shortness of breath or trouble breathing when lying flat and required tracheostomy care and suctioning. Record review of Resident #1's Order Summary Report, generated on 2/4/26 revealed he had an order to change disposable trach Shiley 6 inner cannula (a removable liner inserted into the main outer trach tube to prevent mucus build-up) as needed and every shift with an order date of 6/2/24. Record review of Resident #1's progress note, dated 1/2/26, revealed RN A noticed his trach was no longer in place. His oxygen saturation was 94% and he denied shortness of breath. He was sent to the hospital for evaluation and treatment.Record review of Resident #1's emergency provider report from an acute care hospital, dated 1/2/26, revealed Resident #1 was sent to the hospital to have his trach replaced. Chief complaint was noted to be trach dislodged. His first documented pulse oximeter result (a measure of blood oxygen transport) was 96% and he was receiving oxygen by nasal cannula at 1:30 pm. The trach was replaced with the use of bronchoscopy (a procedure in which a doctor inserts a thin, flexible tube with a camera through the nose or mouth to examine the airways, lungs, and trachea) and tolerated well.Record review of Resident #1's Physician Orders revealed an order dated 1/2/26 that read, send to ER to evaluate and treat for dislodge trach. Record review of Resident #1's progress note, dated 1/12/26, revealed RN A replaced the trach tie (adjustable, often Velcro-based straps used to secure a tracheostomy tube to a patient's neck, preventing accidental dislodgement) when the resident coughed and the trach came out. The trach was replaced. He had difficulty breathing and was given 2L of oxygen. He was sent to the hospital for evaluation.Record review of Resident #1's Physician Orders revealed an order dated 1/12/26 that read, send to ER to evaluate and treat. Record review of Resident #1's Emergency Department Report from an acute care hospital, dated 1/12/26, revealed Resident #1 visited the emergency department because the nursing home staff put the tracheostomy back in after it became dislodged and they were .unsure if it is in correct position. Patient is breathing well and has no complaints now. trach appears to be in appropriate position. In an interview on 1/22/2026 at 4:00 PM, RN A said Resident #1's trach dislodged on two occasions during her shifts. She said the first time it was dislodged, she walked into the room and noticed it was out. She said he did not appear to be in respiratory distress. She said she notified the nurse practitioner, who told her to send the resident to the emergency room. She said the second time it was dislodged, she was changing the gauze during trach care and he coughed hard and the trach blew out. She said she did not know that was possible. She said another nurse replaced the trach. She said she did not feel comfortable replacing the whole trach, only the inner cannula. In an observation and interview on 1/22/26 at 12:04 PM, revealed Resident #1 was lying in bed watching television. His tracheostomy gauze was clean and he was not in distress. He stated he wanted his trach removed and was breathing fine without oxygen. He did not respond when asked about past incidents of his trach coming out. In an interview on 2/3/26 at 3:07 PM, RN B said she was present when Resident #1's trach became dislodged. She said she was not assigned to care for Resident #1, but assisted RN A. She said she put in a smaller sized trach since that was the device that was available at bedside. She said the nurse practitioner told her to put in the correct size, so she went to the storage room, found the right size, then replaced it again. She said she could not remember the sizes of the trach. She could not state why RN A was unable to replace the trach. In an observation and interview on 2/3/26 at 5:22 PM, LVN O said if Resident #1's trach fell out, she would call for help, call the nurse practitioner and send him to the hospital immediately, because that is how he breaths. She said she would not know how to replace it. She showed the state surveyor the resident's supplies in his room, which included the inner cannula, suction kit and oxygen supplies, but not the trach kit with insertion tool. In an interview on 2/4/26 at 11:20 AM, NP said when Resident #1's trach was dislodged, she would expect the nurses to make sure the resident was breathing, try to replace the trach, check the oxygen saturation, then call the nurse practitioner. She said if the nurses did not replace the trach, they could use mechanical ventilation using BVM (bag-valve-mask). She said the resident could stop breathing if the nurses did not know what to do. In an interview on 2/4/26 at 12:08 PM, the DON said Resident #1's trach was dislodged twice. She was on leave when it happened on 1/2/26. She said on 1/12/26, RN A was changing the trach ties, the resident coughed, they put the cannula back in and sent him to the hospital to confirm the placement. She said they were making sure the nurses were trained on trach care since they had some recent new hires and rehires. She said if a nurse was uncomfortable with the procedure of inserting a trach, they should grab another nurse to help. She said even in an emergency, the nurse would have time to ask for help from another nurse. She said the facility's policy was to follow the competency assessment procedures. Record review of the, undated, tracheostomy care competency assessment revealed the following: .able to verbalize steps to take when there is an accidental decannulation. Call for assistance and assess your patient. Replace the old tracheostomy tube with the new tube that is the same-size. Be prepared to manually ventilate the resident in whom respiratory distress develops. Notify emergency personnel, if necessary. Continue to manually ventilate until emergency personnel arrives and takes over ventilation. In an interview on 2:55 PM, the Administrator stated they did not have a policy on respiratory care or trach care. He said they used the Lippincott Manual of Nursing Practice.Record review of the Lippincott Manual of Nursing Practice, Eleventh Edition dated 2019 provided by the Administrator read, Artificial Airway Management. Types of Airways. Tracheostomy tube- firm, curved artificial airway inserted directly into the trachea at the level of the second or third tracheal ring through a surgically made incision. a. Permits mechanical ventilation and facilitates secretion removal. b. Can be for long-term use. c. Bypasses upper airway defenses, increasing susceptibility to infection. d. allows the patient to eat and swallow. Tracheostomy tube insertion. 1. Tube types vary according to presence of inner cannula.and type of cuff. 3. Tracheostomy is usually planned, either as an adjunct to therapy for respiratory dysfunction or for longer-term airway management when (endotracheal) intubation has been used for more than 14 days. 4. May be done at the bedside in an emergency when other means of creating an airway have failed.In a telephone interview on 2/5/26 at 10:15 AM, the previous ADON said she was present when Resident #1's trach was dislodged during the second time in January 2026. She said when she arrived to the room, a nurse had put in a smaller trach than the one he needed. She could not recall what happened after the nurse completed this task. In an observation and interview on 2/5/26 at 11:15 AM, Central Supply Personnel said she counted Resident #1's trach supplies in his room to ensure there were enough. She said the emergency supply in his room was the trach size that he used and one size down from the one he used. When asked about the nurse reporting Resident #1 had a smaller size at the bedside, she said the nurse did not look hard enough. She said there was no way they did not have the correct size at the bedside. Central Supply Personnel walked to the supply closet with the State Surveyor and saw Shiley trach kits that included the obturator in different sizes. When asked what size Resident #1 wore, she pointed to the box with an item number of 4UN65H. She stated this box showed the ID (the inner diameter [ID]) determined the size of the airway) was 6.5mm and should be the correct one. There was one box labeled 6UN65H in the supply closet. We walked to Resident #1's room and looked in the bag that contained his emergency supplies next to his bed. She pulled out one box each of the 4UN65H and 6UN65H sizes. When asked if one of the boxes contained a smaller size than the one he wore, she said she was not sure. She said she was not a nurse and she ordered what the nurses requested. In an interview on 2/5/26 at 11:32 AM, the DON said she was not the most knowledgeable about trach sizes and could not explain the different sizes of the trachs and inner cannulas. In an observation and interview on 2/5/26 at 12:08 PM, the DON said Resident #1 wore a trach that had a 7.5 mm outer cannula and 6 mm inner cannula. The State Surveyor asked if we could view the measurements on the box, and we walked to Resident #1's room. When we walked into the room, ADON #2, RN B, and RCS were in the room with Resident #1. The RCS said they were looking at his new trach to determine the size of it. They showed the State Surveyor the tracheostomy boxes in his emergency supplies at bedside and one was labeled 4UN65H and the other 6UN65H. The RCS pointed to the diagram of the inner cannula on the package and said the emergency supply contained the correct sized packages because the diameter of the inner cannula of the smaller trach was 5.5 mm and the diameter of the inner cannula of the correct size trach was 6.5 mm. When asked if the inner cannula size should be 6mm or 6.5mm, the RCS said they would look into it. In an interview on 2/5/26 at 12:40 PM, the RCS said she spoke to the RT who said they used the first number of the label to determine the size of the trach supplies. She said Resident #1 used a size 6 Shiley trach, which was the trach labeled 6UN75H. In an interview on 2/5/26 at 1:00 PM, ADON #1 said if a resident's trach was dislodged and they were in respiratory distress, the nurses would insert the trach cannula and use oxygen, then send the resident to the hospital. She said Central Supply Personnel checked the supplies in Resident #1's room to ensure there was always a supply available. She said at times, the ADONs or the nurses would stock his room with supplies. In an interview on 2/5/26 at 2:58 PM, NP, when asked about Resident #1's trach order of size 6 inner cannula, she said that meant the inner cannula was 6 mm in size. She said the nursing staff should use a 6 mm inner cannula.In an interview on 2/5/26 at 3:45 PM, the RT said she did not work full time at the facility. She said Resident #1 required a size 6, which would be a 6UN75H trach. She said the item number included the size (6), whether the trach was uncuffed or cuffed (UN), the size of the ID (75), and whether the trach was disposable or not (H). She said there should be emergency supplies at his bedside that included his trach size and a size smaller, either a size 4 or 5. She said the nurses should be comfortable to put in a new trach if it became dislodged and said they should ask the DON if they needed extra training. This was determined to be an Immediate Jeopardy (IJ) on 2/5/26 at 4:40pm. The Administrator and DON were notified. The DON and Administrator were provided with the IJ template on 2/5/26 at 4:40 p.m. The following Plan of Removal submitted by the facility was accepted on 2/6/26 at 2:56pm: Letter of Credible Allegationfor Removal of Immediate JeopardyAttention Sir or Madam: On February 5, 2026, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The alleged Immediate jeopardy allegations are as follows: Issue: F695 - Respiratory/Tracheostomy Care and Suctioning The facility failed to ensure Resident #1 received respiratory care, including tracheostomy care, consistent with professional standards of practice and the comprehensive person-centered care plan in that 2 of 4 staff were not aware of the location of emergency equipment or how to use it in case of accidental extubation of Resident #1's tracheostomy and failed to ensure a same-size tracheostomy was present at bedside in case of emergency. Actions for Resident Involved On 2/5/2026, Resident #1 was assessed by the Respiratory Therapist related to respiratory and tracheostomy status with no concerns noted. The Respiratory Therapist validated that physician orders and plan of care for Resident #1's tracheostomy care were being followed. On 2/5/2026, the Respiratory Therapist observed the bedside and emergency tracheostomy equipment for Resident #1 and confirmed the presence of size 6, size 5 and size 4 tracheostomies, as well as an Ambu bag (also referred to as bag-valve-mask, BVM, is a handheld, self-inflating device used to provide manual positive-pressure ventilation to patients who are not breathing or breathing inadequately) for emergency use. Identify residents who could be affected: No other facility resident has tracheostomies and/ or receive tracheostomy care. Action Taken/ System Change: The Director of Nursing was reeducated by the Respiratory Therapist on 2/5/26 and received 1:1 education on the following: o Tracheostomy Care to include trach care supplies with passed return demonstration.o Emergency response during an accidental extubation of tracheostomy, to include tracheostomy tube reinsertion, identification of tracheostomy size, location and related equipment with passed return demonstration. o Daily shift observation and documentation for compliance with physician orders for tracheostomy size, as well as presence of emergency equipment at bedside i.e. extra tracheostomy in current size, as well as a size below current size and Ambu bag and tracheostomy care supplies. Licensed Nurses reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed. LVN A was reeducated by the Director of Nursing, Respiratory Therapist and/or designee on 2/5/26 and received 1:1 education on the following: o Tracheostomy Care to include trach care supplies with passed return demonstration.o Emergency response during an accidental extubation of tracheostomy, to include tracheostomy tube reinsertion, identification of tracheostomy size, location and related equipment with passed return demonstration. o Daily shift observation and documentation for compliance with physician orders for tracheostomy size, as well as presence of emergency equipment at bedside i.e. extra tracheostomy in current size, as well as a size below current size and Ambu bag and tracheostomy care supplies. Licensed Nurses reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed. RN A will be reeducated by the Director of Nursing, Respiratory Therapist and/or designee before her next shift and will receive 1:1 education on the following: o Tracheostomy Care to include trach care supplies with passed return o Emergency response during an accidental extubation of tracheostomy, to include tracheostomy tube reinsertion, identification of tracheostomy size, location and related equipment with passed return demonstration. o Daily shift observation and documentation for compliance with physician orders for tracheostomy size, as well as presence of emergency equipment at bedside i.e. extra tracheostomy in current size, as well as a size below current size and Ambu bag and tracheostomy care supplies. Licensed Nurses reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed. Beginning 2/5/2026, 100% of Licensed Nurses were reeducated 1:1 by the Director of Nursing, Respiratory Therapist and/or designee on: o Tracheostomy Care to include trach care supplies with passed return o Emergency response during an accidental extubation of tracheostomy, to include tracheostomy tube reinsertion, identification of tracheostomy size, location and related equipment with passed return demonstration.o Daily shift observation and documentation for compliance with physician orders for tracheostomy size, as well as presence of emergency equipment at bedside i.e. extra tracheostomy in current size, as well as a size below current size and Ambu bag and tracheostomy care supplies. Licensed Nurses reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed. Beginning 2/5/2026, Licensed Nurses who are out on PTO/ FMLA/ Leave of Absence will have the re-education completed and return demonstration prior to the start of their next scheduled shift. Beginning 2/5/2026 and ongoing, newly hired licensed nurses will receive this training and passed a return demonstration during orientation prior to providing care to residents. The training will include the above-stated educational components New Admissions/Readmissions with Tracheostomies will be reviewed by the Director of Nursing and/ or designee for compliance with physician orders for tracheostomy size, as well as the presence of appropriate tracheostomies sizes, equipment and Ambu bag at bedside. Completion date: 2/5/2026Monitoring: Beginning 2/5/2026 and going forward, the Director of Nursing and/or designee will monitor compliance with physician orders for tracheostomy care and presence of accurate emergency tracheostomy equipment at the bedside by validating through rounding on residents with a tracheostomy. Beginning 2/5/2026 and going forward, the Director of Nursing and/ or designee will monitor compliance with Licensed Nurse competency in tracheostomy care via observations and competency checks. Beginning 2/5/2026 and going forward, the Director of Nursing and/ or designee will monitor compliance with daily verification and documentation of presence of emergency supplies at resident bedside (i.e. extra tracheostomy in current size, one sicxe down and Ambu bag) by rounding on residents with tracheostomy. On 2/5/2026, an Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, Regional Clinical Specialist and Regional [NAME] President of Operations to discuss the immediate jeopardy and review the plan of removal.We respectfully submit this action plan for the removal of Immediate Jeopardy. Monitoring of the POR included the following: In an observation on 2/6/26 at 10:30 AM revealed Resident #1 had emergency equipment at the bedside which included: Shiley size 4, 5, and 6 trachs, ambu bag, concentrator, air compressor, and suction.Interviews with LVN E on 2/5/26 at 6:15 PM and with the DON, LVN A, ADON #2, LVN R and LVN C on 2/6/26 between 3:34 PM and 4:56 PM revealed they could describe their training with the RT, including trach emergency supplies, trach sizing, and procedures of accidental extubation.Record review of the staff sign-in sheet dated 2/5/26 and 2/6/26 revealed RN A was not assigned to work. In an interview on 2/6/26 at 4:56 PM, the DON said she would verify placement of trach supplies in Resident #1's room to ensure emergency supplies were available. She said she would monitor the nursing staff for competency of trach care and emergency procedures. Record review of Resident #1's Respiratory Therapy Note, dated 2/5/26 at 7:40 PM, revealed the RT assessed the resident, determined he was wearing a 6UN75H trach, and stated there were three sizes of trachs, including Shiley 4, 5 and 6 at bedside for the emergency supplies. Record review of an in-service training report, dated 2/5/26, attended by licensed nurses conducted by the RT revealed all nurses received 1-to-1 education on the following topics: Trach care to include trach care supplies with passed return demonstration; Emergency response during an accidental extubation of trach, to include trach tube reinsertion identification of trach size location and related equipment with passed return demonstration; Daily shift observation and documentation for compliance with physician orders for trach size as well as presence of emergency equipment at bedside; Extra trach in current size and size below current size and ambu bag and trach care supplies; POC nurse responsibility for checking and stocking trach supplies each shift and as needed. Nurses who worked last night and today signed the sign-in sheet.Record review of a QAPI sign-in sheet, dated 2/5/26, revealed a meeting was held with the Medical Director, Facility Administrator, Director of Nursing, Regional Clinical Specialist and Regional [NAME] President of Operations. The Administrator was informed the Immediate Jeopardy was removed on 2/6/26 at 5:24 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets to care for resident's needs, as identified through resident assessments and described in the plan of care for 4 of 8 nurses (RN A, LVN O, DON and RCS) reviewed for competency.1. The facility failed to ensure RN A and LVN O, who were assigned to care for Resident #1, were aware of the location of emergency equipment or how to use it in case of accidental extubation of his tracheostomy. 2. The facility failed to ensure the DON and RCS were aware of tracheostomy sizes and the size Resident #1 required based on his physician's order. An Immediate Jeopardy (IJ) situation was identified on 2/5/26. While the IJ was removed on 2/6/26, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of corrective systems. These failures could place residents at risk of respiratory distress which could lead to low oxygen levels, airway loss, cognitive and emotional damage, organ failure or death.Findings include:Record review of Resident #1's admission Record revealed a male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included epileptic seizure, shortness of breath, other specified respiratory disorders and tracheostomy. He was [AGE] years old.Record review of Resident #1's care plan dated 4/12/2023 and revised on 1/18/2024 revealed he had a tracheostomy related to injury to his larynx and was at risk of alterations in respiratory status. Intervention included, Change disposable trach (Shiley #6) inner cannula secure with trach tie every shift for trach care. TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, and tube cannot be reinserted, monitor/document for signs of respiratory distress.obtain medical help IMMEDIATELY.Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 4, indicating he had severe cognitive impairment. He was dependent on others for personal and oral hygiene. The assessment indicated he had shortness of breath or trouble breathing when lying flat and required tracheostomy care and suctioning. Record review of Resident #1's Order Summary Report generated on 2/4/26 revealed he had an order to change disposable trach Shiley 6 inner cannula as needed and every shift with an order date of 6/2/24. Record review of Resident #1's progress note dated 1/2/26 revealed RN A noticed his trach was no longer in place. His oxygen saturation was 94% and he denied shortness of breath. He was sent to the hospital for evaluation and treatment.Record review of Resident #1's emergency provider report from an acute care hospital dated 1/2/26 revealed Resident #1 was sent to the hospital to have his trach replaced. Chief complaint was noted to be trach dislodged. His first documented pulse oximeter result (a measure of blood oxygen transport) was 96% and he was receiving oxygen by nasal cannula at 1:30pm. The trach was replaced with the use of bronchoscopy and tolerated well.Record review of Resident #1's progress note dated 1/12/26 revealed RN A was replacing the trach tie when the resident coughed and the trach came out. The trach was replaced. He had difficulty breathing and was given 2L of oxygen. He was sent to the hospital for evaluation.Record review of Resident #1's Emergency Department Report from an acute care hospital dated 1/12/26 revealed Resident #1 visited the emergency department because nursing home staff put the tracheostomy back in after it became dislodged and they are .unsure if it is in correct position. Patient is breathing well and has no complaints now. trach appears to be in appropriate position. In an interview on 1/22/2026 at 4:00 PM, RN A said Resident #1's trach dislodged on two occasions during her shifts. She said the first time, when she notified the nurse practitioner, she said to send the resident to the emergency room. She said the second time it was dislodged, she was changing the gauze during trach care and he coughed hard and the trach blew out. She said she did not know that was possible. She said another nurse replaced the trach. She said she did not feel comfortable replacing the whole trach, only the inner cannula. She said the last training she had on trach care was most likely in 2023.In an interview on 2/3/26 at 3:07 PM, RN B said she was present when Resident #1's trach became dislodged. She said RN A was assigned to care for Resident #1, and she helped her by putting a trach back in when the tube became dislodged. She could not state why RN A was unable to replace the trach. In an observation and interview on 2/3/26 at 5:22 PM, LVN O said if Resident #1's trach fell out, she would call the nurse practitioner and send him to the hospital immediately, because that is how he breaths. She said she would not know how to replace it. In an observation and interview on 2/4/26 at 4:43 AM, LVN W said if Resident #1's trach became dislodged, she would replace it with the kit available in his room. She showed the State Surveyor the kit, which included the insertion tool. There were two sizes, one Shiley 6 and one Shiley 4. She said he wore a size 6, so she would use the size Shiley 6. She said she had not received trach training or any type of skills checkoff since she started in November 2025. She said she had been trained on the procedure in other positions before she started at the facility. In an interview on 2/4/26 at 11:20 AM, NP said when Resident #1's trach was dislodged, she would expect the nurses to make sure the resident was breathing, try to replace the trach, check the oxygen saturation, then call the nurse practitioner. She said if the nurses did not replace the trach, they could use mechanical ventilation using BVM (bag-valve-mask). She said the resident could stop breathing if the nurses did not know what to do. In an interview on 2/4/26 at 12:08 PM, the DON said they were making sure the nurses were trained on trach care since they had some recent new hires and rehires. She stated RN A and LVN O received competency assessments on tracheostomy care last year. She said the facility's policy was to follow the competency assessment procedures. Record review of the, undated, tracheostomy care competency assessment revealed the following: .able to verbalize steps to take when there is an accidental decannulation. Call for assistance and assess your patient. Replace the old tracheostomy tube with the new tube that is the same-size. Be prepared to manually ventilate the resident in whom respiratory distress develops. Notify emergency personnel, if necessary. Continue to manually ventilate until emergency personnel arrives and takes over ventilation. In a telephone interview on 2/5/26 at 10:15 AM, the previous ADON said the RT visited every year and she did respiratory training and trach training. She said the RT brought a mannequin that showed you how to remove a trach and put another one in. She said the RT would allow the nurses to be checked off for competency one-by one. She said most of the nurses did not attend that training. She said she knew LVN O and RN A did not attend. She said they did not feel comfortable providing that kind of care. In an interview on 2/5/26 at 11:32 AM, the DON said she was not the most knowledgeable about trach sizes and could not explain the different sizes of the trachs and inner cannulas. In an observation and interview on 2/5/26 at 12:08 PM, the DON said Resident #1 wore a trach that had a 7.5 mm outer cannula and 6 mm inner cannula. The DON walked to Resident #1's room. ADON #2, RN B, and RCS were in the room with Resident #1. The RCS said that they were looking at his new trach to determine the size of it. They showed the State Surveyor the tracheostomy boxes in his emergency supplies at bedside and one was labeled 4UN65H and the other 6UN65H. The RCS pointed to the diagram of the inner cannula on the package and said the emergency supply contained the correct sized packages because the diameter of the inner cannula of the smaller trach was 5.5 mm and the diameter of the inner cannula of the correct size trach was 6.5 mm. When asked if the inner cannula size should be 6 mm or 6.5 mm, the RCS said they would look into it. In an interview on 2/5/26 at 12:40 PM, the RCS said she spoke to the RT who said they use the first number of the label to determine the size of the trach supplies. She said Resident #1 used a size 6 Shiley trach, which was the trach labeled 6UN75H. In an interview on 2/5/26 at 1:00 PM, ADON #1 said if a resident's trach was dislodged and they were in respiratory distress, the nurses would insert the trach cannula and use oxygen, then send the resident to the hospital. When asked about the training she had received on trachs and trach care, she said she used to work in a hospital and received training from them. She said they had a skills fair (a training for staff that covers various topics) and RT training in the last few months, but they did not address trachs or trach care. In an interview on 2/5/26 at 2:58 PM with NP, when asked about Resident #1's trach order of size 6 inner cannula, she said that meant the inner cannula was 6 mm in size. She said the nursing staff should use a 6 mm inner cannula.In an interview on 2/5/26 at 3:45 PM, the RT said she completed annual training on tracheostomies that included putting a new trach in during emergencies. She said she was available to complete trainings for new nurses or if a facility had a new admission. She said she was at the facility on 12/2/25 completing a training about oxygen and respiratory care, not regarding trach care. She said Resident #1 required a size 6, which would be a 6UN75H trach. She said the item number included the size (6), whether the trach was uncuffed or cuffed (UN), the size of the ID (75), and whether the trach was disposable or not (H). She said there should be emergency supplies at his bedside that included his trach size and a size smaller, either a size 4 or 5.Record review of a new hire Tracheostomy Care Competency Assessment, dated 9/17/25, revealed LVN O's competencies were checked as 'met' with no comments, which included the following procedures: .able to verbalize steps to take when there is an accidental decannulation, call for assistance and assess your patient, replace the old tracheostomy tube with the new tube that is the same-size, be prepared to manually ventilate the resident in whom respiratory distress develops.make sure extra tracheostomy tubes, obturator and resuscitation bag are readily available in case of emergency. Record review of an annual Tracheostomy Care Competency Assessment, dated 9/24/25, revealed RN A's competencies were checked as 'met' with no comments, including the following procedures: .able to verbalize steps to take when there is an accidental decannulation, call for assistance and assess your patient, replace the old tracheostomy tube with the new tube that is the same-size, be prepared to manually ventilate the resident in whom respiratory distress develops.make sure extra tracheostomy tubes, obturator and resuscitation bag are readily available in case of emergency. Record review of a Respiratory Therapy Certificate, dated 12/2/26, revealed RN A completed Respiratory Therapy training presented by RT. Record review of a Respiratory Therapy Certificate, dated 12/2/26, revealed LVN O completed Respiratory Therapy training presented by RT. Record review of Respiratory Certification Tests and Respiratory Skills Checklist, dated 12/2/26, completed by RN A and LVN O revealed there were no questions or areas concerning tracheostomy care. This was determined to be an Immediate Jeopardy (IJ) on 2/5/26 at 4:40pm. The Administrator and DON were notified. The DON and Administrator were provided with the IJ template on 2/5/26 at 4:40 p.m. The following Plan of Removal submitted by the facility was accepted on 2/6/26 at 2:56pm:Letter of Credible Allegationfor Removal of Immediate JeopardyAttention Sir or Madam: On February 5, 2026, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The alleged Immediate jeopardy allegations are as follows: Issue: F726 - Competent Nursing StaffThe facility failed to have ensure that licensed nurses had the specific competencies and skill sets necessary to care for resident's needs, as described in the plan of care in that 2 of 4 nurses did not know how to use emergency equipment in case of accidental extubation of Resident #1's tracheostomy. Actions for Resident Involved On 2/5/2026, Resident #1 was assessed by the Respiratory Therapist related to respiratory and tracheostomy status with no concerns noted. The Respiratory Therapist validated that physician orders and plan of care for Resident #1's tracheostomy care were being followed. On 2/5/2026, the Respiratory Therapist observed the bedside and emergency tracheostomy equipment for Resident #1 and confirmed the presence of size 6, size 5 and size 4 tracheostomies, as well as an Ambu bag for emergency use. Identify residents who could be affected: No other facility resident has tracheostomies and/ or receive tracheostomy care. Action Taken/ System Change: The Director of Nursing was reeducated by the Respiratory Therapist on 2/5/26 and received 1:1 education on the following: o Tracheostomy Care to include trach care supplies with passed return demonstration.o Emergency response during an accidental extubation of tracheostomy, to include tracheostomy tube reinsertion, identification of tracheostomy size, location and related equipment with passed return demonstration. o Daily shift observation and documentation for compliance with physician orders for tracheostomy size, as well as presence of emergency equipment at bedside i.e. extra tracheostomy in current size, as well as a size below current size and Ambu bag and tracheostomy care supplies. Licensed Nurses reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed. LVN A was reeducated by the Director of Nursing, Respiratory Therapist and/or designee on 2/5/26 and received 1:1 education on the following: o Tracheostomy Care to include trach care supplies with passed return demonstration.o Emergency response during an accidental extubation of tracheostomy, to include tracheostomy tube reinsertion, identification of tracheostomy size, location and related equipment with passed return demonstration. o Daily shift observation and documentation for compliance with physician orders for tracheostomy size, as well as presence of emergency equipment at bedside i.e. extra tracheostomy in current size, as well as a size below current size and Ambu bag and tracheostomy care supplies. Licensed Nurses reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed. RN A will be reeducated by the Director of Nursing, Respiratory Therapist and/or designee before her next shift and will receive 1:1 education on the following: o Tracheostomy Care to include trach care supplies with passed return o Emergency response during an accidental extubation of tracheostomy, to include tracheostomy tube reinsertion, identification of tracheostomy size, location and related equipment with passed return demonstration. o Daily shift observation and documentation for compliance with physician orders for tracheostomy size, as well as presence of emergency equipment at bedside i.e. extra tracheostomy in current size, as well as a size below current size and Ambu bag and tracheostomy care supplies. Licensed Nurses reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed. Beginning 2/5/2026, 100% of Licensed Nurses were reeducated 1:1 by the Director of Nursing, Respiratory Therapist and/or designee on: o Tracheostomy Care to include trach care supplies with passed return o Emergency response during an accidental extubation of tracheostomy, to include tracheostomy tube reinsertion, identification of tracheostomy size, location and related equipment with passed return demonstration.o Daily shift observation and documentation for compliance with physician orders for tracheostomy size, as well as presence of emergency equipment at bedside i.e. extra tracheostomy in current size, as well as a size below current size and Ambu bag and tracheostomy care supplies. Licensed Nurses reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed. Beginning 2/5/2026, Licensed Nurses who are out on PTO/ FMLA/ Leave of Absence will have the re-education completed and return demonstration prior to the start of their next scheduled shift. Beginning 2/5/2026 and ongoing, newly hired licensed nurses will receive this training and passed a return demonstration during orientation prior to providing care to residents. The training will include the above-stated educational components New Admissions/Readmissions with Tracheostomies will be reviewed by the Director of Nursing and/ or designee for compliance with physician orders for tracheostomy size, as well as the presence of appropriate tracheostomies sizes, equipment and Ambu bag at bedside. Completion date: 2/5/2026Monitoring: Beginning 2/5/2026 and going forward, the Director of Nursing and/or designee will monitor compliance with physician orders for tracheostomy care and presence of accurate emergency tracheostomy equipment at the bedside by validating through rounding on residents with a tracheostomy. Beginning 2/5/2026 and going forward, the Director of Nursing and/ or designee will monitor compliance with Licensed Nurse competency in tracheostomy care via observations and competency checks. Beginning 2/5/2026 and going forward, the Director of Nursing and/ or designee will monitor compliance with daily verification and documentation of presence of emergency supplies at resident bedside (i.e extra tracheostomy in current size, one sicxe down and Ambu bag) by rounding on residents with tracheostomy. On 2/5/2026, an Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, Regional Clinical Specialist and Regional [NAME] President of Operations to discuss the immediate jeopardy and review the plan of removal.We respectfully submit this action plan for the removal of Immediate Jeopardy. Monitoring of the POR included the following:Record review of Resident #1's Respiratory Therapy Note dated 2/5/26 at 7:40pm revealed the RT assessed the resident, determined he was wearing a 6UN75H trach, and stated there were three sizes of trachs, including Shiley 4, 5 and 6 at bedside for the emergency supplies. In an observation on 2/6/26 at 10:30am revealed Resident #1 had emergency equipment at the bedside which included: Shiley size 4, 5, and 6 trachs, ambu bag, concentrator, air compressor, and suction.Record review of an in-service training report dated 2/5/26 attended by licensed nurses conducted by the RT revealed all nurses received 1-to-1 education on the following topics: Trach care to include trach care supplies with passed return demonstration; Emergency response during an accidental extubation of trach, to include trach tube reinsertion identification of trach size location and related equipment with passed return demonstration; Daily shift observation and documentation for compliance with physician orders for trach size as well as presence of emergency equipment at bedside; Extra trach in current size and size below current size and ambu bag and trach care supplies; POC nurse responsibility for checking and stocking trach supplies each shift and as needed. Nurses who worked last night and today signed the sign-in sheet.Interviews with LVN E on 2/5/26 at 6:15pm and with DON, LVN O, ADON #2, LVN R and LVN C on 2/6/26 between 3:34pm and 4:56pm revealed they could describe their training with the RT, including trach emergency supplies, trach sizing, and procedures of accidental extubation. In an interview on 2/6/26 at 4:56pm, the DON said she would verify placement of trach supplies in Resident #1's room to ensure emergency supplies were available. She said she would monitor the nursing staff for competency of trach care and emergency procedures. Record review of a QAPI sign-in sheet dated 2/5/26 revealed a meeting was held with the Medical Director, Facility Administrator, Director of Nursing, Regional Clinical Specialist and Regional [NAME] President of Operations. The Administrator was informed the Immediate Jeopardy was removed on 2/6/26 at 5:24 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure a resident had a right to a safe, clean, comfortable and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 residents (Resident #2) reviewed for environmental concerns.1. The facility failed to ensure there were not dried, thick streaks of mucus covering Resident #2's dresser and the walls surrounding his dresser spanning an area of approximately 5 feet by 5 feet. 2. The facility failed to ensure there were no crayon and/or pen marks of multiple colors on the wall next to Resident #2's bed.These failures could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant, unsanitary, and unsafe.The findings include:Record review of Resident #2's admission Record generated on 2/6/26 revealed he was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, heart failure, bipolar disorder, gastro-esophageal reflux disease and chronic obstructive pulmonary disease. He was [AGE] years of age. Record review of Resident #2's Care Plan Report dated 11/6/24 revealed he had a behavior problem of spitting on the floors and walls in his room. Interventions included, .Anticipate and meet The resident's needs, caregivers to provided (sic) opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. In an observation on 2/3/26 at 4:23 PM, Resident #2's dresser, and walls next to his dresser were covered in dried, thick streaks of mucus that were brown, red, or pink in color. They covered an area of approximately 5 feet by 5 feet. On the wall next to his bed there were crayon and/or pen marks of multiple colors, scribbled on the wall in the size of approximately 2 feet by 1 foot. In an interview on 2/3/26 at 4:30 PM, CNA A said she heard Resident #2 spit on the walls. She said the nurses and nurse managers were aware. In an attempted interview with Resident #2 on 2/3/26 at 4:31pm revealed he could not be interviewed. In an interview on 2/6/26 at 12:58 PM, the Maintenance Director, said housekeeping staff would remove the mucus material in Resident #2's room. He said they were going to start using a magic eraser product. He said housekeeping staff were still cleaning the room, and they could not paint over biological material and would want them to remove it as best as they could before they painted the wall or made any repairs. In an interview on 2/6/26 at 2:00 PM, the Environmental Supervisor said Resident #2 spit so much, they had to clean his room twice daily sometimes. She said right now it was clean and in 2 hours some of the wall would be covered again. She said they used disinfectant to clean the walls and washed his curtain. She said they cleaned it last night. She said it was not hard to clean the stain off. She said if it stayed too long it was difficult to clean. In an observation on 2/6/26 at 2:00 PM, Resident #2's walls were clean. There were some small spots on the wall where the sheetrock was damaged. In an interview on 2/6/26 at 4:00 PM, ADON B said Resident #2 spit on his walls. She said she did not believe the housekeepers were cleaning/removing the mucus from the walls daily because there was so much there. Record review of the facility's, undated, policy regarding General Housekeeping Policies read, The facility provides sufficient housekeeping and maintenance personnel, equipment and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. each occupied resident room is cleaned and put in order daily and as needed.

Based on interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 of 1 (CNA A) employees reviewed for abuse and neglect.The facility did not follow their policy on abuse when they screened CNA A for hire. CNA A had worked in the facility from 2/25/2025 through 6/27/2025. This failure could place residents at risk for possible abuse, neglect or exploitation. Findings included: Record review of an undated personnel file for CNA A indicated a hire date of 2/24/2025.Further review revealed a national background check had been conducted on 2/24/2025. It revealed CNA A had an offense date of 11/29/2023 and disposition date of 1/8/2025 charged with assault causing bodily injury statute: 22.01 (A) (1) - misdemeanor sentenced to 12-month probation; a $200 fine and $297.00 court costs. Record review of CNA A's time sheets revealed she worked 14 out of 30 days in June 2025. An interview on 7/1/2025 at 2:27pm CNA A she said had been employed at the facility since February 2025. She worked the 6a-6pm shift in the memory care unit. She said she had a deferred adjudication assault case that happened in 2023. But she received probation in January 2025. She said she preferred not to discuss the details of her case. She said she received a call on Friday (7/27/25) and HR terminated her. She said it was an unknown person from their corporate office and HRC called her around 3:54pm due to her having a background that prevented them from keeping her employed at the facility. She said the previous HRC was supposed to get a letter from her probation supervisor about her case and this was why she was allowed to be hired. An interview with HRC on 7/1/2025 at 2:58pm, revealed he was employed on 6/17/2025. He said he was responsible for new hire requests for background through a third-party company. He stated he realized that CNA A's background was not clear after Investigator requested her personnel record on last Friday (6/27/2025). He stated he called his corporate office, notified the Administrator and corporate member (last name unknown) told him that they would be terminating CNA A due to her having an assault in her background. He stated they called CNA A on Friday evening and informed her of the termination. He said since he had only been employed less than two weeks, he had not done an audit of the personnel records. He stated his audit of personnel records began on Friday (6/27/2025). He said he did not find any other employees that were unemployable. An interview with the Interim Administrator on 7/1/2025 at 3:15pm revealed he was told by the HRC that CNA A had an assault in her background, and he did not think that the previous HRC was supposed to hire her. He said the HRC immediately called corporate, and they terminated her. He said someone with an assault background could have abused the residents.Record review of Form 672 revealed census of 19 residents on the Memory Care unit where CNA A worked.Record review of the State of Texas, Health and Safety Code, Chapter 250, Section 250.006 Convictions Barring Employment revealed (Revision 24-1, Effective [DATE]): A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of: an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony.Record review of the facility's abuse policy revealed: It was the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriations of resident property.The components of the facility abuse prohibition plan are discussed herein: 1. Screening -(A) Potential employees will be screened for a history of abuse, neglect exploitation and misappropriation of property.(B) Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants.

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. 1. The facility failed to store a mop in the proper position in the utility closet. 2. The facility failed to store bowls and cups properly. 3. The facility failed to ensure the food preparation area was free of personal food and beverage items. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 03/25/2025 at 10:58 AM revealed a soiled mop was stored head-side down in the drain compartment of a mop bucket in the utility closet. There was dirty water in the bottom of the bucket. The mop was not in use at the time of the observation. During an interview on 03/25/2025 at 11:19 AM, the regional dietary manager stated the mop should have been stored in an upright position on one of the hooks inside the utility closet to ensure it dried properly and did not harbor bacteria. 2. Observation on 03/25/2025 at 11:31 AM in the dish room revealed there were 14 trays of plastic bowls, each with 11-12 bowls, stored face-down on wet trays. There were also two trays of translucent plastic cups, one with 42 cups and one with 15 cups, stacked on top of each other and face-down on wet trays. During an interview on 03/25/2025 at 11:32 AM, the regional dietary manager stated the trays were missing air-drying nets separating the bowls and cups from the trays. It was important to ensure clean dishes were air-dried to prevent the potential accumulation of germs and bacteria which could lead to foodborne illness. 3. Observation on 03/27/2025 at 10:23 AM in the kitchen revealed a quart-sized plastic container next to the toaster with contents resembling a chopped salad. There was no label or date indicating the contents of the container or a use-by date. Further observation revealed a large Styrofoam cup filled with ice and a brown liquid on a shelf below the container. There was no lid on the cup. During an interview on 03/27/2025 at 11:26 AM, [NAME] C stated the container belonged to her and was salsa for her lunch. The cup with the brown beverage without the lid was also hers. She knew personal food items should not be stored in the food preparation area of the kitchen and had no explanation as to why the items were there. During an interview on 03/27/2025 at 11:27 AM, the DM stated the personal food item belonging to [NAME] C should not have been in the food preparation area of the kitchen and the cup should have been covered. All dietary staff had been trained on the proper place to store personal food and to cover beverages. He conducted training for staff upon hire and monthly. Record review of the facility's policy Janitor's Closet approved 10/01/2018 revealed, Policy: The facility will maintain the janitor's closet in a sanitary manner to minimize the risk of food hazards. The janitor's closet will be cleaned once per week or more often as needed. 8. Mops and brooms must be stored head up. Record review of the facility's policy Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment approved 10/01/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 9. Air dry all equipment and utensils after sanitizing. Handle cleaned and sanitized equipment and utensils and all single-service articles in a way that protects them from contamination. Record review of the facility's policy Employee Sanitation approved 10/01/2018 revealed, Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. e. Employees will not eat or drink in food storage and preparation areas, or in areas containing exposed food or unwrapped utensils, or where utensils are cleaned or stored. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. 2-401.11 Eating, Drinking, or Using TOBACCO PRODUCTS. (A) Except as specified in (B) of this section, an EMPLOYEE shall eat, drink, or use any form of TOBACCO PRODUCTS only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection can not result. (B) A FOOD EMPLOYEE may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container; and (3) Exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, as well as to help prevent the development of communicable diseases and infections, for 1 of 3 residents (Resident #47) reviewed for infection control. The facility did not ensure that LVN (A) followed proper infection control practices, including hand hygiene /glove changes, while checking Resident #47's blood sugar. This failure could place residents at risk of contracting disease and infection. The findings included: Record review of Resident # 47's Face sheet, dated 3/27/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes (a disorder when the body cannot use insulin correctly and sugar builds up in the blood), Hyperlipidemia (excess of lipids or fats in your blood) and Hypertension (a common condition that affects the body's arteries). Record review of Resident # 47's quarterly MDS, dated [DATE], revealed a BIMS score of 6, which indicated the resident had severely impaired cognition for daily decision making. Record review of Resident # 47's care plan, dated 10/17/24, revealed that Resident #47 has a need for enhanced barrier precautions with interventions to wear gloves. Record review of Resident #47's order summary, dated 3/27/25, revealed an order for enhanced barrier precautions: PPE required for high resident contact care activities. During an observation on 3/27/25 at 8:35 AM, LVN (A )administered all morning scheduled GT medications to Resident #47 while wearing gloves and then proceeded to check the resident's blood sugar and did not change gloves. During an Interview with LVN (A) on 3/27/25 at 8:50 AM, she stated she should have changed gloves after completing GT medications for Resident # 47 and then proceeded to check his blood sugar without changing gloves. LVN (A)stated she cross-contaminated while providing care to resident #47, therefore increasing his risk for infection and added that this error in deficent practice occurred as she was nervous because she is not used to being observed by a state surveyor. During an interview on 3/27/25 at 11:23 a.m., the ADON stated that LVN (A) should have sanitized or washed her hands between glove changes to disinfect her hands and to get rid of organisms. The ADON stated she had trained all staff a few months ago on infection control practices; however, LVN (A) was recently hired and had not been checked off on infection control practices. The ADON further stated that not practicing proper hand hygiene was a potential for spreading germs and a risk of infection to resident # 47. During an interview on 3/27/2025 at 3:18 PM, the Administrator expressed agreement with the Assistant Director of Nursing's expectations for infection control and prevention. She noted that the building is currently undergoing a transition in leadership, which will help ensure that these issues do not occur again. Record review of the facility's policy titled Infection Prevention and Control Program revealed that hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #81) whose comprehensive person-centered care plans were reviewed. The facility failed to ensure that Resident #81's diagnosis of depression was a focus area in the resident's comprehensive care plan. This deficient practice could affect residents by failing to ensure residents received appropriate care for their health conditions. The findings included: Record review of Resident #81's face sheet dated 08/21/2024 revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels) and hyperlipidemia (a condition characterized by high levels of fats in the blood). Record review of Resident #81's admission MDS dated [DATE] revealed a BIMS of 04, indicating severely impaired cognition. Further review of this MDS revealed Depression (other than bipolar) was checked in Section I - Active Diagnoses. Record review of Resident #81's comprehensive care plan, updated 02/11/2025, revealed the diagnosis of depression as was not listed as a focus area. During an interview on 03/27/2025 at 2:47 PM, MDS RN B stated a focus area of Depression was missing from Resident #81's comprehensive care plan, and this diagnosis should have been noted as a focus area. The resident recently discontinued use of all psychotropic medications, and when the focus area listing the medications was removed from the care plan, the diagnosis of depression was inadvertently removed as well. RN B usually did not list the diagnosis and medications together in one focus area and she did not know why she had done so this time. RN B was responsible for updating care plans, and they were updated quarterly or when there was a significant change requiring an update. It was important the diagnosis of depression was a focus area to ensure the resident was monitored for signs and symptoms of the depression and received appropriate treatment and care. The MDS RN received yearly training on the latest updates to MDS and care plans. During an interview on 03/27/2025 at 3:30 PM the Regional Nurse Consultant stated Resident #81's diagnosis of depression needed to be a focus area in the resident's care plan even if the resident was not taking medication to ensure all her needs are addressed. Record review of the facility's policy Comprehensive Care Plans implemented 10/24/2022 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision: The facility failed to supervise Resident #1 who eloped from the facility on 12/5/2024. An Immediate Jeopardy (IJ) was identified as past non-compliance on 03/05/25. The non-compliance began on 12/05/24 and ended on 12/06/24. The facility had corrected the non-compliance before the investigation began on 03/04/25. This deficient practice could place at-risk for elopement residents at-risk of harm, serious injury, or death. The findings included: Record review of Resident #1's admission record, dated 11/05/24, reflected a [AGE] year-old resident with an admitted [DATE], and diagnoses which included Alzheimer's disease, delusions, major depressive disorder with psychotic features, and encephalopathy (a disturbance of brain function which can cause confusion and memory loss). Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS of 00 indicating severe cognitive impairment and had exhibited behaviors of wandering. Record review of Resident #1's Wandering Evaluation, dated 11/06/24, reflected him to be independent with ambulation, with a history of wandering. Record review of Resident #1's Comprehensive Person-Centered Care Plan, dated 11/06/24, reflected resident is elopement risk/wanderer. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Record review on 3/5/25 at 8:31 AM of the Facility Provider Investigation Report, dated 12/6/24, reflected that on 12/5/24 around 6:15 AM, Resident #1 walked to a drycleaner approximately a 5-minute walk from the facility where he was found by the dietary manager. In an interview with CNA A on 3/4/25 at 6:50 PM, CNA A stated on the night of the elopement on 12/5/24, the alarm sounded at approximately 3:30 or 4:00 AM. CNA A stated she performed a head count of the residents, and all residents were present, including Resident #1. In an interview with LVN A on 3/4/25 at 7:45 PM, LVN A stated the alarm sounded around 5:00 AM to 5:15 AM. LVN A stated she looked out the window of the door to the courtyard, and it was misty outside. LVN A stated they did a head count and discovered Resident #1 was missing. LVN A stated she went back to the window of the courtyard door and saw a chair by the fence. LVN A stated the gazebo had a sofa and two chairs and one of the chairs was by the fence. LVN A stated Resident #1 could ambulate and was fit, and assumed he climbed over the fence. LVN A stated she thought Resident #1 had basic safety awareness, but with the fog and low light and his cognitive deficits, noting it was still dark outside when he left, Resident #1 could have injured himself climbing over the fence and walking through the field to get to where he was found. In an interview with the Dietary Manager on 3/5/25 at 11:19 AM, the dietary manager stated he found Resident #1 at a drycleaner across from the facility around 6:15 AM during his search for the resident which began shortly after he arrived for his shift at the facility around 5:30 AM. Resident #1 was fully dressed and had a blanket and had a bag of his belongings. The dietary manager stated that the temperature at the time was cool, not cold, and Resident #1 appeared to be in no distress, although Resident #1 did become agitated and verbally and physically aggressive when he thought the dietary manager was going to take him back to the facility. During an interview with the Acting Administrator on 3/5/25 at 3:56 PM, the Acting Administrator stated they found Resident #1 a more appropriate place that would accept him for admission. The Acting Administrator stated they did abuse, neglect and exploitation training, elopement training, elopement drills, and education on resident exit-seeking behaviors. The Acting Administrator stated there have been no elopements since Resident #1 eloped, and that he had never attempted to exit the facility before the incident. During an interview with LVN A on 3/4/25 at 7:45 PM, LVN A stated Resident #1 was discharged to the Hospital on 12/5/24 in order to find more appropriate placement. During an interview with CNA B on 3/5/25 at 12:06 PM, CNA B stated she was called in to work to provide one on one with Resident #1 until he was discharged . Record review of the Facility Provider Investigation Report on 3/5/25 at 8:31 AM revealed the medical director and responsible party were notified of the elopement on 12/5/24. The report further revealed 83 of 83 staff were in-serviced on the elopement policy and protocol from 12/5/24 to 12/6/24 and confirmed by the Administrator on 12/6/24. Staff from the day and night shifts were interviewed regarding the incident including 2 CNAs (A and C) and 1 LVN from the night shift (LVN A), 2 CNAs (B and D) and 2 LVNs (B and C) and from the day shift, 1 Dietary Manager, 1 Maintenance Director, 1 facility receptionist, and 1 laundry aide on the day shift. The staff were able to confirm they had received the in-service training. The staff were able to verbalize what to do in the event of an elopement, who to notify, recognizing exit seeking behaviors, and the purpose of the elopement protocol. The Acting Administrator was notified on 3/6/25 at 4:18 p.m., that a past non-compliance IJ situation had been identified due to the above failure. It was determined the failure placed Resident #1 in an IJ situation on 12/5/24. The facility implemented the following interventions: In an interview with the Maintenance Director on 3/4/25 at 4:27 PM, the director stated he tested each door and alarm in the facility after the elopement on 12/5/24. On conclusion of the interview, an observation of the doors and alarms was made with the Maintenance Director. All doors and alarms were working properly during the tour and the courtyard was observed to have a couch only with no chairs. In an interview with LVN A on 3/4/25 at 7:45 PM, LVN A stated an elopement protocol binder was created and stored at the nurse's station along with descriptive information for each resident and was observed by the state surveyors during the interview. In an interview with the receptionist on 03/05/2025 at 2:50 PM, the receptionist stated there was a binder at the front desk indicating which residents can go outside the facility and was observed by the state surveyor during the interview. In an interview with the Maintenance Director on 3/4/25 at 4:27 PM, the maintenance director stated facility alarms and doors were tested on [DATE] after the elopement. Upon completion of the interview, an observation of the doors and alarms was made with the maintenance director. All doors and alarms were observed to be functioning properly. All chairs in the courtyard were observed to have been removed. During interviews on 3/4/25 from 6:50 PM to 7:45 PM two staff members, (CNA A and LVN A) stated they had received the facility in-service on elopement conducted from 12/5/24 to 12/6/24 which included information on elopement protocol, awareness of the elopement binder, and monitoring residents for exit seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility. During interviews on 3/5/25 from 9:57 AM to 2:50 PM 3 CNAs (B, C, D), 2 LVNs (B, C), the Dietary Manager, 1 laundry aide and the facility receptionist stated they had received the facility in-service on elopement conducted from 12/5/24 to 12/6/24 which included information on elopement protocol, awareness of the elopement binder, and monitoring residents for exit seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility. Record review of the facility's policy titled, Elopements and Wandering Residents, dated 11/21/22, revealed the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. An Immediate Jeopardy (IJ) was identified as past non-compliance on 03/05/25. The non-compliance began on 12/05/24 and ended on 12/06/24. The facility had corrected the non-compliance before the investigation began on 03/04/25.

Based on interviews and record reviews the facility failed to provide routine and emergency drugs and biologicals to residents for 1 of 6 residents (Resident #2) reviewed for pharmacy services. The facility failed to administer Resident #2's dementia medication, Memantine 10mg twice daily (a cognitive enhancer also known as Namenda) as prescribed, as the medication was never added to her MAR until the day she was discharged . As a result of this failure, Resident #2 missed all doses of her Memantine 10mg twice daily for 47 days between 07/12/2024 through 08/27/2024. This failure could place residents at risk of not achieving the therapeutic effects intended by the physician. Findings included: Record review of Resident #2's Face Sheet dated 04/04/2025 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Metabolic Encephalopathy (condition where brain function is impaired due to underlying metabolic disturbance) and Alzheimer's Disease (also known as senile dementia, a progressive disease that destroys memory and other mental functions). Record review of Resident #2's Discharge Transfer Report revealed she was discharged from the facility on 08/27/2024. Record review of resident #2's Admission MDS, dated [DATE], revealed a BIMS score of 3 indicating severe cognitive impairment. Record review of Resident #2's care plan initiated 07/10/2024, revealed she had a focus area for impaired cognitive function/dementia or impaired thought processes, with interventions which included Administer medications as ordered. Record Review of Resident #2's Physician Progress note dated 07/12/2024 revealed under Section Assessment & Plan. Alzheimer's dementia - chronic illness with progression-continue memantine; and under Medication List: Memantine 10mg twice daily. Record review Resident #2's Order Summary as of 08/31/2024 revealed an order for Namenda Oral Tablet 10 mg (Memantine HCL) Give 1 tablet by mouth two times a day related to ALZHEIMER'S DISEASE, UNSPECIFIED (G30.9) with order and start date of 08/27/2024. Record review of Resident's #2's MARs from July 2024 through August 2024, revealed Memantine 10 mg twice daily was not listed on her MAR until 08/27/2024 effective 1700, the day she was discharged and was added after she was already gone from the facility, reflecting she did not receive her Memantine the entire time she was at the facility. During a telephone interview with a family member on 03/04/2025 at 12:25 p.m. the family member stated that when she was reviewing Resident #2's discharge medications with the discharge Nurse on 08/27/2024, she realized that Resident #2's dementia medication (Namenda) was not on the discharge medication list. When she asked about it, she discovered that the Namenda had never been started, even though it had been listed on the discharge medication list from the hospital when she was first admitted to the facility, and her physician had told them the medication would be continued at the facility. The family member stated that the discharge Nurse checked the admission note from the physician and told her that Resident #2's Namenda should have been continued while at the facility. The Nurse added the Namenda to Resident #2's medication list that day, as she was being discharged . The family member stated she visited Resident #2 frequently while she was at the facility and had noted that Resident #2 seemed to have worsening confusion. She had been receiving reports from the Nursing staff that Resident #2 was getting up at night and was out of it and she felt that some of that increased confusion may have been because Resident #2 did not receive her Namenda while at the facility. During an interview with the ADON on 03/06/2025 at 1:08 p.m., the ADON reviewed the Physician Progress Note dated 07/12/2024 and the July and August 2024 MAR's for Resident #2, and confirmed that the Nurse Practioner did order that the Memantine be continued for Resident #2. She stated it should have been added to her MAR at that time, but was not added until 08/27/2024, the day of her discharge. The ADON stated she did not know why the Memantine was not added to Resident #2's MAR, and believes it was just missed. The ADON stated that not receiving her Memantine could result in Resident #2 having worsening dementia. Interview with the Interim DON on 03/07/2025 at 2:10 p.m. revealed she has only been at the facility for about one week, but upon review of the Physician Progress Note dated 07/12/2024, and the July and August 2024 MAR's, confirmed that Resident #2 should have continued to receive her Memantine after she was admitted to the facility in July2024. She stated that not receiving medication as ordered could result in worsening of the resident's dementia. Record review of the facility policy titled Medication Reconciliation dated 4/10/2023 revealed This facility reconciles medication frequently throughout a resident's stay to ensure that the resident ifs free of any significant medication errors, and the facility's medication error rate is less than 5 percent. Further review revealed Medication Reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians and pharmacy staff. Under section titled Pre-Admission Processes: a. Obtain current medication list from referral source (hospital, home health, hospice or primary care provider); and under section titled Admission Processes: Compare orders to hospital records, etc. Obtain clarification orders as needed. Transcribe orders in accordance with procedures for admission orders.

Based on observations, interviews and record reviews, the facility failed to immediately consult with the residents' Physician; and notify her authority, the resident' representative when there was need to alter treatment for 1 of 1 resident (Resident # 1)reviewed for notification . The facility failed to notify Resident #1's physician and Relative # 1 when Resident # 1 experienced a change of condition including low blood sugar on 6/23/2024. This failure placed residents experiencing a delay in medical treatment and worsening of condition symptoms. Findings include: Record review of Resident # 1's face sheet, dated 12/7/2021, revealed she was [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with End Stage Renal Disease (a medical condition in which kidneys cease functioning on a permanent basis), Essential (Primary) Hypertension (high blood pressure), Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar levels), Dependence on Renal Dialysis ( someone's kidneys are no longer working properly and they need regular dialysis to survive), Hyperglyceridemia ( too much cholesterol), Shortness of Breath (difficult breathing), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident # 1's MDS, dated [DATE], revealed she a BIMS score of 5 ( severe cognitive Impairment); Resident # 1 had difficulty focusing attention and altered level of consciousness. Resident # 1 required limited assistance from at least one staff for transfers and bed mobility. Insulin injections were received during the last 7 days. Record review of Resident # 1's care plan, revised 11/30/2023 revealed the following care areas: o Resident # 1 has Diabetes Mellitus and was at risk for unstable blood glucose levels. Goals include resident will be free from any s/sx of hyperglycemia. Resident # 1 will have no complications related to diabetes. Resident # 1 will be from any s/sx hypoglycemia. Intervention include administer medication as ordered per MD, monitor/document /report PRN any s/sx of hypoglycemia (low blood sugar), Sweating, Tremor, Increased heart rate (Tachycardia) Pallor ( loss of skin color) , Nervousness, Confusion, slurred speech, lack of coordination, staggering gait( unsteady walking pattern). o Resident # 1 was on hemodialysis related to end stage renal disease on Monday, Wednesday and Friday at 11:30 am. Days may vary based on holidays and dialysis center schedule. Goals include intervention should any s/sx of complication from dialysis occurs. Interventions incudes monitor vital signs and notify MD of significant. Record review of Resident #1's progress note dated 6/23/2023 at 12:10 pm, LVN A wrote Resident with BGS of 47, this nurse provided snack and drink to resident and stayed at bedside. Rechecked BGS approximately 10 minutes later and sugar was 157. No hypoglycemic symptoms displayed during this episode. Record review of Resident # 1's Blood Sugar Summary for June 2024 revealed: o 6/23/2024 at 7:53 am blood sugar was 167 mg/dl o 6/23/2024 at 11:47 am blood sugar was 47 mg/dl o 6/23/2024 at 6:28 pm blood sugar was 226 mg/dl o 6/23/2024 at 10:01 pm blood sugar was 122 mg/dl Record review of Resident # 1's reviewed on 5/28/2024 revealed: o Novolog injection solution 100 unit/ml-insulin aspart (an insulin analog indicated to improve glycemic control in patients with diabetes mellitus). Directions: inject 10 unit subcutaneous; start date 6/3/2024. End date: open ended o Give a peanut butter and jelly sandwich. Directions: at bedtime for Diabetes Mellitus; start date 5/1/2024. End date: open ended o Ozempic (0.25 or 0.5 mg/dose) Subcutaneous solution pen injector 2mg/3/ml (Semaglutide). Direction: Inject 0.5 mg subcutaneous; start date 4/29/2024. End date: open ended o Novolog Injection Solution 100 unit/ml (insulin aspart). Directions: Inject as per sliding scale; start date 3/27/2024. End date: open ended o ACCUCHECKS before meals and at bedtime. Directions: before meals and at bedtime; start date 6/22/2023. End date: open ended o Glucan emergency injection kit 1 mg (Glucagon rDNA). Directions: Inject 1 dose intramuscular; start date 6/21/2023. End date: open ended In an interview with Relative # 1 on 6/27/2024 at 10:30 am she stated that Resident # 1 was a diabetic. She stated that on 6/23/2024 Resident # 1's sugar was 47. She stated that no one from the facility contact her about Resident # 1's change of condition. She stated that on 6/24/2024 LVN A told informed her that Resident # 1's sugar was low on 6/23/2024. She stated that LVN A stated that Resident # 1's sugar was 47 and she gave Resident# 1 cookie and juice. She stated that LVN A rechecked Resident # 1's sugar and Resident # 1's sugar was 150. She stated that LVN A did not contact Resident # 1's doctor or Relative # 1 because Resident # 1 did not have any signs of distress and Resident # 1 was talking to her and stated she was okay. She stated LVN A stated that she stayed by Resident # 1's side and she made certain Resident # 1 was not in distress and not having signs of Hypoglycemia. Relative # 1 stated that she spoke with the Administrator about Resident # 1's sugar levels. She stated that the Administrator stated that she did not know that Resident # 1's sugar dropped as LVN did not notify her, Resident # 1's doctor or the DON. Observation of Resident # 1 on 6/27/2024 at 2:20 pm. Resident # 1 was in a wheelchair and Relative # 1 was taking her out for fresh air. Resident # 1 was non-interview able as she had limited verbal skills. In an interview with LVNA on 6/27/2024 at 4:40 pm she stated she checked Resident #1's sugar on 6/23/2024 at 11:30 am and Resident # 1's sugar was 47. She stated that Resident # 1 had a can of sprite and cookies by her bed. She stated that she gave Resident # 1 sprite and cookies. She stated that Resident # 1 was talking to her and did not have any sign of distress. She stated that 10 minutes later she rechecked Resident # 1's sugar and it was 152. She stated she did not consider this a change of condition because Resident # 1 talking and was not altered. She stated Resident # 1's sugar was out of range. LVN A stated that she apologized to Resident # 1's family. LVN A stated that if a resident's sugar was at 47 the resident could go into a coma and lose consciousness. LVN stated that she did not contract Resident # 1's doctor or representative. LVN A stated that she did not contact the DON. LVN A stated that she in-serviced on change of conditions. In an interview on 6/27/2024 at 4:00 pm with the DON she stated she found out about Resident # 1's low blood sugar on 6/26/2024. She stated LVN A told her Resident # 1's blood sugar was 47 and Resident # 1 did not display hypoglycemia. The DON stated LVN A gave Resident # 1 snacks and rechecked Resident # 1's blood sugar and it was 157. She stated she told LVN A that since Resident # 1's blood sugar was below 60 she should have notified the NP and family. She stated that LVN A did not notify the NP and family because when LVN A rechecked Resident # 1's blood sugar it was within normal range. The DON stated that if a resident's blood sugar is low the resident may experience sweating, confusion, and tremors. She stated that LVN A has been in-serviced on change of condition. In an interview on 7/2/2024 at 8:20 pm with the ADON she stated that LVN A reported Resident # 1's low blood sugar after the fact. She stated that when she read the 24 hours report she noticed that Resident # 1's blood sugar was low. She stated LVN A checked Resident # 1's blood sugar and it was low. She stated LVN A gave Resident # 1 snack and later rechecked Resident # 1's blood sugar and it was within normal range. The ADON stated that she could not remember the sugar levels for Resident # 1. The ADON stated she expected the nurses to contact the residents Doctor/NP, family and DON. She stated that LVN A should have contacted the resident's doctor and received orders from the doctor. She stated that staff was in-serviced on change of condition on 6/27/2024. Record review of Notification of Changes policy, dated 10/24/2024, revealed: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician: and notifies consistent with his or her authority, the representative when there is a change requiring notification. Circumstances requiring notification include: 2) Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a) Life-threatening conditions or b) Clinical complications Record review of In-service training report: Notification of Change, dated 4/6/2024, revealed For all changes of conditions, please call DON and/or Administrator. Texting is not acceptable. Signed by LVN A on 4/8/2024. Record review of In-Service training report: Notification of Change, dated 6/27/2024, revealed When a resident has any change of condition, the physician, or NP, RP, and DON must be notified. This should be documented in PCC on Change of Condition form and a progress note should be completed with any additional information. Signed by LVN A on 6/27/2024.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that: -The facility stored unlabeled and unsealed foods in the freezer. This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status. Findings Included: Interview and observations on 01/17/2024 at 8:22 AM with the Dietary Manager. In freezer #1 there were unlabeled bags of what the Dietary Manager identified as diced ham, chicken fried steak, and taquitos. The Dietary Manager said the bags should be labeled. Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said he was responsible for ensuring residents are served what they needed and what they were supposed to have. He said he was responsible for the day-to-day things like inventory, ordering, training, and interviewing patients on their preferences He said the food items must be dated with the pick sticker. The pick stick contains ithe information of the date delivered, and the date it was received which he said he physically wrote on the sticker. He said the reason for the failure was the items that were unlabeled were uncooked, they were not labeled and placed in freezer #1. He said the taquitos had not been served since he had been at the facility. He said he discarded the unlabeled foods yesterday (1/17/24). He said he had not been in-serviced on food storage. He said he was responsible for ensuring policy was followed. He said the risk to residents if policy was not followed was a health risk to the residents. He said death was the worst thing to happen if policy was not followed. He said he did not know why the failure occurred, just that those foods had not been served since he had been there. Interview on 01/18/2024 at 11:01 AM with the Administrator. She said she had worked at the facility for five months. She said she oversaw all departments, was abuse coordinator, problem solver and ensured residents were taken care of. She said the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. She said the shelf life of items in the fridge was three days. She said she did not know why the items were not dated and that staff did not follow up. She said she last had training on food storage about two months ago. She said the risk to residents if policy were not followed was, they could get sick from food borne illnesses. She said the worst thing that could happen was residents got sick and ended up in the hospital or worse. She said she thought the failure occurred because staff may have been in a rush and did not follow policy. Record review of the Food Storage policy dated October 01, 2018, reflected in part . 2. Refrigerators: D: Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezers: E: Store frozen foods in moisture-proof wrap or containers that are labeled and dated . Review of Texas food Establishment Rules accessed https://www.fda.gov/media/164194/download 08/16/2023 revealed in annex 3 page 17: the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer ' s information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for one waste receptacle reviewed for garbage disposal. -The waste receptacle had its top left lid opened when no one was disposing of trash. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings include: Observation 01/17/2024 at 8:42 AM. The left lid on the outside dumpster was observed to be open. Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said the policy on the dumpster was the lids should have been closed. He said it was difficult to close the lids and he said he would talk to the Maintenance director for something to help close the lids. He said the wind may have helped close or open the lid to the dumpster. He said he did not know who was responsible for ensuring the dumpster lid was closed. He said the risk to residents if policy were not followed was it could draw in rodents and pests, and they could then get into the building. Interview on 01/18/2024 at 11:01 AM with the Administrator. She said the policy on the dumpster was the lid should always be closed. She said risk to residents if policy were not followed was residents could be harmed by animals and pests getting in the dumpster. She said she thought the failure occurred because staff were careless. Record review of the Garbage Receptacles dated October 01, 2018, read in part . Outdoor receptacles: It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to ensure catheter changing procedures were followed by staff in the direct care for 2 (Resident #1 and Resident #2) of 5 residents reviewed for catheter care. The facility failed to change Resident #1 and Resident #2's foley catheters when ordered. These failures could place residents at risk for infection and blocked urinary catheters. Findings: Resident #1 Record review of Resident #1's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnosis of Unspecified Dementia (Memory Loss), Heart Failure (Loss of heart Function), Pressure Ulcer Sacral Region (Wound to Buttock), Heart Disease (Blocked Arteries in the Heart), Muscle Wasting and Atrophy (Loss of Muscles). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident was severely cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing and toileting with 2 persons. Section H noted indwelling catheter. Record review of Resident #1's Care Plan dated 12/15/2022 revealed . a Foley Catheter related to BPH with retention, stage IV pressure ulcer to sacrum .Goal .The resident will show no s/sx of urinary infection through review date .Interventions . change catheter every Wednesday and PRN .Change Foley Cath each month on the 15th .Change foley cath bag the 1st and the 15th of each month . Record review of Resident #1's Physician Orders dated 4/26/2023 revealed . Change Foley Catheter once monthly one time a day starting on the 15th and ending on the 15th every month related to Pressure Ulcer of Sacral Region, Stage 4, Obstructive and Reflux Uropathy, Unspecified . Observation on 8/16/2023 at 10:10am Resident #1's Foley bag was dated 6/16/2023 written in black ink. Resident #2 Record review of Resident #2's Face Sheet revealed a [AGE] year-old male with a history of Unspecified Dementia, Moderate with Other Behavioral Disturbance (Memory Loss), Cerebral Infarction (Disrupted Blood Flow to the Brain), Muscle Wasting and Atrophy (Muscle Loss), Atherosclerotic Heart Disease of Native Coronary Artery (Heart Disease). Record Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating the resident was moderately cognitively impaired. Resident #2 required limited assistance with bed mobility, dressing and toileting. Resident #2 required extensive assistance with transfers and required the assistance of one person. Section H noted indwelling catheter. Record review of Resident #2's Physician Orders dated 6/27/2023 revealed . Foley Catheter: Change 16F with 10ml bulb every night shift starting on the 27th and ending on the 28th every month . Neuromuscular Dysfunction of Bladder. Observation on 8/16/2023 at 10:30am Resident #2's Foley bag was dated 6/27/23 written in black ink. In an interview on 8/16/2023 at 11:05am with the Wound Care Nurse she said she had worked at the facility for 2 weeks. She said the importance of changing the foley catheter bag out every 30 days was to prevent bacteria from growing in the catheter and to prevent infections. She said she had not been in serviced on foley catheter care since working at the facility. In an interview on 8/16/2023 at 11:35am with CNA A she said she had worked at the facility since June of 2023. She said she had been a CNAs for 5 years. She said her duties were to clean, feed, change and reposition residents. She said she transferred residents, showered, and groomed them. She said the reason for changing the foley out was to prevent infection. She said she had last been in serviced on foley care 1 or 2 weeks ago. In an interview on 8/16/2023 at 12:50pm ADON A said she had worked at the facility since April 24,2023 and had been a nurse for almost [AGE] years. She said her duties were to check orders, check CNAs, help nurses, call physicians, and help where needed. She said she conducted in services and trainings. She said the last in service on foley care was not long ago and was not sure when. She said it was important to change a foley catheter out every 30 days because residents developed residue inside of the foleys and to prevent infection. She said foley catheters can get clogged and urine may not drain from the bladder due to not being changed out. In an interview on 8/16/2023 at 1:25pm with the DON who said she had worked at the facility for 7 days. She said she oversaw nursing care at the facility. She said she transferred from another facility to improve care. She said changing a foley catheter as ordered was for infection prevention. She said if foleys were not changed as ordered there was potential for backflow of urine. She said she did not know when the last in service on foley care was conducted. In an interview on 8/16/2023 at 1:36pm ADON B said she had been ADON at the facility for almost 3 months. She said she had been a nurse for almost 3 years. She said her duties were to oversee halls three and four. She said the importance of changing a foley bag out once a month was to prevent an infection of the urinary tract. On 8/16/2023 at 1:40pm surveyor requested policy on catheter care from the DON and did not receive one.

Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 (Resident #1) of 5 residents reviewed for dignity. The facility failed to provide dignity and respect for Resident #1 by leaving the residents privacy bag off his foley bag exposing the full urinary bag to open doorway. This failure placed resident and could place other residents at risk for embarrassment and low self esteem. Findings: Record review of Resident #1's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnosis of Unspecified Dementia (Memory Loss), Heart Failure (Loss of heart Function), Pressure Ulcer Sacral Region (Wound to Buttock), Heart Disease (Blocked Arteries in the Heart), Muscle Wasting and Atrophy (Loss of Muscles). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident was severely cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing and toileting with 2-person assistance. Section H noted indwelling catheter. Record review of Resident #1's Care Plan dated 12/15/2022 revealed . has a Foley Catheter related to BPH with retention, stage IV pressure ulcer to sacrum .Goal .The resident will show no s/sx of urinary infection through review date .Interventions . change catheter every Wednesday and PRN .Change Foley Cath each month on the 15th .Change foley Cath bag the 1st and the 15th of each month . Record review of Resident #1's Physician Orders dated 4/26/2023 revealed . Change Foley Catheter once monthly one time a day starting on the 15th and ending on the 15th every month related to Pressure Ulcer of Sacral Region, Stage 4, Obstructive and Reflux Uropathy, Unspecified . On 8/16/2023 at 10:10am Surveyor observed Resident #1's foley catheter bag without privacy bag on. Catheter bag was observed full of urine, hanging at the end of the bed, face out to doorway. In an interview on 8/16/2023 at 11:27am with the Wound Care Nurse she said she had worked at the facility for two weeks. She said the importance of covering the foley bag was for privacy and dignity with residents. She said she had not been in serviced on privacy and dignity since coming to work at the facility. She said she had not been in serviced on foley catheters since coming to work at the facility. In an interview on 8/16/2023 at 11:35am with CNA A she said she had worked at the facility since June 2023. She said the privacy bag for foley catheters was to prevent others from seeing urine in the bag. She said it was embarrassing to some residents when others could see urine in their foley bag. She said she had not been in serviced on foley care since working at the facility. In an interview on 8/16/2023 at 12:50pm with ADON A she said she had worked at the facility since April 24, 2023. She said she had been a nurse for almost [AGE] years. She said her duties were to check orders, check CNAs, help nurses, call doctors, help where needed, do in services, and training. She said the privacy bags on the foleys were for dignity issues for the residents, so they had privacy. She said the residents could get upset and embarrassed when others saw urine in the foley bag. In an interview with the DON, she said she had been working at the facility for seven days. She said the reason for privacy bags was to protect resident rights and dignity. She said when privacy bags are not used, residents were embarrassed. She said she did not know when the last in service on foley care was conducted. In an interview on 8/16/2023 at 1:36pm with ADON B she said she had been the ADON at the facility for almost three months. She said she had been a nurse for three years. She said her duties were to oversee nurses for halls three and four. She said they were last in serviced on Foleys yesterday, but she was not at work. She said the importance of having a privacy bag over a Foley was it gave resident dignity, she said staff should have had to cover the bag as it looked gross from the resident's perspective. She said the residents could have become insecure from having their urine exposed. Record review of facilities policy titled, Promoting/Maintaining Resident Dignity read in part . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Maintain resident privacy .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to ensure a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 staff (CNA B) observed for hand hygiene. The facility staff failed to use proper handwashing technique when assisting Resident #3. This failure could place Resident #3, other residents and staff at risk for infection. Findings: Record review of Resident #3 s Face Sheet revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety (Memory Loss), Unspecified Protein Calorie Malnutrition (Lack of Nutrition), Type 2 Diabetes (High Blood Sugars), Dysphagia (Difficulty Swallowing). Record Review of residents quarterly MDS dated [DATE] revealed a BIMS score of 0 out of 15 indicating severely cognitively impaired. Resident #3 required total dependence on bed mobility, transfers, dressing and toileting with one person assistance. Section K noted a feeding tube. Record Review of residents Care Plan dated 8/4/2023 revealed . requires tube feeding r/t swallowing problem .The resident will remain free of side effect or complications . On 8/16/2023 at 9:50am surveyor observed CNA B manipulating Resident #3's g tube and gown. CNA B walked to doorway, took off gloves and did not use hand sanitizer or wash hands. CNA B walked out into hallway, touched door handle of linen room, entered linen room, gathered clean linens, and entered resident #3's room. CNA B did not wash her hands or use hand sanitizer, she did not don gloves. CNA B began touching Resident #3's G tube. Surveyor observed leakage coming from G tube and onto Resident #3's gown. Surveyor observed CNA B place a towel under leaking G tube, wipe her hands on the towel and then place gloves on. After care was provided surveyor observed CNA B walk to trash can, take gloves off, gather trash bag, leave room without washing hands or using hand sanitizer, walk over to dirty utility room, punch in door code, enter dirty utility room, leave utility room, come back out and reenter Resident #3's room without washing hands or using hand sanitizer. CNA B then donned gloves and assisted resident. CNA B completed care, discarded gloves, and came out of room without washing hands or using hand sanitizer. In an interview on 8/17/2023 at 09:58am with CNA B she said she had been a CNAs since 2019. She said she knew the process for coming in and out of a resident's room was to wash hands. She said she knew she did not wash her hands both times she came out of Resident #3's room and she did not use hand sanitizer. She said Germs could have spread when hands were not sanitized, and they could carry bacteria and infection. CNA B said she would wash her hands and use hand sanitizer in the future. CNA B said her last in service on handwashing was in nursing school in April 2023. In an interview on 8/17/2023 at 10:00am with ADON B she said she had worked at the facility for 3 months. She said she had been a nurse for 3 years. She said the last time she was in serviced on handwashing was 2 weeks ago. She said she was supposed to use hand sanitizer prior to going into and leaving a resident's room. She said she could wash her hands as well. She said if hands were not sanitized, they could carry different diseases to residents, staff to staff and to visitors. She said the environment could be contaminated. In an interview on 8/16/2023 12:50pm with ADON A she said the importance of hand sanitizer or hand washing prior to going in a resident's room was to prevent carrying germs in. She said cleansing hands between glove changes was important because there may have been a tear or hole in the glove allowing bacteria to pass through. She said hand hygiene was important after caring for a resident, so germs were not carried out of the room to the next resident. She said hand hygiene was to prevent infection. In an interview on 8/16/2023 at 1:18pm with CNA C she said washing hands and gloving were important prior to resident care for infection control so the resident was not given disease. She said after providing care she took her gloves off and used hand sanitizer as it was important to prevent the spread of infection. She said the last in service on handwashing was today. In an interview on 8/16/2023 at 1:25pm with the DON she said infection control was the basis of everything they did to prevent cross contamination. She said handwashing and sanitization was the number one prevention and she was not aware staff did not sanitize their hands. In an interview on 8/16/2023 at 1:36pm with ADON B she said the last in service on handwashing was 2 weeks ago when they had a couple of residents with Covid. She said the Covid in service included hand washing. She said the process for going into a resident's room was to use hand sanitizer going in and out. She said after 3 hand sanitizers then they washed hands. She said between glove changes they would have washed hands or used hand sanitizer. She said cross contamination with germs can happen if these processes were not followed and residents and staff could have acquired an infection. Record review of facilities policy titled, Hand Hygiene dated 10/24/2022 read in part . All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working within the facility .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

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 1 (Resident#1) of 1 resident reviewed for infection control in that: 1. LVN A failed to demonstrate proper hand hygiene and changing of gloves when providing wound care for Resident#1. 2. LVN A changed dressing to Resident#1's sacral area while Resident#1 was on soiled bed linens. 3. LVN A did not prepare a sanitary area for clean dressings prior to wound care. These deficient practices could place residents at risk for infection and inadequate wound healing. Findings Included: Record review of Resident#1's face sheet revealed a [AGE] year-old male admitted on [DATE]. Resident#1's diagnoses were Other Frontotemporal Neurocognitive Disorder (Impaired Memory), Dysphagia (Impaired Swallowing), Oral Phase, Muscle Wasting and Atrophy (Inability to Move Muscles), Cognitive Communication Deficit (Difficulty with Communication), Unspecified Dementia (Impaired Thinking), Stage 4 Pressure Wound Sacrum Full Thickness (Deep Wound to Buttocks). Record Review of Resident#1's quarterly MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating Resident#1 was severely cognitively impaired. Resident#1 required total dependance on Bed Mobility, Dressing, Eating, Toilet Use for Bowel and Bladder with two person's for assistance. Section M read . Resident has unhealed pressure ulcers . Record review of Resident#1's Care plan dated 5/1/2023 read in part .6/6/2023-Stage 3 pressure Wound Sacrum. The residents pressure ulcer/injury will show signs of healing .Decrease in size/measurements and will remain free from signs and symptoms of complications (including infection) by/through next review date . Record review of Resident#1's Wound Physician's note dated 7/7/2023 read in part . Stage 4 Pressure Wound Sacrum .Surgical Excisional Debridement Procedure .Remove Necrotic Tissue . Record review of Resident#1's Physician Orders dated 7/8/2023 read in part . Cleanse wound with wound cleanser or normal saline. Pat dry. Apply Medi Honey (Dressing). Cover with Calcium Alginate (Dressing) and dry dressing as needed for dislodgement or soilage . Observation on 7/10/2023 at 9:04am revealed Resident#1 for pressure ulcer treatment performed by LVN A, resident on his side with urine-soaked linens pushed up alongside Resident#1's back, buttocks and legs. Surveyor noted dressing change performed while resident on soiled linens. Surveyor noted no sanitary area for wound supplies. Surveyor observed clean wound supplies on soiled bedside table with no barrier, and wound cleanser bottle in resident's bed. Surveyor observed LVN A wash and dry hands, apply gloves, remove dressings, remove gloves, don new gloves with no handwashing or hand sanitizer, clean wound, remove gloves, and not wash hands or use hand sanitizer. LVN A donned new gloves and applied new dressings. LVN A did not wash her hands or use hand sanitizer prior to leaving room. In an interview on 7/10/2023 at 9:04am with LVN A, she said she was not certified in wound care and was an agency nurse. She said this was her third time at the facility. She said she had been a nurse for nineteen years and had done wound care in the past, but not consistently. She said she knew about proper handwashing technique and hand sanitizer and she said she had not been performing hand sanitizing. She said she learned about hand washing in nursing school and knew consequences to residents such as infection and prolonged healing if hands are not sanitized. She said the physician was here on Friday and Resident#1 wound was found to be not healing. She said the physician debrided the wound. She said she should have changed the soiled linens before administering wound care. In an interview on 7/10/2023 at 9:30am with the DON, she said they took steps in wound care and the first steps were to assess for pain. She said they should have gathered supplies and placed them on a clean surface like wax paper. She said the wound cleanser is located on the treatment cart and it is applied to 4x4's and taken into the resident's room. She said when dressings were removed the nurse should have removed her gloves, cleaned hands, and reapplied gloves. She said when residents are soiled, incontinent care would be provided prior to wound care to prevent contamination of wound. She said applying hand sanitizer between glove changes is to prevent infection, she said it was policy to do this. In an interview on 7/10/2023 at 12:45pm with LVN B she said she had worked at the facility since November. She said they had done in services last week but could not remember if one of them was on infection control. She said she had been a nurse for [AGE] years and when residents were soiled, she cleaned them up prior to performing wound care. She said she also placed a barrier under the residents prior to starting wound care. She said when she prepped for the procedure, she cleaned the bedside table and then placed a barrier such as wax paper to put the dressings on and said the reason for this was to prevent infection. She said everything needed to be clean prior to performing the procedure. Record review of facility policy titled, Hand Hygiene, dated 10/24/22, read in part . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Staff will perform hand hygiene .consistent with accepted standards of practice .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections involving 4 of 4 staff (Medication Aide B, ADON A, Treatment nurse and Housekeeper CC) and 4 of 6 residents (Resident #10, #78, #55 and#45) reviewed for infection control in that: -Medication Aide B did not disinfect the wrist blood pressure monitor in between Resident #10 and #78 when checking their vital signs. -Medication Aide B did not wash or sanitize her hands before entering Resident #10 and #78's room to check their vital signs through direct resident touch. -ADON A did not wash her hands or use hand sanitizer after performing [CONDITION(S)] care for Resident#55. -Treatment nurse did not wash her hands or use hand sanitizer after removing soiled brief for Resident#45. These failures could affect residents and place them at risk of infection through cross-contamination. Findings included: Resident #10 Observation of medication pass on 10/25/22 at 9:18a.m., revealed Medication Aide B opening and closing drawers, touching her computer screen without gloves, and then entering into Resident #10's room with a wrist blood pressure monitor without performing hand hygiene. Medication Aide B came out of Resident #10's room without washing or sanitizing her hands or the equipment. Medication Aide B placed the wrist blood pressure monitor on top of the medication cart before documenting the vitals/administering morning meds and went to Resident#78's room. Resident #78 Observation on 10/25/22 at 9:40 a.m., revealed Medication Aide B without washing or sanitizing her hands or the wrist blood pressure monitor checked Resident #78's vitals with the same equipment used on Residents #10. Medication Aide B placed the equipment on top of the medication cart and documented the vitals/administered meds and did not wash her hands or sanitize the equipment she used. In an interview on 10/25/22 at 9:50a.m., with Medication Aide B, she said she was going room to room checking residents' vitals that needed their blood pressure checked before administering their meds. She said she was aware that she needed to wipe all multi use equipment between residents. The surveyor shared med pass observation from earlier with Medication Aide B. Medication Aide B said she received training on infection control almost every month. She said she was nervous and forgot to sanitize her hands/wrist blood pressure monitor in between residents. She said not washing hands and sanitizing multi use equipment increases the risk for spreading germs and cross contamination. Resident #55 Record review of the admission sheet for Resident #55 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), [CONDITION(S)] status (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) and functional [CONDITION(S)] (complete immobility due to severe physical disability or frailty). Record review of Resident #55's quarterly MDS assessment dated [DATE] revealed his BIMS score was 14 out of 15 indicating intact cognition. Record review of Resident #55's care plan initiated 06/02/2022 revealed the following care plan: Problem: [Resident#55] has constipation r/t decreased mobility [CONDITION(S)] disorder d/t bed confinement status functional [CONDITION(S)] and has a [CONDITION(S)]. Goal: The resident will pass soft, formed stool at the preferred frequency of every 3 days through the review date. Interventions: Change [CONDITION(S)] bag every 3 days Observation on 10/25/22 at 9:54a.m., revealed ADON A provided Resident #55 with [CONDITION(S)] care. ADON A completed [CONDITION(S)] care and with the same soiled gloves, touched the resident's clean gown and brief. ADON A picked up the trash, then removed her right-hand soiled glove (carrying the trash with her left-hand soiled glove) and left the room without washing or sanitizing her hands. This Surveyor followed ADON A. ADON A went to the shower room on hall 400. ADON A opened the shower room with a code, looked inside and said, no barrels. ADON then went through the dining room to hall 300's shower room, still holding the trash with her left hand In an interview on 10/25/22 at 10:03a.m., with ADON A, she said she emptied Resident #55's [CONDITION(S)], went to the Hall 400 shower room but there were no barrels, so she went to Hall 300 shower room to throw the trash. She said she did not wash or sanitize her hands after leaving Resident #55's room. She said, I had glove on because I was carrying possible soil trash bag with my left hand, so I didn't remove my left-hand glove. My right hand was clean I pressed the code on the shower room door with my right hand. I didn't see the barrels someone might have taken it out, so I went to hall 300 shower room to throw the trash. She said she had been in-serviced on hand washing/ infection control recently. She could not recall the exact date. Resident# 45 Record review of the admission sheet for Resident #45 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #45's quarterly MDS assessment dated [DATE] revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. She was totally dependent on two persons physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #45's care plan initiated 10/29/2021 revealed the following care plan: Problem: Pressure ulcer/injury: The resident has an alteration in skin integrity r/t the presence of a stage 2 pressure ulcer/injury on my sacral with a date of origin of 4/8/22. See skin integrity care plan for risk factors contributing to pressure ulcer/injury development. Stage 2 being treated with medi-honey and CA. 10/18/022-stg 4 to sacrum apply leptospermum honey and calcium Alginate apply gauze island w/boarder. Goal: The resident will remain free from additional pressure ulcers/injuries through next review date. Interventions: evolution of the status of the dressing and surrounding skin (i.e , Q3D dressing changes) as needed. Observation and interview on 10/26/22 at 2:40p.m., revealed Treatment nurse performed wound care on Resident#45 assisted by ADON A. Resident#45 was assisted on her left side prior to starting the wound care. Treatment nurse removed Resident#45's soiled brief and said, there is no trash bag I will be back. The Treatment nurse removed soiled glove from her right hand and carried the soiled brief on her left hand with glove on and left the room. This Surveyor followed the Treatment nurse. The Treatment nurse went to the shower room and disposed the soiled brief in the barrel. In an interview on 10/26/22 at 2:56p.m., with the Treatment Nurse, she said there was no trash bag in the trash can, so she had to take the soiled brief to the shower room to throw it in the barrels. She said she did not wash or sanitize her hands before leaving the room. She said she had the glove on her left hand because she was carrying the soiled brief. In an interview on 10/27/22 at 10:42a.m., with the DON, surveyor shared her observations from earlier. The DON said her expectation for the staff was to either sanitize or wash their hands after glove changes and to wipe down multi use equipment after every resident use. She said she was the facility's infection preventionist. She said she in serviced staff periodically and as needed monthly on different subjects to include infection control and hand hygiene. She said staff were educated to remove gloves prior to leaving the residents room and to not have gloves on the hallway. She said the bacteria could travel from which may or may not be on the gloves and to keep it contained. She said ADON A was going to throw the soiled trash in the shower room, but somebody took the barrels out. She said the Treatment nurse should have placed the brief in the trash can and disinfected the trash can after. She said the staff needed to be re-educated and in-serviced on infection control as it was at risk for spreading infections. In an interview on 10/27/22 at 12:35p.m., with the DON, she said the facility did not have a policy on standard infection control. Record review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy (revised January 2018) read in part: .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne pathogens standards . Record review of facility's Hand Hygiene policy (dated 10/24/22) read in part: .Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with the accepted standards of practice. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for comprehensive assessments. 1. The facility failed to ensure Resident #1's comprehensive care plan reflected Resident refusal of meal trays related to paranoia and that Resident #1 believed the aids would try to put something in her food to harm her. 2. The facility failed to ensure Resident #1's comprehensive care plan was developed to address that Resident #1 was placed on 1 to 1 supervision for a suicidal attempt as of 1/12/22. These failures could place residents at risk of not receiving the care and treatment listed in the care plan and could lead to a diminished quality of care, injury to skin, and development of urinary tract infections. Findings include: Record review of the admission sheet for Resident #1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed the BIMS score was 14 out of 15, which indicated intact cognitive mental status The MDS revealed she required total dependence from two staff with transfers, dressing and toilet use. Record review of Resident #1's nurses notes, dated 1/12/2022 at 3:34 pm written by RN A, read in part: .The resident had broken a glass tabasco sauce bottle and attempted to cut herself . In an observation and interview on 1/20/22 at 9:46 a.m., with Resident #1 revealed she had 1:1 sitter at her bedside. Resident #1 said she was placed on 1 to 1 since last week. She said I usually refuse to eat dinner meal tray because I do not trust 2 to10 p.m. shift staff. The aides will mess with my food. So, I order food from outside. In an interview on 1/20/22 at 9:51 a.m. with CNA A, she said she was sitting with Resident #1 as 1:1 sitter. She said Resident #1 was placed on 1 to 1 for week and a half because the resident tried to hurt herself. In an interview on 1/20/22 at 9:57 a.m., with the ADON, she said she was the change nurse for hall 300. She said Resident #1 was placed on 1 to1 because she had suicidal ideation and threatened to follow through with the plan. In an interview on 1/20/22 at 10:49 a.m. with the DON, she said Resident #1 has Paranoia that aides were putting something in her food. She said the resident was placed on 1:1 with a sitter at her bedside for a suicide attempt since she had returned from the ER. Record review of Resident # 1's care plan, initiated 9/29/2021 revealed no documentation of care plans addressing refusal of food due to paranoia and cutting herself and having to be placed on 1:1 due to suicidal ideation. In an interview on 1/20/22 at 1:45 p.m., with the Care Management nurse, she said she updated Resident #1's care plan when the DON brought it to her attention today. She said the resident was not care planned for the refusal of meal tray and eating intervention were not added. She said Resident #1 went to the ER last week and was on her list to update the care plan. She said she was out for the last 3 days. She said in her absence the Social Worker and nurses could update the care plan. She said it was important to update the care plan because nurses followed the care plan. In an interview on 1/20/22 at 2:04 p.m. the DON said the Care Management nurse was responsible for updating and completing the comprehensive care plan. She said corporate had travel nurses that assisted with care plans. She said it was important to update the care plan because it was the plan that told how the facility would care for her. Record review of the facility's Care planning policy (revised December 2017) read in part: .A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial and functional needs. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team which includes, but is to necessarily limited to the following personnel: a. The Registered Nurse who has responsibility for the resident; c. The Social Services worker responsible for the resident, g. The Director of Nursing (as applicable); h. The Charge Nurse responsible for resident care .

Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 3 residents reviewed for transfers (Resident #274). NA G initiated a mechanical lift transfer without the assistance of additional staff for Resident #274. The facility did not make sure two staff members were always available during a mechanical lift transfer for Resident #274 who sustained a fractured left femur. This failure could place residents who required assistance with transfers at risk for discomfort, pain and injury. Findings included: Record review of physician orders dated [DATE] indicated Resident #274 was [AGE] years old readmitted on [DATE] (original admitted [DATE]) with diagnoses including cerebral infarction (stroke), history of traumatic brain injury, cortical [CONDITION(S)] of the left and right side of the brain, lack of coordination and muscle wasting and atrophy. Record review of the MDS dated [DATE] indicated Resident #274 was severely impaired cognitively, usually understood other and sometimes made herself understood. The MDS indicated Resident #274 BIMS (Brief Interview of Mental Status) was 06 on a scale of ,d+[DATE] which indicated her cognition was severely impaired. The MDS indicated she required limited assistance with bed mobility, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident #274 required extensive assistance with transfers requiring 2-person (staff) assistance. Resident #274 was totally dependent on staff for bathing. Record review of an undated care plan indicated Resident #274 was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits and immobility. The care plan indicated Resident #274 had an ADL self-care performance deficit related to confusion, impaired balance, history of CVA (cerebral vascular accident), generalized weakness, muscle atrophy and wasting, and poor safety awareness. One of the interventions to this ADL performance self-care deficit was during transfers the resident was totally dependent on two staff and required a mechanical lift that required 2 staff for transfers. The care plan indicated Resident #274 had limited physical mobility related to neurological deficits, weakness, traumatic brain injury, impaired mobility and impaired cognition and thus, the resident was non-weight bearing (she could not bear weight on her legs). The care plan indicated Resident #274 had [CONDITION(S)] related to inadequate calcium intake and was at risk for fractures and the interventions included to monitor the resident for falls and injuries. A record review of the facility's undated investigation report revealed on [DATE] Resident #274 complained of pain and had discoloration noted to her lower left extremity. The investigation report indicated Resident #274 was assessed by nurse and treated for pain. The nurse updated the resident's provider and the provider ordered STAT x-rays. The report indicated x-rays completed on [DATE] returned with a finding of a left femoral diaphyseal fracture and the provider was updated on the findings. The report indicated the provider ordered the resident to be sent to local hospital via ambulance for further treatment. The report indicated the resident's responsible party was notified and a full investigation was in progress. The report revealed NA G provided care to resident on the morning shift of [DATE] and was placed on suspension pending the investigation. The report indicated the facility provided staff education related to findings of the investigation. A record review of a facility investigation interview dated [DATE], the Interim DON documented a conversation with CNA L . CNA L was working on 300 Hall and helped transfer Resident #274 back to bed with the help of RN J. CNA L noted the swollen area to the posterior thigh of the resident's left leg and alerted the charge nurse, LVN K and the DON. Upon assessment of the area it was noted that there was localized soft tissue swelling approximately 7 inches by 4 inches . A record review of a facility investigation phone interview on [DATE], the Administrator documented .NA G worked the 6 a.m. to 2 p.m. shift on [DATE] and was assigned to work the 300 Hall. NA G did care for Resident #274 who required to be transferred with a mechanical lift. NA G said she did get Resident #274 up to her wheelchair with the sling and mechanical lift. When asked if there was any incident during this transfer or if the resident had any complaints of pain, NA G denied any incident. When asked who completed the transfer with her, she indicated the used the mechanical lift by herself . A record review on an incident report dated [DATE] indicated Resident #274 was up in her chair and asked to go back to her bed. The report revealed CNA L and RN J transferred resident to her bed and when the resident's pants were removed to check and change her there was swelling seen to the outer aspect of the left upper leg. The incident report indicated the resident was unable to describe what happened and only said she was hurting in her leg. The incident report indicated no witnesses to this event and the DON and administrator were notified and made aware of the requested x-rays that were ordered STAT (immediately). The incident report indicated the x-ray was not completed that day and was completed the next day and revealed a femur fracture. The incident report indicated this finding was confirmed with a radiologist at 6:40 p.m., and the Nurse Practitioner was notified and gave orders to have resident sent to local hospital, via ambulance, for further treatment. A record review of NA G employment record dated [DATE] indicated NA G was trained and checked off on the proper use of a mechanical lift. This employment record check-off sheet was signed and dated by NA G. During a phone interview on [DATE] at 10:36 a.m., NA G said that the morning of [DATE] she needed to get Resident #274 up from bed and into her geriatric chair. She said the resident's family member came to the facility every day and she wanted the resident out of bed. NA G said the resident required total assistance with transfers and required a mechanical lift. She said she knew the mechanical lift required a mandatory of two staff to operate but she could not find anyone to help her. She said she CNA H was working with her and she was busy giving a resident a bath and she could not assist at that time. She said she knew the mechanical lift always required two staff to operate and she should have left the resident in the bed until she could get help. She said completed the mechanical lift transfer on Resident #274 without additional staff assistance and the transfer was successful and without incident. She said the resident never complained of pain and was comfortably placed in her geriatric chair. She said Resident #274 could communicate needs by answering yes/no to questions. She said she had been trained on abuse, neglect, fall prevention but had not been trained by facility on mechanical lift proper procedure. She said she was a CNA at this facility from [DATE] to [DATE] and then returned to work at the facility on [DATE] and was put on suspension [DATE], due to the inappropriate transfer with use of the mechanical lift. She said she was then terminated from her employment at this facility after investigation was completed. During an interview on [DATE] at 10:56 a.m., CNA L said when she walked by Resident #274's room the morning of [DATE] the resident was sitting in the wheelchair crying and complaining of pain to her left thigh and lower left leg. She said the resident could not tell her what happened because the resident was severely cognitively impaired, but she can answer yes or no questions appropriately. She said she went an informed the charge nurse, LVN K, of the resident's pain complaints and asked RN J to help transfer the resident back to bed at the resident's request. She said the resident required a mechanical lift for transfers and this type of mechanical lift always required two staff members. She said they transferred the resident to the bed successfully and without incident. She said she was going to preform person hygiene care for Resident #274 and when she pulled her pants down, she noticed swelling on the resident's left thigh and left knee. She said she also noticed bruising around her left shin area. She said she went and reported the findings to RN J and the DON. She said she had never seen NA G be aggressive towards any residents. She said Resident #274 can use the side rails of her bed to reposition herself in bed. CNA L said she had been trained on using a mechanical lift and checked off on this skill after hire. She said she understood it required two staff to operate and transfer a resident using the mechanical lift. During an interview on [DATE] at 11:10 a.m., CNA H said she was working 300 and 400 Hall on [DATE] with NA G. She said she did not recall NA G asking her for help with the mechanical lift to transfer Resident #274 to her wheelchair. CNA H said she had been trained on proper mechanical lift procedures and knew it required two staff members to operate during a resident transfer. During an interview on [DATE] at 11:24 a.m., LVN K said Resident #274 could communicate her needs with yes and no questions, and she could say when she was feeling pain. She said RN J did report to her that Resident #274 was crying and complaining of pain. She said after lunch when the RN J and CNA L reported the swelling and bruising to the resident's left leg. She said she and the DON went in and assessed the resident's leg and found swelling at the left thigh and knee. She said there was also a bluish-purple bruise seen at the resident's left shin. She said she called the NP, reported the findings and obtained new orders for STAT (immediate) x-rays and administered pain medication as ordered. She said she notified the family member as well. She said the findings of the x-ray revealed a left femur fracture and the resident was sent to local hospital for further treatment. During an interview on [DATE] at 11:50 a.m., the DON said on [DATE] it was reported to her by LVN K that Resident #274 had swelling and bruising to her left thigh and knee. She said she assessed the resident and instructed LVN K to call the NP and family representative. She said the resident could not say what happened to her leg and she reported that injury of unknown origin to the Administrator immediately. The DON said they began an investigation immediately and went back 72 hours talking to nursing staff. She said she spoke with NA G on [DATE] and NA G admitted to using the mechanical lift without additional staff assistance but said there was not an incident and the resident did not complain of any pain. She said the facility then suspended NA G due to the inappropriate transfer using mechanical lift until the investigation was complete. She said all nursing staff including CNAs were trained on mechanical lifts as part of the on-boarding process and there were check off lists that must be completed. She said once the facility found Resident #274 had a fracture of her left femur, they then terminated NA G from employment. She said since NA G was just recently employed in [DATE] and then re-employed in [DATE] the training that was given in the first employment term upheld because it was within 6 months of the previous employment. She said she expected staff to follow proper procedures and not to inappropriately use the mechanical lift, because it could cause injury to the residents. During an interview on [DATE] at 12:15 p.m., the Administrator said she was notified of the resident's injury on [DATE] when the injury was found. She said she and the DON began the investigation and reported the injury to the state agency. She said NA G certified nurse's aide license had expired and she was working under a waiver until she could get certified in [DATE]. She said NA G had worked for the facility back in [DATE] until [DATE] and then restarted employment [DATE]th, 2021. She said they suspended NA G for the inappropriate transfer when using the mechanical lift and then terminated NA G when the investigation was complete. She said the investigation never determined the root cause of Resident #274 fracture. She said she expected staff to follow proper procedures and not to inappropriately use the mechanical lift, because it could cause injury to the residents. She said in-service training on appropriate transfers and using the Hoyer lift was conducted on [DATE] to all nursing staff. During an interview on [DATE] at 10:30 a.m., the Nurse Practitioner said he remembered being advised of the injury initially and that the resident had to wait until the next day for x-ray due to the staffing at the radiology company. He said when the fracture was discovered he gave orders to staff to have Resident #274 sent to the local hospital for further evaluation. He said he spoke with the surgeon that performed the resident's surgery and it was discovered that the resident had advanced [CONDITION(S)]. He said the surgeon told him, She could roll over in bed and break a bone. He said Resident #274 bones were extremely brittle. He said he expected all nursing staff to follow proper procedure when using the Hoyer lift and any resident care. During an interview on [DATE] at 11:00 a.m., Resident #274 family member said she knew NA G had done an inappropriate transfer with the Hoyer lift and felt the facility handled the situation appropriately. She said she was informed about everything that had happened. She said the surgeon told her that Resident #274's bones were very brittle, and she could bump her elbow and it would break. Record review of the facility policy Safe Lifting and Movement of Resident, revised ,d+[DATE], indicated .In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents .resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .manual lifting of residents shall be eliminated when feasible .the use of a mechanical lift with residents requires the assistance of two staff members .

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #2) of 9 residents reviewed for accidents in that: -The facility failed to ensure staff performed ADL activities for Resident #2 using 2 staff. -The facility failed to ensure Resident #2's care plan accurately addressed her individually assessed needs for ADL activities. -CNA F performed a two person transfer alone on 12/25/19. -CNA D performed ADL care alone, including turning and repositioning on 12/26/19. -Resident #2 suffered a [MEDICAL CONDITION] that was identified via X-ray on 12/26/19. These failures affected one resident and placed her at risk of injury, pain, hospitalization and a diminished quality of life. Findings include: Record review of Resident #2's face sheet revealed she was a [AGE] year old female who was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's annual MDS assessment, dated 10/11/19, revealed Resident #2 had a BIMS score of 6 out of 15 which indicated severe cognitive impairment. She required extensive assistance from two staff for transfers and bed mobility. She was always incontinent of bowel and bladder. Record review of Resident #2's Comprehensive Plan of Care dated 5/24/19 revealed Resident #2 required extensive assistance from one to two staff for transfers and bed mobility. Observation of Resident #2 on 1/9/2020 at 10:03 a.m. revealed she was in her room in bed. She had a PICC line. LVN D was performing a PICC line dressing change. Record review of the facility Provider Investigation report dated 12/26/19, for Resident #2, revealed the facility identified the injury on 12/26/19 at approximately 1:45 a.m. Record review of the section Description of Injury, read, in part: .CNA D was performing ADL care when CNA D attempted to turn her to her left side, Resident #2 expressed Pain, the CNA noticed swelling and discoloration . Further review of the section, Investigation Summary, read in part: .Resident #2's aide stated she turned and repositioned Resident #2 to her right side at approximately 9 p.m. The investigation summary contained no evidence to support Resident #2 was being assisted by two staff for ADL care or repositioning on 12/26/19 as reflected on the annual MDS assessment. During an interview with CNA B on 1/9/2020 at 10:32 a.m. she said Resident #2 required a Hoyer lift to move between surfaces. She said she always needed 2 persons to assist. She said she was working the morning shift when Resident #2 injured her leg. She said she assisted transferring Resident #2 with an unknown CNA on 12/25/19 after lunch, with no issues. She said she was called the next day, when she was off, and was informed of the injured leg. Record review of Resident #2's X-ray results dated 12/26/19 revealed an acute nondisplaced fracture in the proximal diametaphyseal region of the tibia (shin bone). During an interview with a Family Member of Resident #2 on 1/06/2020 at 9:52 a.m. she said she informed the Administrator she was upset and requested a meeting. She said in the meeting, she was informed CNA F completed an improper transfer and caused the fracture. She said, They fired the CN[NAME] She said she had observed facility staff transfer Resident #2 with 1 staff member forever, so she thought Resident #2 was identified as a 1 person assist. She said in the meeting she was told Resident #2 was a two-person transfer. Record review of Resident #2's nurse's progress notes dated 12/26/19 read in part: .RP is upset about what happened and wants to know what happened and wants to have a meeting with the administrator and DON . During interview with the Administrator on 1/9/2020 at 2:27 p.m. she said CNA D identified swelling and bruising during ADL care. She said the family was upset about the fracture sustained by Resident #2. She said CNA F was terminated after the incident investigation identified CNA F did not complete the transfer of Resident #2 on 12/25/19 properly. When asked what was improper, the Administrator said she had to consult with the DON. During interview with CNA D on 1/9/2020 at 3:22 p.m. she said Resident #2 seemed fine. She said on 12/26/19 at approximately 1:45 a.m. she attempted to change Resident #2. She said she crossed Resident #2's leg to turn her to the left, cleaned her, then turned her onto her back. She said she cleaned Resident #2 and fastened a new brief on her. She said she attempted to turn Resident #2 but Resident #2 expressed pain. She said she stated hurt repeatedly. She said she was by herself completing the care. She said the facility conducted an in-service training on repositioning on 12/26/19. In an interview with the DON on 1/10/2020 at 10:33 a.m. she said after the incident the facility began the investigation into the possible cause of injury after assessment findings. She said she interviewed CNA F to determine the transfer status of the Resident #2. She said the facility identified Resident #2 was a 2-person transfer. She said she asked CNA F to demonstrate how she completed the transfer. She said CNA F demonstrated and explained she completed the transfer of Resident #2 by herself. She said CNA F said, That's how I do it. She said she explained to the CNA the importance of following the identified transfer status based on the MDS and care plan. Record review of the training record provided for CNA F dated 11/26/19 revealed no signature to verify CNA F completed training on proper transfers. During an interview with the Rehab Director on 1/10/2020 at 9:52 a.m. she said she provides facility staff with transfer training. She said she takes the CNA into a vacant room to demonstrate the task. She said she instructs them first to check the kiosk containing the electronic health record to ensure they are knowledgeable of how many staff members are required to assist the resident. She said she trains the staff to not enter the room until they have verified how many staff are required to assist for the transfer. She said she did complete the onboarding training with CNA F. She said she instructs the staff to tell the resident to grab the elbow area if they can and proceed with the transfer. She said she also trains the staff to observe for changes and if they enter the room and they feel a resident needs more assistance than was previously identified on the MDS or care plan. She said trains staff to not try to transfer a resident if they do not feel it is safe. She said the trainings for CNA F must have slipped through without a signature. Record review of the facility policy, Safe Lifting and Movement of Residents, revised (YEAR), read in part: .Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of Residents. Manual lifting of Residents shall be eliminated when feasible. The use of a mechanical lift with Residents requires the assistance of 2 staff members at all times.

Based on observation, interview and record review, the facility failed to ensure that Residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 2 of 3 Residents (Resident #3 and CR #1) reviewed for pressure sores in that: - Resident #3 and CR #1 were not provided wound care in accordance with physician orders. These failures affected one current and one former resident and placed them at risk of delayed healing, infection, pain, complications, and and hospitalization . Findings include: Resident #3 Record review of the face sheet for Resident #3 revealed he was [AGE] years old. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. ( Generalized), pain due to internal orthopedic prosthetic devices, implants and grafts, subsequent encounter, presence of other vascular implants and grafts, and dependence on [MEDICAL TREATMENT]. Record review of Resident #3's admission skin assessment dated [DATE] titled Nursing-Weekly pressure Ulcer Evaluation revealed Resident #3 had on pressure sore on his right buttock measuing 4.0 cm x 1.0 cm x 0.1 cm classified as a Stage II. He was assessed as having a right inner buttock pressure ulcer measuring 1.5 cm x 1.0 cm x 0.1 cm classified as a Stage II, and a left buttock pressure ulcer measuring 3.0 cm x 1.0 cm x 0.1 cm classified as a Stage II. All three pressure sores were documented as admitted With. Record review of Resident #3' s admission MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderately impaired cognition. He needed extensive assistance of two staff with bed mobility, toilet use, and personal hygiene. He was incontinent of bowel. Resident #3 was totally dependent on staff for transfers. He was assessed as having a Stage 2 pressure sore on the right and left gluteal fold buttock at that time. Record review of the Care Plan, revised 11/19/19, revealed Resident #3 had stage 2 on the right and left gluteal (buttock) fold. The right gluteal fold buttock ulcer measured 1.5 cm x 1 cm x 0.1 cm and the left gluteal fold buttock ulcer measured 3.0 cm x 1.0 cm x 0.1 cm. The Care Plan interventions included, Treatment as ordered by MD. Further record review of Resident #3's Plan of Care revealed an undated care plan for Stage 2 pressure ulcer (Right and Left Buttocks or potential for pressure ulcer development r/t unrepairable right [MEDICAL CONDITION] and immobility with interventions that included: -Administer Medications as ordered per MD (Vitamin C) -Administer medication as ordered per MD (Zinc) -Administer treatments as ordered and monitor for effectivementss. -Assess/record/monitor wound healing. measure length, width and depth where possible. Assess and document status of wound perimeter, wound ed and healing progress. Report improvements and declines to the MD. -Educate the resident/family/caregivers as to causes of skinbreakdown; including: transfer/positioning requirements; importance of taking care during ambulating/movility, good nutrition and frequent repositioning. -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. -Monitor nutritional status. Servie diet as ordered, monitor intake and record. -Obtain an dmonitor la/diagnostic work as ordered. Report results to MD and follow up as indicated. -The resident requires (Pressure relieving/reducing device on (bed/chair). Record review of Resident #3's electronic records revealed Physician orders for: -Cleanse open areas to butocks/sacrum with normal saline, pat dy, apply Zinc Oxide daily. Every day shift with a start date of 11/20/19. The end date was 11/25/19. -Cleanse Stage 2 to left gluteal fold buttock with NS, pat dry, apply collagen to wound bed and cover with adapic and gauze with dressing daily and as needed. The start date was 11/30/19 and the end date was 12/7/19. -Cleanse Stage 2 to right gluteal fold buttock with NS, pat dry, apply collagen to wound bed and cover with dressing daily and as needed. The start date was 11/30/19 and the end date was 12/7/19. -Cleanse Stage 2 with to left gluteal fold with normal saline, pat dry, apply Zinc Oxide with dressing twice daily and as needed for soilage/dislodgement. The start date was 11/26/19 and the end date was 12/7/19. -Cleanse left and right Stage 2 to buttock wounds with NS, apply collagen to wound bed and cover with [MEDICATION NAME] and gauze each day and as needed one time a day for wound care. The had a start date of 11/27/19 and an end date of 11/29/19. Continued record review of Resident #3's Physician Order Recap dated 12/11/19 2019 revealed no evidence of active physician orders for wound care. Record review of Resident #3's Treatment Administration History for (MONTH) 2019 revealed a physician's order dated 11/19/19, which revealed the wound was to be treated daily, and was to be covered with a dressing. The order' special instructions read in part, (MONTH) replace as needed if dressing soiled or not intact. Sign out PRN order in Matrix if PRN replacement needed. Observation on 12/10/19 at 12:30 p.m. of wound care for Resident #3 revealed LVN D provided wound care, with the assistance of CNA B and CNA E. Resident #3 was repositioned onto his right side. Resident #3 had a large, dry bowel movement (BM) covering his buttocks and the old ulcer dressing, covering both buttocks, dated 12/7/19. The chux pad under the resident was saturated with dry BM . Both staff verbalized that the soiled dressing was dated 12/7/19. LVN D cleaned and measured his right gluteal fold buttock pressure ulcer and it measured 1 cm x 0.4 cm x 0.1 cm and his left gluteal fold buttock measured 6.0 cm x 1.0 cm x 0.1 cm. LVN D said she was just filling in for the treatment nurse and she worked on the night shift. Record review of Resident #3's TAR dated 11/2019 in the documentation section for PRN wound care revealed no documentation of initials on the previous shifts from 12/8/19 showing the dressing had not been changed. There waqs no documentation of his dressing being changed since 12/8/19 and there was no documentation to indicate the resident had refused any dressing changes. Interview on 12/10/19 at 2:39 p.m. the DON said the facility had a weekend nurse that did the treatments. The DON she would call him to find out what happened. On 12/10/19 at 4:00 p.m. the DON said the weekend treatment nurse, RN A, told her she tried performing the treatment but Resident #3 refused. The DON said RN A told her she forgot to document the refusal. During an interview on 12/11/19 at 4:30 p.m. with RN A she said she had attempted to perform Resident #3's dressing change over the weekend, (MONTH) 8, 2019, but he refused the treatment. She said she forgot to document his refusal. CR #1 Record review of the face sheet for CR #1 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. His [DIAGNOSES REDACTED]. He was discharged on [DATE] to the hospital. Record review of CR #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating he was unable to answer the questions for the assessment. He required total assistance with all activities of daily living. For Section M: Skin Conditions, he had one Stage II pressure ulcer not present upon admission and one Stage III pressure ulcer present upon admission. Record review of the Care Plan for CR #1 initiated on 5/14/19 and updated on 11/6/19 revealed CR #1 had an unstageable pressure ulcer to the Right outer ankle and shin. Interventions included: -Administer Prostat per md orders. -Administer treatments as ordered and monitor for effectiveness. -Administer Vit (Vitamin) C per md orders. D/C (discontinued) 7/16/19. -Assess/record/monitor wound healing every 7 days. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. -Inform the resident/family/caregivers of any new area of skin breakdown. -Monitor dressing to ensure it is intact and adhering. Report lose (sic) (loose) dressing to Charge nurse. -Monitor/document/report as needed any changes i skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage. -The resident requires LAL (low air loss) mattress on the bed. -Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Record review of CR #1's laboratory results revealed a culture of the right outer shin wound dated 10/3/19 with a result of: .Heavy Growth of Proteus mirabilis isolated. Moderate Growth of Escherichia coli isolated. Record review of CR #1's laboratory results revealed a culture of the right outer shin wound dated 11/17/19 with a result of: .Heavy Grown of Proteus mirabilis isolated. Record review of the Physician's orders for CR #1 for (MONTH) 2019 revealed the following wound care orders: -10/28/19- Cleanse Stage 3 to right outer ankle, with Dakins solution, pat dry, apply Santyl ointment to wound bed. Cover with calcium alginate. Wrap with kerlix every M-W-F and PRN soilage/dislodgement every day shift. The pressure ulcer was identified as having developed on 2/26/19. -10/28/19- Cleanse Stage 3 to right outer shin, with Dakins solution, pat dry, apply Santyl ointment to wound bed. Cover with calcium alginate. Wrap with kerlix every Monday-Wednesday-Friday and PRN soilage/dislodgement every day shift. The pressure ulcer was identified as having developed on 7/24/19. Record review of the (MONTH) 2019 TAR for CR #1 revealed the last wound care treatment that was completed was on 11/22/19. On 11/25/19, the treatment listed code 6, indicating CR #1 was in the hospital/ER. Record review of CR #1's Nurse's Notes revealed a note dated 11/20/19 at 10:19 a.m. written by LVN [NAME] which read in part, .Wounds to right outer shin and left heel have deteriorated. Notified Nurse Practitioner A of wound re-culture preliminary report and requested consult for (Wound Care Clinic). Record review of CR #1's Weekly Pressure Ulcer Evaluation dated 11/20/19 revealed a right outer ankle pressure ulcer present upon admitted d as developing 2/26/19 having a slight odor and serosanguineous drainage. The ulcer measured 2.5 cm x 1.5 cm x 0.2 cm classified as a Stage III. The current treatment was documented as having been started on 5/14/19 and the response to treatment was documented as improved. Record review of CR #1's Weekly Pressure Ulcer Evaluation dated 11/20/19 revealed a right outer shin pressure ulcer dated as developing 7/24/19 in-house and having purulent drainage with a foul odor. The ulcer measured 13.5 cm x 7.5 cm x 1.0 cm classified as unstageable. The current treatment was documented as having been started on 7/24/19 and the response to treatment was documented as deteriorated. Notes Comments documented, Order given for Outpaitent WCC (Name of Clinica). Record review of CR #1's Nurse's Note dated 11/21/19 at 5:47 p.m. written by revealed documentation that the resident was on day 1 of 5 of the antibiotic [MEDICATION NAME]. Record review of the Nurse's progress notes dated 11/26/19 for CR #1 revealed he was transferred to the hospital on [DATE] for [DEVICE] replacement. Record review of hospital records dated 11/26/19 documented CR #1 had a large necrotic wound to the right leg with a bandage with the date 11/22/19 written on it. In an interview with the Corporate Nurse on 12/10/19 at 5:15 p.m. she said CR #1 only had orders for care for Monday, Wednesday, and Friday. She said per the TAR, the last treatment was completed on 11/25/19. The surveyor informed her that hospital records indicated the bandage to the right leg was dated 11/22/19. She said the code 6 on the TAR indicated that CR #1 was not at the facility while treatments were being done. She said when the Wound Care Nurse was not at the facility, the charge nurses could do wound treatments. She said she was not sure why the treatment for [REDACTED]. Interview with the DON on 12/11/19 at 2:00 p.m. about the the facility pressure ulcer treatment policy, she said they followed the Lippincott Nursing Procedures Seventh Edition for pressure sores. Record review of the Lippincott Nursing Procedures Seventh Edition read in part: . Implementation: Perform a comprehensive skin assessment using a facility approved skin assessment tool; a comprehensive skin assessment may be the first step in pressure ulcer prevention .

Based on observation, interview, and record review, the facility failed to ensure for resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 1 residents (Resident #3 ) reviewed for ADL care in that: -Resident #3 was not provided incontinent care in a timely manner. This failure affected 1 resident and placed him at risk of skin impairment and a decreased quality of life. Findings include: Record review of the face sheet for Resident #3 revealed he was [AGE] years old. He was admitted to the facility on [DATE] with the Diagnoses: [REDACTED].( Generalized), pain due to internal orthopedic prosthetic devices, implants and grafts, subsequent encounter, presence of other vascular implants and grafts, and dependence on [MEDICAL TREATMENT]. Record review of Resident #3' s admission MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderately impaired cognition. He needed extensive assistance of two staff with bed mobility, toilet use, and personal hygiene. He was incontinent of bowel. He was totally dependent on staff for transfers. Record review of Resident #3's care plan dated 11/19/2019 read in part, .Reposition and provide incontinent care every 2 hours and as needed. Observation on 12/10/19 at 11:20 a.m. of Resident #3 with CNA B revealed Resident #3 was lying on his back in his bed. He was positioned on top of a chux pad. CNA B moved the top cover sheet and looked in between Resident #3's thigh and said he was not wet. In an interview with a Family Member on 12/10/19 at 11:25 a.m. she said she had concerns regarding Resident #3 not being repositioned, cleaned, or changed every two hours. The Family Member said when the ambulance picked up Resident #3 for [MEDICAL TREATMENT], they always complained of him always being soiled from a bowel movement. The Family Member aid Resident #3 had [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. Observation and interview of incontinent care for Resident #3 on 12/10/19 at 12:30 p.m. revealed CNA B performed the care and was assisted by CNA E. Both CNA's repositioned Resident #3 onto his right side. Resident #3 had a large, dry bowel movement (BM) over the buttocks and on his dressing. The chux pad under Resident #3 was saturated with dry BM. Family Member, who was present in the room, said, See what I told you about the staff not changing him every 2 hours. CNA B started using wet wipes to clean Resident #3. Resident #3 was screaming, Ouch! Ouch! The surveyor stopped CNA B, told her about using a soapy soaked towel in water to loosen the dry BM on Resident #3's buttocks. The family member got a soapy soaked wash towel for CNA B to use in cleaning Resident #3. In an interview on 12/10/19 at 1:17 p.m. with CNA B regarding when Resident #3 was checked and changed last, she said she came to work late about 10:00 a.m. on 12/10/16 and CNA [NAME] was taking care of her residents. She said the last time she checked on Resident #3 was at 11:20 a.m. She said she made rounds every two hours and as needed for heavy wetter's. In an interview on 12/10/19 at 1:25 p.m. with CNA [NAME] regarding when Resident #3's incontinent care was done last, she said she checked Resident #3 on 12/10/19 between 7:15 a.m. or 7:30 a.m. and he was dry. She said she told CNA B. She said she made rounds every two hours and as needed. In an interview with the DON and the Corporate Nurse on 12/10/19 at 5:30 p.m. regarding Resident #3's incontinent care and activity of daily living policies and procedures were requested. Both the DON and Corporate Nurse said Resident #3 should be checked every 2 hours. The policies and procedures were not provided prior to exit on 12/11/19.

Based on observation, interview, and record review, the facility failed to consult with the physican or the physician's representative when there wa need to alter treatment s a significant change in the resident's physical status and a need to alter treatment for one of four residents reviewed for notification of changes (CR#1) in that, -The facility did not inform the NP that the resident was not administered his hypertensive medications since admission. The NP was not made aware until after the resident had been send to the hospital. CR #1 exhibited respiratory distressed and high blood pressure and was send to the hospital and admitted to ICU with acute [MEDICAL CONDITION] due to [MEDICAL CONDITION] exacerbation that needed intubation, [MEDICAL CONDITIONS], and accelerated hypertension. An IJ was identified on 06/25/19. While the IJ was lowered on 06/27/19, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure affected one discharged resident and placed residents at risk of elevated blood pressures, exacerbation of [MEDICAL CONDITIONS], hospitalization and death. Findings included: Record review of the Admission Record for CR #1 revealed he was [AGE] years of age and was admitted to the facility on [DATE] at 11:00 pm. [DIAGNOSES REDACTED]. Record review of the hospital transfer paperwork dated 06/19/19 in CR #1's facility paper chart, page 6, revealed CR #1 had no known drug allergies [REDACTED].>Record review of CR #1's Admission/Readmission Nursing Evaluation dated 06/20/19 at 6:45 a.m. revealed the Admitting [DIAGNOSES REDACTED]. The document reflected no known allergies [REDACTED].#1's heart rate was 116 bpm, and respirations were 18. There was no blood pressure reflected on the document. Record review of the physician's orders [REDACTED]. [MEDICATION NAME] (diuretic used to reduce extra fluid in the body ([MEDICAL CONDITION]) caused by conditions such as heart failure, liver disease, and kidney disease) tablet 2 mg 1 tablet once daily related to acute diastolic (congestive) heart failure. Carvedilol (beta blocker) 12.5 mg 2 tablets daily related to essential hypertension. [MEDICATION NAME] (antihypertensive) 50 mg tablet three times daily related to essential hypertension. [MEDICATION NAME] Extended Release (Calcium channel blocker) 60 mg 1 tablet twice daily related to essential hypertension. Losartan Potassium (angiotensin II receptor agonist) 100 mg 1 tablet once daily related to essential hypertension. [MEDICATION NAME] Bisulfate (anti-platelet) 75 mg 1 tablet once daily related to essential hypertension. Record review of CR #1's (MONTH) 2019 MAR indicated [REDACTED] Record review of CR #1's nurses' notes done by LVN B dated 06/20/19 at 9 minutes past midnight revealed the resident was admitted to the facility at 11:00 pm on 06/19/19. The resident's blood pressure was 171/82 mmHg with a pulse rate of 116 bpm. Respirations were 18 per minute. The nurses' notes reflected the breath sounds were clear to auscultation. The residents blood sugar was 337. Notification was given to the NP of the above and she that stated to continue resident's medication upon discharge and gave sliding scale dosage of insulin due to elevated blood glucose. Record review of CR #1's nurses' notes dated 06/20/19 at 7:24 a.m. revealed the resident's blood pressure was 171/82 mmHg and the pulse rate was 117 bpm. Respirations were 18 per minute. There was no documentation that the physician or NP was notified of the elevated blood pressure and pulse reading. Record review of a hand-written note in CR #1's nurses' notes completed by LVN A and dated 6/20/19 at 10:30 am revealed: .medication in MAR indicated [REDACTED].allergies [REDACTED].allergies [REDACTED].medication will be sent out on first run . Record review of the CR #1's late entry nurses' notes dated 06/20/19 revealed in part revealed a CNA informed the nurse at around 11:30 am on 06/20/19 nurse that she noted blood on the residents' bed sheets when she assisted him to the bathroom. The resident's vital signs were assessed at the time and blood pressure at 11:30 a.m. was 157/88 mmHg and the pulse rate was 97 bpm. Respirations were 18 per minute. Record review of CR #1's late entry nurses' note dated 6/20/19 revealed LVN A entered the room to assess the resident's skin and noted 2 small abrasions to the penis, but no blood at the time. She reported this to the NP and she said will be in the facility at 1:30 pm to see the resident. there was no documentation to indicate the NP was notified that the medications were not given to the resident. Record review of late entry Nurses' notes for CR #1 dated 06/20/19 revealed in part that the therapy staff informed the nurse (LVN A) at 2:45 pm that the resident's O2 stats where at 68% on room air. The nurse administered O2 at 4LPM and assessed residents VS's 177/105 bp, 114 pulse ,97.7 temp, 20 labored. O2 ranging from 79%-86% on 4LPM NC. Blood sugar was checked, and it was 205, CR #1's skin was cool and clammy to touch, resident mumbling when trying to speak. At 3:10 pm, the NP arrived at facility and entered room assessed resident and placed resident on non-rebreather mask with O2 .LVN called 911. EMS arrived at facility at 4:25 pm to transport resident to the hospital. Record review of the hospital face sheet revealed CR #1 was admitted to the hospital on [DATE] at 5:47 p.m. The Admit Complaint was reflected as respiratory distress, acute [MEDICAL CONDITIONS], and Flash [MEDICAL CONDITIONS]. Record review of the chest x-ray for CR #1, dated 06/20/19 revealed the resident had moderate congestion and [MEDICAL CONDITIONS]. Record review of the hospital Emergency Care Center Triage Report dated 06/20/19 at 6:02 p.m. revealed CR #1's blood pressure was 169/94 mmHg and his heart rate was 104 bpm. Respirations were 23 per minute. The Chief Complaint was reflected as respiratory distress. Record review of the hospital Clinical Report - Physicians/Mid-Levels dated 06/20/19 at 6:41 p.m. revealed the Chief Complaint was dyspnea. The report reflected the resident required an ambu-bag to assist with breaths in route to the hospital and was in severe distress in the Emergency Department. The CVS (Cardiovascular System) review reflected normal heart rate and rhythm at that time. The Respiratory System review reflected the resident exhibited severe respiratory distress with accessory muscle use, tachypnea and hyperventilation. The Report reflected the resident was intubated. The resident was admitted to the ICU. The Clinical Impression was reflected as respiratory distress, acute dyspnea, and acute severe systolic and diastolic, [MEDICAL CONDITION]. Record review of the Attending physician progress notes [REDACTED].#1: .was brought in due to difficulty breathing with bilateral lower extremity [MEDICAL CONDITION] at _____ (the facility). The patient needed intubation in the emergency room due to volume overload. The patient was admitted to the ICU, was hemodynamically stable, with a significantly elevated blood pressure which improved on IV antihypertensive medications as needed . The Assessment and Plan section reflected: 1) Acute hypercapnic [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] exasperation. 2) History of new onset [MEDICAL CONDITION], which presented with significant volume overload with [MEDICAL CONDITIONS]. 3) Elevated troponins probably secondary to [MEDICAL CONDITION] exacerbation .6) Accelerated hypertension. Observation on 06/21/19 at 3:40 p.m. revealed the [NAME] kit for the facility was sealed. The label reflected it had been delivered to the facility on [DATE] (prior to CR #1's admission). Review of the label revealed the [NAME] kit contained the following medications that were ordered for CR #1: Carvedilol 3.125 mg tablets. [MEDICATION NAME] 25 mg tablets. [MEDICATION NAME] Bisulfate 75 mg tablets. In addition to these medications, other medications such as [MEDICATION NAME] (antihypertensive) and [MEDICATION NAME] (diuretic) were available in the [NAME] kit. Observation on 06/24/19 at 9:00 a.m. revealed CR #1 was in the hospital ICU. He was awake and alert. CR #1 was intubated and required a ventilator to assist with breathing. Interview on 06/24/19 at 11:45 a.m. with the RP of CR #1 revealed she said CR #1 arrived at the facility on 06/19/19 at approximately 10:30 p.m. She said the facility had given her paperwork that reflected the resident did not receive any medications prior to being sent to the hospital the next day. When presented with the (MONTH) 2019 MAR for CR #1, the RP acknowledged it was what was provided to her. The RP said LVN A had said that all of the resident's medications were pending clarification. The RP said she was in the facility on 06/20/19 from 7:40 a.m. to 8:15 a.m. and was not informed there was any issues with the medications. She said, If there was a problem with the meds, they could have said something .How do you not follow doctor's orders? She said the Physician's representative (NP) was in the building at that time. She said she was not notified by the facility that CR #1 did not receive any medications prior to being sent to the hospital. Interview via telephone on 06/24/19 at 12:20 p.m. LVN A said CR #1 was new to the facility. She said she did not receive a lot of information in report. She said she learned all medications were pending in the computer system MAR indicated [REDACTED]. She said she could not tell where the blood was coming from. She said the NP was going to be at the facility at 3:00 p.m. that day. LVN A said someone from Therapy called her and told her the resident's oxygen saturation had dropped to 68%. She said she went to the room with oxygen, and the NP came in as well. She said at that time, they sent the resident to the hospital. Continued interview with LVN A revealed she said she had not seen pending before on the MAR. She said she called the pharmacy, and they said there was a problem with his drug allergies [REDACTED].#1 received no medications at the facility. She also confirmed she did not inform the NP that the resident had received no medications. LVN A confirmed she did not check the [NAME] Kit to see if medications were available. LVN A said she found CR #1's home medications just before the resident was sent out. Interview on 06/24/19 at 4:18 p.m. the NP said she received the call on 06/20/19 at 2:20 p.m. from LVN A. She told LVN A she would be at the facility at 3:00 p.m. The NP said when she arrived, CR #1 was in respiratory distress. She said she was in the facility from 8:00 a.m. until 11:30 a.m. She said she was not made aware the resident was not provided any medication until after the resident left the facility. She said she was not certain not receiving the medications caused the change of condition, but if the symptoms had been communicated, she could have assessed him earlier. She said he did have a change of condition, and she would have sent him to the hospital sooner. She said she could have addressed the fluid overload. The NP said she was aware of the [NAME] kit availability. In a phone interview with LVN B on 06/27/19 at 7:45 am she said CR #1 was admitted during her shift. She said he had recently had 2L of fluid removed in the hospital and that he looked very swollen, with generalized [MEDICAL CONDITION]. She said she called the NP and told her about his vital signs and blood sugar. She said she received a sliding scale order for the BS. LVN B said the NP told her to continue with the discharge orders and that she would be in to see the resident the next day. LVN B said she gave the insulin per s/s. She said she did put in the orders in the system, but it said pending confirmation, needed to put the allergies [REDACTED]. She said this happened late in her shift. LVN B said CR #1 came in with a bag of medications. LVN B said she put in the allergy information and hit accept. And that cleared the pending in the system. She said they had to order meds, because they could not use home meds because of Medicare rules. She said they had the home meds and the [NAME] kit available. LVN B said she did not look in to the bag of home meds. She confirmed that the MAR indicated [REDACTED]. She said she left the facility around an hour after her shift was over at around 7:00 am. Record review of the personnel file for LVN A revealed that she was hired on 09/08/2017. Further review revealed counseling reports for: 1/21/19: .IV ABT must be initial dose within 4 hours of obtaining the order. Any missed dosage, the RP and NP need notified . 1/30/19: .On admit resident meds not entered correctly resulting in error . The Administrator and Corporate RN were notified of the Immediate Jeopardy (IJ) on 06/25/19 at 4:30pm due to the above referenced failures. A Plan of Removal was requested at that time. After two revision, the final Plan of Removal was accepted on 06/27/19 at 12:52 p.m. Interview on 06/27/19 at 4:15 p.m. with the Administrator said he thought the IJ situation was the result of LVN A's error. He said he thought she had been properly trained and supervised. The plan read in part: .CR #1 was admitted to the hospital on [DATE] after discharge from the facility. Effective 6/25/19, the Director of Nursing and/ or designee will reeducate Licensed Nurses and Certified Medication Aides on Medication Administration. Reeducation included medication administration times and when to communicate with MD/NP. This will be completed by 6/25/19 and will continue for new hire/ re-hire fulltime or PRN staff. Effective 6/26/19, the Director of Nursing and/ or designee will monitor compliance with change of condition related to blood pressure and pulse by reviewing blood pressure and pulse data for deviations and interventions twice weekly for four weeks, then monthly for two months. Effective 6/26/19, the Director of Nursing and/ or designee will monitor compliance with medication administration by reviewing the Medication Administration Records of three residents weekly for four weeks, then monthly for two months Effective 6/25/19, the Registered Nurse reviewed the Physician order [REDACTED]. This will be completed by 6/25/19. Effective 6/25/19, the Registered Nurse reviewed the Physician order [REDACTED]. This will be completed by 6/25/19 . Effective 6/25/19, the Director of Nursing and/ or designee reeducated Licensed Nurses and Certified Medication Aides on the Policy and Procedures for Ordering and Receiving Medication. Reeducation included use of the facility Ekits. Ekit reeducation included location of the Ekits, when and how to access the Ekits. Licensed Nurses and Certified Medication Aides were also reeducated on the 'stat' process for requesting medications outside of regularly scheduled delivery times which is available as needed. Reeducation included how and when to contact the pharmacy and request as needed medication deliveries e.g. for admissions and/ or readmissions. This will be completed by 6/25/19 and will continue for new hire/ re-hire fulltime or PRN staff .On 6/25/19 an adhoc Performance Improvement Meeting was held with the Administrator, Assistant Director of Nursing, and two other persons present to discuss the above plan . Following acceptance of the facility's Plan of Removal, the facility was monitored from 06/26/19 to 06/27/19. Record review was conducted of the facility's in-services that had been initiated for Licensed Nurses and Medication Aides. Documentation of the following was reviewed: Documentation of in-services for Licensed Nurses and Medication Aides from 06/25/19 to 06/27/19 on the topics of medication time frames, communicating with the physician or the physician's representative when medications or treatments could not be provided, what to do in case of a change of condition (all direct care staff), how to document regarding change of condition (nurses only), how to utilize the [NAME] kit, and how to obtain medications that were needed prior to the next regularly scheduled delivery. Interviews were conducted with four nurses, one medication aide, and four CNAs to verify the in-services had in fact been conducted and to validate the staff understanding of the information presented to them. The Administrator was notified that the IJ was lowered on 06/27/19 at 4:20 p.m. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including the dispensing and administering of drugs and biologicals to meet the needs of one resident (CR #1) of four residents reviewed pharmacy services in that; -CR #1 was newly admitted to the facility after placement of a cardiac pacemaker with orders for 6 cardiac medications that were not administered as ordered by the physician. - The facility staff failed to use the facility E-kit to administer some of the ordered cardiac medications. CR #1 exhibited respiratory distressed and high blood pressure and was send to the hospital and admitted to ICU with acute [MEDICAL CONDITION] due to [MEDICAL CONDITION] exacerbation that needed intubation, [MEDICAL CONDITIONS], and accelerated hypertension. An IJ was identified on 06/25/19. While the IJ was lowered on 06/27/19, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure affected one discharged resident placing him at risk of elevated blood pressures, exacerbation of [MEDICAL CONDITIONS], hospitalization and death. Findings included: Record review of the Admission Record for CR #1 revealed he was [AGE] years of age and was admitted to the facility on [DATE] at 11:00 pm. [DIAGNOSES REDACTED]. Record review of the hospital transfer paperwork dated 06/19/19 in CR #1's facility paper chart, page 6, revealed CR #1 had no known drug allergies [REDACTED].>Record review of CR #1's Admission/Readmission Nursing Evaluation dated 06/20/19 at 6:45 a.m. revealed the Admitting [DIAGNOSES REDACTED]. The document reflected no known allergies [REDACTED].#1's heart rate was 116 bpm, and respirations were 18. There was no blood pressure reflected on the document. Record review of the Physician's Orders for CR #1 with a start date of 6/20/19 revealed the following ordered medications were scheduled to be administered: [MEDICATION NAME] (diuretic used to reduce extra fluid in the body ([MEDICAL CONDITION]) caused by conditions such as heart failure, liver disease, and kidney disease) tablet 2 mg 1 tablet once daily related to acute diastolic (congestive) heart failure. Carvedilol (beta blocker) 12.5 mg 2 tablets daily related to essential hypertension. [MEDICATION NAME] (antihypertensive) 50 mg tablet three times daily related to essential hypertension. [MEDICATION NAME] Extended Release (Calcium channel blocker) 60 mg 1 tablet twice daily related to essential hypertension. Losartan Potassium (angiotensin II receptor agonist) 100 mg 1 tablet once daily related to essential hypertension. [MEDICATION NAME] Bisulfate (anti-platelet) 75 mg 1 tablet once daily related to essential hypertension. Record review of CR #1's (MONTH) 2019 MAR indicated [REDACTED] Record review of CR #1's nurses' notes done by LVN B dated 06/20/19 at 9 minutes past midnight revealed the resident was admitted to the facility at 11:00 pm on 06/19/19. The resident's blood pressure was 171/82 mmHg with a pulse rate of 116 bpm. Respirations were 18 per minute. The nurses' notes reflected the breath sounds were clear to auscultation. The residents blood sugar was 337. Notification was given to the NP of the above and she that stated to continue resident's medication upon discharge and gave sliding scale dosage of insulin due to elevated blood glucose. Record review of CR #1's nurses' notes dated 06/20/19 at 7:24 a.m. revealed the resident's blood pressure was 171/82 mmHg and the pulse rate was 117 bpm. Respirations were 18 per minute. There was no documentation that the physician or NP was notified of the elevated blood pressure and pulse reading. Record review of a hand-written note in CR #1's nurses' notes completed by LVN A and dated 6/20/19 at 10:30 am revealed: .medication in MAR indicated [REDACTED].allergies [REDACTED].allergies [REDACTED].medication will be sent out on first run . Record review of the CR #1's late entry nurses' notes dated 06/20/19 revealed in part revealed a CNA informed the nurse at around 11:30 am on 06/20/19 nurse that she noted blood on the residents' bed sheets when she assisted him to the bathroom. The resident's vital signs were assessed at the time and blood pressure at 11:30 a.m. was 157/88 mmHg and the pulse rate was 97 bpm. Respirations were 18 per minute. Record review of CR #1's late entry nurses' note dated 6/20/19 revealed LVN A entered the room to assess the resident's skin and noted 2 small abrasions to the penis, but no blood at the time. She reported this to the NP and she said will be in the facility at 1:30 pm to see the resident. there was no documentation to indicate the NP was notified that the medications were not given to the resident. Record review of late entry Nurses' notes for CR #1 dated 06/20/19 revealed in part that the therapy staff informed the nurse (LVN A) at 2:45 pm that the resident's O2 stats where at 68% on room air. The nurse administered O2 at 4LPM and assessed residents VS's 177/105 bp, 114 pulse ,97.7 temp, 20 labored. O2 ranging from 79%-86% on 4LPM NC. Blood sugar was checked, and it was 205, CR #1's skin was cool and clammy to touch, resident mumbling when trying to speak. At 3:10 pm, the NP arrived at facility and entered room assessed resident and placed resident on non-rebreather mask with O2 .LVN called 911. EMS arrived at facility at 4:25 pm to transport resident to the hospital. Record review of the hospital face sheet revealed CR #1 was admitted to the hospital on [DATE] at 5:47 p.m. The Admit Complaint was reflected as respiratory distress, acute [MEDICAL CONDITIONS], and Flash [MEDICAL CONDITIONS]. Record review of the chest x-ray for CR #1, dated 06/20/19 revealed the resident had moderate congestion and [MEDICAL CONDITIONS]. Record review of the hospital Emergency Care Center Triage Report dated 06/20/19 at 6:02 p.m. revealed CR #1's blood pressure was 169/94 mmHg and his heart rate was 104 bpm. Respirations were 23 per minute. The Chief Complaint was reflected as respiratory distress. Record review of the hospital Clinical Report - Physicians/Mid-Levels dated 06/20/19 at 6:41 p.m. revealed the Chief Complaint was dyspnea. The report reflected the resident required an ambu-bag to assist with breaths in route to the hospital and was in severe distress in the Emergency Department. The CVS (Cardiovascular System) review reflected normal heart rate and rhythm at that time. The Respiratory System review reflected the resident exhibited severe respiratory distress with accessory muscle use, tachypnea and hyperventilation. The Report reflected the resident was intubated. The resident was admitted to the ICU. The Clinical Impression was reflected as respiratory distress, acute dyspnea, and acute severe systolic and diastolic, [MEDICAL CONDITION]. Record review of the Attending physician progress notes [REDACTED].#1: .was brought in due to difficulty breathing with bilateral lower extremity [MEDICAL CONDITION] at _____ (the facility). The patient needed intubation in the emergency room due to volume overload. The patient was admitted to the ICU, was hemodynamically stable, with a significantly elevated blood pressure which improved on IV antihypertensive medications as needed . The Assessment and Plan section reflected: 1) Acute hypercapnic [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] exasperation. 2) History of new onset [MEDICAL CONDITION], which presented with significant volume overload with [MEDICAL CONDITIONS]. 3) Elevated troponins probably secondary to [MEDICAL CONDITION] exacerbation .6) Accelerated hypertension. Observation on 06/21/19 at 3:40 p.m. revealed the [NAME] kit for the facility was sealed. The label reflected it had been delivered to the facility on [DATE] (prior to CR #1's admission). Review of the label revealed the [NAME] kit contained the following medications that were ordered for CR #1: Carvedilol 3.125 mg tablets. [MEDICATION NAME] 25 mg tablets. [MEDICATION NAME] Bisulfate 75 mg tablets. In addition to these medications, other medications such as [MEDICATION NAME] (antihypertensive) and [MEDICATION NAME] (diuretic) were available in the [NAME] kit.Observation on 06/24/19 at 9:00 a.m. revealed CR #1 was in the hospital ICU. He was awake and alert. CR #1 was intubated and required a ventilator to assist with breathing. Interview on 06/24/19 at 11:45 a.m. with the RP of CR #1 revealed she said CR #1 arrived at the facility on 06/19/19 at approximately 10:30 p.m. She said the facility had given her paperwork that reflected the resident did not receive any medications prior to being sent to the hospital the next day. When presented with the (MONTH) 2019 MAR for CR #1, the RP acknowledged it was what was provided to her. The RP said LVN A had said that all of the resident's medications were pending clarification. The RP said she was in the facility on 06/20/19 from 7:40 a.m. to 8:15 a.m. and was not informed there was any issues with the medications. She said, If there was a problem with the meds, they could have said something .How do you not follow doctor's orders? She said the Physician's representative (NP) was in the building at that time. She said she was not notified by the facility that CR #1 did not receive any medications prior to being sent to the hospital. Interview via telephone on 06/24/19 at 12:20 p.m. LVN A said CR #1 was new to the facility. She said she did not receive a lot of information in report. She said she learned all medications were pending in the computer system MAR indicated [REDACTED]. She said she could not tell where the blood was coming from. She said the NP was going to be at the facility at 3:00 p.m. that day. LVN A said someone from Therapy called her and told her the resident's oxygen saturation had dropped to 68%. She said she went to the room with oxygen, and the NP came in as well. She said at that time, they sent the resident to the hospital. Continued interview with LVN A revealed she said she had not seen pending before on the MAR. She said she called the pharmacy, and they said there was a problem with his drug allergies [REDACTED].#1 received no medications at the facility. She also confirmed she did not inform the NP that the resident had received no medications. LVN A confirmed she did not check the [NAME] Kit to see if medications were available. LVN A said she found CR #1's home medications just before the resident was sent out. Interview with the Corporate RN on 06/24/19 at 1:15 p.m. she said the DON was on leave. She said the process for medication orders was that the nurse submitted the orders, allergies [REDACTED]. Nothing was to be faxed to the pharmacy. She said if an order was 'pending' there would be a notice in red at the top of the screen. She said CR #1 arrived at the facility at 11:00 p.m. on 06/19/19, so LVN B should have confirmed the orders with the doctor or doctor's representative. She said that when the 'pending' message was displayed, the nurse should clarify why. She said most of the time it was because of allergies [REDACTED]. The Corporate RN said insulin was given from the [NAME] kit. She said the facility was unaware of the resident's allergy status at the time. Interview via telephone on 06/24/19 at 4:04 p.m. the pharmacy representative said there was no set delivery time for the facility because of variables such as traffic. She did say that the pharmacy delivered to the facility twice daily. She said the 'cut off' time order for morning deliveries was 10:00 p.m. and medications would be in the facility by 4 am. The 'cut off' time for evening deliveries was 11:00 a.m. for medication to be delivered at 4 pm. Interview on 06/24/19 at 4:18 p.m. the NP said she received the call on 06/20/19 at 2:20 p.m. from LVN A. She told LVN A she would be at the facility at 3:00 p.m. The NP said when she arrived, CR #1 was in respiratory distress. She said she was in the facility from 8:00 a.m. until 11:30 a.m. She said she was not made aware the resident was not provided any medication until after the resident left the facility. She said she was not certain not receiving the medications caused the change of condition, but if the symptoms had been communicated, she could have assessed him earlier. She said he did have a change of condition, and she would have sent him to the hospital sooner. She said she could have addressed the fluid overload. The NP said she was aware of the [NAME] kit availability. In a phone interview with LVN B on 06/27/19 at 7:45 am she said CR #1 was admitted during her shift. She said he had recently had 2L of fluid removed in the hospital and that he looked very swollen, with generalized [MEDICAL CONDITION]. She said she called the NP and told her about his vital signs and blood sugar. She said she received a sliding scale order for the BS. LVN B said the NP told her to continue with the discharge orders and that she would be in to see the resident the next day. LVN B said she gave the insulin per s/s. She said she did put in the orders in the system, but it said pending confirmation, needed to put the allergies [REDACTED]. She said this happened late in her shift. LVN B said CR #1 came in with a bag of medications. She said she let LVN A know that he had an antibiotic ordered. LVN B said she put in the allergy information and hit accept. And that cleared the pending in the system. She said they had to order meds, because they could not use home meds because of Medicare rules. She said they had the home meds and the [NAME] kit available. LVN B said she did not look in to the bag of home meds. She confirmed that the MAR indicated [REDACTED]. She said she left the facility around an hour after her shift was over at around 7:00 am. Record review of the personnel file for LVN A revealed that she was hired on 09/08/2017. Further review revealed counseling reports for: 1/21/19: .IV ABT must be initial dose within 4 hours of obtaining the order. Any missed dosage, the RP and NP need notified . 1/30/19: .On admit resident meds not entered correctly resulting in error . Record review of the facility policy ordering and receiving of non-controlled medications dated 2010 revealed in part: .All new medication orders are transmitted to the pharmacy .new medications, except for emergency or stat medications are ordered as follows: if the first dose of medication is schedules to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt .inform the pharmacy for the need for prompt delivery .timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery .new admission orders [REDACTED].medication allergies [REDACTED]. The Administrator and Corporate RN were notified of the Immediate Jeopardy (IJ) on 06/25/19 at 4:30pm due to the above referenced failures. A Plan of Removal was requested at that time. After two revision, the final Plan of Removal was accepted on 06/27/19 at 12:52 p.m. Interview on 06/27/19 at 4:15 p.m. with the Administrator said he thought the IJ situation was the result of LVN A's error. He said he thought she had been properly trained and supervised. The plan read in part: .CR #1 was admitted to the hospital on [DATE] after discharge from the facility. Effective 6/25/19, the Registered Nurse will identify residents with a potential change in condition related to elevated blood pressure and pulse by reviewing vital sign data .looking at blood pressure and pulse outside normal range .Effective 6/25/19, the Registered Nurse will reassess residents with blood pressure and/or pulse deviations and report assessment findings to the MD/NP. This will be completed by 6/25/19 . Effective 6/25/19, the Registered Nurse will identify residents who did not receive medications by reviewing medication admission records for omissions. The resident will be reassessed by the Registered Nurse and the MD/NP will be notified . Effective 6/25/19, the Director of Nursing and/ or designee reeducated all staff on reporting/ communicating observations related to resident changes in condition. Reeducation included communicating abnormal vital signs or vital signs outside of resident parameters. This will be completed by 6/25/19 and will continue for new hire/re-hire fulltime or PRN staff. Effective 6/25/19, the Director of Nursing and/ or designee will reeducate Licensed Nurses and Certified Medication Aides on Medication Administration. Reeducation included medication administration times and when to communicate with MD/NP. This will be completed by 6/25/19 and will continue for new hire/ re-hire fulltime or PRN staff. Effective 6/26/19, the Director of Nursing and/ or designee will monitor compliance with change of condition related to blood pressure and pulse by reviewing blood pressure and pulse data for deviations and interventions twice weekly for four weeks, then monthly for two months. Effective 6/26/19, the Director of Nursing and/ or designee will monitor compliance with medication administration by reviewing the Medication Administration Records of three residents weekly for four weeks, then monthly for two months Effective 6/25/19, the Registered Nurse reviewed the Physician Orders and Medication Administration Records for residents admitted / readmitted to the facility on [DATE] to identify new admissions/ readmissions who may not have received medication. This will be completed by 6/25/19. Effective 6/25/19, the Registered Nurse reviewed the Physician Orders and Medication Administration Records for residents admitted / readmitted to the facility within the prior seven days to identify new admissions/ readmissions who may not have received medication. This will be completed by 6/25/19 . Effective 6/25/19, the Director of Nursing and/ or designee reeducated Licensed Nurses and Certified Medication Aides on the Policy and Procedures for Ordering and Receiving Medication. Reeducation included use of the facility Ekits. Ekit reeducation included location of the Ekits, when and how to access the Ekits. Licensed Nurses and Certified Medication Aides were also reeducated on the 'stat' process for requesting medications outside of regularly scheduled delivery times which is available as needed. Reeducation included how and when to contact the pharmacy and request as needed medication deliveries e.g. for admissions and/ or readmissions. This will be completed by 6/25/19 and will continue for new hire/ re-hire fulltime or PRN staff .On 6/25/19 an adhoc Performance Improvement Meeting was held with the Administrator, Assistant Director of Nursing, and two other persons present to discuss the above plan . Following acceptance of the facility's Plan of Removal, the facility was monitored from 06/26/19 to 06/27/19. Record review was conducted of the facility's in-services that had been initiated for Licensed Nurses and Medication Aides. Documentation of the following was reviewed: Documentation of in-services for Licensed Nurses and Medication Aides from 06/25/19 to 06/27/19 on the topics of medication time frames, communicating with the physician or the physician's representative when medications or treatments could not be provided, what to do in case of a change of condition (all direct care staff), how to document regarding change of condition (nurses only), how to utilize the [NAME] kit, and how to obtain medications that were needed prior to the next regularly scheduled delivery. Interviews were conducted with four nurses, one medication aide, and four CNAs to verify the in-services had in fact been conducted and to validate the staff understanding of the information presented to them. The Administrator was notified that the IJ was lowered on 06/27/19 at 4:20 p.m. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview, and record review the facility failed to ensure a resident who entered the facility with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development or worsen of pressure ulcers for 1 of 4 residents (CR #13) reviewed for pressure ulcers. -The facility failed to assess and document a detailed description of CR#13 pressure ulcers upon admission. -The facility failed to consult and obtain wound care orders from the doctor for CR #13's pressure ulcers upon admission. - The facility failed to provide treatments for CR#13's community acquired Stage 3 ulcer for six days and the wound deteriorated. These failures affected one discharged resident and placed him at risk of worsening of pressure ulcers to include infection and need for hospitalization . Complaint # 9 Findings include: CR #13: Record review of CR #13's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was discharge to the hospital on [DATE]. Record review of CR #13's Hospital's Wound Assessment/Treatment Report dated 3/5/19, revealed that CR#13 had a stage 3 pressure ulcer to the coccyx measuring 4.5 cm x 1.5 cm x 0 cm. No drainage or odor noted, surgical incision measuring 7 cm in the groin area, surgical incision to the right lower leg measuring 12.5 cm and no drainage. Record review of the Treatment Nurse documentation for CR#13 dated 3/6/19 revealed resident had a healing stage 3 pressure ulcer to the coccyx measuring 4.5 cm x1.5 cm x 0.0 cm, no drainage or odor noted. Minimal granulation present 25% and surrounded by pink tissue. Peri wound intact. Barrier cream with every brief change. Record review of the care plan dated 3/6/19 revealed: Problem CR #13 had coccyx pressure ulcer. Goal: The resident's pressure ulcer will show signs of healing, risk for further skin break down will be reduced and no signs and symptoms of infection. Approach: Low air mattress, Treatments barrier cream, assess wound weekly and incontinent care as needed. Record review of CR #13's Pressure Sore Braden Scale Assessments, dated 03/06/19, revealed a score of 16 meaning the resident was at high risk for pressure ulcers. Record review of CR #13's Nursing Weekly Pressure Ulcer Evaluation dated 03/06/19 revealed resident was admitted with a stage 3 pressure sore, with no odor or drainage and wound bed had granulation tissue (pink/beefy red). Current treatment barrier cream. Further record review revealed in the skin section assessment the resident was checked as skin within normal limits. Meaning the wound was not open. Record review of CR #13's Weekly Skin Assessment Check dated 3/12/19, revealed Stage 3 pressure ulcer to the Coccyx measures 4.5 cm x 1.5 cm x <0.1 cm. 25% granulation and 75% [MEDICATION NAME] growth. New order obtained to clean with normal saline, pat dry, apply collagen and calcium alginate. Cover with foam dressing QD. Apply zinc paste to healed previous pressure areas QD. Record review of the Nurse Practitioner order dated 3/12/19 revealed Coccyx/sacral wound: clean coccyx/sacrum with normal saline, pat dry, apply collagen and calcium alginate and cover with foam dressing daily and PRN. Record review of the nurse's notes dated 3/12/19 for CR#13 revealed the family and the physician were notified of the pressure ulcer on 3/12/19, and that the resident had treatment documented with the treatment being clean with normal saline, pat dry, apply collagen and calcium alginate and cover with foam dressing daily and PRN. Record of review of CR#13's Treatment Nurse Evaluation, dated 03/19/19, revealed: - CR#13's Stage 3 pressure ulcer to coccyx has deteriorated and was now an unstageable wound to the coccyx/left buttock/sacral area which measures 12.0 cm x 5.0 cm x <0.1. cm with 100% slough. New order revealed to clean with saline, pat dry. Apply Santyl to wound bed. Cover with foam dressing QD. -Reopened pressure sore wound to the right buttock was unstageable and measured 4.0 cm x 3.0 cm x<0.1 cm with 100% slough. New Order: Apply Santyl to wound bed. Cover with foam dressing QD. -Healed pressure sore to mid right buttock reopened and was now unstageable measuring 1.7 cm x 3.0 cm x <0.1 cm with 100% slough. New order: Apply Santyl to wound bed. Cover with foam dressing QD. Record review of CR#13's nurses notes revealed he was sent to the hospital on [DATE] due to right knee/right foot pain and swelling. The nurse's notes further documented that CR#13's MD did not want to wait for an orthopedic consult because he wanted to address the swelling in the knee as soon as possible. Record review of CR#13's hospital admission notes dated 3/20/19 documented that the resident was having a lot of pain to his groin. Culture of the groin revealed it was positive [MEDICAL CONDITION]. Patient also had a stage IV sacral decubitus ulcer which was subsequently debrided and was found to have involvement all the way down to the sacral bone. MRI of the pelvis showed the patient also has osteo[DIAGNOSES REDACTED] of the sacrum. Record review of lab report dated 3/21/19 revealed: Culture: Body fluid/tissue: Site Back Many [MEDICAL CONDITION] (a bacterial infection) Stains: Moderate Gram-Positive Cocci. In an interview on 4/11/19 at 8:15 AM CR #13's family member said that the resident had a wound that looked infected, and the facility was not treating it. The family member said the wound was black, yellow and red. She said prior to 3/12/19 she was not aware of the pressure sore. She said she spoke to the staff about it but had not gotten an answer. Interview on 4/11/19 at 1:20 PM the Treatment Nurse said that her documentation was based on the hospital notes, that documented that CR #13 had a Stage 3 to the coccyx area. She said CR #13's pressure sore to the coccyx was a healing Stage 3 pressure sore because it was not opened. She said because it was not opened they did not get any order for treatment, they were just using barrier cream. She said that they did not need an order for [REDACTED]. However, on her evaluation on 03/12/2019 the pressure sore was not getting worse and it was not getting better so she discussed it with the NP and treatment was ordered. Further interview regarding the order of collagen and calcium alginate and to cover with foam dressing she said it was changed [MEDICATION NAME], and the responsible party was notified. She said if there was a change the CNA's should have notified her or the Charge Nurse regarding CR#13's pressure sore issues but she was not notified. In an interview on 4/11/19 at 10:30 AM with LVN P she said when CR#13 was admitted he had a pink area to the buttocks. She said it was pink in color and it was not opened. She said they were using barrier cream as preventative treatment. She said she personally saw the wound when pericare was provided and it was not open. She said usually if the CNA's see any change in a resident skin condition they would notify the charge nurse or treatment nurse. In an interview on 4/11/19 at 4:30 p.m. with the DON regarding policy and procedures for care and treatment of [REDACTED]. She said the treatment Nurse was trained to do wound care and was in-serviced on wound care on 4/10/19. In an interview on 4/26/19 11:00 AM with CNA M and CNA L they said the day before CR#13 was sent to the hospital they were providing care for CR#13 and the dressing had feces on it and they removed it and called the treatment nurse. The CNA's said the wound was really bad. The CNA's said they called the treatment nurse and she dressed it. CNA M said resident was sent to the hospital the following day and he never returned. In an interview with the DON on 4/26/2019 at 1:30PM regarding care and treatment of [REDACTED]. She said prior to the treatment order on 3/12/2019 there was no issue with the pressure sore. She said the resident was high risk for pressure sore due to the fact that he was on [MEDICAL TREATMENT] and sitting for long period of time on his [MEDICAL TREATMENT] day, having [DIAGNOSES REDACTED]. In an interview on 5/2/19 at 12:15pm with the Treatment Nurse regarding CR#13's pink skin on his sacrum which seemed like a healing pressure ulcer as the resident was dark skin in color it was clear to see that he had a large old pressure ulcer in that area. She said CR#13 refuses to turn/reposition. She said he preferred to lay on his back. The Treatment Nurse said there was one small open area noted which was treated with Collagen, zinc and calcium alginate to dry up the sweat because the resident was constantly laying on his back. She said his wound treatment were scheduled daily. She said she performed treatment on (MONTH) 17 and 18th since nothing had changed she didn't document. She said on (MONTH) 19th when she did his dressing change she noted slough (yellow skin). She said all the pink skin was turned into yellow. She said at that time she called NP to come and look at the pressure sore. She said the NP assessed the wound and staged it as unstageable and new order was received to cleanse with NS, pat dry and apply Santyl and cover with dry dressing. The Treatment Nurse said she was an LVN, so she could not stage wound. She said the resident was discharged to the hospital on (MONTH) 20th and she later learned he passed away. She said it was not unusual for the wound to develop from Stage 2 to unstageable. She said CR#13 had a lot of health issues. He had end stage [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. He was also eating less, was unable to eat a lot of protein to promote new tissue growth because he was a renal patient. She said she worked with residents in the past and had seen wounds change quickly. She said CR#13's skin actually changed overnight. She further stated that she was not aware that CR#13 had any infected wounds. In an interview on 5/2/2019 at 1:20 PM with LVN J she said she worked with CR#13 and he had a pinkish area to the bottom and it was a superficial wound very small. Said it was not opened and they were applying barrier cream to it. She said they were repositioning the resident every two hours. She said the resident complaint of pain to the back and was getting routine medication for pain. She said he never complaint of pain to the to the sacral area. In an interview on 5/2/19 at 1:55pm with the NP- she said she assessed CR#13's pressure ulcer on his sacral area on 3/12/19 and it was very superficial with a small opening. She said she staged it as Stage ll and ordered collagen and foam dressing. She said she did not know the exact order she had written. She said on 3/19/19 was the second time she assessed CR#13's pressure ulcer and it was all slough. At that time, it was unstageable. She said skin changes very fast and for CR#13 the pressure sore was unavoidable. She said resident laid on his back, was not eating, had [DIAGNOSES REDACTED]. In an interview via telephone on 5/2/19 at 2:38 pm CR#13's MD he said wounds are not his specialty. However, he would collaborate with the wound care nurse and Nurse practitioners at the facility. He said stage 2 is an opening on the skin. Treatment could be barrier cream and offloading the pressure site. He said it would not hurt to add collagen and calcium alginate to the site. He said skin condition can change as quickly as two hours. Interview with the DON on 4/26/18 at 1:00 p.m. she said they just followed the Lippincott Nursing Procedures Seventh Edition for pressure sore assessment. Record review of the Lippincott Nursing Procedures Seventh Edition read in part: . Implementation: Perform a comprehensive skin assessment using a facility approved skin assessment tool; a comprehensive skin assessment may be the first step in pressure ulcer prevention .

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents for 1 of 7 residents reviewed for accidents and supervision. (Resident #1) CNA-A woke Resident # 1 then left her unattended in her room on the side of the bed and did not help her with hygine care or a transfer according to the plan of care. As a result, Resident #1 fell and sustained fractures to L1, L2 and L3. This failure affected 1 resident placing her at risk of accidents resulting in injuries. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old female who was originally admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]., Record review of Resident #1 quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS score of 11 indicating moderately cognitive issues. She was assessed for activities of daily living as needing supervision for bed mobility, transfer, locomotion on and off the unit and required one person physical assisted. For dressing, toilet use, personal hygiene and bathing she was extensive assistance and required one person physical assisted. The resident was continent of bowel and frequently incontinent of bladder. Record review of Resident #1 Care Plan revised 10/31/18 revealed Resident #1 has an ADL self-care deficit due to confusion, dementia, impaired balance/unsteady [MEDICAL CONDITION] and altered mental status. Interventions: Bed Mobility: The resident required (supervision-limited assistance) by 1 staff to turn and reposition in bed Q shift as necessary. Dressing: The resident required (supervision-limited assistance) by 1 staff to turn and reposition in bed every shift as necessary. Personal Hygiene: The resident required (supervision-limited assistance) by 1 staff to turn and reposition in bed every shift as necessary. Toilet Use: The resident required (supervision-limited assistance) by 1 staff for toileting. Required more assistance at night with incontinent episodes. Transfer: The resident required (supervision-limited assistance) by 1 staff to move between surfaces every shift and as necessary. Record review of a facility Incident Report completed by the Administrator on Resident #1 dated 12/09/18 revealed that around 5:05 a.m., Resident #1 sustained an un witnessed fall in her room. When questioned the resident said she fell and landed on her bottom. The resident was sent to the hospital and returned to the facility on [DATE] . the family member reported that the resident had sustained fractures to L1, L2 and L3. Record review of investigation report completed by the facility revealed CNA A was completing her final rounds at about 5:03 a.m. on 12/9/18 and she told Resident #1 good morning and asked the resident if she was wet and the resident told her she was wet. CNA A approached the bed pulling the covers back asking her if the bed was wet. The CNA told the Resident to get up. At 5:04 a.m. while the resident was sitting on the side of the bed CNA A exited the room stating she needed to retrieve her barrels. The CNA then told the resident not to get up and that she would be right back. Shortly after CNA A left the room Resident #1 independently and ambulated to the closet door with the use of her wheelchair as a walker. She then lost her balance and stumbled backward subsequently falling and hit her back on the side of her bed then landed on her bottom. Observation and interview on 12/18/18 at 12:40 p.m. Resident #1 was observed in bed with a family member in her room. Her lunch tray was on the over bed table untouched. The resident said that she fell and fractured her back. At that point she said she fell a long time ago and she did not remember what had happened. In an interview on 12/18/18 at 12:50 p.m. Family Member B said he was called by the facility after 5:00 a.m. on 12/09/18 informing him that Resident #1 had fallen. Family Member B said he asked if she was ok and they said yes, but she was complaining of pain. He said they have a camera in the room and he decided to review the tape and saw that Resident #1 had a hard fall. He said he immediately called the facility and told them they needed to send the resident to the hospital to be evaluated. He said further review of the tape revealed that the last time the CNA checked on Resident #1 was 1:30 a.m. prior to the fall at 5:03 a.m. At that time, he showed the Surveyor a Recording of the fall which took place on 12/09/18 starting at 5:03 a.m. and lasted for 35 minutes. Record review of the tape provided by the family revealed in parts that at 5:03 a.m. CNA A entered Resident #1's room and said good morning. She then proceeded to asked her if she needed to use the restroom. Resident #1 replied that she was wet. As CNA A got closer to the resident she asked her if the bed was wet and the covers, at the same time start pulling the covers and telling the resident to get up. As the covers were pull off the resident it revealed the bed was wet with rings and the resident had no clothes on from the waist down. The resident started getting up the CNA did not assist her she started leaving the room saying she was going to get her barrels. As she was going through the door she said, don't get up. The CNA did not look back to see what the resident was doing or if the resident heard what she said when she was going through the door. The resident continued to get up after several attempts the resident put her shoes on and pushed her wheelchair to the closet with no clothes on from the waist down. The resident opened the first closet door and attempted to open the second door at that point she lost her balance and fell on her bottom and hit her back on the bed rail. The resident started yelling for help and saying her back was hurting. A few seconds later LVN D ran to the room and assisted Resident #1. CNA A did not return to the room until after 7 minutes of the resident falling. Record review of the X-ray result dated 12/09/18 revealed: Impression 1. Subacute minimally displaced fractures of the left L1, L2, L3 [MEDICATION NAME] process Impression and plan: [MEDICAL CONDITION] spine In an interview with the DON on 12/18/18 at 1:40 p.m. she said she looked at the video and determined that the CNA A did not assist the resident as she should. She said they also looked at the timing and said the CNA did not return to the room in a timely manner. She said CNA A was terminated. In an interview on 12/18/18 at 4:05 p.m. LVN D said she was doing her last round when she heard a loud sound and heard Resident #1 calling for help and she went to the room and saw her on the floor. She said Resident #1 told her she was pushing her wheelchair and she fell on her bottom and hit her back on the bed rail. She said she looked at her and call for help and the resident was complaining of back pain. In an interview on 12/20/18 at 2:30 p.m. with CNA C she said she was called to the room by LVN D to assist her in getting Resident #1 off the floor. She said when she got to the room Resident #1 was on the floor and complaining of back pain. She said her clothes were wet and her bed was wet all the way to the pillow and had multiple urine rings. She said this indicated that the resident had wet the bed more than once. She said there was urine on the floor, but she did not know if the urine was from before or after the fall. She said CNA A was not in the room at the time of the transfer. During an interview with the Administrator on 12/20/18 at 4:00 p.m. she said she saw a brief tape recording of the fall. She said after reviewing the recording she immediately terminated CNA A. She said the CNA's conduct was not acceptable. Further interview revealed they had no policies and procedures on accidents and supervision, falls and transfers. Several attempts were made to interview CNA A by phone on 12/18/18 and 12/20/18 but there was no response.

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents reviewed for accidents in that, (Resident #1) CNA-A transfered Resident #1 without a Hoyer lift and according to the plan of care. As a result, Resident #1 sustained a left humerus fracture. This failure affected 1 resident and placed 4 residents on 100 hall that require assistance with transfers at risk of accidents resulting in injuries. Findings include: Resident #1: Record review of Resident #1 face sheet revealed a [AGE] year old female who was originally admitted to the facility on [DATE] with the following diagnoses; muscle wasting and atrophy, multiple site, muscle wasting and atrophy right arm, heart failure unspecified, vitamin deficiency, major [MEDICAL CONDITION], unspecified obstructive and reflux [MEDICAL CONDITION], abdominal distension, acute embolism and [MEDICAL CONDITION], age related [MEDICAL CONDITION] without current pathological fracture, contracture right and left knee contracture right ankle and lack of coordination Record review of Resident #1 quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 indicating severely Impaired cognitive skills. The resident required total dependence of two people for transfers, bed mobility, locomotion on unit, dressing, toilet use, and personal hygiene. Further record review of Resident # 1 MDS revealed the functional limitation in range of motion was impaired on both sides on the upper and lower extremity. Record review of Resident #1 Care Plan dated 03/07/17 revealed Resident #1 had impaired bed mobility related to [MEDICAL CONDITIONS] and [MEDICAL CONDITION] joint disease. The approach was required total assist of 1-2 staff for performance using full body lift with transfers 2 persons. Record review of an Incident Report on Resident #1 dated 5/21/18 revealed that on 05/21/18 at 1:40 p.m., CNA A reported to LVN A and the DON that she heard a pop from Resident #1's left arm while rolling the resident in bed. Resident #1's responsible party and doctor were notified. The NP gave orders for an X-ray to rule out fracture. Record review of X-ray result dated 5/21/18 revealed: 2 views of the left shoulder Impression: Displaced [MEDICAL CONDITION] left humerus. There is a displaced [MEDICAL CONDITION] left humerus. The joint spaces are normal. No osseous [MEDICAL CONDITION] are identified. The overlying soft tissues are normal. In an interview on 6/5/18 at 1:12 p.m. Resident #2 said she saw CNA A picked up Resident #1 from bed under the resident's shoulder and arms and placed her on the shower chair without assistance from another staff. Resident #2 said she asked CNA A to wait for another CNA to assist her, but CNA A said she could transfer Resident #1 herself. The resident said CNA A transferred Resident #1 to the shower chair and transferred her back to bed from the shower chair alone. Resident #2 said that staff always used 2 people to transfer Resident #1 on her showers days and she was not surprised when the fracture occur that very day she was transferred by CNA A. Record review of the MDS assessment for Resident #2 dated 3/22/18 revealed a BIMS score of '15,' indicative of intact cognition skills. The MDS reflected no behavioral issues. Observation on 06/04/18 at 3:25 p.m. revealed Resident #1 lying in bed with a sling over her left shoulder, arm and hand. The Resident was not interviewable. Interview with CNA A on 6/4/18 at 5:19 p.m. she said she was pulling Resident #1 up in bed herself when she heard a pop and she reported it to the charge nurse (LVN A) and the DON. CNA said she always used two people to transfer the resident and one person to reposition Resident #1 in bed. In an interview on 6/4/18 at 5:20 p.m. LVN A said CNA A told her that she was pulling Resident #1 up in bed when she heard a pop. LVN A said she assessed Resident #1 in bed and noted the left humerus was out of the socket, she called the doctor, but the family wanted Resident #1 transferred to a local hospital. LVN A said CNA A #1 should have used the Hoyer lift to transfer. Record review of the facility list of residents requiring Hoyer lifts on 100 Hall (no date) revealed that Resident #1 was on the list as requiring a Hoyer lift with two persons assist. In an interview on 6/4/18 at 5:30 p.m. the DON said Resident #1 required a Hoyer lift for transfers and one person assist for bed mobility. The DON said CNA A did not tell them about transferring Resident #1 by herself to a shower chair. She said she was just finding out this information from the surveyor. She said that the CNA reported resident #1 was lying in bed when the incident of hearing a pop to resident left shoulder happened. She said she did not know that the roommate had witnessed the incident. In an interview on 6/4/18 at 5:40 pm, the DON said she just interviewed Resident #2 who told her she witnessed CNA A transferring Resident #1 by herself the day the resident suffered a fracture. The DON said CNA A would be suspended and more in-services would be done. In an interview with the Nurse Practitioner on 6/5/18 at 2:00 p.m. NP said she was notified about Resident #1's incident of the left humerus popping, she sends her to a local hospital as requested by her family. Record review of the facility in-services revealed an in service dated 5/26/18 for transfers. Further review of the form sign-in sheet revealed that CNA A signed as attending the in-service. According to the list provided by the facility, 5 residents require use of a Hoyer lift on the 100 hall.

Based on record review and interview facility failed to consult with the resident's physician when there was an accident involving a resident which resulted in injury for one of four residents (Resident #4) reviewed for notification of changes. -The facility did not consult Resident #4's Physician when Resident #4 was lowered to the ground by a staff during incontinent care resulting in a left femoral neck facture. This failure affected one resident and placed 29 residents in hall 100 residents at risk of not receiving care as ordered by their physician which could result in decline in their health status. Findings include: Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's significant change MDS assessment dated [DATE] revealed Resident #4 bed mobility coded as 3 (extensive assistance) and 3 (two + person physical assist), Toilet use coded 3 (extensive assistance) and 3 (two + person physical assist).Continued review of significant change MDS assessment dated [DATE] revealed CAA triggers for ADL functional/rehab potential and falls. Record review of Resident #4's care plan with a revised date of 10/05/2017 revealed ADL task bed mobility was care planned for extensive assistance X 2. Record review of the facility incident report and completed by LVN B revealed that on 11/3/17, Resident #4 was lowered to the floor by CNA A while providing incontinent care. CNA A reported the incident to LVN B. The resident was assessed with [REDACTED]. Further review of the incident report form revealed that the section indicating if the physician or family were notified were blank. Record review of late entry nurses note dated 11/3/17 at 7:53 pm revealed that the resident complaint of pain on 11/3/17 at 11:30 am., PRN pain medication administered, nurse practitioner called and X ray ordered. X ray received indicating fracture. Hospice and family contacted and Resident #4 was sent to the hospital. Record review of X-ray result dated 11/3/17 revealed left hip diffused [MEDICAL CONDITION]. The left femoral neck fracture is visualized .age of fracture undetermined . In an interview with the CNA-A on 11/14/2017 at 10:27 A.M she said she was performing incontinent care for Resident #4 alone and when she went to adjust Resident #4's the resident kicked her legs up causing weight to shift. CNA-A stated she kicked her leg up causing me to have her legs. If I would have let her go she could have hit head on the nightstand so all I could do was slowly bring her to the floor. I left to get help. CNA-A said she notified Charge Nurse (LVN-A) and the nurse assisted her putting Resident #4 back in bed with a Hoyer lift. In an interview with LVN-B on 11/14/2017 at 12:05 pm she said she was the incoming nurse in the morning after the incident. She said she was not aware of an incident that happened involving Resident#4 on the night shift. LVN-B said she only became aware of incident after Resident#4 complained of pain. LVN-B said she then notified the Nurse Practitioner of Resident #4 and asked to have x-rays ordered. In an interview with the DON on 11/14/2017 at 12:20 pm she said she did not know about the incident until X-RAY results were received revealing a facture of unknown origin. The DON said the resident was then sent to the hospital. In an interview with the Nurse Practitioner on 11/14/2017 at 12:25 pm she said she was not notified of the incident prior to LVN-B. NP stated I asked what happened, she (Resident#4) said she fell . I ordered X-rays. In an interview with LVN-A on 11/14/17 at 12:45 p.m. she said she did not notify anyone of the incident because she did not think it was an incident. LVN-A further stated that the incoming staff, the physician or the family were notified. LVN-A said she did assess the resident at time of incident and did not see any injuries. She said that Resident #4 did not complain of pain and no redness was visible. According to the room roster there are 29 residents in Hall 100.

Based on interview and record review the facility failed to ensure the tesident environment remained as free of accidents as possible for 1 of 4 residents reviewed for accidents. (Resident #4) - CNA- A provided incontinent care to Resident #4 alone instead of following the care plan. The resident had to be lowered to the ground by the staff resulting in a left femoral neck facture. This failure affected one resident and placed 29 residents in hall 100 residents at risk of injuries, unecessary pain, and a decline in quality of life. Findings include: Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's significant change MDS assessment dated [DATE] revealed Resident #4 bed mobility coded as 3 (extensive assistance) and 3 (two + person physical assist), Toilet use coded 3 (extensive assistance) and 3 (two + person physical assist).Continued review of significant change MDS assessment dated [DATE] revealed CAA triggers for ADL functional/rehab potential and falls. Record review of Resident #4's care plan with a revised date of 10/05/2017 revealed ADL task bed mobility was care planned for extensive assistance X 2. Record review of the facility incident report and completed by LVN B revealed that on 11/3/17, Resident #4 was lowered to the floor by CNA A while providing incontinent care. CNA A reported the incident to LVN B. The resident was assessed with [REDACTED]. Further review of the incident report form revealed that the section indicating if the physician or family were notified were blank. Record review of a one on one in-service dated 11/3/17 at 2:00 pm revealed that CNA-A was counseled on transfers and bed mobility to when taking care of residents always check the ADL book for the number of staff needed to care for patients. Record review of late entry nurses note dated 11/3/17 at 7:53 pm revealed that the resident complaint of pain on 11/3/17 at 11:30 am., PRN pain medication administered, nurse practitioner called and X ray ordered. X ray received indicating fracture. Hospice and family contacted and Resident #4 was sent to the hospital. Record review of X-ray result dated 11/3/17 revealed left hip diffused osteoporosis. The left femoral neck fracture is visualized .age of fracture undetermined . In an interview with the CNA-A on 11/14/2017 at 10:27 A.M she said she was performing incontinent care for Resident #4 alone and when she went to adjust Resident #4's the resident kicked her legs up causing weight to shift. CNA-A stated she kicked her leg up causing me to have her legs. If I would have let her go she could have hit head on the nightstand so all I could do was slowly bring her to the floor. I left to get help. CNA-A said she notified Charge Nurse (LVN-A) and the nurse assisted her putting Resident #4 back in bed with a Hoyer lift. In further interview with CNA-A at 11:21 am she said that she was familiar with the resident and she thought she needed only one person assistance for incontinent care. In an interview with the DON on 11/14/2017 at 12:20 pm she said she did not know about the incident until X-RAY results were received revealing a facture of unknown origin. The DON said the resident was then sent to the hospital. In an interview with the Nurse Practitioner on 11/14/2017 at 12:25 pm she said she was not notified of the incident prior to LVN-B. NP stated I asked what happened, she (Resident#4) said she fell . I ordered X-rays. In an interview with LVN-A on 11/14/17 at 12:45 p.m. she said she did not notify anyone of the incident because she did not think it was an incident. LVN-A further stated that the incoming staff, the physician or the family were notified. LVN-A said she did assess the resident at time of incident and did not see any injuries. She said that Resident #4 did not complain of pain and no redness was visible. According to the room roster there are 29 residents in Hall 100.

\Based on observation, interview and record review, the facility failed to consult with the resident physician when the resident experience a significant change in condition for one of 5 residents (Resident #2) reviewed for notification of changes. - Resident #2 physician was not consulted when she began experiencing pain when moving her right lower extremity and 3 days later found with [MEDICAL CONDITION]. This failure affected one resident and placed the other 14 residents that reside in the Secured Unit at risk of not being provided with appropriate and timely medical intervention resulting in a decline in health and quality of life. Findings Included: Record review of Resident #2 face sheet revealed a [AGE] year old admitted to the facility on [DATE]. Resident # 2 [DIAGNOSES REDACTED]. Record review of Resident #2 Minimum (MDS) data set [DATE] revealed that Resident #2 cognitive skills were severely impaired and requiring extensive assistance with bed mobility and transfers with 1 person assist. Record review of Resident #2 care plan dated 03/24/2015 revealed that resident was being care planned for acute pain. The approaches that were to be taken for Resident #2 pain included monitor resident for complaints of pain or signs and symptoms of pain every shift and document: restlessness, tearfulness, moaning, anxiety, agitation, and actual complaints of pain. Record review of Resident #2 Medication Administration Record [REDACTED]. The order date was 06/08/16. Record review of Resident #2 ' s Nurses Notes written by LVN-R and dated 09/18/16 at 6:31 a.m. revealed in part: . at approximately 0500 (5:00a.m.) I was called to the resident room by the CNA and she stated that while she was trying to pull off the resident ' s clothes she began to scream stating that she was hurting. When I assessed the resident, I asked her where was the pain coming from and she began to rub on her right thigh. Upon palpation of the resident ' s thigh she began to screams stating that she was hurting. LVN-R documented that she will continue to monitor and notify the MD. Further review of the record revealed no indication that the physician was consulted. Further review of the nurses ' notes revealed: -Late entry for 09/18/16 to 09/19/16 (night shift 6 pm-6am) RN A- monitored resident throughout the shift for right hip pain .resident did not voice complaints of pain .no facial grimacing, moaning .passed to oncoming shift . -Late entry for 09/19/16 at 11:00 am ADON N- Assessed resident at the time, voices no complaints of pain, moves extremities, no abduction to extremities noted, moves limbs without difficulty . -note dated 09/20/16 at 7:34 pm for late entry 09/20/16 2:00pm ADON T- CNA reported that resident had bruise to tight, upon assessment noted light blue discoloration .called NP .new order for X ray received .given Tylenol 500 mg 2 tab . Record review of physician progress notes [REDACTED]. Patient will be sent to local hospital for evaluation and treatment. Record review of Nursing Notes by the DON dated 09/20/16 charted at 5:52p.m. revealed in part . Resident was assessed by her and the ADON. Resident right thigh with pain and resident did not want nurse to touch her right thigh area or her or her right leg. Light bruising noted to her inner thigh. This was all the DON could assess at this due to her discomfort with touch to her right inner thigh. She did experience pain when the DON attempted to asses her inner thigh area. She had very limited movement to right leg, leg warm to touch. Resident was previously medicated with Tylenol. NP informed of findings and wants resident transferred to (hospital) for evaluation and treatment at this time. Interview on 10/04/16 at 11:43 a.m. with CNA-M when asked about 09/18/16 she said that , she began to reposition Resident #2 right hip slightly and Resident #2 began to scream saying no baby it hurts. CNA-M said she then went to the nurse that worked the night shift after making rounds on the resident and reported to the nurse about Resident #2 complaints of pain to right hip when moving or touching and the nurse said she was aware of Resident #2 complaints of pain to the right hip . CNA-M said she could not remember the nurses real name just call her by her nick name. CNA-M said she observed Resident #2 inner thigh area with slight redness. Observation on 10/04/16 at 12:15 p.m. of Resident #2 resting quietly in bed. Observed Resident #2 right hip with 17 staples intact. The surgical wound was open to air with slight redness noted to lower incision site no drainage. Resident #2 was non-interviewable. Interview on 10/04/16 at 3:05 p.m. with LVN-R saying she went to Resident #2 room to do an assessment after being told by the CNA of resident complaints. LVN-R said she instructed the CNA ' s not to move Resident #2 and will put in a call to the NP. LVN-R said she attempted to call the NP 3 times to notify of Resident complaints of pain to right hip and only got NP voice-mail but did not leave NP a voice-mail because she was going to try to call NP again later. LVN-R said she was wrote up and suspended from work for not notifying the physician immediately. Interview on 10/04/16 at 3:50p.m. during the exit conference the DON said she understood why the facility was being cited because LVN-R did not communicate with the Physician or herself on 09/18/16 about Resident #2 complaints of pain to right hip upon movement. The DON said she was in the building and the LVN should have told her. The DON said that LVN-R was written up as well as suspended. She also said that nursing staff was in-serviced. Record review of In-service training report dated 09/26/16 topic: STOP AND WATCH revealed in part: .When a resident is noted to have any change, a stop and watch is to be completed and turned in immediately. This is to be copied, the original is to go the charge nurse and the copy goes to the DON. When giving to the Charge Nurse, please give a verbal, brief, summary of the change. The Charge Nurse will then assess the resident and generate a SBAR as necessary. Documentation of the change will go on the 24hr. report and the nurses ' note. According to the room roster there were 14 residents in the secure unit.

Based on observation, interview and record review the facility failed to assess 1 of 5 residents (Resident #2) when she complained of severe pain to her right thigh. -The Physcian was not consulted -Resident #2 continued to be in pain and was found to have a right [MEDICAL CONDITION] 3 days later. This failure affected one resident and placed the other 14 residents that reside in the Secured Unit at risk for not having health concerns assessed, reported to physicians and no orders to promote healing or further decline of health. Findings Included: Record review of Resident #2 face sheet revealed a [AGE] year old admitted to the facility on [DATE]. Resident # 2 [DIAGNOSES REDACTED]. Record review of Resident #2 Minimum (MDS) data set [DATE] revealed that Resident #2 cognitive skills were severely impaired and requiring extensive assistance with bed mobility and transfers with 1 person assist. Record review of Resident #2 care plan dated 03/24/2015 revealed that resident was being care planned for acute pain. The approaches that were to be taken for Resident #2 pain included monitor resident for complaints of pain or signs and symptoms of pain every shift and document: restlessness, tearfulness, moaning, anxiety, agitation, and actual complaints of pain. Record review of Resident #2 Medication Administration Record [REDACTED]. The order date was 06/08/16. Record review of Resident #2 ' s Nurses Notes written by LVN-R and dated 09/18/16 at 6:31 a.m. revealed in part: . at approximately 0500 (5:00a.m.) I was called to the resident room by the CNA and she stated that while she was trying to pull off the resident ' s clothes she began to scream stating that she was hurting. When I assessed the resident, I asked her where was the pain coming from and she began to rub on her right thigh. Upon palpation of the resident ' s thigh she began to screams stating that she was hurting. LVN-R documented that she will continue to monitor and notify the MD. Further review of the record revealed no indication that the physician was consulted. Further review of the nurses ' notes revealed: -Late entry for 09/18/16 to 09/19/16 (night shift 6 pm-6am) RN A- monitored resident throughout the shift for right hip pain .resident did not voice complaints of pain .no facial grimacing, moaning .passed to oncoming shift . -Late entry for 09/19/16 at 11:00 am ADON N- Assessed resident at the time, voices no complaints of pain, moves extremities, no abduction to extremities noted, moves limbs without difficulty . -note dated 09/20/16 at 7:34 pm for late entry 09/20/16 2:00pm ADON T- CNA reported that resident had bruise to tight, upon assessment noted light blue discoloration .called NP .new order for X ray received .given Tylenol 500 mg 2 tab . Record review of physician progress notes [REDACTED]. Patient will be sent to local hospital for evaluation and treatment. Record review of Nursing Notes by the DON dated 09/20/16 charted at 5:52p.m. revealed in part . Resident was assessed by her and the ADON. Resident right thigh with pain and resident did not want nurse to touch her right thigh area or her or her right leg. Light bruising noted to her inner thigh. This was all the DON could assess at this due to her discomfort with touch to her right inner thigh. She did experience pain when the DON attempted to asses her inner thigh area. She had very limited movement to right leg, leg warm to touch. Resident was previously medicated with Tylenol. NP informed of findings and wants resident transferred to (hospital) for evaluation and treatment at this time. Interview on 10/04/16 at 11:43 a.m. with CNA-M when asked about 09/18/16 she said that , she began to reposition Resident #2 right hip slightly and Resident #2 began to scream saying no baby it hurts. CNA-M said she then went to the nurse that worked the night shift after making rounds on the resident and reported to the nurse about Resident #2 complaints of pain to right hip when moving or touching and the nurse said she was aware of Resident #2 complaints of pain to the right hip . CNA-M said she could not remember the nurses real name just call her by her nick name. CNA-M said she observed Resident #2 inner thigh area with slight redness. Observation on 10/04/16 at 12:15 p.m. of Resident #2 resting quietly in bed. Observed Resident #2 right hip with 17 staples intact. The surgical wound was open to air with slight redness noted to lower incision site no drainage. Resident #2 was non-interviewable. Interview on 10/04/16 at 3:05 p.m. with LVN-R saying she went to Resident #2 room to do an assessment after being told by the CNA of resident complaints. LVN-R said she instructed the CNA ' s not to move Resident #2 and will put in a call to the NP. LVN-R said she attempted to call the NP 3 times to notify of Resident complaints of pain to right hip and only got NP voice-mail but did not leave NP a voice-mail because she was going to try to call NP again later. LVN-R said she was wrote up and suspended from work for not notifying the physician immediately. Interview on 10/04/16 at 3:50p.m. during the exit conference the DON said she understood why the facility was being cited because LVN-R did not communicate with the Physician or herself on 09/18/16 about Resident #2 complaints of pain to right hip upon movement. The DON said she was in the building and the LVN should have told her. The DON said that LVN-R was written up as well as suspended. She also said that nursing staff was in-serviced. Record review of In-service training report dated 09/26/16 topic: STOP AND WATCH revealed in part: .When a resident is noted to have any change, a stop and watch is to be completed and turned in immediately. This is to be copied, the original is to go the charge nurse and the copy goes to the DON. When giving to the Charge Nurse, please give a verbal, brief, summary of the change. The Charge Nurse will then assess the resident and generate a SBAR as necessary. Documentation of the change will go on the 24hr. report and the nurses ' note. According to the room roster there were 14 residents in the secure unit.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to prevent the neglect of one resident (CR #1) of four residents reviewed for neglect. -CR #1 was admitted to the facility on [DATE] for respite care with one deep tissue injury to the left hip. The facility failed to identify and treat new pressure sores. On 8/9/16, less than 24 hours after discharge from the facility, she was admitted to the hospital with [REDACTED]. -The facility failed ensure CR #1 received proper nutrition and did not weight her during her stay and did not provide her the dietician-recommended supplements. CR#1 had a severe weight loss of 25 lbs in 15 days. CR #1 now has a feeding tube to receive nutrition. -The facility failed to consult CR #1's physician when she had a finger stick blood sugar of 410 and elevated blood sugar levels in August 2016. An Immediate Jeopardy (IJ) was identified on 08/17/16. While the IJ was lowered on 08/19/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected CR #1 and placed 106 that require extensive assistance from staff at risk of skin deterioration, weight loss risk and decline in their medical conditions. Intake # 4 Findings included: Record review of the Face Sheet for CR #1, revealed she was [AGE] years old. She was admitted to the facility on [DATE] for respite care. Her current [DIAGNOSES REDACTED]. CR #1 was discharged home on[DATE] and was admitted to the hospital on [DATE]. Record review of the Minimum Data Set (MDS) assessment, dated 07/28/16 revealed CR #1 had severely impaired cognitive skills for daily living. She was totally dependent on one staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. She had range-of-motion limitations of all four extremities. She was incontinent of bowel and bladder. Diabetes Mellitus and [MEDICAL CONDITION] were reflected as active diagnoses. She was at risk for developing pressure ulcers. She had one unstageable deep tissue injury (DTI) upon admission. Further review revealed that her weight on admission was 150 lbs. Record review of the only care plans located in CR #1s chart revealed skin acute care plans dated 07/20/16 indicating the resident had only the following skin issues: pimple to left elbow, , deep tissue injury (DTI) to the left hip and a callous on the left heel. Approaches for the elbow and the DTI included repositioning every two hours, nutritional supplements, vitamins, treatment and low air mattress. Record review of the Admission Nursing Assessment, dated 07/20/16, revealed CR #1 was assessed as having only a healed surgical area to the right buttock, a pink area to left trochanter (hip), a purple discoloration to left forearm, and a callous to the left heel. Record review of CR #1's Admission/Readmission Skin Audit dated 07/20/16 revealed the same information as the Admission Nursing Assessment. Record review of CR #1's Braden Scale for Predicting Pressure Ulcer Risk, dated 07/20/16, revealed a score of 11, indicating a High Risk. Record review of the Nurses' Note (NN) dated 07/20/16 revealed purple discoloration to left forearm; pink area with brown color .on left trochanter, no drainage; healed area to right buttock; family states surgical debridement in the past was done r/t (related to) decubitus; callous to left heel; pin size black area to left fifth toe; . There was no information indicating the resident had any skin breakdown on the sacral area. Record review of CR #1's Weekly Focused Skin Integrity Assessment (Non-Pressure) for July 2016 revealed only one measurement, dated 07/20/16 (the admitted ). The sheet revealed there was a Discoloration .Pimple .skin intact Gray 2.5 x 3.3 x 0 cm. Record review of CR #1's Weekly Focused Skin Integrity Assessment (Non-Pressure) for 07/26/16 indicated that the wound was improved, but was an open wound. There were no measurements on the form. Further review of the Weekly Focused Skin Integrity Assessment (Non-Pressure) for August revealedno documentation of the left elbow ' s condition or measurements. Record review of CR #1's Registered Dietitian (RD) Initial assessment dated [DATE] revealed weight was 150 pounds. The Assessment reflected the resident had a DTI on the left hip. The dietitian reported that CR #1 had increased nutrient needs related to skin breakdown as evidenced by deep tissue injury to her left hip. The dietitian recommended liquid protein 30 cc (cubic centimeters) every day times for 30 days, 500 mg (milligrams) of Vitamin C twice daily for 30 days, and 220 mg Zinc sulfate for 14 days. Record review of CR #1's computerized chart and the paper chart for July and August 2016 revealed no order for Vitamin C, Zinc Sulfate or liquid protein. Record review of the July and August 2016 MARs revealed no Vitamin C, Zinc Sulfate or protein was administered. Record review of telephone orders revealed Ensure, a liquid dietary supplement was not ordered until 08/01/16. Record review of CR #1's Physician's Telephone Order dated 07/26/16 revealed,Clean discoloration/pimple by left elbow with normal saline. Pat dry. Apply calcium alginate every 3 days and as needed. Secure with foam dressing. Record review of CR #1's skin treatment sheets for August 2016 the treatment was conducted on 08/01/16, and 08/03/2016 and was not provided again for the five days prior to discharge, on 08/08/16. Record review of CR #1's Weekly Focused Skin Integrity assessment dated [DATE] revealed wound on left hip, DTI, measuring 2.0 x 2.5 x 0. The periwound was clear with no drainage. The back of the form had a diagram of a human body were only an X was marked by the left hip. Further review of the form and the diagram revealed no indication that the resident had a wound in the sacral area or the buttocks. Wound status was- improved. Record review of CR #1's Weekly Focused Skin Integrity Assessment (Non-Pressure) revealed that the last skin assessment was performed on 08/05/16. The facility documented that the resident had skin issues on her left heel (callous), Right fifth toe, and Right ear. Record review of CR #1's Nurses' Note (NN) dated 07/31/16 at 6:16 p.m. revealed, Resident's family member noticed that the right ear was swollen, red, and warm to the touch. The NN reflected Physician A was notified, and an order for [REDACTED].>Record review of CR #1's Braden Scale dated 08/04/16 revealed a score of 13, indicating a Moderate Risk. Record review of CR #1's Discharge Nursing assessment dated [DATE] at 10:10 a.m. revealed facility marked that the resident has issues in the following areas: left hip area, DTI (Deep Tissue Injury) intact. No measurements were written on the form. The diagram had a dot on the left (incorrect ear) ear, and [MEDICAL CONDITION] was hand written beside the dot. There were no measurements or description. She had a wound on her left elbow. The page reflected (illegible) open area upon admission. No measurement was reflected. There was no documentation that the resident had any open areas on her sacral area or buttocks. Record review of CR #1's Physician's Progress (Physician A's Office) note dated 08/08/16 at 10:42 a.m. revealed CR #1 took the resident to his office for a consult after discharge. The notes indicated the physician addressed the decubitus ulcer on the elbow, but no other areas. Record review of the CR #1's nurses' notes dated 08/08/16 at 12:47 p.m. (late entry) revealed, Family informed that nurse checked blood glucose this morning read high, Physician A was notified. Awaiting response. Since family was taking resident home family was notified to follow up with the physician regarding glucose medications. Communication barrier noted. Translator needed. Family stated at home blood sugars were taken and no medication was needed however labs showed elevated Hemoglobin A1c. Physician notified no new orders given at this time. The nurses' note reflected CR #1 had an appointment with Physician A at 10:30 a.m. on 08/08/16. The nurses' note was signed by Licensed Vocational Nurse (LVN) B. Record review of the Insulin/Accu-checks sheet for CR #1 dated August 2016 revealed a reading of 410 mg/dL (milligrams per deciliter) for 08/08/16 at 6:30 a.m. Review of the clinical record did not reveal any intervention or that the physician was contacted. Record review of the MAR for 08/2016 revealed that CR #1 ' s blood sugar levels were checked every morning. The blood sugar readings fluctuated between 200 and 280. There was no indication in the back of the form that the physician had been contacted regarding any of the high blood sugar readings. Further review of the MAR indicated [REDACTED]. Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's Weekly Focused Skin Integrity Assessment (non-pressure) for August 2016 revealed her right ear had [MEDICAL CONDITION], which was identified on 07/31/16 by the family. The 'size and description' was reflected as red/skin intact. Treatment: Observe. The sheet reflected on 08/05/16, the right ear was improved skin intact. In an interview via telephone on 08/15/16 at 3:00 p.m., CR #1's family member said that on Monday (08/08/16), she and some other family members went to the facility to pick up the resident. She said that when she saw the resident she looked deterionated and the resident had a dressing on her left elbow for a big wound and had a wound on the ear. She said she was told the resident ' s blood sugar was a little elevated. She stated no one had discussed insulin of blood sugar issues with her. The family member said she started crying because the resident did not have issues with her diabetes at home and it had been controlled without medication. She said they went directly from the facility to Physician A's office. She said that the next morning at home, they noticed the resident would not eat, and had declined. She said when they turned the resident they noticed a very large wound on the sacral area that covered part or both buttocks. She said the skin was black and peeling off. She said she called 911 took her to the hospital. The family member said that the resident needed total care before admission but that she did not have any open areas on her body. The family member said the facility did not notify them that the resident had opened areas on her back. Further interview with the family on the above date and time revealed that CR #1 was diagnosed with [REDACTED]. Record view of CR #1's Hospital Comprehensive Metabolic Panel (CMP) dated 08/09/16 at 12:02 p.m. (shortly after arrival at the Hospital) revealed a Glucose level of 988 mg/dL (milligrams per deciliter), Critical High, with a Reference Range of 75-100 mg/dL. The BUN (Blood Urea Nitrogen) was reflected as 80 mg/dL, High, with a Reference Range of 7-18 mg/dL. The BUN/[MEDICATION NAME] Ratio was reflected as 30%, with a Reference Range of 12-20%. The Complete Blood Count (CBC) dated 08/09/16 at 12:02 p.m. reflected a White Blood Cell (WBC) count of 12.0, with a Reference Range of 4.5 -11.0 (Thousands per microliter). Record review of CR #1's Hospital Admission Assessment Inquiry dated 08/09/16 at 2:16 p.m., revealed, pt (patient) has wound on right ear. The '[MEDICAL CONDITION]' section revealed right ear stage 2.pt (patient) has stage 3 sacral wound. There was a stage 3 pressure ulcer on the left elbow. Record review of CR #1's Hospital Physician's referral, dated 08/09/16 at 4:30 p.m., revealed, Decubs on right ear, left elbow, left hip, and sacrum. The referral revealed, Imp. (Impression) .6.[MEDICAL CONDITION] 2/2 (secondary to) decubitus ulcers. Record review of CR #1's hospital Wound Care Consult dated 08/09/16 at 4:45 p.m. revealed, Skin assessment performed. Stage 2 decubitus to sacrum secondary to pressure, incontinence, shearing: cluster of several ulcers in sacrum 9.5 x 7.5 x 3.5 cm. Right ear ulcer 2 x 0.5 x 0.1 cm with slough. Left elbow ulcer 2 x 2.0 x 0.2 cm with slough. Record review of CR #1's Hospital documentation dated 08/09/16 revealed the resident weighed 125 pounds, a loss of 25 pounds, or 16% in less than one month. She was on TPN (feeding a person intravenously, bypassing the usual process of eating and digestion) until tube feeding insertion procedure. Record review of CR #1's Hospital Internal Medicine Note, dated 08/10/16, reflected the Admitting [DIAGNOSES REDACTED]. Hyperosmolar [MEDICAL CONDITION] state (HHS), likely due to non-compliance with insulin .2. [MEDICAL CONDITION]ly due to dehydration .3. Acute [MEDICAL CONDITION], likely .due to dehydration .4. Systematic [MEDICAL CONDITION] Response Syndrome, likely due to Sacral decubitus .5. Infected sacral decubitus .6. Toxic Metabolic [MEDICAL CONDITION]ly to HHS and [MEDICAL CONDITION] .6. [MEDICAL CONDITION]. Record review of hospital speech therapy evaluation and swallowing study dated 08/10/16 revealed CR #1 was found to have severe and profound oral stage dysphagia with possible pharyngeal involvement. She was at high risk for aspiration and nutritional risks, malnutrition, continued weight loss and worsening of decubitus. CR #1 pocketed food and liquids during trials, would not follow commands. Speech therapy recommended for CR #1 to ne NPO due to unsafe and inefficient swallowing, inability to tolerate oral intake, high aspiration risk. Observation of CR #1 on 08/16/16 at 9:00 am revealed she was in a hospital bed. She was unable to communicate and was in the endoscopy area of the hospital waiting for a feeding tube insertion procedure. In an interview with LVN G on 08/16/16 at 1:00 p.m., she said she did the weekly skin assessments as follows: 100 Hall on Monday, 200 Hall on Tuesday, 300 Hall on Wednesday, and 400 Hall on Thursday. Review of the Face Sheet for CR #1 revealed she had been residing on the 200 Hall. In an interview with LVN G on 08/16/16 at 3:00 p.m., she said the most recent weekly skin assessment for CR #1 would have been on Tuesday 8/2/16, because the resident was discharged on the next Monday. She stated the resident had a DTI on the left hip, and a 'discoloration/blister' on her left elbow. She said the resident had [MEDICAL CONDITION] on her right ear. She stated she most recently performed wound care for the resident on 08/03/16. She stated she used a foam dressing on the left hip because it was not an open area. She stated she did a full body skin assessment on 08/05/16. The LVN did not mention any opened areas in the sacral area or buttocks. In an interview on 08/17/16 at 11:03 a.m., LVN B said CR #1 left the facility between 9:00 a.m. and 10:00 a.m. on 08/08/16. She stated she did the finger-stick blood glucose check that morning between 6:30 a.m. and 7:00 a.m. She said It showed very high. She said at the time, the doctor's office, Physician A, was closed. She said she waited for a call back from the doctor's office, but did not receive one. When asked if she had left a message, LVN B answered, They're not open tilt after 8. LVN B said she called after 8:00 a.m. and stated, I was put on hold for a long time, but I had to do something else. LVN B was asked if a 410 mg/dL blood glucose level was high. She answered, Yes. LVN B was then asked if a 410 mg/dL blood glucose level was dangerously high. LVN B answered, Yes. When asked if there was any intervention prior to CR #1 leaving the facility, LVN B answered, No. LVN B confirmed she did not speak with Physician A or his representative prior to CR #1 leaving the facility. LVN B In an interview on 08/17/16 at 11:17 a.m., Assistant Director of Nursing (ADON) E said she was at the facility on 08/08/16. She said she had called Physician A's office to make the appointment for 10:30 a.m. When asked if she addressed the 410 mg/dL blood glucose level, ADON E replied that LVN B had called, and that Physician A was to call back. She stated she did not document any of the events. ADON E acknowledged that a 410 mg/dL blood glucose level was dangerously high. In an interview with Physician A on 08/17/16 at 4:00 p.m., he said he remembered CR #1 going to his office for her appointment on 08/08/16. He said the pressure sore on her left elbow was horrible. He confirmed it was a decubitus, not the result of an insect bite. When asked if the facility had informed him of the 410 mg/dL blood glucose level from that morning, he replied, That's an easy one. If they had told me, I would have addressed it. He said he thought he had asked the facility if the resident had any decubiti, and was told, 'no.' He added, But surely she had one on her elbow. He said he did not perform a full skin assessment during the appointment, but prescribed an antibiotic for the decubitus on the left elbow. Record review of the facility-wide Weekly Weight Records for July and August 2016 did not reveal any weights for CR #1. In an interview on 08/17/16 at 1:10 p.m., Restorative Aide (RA) D stated the RAs were responsible for weights. She stated the protocol was for newly admitted residents were to be weighed upon admission, then weekly for the first two to four weeks. She confirmed that she had not weighted CR#1. Record review of telephone order dated 08/05/16 revealed that the resident ' s diet had been downgraded from mechanical soft to pureed with thin liquids. Further review of the nurses ' notes, dietary notes and care plan section revealed no documentation indicating the reason the diet had to be downgraded. Record review of CR #1's Individual Meal Intake Report dated August 2016 revealed her meal intake percentages were not recorded at every meal. The meal intake recorded were between 50-100%. Further review of the from revealed staff continued to document that CR #1 ate 50-75% on every meal from 08/09/16 to 08/13/16. The resident was discharged on [DATE] in the am. In an interview on 08/17/16 at 1:25 p.m., the Director of Nursing (DON) confirmed that the meal intake percentages for CR #1 were not accurate. When asked about the procedure for dietary communications, the DON said the Dietitian would give the recommendation to the nurse, and the nurse was to send the letter to the Physician. The DON was asked to review the Dietitian Initial assessment dated [DATE] for CR #1. The DON confirmed that there were recommendations for protein,Vitamin C and Zinc sulfate. The DON said the nursing department was responsible for following up the recommendations, but did not specify a particular person or title. Review of the facility ' s undated Abuse Prevention Program revealed: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Policy Interpretation and Implementation .3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of [REDACTED].e. The development of investigation procedures governing resident abuse, theft/misappropriation of resident property, resident to resident abuse and resident to staff abuse f. Timely and through investigations of all reports and allegations of abuse; g. The reporting and filing of accurate documents relative to incidents of abuse. An Immediate Jeopardy (IJ) was identified on 08/17/16 at 4:40 p.m. The Administrator, DON, the Assistant Administrator, the Regional Nurse, the Corporate Education Coordinator, and the Corporate Vice President of Operations were informed at 4:45 p.m. A Plan of Removal (POR) was requested at that time. A POR for the IJ was submitted on 08/18/16. After one revision the plan was accepted on 08/18/16 at 2:38 p.m. The POR included in part: Skin Assessment Effective 8/17/16 licensed Nurse will assess residents' skin for the presence of abnormal skin conditions. This will be completed by 8/18/16. Effective 8/18/16 licensed Nurse will review resident treatments to ensure the presence of appropriate treatment orders. Effective 8/18/16 licensed Nurse will review resident skin assessments for completion and accuracy. This will be completed by 8/18/16. The POR reflected the staff would be in-serviced on methods for identifying and reporting skin abnormalities. The POR reflected Certified Nurse Aides (CNA) would be in-serviced on management and prevention regarding skin integrity and use of positioning devices. The POR reflected a plan for the Treatment Nurse to conduct weekly skin assessments, with changes of condition reported to the Physician, Nurse Practitioner, and the Administrator daily. The POR reflected the DON, ADON (Assistant Director of Nurses), and/or Nurse Consultant would conduct skin assessments for five residents on each hall weekly for four weeks; then monthly for two months. Nutrition Effective 8/17/16, licensed Nurses will review resident records for dietician recommendations over the last 30 days. Dietician recommendations will be reviewed to ensure physician review and applicable implementation. This will be completed by 8/8/16. Effective 8/18/16, the Dietician will audit prior visit recommendations for completeness monthly during site visits. The POR reflected the Nurse Consultant would re-educate the DON and ADONs on the process of managing, monitoring, and implementation of Dietician recommendations. The POR reflected the DON would re-educate the nursing staff on identifying, reporting, and interventions for residents with a change of condition. The POR reflected the DON would review Dietician recommendations for completeness within 7 days of receipt of notifications weekly for four weeks; then monthly for two months. The POR reflected the Nurse Consultants and/or designee would review 15% of dietician recommendations for completeness weekly for four weeks, then monthly for two months. Weight Loss Effective 8/18/18 (16), restorative aides and licensed nurse will review resident medical records for the presence of weights. This will be completed by 8/18/16. Effective 8/8/16, restorative aides and licensed nurse will assess resident weights for presence of weight loss. This will be completed by 08/18/16. Effective 8/17/16, residents with a 5 lb or greater weight loss in one week, or a 5% or greater weight loss in 30 days will be evaluated by the dietician. The POR reflected the DON would provide in-services for the licensed nurses and restorative aides on the process and frequency for managing and monitoring resident weights. The POR reflected the DON would provide in-services for nursing staff on when and what to report related to residents with poor meal intake. The POR reflected the DON and/or designee would review resident weights for completeness and recommendations weekly for four weeks, then monthly for two months. The POR reflected the Dietician would review resident weights for completeness and interventions monthly during routine site visits. Blood Glucose Monitoring and Interventions Effective 8/17/16, licensed nurse will assess the blood sugar level for diabetic residents. The MD/NP will be notified of adverse findings. Effective 8/17/16, licensed nurse will implement MD/NP orders to address adverse findings from blood sugar level assessment. The POR reflected the DON and/or designee would provide in-services for licensed nurses on MD/NP notification of adverse blood sugar findings. The POR reflected the ADONs and/or designee would monitor staff compliance with interventions for adverse blood sugar level findings through daily review of resident MARS during the daily clinical start up meetings for four weeks, then monthly for two months. The plan was monitored from 08/17/16 to 08/19/16 by a surveyor with the following results: Skin Assessment Facility staff, including CNAs, Nurses, and Nursing Management were interviewed for effectiveness of in-services regarding skin assessment, positioning, and reporting. They attended in-service training and described correct repositioning techniques and schedules. They described correct procedures for reporting changes in skin. The Treatment Nurse was interviewed regarding skin assessment protocol. The treatment nurse described correct skin assessment protocol and schedule. The documentation regarding audits of treatment orders was reviewed. No new concerns were noted. The documentation regarding comprehensive skin assessments was reviewed. No new concerns were noted. Nutrition Facility staff, including CNAs, Nurses, and Nursing Management were interviewed for effectiveness of in-services regarding Dietitian recommendations. They described correct procedures for implementing dietitian recommendations. The two Dieticians were interviewed and they expressed an understanding of the POR. The documentation regarding audits of Dietitian recommendations was reviewed. No new concerns were noted. Weight Loss Facility staff, including CNAs, Nurses, Nursing Management were interviewed for effectiveness of in-services regarding weight loss. They described correct weight loss prevention program procedures. The two Dieticians were interviewed and they expressed an understanding of the POR. The documentation regarding audits of weights was reviewed. No new concerns were noted. Blood Glucose Monitoring and Interventions Licensed nurses were interviewed for effectiveness of in-services regarding blood glucose monitoring and interventions, including clarification of what adverse findings was. They correctly described interventions. Review of blood glucose monitoring for the IJ monitoring period was conducted. No new concerns were noted. In an interview on 08/18/16 at 9:48 a.m., the DON stated she monitored the direct care staff with yearly skill check lists. She stated she provided in-services regarding dietary recommendations, weight monitoring, meal intake percentage documentation, blood glucose monitoring, and treatments. Review of the personnel file of LVN B revealed no skills checklist. Review of the personnel file of LVN G, the Treatment Nurse, revealed the most recent skills check list was dated 01/23/15. Review of the most recent skills check list for ADON E revealed it was dated 01/20/15. On 08/19/16 at 1:30 p.m. the surveyor requested the most recent skills check list from the Human Resources (HR) Director. He stated that the DON would have them, and he would request them from her. As of exit on 08/19/16 at 4:30 p.m., no additional skills check lists were provided by the facility. In an interview with the Administrator on 08/18/16 at 3:15 p.m., he said he monitored the direct care staff via meetings, and communication with the DON. He stated he had been out of the facility during much of the time during CR #1's stay due to a personal situation. The Administrator stated he had provided the facility with notice of resignation (prior to the investigation), and that his last day was to be during the next week. On 08/19/16 at 4:00 p.m., a meeting was conducted with the following facility/corporate personnel: The Senior Vice President of Operations, the Vice President of Operations, the Regional Nurse, the Corporate Education Coordinator, the Assistant Administrator, an Administrator from a sister facility, and the DON. At that time the facility representatives were informed that the IJ was lowered on 08/19/16 at 4:00 p.m. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The facility CMS form 672 revealed that 106 residents required extensive to total care of staff for activities of daily living to include eating, repositioning and toileting.

Based on observation, interview, and record review, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that at the pressure ulcers were unavoidable; and a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one resident (CR #1) of four residents reviewed for pressure sores. -CR #1 was admitted to the facility on [DATE] for respite care with one deep tissue injury to the left hip. The facility failed to identify and treat new pressure sores. -The facility failed to follow dietary recommendations to add liquid protein, Zinc and Vitamin C for increased nutrient needs related to skin breakdown as evidenced by deep tissue injury. -On 8/9/16, less than 24 hours after discharge from the facility, she was admitted to the hospital with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 08/17/16. While the IJ was lowered on 08/19/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected CR #1 and placed eight current residents with pressure sores at risk for complications including deterioration of existing pressure sores and development of new pressure sores. Intake # 4 Findings included: Record review of the Face Sheet for CR #1, revealed she was [AGE] years old. She was admitted to the facility on [DATE] for respite care. Her current [DIAGNOSES REDACTED]. CR #1 was discharged home on[DATE] and was admitted to the hospital on [DATE]. Record review of the Minimum Data Set (MDS) assessment, dated 07/28/16 revealed CR #1 had severely impaired cognitive skills for daily living. She was totally dependent on one staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. She had range-of-motion limitations of all four extremities. She was incontinent of bowel and bladder. Diabetes Mellitus and [MEDICAL CONDITION] were reflected as active diagnoses. She was at risk for developing pressure ulcers. She had one unstageable deep tissue injury (DTI) upon admission. Further review revealed that her weight on admission was 150 lbs. Record review of the only care plans located in CR #1s chart revealed skin acute care plans dated 07/20/16 indicating the resident had only the following skin issues: pimple to left elbow, , deep tissue injury (DTI) to the left hip and a callous on the left heel. Approaches for the elbow and the DTI included repositioning every two hours, nutritional supplements, vitamins, treatment and low air mattress. Record review of the Admission Nursing Assessment, dated 07/20/16, revealed CR #1 was assessed as having only a healed surgical area to the right buttock, a pink area to left trochanter (hip), a purple discoloration to left forearm, and a callous to the left heel. Record review of CR #1's Admission/Readmission Skin Audit dated 07/20/16 revealed the same information as the Admission Nursing Assessment. Record review of CR #1's Braden Scale for Predicting Pressure Ulcer Risk, dated 07/20/16, revealed a score of 11, indicating a High Risk. Record review of the Nurses' Note (NN) dated 07/20/16 revealed purple discoloration to left forearm; pink area with brown color .on left trochanter, no drainage; healed area to right buttock; family states surgical debridement in the past was done r/t (related to) decubitus; callous to left heel; pin size black area to left fifth toe; . There was no information indicating the resident had any skin breakdown on the sacral area. Record review of CR #1's Weekly Focused Skin Integrity Assessment (Non-Pressure) for July 2016 revealed only one measurement, dated 07/20/16 (the admitted ). The sheet revealed there was a Discoloration .Pimple .skin intact on the elbow, Gray 2.5 x 3.3 x 0 cm. Record review of CR #1's Weekly Focused Skin Integrity Assessment (Non-Pressure) for 07/26/16 indicated that the wound was improved, but was an open wound. There were no measurements on the form. Further review of the Weekly Focused Skin Integrity Assessment (Non-Pressure) for August revealed no documentation of the left elbow ' s condition or measurements. Record review of CR #1's Registered Dietitian (RD) Initial assessment dated [DATE] revealed weight was 150 pounds. The Assessment reflected the resident had a DTI on the left hip. The dietitian reported that CR #1 had increased nutrient needs related to skin breakdown as evidenced by deep tissue injury to her left hip. The dietitian recommended liquid protein 30 cc (cubic centimeters) every day times for 30 days, 500 mg (milligrams) of Vitamin C twice daily for 30 days, and 220 mg Zinc sulfate for 14 days. Record review of CR #1's computerized chart and the paper chart for July and August 2016 revealed no order for Vitamin C, Zinc Sulfate or liquid protein. Record review of the July and August 2016 MARs revealed no Vitamin C, Zinc Sulfate or protein was administered. Record review of telephone orders revealed Ensure, a liquid dietary supplement was not ordered until 08/01/16. Record review of CR #1's Physician's Telephone Order dated 07/26/16 revealed,Clean discoloration/pimple by left elbow with normal saline. Pat dry. Apply calcium alginate every 3 days and as needed. Secure with foam dressing. Record review of CR #1's skin treatment sheets for August 2016 the treatment was conducted on 08/01/16, and 08/03/2016 and was not provided again for the five days prior to discharge, on 08/08/16. Record review of CR #1's Weekly Focused Skin Integrity assessment dated [DATE] revealed wound on left hip, DTI, measuring 2.0 x 2.5 x 0. The periwound was clear with no drainage. The back of the form had a diagram of a human body were only an X was marked by the left hip. Further review of the form and the diagram revealed no indication that the resident had a wound in the sacral area or the buttocks. Wound status was- improved. Record review of CR #1's Weekly Focused Skin Integrity Assessment (Non-Pressure) revealed that the last skin assessment was performed on 08/05/16. The facility documented that the resident had skin issues on her left heel (callous), Right fifth toe, and Right ear. Record review of CR #1's Nurses' Note (NN) dated 07/31/16 at 6:16 p.m. revealed, Resident's family member noticed that the right ear was swollen, red, and warm to the touch. The NN reflected Physician A was notified, and an order for [REDACTED].>Record review of CR #1's Braden Scale dated 08/04/16 revealed a score of 13, indicating a Moderate Risk. Record review of CR #1's Discharge Nursing assessment dated [DATE] at 10:10 a.m. revealed facility marked that the resident has issues in the following areas: left hip area, DTI (Deep Tissue Injury) intact. No measurements were written on the form. The diagram had a dot on the left (incorrect ear) ear, and [MEDICAL CONDITION] was hand written beside the dot. There were no measurements or description. She had a wound on her left elbow. The page reflected (illegible) open area upon admission. No measurement was reflected. There was no documentation that the resident had any open areas on her sacral area or buttocks. Record review of CR #1's Physician's Progress (Physician A's Office) note dated 08/08/16 at 10:42 a.m. revealed CR #1' sfamily member took the resident to his office for a consult after discharge. The notes indicated the physician addressed the decubitus ulcer on the elbow, but no other areas were assessed. Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's Weekly Focused Skin Integrity Assessment (non-pressure) for August 2016 revealed her right ear had [MEDICAL CONDITION], which was identified on 07/31/16 by the family. The 'size and description' was reflected as red/skin intact. Treatment: Observe. The sheet reflected on 08/05/16, the right ear was improved skin intact. In an interview via telephone on 08/15/16 at 3:00 p.m., CR #1's family member said that on Monday (08/08/16), she and some other family members went to the facility to pick up the resident. She said that when she saw the resident she looked deterionated and the resident had a dressing on her left elbow for a big wound and had a wound on the ear. She said she was told the resident ' s blood sugar was a little elevated. She stated no one had discussed insulin of blood sugar issues with her. The family member said she started crying because the resident did not have issues with her diabetes at home and it had been controlled without medication. She said they went directly from the facility to Physician A's office. She said that the next morning at home, they noticed the resident would not eat, and had declined. She said when they turned the resident they noticed a very large wound on the sacral area that covered part or both buttocks. She said the skin was black and peeling off. She said she called 911 took her to the hospital. The family member said that the resident needed total care before admission but that she did not have any open areas on her body. The family member said the facility did not notify them that the resident had opened areas on her back. Record view of CR #1's Hospital Comprehensive Metabolic Panel (CMP) dated 08/09/16 at 12:02 p.m. (shortly after arrival at the Hospital) revealed a Glucose level of 988 mg/dL (milligrams per deciliter), Critical High, with a Reference Range of 75-100 mg/dL. The BUN (Blood Urea Nitrogen) was reflected as 80 mg/dL, High, with a Reference Range of 7-18 mg/dL. The BUN/[MEDICATION NAME] Ratio was reflected as 30%, with a Reference Range of 12-20%. The Complete Blood Count (CBC) dated 08/09/16 at 12:02 p.m. reflected a White Blood Cell (WBC) count of 12.0, with a Reference Range of 4.5 -11.0 (Thousands per microliter). Record review of CR #1's Hospital Admission Assessment Inquiry dated 08/09/16 at 2:16 p.m., revealed, pt (patient) has wound on right ear. The '[MEDICAL CONDITION]' section revealed right ear stage 2.pt (patient) has stage 3 sacral wound. There was a stage 3 pressure ulcer on the left elbow. Record review of CR #1's Hospital Physician's referral, dated 08/09/16 at 4:30 p.m., revealed, Decubs on right ear, left elbow, left hip, and sacrum. The referral revealed, Imp. (Impression) .6.[MEDICAL CONDITION] 2/2 (secondary to) decubitus ulcers. Record review of CR #1's hospital Wound Care Consult dated 08/09/16 at 4:45 p.m. revealed, Skin assessment performed. Stage 2 decubitus to sacrum secondary to pressure, incontinence, shearing: cluster of several ulcers in sacrum 9.5 x 7.5 x 3.5 cm. Right ear ulcer 2 x 0.5 x 0.1 cm with slough. Left elbow ulcer 2 x 2.0 x 0.2 cm with slough. Record review of CR #1's Hospital Internal Medicine Note, dated 08/10/16, reflected the Admitting [DIAGNOSES REDACTED]. Hyperosmolar [MEDICAL CONDITION] state (HHS), likely due to non-compliance with insulin .2. [MEDICAL CONDITION]ly due to dehydration .3. Acute [MEDICAL CONDITION], likely .due to dehydration .4. Systematic [MEDICAL CONDITION] Response Syndrome, likely due to Sacral decubitus .5. Infected sacral decubitus .6. Toxic Metabolic [MEDICAL CONDITION]ly to HHS and [MEDICAL CONDITION] .6. [MEDICAL CONDITION]. Observation of CR #1 on 08/16/16 at 9:00 am revealed she was in a hospital bed. She was unable to communicate and was in the endoscopy area of the hospital waiting for a feeding tube insertion procedure. In an interview with LVN G on 08/16/16 at 1:00 p.m., she said she did the weekly skin assessments as follows: 100 Hall on Monday, 200 Hall on Tuesday, 300 Hall on Wednesday, and 400 Hall on Thursday. Review of the Face Sheet for CR #1 revealed she had been residing on the 200 Hall. In an interview with LVN G on 08/16/16 at 3:00 p.m., she said the most recent weekly skin assessment for CR #1 would have been on Tuesday 8/2/16, because the resident was discharged on the next Monday. She stated the resident had a DTI on the left hip, and a 'discoloration/blister' on her left elbow. She said the resident had [MEDICAL CONDITION] on her right ear. She stated she most recently performed wound care for the resident on 08/03/16. She stated she used a foam dressing on the left hip because it was not an open area. She stated she did a full body skin assessment on 08/05/16. The LVN did not mention any opened areas in the sacral area or buttocks. In an interview with Physician A on 08/17/16 at 4:00 p.m., he said he remembered CR #1 going to his office for her appointment on 08/08/16. He said the pressure sore on her left elbow was horrible. He confirmed it was a decubitus, not the result of an insect bite. When asked if the facility had informed him of the 410 mg/dL blood glucose level from that morning, he replied, That's an easy one. If they had told me, I would have addressed it. He said he thought he had asked the facility if the resident had any decubiti, and was told, 'no.' He added, But surely she had one on her elbow. He said he did not perform a full skin assessment during the appointment, but prescribed an antibiotic for the decubitus on the left elbow. In an interview on 08/17/16 at 1:25 p.m., the Director of Nursing (DON) confirmed that the meal intake percentages for CR #1 were not accurate. When asked about the procedure for dietary communications, the DON said the Dietitian would give the recommendation to the nurse, and the nurse was to send the letter to the Physician. The DON was asked to review the Dietitian Initial assessment dated [DATE] for CR #1. The DON confirmed that there were recommendations for protein,Vitamin C and Zinc sulfate. The DON said the nursing department was responsible for following up the recommendations, but did not specify a particular person or title. Record review of the facility's undated Weekly Skin Assessment Policy revealed, each resident's skin should be assessed at least weekly to identify alterations in skin integrity (i.e. skin tears, bruises, abrasions, redness, pressure ulcers, etc). In addition, each resident's skin should be assessed during direct care procedures for changes in skin integrity. Record review of the document presented by the facility as the Pressure Sore policy revealed it was a page from a textbook (unknown). The page revealed, As the name implies, pressure ulcers result when pressure - applied with great force for a short period or with less force over a long period - impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, resulting ischemic [MEDICAL CONDITION] can lead to serious infection. The document revealed, Successful pressure ulcer treatment involves relieving pressure, restoring circulation, promoting adequate nutrition, and, if possible, resolving or managing related disorders. The document reflected, Preventative measures include .maintaining adequate nourishment . An Immediate Jeopardy (IJ) was identified on 08/17/16 at 4:40 p.m. The Administrator, DON, the Assistant Administrator, the Regional Nurse, the Corporate Education Coordinator, and the Corporate Vice President of Operations were informed at 4:45 p.m. A Plan of Removal (POR) was requested at that time. A POR for the IJ was submitted on 08/18/16. After one revision the plan was accepted on 08/18/16 at 2:38 p.m. The POR included in part: Skin Assessment Effective 8/17/16 licensed Nurse will assess residents' skin for the presence of abnormal skin conditions. This will be completed by 8/18/16. Effective 8/18/16 licensed Nurse will review resident treatments to ensure the presence of appropriate treatment orders. Effective 8/18/16 licensed Nurse will review resident skin assessments for completion and accuracy. This will be completed by 8/18/16. The POR reflected the staff would be in-serviced on methods for identifying and reporting skin abnormalities. The POR reflected Certified Nurse Aides (CNA) would be in-serviced on management and prevention regarding skin integrity and use of positioning devices. The POR reflected a plan for the Treatment Nurse to conduct weekly skin assessments, with changes of condition reported to the Physician, Nurse Practitioner, and the Administrator daily. The POR reflected the DON, ADON (Assistant Director of Nurses), and/or Nurse Consultant would conduct skin assessments for five residents on each hall weekly for four weeks; then monthly for two months. Nutrition Effective 8/17/16, licensed Nurses will review resident records for dietician recommendations over the last 30 days. Dietician recommendations will be reviewed to ensure physician review and applicable implementation. This will be completed by 8/8/16. Effective 8/18/16, the Dietician will audit prior visit recommendations for completeness monthly during site visits. The POR reflected the Nurse Consultant would re-educate the DON and ADONs on the process of managing, monitoring, and implementation of Dietician recommendations. The POR reflected the DON would re-educate the nursing staff on identifying, reporting, and interventions for residents with a change of condition. The POR reflected the DON would review Dietician recommendations for completeness within 7 days of receipt of notifications weekly for four weeks; then monthly for two months. The POR reflected the Nurse Consultants and/or designee would review 15% of dietician recommendations for completeness weekly for four weeks, then monthly for two months. The plan was monitored from 08/17/16 to 08/19/16 by a surveyor with the following results: Skin Assessment Facility staff, including CNAs, Nurses, and Nursing Management were interviewed for effectiveness of in-services regarding skin assessment, positioning, and reporting. They attended in-service training and described correct repositioning techniques and schedules. They described correct procedures for reporting changes in skin. The Treatment Nurse was interviewed regarding skin assessment protocol. The treatment nurse described correct skin assessment protocol and schedule. The documentation regarding audits of treatment orders was reviewed. No new concerns were noted. The documentation regarding comprehensive skin assessments was reviewed. No new concerns were noted. Nutrition Facility staff, including CNAs, Nurses, and Nursing Management were interviewed for effectiveness of in-services regarding Dietitian recommendations. They described correct procedures for implementing dietitian recommendations. The two Dieticians were interviewed and they expressed an understanding of the POR. The documentation regarding audits of Dietitian recommendations was reviewed. No new concerns were noted. Weight Loss Facility staff, including CNAs, Nurses, Nursing Management were interviewed for effectiveness of in-services regarding weight loss. They described correct weight loss prevention program procedures. The two Dieticians were interviewed and they expressed an understanding of the POR. The documentation regarding audits of weights was reviewed. No new concerns were noted. Blood Glucose Monitoring and Interventions Licensed nurses were interviewed for effectiveness of in-services regarding blood glucose monitoring and interventions, including clarification of what adverse findings was. They correctly described interventions. Review of blood glucose monitoring for the IJ monitoring period was conducted. No new concerns were noted. In an interview on 08/18/16 at 9:48 a.m., the DON stated she monitored the direct care staff with yearly skill check lists. She stated she provided in-services regarding dietary recommendations, weight monitoring, meal intake percentage documentation, blood glucose monitoring, and treatments. Review of the personnel file of LVN B revealed no skills checklist. Review of the personnel file of LVN G, the Treatment Nurse, revealed the most recent skills check list was dated 01/23/15. Review of the most recent skills check list for ADON E revealed it was dated 01/20/15. On 08/19/16 at 1:30 p.m. the surveyor requested the most recent skills check list from the Human Resources (HR) Director. He stated that the DON would have them, and he would request them from her. As of exit on 08/19/16 at 4:30 p.m., no additional skills check lists were provided by the facility. In an interview with the Administrator on 08/18/16 at 3:15 p.m., he said he monitored the direct care staff via meetings, and communication with the DON. He stated he had been out of the facility during much of the time during CR #1's stay due to a personal situation. The Administrator stated he had provided the facility with notice of resignation (prior to the investigation), and that his last day was to be during the next week. On 08/19/16 at 4:00 p.m., a meeting was conducted with the following facility/corporate personnel: The Senior Vice President of Operations, the Vice President of Operations, the Regional Nurse, the Corporate Education Coordinator, the Assistant Administrator, an Administrator from a sister facility, and the DON. At that time the facility representatives were informed that the IJ was lowered on 08/19/16 at 4:00 p.m. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The facility CMS form 672 revealed that 8 residents had pressure sores.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on a resident's comprehensive assessment for one resident (CR #1) of eight residents reviewed for weight loss. -CR #1 was admitted to the facility for respite care on 07/20/16, and the facility documented her weight as 150 pounds. CR #1 was admitted to a hospital on [DATE] at a weight of 125 pounds, a 16% severe weight loss in less than 20 days. CR #1 is no longer able to eat and a feeding tube was placed for nutrition on 08/16/16. -The facility failed to implement CR #1's Dietician's recommendations for liquid protein, Vitamin C and Zinc sulfate as supplements to aide in the healing of pressure sores. An Immediate Jeopardy (IJ) was identified on 08/17/16. While the IJ was lowered on 08/19/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected CR #1 and placed 11 residents with unplanned weight loss at risk for continued weight loss and decline in health related to poor nutrition. Intake # 4 Findings included: Record review of the Face Sheet for CR #1, revealed she was [AGE] years old. She was admitted to the facility on [DATE] for respite care. Her current [DIAGNOSES REDACTED]. CR #1 was discharged home on[DATE] and was admitted to the hospital on [DATE]. Record review of the Minimum Data Set (MDS) assessment, dated 07/28/16 revealed CR #1 had severely impaired cognitive skills for daily living. She was totally dependent on one staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. She had range-of-motion limitations of all four extremities. She was incontinent of bowel and bladder. Diabetes Mellitus and [MEDICAL CONDITION] were reflected as active diagnoses. She was at risk for developing pressure ulcers. She had one unstageable deep tissue injury (DTI) upon admission. Further review revealed that her weight on admission was 150 lbs. Record review of the only care plans located in CR #1s chart revealed skin acute care plans dated 07/20/16 indicating the resident had only the following skin issues: pimple to left elbow, , deep tissue injury (DTI) to the left hip and a callous on the left heel. Approaches for the elbow and the DTI included repositioning every two hours, nutritional supplements, vitamins, treatment and low air mattress. Record review of the Admission Nursing Assessment, dated 07/20/16, revealed CR #1 was assessed as having only a healed surgical area to the right buttock, a pink area to left trochanter (hip), a purple discoloration to left forearm, and a callous to the left heel. Record review of CR #1's Admission/Readmission Skin Audit dated 07/20/16 revealed the same information as the Admission Nursing Assessment. Record review of CR #1's Braden Scale for Predicting Pressure Ulcer Risk, dated 07/20/16, revealed a score of 11, indicating a High Risk. Record review of CR #1's Registered Dietitian (RD) Initial assessment dated [DATE] revealed weight was 150 pounds. The Assessment reflected the resident had a DTI on the left hip. The dietitian reported that CR #1 had increased nutrient needs related to skin breakdown as evidenced by deep tissue injury to her left hip. The dietitian recommended liquid protein 30 cc (cubic centimeters) every day times for 30 days, 500 mg (milligrams) of Vitamin C twice daily for 30 days, and 220 mg Zinc sulfate for 14 days. Record review of CR #1's computerized chart and the paper chart for July and August 2016 revealed no order for Vitamin C, Zinc Sulfate or liquid protein. Record review of the July and August 2016 MARs revealed no Vitamin C, Zinc Sulfate or protein was administered. Record review of telephone orders revealed Ensure, a liquid dietary supplement was not ordered until 08/01/16. Record review of CR #1's Physician's Progress (Physician A's Office) note dated 08/08/16 at 10:42 a.m. revealed CR #1 took the resident to his office for a consult after discharge. The notes indicated the physician addressed the decubitus ulcer on the elbow, but no other areas. In an interview via telephone on 08/15/16 at 3:00 p.m., CR #1's family member said that on Monday (08/08/16), she and some other family members went to the facility to pick up the resident. She said that when she saw the resident she looked deterionated and the resident had a dressing on her left elbow for a big wound and had a wound on the ear. She said she was told the resident ' s blood sugar was a little elevated. She stated no one had discussed insulin or blood sugar issues with her. The family member said she started crying because the resident did not have issues with her diabetes at home and it had been controlled without medication. She said they went directly from the facility to Physician A's office. She said that the next morning at home, they noticed the resident would not eat, and had declined. She said when they turned the resident they noticed a very large wound on the sacral area that covered part or both buttocks. She said the skin was black and peeling off. She said she called 911 took her to the hospital. The family member said that the resident needed total care before admission but that she did not have any open areas on her body. The family member said the facility did not notify them that the resident had opened areas on her back. Further interview with the family on the above date and time revealed that CR #1 was diagnosed with [REDACTED]. Record view of CR #1's Hospital Comprehensive Metabolic Panel (CMP) dated 08/09/16 at 12:02 p.m. (shortly after arrival at the Hospital) revealed a Glucose level of 988 mg/dL (milligrams per deciliter), Critical High, with a Reference Range of 75-100 mg/dL. The BUN (Blood Urea Nitrogen) was reflected as 80 mg/dL, High, with a Reference Range of 7-18 mg/dL. The BUN/[MEDICATION NAME] Ratio was reflected as 30%, with a Reference Range of 12-20%. The [MEDICATION NAME] level was low at 3.1 (normal 3.5-4.8) Record review of CR #1's Hospital documentation dated 08/09/16 revealed the resident weighed 125 pounds, a loss of 25 pounds, or 16% in less than one month. She was on TPN (feeding a person intravenously, bypassing the usual process of eating and digestion) until tube feeding insertion procedure. Record review of CR #1's Hospital Internal Medicine Note, dated 08/10/16, reflected the Admitting [DIAGNOSES REDACTED]. Hyperosmolar [MEDICAL CONDITION] state (HHS), likely due to non-compliance with insulin .2. [MEDICAL CONDITION]ly due to dehydration .3. Acute [MEDICAL CONDITION], likely .due to dehydration .4. Systematic [MEDICAL CONDITION] Response Syndrome, likely due to Sacral decubitus .5. Infected sacral decubitus .6. Toxic Metabolic [MEDICAL CONDITION]ly to HHS and [MEDICAL CONDITION] .6. [MEDICAL CONDITION]. Record review of hospital speech therapy evaluation and swallowing study revealed CR #1 was found to have severe and profound oral stage dysphagia with possible pharyngeal involvement. She was at high risk for aspiration and nutritional risks, malnutrition, continued weight loss and worsening of decubitus. Cr #1 pocketed food and liquids during trials, would not follow commands. Speech therapy recommended for CR #1 to ne NPO due to unsafe and inefficient swallowing, inability to tolerate oral intake, high aspiration risk. Observation of CR #1 on 08/16/16 at 9:00 am revealed she was in a hospital bed. She was unable to communicate and was in the endoscopy area of the hospital waiting for a feeding tube insertion procedure. In an interview with Physician A on 08/17/16 at 4:00 p.m., he said he remembered CR #1 going to his office for her appointment on 08/08/16. He said the pressure sore on her left elbow was horrible. He confirmed it was a decubitus, not the result of an insect bite. When asked if the facility had informed him of the 410 mg/dL blood glucose level from that morning, he replied, That's an easy one. If they had told me, I would have addressed it. He said he thought he had asked the facility if the resident had any decubiti, and was told, 'no.' He added, But surely she had one on her elbow. He said he did not perform a full skin assessment during the appointment, but prescribed an antibiotic for the decubitus on the left elbow. Record review of the facility-wide Weekly Weight Records for July and August 2016 did not reveal any weights for CR #1. In an interview on 08/17/16 at 1:10 p.m., Restorative Aide (RA) D stated the RAs were responsible for weights. She stated the protocol was for newly admitted residents were to be weighed upon admission, then weekly for the first two to four weeks. She confirmed that she had not weighted CR#1. Record review of telephone order dated 08/05/16 revealed that the resident ' s diet had been downgraded from mechanical soft to pureed with thin liquids. Further review of the nurses ' notes, dietary notes and care plan section revealed no documentation indicating the reason the diet had to be downgraded. Record review of CR #1's Individual Meal Intake Report dated August 2016 revealed her meal intake percentages were not recorded at every meal. The meal intake recorded were between 50-100%. Further review of the form revealed staff continued to document that CR #1 ate 50-75% on every meal from 08/09/16 to 08/13/16. The resident was discharged on [DATE] in the am. In an interview on 08/17/16 at 1:25 p.m., the Director of Nursing (DON) confirmed that the meal intake percentages for CR #1 were not accurate. When asked about the procedure for dietary communications, the DON said the Dietitian would give the recommendation to the nurse, and the nurse was to send the letter to the Physician. The DON was asked to review the Dietitian Initial assessment dated [DATE] for CR #1. The DON confirmed that there were recommendations for protein,Vitamin C and Zinc sulfate. The DON said the nursing department was responsible for following up the recommendations, but did not specify a particular person or title. Record review of the document presented by the facility as the Pressure Sore policy revealed it was a page from a textbook (unknown). The page revealed, As the name implies, pressure ulcers result when pressure - applied with great force for a short period or with less force over a long period - impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, resulting ischemic [MEDICAL CONDITION] can lead to serious infection. The document revealed, Successful pressure ulcer treatment involves relieving pressure, restoring circulation, promoting adequate nutrition, and, if possible, resolving or managing related disorders. The document reflected, Preventative measures include .maintaining adequate nourishment . An Immediate Jeopardy (IJ) was identified on 08/17/16 at 4:40 p.m. The Administrator, DON, the Assistant Administrator, the Regional Nurse, the Corporate Education Coordinator, and the Corporate Vice President of Operations were informed at 4:45 p.m. A Plan of Removal (POR) was requested at that time. A POR for the IJ was submitted on 08/18/16. After one revision the plan was accepted on 08/18/16 at 2:38 p.m. The POR included in part: Nutrition Effective 8/17/16, licensed Nurses will review resident records for dietician recommendations over the last 30 days. Dietician recommendations will be reviewed to ensure physician review and applicable implementation. This will be completed by 8/8/16. Effective 8/18/16, the Dietician will audit prior visit recommendations for completeness monthly during site visits. The POR reflected the Nurse Consultant would re-educate the DON and ADONs on the process of managing, monitoring, and implementation of Dietician recommendations. The POR reflected the DON would re-educate the nursing staff on identifying, reporting, and interventions for residents with a change of condition. The POR reflected the DON would review Dietician recommendations for completeness within 7 days of receipt of notifications weekly for four weeks; then monthly for two months. The POR reflected the Nurse Consultants and/or designee would review 15% of dietician recommendations for completeness weekly for four weeks, then monthly for two months. Weight Loss Effective 8/18/18 (16), restorative aides and licensed nurse will review resident medical records for the presence of weights. This will be completed by 8/18/16. Effective 8/8/16, restorative aides and licensed nurse will assess resident weights for presence of weight loss. This will be completed by 08/18/16. Effective 8/17/16, residents with a 5 lb or greater weight loss in one week, or a 5% or greater weight loss in 30 days will be evaluated by the dietician. The POR reflected the DON would provide in-services for the licensed nurses and restorative aides on the process and frequency for managing and monitoring resident weights. The POR reflected the DON would provide in-services for nursing staff on when and what to report related to residents with poor meal intake. The POR reflected the DON and/or designee would review resident weights for completeness and recommendations weekly for four weeks, then monthly for two months. The POR reflected the Dietician would review resident weights for completeness and interventions monthly during routine site visits. Blood Glucose Monitoring and Interventions Effective 8/17/16, licensed nurse will assess the blood sugar level for diabetic residents. The MD/NP will be notified of adverse findings. Effective 8/17/16, licensed nurse will implement MD/NP orders to address adverse findings from blood sugar level assessment. The POR reflected the DON and/or designee would provide in-services for licensed nurses on MD/NP notification of adverse blood sugar findings. The POR reflected the ADONs and/or designee would monitor staff compliance with interventions for adverse blood sugar level findings through daily review of resident MARS during the daily clinical start up meetings for four weeks, then monthly for two months. The plan was monitored from 08/17/16 to 08/19/16 by a surveyor with the following results: Nutrition Facility staff, including CNAs, Nurses, and Nursing Management were interviewed for effectiveness of in-services regarding Dietitian recommendations. They described correct procedures for implementing dietitian recommendations. The two Dieticians were interviewed and they expressed an understanding of the POR. The documentation regarding audits of Dietitian recommendations was reviewed. No new concerns were noted. Weight Loss Facility staff, including CNAs, Nurses, Nursing Management were interviewed for effectiveness of in-services regarding weight loss. They described correct weight loss prevention program procedures. The two Dieticians were interviewed and they expressed an understanding of the POR. The documentation regarding audits of weights was reviewed. No new concerns were noted. Blood Glucose Monitoring and Interventions Licensed nurses were interviewed for effectiveness of in-services regarding blood glucose monitoring and interventions, including clarification of what adverse findings was. They correctly described interventions. Review of blood glucose monitoring for the IJ monitoring period was conducted. No new concerns were noted. In an interview on 08/18/16 at 9:48 a.m., the DON stated she monitored the direct care staff with yearly skill check lists. She stated she provided in-services regarding dietary recommendations, weight monitoring, meal intake percentage documentation, blood glucose monitoring, and treatments. Review of the personnel file of LVN B revealed no skills checklist. Review of the personnel file of LVN G, the Treatment Nurse, revealed the most recent skills check list was dated 01/23/15. Review of the most recent skills check list for ADON E revealed it was dated 01/20/15. On 08/19/16 at 1:30 p.m. the surveyor requested the most recent skills check list from the Human Resources (HR) Director. He stated that the DON would have them, and he would request them from her. As of exit on 08/19/16 at 4:30 p.m., no additional skills check lists were provided by the facility. In an interview with the Administrator on 08/18/16 at 3:15 p.m., he said he monitored the direct care staff via meetings, and communication with the DON. He stated he had been out of the facility during much of the time during CR #1's stay due to a personal situation. The Administrator stated he had provided the facility with notice of resignation (prior to the investigation), and that his last day was to be during the next week. On 08/19/16 at 4:00 p.m., a meeting was conducted with the following facility/corporate personnel: The Senior Vice President of Operations, the Vice President of Operations, the Regional Nurse, the Corporate Education Coordinator, the Assistant Administrator, an Administrator from a sister facility, and the DON. At that time the facility representatives were informed that the IJ was lowered on 08/19/16 at 4:00 p.m. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The facility CMS form 672 revealed that 11 residents with unplanned weight loss.

Based on observation, interview, and record review, the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (CR #1) of four residents reviewed for pressure sores. -The Administrator failed to supervise the Director of Nursing to ensure she was monitoring and training the nursing staff to provide accurate skin assessments, weight monitoring, follow dietary recommendation and consult with physicians when needed. -The DON failed to monitor, train and supervise the nursing staff to ensure they were providinf care to include accurate skin assessments, weight monitoring, follow dietary recommendation and consult with physicians when needed. An Immediate Jeopardy (IJ) was identified on 08/17/16. While the IJ was lowered on 08/19/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. Findings included: Record review of the Face Sheet for CR #1, revealed she was [AGE] years old. She was admitted to the facility on [DATE] for respite care. Her current [DIAGNOSES REDACTED]. CR #1 was discharged home on[DATE] and was admitted to the hospital on [DATE]. Record review of the Minimum Data Set (MDS) assessment, dated 07/28/16 revealed CR #1 had severely impaired cognitive skills for daily living. She was totally dependent on one staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. She had range-of-motion limitations of all four extremities. She was incontinent of bowel and bladder. Diabetes Mellitus and [MEDICAL CONDITION] were reflected as active diagnoses. She was at risk for developing pressure ulcers. She had one unstageable deep tissue injury (DTI) upon admission. Further review revealed that her weight on admission was 150 lbs. Record review of the only care plans located in CR #1s chart revealed skin acute care plans dated 07/20/16 indicating the resident had only the following skin issues: pimple to left elbow, , deep tissue injury (DTI) to the left hip and a callous on the left heel. Approaches for the elbow and the DTI included repositioning every two hours, nutritional supplements, vitamins, treatment and low air mattress. Record review of the Admission Nursing Assessment, dated 07/20/16, revealed CR #1 was assessed as having only a healed surgical area to the right buttock, a pink area to left trochanter (hip), a purple discoloration to left forearm, and a callous to the left heel. Record review of CR #1's Registered Dietitian (RD) Initial assessment dated [DATE] revealed weight was 150 pounds. The Assessment reflected the resident had a DTI on the left hip. The dietitian reported that CR #1 had increased nutrient needs related to skin breakdown as evidenced by deep tissue injury to her left hip. The dietitian recommended liquid protein 30 cc (cubic centimeters) every day times for 30 days, 500 mg (milligrams) of Vitamin C twice daily for 30 days, and 220 mg Zinc sulfate for 14 days. Record review of CR #1's computerized chart and the paper chart for July and August 2016 revealed no order for Vitamin C, Zinc Sulfate or liquid protein. Record review of the July and August 2016 MARs revealed no Vitamin C, Zinc Sulfate or protein was administered. Record review of telephone orders revealed Ensure, a liquid dietary supplement was not ordered until 08/01/16. Record review of the facility-wide Weekly Weight Records for July and August 2016 did not reveal any weights for CR #1. The resident was discharged on Monday, 08/08/16. In an interview via telephone on 08/15/16 at 3:00 p.m., CR #1's family member said that on Monday (08/08/16), she and some other family members went to the facility to pick up the resident. She said that when she saw the resident she looked deterionated and the resident had a dressing on her left elbow for a big wound and had a wound on the ear. She said she was told the resident ' s blood sugar was a little elevated. She stated no one had discussed insulin of blood sugar issues with her. The family member said she started crying because the resident did not have issues with her diabetes at home and it had been controlled without medication. She said they went directly from the facility to Physician A's office. She said that the next morning at home, they noticed the resident would not eat, and had declined. She said when they turned the resident they noticed a very large wound on the sacral area that covered part or both buttocks. She said the skin was black and peeling off. She said she called 911 took her to the hospital. The family member said that the resident needed total care before admission but that she did not have any open areas on her body. The family member said the facility did not notify them that the resident had opened areas on her back. Further interview with the family on the above date and time revealed that CR #1 was diagnosed with [REDACTED]. In an interview with the DON on 08/16/16 at 4:20 pm the facility was informed that a family member for CR #1 was complaining the the resident had pressure sores that were not there when she was admitted to the facility. The DON said that they were turing and repositioning her and the resident had many bony prominences. If she had wounds it was not here Record review of CR #1's Hospital Admission Assessment Inquiry dated 08/09/16 at 2:16 p.m., revealed, pt (patient) has wound on right ear. The '[MEDICAL CONDITION]' section revealed right ear stage 2.pt (patient) has stage 3 sacral wound. There was a stage 3 pressure ulcer on the left elbow. Record review of CR #1's Hospital Physician's referral, dated 08/09/16 at 4:30 p.m., revealed, Decubs on right ear, left elbow, left hip, and sacrum. The referral revealed, Imp. (Impression) .6.[MEDICAL CONDITION] 2/2 (secondary to) decubitus ulcers. Record review of CR #1's Hospital documentation dated 08/09/16 revealed the resident weighed 125 pounds, a loss of 25 pounds, or 16% in less than one month. Record review of CR #1's Hospital Internal Medicine Note, dated 08/10/16, reflected the Admitting [DIAGNOSES REDACTED]. Hyperosmolar [MEDICAL CONDITION] state (HHS), likely due to non-compliance with insulin .2. [MEDICAL CONDITION]ly due to dehydration .3. Acute [MEDICAL CONDITION], likely .due to dehydration .4. Systematic [MEDICAL CONDITION] Response Syndrome, likely due to Sacral decubitus .5. Infected sacral decubitus .6. Toxic Metabolic [MEDICAL CONDITION]ly to HHS and [MEDICAL CONDITION] .6. [MEDICAL CONDITION]. In an interview with Physician A on 08/17/16 at 4:00 p.m., he said he remembered CR #1 going to his office for her appointment on 08/08/16. He said the pressure sore on her left elbow was horrible. He confirmed it was a decubitus, not the result of an insect bite. When asked if the facility had informed him of the 410 mg/dL blood glucose level from that morning, he replied, That's an easy one. If they had told me, I would have addressed it. He said he thought he had asked the facility if the resident had any decubiti, and was told, 'no.' He added, But surely she had one on her elbow. He said he did not perform a full skin assessment during the appointment, but prescribed an antibiotic for the decubitus on the left elbow. In an interview on 08/17/16 at 1:25 p.m., the Director of Nursing (DON) confirmed that the meal intake percentages for CR #1 were not accurate. When asked about the procedure for dietary communications, the DON said the Dietitian would give the recommendation to the nurse, and the nurse was to send the letter to the Physician. The DON was asked to review the Dietitian Initial assessment dated [DATE] for CR #1. The DON confirmed the Admit weight was 'pending' and that there were recommendations for Vitamin C and Zinc sulfate. The DON said nursing department was responsible for following up the recommendations, but did not specify a particular person or title. Review of a sheet of scratch paper presented by the DON on 08/17/16 at 1:45 p.m. revealed CR #1 150. The DON stated she found the paper, and that a former RA had written it. The paper reflected a date of 07/25/16. In an interview on 08/18/16 at 9:48 a.m., the DON stated she monitored the direct care staff with yearly skill check lists. In an interview with the Administrator on 08/18/16 at 3:15 p.m., he said he monitored the direct care staff via meetings, and communication with the DON. When asked how did he think this incident of IJ came about he stated he had been out of the facility during much of the time during CR #1's stay due to a personal situation. The Administrator stated he had provided the facility with notice of resignation (prior to the investigation), and that his last day was to be next week. he said he was let go today. Review of the personnel file of LVN B revealed no skills checklist. Review of the personnel file of LVN G, the Treatment Nurse, revealed the most recent skills check list was dated 01/23/15. Review of the most recent skills check list for ADON E revealed it was dated 01/20/15. On 08/19/16 at 1:30 p.m. the surveyor requested the most recent skills check list from the Human Resources (HR) Director. He stated that the DON would have them, and he would request them from her. As of exit on 08/19/16 at 4:30 p.m., no additional skills check lists were provided by the facility. An Immediate Jeopardy (IJ) was identified on 08/17/16 at 4:40 p.m. The Administrator, DON, the Assistant Administrator, the Regional Nurse, the Corporate Education Coordinator, and the Corporate Vice President of Operations were informed at 4:45 p.m. A Plan of Removal (POR) was requested at that time. A POR for the IJ was submitted on 08/18/16. After one revision the plan was accepted on 08/18/16 at 2:38 p.m. The POR included in part: Skin Assessment Effective 8/17/16 licensed Nurse will assess residents' skin for the presence of abnormal skin conditions. This will be completed by 8/18/16. Effective 8/18/16 licensed Nurse will review resident treatments to ensure the presence of appropriate treatment orders. Effective 8/18/16 licensed Nurse will review resident skin assessments for completion and accuracy. This will be completed by 8/18/16. The POR reflected the staff would be in-serviced on methods for identifying and reporting skin abnormalities. The POR reflected Certified Nurse Aides (CNA) would be in-serviced on management and prevention regarding skin integrity and use of positioning devices. The POR reflected a plan for the Treatment Nurse to conduct weekly skin assessments, with changes of condition reported to the Physician, Nurse Practitioner, and the Administrator daily. The POR reflected the DON, ADON (Assistant Director of Nurses), and/or Nurse Consultant would conduct skin assessments for five residents on each hall weekly for four weeks; then monthly for two months. Nutrition Effective 8/17/16, licensed Nurses will review resident records for dietician recommendations over the last 30 days. Dietician recommendations will be reviewed to ensure physician review and applicable implementation. This will be completed by 8/8/16. Effective 8/18/16, the Dietician will audit prior visit recommendations for completeness monthly during site visits. The POR reflected the Nurse Consultant would re-educate the DON and ADONs on the process of managing, monitoring, and implementation of Dietician recommendations. The POR reflected the DON would re-educate the nursing staff on identifying, reporting, and interventions for residents with a change of condition. The POR reflected the DON would review Dietician recommendations for completeness within 7 days of receipt of notifications weekly for four weeks; then monthly for two months. The POR reflected the Nurse Consultants and/or designee would review 15% of dietician recommendations for completeness weekly for four weeks, then monthly for two months. Weight Loss Effective 8/18/18 (16), restorative aides and licensed nurse will review resident medical records for the presence of weights. This will be completed by 8/18/16. Effective 8/8/16, restorative aides and licensed nurse will assess resident weights for presence of weight loss. This will be completed by 08/18/16. Effective 8/17/16, residents with a 5 lb or greater weight loss in one week, or a 5% or greater weight loss in 30 days will be evaluated by the dietician. The POR reflected the DON would provide in-services for the licensed nurses and restorative aides on the process and frequency for managing and monitoring resident weights. The POR reflected the DON would provide in-services for nursing staff on when and what to report related to residents with poor meal intake. The POR reflected the DON and/or designee would review resident weights for completeness and recommendations weekly for four weeks, then monthly for two months. The POR reflected the Dietician would review resident weights for completeness and interventions monthly during routine site visits. Blood Glucose Monitoring and Interventions Effective 8/17/16, licensed nurse will assess the blood sugar level for diabetic residents. The MD/NP will be notified of adverse findings. Effective 8/17/16, licensed nurse will implement MD/NP orders to address adverse findings from blood sugar level assessment. The POR reflected the DON and/or designee would provide in-services for licensed nurses on MD/NP notification of adverse blood sugar findings. The POR reflected the ADONs and/or designee would monitor staff compliance with interventions for adverse blood sugar level findings through daily review of resident MARS during the daily clinical start up meetings for four weeks, then monthly for two months. The plan was monitored from 08/17/16 to 08/19/16 by a surveyor with the following results: Skin Assessment Facility staff, including CNAs, Nurses, and Nursing Management were interviewed for effectiveness of in-services regarding skin assessment, positioning, and reporting. They attended in-service training and described correct repositioning techniques and schedules. They described correct procedures for reporting changes in skin. The Treatment Nurse was interviewed regarding skin assessment protocol. The treatment nurse described correct skin assessment protocol and schedule. The documentation regarding audits of treatment orders was reviewed. No new concerns were noted. The documentation regarding comprehensive skin assessments was reviewed. No new concerns were noted. Nutrition Facility staff, including CNAs, Nurses, and Nursing Management were interviewed for effectiveness of in-services regarding Dietitian recommendations. They described correct procedures for implementing dietitian recommendations. The two Dieticians were interviewed and they expressed an understanding of the POR. The documentation regarding audits of Dietitian recommendations was reviewed. No new concerns were noted. Weight Loss Facility staff, including CNAs, Nurses, Nursing Management were interviewed for effectiveness of in-services regarding weight loss. They described correct weight loss prevention program procedures. The two Dieticians were interviewed and they expressed an understanding of the POR. The documentation regarding audits of weights was reviewed. No new concerns were noted. Blood Glucose Monitoring and Interventions Licensed nurses were interviewed for effectiveness of in-services regarding blood glucose monitoring and interventions, including clarification of what adverse findings was. They correctly described interventions. Review of blood glucose monitoring for the IJ monitoring period was conducted. No new concerns were noted. In an interview on 08/18/16 at 9:48 a.m., the DON stated she monitored the direct care staff with yearly skill check lists. She stated she provided in-services regarding dietary recommendations, weight monitoring, meal intake percentage documentation, blood glucose monitoring, and treatments. Review of the personnel file of LVN B revealed no skills checklist. Review of the personnel file of LVN G, the Treatment Nurse, revealed the most recent skills check list was dated 01/23/15. Review of the most recent skills check list for ADON E revealed it was dated 01/20/15. On 08/19/16 at 1:30 p.m. the surveyor requested the most recent skills check list from the Human Resources (HR) Director. He stated that the DON would have them, and he would request them from her. As of exit on 08/19/16 at 4:30 p.m., no additional skills check lists were provided by the facility. In an interview with the Administrator on 08/18/16 at 3:15 p.m., he said he monitored the direct care staff via meetings, and communication with the DON. He stated he had been out of the facility during much of the time during CR #1's stay due to a personal situation. The Administrator stated he had provided the facility with notice of resignation (prior to the investigation), and that his last day was to be during the next week. On 08/19/16 at 4:00 p.m., a meeting was conducted with the following facility/corporate personnel: The Senior Vice President of Operations, the Vice President of Operations, the Regional Nurse, the Corporate Education Coordinator, the Assistant Administrator, an Administrator from a sister facility, and the DON. At that time the facility representatives were informed that the IJ was lowered on 08/19/16 at 4:00 p.m. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The facility CMS form 672 revealed that 106 residents required extensive to total care of staff for activities of daily living to include eating, repositioning and toileting.

Based on interview and record review, the facility failed to ensure that 1 of 11 residents, (CR#1), reviewed for accidents received adequate supervision to prevent possible injury. -CR#1 had four falls in 6 hours on 05-17-15 and 05-18-15 without effective interventions or supervision to prevent the falls. CR #1 required hospitalization due to injuries and sustained a subdural hematoma. This failure affected 1 discharged resident and placed 101 current residents at risk of serious injury due to falls. Intake # 9 Findings include: Record review of CR#1's file revealed an [AGE] year old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of CR#1's MDS assessment dated [DATE] revealed he was alert with moderately impaired decision skills and poor memory. He was at high risk for falls and had falls prior to his admission to the facility. CR #1 had disturbances of balance, gait, and positioning ability. He required limited assistance with bed mobility and transfers. He was able to walk with supervision and used a cane to walk. His balance was marked as unsteady. Record review of CR#1's care plan dated 5/1/15 revealed he had a history of [REDACTED]. The objective indicated for him not to have any falls or experience any injuries from falls by 8/1/15. The plan included to monitor changes in his condition that may warrant increased supervision/assistance. no other interventions were listed in the care plan. Record review of the Resident Incident report for CR#1, dated 5-17-15 at 11:15 PM revealed he was found lying on the floor face down under the bed. The type of injury was described as a skin tear, bruise/discoloration, Hematoma to the anterior forearm. Immediate action taken was documented as resident assessed and assisted back to bed. Record review of the Resident Incident report for CR#1, dated 5-17-15 at 11:34 PM revealed CR #1 fell out of the bed after the nurse went out of the room to get equipment for neuros. There were no new injuries. Immediate action taken was documented as taken to the nurse's station for one- on- one monitoring. Further review revealed that the Nurse Practitioner was informed of the fall and that the resident was agitated and Ativan 0.5 mg was ordered and administered. Record review of an entry made in the nursing notes for CR#1 by LVN B on 5/17/15 read in part: 11:15 PM: . Resident was found lying face down with head under the bed. Resident was assessed for injuries. Move all extremities well. Confused and oriented. Skin tears to left elbow. Resident was assisted into bed and nurse went to get equipment for neuros. Upon return, Resident on the floor again. Reassessed injuries. Hematoma and discoloration to right anterior forearm. Resident remains confused and insists that he has to go to his sister's house. Resident refusing to stay in bed and gait unsteady even with a cane . In an interview on 6/29/15 at 3:19 PM, LVN B stated she did not leave the resident alone to get the neuro check equipment. She said she left CR#1 with a CNA. She stated when she came back, the resident was on the floor and the CNA was no longer in the room. When she later confronted the CNA, she told her she had to leave to answer the bathroom call light of another resident. She stated they were shorthanded that night and that every staff was floating everywhere. She was not able to identify which CNA it was. Record review of nurse entry note dated 05/18/15 at 5:59 am revealed in part: .passing meds when noted residents bed pulled away from wall blocking the pathway.found resident on the floor.resident confused.was assisted up and taken to the nurses station for one on one monitoring. There are no other notes until 7:38 am indicating the resident was found on the floor again in the dining area and was send out to the hospital. Record review of the Resident Incident report for CR#1, dated 5-18-15 at 5:55 AM revealed .CR#1 was in bed while nursing was passing medications. Upon leaving the unit noted CR#1's bed was in the middle of the room blocking the pathway. CR#1 was found on his side unable to get up. There were no new injuries. Immediate action taken was documented as assessed for injury and taken to the nurse's station for increased supervision. Record review of an entry made in the nursing notes for CR#1 by LVN B on 5/18/15 read : 5:55 AM: Passing medications when noted resident bed pulled away from wall blocking pathway through resident's room. Found resident again on the floor. No new injuries noted. Resident confused stating he was looking for the hog that ran through the room. Resident was assisted up and taken to the nurse's station for one-on-one monitoring. Record review of the Resident Incident report for CR#1, dated 5-18-15 at 7:00 AM revealed CR#1 was noted lying on the floor in the dining area, right side lying position with hips supine, alert, unable to provide history of incident, moves all extremities well . pupillary reaction sluggish to the right eye. There were not any new injuries. Immediate action taken was documented as assessed for injury and taken to the nurse's station for increased supervision. Resident was sent to the emergency room for evaluation and treatment. In an interview with LVN A on 6/29/15 at 12:00 PM, he stated on 5/18/15, he heard a call for help and ran to the scene to find CR #1 on the floor. He said the resident was not assigned to him for the day. He said that because he was first to arrive at the scene of the incident, and being the nurse who assessed the resident, he made the entry in the nurse's notes. He said he did not know CR#1 had falls the night before. Record review of the hospital records for CR#1, dated 5/18/15 revealed the chief complaint was listed as falls-4 over the past 6 hours. No apparent injury except skin tear to the left elbow. Further review of hospital records revealed CR#1 was transferred to another hospital, into the ICU unit due to subdural hematoma on 5/18/15 at 9:00 AM. Record review of the facility undated policy for Fall Risk Assessment Management revealed in part : ''. the nursing staff should seek to identify resident risk factors for falls.the staff should strive to determine the onset of falling or an increase in falling episodes is related to recent condition changes or new or changed medication. The nursing staff should review the medication.evaluate functional and psychosocial factors.identify environmental factors.consider use of a fall monitoring program or devices. According to the facility's CMS-672, the census was 101.